Abdominal Pain

Abdominal Pain

We have described in article :

Causes of Abdominal pain

Diagnosis of Abdominal pain

Clinical examination of Abdominal pain.

Investigation of Abdominal pain

Managementof Abdominal pain.

Abdominal Pain

Causes of pain in the abdomen:

A. Inflammation:

  1. Appendicitis.
  2. Diverticulitis. 
  3. Cholecystitis
  4. Pancreatitis.
  5. Pyelonephritis.
  6. Intra abdominal absecess.

B. Perforation or rupture :

  1. Peptic ulcer.
  2. Diverticular disease.
  3. Ovarian cyst.
  4. Aortic aneurysm.

C. Obstruction:

  1. Intestinal obstruction.
  2. Ureteric colic.

D. Extra-intestinal causes of chronic or recurrent abdominal pain

  1. Diabetes mellitus.
  2.  Addison’s disease.
  3. Sickle cell disease.
  4. Haemolytic disorders.
  5. Drugs: Corticosteriods, lead, alcohol.

E. Other (rare);

1) Retroperitoneal:  Aortic aneurysm, Malignancy, Lymphadenopathy, Abscess.

2) Psychogenic: Depression, Anxiety, Hypochondriasis, Somatisation.

3) Locomotor: Vertebral compression, Abdominal muscle strain.

4) Metabolic/endocrine: Diabetes mellitus, Addison’s disease, Acute intermittent prophyria Hypercalcaemia.

5) Drugs/toxins: Corticosteroids, Azathioprine, Lead, Alcohol.

6) Haematological: Sickle cell disease, Haemolytic disorders.

7) Neurological: Spinal cord lesions, Tabes dorsalis, Radiculopathy.

Common causes of acute upper abdominal pain:
  1. Acute pancreatitis.
  2. Peptic ulcer disease.
  3. Acute cholecystitis.
  4. Acute cholangitis. 
  5. Acute Cholangitis
  6. Renal colic.
  7. Acute inferior MI
Differential diagnosis of upper abdominal pain:

A. GIT:

  1. Peptic ulcer disease.
  2. Perforation.
  3. Intestinal obstruction.
  4. Perforated oesophagus.
  5. Ca stomach.

B. Hepatobiliary & pancreatic:

  1. Cholecystitis.
  2. Hepatitis.
  3. Pancreatitis.

C. Cardiovascular:

  1. MI
  2. Aortic aneurysm.

D. Renal:

  • Pyelonephritis.

E. Others:

Pneumonia.

Ruptured spleen.

Approach to a patient with abdominal pain:

History:

  • History of taking NSAIDS.
  • History of previous peptic ulcer disease.
  • Relation of pain with eating, defaecation or micturition.
  • Nausea, vomiting.
  • Weight loss.
  • Change in bowel habit.
  • Previous jaundice.
  • Recent dysentery.
  • Previous abdominal surgery.
  • Previous tuberculosis.
  • Personal history-Diet, smoking, alcohol.

Clinical evaluation:

The pain should be evaluated by the following points-

  • Site
  • Radiation
  • Duration
  • Severity
  • Nature
  • Mode of onset
  • Aggravating and relieving
  • Associated feature

Clinical examination of abdominal Pain :

1`. General examination:

  • Hippocratic face in peritonitis.
  • Body built-Cachectic in abdominal TB, malignancy.
  • Knee-elbow position in acute pancreatitis. 
  • Anaemia-In acute or chronic Gl bleeding.
  • Jaundice.
  • Clubbing-In IBD.
  • Koilonychia – In iron deficiency anaemia due to chronic GI bleeding.
  • Pulse and BP-To assess haemodynamic status.
  • Temperature – Raised in inflammatory conditions.
  • Dehydration – In vomiting, diarrhoea.

2) Examination of abdomen:

Features of peritonitis: Rigid abdomen. 

Tenderness in any particular area.

Ascites.

Abdominal mass.

Organomegaly.

Investigations of abdominal pain :

  1. Full blood count (leucocytosis). 
  2. Urea and electrolytes (dehydration).
  3. Serum amylase or lipase level (acute pancreatitis).
  4. Erect chest X-ray (air under the diaphragm).
  5. Abdominal X-ray (obstruction).
  6. Upper Gl endoscopy.
  7. Abdominal ultrasound.
  8. Contrast studies for intestinal obstruction.
  9. CT (pancreatitis, retroperitoneal collections or masses.
  10. Aangiography (mesenteric ischaemia).
  11. Multi-slice CT angiography (newer technique).

Management of Abdominal Pain :

1. . Conservative: In acute abdomen-

  • Nothing by mouth. Intravenous fluid.
  • Empirical intravenous antibiotic.
  • Intravenous proton pump inhibitor.
  • Parenteral antispasmodic.

2. Specific treatment :  According to cause.

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