ABDOMINAL PAIN
UPPER ABDOMINAL PAIN
Epigastric pain is very common ,it is often a dull ache ,but sometimes sharp and severe .Its relationship to food intake should be ascertained .It is a common feature of peptic ulcer disease ,but also occurs in functional dyspepsia.
Right hypochondrial pain is usually from the gall bladder or biliary tract .Hepatic congestion ( e.g in hepatitis ) and sometimes peptic ulcer can present with pain in the right hypochondrium .Chronic ,often persistent ,pain in the right hypochondrium is a frequent symptoms in healthy females suffering from functional bowel disorders .This chronic pain is not due to gall bladder disease.
LOWER ABDOMINAL PAIN
Acute pain in the left iliac fossa is usually colonic in origin ( e.g acute diverticulitis ).Chronic pain is most commonly associated with functional bowel disorders.In females ,lower abdominal pain occurs in a number of gynaecological disorders and the differentiation from gastrointestinal disease is often difficult .
Persistent pain in the right iliac fossa over a long period is not due to chronic appendicitis.
Proctalgia is a severe pain deep in the rectum that comes on suddenly but lasts only for a short time.It is not due to organic disease.
ABDOMINAL WALL PAIN
Recurrent localized abdominal pain with local tenderness can very rarely arise from the abdominal wall itself.Causes are thought to include nerve entrapment ,external hernias and entrapment of internal viscera ( commonly omentum ) within traumatic ruptures of abdominal wall musculature.
Many reasons ranging from acute life-threatening emergencies to chronic diseases and functional disorders of the different parts of the body, may cause abdominal pain.Evaluation of abdominal pain requires immediate assessment of the likely reasons and early initiation of required treatment. A more comprehensive and more time for diagnosis can be followed in less serious situations.
PHYSICAL EXAMINATION
The general condition of the person should be noted.Does the patient look ill ? Large volumes of fluid may be lost from the vascular compartment into the peritoneal cavity or into the lumen of the bowel giving rise to hypovolemia i.e a pale cold skin, a weak rapid pulse and hypotension.
THE ABDOMEN
PELVIC AND RECTAL EXAMINATION
Pelvic examination can be very helpful ,particularly in diagnosing gynaecological causes of an acute abdomen ( e.g a ruptured ectopic pregnancy ).Rectal examination is less helpful as localized tenderness may be due to any cause ,it may show blood on the finger stall.
SIGMOIDOSCOPY
If diarrhoea is present ,sigmoidoscopy is indicated to aid exclusion of infective ,inflammatory and ischemic causes of acute pain .A specimen of stool should be taken for stool culture for bacterial pathogens ( e.g campylobacter ,salmonella ,shigella ) when diarrhoea is present - stool should also be tested for Clostridium difficile toxin if antibiotic herapy precedes onset of diarrhoea and acute abdominal pain.
OTHER OBSERVATIONS
INVESTIGATIONS
UPPER ABDOMINAL PAIN
Epigastric pain is very common ,it is often a dull ache ,but sometimes sharp and severe .Its relationship to food intake should be ascertained .It is a common feature of peptic ulcer disease ,but also occurs in functional dyspepsia.
Right hypochondrial pain is usually from the gall bladder or biliary tract .Hepatic congestion ( e.g in hepatitis ) and sometimes peptic ulcer can present with pain in the right hypochondrium .Chronic ,often persistent ,pain in the right hypochondrium is a frequent symptoms in healthy females suffering from functional bowel disorders .This chronic pain is not due to gall bladder disease.
LOWER ABDOMINAL PAIN
Acute pain in the left iliac fossa is usually colonic in origin ( e.g acute diverticulitis ).Chronic pain is most commonly associated with functional bowel disorders.In females ,lower abdominal pain occurs in a number of gynaecological disorders and the differentiation from gastrointestinal disease is often difficult .
Persistent pain in the right iliac fossa over a long period is not due to chronic appendicitis.
Proctalgia is a severe pain deep in the rectum that comes on suddenly but lasts only for a short time.It is not due to organic disease.
ABDOMINAL WALL PAIN
Recurrent localized abdominal pain with local tenderness can very rarely arise from the abdominal wall itself.Causes are thought to include nerve entrapment ,external hernias and entrapment of internal viscera ( commonly omentum ) within traumatic ruptures of abdominal wall musculature.
Many reasons ranging from acute life-threatening emergencies to chronic diseases and functional disorders of the different parts of the body, may cause abdominal pain.Evaluation of abdominal pain requires immediate assessment of the likely reasons and early initiation of required treatment. A more comprehensive and more time for diagnosis can be followed in less serious situations.
PHYSICAL EXAMINATION
The general condition of the person should be noted.Does the patient look ill ? Large volumes of fluid may be lost from the vascular compartment into the peritoneal cavity or into the lumen of the bowel giving rise to hypovolemia i.e a pale cold skin, a weak rapid pulse and hypotension.
THE ABDOMEN
- Inspection .Look for the presence of scars ,distension or masses.
- Palpation .The abdomen should be examined gently for sites of tenderness and the presence or absence of guarding.Guarding is involuntary spasm of the abdominal walll and it indicates peritonitis.This can be localized to one area or it may be generalized ,involving the whole abdomen .
- Bowel sounds .Increased high -pitch tinkling bowel sounds indicate fluid obstruction ,this occurs because of fluid movement within the large dilated bowel lumen.Absent bowel sounds suggest peritoneal involvement .In an obstructed patient ,absent bowel sound suggest strangulation or ischemia or ileus.It is essential that the hernial orifices be examined if intestinal obstruction is suspected.
PELVIC AND RECTAL EXAMINATION
Pelvic examination can be very helpful ,particularly in diagnosing gynaecological causes of an acute abdomen ( e.g a ruptured ectopic pregnancy ).Rectal examination is less helpful as localized tenderness may be due to any cause ,it may show blood on the finger stall.
SIGMOIDOSCOPY
If diarrhoea is present ,sigmoidoscopy is indicated to aid exclusion of infective ,inflammatory and ischemic causes of acute pain .A specimen of stool should be taken for stool culture for bacterial pathogens ( e.g campylobacter ,salmonella ,shigella ) when diarrhoea is present - stool should also be tested for Clostridium difficile toxin if antibiotic herapy precedes onset of diarrhoea and acute abdominal pain.
OTHER OBSERVATIONS
- Mouth . The tongue is furred in some cases and a fetor is present.
- Temperature. Fever is more common in acute inflammatory processes.
- Urine. Examine for :
- Blood - suggest urinary tract infection or renal colic.
- Glucose and ketones - ketoacidosis can present with acute pain .
- Protien and white cells - to exclude acte pyelonephritis.
- Think of medical causes
INVESTIGATIONS
- Blood count . A raised white cell occurs in inflammatory conditions.
- Serum amylase. High levels ( more than five times normal ) indicate acute pancreatitis .Raised levels below this can occur in any acute abdomen and should not be considered dignostic of pancreatitis.
- Serum electrolytes . These are not particularly helpful for diagnosis but useful for general evaluation of the patient.
- Pregnancy. A urine dipstick is used with women of child bearing age.
- X-rays. A chest x-ray is useful to detect air under the diaphragm owing to a perforatio .Dilated loops of owel or fluid levels are suggestive of obstruction ( supine abdominal X-ray ).
- Ultrasound. This is useful in the diagnosis of acute cholangitis ,cholecystitis and aortic aneurysm and in expert hands is reliable in the diagnosis of acute appendicitis ,Gynaecological and other pelvic causes of pain can be detected.
- CT scan. Spinal CT is the most accurate investigation in most acute emergencies.
- Laparoscopy. This has gained increasing importance as a diagnostic tool prior to proceeding with surgery , particularly in men and women over the age of 50 years.In addition , therapeutic manoeuvers ,such as appendicectomy can be performed.
