Back pains

CHRONIC BACK PAIN IS CAUSE OF 14% OF LONG TERM DISABILITY IN THE UK

BACK PAIN TYPES AND RISK FACTORS

Low back pain is a common symptom.It is often traumatic and work related ,although lifting apparatus and other mechanical devices are used to avoid it .Episodes are generally short lived and self limiting ,and patients attend a physiotherapist or osteopath more often than a doctor.Chronic back pain is the cause of 14% of long term disability in the UK .

FIVE TYPES OF LOW BACK PAIN

1. LOCAL PAIN 

   Caused by activation of pain -sensitive nerve endings near affected part of the spine (e.g tears    ,stretching ).

2. PAIN REFFERED TO THE BACK

   Abdominal or pelvic origin ,back pain unafected by spine movement.

3. PAIN OF SPINE ORIGIN

   Restricted to the back or reffered to lower limbs.Disease of upper lumbar spine refer pain to upper lumbar region,groin ,or anterior thighs.Disease of lower lumbar spine refer pain to buttocks or posterior thighs.

4. RADICULAR PAIN

   Radiates from spne to leg in specific nerve root territory.Coughing,sneezing ,lifting heavy objects or straining may eicit pain.

5. PAIN ASSOCIATED WITH MUSCLE SPASM

   Diverse causes ,accompanied by taut paraspinal muscles.

RISK FACTORS FOR POSSIBLE SERIOUS CAUSES OF ACUTE LOW BACK PAIN

HISTORY

Pain worse at rest or at night  _______  Age >50 years.

Prior history of cancer   _______   Intravenous drug use.

History of chronic infection ( especially pulmonary ,urinary tract or skin)  _____Rapidly progressive neurologic deficit

History of trauma

EXAMINATION

Unexplained fever.

Unexplained weight loss.

Straight leg raising sign.

Percussion tenderness ___ low spine or costovertebral angle.

Abdominal, rectal or pelvic mass.

Rapidly progressive focal neurologic deficit ( e.g sensory loss ,leg weakness ,asymmetric or absent leg reflexes ,abnormal bladder function ) 

LABORATORY STUDIES

Routine laboratory studies and lumbar spine X-rays ___rarely needed for acute low back pain but indicated when risk factors for serious underlying disease are present MRI ans CT -myelography are tests of choice for anatomic definition of spine disease .Electromyography ( EMG) and nerve conduction studies useful for functional assessment of peripheral nervous system.

VISCERAL CAUSES OF LOW BACK PAIN

Stomach ( posterior wall ) __ Gall bladder ___Gall stones.

Pancreatic__tumor ,cyst ,pancreatitis.

Retroperitoneal __hemmorrhage ,tumor ,pyelonephritis.

Vascular __ abdominal aortic aneurysm ,renal artery and vein thrombosis.

Colon __ colitis ,diverticulitis ,neoplasm.

uterosacral ligaments __ endometriosis ,carcinoma.

Uterine malposition.

Menstrual pain.

Neoplastic infiltration of nerves.

Radiation neurosis of tumor/nerves.

Prostate ___ carcinoma ,prostatitis.

Kidney __ renal stones, inflammatory disease , neoplasm ,infection.

Pain in the wrist - Carpal tunnel - Hand pain

PAIN IN THE HAND AND WRIST 

Hand pain is commonly caused by injury or repetitive work-related use .When associated with pins and needles or numbness it suggests a neurological cause arising at the wrist ,elbow or neck.Pain and stiffness that are worse in the morning are due to tenosynovitis or inflammatory arthritis.The distribution of hand pain often indicates the diagnosis.

TENOSYNOVITIS

The finger flexor tendons run through a series of synovial sheath and under loops which hold them in place.Inflammation occurs with repeated or unaccustomed use ,or in inflammatory arthritis when the thickened sheaths are palpable .

Flexor tenosynovitis cause finger pain when gripping and stiffness of the fingers in the morning.Occasionally a tendon causes a trigger ,when the finger remains flexed after gripping and has to be pulled straight.A tendon nodule is palpable ,usually in the palm.

Dorsal tenosynovitis is less common except in rheumatoid arthriris.The swelling is on the back of the hand and wrist.

De Quervain's tenosynovitis causes pain and swelling around the radial styloid where the abductor policis longus tendon is held in place by a retaining band.There is local tenderness ,and the pain at the styloid is worsened by flexing the thumb into the palm.

PAIN IN THE HAND AND WRIST - CAUSES 

ALL AGES 

Trauma / fractures.

Tenosynovitis.

- Flexor with /without triggering.

- Dorsal.

- De Quervain's.

Carpal tunnel syndrome.

Ganglion.

Inflammatory arthritis.

Raynaud's syndrome.

Chronic regional pain .

OLDR PATIENTS .

Nodal osteoarthritis .

- DIPs ( heberden's nodes ).

- PIPs ( Bouchard's nodes ).

- First carpometacarpal joint.

Trauma - scaphoid fracture .

Pseudogout.

Gout.

- Acute.

- Tophaceous.

TREATMENT 

Therapeutic ultrasound helps some people.Usually corticosteroid is injected alogside the tendon under low pressure ( not into tendon itself ) .Occasionally surgery is needed.

OTHER CONDITIONS CAUSING PAIN 

*  CARPAL TUNNEL SYNDROME 

This is due to thickened tendons or synovitis in the carpal tunnel .The history is usually typical and diagnostic with the patient waking with numbness ,tingling and pain in a median nerve distribution.The pain radiates to the forearm.The fingers feel swollen but usually are not .It is also seen during the last trimester of pregnancy.

Treatment is with a splint to hold the wrist in dorsiflexion overnight.This relieves the symptoms and is diagnostic ,used nightly for several weeks it may produce full recovery .If it does not ,a corticosteroid injection into the carpal tunnel helps in about 70% of cases ,although it may recur .Persistent symptoms or nerve damage requires nerve conduction studies and surgical decompression of the carpal tunnel.

*  INFLAMMATORY ARTHRITIS 

This may present with pain ,swelling and stiffness of the hands .In Rheumatoid arthritis the wrists ,proximal interphalangeal ( PIP ) joints and metacarpophalangeal  (MCP ) joints are affected symmetrically.In psoriatic arthritis and Reiter's disease a finger may be swollen ( dactylitis ) or the distal interphalangeal ( DIP ) joints are affected asymmetrically.

*  NODAL OSTEOARTHRITIS 

This affects the DIP and less commonly PIP joints ,which are initially swollen and red.The inflammation and pain settle but bony swellings remain. There is often a strong family history and it rarely presents before 50 years of age .Reassurance and local treatment are all that is needed .

*  FIRST CARPOMETACARPAL OSTEOARTHRITHIS 

This causes pain at the base of the thumb when gripping or painless stiffness at the base of the thumb.

 *  SCAPHOID FRACTURES 

These causes pain in the anatomical snuff box.They may not be seen immediately on X-ray ,Ultrasound scaphoid fractures evetually cause pain because of failed union.

*  GANGLION

A ganglion is a jelly-filled ,often painless swelling caused by a partial tear of the joint capsule.The wrist is a common site.Treatment is not essential as many resolve or cause little trouble.They rarely respond to injection ,and surgical excision is possibly the best option.

DUPUYTREN'S CONTRACTURE

This is a painless palpable fibrosis of the palmar aponeurosos ,with fibroblasts invading the dermis .It causes puckering of the skin and gradual flexion of the affected fingers ,usually the ring and little fingers .It is more common in males .Caucasians ,in diabetes mellitus and in those who abuse alcohol .It is associated with Peyronie's disease of the penis - a painful inflammatory disorder of the corpora cavernosa ,leading eventually to painless fibrosis and angulation of the penis during erection .Plastic surgical release of the contracture is restricted to those with severe deformity of the fingers.

Fibromyalgia

Middle class and middle age women are more prone for  fibromyalgia widespread pain


CHRONIC WIDESPREAD PAIN ( FIBROMYALGIA OR FIBROSITIS SYNDROME ) 


Fibromyalgia is a useful diagnosis of exclusion although it is not universally accepted as a diagnosis.Patients value a name to explain symptoms previously dismissed or attributed simply to psychological or social problems.A typical features of fibromyalgia is tender trigger points.The tenderness is not all over a point which distinguishes it from anxiety states.The patient is usually a middle aged ,middle class woman who struggles on with her work and /or housework despite the pain .


Such individuals are difficult to live with and there is often family discord.Many patients have sleep disturbances ,so they awake unrefreshed and have poor concentration.The pain is a widespread ,unremitting ,aching discomfort.There are often other health problems.Such as chronic fatigue syndrome ,irritable bowel syndrome,premenstrual syndrome ,tension ,headache,anxiety and depression , doctors sometimes inappropriate label them 'heart sink ' patients.The patient's frustration is compounded by the fact that most tests are normal ,and they fear doctors believe it is all in their mind.


The controversial condition of unknown aetiology overlaps with chronic fatigue syndrome,with both conditions causing fatigue and sleep disturbance,Diffuse muscle and joint pains are more constant and severe in chronic widespread pain ,although the tender points previously consideed to be pathognomonic are now known to be ubiquitous ,associated with psychological distress,and of no diagnostic importance .Chronic widespread pain occurs most commonly in woman aged 40-65 years old,with a prevalence in the community of between 1 and 11% ,There are association with depressive and anxiety disorders,other functional disorders ,physical deconditioning and a possibly characteristic sleep disturbance


TREATMENT
The first principle is the identification and treatment of maintaining factors ( e.g dysfunction beliefs and behaviors ,mood and sleep disorders ).
Communication
Explanation of health ,including diagnosis and causes .
Education about management ( including self-help leaflets )
Stopping drugs 9e.g caffeine causing insomnia ,analgesics causing dependence )
Rehabilitative therapies.
Cognitive behavior therapy ( to challenge unhelpful beliefs and change coping strategies ).
Supervised and graded exercise therapy ( to reduce inactivity and improve fitness ).
Pharmacotherapies .
Specific antidepressants for mood disorders ,analgesia and sleep disturbamce.
Symptomatic medicines ( e.g appropriate analgesia ,taken only when necessary ).
Management consist of symptomatic analgesia ,reversing the sleep disturbance,and a physically oriented rehabilitation programme .A recent meta analysis suggests that tricyclic antidepressants that inhibit reuptake of both serotinin and norepinephrine ( noradrenaline ) have the greatest effect on sleep ,fatigue and pain.The doses used were too low for antidepressant efficacy and the drugs may work through their hypnotic and analgesic effects.


A sympathetic approach is appropriate ,with reassurance for the patient that fibromyalgia often improves and is not inevitably disabling.Encouragement should be given to undertake a graded aerobic exercise regimen.When depression is present ,it should be treated ,but potentially addictive anxiolytic agents are best avoided.A behavioral psychologist may persaude the person to pace their life more effectively and to cope better, although patients often resist reffered for psychological help.


DRUGS
Analgesics or NSAIDs help in some cases but are best used intermittently.
Low doses of sedative antidepressant drugs ,such as amitriptyline or dosulepin ( dothiepin ) help when taken a few hours before bedtime .It should be explained that these doses are analgesic and not antidepressant , and their side effects should be outlined.

Trigger point injections with local anaesthetic,corticosteroids or acupuncture are sometimes helpful.Oral corticosteroids ar not helpful.

Face pain

FACE PAIN CAUSES AND TREATMENT  

FACE PAIN 

Most common cause of facial pain is dental : triggered by hot ,cold or sweet foods.Exposure to cold repeatedly induces dental pain .Trigeminal neuralgia consist of paroxysmal ,electric shock-like episodes of pain in the distribution of trigeminal nerve : occipital neuralgia presents as lancinating occipital pain.

The face is richly supplied with pain-senstive structures - the teeth ,gums ,sinuses ,temporomandibular joints , jaw and eyes .Disease of these causes facial pain.Facial pain is also caused by specific neurological coditions. such as ,

Trigeminal neuralgia ,trigeminal nerve lesions and postherpetis neuralgia.

TRIGEMINAL NEURALGIA ( TIC DOULOUREUX )

Frequent ,excruciating paroxysms of pain in lips ,gums ,cheek ,or chin ( rarely in opthalmic division of fifth nerve ) lasting seconds to minuts .Typically presents in middle or old age.Pain is often stimulated at trigger points.Sensory deficit cannot be demonstrated.Must be distinguished from other forms of facial pain arising from diseases of jaw ,teeth ,or sinuses.Rare causes are herpes zoster or a tumor.Onset in young adulthood raises the possibility of multiple sclerosis.

TREATMENT

Carbamazepine is effective in 50 - 75% of cases .Begin at 100 mg single daily dose taken with food and advance by 100 mg every 1-2 days until substantial ( 50%) pain relief occurs.Most patients require 200 mg qid : doses > 1200 mg daily usually provide no additional benefit.Follow complete blood count for rare complication of agranulocytosis .

For nonresponders ,phenytoin ( 300 -400 mg qd ) or baclofen ( 5-20 mg tid -qid ) can be tried .When medications fail ,surgical lesions ( heat or glycerol injection ) can be effective : in some centers , microvascular decompression  recommended in a tortuous blood vessel found in posterior fossa near trigeminal nerve.

CLUSTER HEADACHE ( MIGRAINOUS NEURALGIA )

This condition ,distinct from migraine despite its name ,describes recurrent bouts of excruciating unilateral pain that wake the patients .Attacks cluster around one eye .It affects adults ,commencing in the third and fourth decades and is more common in men.Alcohol sometimes provokes an attack ,and also experimentally ,nitroglycerin .There are suggestions that there is a change in grey matter density on functional imaging in the posterior hypothalamus.The pain rises to a crescendo over half an hour and lasts for several hours.Vomiting occurs .One cheek and nostril feel congested .Transiet ipsilateral Horner's syndrome is common.

Despite very severe pain there are no serious sequelae.Attacks recur at intervals over several years but tend to disappear after 55.Analgesics are unhelpful.Triptans may abort an attack.Prophylactic migraine drugs are of little value.Lithium carbonate ( 400 - 1200 mg daily ) sometimes has a dramatic effect in preventing attacks: the drug level should be monitored .Inhalation of oxygen sometimes helps stop an attack.

PAROXYSMAL HEMICRANIA

Episodic paroxysmal hemicrania is a rare condition describing unilateral sudden brief ( < 20 minutes ) pain with characteristics of headaches.The pains may occur many times each day .Typically they respond to indomethacin.

ATYPICAL FACE PAIN

Facial pain for which no cause can be found is seen in the elderly ,mainly in women .It is believed to be a somatic equivalent of depression .Tricyclic antidepressants are sometimes helpful.

OTHER CAUSES OF FACE PAIN 

Facial pain occurs in variants of migraine and in giant cell arteritis .

GIANT CELL ARTERITIS ( GCA , CRANIAL ARTERITIS ,TEMPORAL ARTERITIS ) 

This condition is a granulomatous arteritis of unknown aetiology occuring chiefly over the age of 60 .It affects extradural arteries .Other forms of arteritis ,such as systemic lupus erythematosus ( SLE ) and microscopic polyangitis ,can occasionally present with similar features .Giant cell arteritis is closely related to polymyalgia rheumatica and can coexist.

FACE PAIN IN GIANT CELL ARTERITIS 

Pain in the face ,jaw and mouth is caused by inflammation of facial ,maxillary and lingual branches of the external carotid artery in Giant cell arteritis.Pain is characteristically worse on eating ( jaw claudication ) .Openin the mouth and protruding the tongue becomes difficult.A pain ful ischaemic tongue occurs rarely.

Neck pains - Shoulder pains

Worry and stress also cause muscle tension and lead to chronic neck and shoulder pain


NECK AND SHOULDER PAIN 

Worry and stress  also cause muscle tension and lead to chronic neck pain,which is often burning in quality.Spondylosis seen on X-ray increases after the age of 40 years ,but it is not always causal ,as the pain often settles whilst the radiological changes persist.Spondylosis can ,however cause stiffness and increases the risk of mechanical or muscular neck pain .Muscle spasm can be palpable ,is tender and may lead to abnormal neck posture ( e.g acute torticollis ) . Muscular pattern neck pain is not localized but affects the trapezius muscle, the C7 spinous process ,the paracervical musculature or all three .It is also called shoulder girdle pain.Pain often radiates to the occiput but rarely beyond the tip of the shoulder .It is commonly associated with unilateral or bilateral tension headaches ,pain radiating over the head to the temple and eye ,described as like a pressure or tight band .These features are also seen in fibromyalgia.

ETIOLOGY

TRAUMA TO THE CERVICAL SPINE

Whiplash injury is due to tauma ( usually automobile accidents ) causing cervical musculoligamental sprain or strain due to hyperflexion or hyperextension.This diagnosis should not be applied to patients with fractures ,disk herniation ,head injury ,or altered consciousness.In one study ,18% of patients with hiplash injury had persistent injury-related symptoms 2 years after the car accident.

CERVICAL DISK DISEASE

Herniation of a lower cervical disk is a common cause of neck ,shoulder ,arm,or hand pain.Neck pain ( worse with movements\ ),stiffness ,and limited range of neck motion are common.With nerve root compression ,pain may radiate into a shoulder or arm.Extension and latera rotation of neck narrows he intervertebral foramen and may reproduce radicular ymptoms ( Spurling's sign ).In young individuals ,acute radiculopathy from a ruptured disk is pften traumatic .Subacute radiculopathy is less likely to be related to a specific traumatic incident and may involve both disk disease and spondylosis.

CERVICAL SPONDYLOSIS

Osteoarthritis of the cervical spine may produce neck pain that radiates into the back of the head ,shoulders, or arms ,can also be source of hedaches in the posterior occipital region.A combined radiculopathy and myelopathy may occur.An electrical sensation elicited by neck flexion and raiating down the spine from the neck ( Lhermitte's symptoms ) usually indicates cervical or upper thoracic spinal cord involvement.MRI or CT -myelography can define the anatomic abnormalities,and EMG and nerve conduction studis can quality the severity and localize the levels of nerve root injury.

OTHER CAUSES OF NECK PAIN

Includes rheumatoid arthritis of the cervical apophyseal joints,ankylosing spondylitis ,herpes zoster ( shingles ),neoplasm metastatic to the cervical spine,infection ( osteomyelitis and epidural abscess ), nd metabolic bone disease.Neck pain may also be reffered from the heart with coronary artery ischemia ( cervical angina syndrome ).

THORACIC OUTLET

An anatomic region containing the first rib ,the subclavian artery and vein ,the brachial plexus ,the clavicle ,and the lung apex.Injury may result in posture -or task related pain around the shoulder and supraclavicular region.True neurogenic thoracic outlet syndrome results from compression of the lower trunk of the brachial plexus by an anomalus band of tissue ,tratment consists of surgical division of the band.Arterial thoracic outlet syndrome results from compression of the subclavian artery by a cervical rib ,treatment is with thrombolysis or anticoagulation ,and surgical excision of the cervical rib.Disputed thoracic outlet syndrome includes a large number of patients with chronic arm and shoulder pain of unclear cause ,surgery is controversial and treatment often unsuccessful.

BRACHIAL PLEXUS AND NERVES

Pain from injury to the brachial plexus or arm peripheral nerves can mimic pain of cervical spine origin.Neoplastic infiltration can produce this syndrome ,as can postradiation fibrosis ( pain less often present ). Acute brachial neuritis consist of acute onset of severe shoulder or scapular pain followed over days by weakness of proximal arm and shoulder girdle muscles innevated by the upper brachial plexus ,onset often preceded by an infection or immunization .Complete recovery occurs in 75% of patients after 2 years and in 89% after 3 years.

SHOULDER

If sign of radiculopathy are absent ,differential diagnosis includes mechanical shoulder pain ( tendonitis ,bursitis ,rotator cuff tear ,dislocation ,adhesive capsulitis and cuff impingement under the acromion ) and reffered pain ( subdiaphramatic irritation ,angina ,Pancoast tumor ).Mechanical pain is often worse at night ,associated with shoulder tenderness and aggravated by abduction ,internal rotation or extension of arm.

TREATMENT

Symptomatic treatment of neck pain includes analgesic medication and /or a soft cervical collar.Indications for cervical disk and lumbar disk surgery are similar ,however with cervical disease an aggressive approach is indicated if spinal cord injury is threatened.Surgery of cervical herniated disks consists of an anterior approach with diskectomy followed by anterior  interbody fusion ,a simple posterior patial laminectomy with diskectomy is an acceptable alternative .The cumulative risk of subsequent radiculopathy or myelopathy at cervical segments adjacent to the fusion is 3% per year and 26% per decade.Nonprogressive cervical radiculopathy ( associated with a focal neurologic deficit ) due to a herniated cervical disk may be treated conservatively with a high rate of success.Cervical spondylosis with bony,compressive cervical radiculopathy is generally treated with surgical decompression to interrupt he progression of neurologic signs ,spondylotic myelopathy is managed with anterior decompression and fusion or laminectomy. 

What is abdominal pain ?

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

• 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 :

1. Blood - suggest urinary tract infection or renal colic.
2. Glucose and ketones - ketoacidosis can present with acute pain .
3. 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.
• 
  

Abdominal pain

Sudden onset of pain suggest a peroration ,rupture ,torsion and acute pancreatitis 

ABDOMINAL PAIN 

Pain is stimulated mainly by the stretching of smooth muscle or organ capsules .Severe acute abdominal pain can be due to a large number of gastrointestinal conditions ,and normally presents as an emergency.An acute abdomen can occasionally be due to referred pain from the chest ,as in pneumonia ,or to metabolic causes ,such as diabetic ketoacidosis .

In patients with abdominal pain the following should be ascertained :

• The site ,intensity ,character ,duration and frquency of the pain .
• The aggravating and relieving factors.
• Associated symptoms ,including non gastrointestinal symptoms.

The onset ,site ,type and subsequent course of the pain should be determined as accurately as possible .In general ,the pain of an acute abdomen can either be constant ( usually  owing to inflammation ) or colicky because of a blocked tube .The inflammatory nature of a constant pain wil be supported by a raised temperature ,tachycardia and /or a raised white cell count .If these are normal, then other causes ( e.g musculoskeletal ,aortic aneurysm ) or rare causes ( e.g porphyria ) should be considered .Colicky pain can be due to an obstruction of the gut ,biliary system ,urogenital system or the uterus .These will probably initially require conservative management along with analgesics .If a colicky pain becomes a constant pain,then inflammation of the organ may have supervened ( e.g strangulated hernia ,ascending cholangitis or salpingitis ).

A sudden onset of pain suggests:

• A perforated ( e.g of a duodenal ulcer ) .
• A rupture ( e.g of an aneurysm ) .
• Torsion ( e.g of an ovarian cyst ).
• Acute pancreatitis.

Back pain suggests :

• Pancreatitis.
• Rupture of an aortic aneurysm.
• Renal tract disease. 

Inflammatory conditions  (e.g appendicitis ) produce a more gradual onset of pain .With peritonitis the pain is continuous and may be made worse by movement.


COMMON CAUSES OF ACUTE ABDOMINAL PAIN


Non-specific abdominal pain.
Acute appendicitis.
Renal colic.
Gynaecological disorders.
Intestinal obstruction.
Urinary tract infection.
Gall bladder disease.
Peritoneal ulcer/ dyspepsia.
Diverticular disease.

MEDICAL CAUSES OF ACUTE ABDOMEN.

REFERRED PAIN


Pneumonia.

Myocardial infarction.

FUNCTIONAL GASTROINTESTINAL DISORDERS


RENAL CAUSES


Pelviureteric colic.
Acute pyelonephritis.


METABOLIC CAUSES.


Diabetic mellitus.
Acute intermittent porphyria.
Lead poisoning.


HAEMATOLOGICAL CAUSES


Haemophilia and other bleeding disorders.
Henoch-Schonlein purpura.
Sickle cell crisis.
Polycythemia vera.


VASCULITIS

Embolic