How To Differentiate Between Abdomen Pains - Part 1

How To Differentiate Between Abdomen Pains - Part 1 of 2

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PAIN

Pain felt in the abdomen may be due to:
1. Diseases involving the abdominal viscera and peritonium.
2. Less commonly, it may be referred from structures outside the abdomen.

Examples:
● Chest: Pneumonia involving the lateral diaphragmatic pleura, may be referred to the epigastrium.
● Cardiac infection: particularly with posterior infarction, pain may be referred to the epigastium.
● spinal nerve roots affection (lower thoracic and lumbar): girdle pain.
● Rarely abdominal pain may be a feature of generalized disorders, e.g. diabetic kertosis, rheumatic fever, Henoch's purpura, or acute porphyria.

Sources of Abdominal Pain:
1. Peritoneum: inflammation.
2. Distension of capsules of solid viscera: Liver, Spleen, Kidneys or Ovaries.
3. Vigorous contractions (and spasms) of hollow muscular organs: Intestines, Biliary ducts, Ureters or Uterus.
4. Mesentery: streching.
5. Abdominal arteries: occlusion by embolism or thrombosis - Dissecting aortic aneurysm.


ANALYSIS OF PAIN


Abdominal pain should be analysed with regard to:
- Site
- Character and intensity
- Reference to other sites
- Aggravating and relieving symptoms
- Associated symptoms


TYPES OF PAIN

OESOPHAGEAL PAIN
Site: retrosternal in the midline at the level of the lesion.
Radiation: to the back.
Associated phenomena: pain may be caused by swallowing rapidly (similar to angina) or hot drinks (burning).

REFLUX OESOPHAGITIS
Site: epigastric or retrosternal (described as heartburn).
Radiation: usually none.
Character: burning caused by oesophagitis.
Distinguishing feature: Pain (or heartburn) may occur on bending or lying down, and may be relieved by standing.

PEPTIC ULCERATION
Site: Epigastrium. Back if ulcer penetrates posteriorly.
Radiation: None usually - may be associated with reflex colonic spasm.
Character: Gnawing or burning.
Associated phenomena: Water brush, nausea and vomiting sometimes.
Distinguishing features: periodicity = tends to recur at predictable times
- The pain often wakens the patient at night.
- Eased immediately by food, antacids or vomiting.
- The patient often points with one finger to the site pain in the epigastrium (pointing sign).

INTESTINAL COLIC
Site: Around the umbilicus.
Character: Waves of intermittent, severs cutting pain.
Associated phenomena: Diarrhoea or vomiting.

BILIARY COLIC
Site: epigastrium, and right hypochondrium.
Radiation: through to the back below the right scapula. Sometimes felt at the right shoulder - tip or behind the lower part of sternum.
Character: Sudden and intense. Usually it fluctuates in intensity, but it may be constant. It reaches its maximum in 5 to 15 minutes, and remains intense sometimes for several hours.
Associated phenomena: Extreme restlessness, and autonomic manifestation: sweating, pallor and vomiting, etc. Jaundice may be present.

PANCREARIC
Acute pancreatitis: Severe pain in epigastrium, which may radicate through to the back (between the scapulae).
Chronic pancreatitis: epigastric pain is experienced during meals.
Carcinoma: May give rise to pain usually felt in the back, which is aggravated by lying flat and relieved by sitting or standing.

APPENDICULAR PAIN
● Initially: felt at the center of the abdomen. Usually persistent (i.e. not intermittent) like that of intestinal colic unless the appendix is obstructed).
● Pain is felt later in the right iliac fossa over McBurney's point when the peritoneum over the appendix becomes inflamed.
● Usual types:
- Pain is felt in the hypogastric region, and is accompanied by diarrhoea.
- Dysuria if the appendix is found in the pelvic (near the ureter).

COLON
Site: right left iliac fossa, sometimes all along the course of the colon.
Character:
- Usual type: continuous dull-aching.
- Severe cramp like, which is intermittent lasting for about 1 minute but sometimes much longer.

RECTUM
Site: localized to the rectum.
Radiation: perineum and sacrum.
Character: dull-aching or cramp like.
Associated phenomena: tenesums, bleeding per rectum.
Short but severe spasms of pain referred to the rectum occur as a result of spasms of sacrococcygeal muscles (Proctalgia fugax).

HEPATIC PAIN
Dull aching pain over the liver results from very rapid enlargement of the liver and stretching of the capsule by coditions like hepatitis, congestive failure, or malignancy.

SPLENIC PAIN
● Huge enlargement causes heaviness in the left hypochondrium.
Sharp pain in the left hypochondrium, which is aggravated by inspiration (may be mistaken for left pleurisy). It results from:
- Perisplenitis
- Infarction
- Infection (abscess)

RENAL COLIC
Site: depends on the site of lesion:
- Junction of ureter with pelvis of kidney: costovertebral angle.
- Distal to this point: initially felt over point of obstruction, but later is diffuse, and is felt all over the flanks due to spasm of the lumber muscles.
- Intravesical portion and distal urethra: Suprapublic region - Penis, scrotum (or labia) and inner side of the thigh.
Character: the pain is usually sudden and intense.
Radiation: if pain starts at costovertebral angle, it may radiate into hypochondrium or down to the groin and into the genitalia.
Associated phenomena:
- Extreme restlessness, the patient may cry out in agony.
- Dysuria and frequency of micturition.
- Sometimes there is haematuria.
- Vomiting (from the severity of pain).

RENAL PAIN
- Diseases which affect the capsule (or cause its stretching) or the pelvis may cause pain which is referred to the back between the twelfth rib and iliac crest.
- The pain is usually low-grade and persistent.

URINARY BLADDER
Site: Suprapubic and spreads to the penis.
Character: intense, scalding pain related to micturition.
Radiation: inflammation of the trigone, or stone in intravesicular portion of ureter may each cause pain referred to the tip of the penis.

PROSTATIC PAIN
Site: perineum.
Pain is usually made worse by local pressure such as during defecation or during digital examination.

URETHRAL PAIN
Wll-localized to the urethra, and is felt during urination.

PERITONEUM
Site: Peritonitis may be localized or generalized.
Character: The pain is severe and constant.
Associated phenomena: The patient is typically immobile - Vomiting.

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