Approach to abdominal pain

DR SITI NUR FA’IZULBA’EDAH MAT RAZI

 What is abdominal pain

 Abdominal pain originate from peritoneum which have 2 layer

that have different nerve supplies(Visceral, Parietal )
 Intra-peritoneal organ: organ that covered by
visceral peritoneum and supported by mesentery 
anterior abdominal wall pain
 Retroperitoneal organ: organ that lies behind
peritoneal wall pain radiated to the back
 Mechanism of pain

 Visceral pain
 Somatic /parietal pain
 Refered pain
 Visceral pain

 Stretching of nerve fibre of walls or capsules of organ

 Described as CRAMPY,DULL,ACHY,
INTERMITTENT, or POORLY LOCALIZED and
VAGUE pain.
 Unable to lie still
 Bilateral innervation
 Visceral pain is triggered by inflammation, ischemia,
and geometric changes such as distention, traction,
and pressure.
 Parietal pain

 Caused by irritation of fibre innervating the parietal

peritoneum by inflammatory process
 Pain is more sharp and localized
 Described as SHARP, SEVERE, and WELL
LOCALIZED
 Eg: inflamed appendix producing parietal peritoneal
irritation, presented with localized pain to one or
more abdominal quadrant.
 Referred pain

 Pain at he location distant to the diseased organ

based on embryological origin
 Usually ipsilateral to the involved organ
 Referred pain pattern based on embryology
development
 ureter and testis: acute urethral obstruction ass. With
ipsilateral testicular pain
 Biliary tract painrefferred to right inferior scapula area
 Diagpharamatic irritation referred to ipsilateral shoulder.
 Classification
Non specific
Intra- extra
abdominal
abdominal abdominal
pain

GIT cardiopulmonary

Genitourinary Neurological

Gynea Toxic metabolic

Vascular Abdominal wall

 History taking

 Time/mode of onset
 Woken up from sleep

 Abrupt/severe vs gradual

 Gradual onser with slow progression

 Intermittent pain

 Ass with certain activity – eating or exersice

 Duration
 Acugte onset vs chronic onset

 Acute, severe amd worseing pain

 Very long duration, maybe suggest less acute cause

 Location
 Four basic quadrant( RUQ,RLQ,LUQ,LLQ)

 Three central area( epigastric, perumbilical, suprapubic)

 Character/progression
 Severity/magnituted of stimulus

 Intermittent cramping

 Severe and colicky

 Sundden increase

 Sudden change in sensation or location

 Medical history
 Previous surgey

 Menstrual hx

 Tracel

 Medicatins

 Co-morbid
 Contributing factor
 Anorexia

 Nausea/vomiting

 Loose stool

 Bleeding

 Constipation

 Dysuria

 Sob

 Chest pain
 Associated symptoms

 GI
 Diarrhea /vomiting
 Constipation
 Bleeding
 Distension

 Hepatobiliary
 Jaundice
 Fever

 Urological
 Dysuria
 Oliguria/ Anuria

 Gynea
 LMP

 Infection
 Fever
 Malaise
 Physical examination

 To confirm suspicious from the history

 To localized area of disease
 To avoid missing extra abdominal cause of pain
 General appearance: including facial expression ,
diaphoresis, pallor and degree of agitator, to
distinguish the intensity of the pain
 Vital sign
 Inspection: look for distension , ecchymosis, scars,
hernia
 Auscultation: bowel sound, pitch, bruits
 Palpation: feel for guarding, masses, tenderness,
rebound
 Percussion: tympany, liver size
 Labaratory investigation

 FBC
 RP and Electrolytes , amylase, lipase
 UFEME
 ECG
2)IMAGING
-CXR- to detect free air ,
-AXR-to screening for obstruction, sigmoid volvulus,
perforation, or severe constipation
-ULTRASOUND: US examination can visualize the
gallbladder, pancreas, kidneys and ureters, urinary
bladder volume, and aortic dimension
-CT ABDOMEN
 Treatment

1) SYMPTOMATIC RELIEF
 Opioid analgesia relieves pain and will not obscure
abdominal findings, delay diagnosis, or lead to
increased morbidity/mortality.
 Administer antiemetics as needed
 Consider placement of nasogastric and urinary
catheters. Nasogastric aspirate may confirm upper
GI bleeding, and nasogastric suction may be used to
decompress a bowel obstruction. A urinary catheter
will relieve bladder obstruction, and hourly urine
output helps to gauge renal perfusion.
 Haemodynamically unstable

 Manage in critical area/ red zone

 Maintain airways and 02 supplement
 v/s monitoring: BP, sp02
 2 large bore branulla
 IVD

 Blood ix: FBC,DXT,LFT,AMYLASE, BLOOD C+S, UPT

 IV Abx if suspect intraabdominal sepsis( eg iv ceftriaxone 2g

stat, iv metronidazole 500mg)
 Imaging: CXR,AXR,KUB, u/s
 CBD-i/o charting
 NBM
 Refer primary team for consultation
 Hemodynamically stable patient

 Can be manage at semi-critical( yellow zone)

 KNBM
 IV line+ blood investigation
 ECG and other imaging can be done depending on
the symptoms
 Evaluate sign of acute abdomen with frequent
examination.
 Special consideration

1. Women of childbearing age

- Atypical presentation
- In pregnant women with appendicitis may present
RUQ pain as the uterus displaced
- Always consider gynea pathology , ectopic pregnancy
2. Elderly patient
- Low threshold for admission
- May present with unclear history, untypical
complain
- Comorbid
3. Children
- Difficult to localize the pain
- Limited history
Thank you