simpo 5 - nonsurgical approach of abdominal pain - dr putut sppd

Non Surgical Approach of Abdominal Pain

dr. Putut Bayupurnama, Sp.PD-KGEHDiv. Gastroenterology & Hepatology Bag/SMF Ilmu Penyakit Dalam RSUP Dr Sardjito/FK-UGM

Simposium 5

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Non Surgical Approach of Abdominal PainPutut Bayupurnama

Div. Gastroenterology & Hepatology

Bag/SMF Ilmu Penyakit Dalam

RSUP Dr Sardjito/FK-UGM,

Yogyakarta


Introduction

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Abdominal pain

• a complaint seen commonly in

the outpatient setting

• may often be a symptom of a disease process with a benign course

• it may also herald a severe, life-threatening condition

• demands prompt recognition and management

• general understanding of abdominal anatomy, physiology, and pathophysiology is vital


The abdominal organs


Three Types of Abdominal Pain

1. Visceral

• Autonomic nerves

• Poorly localized

• Dull ache, colicky

• Location is often midline

• Felt in the abdominal wall in the area of embryonic origin of the pain


Cont…

2. Somatic

• Typically sharp

• well localized

• Irritation of the parietal peritoneum

• parietal innervation is unilateral

• Felt directly over area of inflammation


Cont…

3. Referred pain

• felt in cutaneous site distant from diseased organ

• visceral afferents carrying stimuli from a diseased organ enter the spinal cord at the same level as somatic afferents

• typically well localized

• Awareness of the anatomy and innervation of the abdominal viscera allows one to formulate a differential diagnosis of abdominal pain based on the location and distribution of the pain


History

• Where is your pain? Has it always been there?

• Does the pain radiate anywhere?

• How did the pain begin (sudden vs. gradual onset)? How long have you had the pain?

• What does the pain feel like?

• On a scale of 0–10, how severe is the pain?

• Does anything make the pain better or worse?

• Have you had the pain before?


History cont…

• Although location of abdominal pain guides the initial evaluation, associated signs and symptoms can help narrow the differential diagnosis

• change in bowel habit, blood loss per rectum

• Presence of nausea/vomiting, fullness, bloating, belching, early satiety, are signs of an upper GI cause (dyspeptic symptoms)

• Respiratory symptoms point to basal pneumonia causing diaphragmatic irritation

• Dysuria or haematuria indicates a renal cause


Physical Examination

• General appearance

• patient with peritonitis often lies completely

• a patient with renal colic may writhe in pain

• Vital Signs

• Abdomen

• Inspection

• Auscultation

• Percussion

• Palpation


Differential Diagnosis Abdominal Pain based on

Region


The position of abdominal pain usedabdomen region


Peptic Ulcer

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Experimental pain in the stomachDrewes AM et al. Gut 1997;41-753-757


Differential Diagnosis: RUQ pain


Differential Diagnosis: LUQ and Epigastric pain


Differential Diagnosis: RLQ Pain


Gynecologic Causes of RLQ Pain


Differential Diagnosis: LLQ


Differential Diagnosis: Periumbilical


Pain Patterns of

Abdominal Disease

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009Substernal Epigastric

Onset Chronic Acute Acute Acute

Disease / diagnosis

Refluks esofagitis

Perforated duodenal ulcer

Cholecystitis Pancreatitis

Pain quality Burning; after meal / at night

Severe, ± history of chronic ulcerpain

Steady / biliary colic

Steady

Pain referral Left arm ± back Tip of scapula Back

Pain progression

Upper chest Rapid, over entire abdomen

Intensity increases steady over hours to RUQ

± peritoneal sign

Associated finding

Guarding ; free peritonel air

Fever, gall stone,

Nausea,vomiting


Epigastric

Onset chronic chronic chronic

Disease / diagnosis

Duodenal ulcer Gastric ulcer Non ulcer dyspepsia

Pain quality Gnawing, burning before meals/ at night

Gnawing, worsened by food

Same as duodenal ulcer, ± bloating

Pain referral ± Back Occasionally to the back

None

Pain progression

None None None

Associated finding

Temporary relief with food or antacids

± relief by antacids

± relief with food or antacid


Periumbilical

Onset Acute Acute Acute Chronic Chronic

Disease / diagnosis

Appendici-tis

Small bowel obstruction

Intestinal infarction

Inflammatory bowel disease

Intestinalangina

Pain quality

Cramping, steady

Cramping Severe, aching, diffuse

Cramping, achingin LQ

Colickly, aching, diffuse

Pain referral

± Back or groin

Back None None None

Pain progression

Localization to RLQ

None If Tx is delayed, peritonitis

None Pain relief 1-2 hour

Associated finding

Referredpercusion tenderness to RLQ

Peristaltic >, nausea, vomite, delated bowel

Unimpressive, occult blood stool,peristaltic -

Diarrhea, blood+pus stool, urgency,tenesmus

Weight loss


Lower Quadrant

Onset Acute Acute Chronic Chronic

Disease / diagnosis

Diverticulitis Colon obstruction

Dissecting aortic aneurysm

Irritable bowel syndrome

Pain quality Steady, aching, LLQ

Crampy Sudden, severe, tearing, peri umbilical

Cramping, steady or itermittent

Pain referral Back Back Flank, inguinal region

None

Pain progression

None None None None

Associated finding

Palpableinflamatory mass, fever, constipation, leucocytosis

Vomiting, constipation, distention, peristaltic >

Shock, abdominal bruit, abdomnal mass

Cosntipation, diarrhea, bloating


Diagnostic Tools :

• Laboratory tests

• Transabdominal Ultrasonography

• Endoscopy : Upper, Lower, and Enteroscopy

• Endoscopic Ultrasonography

• CT-Scan, MRCP

• ERCP : Diagnostic and Therapeutic


Abdominal pain management :

• Dyspeptic Symptoms :

• Proton pump inhibitor

• Pro kinetic

• Antidepressant

• Non-dyspeptic symptoms :

• based on etiology


Abdominal pain should be referred :

• No improvement after empiric treatment

• Abdominal pain with emergency :

• Acute appendicitis

• Acute pancreatitis (lipase > 3 times normal value)

• Ileus

• Peritonitis

• Decreased body weight, GI tract bleeding, chronic diarrhea


Take Home Message

• Abdominal pain typically, but not always, has characteristic locations : right upper, right lower, epigastric, periumbilical, left upper, left lower, and diffuse

• The location of pain is a useful starting point and will guide further evaluation

• Performing a thorough history and physical evaluation will allow the practitioner to generate a differential diagnosis that will guide further laboratory, imaging, and management decisions


Terima Kasih

simpo 5 - nonsurgical approach of abdominal pain - dr putut sppd

Documents

fk ugm

location of abdominal

abdominal wall

abdominal viscera

types of abdominal pain1

localized irritation

localized awareness

colicky location