1B abdominal pain Flashcards by angie qiao

What symptom do most intra-abdominal diseases present with alone?

Pain- so a careful history is never wasted

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What are the 2 most significant properties of the pain?

Site
Character
If you know these you have a good chance of making the correct diagnosis

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What framework do we use to ask patients about pain?

SOCRATES

Site- where is it?
Onset- has it come on suddenly or gradually?
Character- what is the pain like? Is it burning? Colicky (sharp, localised)? Aching?
Radiation- where does it go to?
Association- is it associated with vomiting? Fever?
Time course- have they had that pain before?
Exacerbating or relieving factors- what makes it better? What makes it worse?
Severity- how bad is it e.g. /10?

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What are the 2 main ways of marking surface anatomy for site of pain?

Abdominopelvic regions
Abdominopelvic quadrants

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What organs is each region responsible for?

There is a big crossover between the 2 regions- a lot of people say they have biliary-colic pain but its epigastric. If not sure, endoscopy is good to check.

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What are the vertical and horizontal lines passing through?

Umbilicus

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What organ structures are found at the transpyloric plane?

L1
- Pylorus of stomach
- Neck of pancreas
- Fundus of gallbladder
- Renal hilum of left kidney (right kidney is pushed down a bit by liver)
- Duodenojejunal flexure
- End of spinal cord in adult

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What organ structures are found at the subcostal plane and supracristal plane respectively?

Subcostal plane- L3

Origin of inferior mesenteric artery

Supracristal plane- L4

Bifurcation of the aorta

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What is the foregut made of?

Distal oesophagus → proximal half of 2nd part of duodenum

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What innervates the pain in the foregut?

T5-T9

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What pain is the foregut the site of?

Epigastrium

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What is the midgut made of?

Distal half of 2nd part of duodenum → proximal 2/3 of transverse colon

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What innervates the pain in the midgut?

T10 and T11

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What pain is the midgut the site of?

Umbilical

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What is the hindgut made of?

Distal 1/3 of transverse colon → rectum

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What innervates the pain in the hindgut?

L1 and L2

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What pain is the hindgut the site of?

Hypogastrium

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Describe the blood supply of the abdomen

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What is the parietal peritoneum?

Covering of abdominal wall anteriorly + covering of abdominal cavity posteriorly

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What is visceral peritoneum?

Peritoneum covering organs
Liver peritoneum, colon peritoneum

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What is special about the pancreas and duodenum?

They’re both retroperitoneal structures (not acc inside abdomen)

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What nerves supply the parietal peritoneum?

Phrenic nerves that supply sensation from central tendon to diaphragm → C3, C4, C5

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What’s special about the parietal peritoneum nerve supply?

Study These Flashcards

C3 and 5 also innervate right shoulder so patients can present with right shoulder pain when something’s going on under their diaphragm

Segmental innervation from T5 to L2 (umbilicus supplied by T10)

What nerves supply the visceral peritoneum?

Study These Flashcards

Parasympathetic supply from vagus nerve
Parasympathetic supply from S2-4
Sympathetic chain goes T1-12 and L1-2

What nerve plexuses are there?

- Coeliac plexus - Superior mesenteric plexus - Inferior mesenteric plexus

What are the two main categories for character of pain?

- Inflammation - Obstruction of a muscular tube

What kind of pain does inflammation cause?

- Constant ‘aching’ pain - Made worse by movement - Persists until inflammation subsides

What kind of pain does obstruction of a muscular tube cause?

- Colicky ‘gripping’ pain - Fluctuates in severity - Patient moves to try and get comfortable

What happens if colicky has changed and has become a constant stretching pain?

- There has been prolonged obstruction of a hollow viscus that has caused distension - This is different from ache of inflammation and isn’t colicky - There may be impending **ischaemia**

What character of pain do you find in the ureter?

Colicky

What character of pain do you find in the liver?

Constant e.g. could be hepatitis or liver abscess

What character of pain do you find in the biliary-colic?

Colicky e.g. stone trying to get through duct like bile duct

What character of pain do you find in the spleen?

Constant e.g. splenic abscess or rupture

What character of pain do you find in the kidney?

Constant e.g. pyelonephritis or abscess

What character of pain do you find in the small or large bowel?

Colicky

Describe this graph of colicky pain

- Ureteric colic is defo colic- comes in waves- pain intensity gets high then drops - Intestinal colic is still colic but less painful than ureteric - Biliary colic doesn’t have to be true colic as it gets to a high intensity but then fluctuates at that high level

Where does gallbladder (right hypochondriac region) pain radiate?

Through to the back and right- this happens in 50% of cases

Where does stomach, duodenum, pancreas (epigastrium) pain radiate?

- Straight through to back- especially because pancreas and duodenum are retroperitoneal - People with pancreatic cancer present with back pain because tumour infiltrates posteriorly

What position do pancreatic cancer patients feel better in?

Sitting up and leaning forward, because abdominal viscera aren’t pushing against pancreas

Where does tail of pancreas (left hypochondriac region) pain radiate?

Through to the back and the left

Where does right kidney (right lumbar region) pain radiate?

In loin and radiates to groin (following ureter)

Where does small bowel, caecum, retroperitoneal structures (umbilical region) pain radiate?

Doesn’t normally radiate because it’s visceral

Where does left kidney (left lumbar region) pain radiate?

In loin and radiates to groin

What can people with AAA present regarding left kidney pain?

They can describe left ureteric colicky pain

Where do the lower zone organs (appendix and caecum, bladder, transverse colon, uterus, adnexae, sigmoid colon) pain radiate?

- Lower abdominal pain rarely radiates - Pain from structures deep in pelvis is referred to lower back/perineum

What is the diagnosis for the following case: **S →** Central then shifts to right iliac region **O →** Gradual **C →** Constant **R** → No radiation **A →** Nausea, anorexia, fever **T** → No previous pain **E** → Worse on movement **S** → Dull ache

Appendicitis

What is important to know about the location of the appendix?

It can be **retrocaecal** (64% of the time) and **pelvic** (32%) which means if we examine their abdomen and press it you won’t feel the appendix- when it’s pelvic they won’t even have abdominal pain

What is the diagnosis for the following case: **S →** Central **O →** Gradual **C →** Colicky **R** → No radiation **A →** Vomiting, bowels not open **T** → Previous colicky pain **E** → Passing flatus relieves pain **S** → Moderate?

Bowel obstruction (causing intestinal colic)

What is the commonest cause of small bowel obstructions?

Adhesions → if you have an operation you get a scar on anterior abdominal wall but some patients get scarring on inside as well (adhesions) which are fibrous bands

When can adhesions be very bad?

When, just like in right pic, it wraps around and causes a closed loop obstruction (nothing can get in or out) That part of bowel becomes ischaemic quickly and can explode

How are band adhesions treated?

These band adhesions can twist around bowel and obstruct it- can be solved by putting NG tube down and decompress it and it’ll untwist and it’s fine Can do surgery and cut band with pair of scissors

What is the diagnosis for the following case: **S →** Loin **O →** Sudden onset **C →** Colicky **R** → To groin **A →** Vomiting **T** → Previous colicky pain **E** → Cannot find a comfortable position **S** → Severe 10/10

Right uteric colic

What is the diagnosis for the following case: **S →** Right upper quadrant **O →** Sudden onset **C →** Colicky **R** → To right shoulder **A →** Nausea, indigestion **T** → After eating **E** → Fatty foods **S** → Can be severe 10/10?

Biliary colic (a stone trying to get through something- colicky muscular pain)

How is cholelithiasis different to biliary colic?

- Stone gets caught in cystic duct - Bile can’t get in and out - Lining of gallbladder keeps producing mucus which has nowhere to go and becomes infected - Sometimes it can get out as pus - Causes localised pain, not radiating- has Murphy’s sign

What is mesenteric adenitis?

- Can be mistaken for acute appendicitis - You have inflammatory process with bowel and you get **reactive lymph nodes** that cause pain - Could be caused by transient viral infection

What is Meckel’s diverticulitis?

- Outpouching of small bowel that causes inflammation - Can contain ectopic pancreatic or gastric tissue - Very non-specific and rare

1B abdominal pain Flashcards

(56 cards)