Approach To A Patient With Pain Abdomen

APPROACH TO A Presenter:- Dr.
Gaurav
PATIENT WITH PAIN Juneja
ABDOMEN
INTRODUCTION
Abdominal pain is one of the most common complaints of
patients admitted to emergency units, accounting for
approximately 4-5% of emergency department visits.
Recent studies show that self-referrals due to abdominal
pain, as well as primary care physician referrals to emergency
departments, have increased, imposing heavy burdens on
emergency surgical care providers.
Abdominal pain typically derived from one or more of three
distinct pain pathways:
1. Visceral
2. Parietal (somatic)
Recognition of surgical or life-threatening causes is more
important for us in the emergency department.
3
TYPES OF ABDOMINAL PAIN
Visceral pain Parietal pain
Poorly localized Precisely localized

Dull Intense
Gnawing or burning Aggravated by movement
secondary autonomic
symptoms: sweating/ nausea
REFERRED PAIN
Pain felt at a distance from the diseased organ.
Shared central pathways for afferent neurons from different locations
1. Pneumonia may present with abdominal pain (T9 distribution of

neurons is shared by the lung and abdomen)
2. Epigastric pain associated with myocardial infarction (MI)
3. Shoulder pain associated with diaphragmatic irritation (e.g., ruptured
spleen)
4. Right infra scapular pain associated with biliary disease
5. Testicular pain associated with acute ureteral obstruction.
HISTORY
HISTORY -APPROACH-PQRST-A
1. Presentation, Progression, Precipitating factors, Palliative
2. Quality
3. Radiation, Relieving factors
4. Site, Severity
5. Treatment taken
6. Associated symptoms
Recognizing "red flags" (warning signs and symptoms) from

the history and physical examination is important for the
emergency physician.
ONSET
1. The pain of acute appendicitis starts in the early morning.
2. Sudden pain due to perforation of a peptic ulcer usually
takes place in the afternoon.
3. ln acute intestinal obstruction the pain may not be severe
at the onset but gradually increases in intensity.
SITE OF PAIN
It usually coincides with the position of the affected organ.
The patient is asked to indicate the site of pain with tip of one
finger (Pointing test).
pain is at the flank - renal origin is considered.
When it is below the right costal margin liver or gallbladder
disease is suspected.
If it is in the epigastric region, peptic ulcer perforation, acute
pancreatitis, etc. are considered
SITE OF PAIN
Location organ
Epigastrium - Liver, stomach, duodenal, GB, CBD
Periumbilical - Jejunum, ileum, cecum
Suprapubic - Large bowel, OB-GYN, KUB
Diaphragmatic irritation - shoulder pain
Change in location >> marker of progression? E.g.

appendicitis or perforated ulcer
INTENSITY OF PAIN
CHARACTER OF PAIN
(i) Colicky pain.- is a sharp intermittent griping pain which comes on
suddenly and disappears suddenly. ft indicates obstruction to a hollow
organ - either bowel obstruction (intestinal colic) or obstruction of the
common bile duct with a stone (biliary colic) or obstruction of the renal
pelvis or ureter with a stone (renal or ureteric colic).
(ii) Constant burning pain is a feature of peritonitis and often seen in
perforated peptic ulcer.
(iii) Severe agonizing pain is very much characteristic of acute pancreatitis
or of torsion.
(iv) Throbbing pain is suggestive of inflammation, e.g. hepatitis or
cholecystitis.
CHARACTER OF PAIN
Colicky pain of acute intestinal obstruction may change into constant
burning type which indicates strangulation.
In acute appendicitis it may indicate perforation of an obstructive

gangrenous appendix.
In peptic perforation, pain diminishes in intensity although the disease is

continuing. This is due to the fact that the peritoneal exudate dilutes the
irritant gastric content.
RADIATION OF PAIN
Esophagus  middle of back.
Stomach, duodenum  back
GB, CBD  scapular
• Liver  shoulder
AGGRAVATING AND
ALLEVIATING FACTORS
Peritonitis  Lie motionless.
Renal colic  unable to find comfortable position.
Fatty food  worsen biliary colic.
Pain improve with eating  DU.
Pain worsen with eating  GU, mesenteric ischemia.
ASSOCIATED SYMPTOMS
1. Dysuria
1. Nausea
2. Frequency
2. Vomiting
3. Urgency
3. Anorexia
4. Haematuria.
4. Constipation 5. Vaginal discharge or
5. Diarrhea bleeding, Dyspareunia
6. Bleeding. 6. Previous gynecologic

history
7. including surgeries
8. Previous pregnancies
Infections
PAIN – OTHER CAUSES
1. Colicky/Surgical- Intestinal / biliary/ureteric
2. Inflammatory- Peritonitis/IBD.
3. Ischaemic- Mesenteric angina, Renal or splenic

infarcts.
4. Metabolic- DKA
5. Haematological- Sickle Cell Crisis

PHYSICAL PER ABDOMEN
EXAMINATION EXMN.
EXAMINATION OF ORAL
CAVITY
1. Lips
2. Teeth
3. Gum
4. Cheeks
5. Tongue
6. Tonsils
7. Palate
8. Floor of mouth
General rules-
1.) Always extend the
legs of the patient.
2.) Cough impulse/venous
prominence- standing
position
3.) Respiratory
movements/pulsation/perist
alsis -tangential
INSPECTION-ABDOMEN
Shape of abdomen – flat/protuberant
Flanks- full or not.
Venous prominence- ask the patient to cough.
Movement of the Abdomen- respiratory movements/pulsation/peristalsis

Umbilicus – position / midway b/w xiphisternum and symphysis pubis or not
Hernial sites – Inguinal/Femoral/Umbilical/Epigastric/Incisional.
Groin and Genitalia.
Back.
INSPECTION-ABDOMEN
Visible peristalsis- left to right – pyloric stenosis.
SIGNS OF
HERNIAL
HEMOPERIT
SITES
ONEUM
Look for any

ulcer/striae/fistula/sinus/stoma/pigmentation/scar/nodules
around umbilicus .
PALPAT Divided into superficial and deep palpation.
ION Preferable to examine painful area in the last
SUPERFICIAL-PALPATION
Temperature.
Tenderness.
Oedema?
Consistency- normal (elastic feel)/guarding or rigidity.
Localised Lump.
Divarication of recti – widely separated two rectus muscles
Pulsation.
Cough impulse.
Fluid thrill/Abdominal Girth.
DEEP PALPATION
LIVER.
SPLEEN.
KIDNEYS.
Any lump or mass.
Rebound tenderness / deep tender spots-
Hernial orifices , Genitalia and Groin examination.
Urinary Bladder.
ALWAYS PERFORM P/R EXAMINATION

TENDER SPOTS
REBOUND TENDERNESS Mcburneys point
First give firm pressure
NORMAL PERISTALTIC
SOUND
Produced by movement of feces, fluid and flatus in bowel lumenb
as a result peristalsis.
Stethoscope-1min-right of umbilicus-Normal BS are intermittent (at

a 5-10 second interval)
Mechanical Obstruction- Exaggerated BS with frequent loud low

pitched gurgles.
Paralytic Ileus and Peritonitis- silent abdomen(4 minute minimum).
PPROACH TO ACUTE ABDOMINAL
AIN: PRACTICAL ALGORITHMS

Approach To A Patient With Pain Abdomen

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APPROACH TO A Presenter:- Dr.

Poorly localized Precisely localized

1. Pneumonia may present with abdominal pain (T9 distribution of

Recognizing "red flags" (warning signs and symptoms) from

Change in location >> marker of progression? E.g.

In acute appendicitis it may indicate perforation of an obstructive

In peptic perforation, pain diminishes in intensity although the disease is

Stomach, duodenum  back

GB, CBD  scapular

6. Bleeding. 6. Previous gynecologic

1. Colicky/Surgical- Intestinal / biliary/ureteric

3. Ischaemic- Mesenteric angina, Renal or splenic

5. Haematological- Sickle Cell Crisis

1.) Always extend the

legs of the patient.

2.) Cough impulse/venous

Movement of the Abdomen- respiratory movements/pulsation/peristalsis

Look for any

ALWAYS PERFORM P/R EXAMINATION

Stethoscope-1min-right of umbilicus-Normal BS are intermittent (at

Mechanical Obstruction- Exaggerated BS with frequent loud low

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