• ABDOMINAL PAIN
  • CHARACTER OF PAIN
    • PUD: Burning or gnawing pain, epigastric, may radiate to the back.
      • Precipitated by long periods of no food or skipping meals.
      • Often feel pain early in morning, which is relieved by intake of food or antacids.
    • GERD: Burning, epigastric or xiphisternal. Radiates to the retrosternum.
      • Precipitated by over-eating, bending over, or being in a reclined position.
  • LOCATION OF PAIN:
  • RADIATION OF PAIN
    • Renal Colic often radiates to the groin.
    • Gallbladder pain often radiates to back, scapula, or right shoulder.
    • Splenic pain often radiates to back.
    • Pancreatic pain often radiates to back.
  • FACTORS PRECIPITATING AND RELIEVING THE PAIN
  • PATIENT ASSESSMENT OF PAIN SEVERITY: Scale of 0 to 10.
  • COMPARISON WITH OTHER TYPES OF PAIN
• ANOREXIA:
  • Differential diagnosis:
    • Neoplasms
    • Chronic Renal Failure
    • Psychiatric: Anorexia nervosa, depression
    • Infections: Hepatitis, many chronic infections.
  • Polyphagia: Seen in hyperthyroidism, malabsorption syndromes, especially pancreatic insufficiency.
• NAUSEA AND VOMITING:
  • Delayed Gastric Emptying: It is a common cause of nausea. Possible causes of delayed gastric emptying:
    • Pyloric Outlet Obstruction: Ulcers, pyloric stenosis, Crohn's Disease, neoplasms.
    • Neuromuscular: Scleroderma, vagotomy, demyelinating diseases (MS), Polio
    • Metabolic: Diabetic gastroparesis, hypothyroidism.
    • Drugs: Anti-cholinergics, ganglionic blockers, opiates
    • Psychiatric: Anorexia Nervosa
  • Projectile Vomiting: Special vomiting that can signify increased intracranial pressure (ICP).
  • Regurgitation: Vomiting without nasea. Causes:
    • Overeating.
    • Achalasia.
    • Delayed gastric emptying
    • Esophageal rings and webs.
• DYSPHAGIA:
  • Odnyophagia: Painful difficulty swallowing.
  • Common Causes:
    • CVA, stroke
    • Parkinson's
    • Reflux Esophagitis
    • Esophageal rings and webs
    • Achalasia
    • Esophageal Tumors
    • Candidiasis
• DIARRHEA: Excretion of more than 300 g of stool per day.
  • Acute Diarrhea:
    • Infectious Gastroenteritis: Shigella, Salmonella, Campylobacter, invasive E. Coli
      • Symptom Cluster: Fever, myalgia, chills, nausea, vomiting, diarrhea, cramping abdominal pain.
    • Lactose Intolerance
    • Antibiotic-associated (loss of normal flora)
    • Inflammatory bowel
  • Stool Incontinence: Recurrent defecation in pants is not diarrhea and has a very limited differential diagnosis, all relating to anal sphincter dysfunction:
    • Diabetes Mellitus
    • Previous rectal or perirectal surgery.
    • Errant episiotomy from a traumatic childbirth.
  • Chronic diarrhea:
    • Dietary habits (coffee)
    • Parasitic infection: giardiasis, amebiasis.
    • Inflammatory bowel disease
• CONSTIPATION: 2 bowel movements per week is normal in some people.
  • Acute Constipation: Recent change in bowel habits. Causes:
    • Drugs: anticholinergics, psycho-active drugs, many others.
    • Hypothyroidism
    • Hyperparathyroidism
    • Decreased food intake, decreased fluid intake.
    • Chronic debilitating disease (post-stroke).
  • Hirschsprung's Disease: Aganglionic Megacolon
    • Lifelong constipation
    • Ocassional passage of enormous stools
    • Absence or marked dimunition of ganglion cells in rectal tissue
    • Marked colonic distension.
  • Idiopathic Chronic Constipation may be caused by a defect in the pelvis floor in women, in which they contract the anal sphincter, rather than relax it, when defecating.
• HEMATEMESIS
  • Possible Causes:
    • PUD or erosive Gastritis
    • Mallory-Weiss Tear of esophagus
    • Esophageal varices, portal hypertension
• HEMATOCHEZIA and MELENA
  • HEMATOCHEZIA: Occult blood in stool.
    • Possible Causes
    • Colorectal carcinoma
    • Infectious enteritis: Shigella, Salmonella, Campylobacter, invasive E. Coli may all cause hematochezia.
    • Hemorrhoids
    • Chronic diverticular disease
  • MELENA: Passage of black or very dark stool, reflecting heme breakdown products in stool.
    • Other causes of black stool (other than occult blood): Iron-containing drugs, bismuth-containing drugs, charcoal, lots of black cherries.
  • Maroon-Colored Stools are indicative of massive blood loss (2 to 3 units of blood). Usually will see unstable vital signs. Look for complications of PUD, such as perforated ulcer.

INSPECTION:

• PROTUBERANT OR DISTENDED ABDOMEN
  • Partial Bowel Obstruction: Distended abdomen plus peristaltic movements heard over the distension is practically diagnostic.
  • Psuedocyesis, Psudeopregnancy: Woman who wants to be pregnancy develops a distended abdomen psychogenically.
  • Increased air in bowel causing abdominal distension:
    • Mechanical factors, carcinoma or adhesions
    • Adynamic paralytic ileus.
  • Ascites: Most common cause is alcoholic cirrhosis leading to portal hypertension.
    • Fluid Wave: Press down abdomen and create a fluid wave. It is indicative of ascites.
    • Puddle Sign: Have patient lie prone and then get on hands and knees, to get all ascites to go to a dependent position. Then flick and auscultate the abdomen, listening for changes in intensity of sounds. Positive test indicates ascites.
    • Chylous Ascites is milky (lipid) look to transudate, indicating lymphatic blockage. Occurs with intraabdominal lymphomas and Hodgkin's disease.
    • Ascites can be assessed by auscultation by assessing shifting dullness when patient changes position.
• GREY TURNER'S SIGN: Ecchymoses on the abdomen, an unusual place for ecchymoses. It occurs in fulminant acute pancreatitis and carries a grave prognosis.
• JAUNDICE: Most common causes
  • Viral Hepatitis
  • Alcoholic Liver Disease
  • Drug-induced jaundice
  • Chronic active liver disease
  • Choledocolithiasis
  • Pancreatic carcinoma
  • Metastatic liver disease
• ABDOMINAL HERNIAS
  • Anatomical Types of Hernias:
    • Inguinal Hernias: Most common hernia.
      • Direct Inguinal Hernia: Hernia directly penetrates the inguinal triangle. It creates a bulge right above (superior and medial to) the inguinal ligament.
      • Indirect Inguinal Hernia: Hernia passes through the inguinal canal, and creates a bulge in the right over the inguinal ligament, as it passes through the inguinal ring.
        • In men, often herniates into scrotum.
    • Femoral Hernia: Second most common. High risk of strangulation, 20% of cases.
    • Obturator Hernia: Unusual, occuring in elderly, thin, emaciated women. Protrusion of peritoneal sac through Obturator Foramen.
      • Symptom: Pain, paresthesia down anterior thigh, due to compression of femoral nerve.
    • Umbilical Hernia: May occur in people with chronic increased intraabdominal pressure: Multiparous women and COPD.
    • Spigelian Hernia: Occurs between ubilicus and pubic symphysis. Unusual.
  • Reducability:
    • Reducible: The contents of the hernia can be easily displaced.
    • Irreducible, Incarcerated: The contents of the hernia cannot be displaced and are stuck there.
    • Strangulated: An incarcerated hernia that has cut off its blood supply, resulting in tissue necrosis and gangrene.

PERCUSSION:

• Tympany: Increased tympany is heard upon percussion of the abdomen in cases of partial bowel obstruction.
• Normal Liver Span: 10-12 cm in men, 8-11 cm in women.

AUSCULTATION:

• PERISTALTIC SOUNDS:
  • Absent Bowel Sounds: Ileus
  • Increased Bowel Sounds: Gastroenteritis.
  • Borborygmi: High-pitched bowel sounds indicating small bowel obstruction.
• SUCCUSSION SPLASH: Audible presence of increased amount of fluid in stomach.
  • Normal after a large meal.
  • If it occurs after fasting, then it is indicative of pyloric obstruction.
• ABDOMINAL BRUITS: Caused by calcification of aorta, celiac compression, and alcoholic hepatitis.
• PERITONEAL FRICTION RUBS: Hearing a peritoneal friction rub over the liver is indicative of liver metastasis or primary hepatoma.

PALPATION:

• LIVER:
  • Hepatomegaly:
    • Primary or metastatic Hepatoma.
    • Alcoholic liver disease (fatty liver).
    • Severe CHF.
    • Infiltrative diseases of liver like amyloidosis.
    • Myeloproliferative Disorders: CML, Myelofibrosis.
• SPLEEN
  • Splenomegaly:
    • Infections
    • Leukemias
    • Portal hypertension
• GALLBLADDER
  • Courvosier's Law: Gallbladder is palpable in 25% of cases of pancreatic carcinoma, due to painless distension.
  • Murphey's Sign: RUQ pain aggravated by inspiration, indicative of acute cholecystitis.
• KIDNEYS:
  • Enlarged Kidneys: Polycystic Kidney Disease, hypernephroma, renal cysts, hydronephrosis.
  • Ptotic Kidney: Normal-sized kidney displaced inferiorly into abnormal position; pelvic kidney.
• AORTA: Pulsatile mass in midline is suggestive of Aortic Aneurysm.
• MASSES and BOWEL LOOPS
• FEMORAL PULSES and DISTAL AORTA: Decreased or absence femoral pulses can be found in several disorders:
  • Dissecting Aortic Aneurysm
  • Coarctation of Aorta
  • Severe atherosclerotic peripheral vascular disease
  • Leriche's Syndrome: Occlusion of the distal Aorta.
    • Symptom Tetrad: Absent femoral pulses, intermittent claudication, gluteal pain, impotence.
• RECTAL EXAM

ACUTE ABDOMINAL PAIN:

• LOCALIZING PAIN to INTRAABDOMINAL SITES
• INVOLUNTARY GUARDING AND MUSCLE RIGIDITY:
  • Perforated ulcer
  • Perforated bowel
  • Peritonitis
• DIRECT AND INDIRECT TENDERNESS
  • Rebound Tenderness: Tenderness on sudden release of pressure. A reliable sign of peritoneal inflammation.
  • Jar Tenderness: Avoidance of sudden movements due to abdominal pain. Also a sign of peritoneal inflammation.

ABDOMINAL PAIN SYNDROMES:

• ACUTE ABDOMINAL PAIN
  • Differential Diagnosis:
    • Infectious: Appendicitis, cholecystitis, pancreatitis, hepatitis, Gastroenteritis, Diverticulitis.
    • Crohn's Disease
    • Bowel perforation: Peritoneal signs should be present. Patient doesn't want to move.
    • Bowel obstruction: Patient can't stay still and keeps moving around to get comfortable.
    • Colic: Renal or biliary colic.
    • Dissecting Abdominal Aortic Aneurysm.
  • Diabetic Ketoacidosis and other metabolic disorders can simulate an acute abdomen.
• CHRONIC ABDOMINAL PAIN
  • PEPTIC ULCER DISEASE: Gnawing, burning, aching.
    • Pain partially relieved by eating food.
    • Chronicity, Rhythmicity, Periodicity
  • CHOLELITHIASIS and BILIARY COLIC:
    • Paroxysms of sharp colicky RUQ pain, often radiating to back, right mid-abdomen.
    • Intolerance to greasy foods may be found.
    • Ultrasound is usually diagnostic.
  • DELAYED GASTRIC EMPTYING:
    • Often accompanied by nausea, emesis, and early satiety.
    • Pain is worsened by eating.
  • CHRONIC PANCREATITIS:
    • Caused by alcoholism.
    • May be exacerbated by eating
  • PANCREATIC CARCINOMA
    • Weight loss, abdominal pain, anorexia, weakness / fatigue, diarrhea common
    • Pain is variable in quality, and often ameliorated by sitting in knee-chest position.
  • LACTASE DEFICIENCY
  • IRRITABLE BOWEL SYNDROME: Abdominal discomfort with no demonstrable organic cause.
    • Defecation relieves the pain.
• ANTERIOR ABDOMINAL WALL PAIN
  • Neuromas, Herpes Zoster, Hernias.
  • Tightening of abdominal wall should aggravate symptoms, indicating abdominal-wall pain. If tightening of abdominal wall relieved symptoms or were done as a guarding action, then that would be visceral pain.