Abdominal Pain

Abdominal Pain

Definition n

• Pain in the abdomen ranging from acute, life-threatening emergencies to chronic

functional disease and disorders of several organ systems

• Evaluation of acute pain requires rapid assessment of likely causes and early

initiation of appropriate therapy.

• A more detailed and time-consuming approach to diagnosis may be followed in

less-acute situations.  


Symptoms & Signs n

Abdominal origin

• Inflammation of parietal peritoneum: pain characteristics

o Quality: steady and aching

o Location: directly over inflamed area with exact reference possible

o Intensity: dependent on type and amount of material to which peritoneal

surfaces are exposed in a given time period

 Sudden release into peritoneal cavity of small quantity of sterile acid

gastric juice causes much more pain than same amount of grossly

contaminated neutral feces.

 Enzymatically active pancreatic juice causes more pain and

inflammation than same amount of sterile bile containing no potent

enzymes.

 Blood and urine are often so bland they are detected only if contact

with peritoneum is sudden or massive.

 In bacterial contamination (e.g., pelvic inflammatory disease), pain is

frequently of low intensity until bacterial multiplication has caused

elaboration of irritating substances.

o Rate at which irritating material is applied to peritoneum is important.

 Perforated peptic ulcer: clinical picture dependent only on rapidity with

which gastric juice enters peritoneal cavity

o Pain is accentuated by pressure or changes in tension of peritoneum.

 Produced by palpation or movement (e.g., coughing, sneezing)

 Patient with peritonitis lies quietly in bed to avoid painful motion.

 Patient with colic may writhe incessantly.

o Tonic reflex spasm of abdominal musculature

 Localized to involved body segment

 Intensity of spasm is dependent on location and rate of development

of inflammatory process and integrity of nervous system.

 Spasm over perforated retrocecal appendix or perforated ulcer into

lesser peritoneal sac may be minimal or absent because of protective

effect of overlying viscera.

 Slowly developing process often greatly attenuates degree of spasm.

o Obstruction of urinary bladder

 Dull suprapubic pain, usually low in intensity

 Restlessness without specific complaint of pain may be only sign of

distended bladder in obtunded patient.

o Acute obstruction of intravesicular portion of ureter

 Severe suprapubic and flank pain that radiates to penis, scrotum, or

inner aspect of upper thigh

o Obstruction of ureteropelvic junction

 Pain in costovertebral angle

o Obstruction of remainder of ureter

 Flank pain that often extends into same side of abdomen

• Vascular disturbances

o Pain not always sudden or catastrophic

o Embolism or thrombosis of superior mesenteric artery or impending rupture

of abdominal aortic aneurysm

 Pain may be severe and diffuse.

o Occlusion of superior mesenteric artery

 Pain may be mild, continuous, and diffuse for 2 or 3 days before

vascular collapse or findings of peritoneal inflammation appear or may

be severe and diffuse.

 Early, insignificant discomfort is caused by hyperperistalsis rather than

peritoneal inflammation.

 Absence of tenderness and rigidity in presence of continuous, diffuse

pain are characteristic of vascular disease.

o Rupturing abdominal aortic aneurysm

 Abdominal pain with radiation to sacral region, flank, or genitalia

 Pain may persist over several days before rupture and collapse occur.

• Abdominal wall

o Usually constant and aching

o Movement, prolonged standing, and pressure accentuate discomfort and

muscle spasm.

o Hematoma of rectus sheath

 Most frequently with anticoagulant therapy

 Mass may be present in lower quadrants of abdomen.

 Simultaneous involvement of muscles in other parts of body usually

differentiates myositis of abdominal wall from intra-abdominal process

that might cause pain in same region.

Treatment Approach n

• Stabilize patient.

• Ascertain if urgent surgical intervention is required.

o If so, establish venous access for fluid replacement and begin surgery

immediately.

• Provide pain relief.

o Narcotics or analgesics should not be withheld until definitive diagnosis or

definitive plan is formulated.

o Obfuscation of diagnosis by adequate analgesia is unlikely.

• Prescribe empiric antibiotic therapy if intra-abdominal infection suspected.

Abdominal Pain 9

• Provide other symptomatic relief (e.g., antiemetics, antispasmodics).

• Definitive treatment is dependent on etiology of pain.