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1. Abdominal Pain - via Payton (plus some extra old Eric stuff)

Terms in this set (87)

Parietal Peritoneum Pain:
-Describe pain
-Innervation
-Fibers
-Steady/ Constant pain
-Sharp
-Well Localized

-Somatic intercostal nerves

-A-δ fibers
Visceral Peritoneum Pain:
-Describe pain
-Innervation
-Fibers
-Referred Pain
-Intermittent pain
-Cramping/ aching
-Generalized
-Visceral Afferent fibers
-C-Fibers, Autonomic nervous system

Referred Visceral Pain: Dorsal Horn Nuclei→Visceral afferents & somatic cutaneous afferents
Ganglia involved in the GI System
Divisions of the Primitive Tube
Abdominal pain - consider (2)
source of pain
innervation carrying pain fibers
Visceral pain fiber
Afferent nerves of ANS
Unmyelinated C fibers
Unmyelinated C fibers
Slower conduction velocity
Lower density
Unmyelinated C fibers cause which type of pain?
(Visceral peritoneum)
intermittent
dull
cramping
aching
poorly localized
Patient localization of visceral pain
uses hand instead of finger (wider area than parietal pain)
Visceral pain receptor locations in abdomen (general) (3)
serosal surfaces of abdomen
mesentery
walls of hollow viscera
Visceral pain receptors in abdomen activated by chemical factors (4)
subtance P
serotonin
histamine
prostaglandins
Visceral pain receptors in abdomen activated by mechanical factors (5)
stretch
distension
contraction
compression
torsion
Visceral pain is perceived along....
spinal segments where the visceral afferent nerves enter the spinal cord
Most GI pain is perceived in midline, why?
most organs have bilateral visceral innervation
Celiac ganglion nerve(s)
Greater Splanchnic (T5-T8)
Lesser Splanchnic (T9-L1)
Superior Mesenteric ganglion nerve(s)
Least Splanchnic (L1-L2)
Inferior Mesenteric ganglion nerve(s)
Lumbar splanchnic nerve (L2-L5)
Pelvic ganglion nerve(s)
Pelvic nerves (S2-S4)
Referred pain - why?
both visceral afferents and somatic cutaneous afferents synapse on same dorsal horn nuclei
Referred pain transmitted by which pathway to the brain?
spinothalamic (ventrolateral pain)
Referred pain mediated by which fibers?
C fibers
---Not inclusive---Spinal levels and referred pain:
Diaphragm (C3-C5)
Kidney/ureter (T10-T12)
Shoulder (same side as insult)

Unilateral flank pain to groin pain
Parietal peritoneum innervated by
somatic nerves
pain associated with parietal peritoneum localization
exact location
parietal pain signals carried by
A-fibers
Parietal pain description
constant
localized
sharp
Somatic nerves innervating the parietal peritoneum also innervate...
overlying abdominal wall
[Blank]: mild pressure on the skin over the site of parietal inflammation induces pain
hyperesthesia
involuntary guarding
with peritoneal inflammation...tonic reflex spasm of abdominal muscles overlying involved peritoneum
Patient appearance with parietal pain
motionless in bed (changes in tension of peritoneum accentuate pain)
Rebound pain occurs with
parietal inflammation
Abdominal wall pain (muscle spasm, mass, hematoma)
constant
aching
worsened by movement/prolonged standing
Small bowel obstruction pain
intermittnet
poorly localized periumbilical pain
Gallbladder obstruction with sudden distension pain
constant RUQ pain
Abdominal ischemia pain
variable
pain out of proportion to exam
Mesenteric thrombosis pain
constant or intermittnet
poorly localized generalized abdominal pain
Parietal peritoneal inflammatory pain
steady
sharp
aching
(directly over inflamed area)
Intestinal obstruction clinical manifestations
pain
anorexia
bloating
nausea
vomiting (undigested progressing to bilious or feculent)
Intestinal obstruction physical exam findings (maybe) - definitive diagnosis with?
distension
high-pitched or absent bowel sounds
X-ray
CT
Acute peritonitis clinical manifestations
severe abdominal pain
(signs of sepsis:) fever hypotension tachycardia
lying very still
In young children, acute generalized abdominal pain may be a sign of
intussusception
Most metabolic sources of pain produce...
chemical irritation of visceral afferents --> generalized abdominal pain (Example: Diabetic ketoacidosis)
Gastroenteritis
acute-subacute
mild-moderate
nausea
vomiting and/or diarrhea
Acute mesenteric ischemia
acute, severe, persistent pain
History of afib
Chronic Mesenteric Ischemia
Intestinal angina (Self-limited pain after eating)
Weight loss
Eating smaller meals
Small bowel obstruction
Acute, severe persistent pain
Nausea
Emesis (undigested progressing to bilious)
Intussusception
Acute, intermittent, severe progressive pain at 15-30 minute intervals
Anorexia
Nausea
Vomiting (undigested progressing to bilious)
Spontaneous bacterial peritonitis
Acute-subacute
Moderate-severe pain
History of cirrhosis of risk factors for cirrhosis
Diabetic Ketoacidosis
Pain/tenderness that change locations/intensity
History of DM/hyperglycemia
Ruptured aortic aneurysm
Abdominal or back pain
Hypotension
Pulsatile abdominal mass
Irritable bowel syndrome
Chronic, mild-mod pain worse with food/stress, relieved with defecation
Acute onset diarrhea and/or constipation
Constipation
Chronic, intermittent mild-mod pain
Fecal impaction - acute, severe pain and anorexia
Chronic history of decreased stool frequency and hard stools
Acute epigastric pain typically related to (3)
Perforated ulcer diseases
Gastritis
Pancreatitis
Peptic Ulcer Disease
Subacute-chronic
Mild-mod pain relieved OR worsened by eating
Perforation - acute exacerbation/guarding
Gastroesophageal reflux disease
Chronic, mild-mod pain worse with eating/lying down
Regurgitation (sour taste in back of mouth) and heartburn
Gastritis
Acute-chronic, mild-mod pain worse with eating and lying down
Ingestion of aspirin, NSAIDs, and/or alcohol
Gastroparesis
Chronic, insideous postprandial fullness, improved with eating smaller meals
Vomiting
Weight loss
Acute pancreatitis
Acute, sudden knife-like epigastric pain radiating to the back
Nausea
Vomiting
Anorexia
Myocardial infarction
Sudden onset of mod-severe pain often after exertion
Dyspnea
Ruptured aortic aneurysm
Abdominal or back pain
Hypotension
Pulsatile abdominal mass
Diagnostic testing for epigastric abdominal pain targeted at...
pancreatitis (Serum lipase)
peptic ulcer disease (Endoscopy if alarm symptoms present)
MCC RUQ pain
Biliary colic --> cholecystitis or cholangitis
Biliary colic
Intermittent, acute pain provoked by eating
Lasts 1-2 hours
Cholecystitis
Acute, severe pain provoked by eating
Lasts >4-6 hours
Mild fever
Anorexia
Nausea
Vomiting
Cholangitis
Acute, severe pain provoked by eating
Lasting > 4-6 hours
Mod-high fever
Jaundice
Acute hepatitis
Subacute onset mild-mod pain
Fever
Malaise
Anorexia
History: heavy alcohol consumption, hepatitis virus exposure
PUD
Subacute-chronic
Mild-mod pain relieved or worsened by eating
Perforation: acute exacerbation
Urolithiasis
Acute, severe, spastic pain that radiates to groin or testicle
Anorexia
Nausea
Vomiting
Pyelonephritis
Poorly localized pain with CVA tenderness
Dysuria
Urinary frequency
(Possibly) Nausea/vomiting
Initial eval of RUQ pain
AST
ALT
Alk phos
Bilirubin
(followed by US)
Acute LUQ pain - be sure to consider...
splenic infarction
splenic rupture
Causes of splenic infarction (3)
Embolic disease
Vasculitis
Sickle cell disease
Splenic rupture is usually the result of...
Sepsis (can occur with enlargement from infectious mononucleosis)
Causes of referred pain to upper abdomen (consider in cases of LUQ pain) (4)
Pneumonia
Pleural inflammation
Urolithiasis
Pyelonephritis
RLQ pain - always consider...
appendicitis (surgical eval)
Mimics of acute appendicitis pain (6)
Ileitis
PID
Ruptured ectopic pregnancy
Ovarian torsion
Ruptured ovarian cyst
Urolithiasis
Acute appendicitis
Acute periumbilical pain that becomes localized to RLQ over 1-2 days
Fever
Nausea
Vomiting
Crohn's Disease
Subacute-chronic, intermittnet abdominal pain
Weight loss
Diarrhea
Urolithiasis
Acute, severe, spastic pain that radiates to gorin or testicle
Anorexia
Nausea
Vomiting
Pelvic Inflammatory Disease (PID)
Acute-subacute onset of poorly localized pain
Fever
Purulent servical discharge
Ovarian torsion
Acute onset mod-severe pain
Nausea
Adnexal mass on exam
Ruptured ovarian cyst
Acute onset of sharp, focal, mod-severe pain during strenuous activity
Women of reproductive age
Ruptured ectopic pregnancy
Acute, sudden onset severe pain
Missed menstrual period
1st trimester vaginal bleeding
MCC Acute RLQ pain in older adult + others (8)
Diverticulitis
Bowel obstruction
Fecal impaction
Urolithiasis
PID
Ruptured ectopic pregnancy
Ovarian torsion
Ruptured ovarian cyst
Diverticulitis
Acute-subacute constant pain
Fever
Anorexia
Constipation or diarrhea
Ucerative colitis
Subacute-chronic, intermittent abdominal pain
Frequent, small, bloody bowel movements
Ovarian torsion
Acute onset of mod-severe pain
Nausea
Adnexal mass on exam
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