Snapshots in Gastroenterology S Devaji Rao
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Acute Abdominal PainChapter 1

 
Introduction
Abdominal pain is the most common symptom of the pathologies of the gastrointestinal tract. The pain can occur in any part of the abdomen, but for convenience, it can be divided into upper abdominal and lower abdominal.
The main visceral pain receptors in the abdomen respond to mechanical and chemical stimuli.
  • Mechanical stimuli: Stretch, distension, contraction, compression and torsion.
  • Chemical stimuli: Bradykinin, substance P, serotonin and prostaglandins. These receptors are located on the serosal surfaces, within the mesentery and within the walls of hollow viscera.
  • Gut related visceral pain is usually perceived in the midline because it is a midline structure in an embryo and has bilateral symmetric innervations, except for pains originating from the gallbladder and the ascending and descending colon. Pain from other intra-abdominal organs tends to be unilateral.
    1. Pain at epigastrium—Diseases of the foregut (abdominal esophagus, stomach and proximal half of second part of duodenum and their offshoots like liver, gallbladder, pancreas and spleen) (e.g. gastric and duodenal ulcers).
    2. Pain at the umbilical regionDiseases of midgut (distal half of second part of duodenum, small bowel, colon up to the proximal 2/3 of transverse colon) (e.g. intestinal tuberculosis).2
    3. Pain at the hypogastriumDiseases of hindgut (distal 1/3 of transverse colon to the anorectal junction) (e.g. colorectal pathologies).
  • The perception of visceral pain corresponds to the spinal segments where the visceral afferent nerve fibers enter the spinal cord. Table 1.1 shows some common spinal segments where visceral pain is perceived.
  • The abdominal pain has particular pattern and has regional localization. The abdomen is divided into ten arbitrary regions for convenience of understanding and localization (Fig. 1.1).
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Fig. 1.1: Regions of abdomen: 1. Right hypochondrium, 2. Epigastrium, 3. Left hypochondrium, 4. Right lumbar, 5. Umbilical, 6. Left lumbar, 7. Right iliac fossa, 8. Hypogastrium, 9. Left iliac fossa, 10. External genitalia
Table 1.1   Visceral pain and dermatomal perceptions
Organ of pathology
Site of pain
Dermatome
Stomach
Epigastrium
T5–T10
Small bowel
Umbilicus
T9–T10
Large bowel proximal to splenic flexure
Umbilicus
T11–L1
Large bowel distal to splenic flexure
Hypogastrium
L1–L2
Gallbladder
Epigastrium, right scapular region
T7–T9
Pancreas
Epigastrium
T6–T10
3
 
ACUTE UPPER ABDOMINAL PAIN
 
Definition
Severe pain in the upper part of the abdomen.
 
Diagnosis
While evaluating the upper abdominal pain, it is necessary to keep some pathologies in mind (Table 1.2).
 
Symptoms
  1. Nature of pain
    • Continuous (e.g. acute pancreatitis)
    • Episodic (e.g. acute hyperacidity)
    • Colicky (e.g. biliary colic).
  2. Location of pain
    • Epigastric pain (e.g. acute hyperacidity, acute pancreatitis)
    • Left hypochondrial pain (e.g. acute hyperacidity, left renal colic)
    • Right hypochondrial pain (e.g. acute cholecystitis, acute hepatitis).
      Table 1.2   Acute upper abdominal pain and related pathologies
      Right upper quadrant pain
      Epigastric pain
      Left upper quadrant pain
      Acute cholecystitis
      Acute hyperacidity
      Acute pancreatitis
      Acute cholangitis
      Acute pancreatitis
      Acute hyperacidity
      Acute hepatitis
      Perforated duodenal ulcer
      Splenic infarct
      Acute hyperacidity
      Acute hepatitis (left lobe)
      Perforated duodenal ulcer
      4
  3. Association of vomiting
    • Presence of vomiting is not a very reliable symptom to narrow down the diagnosis, as it can be present with any severe painful pathology in the upper abdomen.
  4. Association of fever
    • Fever indicates infective pathology (e.g. acute cholecystitis, acute pancreatitis, acute colitis, perforated duodenal ulcer).
  5. Association of jaundice
    • Jaundice may be present with acute cholangitis, acute hepatitis or acute cholecystitis.
  6. Association of loose stools
    Association of loose stools may indicate colitis or rarely acute pancreatitis.
  7. Radiation
    Radiation to right scapula or shoulder is common with acute cholecystitis, perforated duodenal ulcer due to irritation of diaphragm.
  8. Aggravating factors
    • Food—in acute hyperacidity
    • Lying supine—in acute pancreatitis
    • Deep breathing—in acute cholecystitis.
  9. Relieving factors
    • Leaning forward while sitting—acute pancreatitis.
  10. Referred pain
    In some pathologies, the pathology and the area of the pain are different, since both of them share the same nerve supply. (Fig. 1.2) (Table 1.1).
 
Past History
  • History of pain (e.g. acute on chronic cholecystitis)5
    zoom view
    Fig. 1.2: Referred pain
  • Previous surgery (e.g. cholecystectomy will rule out cholecystitis from consideration).6
 
Family History
  • Gallstones.
 
Signs
 
General
  • Breath for fetor (e.g. alcoholic hepatitis, acute pancreatitis)
  • Conjunctiva for anemia, jaundice
  • Tongue for anemia
  • Neck for lymphadenopathy
  • Hands for signs of liver failure (e.g. clubbing, palmar erythema, liver flap, etc.).
 
Abdomen
  • Inspection
    Distension
    • Generalized (e.g. perforated duodenal ulcer or gallbladder with peritonitis)
    • Right upper abdominal (e.g. hepatomegaly)
    • Epigastric (e.g. left lobar hepatomegaly, carcinoma stomach)
    • Left upper abdominal (e.g. splenomegaly).
  • Palpation
    Tenderness
    • All quadrants—generalized peritonitis
    • Right upper quadrant (e.g. acute hepatitis, acute cholecystitis, acute hyperacidity)
    • Epigastric (e.g. acute gastritis, acute hepatitis)
    • Left upper quadrant (e.g. acute gastritis, acute pancreatitis).7
      Lump
    • Right upper quadrant (e.g. hepatomegaly, distended gallbladder)
    • Epigastric (e.g. carcinoma stomach, left lobar hepatomegaly)
    • Left upper quadrant (e.g. carcinoma stomach, splenomegaly).
  • Percussion
    Percuss the liver for:
    • Its enlargement (e.g. acute hepatitis)
    • Obliteration of liver dullness (e.g. perforated duodenal ulcer).
  • Auscultation
    • Absence of bowel sounds indicates paralytic ileus (e.g. perforated peritonitis).
    • Normal bowel sounds indicate that there is no gross infection of the peritoneum.
 
Differential Diagnosis of Acute Upper Abdominal Pain of GI Etiologies
  • Right hypochondrial pain
    • Without fever and but local tenderness (e.g. acute cholecystitis, acute hepatitis, acute hyperacidity).
    • With fever and local tenderness
      • ± distension (e.g. acute cholecystitis)
      • Obliteration of liver dullness (e.g. perforated duodenal ulcer)
      • ± hepatomegaly (e.g. acute liver abscess).
    • With vomiting and
      • Local tenderness (e.g. acute cholecystitis, acute hyperacidity)
      • Local tenderness with obliteration of liver dullness (e.g. perforated duodenal ulcer).8
    • With diarrhea and local tenderness (e.g. acute colitis).
    • With jaundice and
      • Local tenderness ± hepatomegaly (e.g. acute hepatitis, acute cholecystitis, choledocholithiasis, cholangitis, acute liver abscess)
      • Local tenderness, fever, +/- abdominal lump (e.g. mucocele gallbladder, choledochal cyst)
    • Colicky in nature +/- local tenderness (e.g. biliary colic).
  • Epigastric pain
    • Without fever but with local tenderness (e.g. acute hyperacidity, acute pancreatitis, acute hepatitis—left lobe)
    • With fever and local tenderness ± distension (e.g. acute pancreatitis, perforated duodenal or gastric ulcer).
    • With vomiting and
      • Local tenderness (e.g. acute hyperacidity, acute pancreatitis)
      • Local tenderness and obliteration of liver dullness (e.g. perforated ulcer).
    • With diarrhea and local tenderness (e.g. acute colitis).
    • With jaundice
      • + tender hepatomegaly (e.g. left lobar hepatitis, left lobar liver abscess)
      • Non-tender hepatomegaly (e.g. metastatic liver).
  • Left hypochondrial pain
    • Without fever but with local tenderness (e.g. acute gastritis, acute pancreatitis)
    • With fever and local tenderness +/- splenomegaly (e.g. acute pancreatitis, splenic infarct)
    • With diarrhea and local tenderness (e.g. acute colitis).
9
 
Investigations
 
Blood tests
  • Leukocytosis in infective pathologies (e.g. acute cholecystitis, perforated duodenal ulcer, perforated cholecystitis, acute pancreatitis)
  • Raised ESR in all infective pathologies.
 
Radiology
  • Plain X-ray abdomen—gas under the diaphragm (e.g. perforated hollow viscus). Radiopaque shadows in the right upper abdomen (e.g. renal stones, gallstones)
  • Ultrasonography—renal stones, gallstones.
 
Management
  • Non-perforated pathologies—medical management.
  • Perforated pathologies—early surgical management.
  • Diagnosis not clear and not responding to medical management—exploratory laparotomy.
 
Clinical Pearl
  • Acute nephritis and renal colic can cause upper abdominal pain in their respective sides.
 
ACUTE LOWER ABDOMINAL PAIN
 
Definition
Severe pain in the lower part of the abdomen.10
 
Diagnosis
While evaluating lower abdominal pain, it is necessary to keep some pathologies in mind (Table 1.3).
 
Symptoms
  1. Nature of pain
    • Continuous (e.g. acute appendicitis)
    • Colicky (e.g. appendicular colic).
  2. Location of pain
    • Right lower abdomen (e.g. acute appendicitis, right ureteric colic)
    • Hypogastrium (e.g. acute colorectal pathologies)
    • Left lower abdomen (e.g. acute diverticulitis, left ureteric colic)
  3. Association of nausea and vomiting
    Presence of vomiting is not a very reliable symptom to narrow down the diagnosis, as it can be present with any severe painful pathology in the lower abdomen. Nausea is a predominant symptom of acute appendicitis.
    Table 1.3   Acute lower abdominal pain and GI pathologies
    Right lower quadrant pain
    Hypogastric pain
    Left lower quadrant pain
    Acute appendicitis
    Acute cystitis
    Acute diverticulitis
    Acute Meckel's diverticulitis
    Acute congestive dysmenorrhea
    Perforated appendicitis
    Meckel's diverticulitis
    Acute mesenteric adenitis
    Ureteric colic
    Acute cecal diverticulitis
    Note: Diabetic ketoacidosis is one of the important metabolic causes of acute lower abdominal pain.
    11
  4. Association of fever
    Fever indicates infective pathology (e.g. acute appendicitis, acute colitis).
  5. Association of loose stools
    Association of loose stools may indicate colitis, acute diverticulitis.
 
Past History
  • History of pain (e.g. acute on chronic appendicitis)
  • Previous surgery (e.g. appendicectomy will rule out appendicitis from consideration).
 
Family History
  • Diverticulosis
  • Colonic malignancy.
 
Signs
 
General
  • Conjunctiva for anemia (e.g. GI malignancy)
  • Tongue for anemia (e.g. GI malignancy).
 
Abdomen
  • Inspection
    Distension
    • Generalized (e.g. perforated appendicitis with generalized peritonitis)
    • Right lower abdominal (e.g. ruptured appendicitis).12
  • Palpation
    Tenderness
    • All quadrants—generalized peritonitis
    • Right lower quadrant (e.g. acute appendicitis, acute mesenteric adenitis)
    • Left lower quadrant (e.g. acute colitis, acute diverticulitis).
      Lump
    • Right lower quadrant (e.g. acute appendicitis mesenteric adenitis, right ovarian cyst)
    • Left lower quadrant (e.g. carcinoma colon).
  • Percussion
    Percuss the liver for:
    • Its enlargement (e.g. associated metastases liver)
    • Obliteration of liver dullness (e.g. perforated appendicitis and diverticulitis).
  • Auscultation
    • Absence of bowel sounds indicates paralytic ileus (e.g. perforation and peritonitis)
    • Exaggerated bowel sounds may indicate obstruction of small bowel (e.g. intestinal colic)
    • Normal bowel sounds indicate that there is no gross infection of the peritoneum.
 
Differential Diagnosis of Acute Lower Abdominal Pain of GI Etiologies
  • Pain in the right iliac fossa with
    • Nausea/vomiting and fever and local tenderness (e.g. acute catarrhal/perforated appendicitis, acute typhlitis, acute Meckel's diverticulitis, acute mesenteric adenitis).13
    • Vomiting and
      • ± local tenderness (colicky pain, e.g. appendicular colic)
      • Abdominal lump (e.g. ileocecal tuberculosis, Crohn's disease, cecal malignancy).
    • Diarrhea or dysentery and local tenderness (e.g. acute amebic typhlitis, cecal diverticulitis).
  • Pain in the left iliac fossa with vomiting
    • ± local tenderness (e.g. left ureteric colic)
    • Abdominal lump (e.g. colonic malignancy)
    • Diarrhea or dysentery with or without local tenderness (e.g. acute colitis, acute diverticulitis).
  • Hypogastric pain with
    • Constipation (e.g. rectal pathology).
  • Acute lower abdominal pain (any or all quadrants of lower abdomen) with
    • Vague symptoms and signs (e.g. Metabolic causes- diabetes mellitus).
 
Investigations
 
Blood Tests
  • Reduced hematocrit (e.g. colonic malignancy)
  • Leukocytosis in infective pathologies (e.g. acute appendicitis, perforated appendicitis, and diverticulitis)
  • Raised ESR in all infective pathologies.
 
Radiology
  • Plain X-ray abdomen
    • Gas under the diaphragm (e.g. perforated appendicitis and diverticulitis)14
    • Opaque abdomen (e.g. peritonitis)
    • Radiopaque shadows (e.g. ureteric stone).
  • Ultrasonography
    • Cystic swelling (e.g. appendicular abscess, paracolic abscess).
 
Management
  • Non-perforated pathologies—medical management (except acute appendicitis)
  • Perforated pathologies—early surgical management
  • Diagnosis not clear and not responding to medical management—exploratory laparotomy or diagnostic laparoscopy.
 
Clinical Pearls
  • Obstetric conditions like ruptured ectopic gestation should be thought of in a woman of reproductive age
  • Gynecologic conditions like torsion of ovarian cyst should be considered in acute lower abdominal pain
  • Urologic conditions like acute cystitis should be considered in patients with acute lower abdominal pain with urinary symptoms
  • Ureteric colic should be considered in patients with acute pain in the iliac fossae
  • Complicated hernia should be considered in patients with acute lower abdominal pain.
 
COLIC
 
Definition
Colic is defined as a sudden squeezing or griping pain lasting for about 3–5 minutes with pain free intervals.15
  • Nausea, vomiting and retching are common accompaniments
  • The cause of a colic is partial obstruction of a tubular structure due to varied causes.
 
Diagnosis
While evaluating abdominal colic, the following GI pathologies should be kept in mind (Table 1.4).
 
Clinical Features
The clinical features of various colics of GI pathologies are given in Table 1.5.
Table 1.4   Colic related to GI pathologies
Right hypochondrium
Umbilical region
Right iliac fossa
Biliary colic
Intestinal colic
Appendicular colic
Table 1.5   Clinical features of various colics
Clinical feature
Biliary colic
Intestinal colic
Appendicular colic
Incidence
Fat, fertile, flatulent, female of fifty
Any age
Any age
Etiology
Gallstones
Parasitic infestations (younger age), strictures (middle age), malignancy (old age)
Fecaliths, Worms
Nature of pain
Right hypochondrial pain, referred to right scapula or shoulder
Colicky pain in the umbilical region
Colicky pain in the right iliac fossa
Associated symptom
Dyspepsia
Constipation or diarrhea
Repeated attacks of dull pain in right iliac fossa
16
 
Eliciting History
  1. Nature of pain
    • Severe griping pain with pain free intervals.
  2. Location of pain
    • Location almost gives the clue.
  3. Association of vomiting
    Presence of vomiting is not a very reliable symptom to narrow down the diagnosis, as it can be present with any colic.
  4. Association of fever
    • Fever indicates associated infections (e.g. cholangitis in biliary colic).
  5. Association of jaundice
    • Jaundice may be present with biliary colic (e.g. acute cholangitis, acute hepatitis or acute cholecystitis).
  6. Association of loose stools
    • Association of loose stools may indicate colitis.
  7. Radiation
    • Radiation to right scapula or shoulder is common with biliary colic (e.g. acute cholecystitis).
 
Past History
  • History of pain (e.g. colics can be recurrent)
  • Previous surgery (e.g. intestinal colic can occur in adhesive obstruction of small bowel).
 
Family History
  • Gallstones.17
 
Differential Diagnosis by Clinical History
Depends mostly on:
  • Location of pain
  • Associated jaundice (e.g. cholangitis).
 
Clinical Examination
 
General
  • May not be contributory.
 
Abdomen
  • Inspection
    Distension
    • Generalized (e.g. intestinal colic of intestinal obstruction)
    • Localized (e.g. intussusception).
  • Palpation
    Tenderness
    • Elicitable in infective pathologies.
      Lump
    • Right upper quadrant (e.g. distended gallbladder)
    • Umbilical (e.g. post operative adhesions)
  • Percussion
    • Not a very useful method.
  • Auscultation
    • Exaggerated bowel sounds may indicate obstruction of small bowel (e.g. intestinal colic)
    • Normal bowel sounds does not rule out any pathology.
18
 
Investigations
 
Hematology
  • Leukocytosis in infective pathologies (e.g. acute cholecystitis)
  • Raised ESR in all infective pathologies.
 
Radiology
  • Plain X-ray abdomen—gas filled loops of bowel (e.g. acute intussusceptions, acute intestinal obstruction)
  • Ultrasonography—intussusception.
 
Management
  • Medical management will suffice in most instances
  • Obstructive pathologies may require surgery to relieve the cause of obstruction
  • Repeated attacks of colic will require evaluation and management.