The Acute Abdominal Pain

THE ACUTE ABDOMINAL PAIN

Diagnosis and management of acute abdominal disorder depends on information derived from the history and from the examination.

History: The patient usually presents with acute abdominal pain. In considering theses symptoms, site, severity, radiation, character, time and circumstances of onset and relieving features are all important.

Site: If pain is experienced mostly in the upper abdomen thick of perforation of gastric or duodenal ulcer, cholecystitis or pancreatitis. If pain is located the mid abdomen, disease of small bowel is likely. Pain in right iliac fossa is commonly due to appendicitis and pain is left iliac fossa to diverticulitis, but rupture of an ectopic pregnancy should be considered; the menstrual history is thus important. The coexistence of severe back an abdominal pain indicated a ruptured aneurysm, or a dissecting aneurysm. When the parietal peritoneum is irritated, pain is felt at the site of affected organ, but when the visceral peritoneum is predominantly involved pain is often referred in a somatic distribution.

For example, in acute appendicitis pain is felt near the umbilicus at first but later, with parietal peritoneal involvement, the pain moves towards the site of appendix, usually in the right iliac fossa.

Note: In women who have children compare the severity with labour pain. Sometimes comparison to the pain of a fractured bone is useful.

Radiation: If pain is radiates from the right sub-costal region to the shoulder or to the intera-scapular region, inflammation of the gall bladder (cholecystitis) is a likely diagnosis. If pain begins in the loin but then is felt in the lumbar region a renal stone or renal infection should be considered. Pain beginning in the loin and radiating to groin is likely to be due to a ureteric calculus and umbilical pain radiating to the right iliac fossa is usually due to appendicitis. Central upper abdominal pain, later radiating through the back is common in pancreatitis.

Character and Constancy: Constant severe pain is felt over many hours is be likely due to infection. For example diverticulitis or pyelonephritis can present in the manner. Colicky pain, on the other hand, i.e pain lasting a few seconds or minutes and then passing off, leaving the patient free of pain for a further few minutes, is Pathognomonic of small bowel obstruction. If such pain is suddenly relieved after a period of several hours of severe pain, perforation of a viscus should be considered. Large bowel obstruction produces a more constant pain than small bowel obstruction, but colic is usually prominent.

Mode of onset: In obstruction from the mechanical disorders such as that due to the biliary or ureteric stone, or obstruction of bowel from adhesions or volvulus the onset of colicky pain is usually sudden. It is often related to activity or movement in the previous few hours. In infective or inflammatory disorders the pain usually has a slower onset, sometimes over several days, and there is no relation to activity. Recent ingestion of a rich heavy meal often precedes pancreatitis. Alcohol excess or the ingestion of aspirin or steroid therapy are often observed as precipitating features in patients presenting with perforated peptic ulcer or with haematemesis.

Relieving features: Abdominal pain relieved by rest suggests an infective or inflammatory disorder. If the patient cannot keep still and rolls around in agony then ureteric or biliary colic are likely diagnosis.

Vomiting: A history of vomiting is not in itself very helpful because vomiting occurs as a response to pain of any type. However, effortless projectile vomiting often denotes pyloric Stenosis or high small bowel obstruction. In peritonitis the vomitus is usually small in amount but vomiting is persistent. There may be faeculent smell to the vomitus when there is low small bowel obstruction. Persistent vomiting with associated diarrhea strongly suggests gastroenteritis.

Micturition: Increased frequency of micturition occurs both in urinary tract infection and in other pelvic inflammatory disorders as well as patient with renal infections or ureteric stones. In the later haematuria commonly occurs.

Appetite and weight: In patient with a chronic underlying disorder, such as abdominal cancer, there may be a history of anorexia and weight loss, although weight loss also occurs in a variety of other disorders. Sudden loss of appetite clearly indicates a disorder of sudden onset.

Guarding: Guarding is an involuntary reflex contraction of the muscles of the abdominal wall overlying an inflamed viscus and peritoneum, producing localized rigidity, it indicates localized peritonitis.

Rigidity: Generalized or “board like” rigidity is an indication of diffuse peritonitis. It can be looked upon as an extension of guarding, with involuntary reflex rigidity of the muscles of the anterior abdominal wall. It is quite unmistakable on palpation, as the whole abdominal wall feels hard and “board like” precluding palpation of any underlying viscus. The least downward pressure with a palpating hand in a patient with generalized rigidity produced severe pain.

Rebound tenderness: Rebound tenderness is elicited by palpating slowly and deeply over a viscus and then suddenly releasing the palpating hand. If rebound tenderness is positive then the patients experience pain. This signs is explained by the fact that gradual stretching of the abdominal wall by deep palpation followed by sudden release of this pressure stimulates the parietal peritoneum which, if inflamed, produces pain. Rebound tenderness is not always a reliable sign and should be interpreted with caution, particularly in those patients with a low pain threshold.