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• 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.

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