2. ACUTE ABDOMINAL PAIN
Evaluation of the patient with acute abdominal pain is one of
the most challenging aspects of emergency medicine.
Dr. Carlos Azañero Inope
3. ACUTE ABDOMINAL PAIN
Abdominal pain is the
presenting complaint in as
many as 10% of
emergency departament
patients.
Dr. Carlos Azañero Inope
4. ACUTE ABDOMINAL PAIN
Though the etiology of pain is
initially undetermined in as 30-
40% of patients, recognition of
surgical or life-threatening
causes is most important than
establishing a firm diagnosis.
Dr. Carlos Azañero Inope
5. ANATOMIC ESSENTIALS
Abdominal pain is typically derived
from one or more three distinct
pain pathways: visceral, parietal
(somatic) and referred.
Dr. Carlos Azañero Inope
6. Visceral Abdominal Pain
Visceral Abdominal Pain is
usually caused by distention of
hollow organs or capsular
stretching of solid organs.
Dr. Carlos Azañero Inope
7. Visceral Abdominal Pain
Less commonly, it si caused by isquemia or inflammation.
The tissue congestion sensitizes nerve endings of visceral pain fibers
and lowers the threshold for stimulus.
Dr. Carlos Azañero Inope
8. Visceral Abdominal Pain
If the involved organ is affected
by peristalsis, the pain is often
described as intermittent,
crampy, or colicky in nature.
Dr. Carlos Azañero Inope
9. Visceral Abdominal Pain
The visceral pain fibers are
bilateral, unmyelinated, and enter
the spinal cord at multiple levels.
The visecral abdominal pain is usually dull, poorly localized and
experienced in the midline..
Dr. Carlos Azañero Inope
12. Parietal (Somatic)
Abdominal Pain
Results from ischemia, inflammation,
or stretching of the parietal
peritoneum . Dr. Carlos Azañero Inope
13. Parietal (Somatic)
Abdominal Pain
Myelinated afferent fibers transmit
the painful stimulus to specific dorsal
root ganglia on the same side and
dermatomal level as the origin of the
pain.
Dr. Carlos Azañero Inope
14. Parietal (Somatic)
Abdominal Pain
The parietal pain, in contrast to
visceral pain, often can be localized to
the region of the painful stimulus.
This pain is typically sharp, knife-like
and constant; coughing and moving
are likely to aggravate it..
Dr. Carlos Azañero Inope
15. The classic presentation of
appendicitis involves both
visceral and parietal pain.
The pain of early presentation is often
periumbilical (visceral ) but localizes
to the right lower quadrant ( RLQ)
when the inflammation extends to
the peritoneum (parietal).
Dr. Carlos Azañero Inope
16. Referred Pain
Is defined as pain felt at a
distance from the diseased
organ. It results from
shared central pathways for
afferent neurons from
diferent locations.
Dr. Carlos Azañero Inope
17. HISTORY
1. Where is your pain? Has it
always been there?
Keep in mind that the location of
abdominal pain may vary with time,
especially as the underlying disease
evolves and the pain progresses from
visceral to somatic.
Dr. Carlos Azañero Inope
18. HISTORY
2. Does the pain radiate anywhere?
The pain of biliary colic may radiate to
the right infraescapular region .
The pain of pancreatitis to midback .
Pain that radiates to the flank or
genitals may represent a kidney stone
or rupture AAA.
Dr. Carlos Azañero Inope
19. HISTORY
3. How did the pain begin (sudden
vs gradual onset) ? How long have
you had the pain?
Rupture AAA .
Sudden or abrupt onset of
abdominal pain often indicates Perforated Ulcer .
a serious underlying disorder.
Ectopy Pregnancy .
Dr. Carlos Azañero Inope
20. HISTORY
3. How did the pain begin (sudden
vs gradual onset) ? How long have
you had the pain?
Pain for > 6 hours or < 48 hours
duration, or pain that is steadily
increasing in intensity is more likely
to require surgical intervention .
Dr. Carlos Azañero Inope
21. HISTORY
4. What were you doing the pain
began?
Severe Pain that awakens a
patient from sleep :
PERFORATION OR ISCHEMIA
Dr. Carlos Azañero Inope
22. HISTORY
4. What were you doing the pain
began?
Abdominal Pain following
trauma : INTRA-ABDOMINAL
INJURY to the solid organs or
bowel.
Dr. Carlos Azañero Inope
23. HISTORY
5. What does the pain feel like?
Burning or Gnawing Pain: Peptic
Ulcer Disease
Dr. Carlos Azañero Inope
24. HISTORY
5. What does the pain feel like?
Sharp Pain: Biliary Colic
Tearing Pain: Aortic
Disecction
Penetrating Pain: Pancreatitis
Dr. Carlos Azañero Inope
25. HISTORY
6. Does anything make the pain
better or worse?
Parietal Peritoneal Pain is aggravated
by movement. This finding
necessitates the exclusion of
appendictis.
Dr. Carlos Azañero Inope
26. HISTORY
6. Does anything make the pain
better or worse?
The Pain ulcer peptic disease
improves with eating whereas biliary
colic worsens with measles
Dr. Carlos Azañero Inope
27. HISTORY
The Pain accentuated by
reclining and relieved by
sitting upright should raise
suspicion for a retroperineal
process such as pancreatitis.
Dr. Carlos Azañero Inope
