ACUTE ABDOMEN PAIN

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waleed on Nov 19, 2009 Says :

very important lecture, it mix between surgery ,physiology and neurology. i think everyone should read it. thanks to Dr/Yousef elbouq& dr/Fazili the 1st surgeons in Almadina Almonawara

anis on Oct 19, 2009 Says :

love the presentation.hope u dont mind but can i use some of the pics in the slides.its for educational purposes and its not for any financial benefit.tq

abdul on Oct 08, 2009 Says :

i love this presentation

fiazfazili on Sep 09, 2009 Says :

does anyone know how can i add authors to presentations

fiaz fazili on Sep 09, 2009 Says :

while submitting this ,the actual source of inspiration DR AL bouqs name got blurred deserves apology,and all appreciation from me

doogie on Jun 09, 2009 Says :

the presentation....i like this..

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Slide 1 :

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ANALYSIS OF ACUTE ABDOMINAL PAIN PREPARED BY DR. BOOQ YUOSEF & DR FIAZ FAZILI SURGICAL DEPTT. OHUD HOSPITAL

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depends in large measure on analysis of pain , which requires an understanding of the mechanisms of abdominal pain . DIAGNOSIS OF ACUTE ABDOMINAL PAIN

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OBJECTIVITY OF THIS LECTURE IS To examine the physiologic background of abdominal pain As An aid to accurate interpretation of Symptoms & Signs .

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Anatomic background Parietal peritoneum clothes the anterior & posterior abdominal walls the under surface of the diaphragm & the cavity of the pelvis.( supplied segmentally by the spinal nerves ) . Visceral peritoneum is the continuation of the parietal peritoneum, which leaves the posterior wall of the abdominal cavity to invest certain viscera therein . ( has no nerve supply ).

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DEFINITION OF PAIN It is an unpleasant sensation of varying intensity . Pain fibers are stimulated any time a tissue is being damaged . However , it is not felt very long after the damage has been accomplished.

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1 2 3 4 5 Mechanical trauma to the tissue . Excess heat or cold . STIMULANTS Chemical damage. Radiation damage . Inadequate blood flow.

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Types of abdominal pain 1 Visceral pain is primitive and therefore related to embryologic development . Somatic pain is entirely different from visceral pain 2

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Visceral pain 1- Receptor ( Visceral peritoneum )

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Visceral pain 2 - Stimulus Pat. Experienced pain by traction ,distention & spasm The visceral peritoneum is insensitive to touch & heat or any condition that promotes an inflammatory reaction

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Visceral pain 3 - Mediation Autonomic nervous System Interpreted at the thalamic level of the brain

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Visceral pain 4- Specificity Vague , often dull , poorly described & associated with nausea & vomiting

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Visceral pain 5- Localization Is poor & the pat. Placing the entire hand over the involved region

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Somatic pain 1- Receptor Pain stimuli start in the parietal peritoneum , which is innervated by peripheral nerves

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Touch Pressure Heat Inflammation

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Somatic pain 3- Mediation Central nervous system & Interpreted at a specific cortical location

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Somatic pain 5- Localization The pain is localized with great accuracy by the patient , who can often point to the site with one finger

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Analysis of pain need DATA COLLECTION 1 2 3 History Physical exam. Lab.inv. apply your medical knowledge***

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The history of pain betrays the diagnosis History of pain Site Mode of onset Nature of pain Severity Radiation Duration Factors influencing the clinical manifestation

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Mode of onset Sudden onset [The patient can tell you exactly when the pain started ] The pain that start suddenly has a mechanical basis Some thing has been Ruptured Twisted Occluded

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Cont’ Mode of onset Gradual Onset ( The pat. Usually responds vaguely to questions about time of onset ) Non mechanical or chronic process

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Nature of pain Two Large Categories (1) Conditions associated with obstruction of a muscular conducting tube ( Small bowel , Ureter , Biliary ) (2) Conditions associated with inflammation ( Mild & Localized Response or Severe , Generalized Response )

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Obstruction Sudden prolonged Distention of the viscus ( constant stretching pain ) Colic pain = visceral pain Three Types ( 1 ) Biliary System = ( foregut ) Foregut pain is experienced in the epigastrium 1 (2) Small Intestine = ( midgut ) Pain is experienced in the periumbilical region (3) Renal system = ( retroperitoneal ) Pain is felt in the flank & radiates to the groin

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Important features of colic pain Pat . Is often restless & agitated during exacerbations. Pat. Does not experience a totally pain –free interlude. Colic pain is an intermittent pain . Colic pain is an visceral pain . ( not influenced by changing relationships between the peritoneal layers ) Failing to demonstrate guarding , tenderness ? ????

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Inflammation 2 Intra-abdominal inflammation is peritonitis Peritonitis causes somatic pain Contamination BY Chemicals Bacteria Trauma Foreign body

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Important features of somatic pain Pat. Laying quite in bed . ( movement is limited ) Examination may demonstrate guarding , tenderness . The pain is localized over the inflamed organ . Fever , tachycardia & tachypnea are systemic manifestation for generalized inflammation .

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Ischemic pain Is a somatic pain Occlusion of blood supply cause Tissue Hypoxia With metabolic changes Necrosis After 6-12 h

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Severity of acute abdominal pain The associated psychologic factors Patient perception Severity of the underlying cause

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Factors influencing clinical manifestation (1) Extent of the pathologic process The more severe the process , the more impressive the manifestation .

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Factors influencing clinical manifestation (2) Time of Assessment Depending on the time of assessment , the characteristics will reflect what is present at that time – not previously & not subsequently .

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Factors influencing clinical manifestation (3) Emotional factors Objective criteria are more reliable than subjective factors .When there is a discrepancy between the severity of pain & objective findings ,caution should be exercised .

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Factors influencing clinical manifestation (4) The Patient’s Intelligence A clinical history is only as reliable as its source . If the pat. is Intellectually impaired Senile Very young Or Psychotic Very ill The information obtained must be interpreted carefully . Objective & subjective findings should be compatible .

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Factors influencing clinical manifestation (5) Level of consciousness Some neurologic problems make the interpretation of acute abdominal pain difficult . Unconsciousness Paraplegia Sympathetic denervation Bizarre manifestation of abd. Pain .

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Factors influencing clinical manifestation (6) Drugs Many drugs influence both the character , perception & the course and effects of disease . Corticosteroids Suppress the inflammatory response Sedatives Influence pat. Recognition of problems Analgesics Decrease pain ( minimized or overlooked )

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Clinical Exercise A male pat. ,aged 17, develops mild periumbilical discomfort not influenced by activity . Several hours later , his discomfort increases but is now situated in the right lower quadrant .Movement becomes painful . Examination reveals localized pain , tenderness , and rebound tenderness localized to a small area in the right lower quadrant .

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Analysis of case ( 1 ) The initial pain is visceral & midgut in origin but is replaced by somatic pain . The most common problem in this region & this age is app . Why visceral pain ???? The inflammation starts intraluminally , & the app. Becomes distended. Stretching is a stimulus for visceral pain . As it becomes transmural , the serosal surface is involved . Contact between V. peritoneum & P. peritoneum is established . Somatic pain replaces visceral pain & the localization changes .

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Clinical exercise 47-year- old woman suddenly develops severe midepigastric pain . She cannot find a position that eases the pain , but the pain is not made worse by movement . Examination does not establish the presence of guarding , tenderness ,or rebound tenderness .

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Analysis of case ( 2 ) This example illustrates all the characteristics of visceral pain. The most common type of colic in women in this age group is biliary . This diagnosis can be made with some confidence . Confirmation by ultrasonography is required . The epigastric localization is associated with foregut origin

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Clinical exercise A 62 – year- old man is awakened at 2AM by severe abdominal pain that he describes as generalized over the entire abdomen . He complains also of pain in his left shoulder . He does not move , & his breathing shallow . He feels more comfortable sitting than lying . He is sweating , tachycardiac , & in acute distress . The abdomen is rigid . Tenderness , rebound tenderness , & guarding are evident in all four quadrants . Percussion over the liver demonstrates absence of liver dullness.

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ANALYSIS OF CASE ( 3) This Pat. has generalized peritonitis This example illustrates all the characteristics of Somatic pain. Pain in the left shoulder suggests irritation of the diaphragm . Resonance over the liver is characteristic of air in the peritoneal cavity .This features keeping with bowel perforation .The most common site is the duodenum secondary to an ulcer .

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Clinical exercise A 76- year-old woman who lives alone in an apartment is discovered to be ill by the daughter . She is taken to the hospital, where examination reveals tenderness in the right upper abdomen . Breathing is shallow and rapid . Consolidation is suspected in the right lower lob & confirmed radiographically . Her temperature & wbc . are elevated . Does this pat. Have right –sided bronchopneumonia with pain referred to the upper abdomen , or acute cholecystitis with secondary changes in her chest ????????

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Analysis of case ( 4 ) The differentiation is crucial Deep breathing causes discomfort ,when the GB. is inflamed . The pat. Takes shallow breaths & resists the urge to cough. Atelectasis develops & the atelectatic segment , becomes secondarily infected . Pat. Now has right lower lobe pneumonia & pain in the RUQ. With guarding & rigidity. If you operate the GB. When the correct DG. is pneumonia , the pat. will do poorly . If you miss the DG. Of necrotic GB. The pat may do very badly .

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Clinical exercise A 47- year-old woman develops a severe sharp , knifelike pain in her Lt. Lower chest . She also complains of aching pain at the tip of her Lt . Shoulder . The onset was sudden & not associated with trauma or any other recognized cause . It is difficult for her to take a deep breath or cough effectively . The pain is controlled by analgesics prescribed by her physician ,who thinks she had pleurisy .within 48 hours the pain subsides,& within a week she has recovered uneventfully without further incident .

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How should the woman’s physician have acted differently ?? Clinical exercise

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This pat. had an infarct of a peripheral segment of the spleen ANALYSIS OF CASE ( 5 ) The sudden onset of chest pain was not typical of pleuritis secondary to bacterial or viral infection but of some mechanical event . The onset was in keeping with the sudden occlusion of a vessel .The infarcted area produced an inflammatory reaction that affected the diaphragmatic peritoneum , causing shoulder- tip pain . The movement of the diaphragm brought the infarcted segment into contact with the parietal peritoneum , mimicking pleuritic pain .

Slide 51 :

THANK YOU

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