How can the pain be so bad if it is “only a muscle”?
This is perhaps the most common question asked by patients and parents in patients diagnosed with Abdominal Wall Pain. The reason is that there are a lot more pain fibres in the abdominal muscles than there are anywhere in the abdomen. The reason that I give is that the abdominal wall has two main functions – as muscles keeping us upright and in helping us to sit up, and to protect the insides – the “vital organs”. To do this these muscles have been endowed with lots of pain fibres. When we were cave people, if we were going to be poked with a spear, if the spear went through the abdominal muscles into the intestines, death was a sure thing due to infection. By having lots of pain fibres, the muscles can detect the spear, and let us fall back or protect ourselves, before the spear goes too deep. Therefore, given the huge amount of pain fibres in the abdominal wall compared to those in the vital organs, it is quite understandable that the pain is “that bad”!
Also: Discomfort due to abdominal distension, foetal movement and pressure from the foetus in later pregnency
2. Pathological causes of abdominalpain - Pregnancy Related These conditions will be dealt with in depth in lectures dealing with each specific pathology. This is an overview only.
A Foley’s catheter may be inserted to monitor fluid resuscitation. Such patients are usually kept starving (nothing by mouth) till surgical cause is ruled out.
Nasogastric tube is placed in patients with suspected bowel obstruction, ileus, or upper gastro-intestinal bleed. In suspected biliary tract disease, dicyclomine may be administered for pain. NSAIDs should be administered with caution to elderly patients. In patients with undifferentiated abdominalpain, IV morphine is safe in doses of 2-4 mg; once biliary disease is ruled out (morphine causes spasm of the sphincter of Oddi). Meperidine causes less spasm of sphincter of Oddi, and is the opioid of choice in biliary tract disease. Rapid investigations should be carried out to confirm or rule out acute life threatening illnesses e.g. pneumonia, acute myocardial infarction, diabetic ketoacidosis, ruptured AAA, gut perforation and specific medical or surgical intervention should be carried out. Empirical antibiotics should be started in patients with suspected sepsis, pneumonia, cholecystitis, appendicitis, diverticulitis, or perforated viscus.
Plain-film abdominal radiographs are most useful when intestinal obstruction or perfora- tion of a viscus in the abdomen is a concern.
Chest radiographs may help rule out pneumo- nia. The most contentious issue in emergency medicine may be the usefulness of ultrasonog- raphy and computed tomography (CT) in patients with abdominalpain. 17-20 CT likely is more accurate than ultrasonography. 18 How- ever, the experience of the operator and inter- preter significantly affect the accuracy of both modes. 19 In the emergency department, ultra- sonography probably is most useful in diag- nosing gynecologic pathology such as ovarian cysts, ovarian torsion, or advanced periappen- diceal inflammation. 17,20 CT involves radiation exposure and may require the use of contrast agents. CT may be necessary if excessive bowel gas precludes ultrasonographic examination.
Although pneumonia is a known cause of pediatric abdominalpain, its diagnosis may be missed initially. Diagnostic uncertainty has resulted in the removal of normal appendices 160,161 in patients with acute abdominalpain. Fig. 8 shows right-sided lung infiltrates in a patient who presented with severe abdominalpain in the right lower quadrant and was being evaluated for possible appendicitis. In general, intrathoracic processes may mimic an acute abdomen by referred pain. 162 The diaphragmatic pleura is innervated by the 6 or 7 lowest intercostal nerves peripherally and by the phrenic nerve centrally, 163,164 and therefore pain may be referred to the abdominal wall during the course of a basilar pneumonia. The reported prevalence of pneumonia in children with abdominalpain ranges from 2.7% to 5%. 160,165 It is difficult to rely on the classic triad of fever, cough, and rales when deciding to obtain a chest radiograph, because the positive predictive value of this constellation is 27% and the sensitivity only 35%. 166 This observation is of particular importance in young children, because these patients may offer suboptimal examinations, and it may be difficult to identify clinical signs and symptoms consistent with pneumonia. In a study of 51 patients with extraabdominal causes of acute abdominalpain, 15 patients were diagnosed with pneumonia and 10 of them were 3 years of age or younger. 167 Therefore, in the evaluation of pediatric abdominalpain, it is important to consider evaluating for pneu- monia as an occult cause.
The more common serious causes of constipation in the newborn and infant are imperforate anus, anal stenosis, meconium plug syndrome, meconium ileus, Hirschsprung’s disease, volvulus, anal fissure, infant botulism, hypocalcemia, hypercalcemia, and hypothyroidism. Constipation in the older infant or child is related commonly to changes in diet, especially from breast milk to formula or advancement to solid baby foods. Inadequate fluid intake is another common cause of constipation. The school-aged child may present with constipation caused by high carbohydrate diets and a hesitance to go to the bathroom at school. The child who has rectal retention and encopresis has fecal soiling of the underpants and may paradoxically complain of diarrhea. A lower abdominal mass may be found by palpation, and fecal impaction may be found on rectal examination. Older children may present with abdominalpain, which may be in the right lower quadrant and mimic appendicitis.
The outcome in RAP varies; about one-third of cases resolve spontaneously, one-third continue to have recurrent abdominalpain, and about one-third develop other pain syndromes in adolescence and adulthood, such as irritable bowel syndrome or headaches. Close follow-up is essential. The physi- cian should reassure the parents and child that he or she will continue to follow the problem and to inves- tigate for organic etiologies should the symptoms change in the future. It is important for the parents and child to know that although the pain may not go away, there is nothing dangerous causing it and that the child should continue with as little disruption in daily routine as possible. The major objective after determining that the pain does not represent signif- icant pathology is to limit the pain to a “simple syndrome’’ with pain only, rather than an “extended syndrome’’ that affects other facets of the child’s life. 2 There are a few therapies outside of support and consistent medical follow-up that have proven ben- eficial for RAP. There is some evidence that dietary adjustment may help in some cases. Decreasing dairy intake may reduce symptoms related to lactose in- tolerance, 3 and increasing fiber may reduce consti- pation or dysfunctional motility, which can contrib- ute to RAP. In the only placebo-controlled trial for RAP to yield positive results, Feldman et al, 7 showed that daily intake of 5g of fiber per day in the form of a cookie significantly decreased abdominalpain dur- ing the study period. Specific medications, such as antispasmodics and antacids, are rarely effective in RAP.
Drs alwan and Drake:
In reviewing the literature, childhood appendicitis is well described, but neonatal appendicitis is much rarer, with an incidence of 0.04% to 0.2%. 3 – 5, 9 – 12 There have been ∼50 cases reported in the past 30 years, most commonly involving premature boys. 7, 9, 11 Perhaps given the insidious onset of this disease and the difficulty of the neonatal examination, the mortality rate has been reported as 20% to 25%. 1, 3, 7 – 10 Some speculate that the broadness of the appendix, or its conical shape, combined with the lack of fecaliths in neonates contributes to the rarity of this diagnosis. 7, 9, 12– 14 Anatomically, the neonate’s appendiceal wall is thinner and perhaps more easily perforated. 7, 9, 15, 16 The high morbidity and mortality rate could be attributed to faster progression to perforation, peritonitis, and subsequently septic shock. 3 It is important to evaluate each infant on the basis of their unique presentation, and keep neonatal appendicitis on the differential for abdominal distension and feeding difficulty. Of note, Hirschsprung disease and NEC should always be considered when contemplating neonatal appendicitis. Schwartz
into the food, where they break it down into its basic components so that it can be absorbed into the body.
The duct coming from the pancreas joins with the bile duct then this common duct open into the duodenum through a small hole in the side of the intestine called the ampulla of Vater. Thus stones coming down from the gall bladder can block off the pancreatic juices too. This can lead to a build-up of pressure in the pancreas, forcing the powerful pancreatic enzymes to leak into the abdominal cavity. When this happens the juices digest normal tissues instead of the food they are intended for. This causes the severe pain of acute pancreatitis, and serious illness and even death can result.
Specific physical findings in appendicitis, cholecystitis, diverticulitis, and bowel perforation or infarction vary with the disease. However, if peritonitis is present, certain physical findings are common, regardless of the disease.
The pain of peritonitis is severe, generalized, continuous, and of acute or gradual onset. The patient usually has abdominal tenderness with guarding, stabbing pain with gentle coughing, deep inspiration/expiration, and pain on percussion. Abdominal rigidity is occasionally present. Decreased movement of the abdominal wall occurs with respiration. If rebound pain is present, it is usually found over the area of primary disease. Patients with peritonitis are often in shock, have fever or chills, and present with decreased or absent bowel sounds. The patient usually lies relatively motionless because move- ment aggravates the pain. Depending on the severity of the peritonitis and the prior cardiovascular status of the patient, hypotension, tachycardia, pal- lor, and sweating may also be present. Younger, healthier patients are rela- tively resistant to hypotension but easily experience tachycardia. In contrast, elderly patients with a decreased cardiovascular reserve more readily become hypotensive. The presence of cardiac disease may impair the development of tachycardia.
ASSESSMENT OF ACUTE AND CHRONIC PAIN
NOAH CARPENTER, MD
Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed his Bachelor of Science in chemistry and medical school and training at the University of Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh, Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia, Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Native Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.
ovarian cyst, mittelschmerz, typhlitis, ectopic pregnancy, and mesenteric adenitis. Acute onset of Crohn disease should be suspected if there is right lower quadrant mass and diarrhea. Children with urolithiasis rarely present with the excruciating pain of stone passage seen in adults. Col- icky pain in the abdomen or flank is more common. Hema- turia, either microscopic or macroscopic, occurs in the vast majority of children. The presence of fever greater than 101°F suggests pyelonephritis and salpingitis in addition to a perforated appendix. Urinalysis should be performed in all patients with right lower quadrant abdominalpain, flank pain, or pain radiating into the groin. Pelvic exami- nation with appropriate examinations for sexually trans- mitted diseases is indicated in an adolescent female who has just completed a menstrual period and presents with lower abdominalpain and fever. The patient may report an increased vaginal discharge or irregular bleeding. A compli- cation of salpingitis that evokes clinical signs of peritonitis and shock is a ruptured tubo-ovarian abscess. Typical pri- mary dysmenorrhea consists of crampy, dull, midline, or generalized lower abdominalpain at the onset of the men- strual period. The pain may coincide with the start of bleeding or precede the bleeding by several hours. Associ- ated symptoms include backache, thigh pain, diarrhea, nausea, vomiting, and headache. Endometriosis must be considered when there is chronic, cyclic, undiagnosed pelvic pain in teenagers. Unilateral abdominalpain at the midpoint of the menstrual cycle (time of ovulation), with or without spotty bleeding for 24 hours, is characteristic of mittelschmerz. Typhlitis should be considered in a neu- tropenic patient receiving antineoplastic drugs who pre- sents with right lower quadrant abdominalpain, fever, diarrhea, nausea, and vomiting. Localized tenderness may progress rapidly to diffuse signs of peritonitis as a result of intestinal perforation. Urine or serum pregnancy testing should be performed in adolescent females of reproductive age with lower abdominalpain. Mesenteric adenitis is a commonly used term to describe clustering of inflamed lymph nodes in the region of the terminal ileum in patients undergoing appendectomy. Mesenteric adenitis should not be considered a separate diagnosis but rather a sequela of viral or bacterial gastroenteritis.
Cardiac exam: tacycardic without murmurs rubs or gallops.
Chart review: Patient was day 3 s/p open reduction and internal fixation. She received three doses of Ancef in the peri-operative period and has been receiving morphine shots every 2 hours for pain control. She has not had a bowel movement since the hospital admission and has also been noted to have a decreasing urinary output during the last shift.
T he exact prevalence of chronic abdominalpain in children is not known. It seems to account for 2% to 4% of all pediatric office visits. 1 One study suggested that 13% of middle-school students and 17% of high-school students experience weekly abdominalpain. 2 In the latter study, it was also noted that approximately 8% of all students had seen a physician for evaluation of abdominalpain in the previous year. Quality of life in adult patients with chronic abdominalpain is substantially poorer than that of the general population. 3 The economic cost related to this condition in children is not known but is likely to be substantial, considering that expenses associated with irritable bowel syndrome (IBS) in adults have been estimated to be $8 billion to $30 billion per year. 4–6 The long-term outcome of this condition has not been determined, but preliminary data indicate that young adults with a history of recurrent abdominalpain that began in childhood who are treated by a subspecialist are significantly more likely than their peers without recurrent ab- dominal pain to have lifelong psychiatric problems and migraine headaches. 7 Despite the high preva- lence and effects of this condition, no evidence-based guidelines for its evaluation and treatment exist.
The ENS is also known as the “gut brain” or the
“little brain in the gut.” 2 The ENS interacts with the central nervous system, allowing bidirectional com- munication. A dysregulation of this brain-gut com- munication plays an important role in the pathogen- esis of functional abdominalpain. Most of the research on childhood visceral pain in the 1980s and early 1990s focused on the role of motility disorders and psychiatric abnormalities. Recently, however, more sophisticated diagnostic techniques have failed to identify motor abnormalities severe enough to account for these patients’ symptoms. It is now be- lieved that adults and children with functional bowel disorders, rather than having a baseline motility dis- turbance, may have an abnormal bowel reactivity to physiologic stimuli (meal, gut distension, hormonal changes), noxious stressful stimuli (inflammatory processes), or psychological stressful stimuli (paren- tal separation, anxiety). 3 Additionally, adult patients with functional bowel disorders attending gastroin- testinal clinics were often found to have psycholog- ical disturbances regardless of the final diagnosis. It was concluded that psychological factors may have been more important in determining health-seeking behavior than the cause of the symptom. 4
central nervous system. 1 In a refinement of this theory, called the ‘hyperexcitability theory’, the referred pain occurs through cross connections between second order neurons supplying the different regions, but only when the input reaches a certain threshold. 2 The classic papers of Kellgren 3 and Feinstein 4 show common patterns of pain referral following irritation of thoracic and lumbar spinal somatic structures (Figure 1). Although these pain referral maps have been available to the medical community for over 50 years they are, we believe, still underutilised in clinical practice. Pain is referred outward and downward from its source, in predictable patterns, as far anteriorly as the anterolateral chest and abdomen. Moreover, the pain is usually felt as deep and dull, or aching, and is diffuse in its distribution. This differs from the sharp and burning pain felt in a well defined dermatomal distribution with irritation of a dorsal root ganglion.
Patient was doing fine till the onset of abdominalpain and back pain that has been progressively getting worse. Patient denies history of trauma, no PUD.
On physical exam, patient appeared diaphoretic and in moderate distress; the patient is afebrile with a BP 90/70mm of Hg, HR 100/min, RR 24/min. Lungs were clear to auscultation bilaterally, cardiac exam revealed tachycardia without murmurs, rubs or gallops. Abdomen was diffusely tender without guarding or rebound. There was minimal ecchymosis in the left flank.
Despite ED discharge mainly depends on the final diagnosis, the appropriate management of patients without specific diagnoses for abdominalpain (i.e., NSAP, accounting for about one third of all causes) remains challenging, so that several options can be exercised. The patients can be delivered to surgery, admitted for medical management, kept in observation, or even discharged to home with specific precautions and follow-up evaluation. The different decision to discharge the patients or keep them in observation depends on several factors such as the possibility to undergo timely follow-up, and the ability to return to the hospital when the clinical conditions should eventually worsen.
The term “lower abdomen” refers to the portion of abdomen below the umbilicus.
Three topographic regions can be identi fi ed: the hypogastrium in the middle and the left and right iliac fossa, both located lateral to the hypogastrium, in the left and right inferior part of the surface of the human abdomen, respectively. The majority of men and women will complain, at least once in their life, of a pain localized in the lower abdomen. For this reason, the number of GP’s referrals for a lower abdom- inal pain is expected to be high. A number of different diseases can result in a pain, of variable mode of presentation, intensity, and duration, in the left iliac fossa, the right iliac fossa, and the hypogastrium (this latter also termed “suprapubic pain”), respectively. These may arise from different organs (bowel, lower urinary tract, and female reproductive system) and thus potentially involve different specialists (gen- eral surgeon, urologist, and gynecologist). The aim of this chapter is to provide general criteria (essentially based on patient’s history and examination) that may lead to suspicion of a urological origin for lower abdominalpain (and the need for a urological referral). The main features for the differential diagnosis with diseases belonging to other apparatus will also be provided in order to lead GPs to make the most appropriate specialist referral.