STUDY - Technical - New Dacian's Medicine
Abdominal
Pain
Translation Draft
Even if the title seems to have everything treated in the "section" pain, you will see that this group has its reasons.
Abdominal pain is one of the most considerable challenges in terms of diagnosis, requiring experience, since the most catastrophic developments can only be announced by very subtle symptoms and signs.
One of the main causes of abdominal pain is inflammation of the parietal peritoneum. The pain due to this inflammation is continuous and deaf and is located directly above the inflamed region, its exact location is possible because it is transmitted through the somatic nerves that irritate the parietal peritoneum. The intensity of pain is dependent on the type and quantity of foreign substance to which peritoneal surfaces are subjected over a certain period of time.
For example, the sudden release into the peritoneal cavity of a small amount of sterile acidic gastric juice causes more pain than the same amount of massively contaminated neutral faeces. Enzymatic active pancreatic juice causes more pain and inflammation than the same amount of sterile bile, which does not contain strong enzymes.
Blood and urine are generally undetectable if their overflow into the peritoneal cavity is not sudden and massive. In the case of bacterial contamination, as happens in pelvic inflammatory disease, the pain is frequently of low intensity at first, until the multiplication of bacteria causes the development of irritants.
Very important is the speed with which the irritating material reaches the peritoneum, so in cases of perforated peptic ulcer can be associated with a different clinical appearance, depending only on the speed with which gastric juice penetrates into the peritoneal cavity.
Pain from peritoneal inflammation is invariably accentuated by pressure or changes in peritoneal tension, caused by palpation or movement, coughing or sneezing. Therefore, the patient with peritonitis lies quietly in bed, preferring to avoid movement, in contrast to the patient with colic, which will wriggle incessantly.
Another characteristic of peritoneal irritation is the reflex tonic spasm of the abdominal muscle, located in the region involved. The intensity of the tonic muscle spasm that accompanies peritoneal inflammation depends on the location of the inflammatory process, how it develops and the integrity of the nervous system. Spasm on a perforated retrocecal appendix or perforated ulcer in the lower peritoneal sac may be minimal or absent due to the protective effect of the overadjacent viscera.
A slow development process often greatly reduces the degree of muscle spasm. Major abdominal emergencies, such as perforated ulcers, have been repeatedly associated with minimal or occasionally undetectable pain or muscle spasm in debilitated, seriously ill or psychotic patients.
Another cause is obstruction of cavitational viscera. Pain of obstruction of cavitational abdominal viscera is classically described as intermittent or colicative. However, the lack of cramp character should not be misleading, as the distension of cavitational viscera can cause continuous pain, occasionally exacerbated. Although it is not as well located as the pain from inflammation of the parietal peritoneum, some useful generalizations can be made about its distribution.
Colicative pain of small intestine obstruction is usually periombilical or supraombilical and is poorly localized. As the intestine expands, with loss of muscle tone, the colicative nature of pain may become less obvious.
If the obstruction overlaps with strangulation, the pain may extend to the lower lumbar region if the root of the mesentery is treactated. colicative pain of colonic obstruction is of lower intensity than that of the small intestine and is often localized in the infraombilical region. Low back pain irradiation is common in colonic obstruction.
Sudden dilation of the bile tree produces a type of continuous pain rather than colic (the term bile colic being deceiving). Acute dilation of the gallbladder usually causes pain in the right upper quadrant, with irradiation to the right posterior region of the chest or at the tip of the right scapula, and distension of the common bile duct is often associated with epigastric pain that radiates to the upper part of the lumbar region.
Considerable variations are frequent, so differentiating between them may be impossible. Typical scapular pain or lumbar irradiation is frequently absent. Gradual dilation of the bile shaft, as in the carcinoma of the head of the pancreas, may not cause pain, but only a slight painful sensation in the epigastrium or the right upper quadrant.
The pain of the distension of the pancreatic canals is similar to that described when the common bile duct is dilated but, in addition, it is very frequently accentuated in a horizontal position and aligned in an upright position.
Obstruction of the bladder results in deaf suprapubic pain, usually weak in intensity. Restlessness, without the specific appearance of pain, may be the only sign of a dilated bladder in an over-the-go patient.
In contrast, acute obstruction of the intravescal portion of the ureter is characterized by severe suprapubic pain and on the flanks, irradiating to the penis, scrotum or superointernal area of the thigh. Obstruction of the ureteropelv junction is felt as a pain in the costovertebral angle, as long as the obstruction of the rest of the ureter is associated with pain in the flanks, which often extends to the corresponding part of the abdomen.
Vascular disorders are another common cause of abdominal pain. A common misconception, despite examples that prove otherwise, is that the pain associated with intraabdominal vascular disorders is sudden and terrible.
Pain of embolism or thrombosis of the upper mesenteric artery or that due to an imminent rupture of an abdominal aortic aneurysm is definitely severe and diffuse. Frequently the patient with upper mesenteric artery occlusion has only continuous, gentle diffuse pain for 2 to 3 days before vascular collapse or findings of the presence of peritoneal inflammation.
Early and seemingly insignificant discomfort is caused by hyperperistaltic rather than peritoneal inflammation. Of course, the absence of sensitivity and stiffness in the presence of diffuse and continuous pain in a patient who probably has a tipping disease is characteristic of upper mesenteric artery occlusion.
Abdominal pain with irradiation in the sacral region, flanks or genitals will always signal the possible presence of a ruptured abdominal aortic aneurysm. This pain may persist within a period of several days before rupture and collapse occur.
There would still be pain in the abdominal wall, which is usually constant and persistent. Movement, prolonged orthostatism and pressure accentuate discomfort and muscle spasm. In the case of hematoma of the teat of the right abdominal muscles, commonly found in combination with anticoagulant therapy, a formation can be palpated in the lower abdomen. Simultaneous involvement of muscles of other parts of the body usually helps to differentiate the myositis of the abdominal wall from an intraabdominal process that can cause pain in the same region.
The subject of pain irradiation in abdominal diseases must now be treated separately. Abdominal irradiated pain in the thorax, spinal cord or genitals can be a difficult diagnostic problem, as diseases of the upper region of the abdominal cavity, such as acute cholecystitis or perforated ulcer, are frequently associated with chest complications.
One point of view, often forgotten, is that the possibility of intraoracic disease should be considered in the case of each patient with abdominal pain, especially if the pain is in the upper abdomen.
Thus it is noted the need to identify the presence or absence of myocardial or pulmonary infarction, pneumonia, pericarditis or esophageal diseases (intraoracic diseases that most often take the masked form of abdominal "problems"). Diaphragmatic pleurisy resulting from pneumonia or pulmonary infarction can cause pain in the upper right quadrant and sub-lalaviral area, the second irradiation being clearly evidenced by the irradiated subscapular pain caused by acute distension of the extrahepatic bile tree.
Irradiated pain of hepatic origin is often accompanied by immobility of the hemitorace involved, with a reduction in respiratory movements more pronounced than that observed in the presence of intraabdominal disease. In addition, abdominal muscle spasm apparently caused by irradiated pain will diminish during the breathing breathing phase, persistence throughout both respiratory phases demonstrating abdominal origin.
Palpation of the area with irradiated pain of the abdomen will not usually accentuate the pain and, in many situations, does seem to smooth it. Frequent coexistence of thoracic and abdominal disease can be misleading and confusing, so differentiation can be difficult or impossible.
For example, the patient with known biliary tract disease often has epigastric pain during myocardial infarction, or the bile colic may be irradiated to the precordial region or left shoulder in the case of a patient who has previously suffered from angina (this is the phenomenon of irradiation of pain in a previously affected area).
Irradiated pain in the spine, which usually involves compression or irritation of nerve roots, is characteristically intensified by certain movements, such as coughing, sneezing or straining, and is associated with hyperesthesia of the dermatomas involved.
Irradiated pain in the abdomen from the testicles or seminal vesicles is usually accentuated by the smallest pressure on each of these organs, abdominal discomfort having a painful character without being well located.
I will now address abdominal metabolic seizures, with pain of metabolic origin likely to simulate almost any type of intraabdominal disease. So whenever the cause of abdominal pain is obscure, metabolic origin should be considered.
Examples can be listed: pain in porphyria and pain in Saturnic colic that are difficult to distinguish from that of intestinal occlusion (severe hyperperistaltism being an important feature of both). Pain in uremia or diabetes is not specific, and pain and sensitivity frequently change in location and intensity, and examples could continue.
And finally, there's the neurogenic causes of abdominal pain. Causal pain can occur in diseases with sensory nerve damage and is burn-like and is usually limited to the distribution territory of a peripheral nerve. Normal stimuli, such as touch and temperature changes, can be converted into this type of pain.
Although pain can be precipitated by gentle palpation, stiffness of the abdominal muscles is absent and breathing is not influenced, the distension of the abdomen is unusual, and the pain is not related to food consumption.
Pain originating in the spinal nerves or roots appears and disappears suddenly and is of the lancinant type and can be caused by herpes zoster, favored by arthritis, tumors, hernia of the pulpy nucleus, diabetes or syphilis (and this type of pain is not associated with food consumption, abdominal distension or changes in breathing).
Severe muscle spasm, as in gastric bouts of dorsalis tabes, is common but improved or is not accentuated by abdominal palpation, the pain being accentuated by the movement of the spine, limited to a few dermatomas and hyperesthesia is very common.
Psychogenic pain has a hard-to-define mechanism. The most common problem is the hysteria of the young person or adolescent, who complains of abdominal pain and frequently loses an appendix or other organs because of it. Ovulation and any other natural phenomenon that causes mild abdominal discomfort can sometimes be perceived as an abdominal catastrophe.
This pain varies enormously in type and localization and is not usually related to meals, with nausea and vomiting rarely noticed. Spasm is rarely induced in the abdominal muscles and, if present, does not persist, especially if attention can be distracted.
Persistent localized sensitivity is rare and, if any, muscle spasm in the area is inconsistent and often absent. Limiting the depth of breathing is the most common respiratory abnormality, but it is part of the sensation of suffocation and choking, being part of the state of anxiety.
Even if the title seems to have everything treated in the "section" pain, you will see that this group has its reasons.
Abdominal pain is one of the most considerable challenges in terms of diagnosis, requiring experience, since the most catastrophic developments can only be announced by very subtle symptoms and signs.
One of the main causes of abdominal pain is inflammation of the parietal peritoneum. The pain due to this inflammation is continuous and deaf and is located directly above the inflamed region, its exact location is possible because it is transmitted through the somatic nerves that irritate the parietal peritoneum. The intensity of pain is dependent on the type and quantity of foreign substance to which peritoneal surfaces are subjected over a certain period of time.
For example, the sudden release into the peritoneal cavity of a small amount of sterile acidic gastric juice causes more pain than the same amount of massively contaminated neutral faeces. Enzymatic active pancreatic juice causes more pain and inflammation than the same amount of sterile bile, which does not contain strong enzymes.
Blood and urine are generally undetectable if their overflow into the peritoneal cavity is not sudden and massive. In the case of bacterial contamination, as happens in pelvic inflammatory disease, the pain is frequently of low intensity at first, until the multiplication of bacteria causes the development of irritants.
Very important is the speed with which the irritating material reaches the peritoneum, so in cases of perforated peptic ulcer can be associated with a different clinical appearance, depending only on the speed with which gastric juice penetrates into the peritoneal cavity.
Pain from peritoneal inflammation is invariably accentuated by pressure or changes in peritoneal tension, caused by palpation or movement, coughing or sneezing. Therefore, the patient with peritonitis lies quietly in bed, preferring to avoid movement, in contrast to the patient with colic, which will wriggle incessantly.
Another characteristic of peritoneal irritation is the reflex tonic spasm of the abdominal muscle, located in the region involved. The intensity of the tonic muscle spasm that accompanies peritoneal inflammation depends on the location of the inflammatory process, how it develops and the integrity of the nervous system. Spasm on a perforated retrocecal appendix or perforated ulcer in the lower peritoneal sac may be minimal or absent due to the protective effect of the overadjacent viscera.
A slow development process often greatly reduces the degree of muscle spasm. Major abdominal emergencies, such as perforated ulcers, have been repeatedly associated with minimal or occasionally undetectable pain or muscle spasm in debilitated, seriously ill or psychotic patients.
Another cause is obstruction of cavitational viscera. Pain of obstruction of cavitational abdominal viscera is classically described as intermittent or colicative. However, the lack of cramp character should not be misleading, as the distension of cavitational viscera can cause continuous pain, occasionally exacerbated. Although it is not as well located as the pain from inflammation of the parietal peritoneum, some useful generalizations can be made about its distribution.
Colicative pain of small intestine obstruction is usually periombilical or supraombilical and is poorly localized. As the intestine expands, with loss of muscle tone, the colicative nature of pain may become less obvious.
If the obstruction overlaps with strangulation, the pain may extend to the lower lumbar region if the root of the mesentery is treactated. colicative pain of colonic obstruction is of lower intensity than that of the small intestine and is often localized in the infraombilical region. Low back pain irradiation is common in colonic obstruction.
Sudden dilation of the bile tree produces a type of continuous pain rather than colic (the term bile colic being deceiving). Acute dilation of the gallbladder usually causes pain in the right upper quadrant, with irradiation to the right posterior region of the chest or at the tip of the right scapula, and distension of the common bile duct is often associated with epigastric pain that radiates to the upper part of the lumbar region.
Considerable variations are frequent, so differentiating between them may be impossible. Typical scapular pain or lumbar irradiation is frequently absent. Gradual dilation of the bile shaft, as in the carcinoma of the head of the pancreas, may not cause pain, but only a slight painful sensation in the epigastrium or the right upper quadrant.
The pain of the distension of the pancreatic canals is similar to that described when the common bile duct is dilated but, in addition, it is very frequently accentuated in a horizontal position and aligned in an upright position.
Obstruction of the bladder results in deaf suprapubic pain, usually weak in intensity. Restlessness, without the specific appearance of pain, may be the only sign of a dilated bladder in an over-the-go patient.
In contrast, acute obstruction of the intravescal portion of the ureter is characterized by severe suprapubic pain and on the flanks, irradiating to the penis, scrotum or superointernal area of the thigh. Obstruction of the ureteropelv junction is felt as a pain in the costovertebral angle, as long as the obstruction of the rest of the ureter is associated with pain in the flanks, which often extends to the corresponding part of the abdomen.
Vascular disorders are another common cause of abdominal pain. A common misconception, despite examples that prove otherwise, is that the pain associated with intraabdominal vascular disorders is sudden and terrible.
Pain of embolism or thrombosis of the upper mesenteric artery or that due to an imminent rupture of an abdominal aortic aneurysm is definitely severe and diffuse. Frequently the patient with upper mesenteric artery occlusion has only continuous, gentle diffuse pain for 2 to 3 days before vascular collapse or findings of the presence of peritoneal inflammation.
Early and seemingly insignificant discomfort is caused by hyperperistaltic rather than peritoneal inflammation. Of course, the absence of sensitivity and stiffness in the presence of diffuse and continuous pain in a patient who probably has a tipping disease is characteristic of upper mesenteric artery occlusion.
Abdominal pain with irradiation in the sacral region, flanks or genitals will always signal the possible presence of a ruptured abdominal aortic aneurysm. This pain may persist within a period of several days before rupture and collapse occur.
There would still be pain in the abdominal wall, which is usually constant and persistent. Movement, prolonged orthostatism and pressure accentuate discomfort and muscle spasm. In the case of hematoma of the teat of the right abdominal muscles, commonly found in combination with anticoagulant therapy, a formation can be palpated in the lower abdomen. Simultaneous involvement of muscles of other parts of the body usually helps to differentiate the myositis of the abdominal wall from an intraabdominal process that can cause pain in the same region.
The subject of pain irradiation in abdominal diseases must now be treated separately. Abdominal irradiated pain in the thorax, spinal cord or genitals can be a difficult diagnostic problem, as diseases of the upper region of the abdominal cavity, such as acute cholecystitis or perforated ulcer, are frequently associated with chest complications.
One point of view, often forgotten, is that the possibility of intraoracic disease should be considered in the case of each patient with abdominal pain, especially if the pain is in the upper abdomen.
Thus it is noted the need to identify the presence or absence of myocardial or pulmonary infarction, pneumonia, pericarditis or esophageal diseases (intraoracic diseases that most often take the masked form of abdominal "problems"). Diaphragmatic pleurisy resulting from pneumonia or pulmonary infarction can cause pain in the upper right quadrant and sub-lalaviral area, the second irradiation being clearly evidenced by the irradiated subscapular pain caused by acute distension of the extrahepatic bile tree.
Irradiated pain of hepatic origin is often accompanied by immobility of the hemitorace involved, with a reduction in respiratory movements more pronounced than that observed in the presence of intraabdominal disease. In addition, abdominal muscle spasm apparently caused by irradiated pain will diminish during the breathing breathing phase, persistence throughout both respiratory phases demonstrating abdominal origin.
Palpation of the area with irradiated pain of the abdomen will not usually accentuate the pain and, in many situations, does seem to smooth it. Frequent coexistence of thoracic and abdominal disease can be misleading and confusing, so differentiation can be difficult or impossible.
For example, the patient with known biliary tract disease often has epigastric pain during myocardial infarction, or the bile colic may be irradiated to the precordial region or left shoulder in the case of a patient who has previously suffered from angina (this is the phenomenon of irradiation of pain in a previously affected area).
Irradiated pain in the spine, which usually involves compression or irritation of nerve roots, is characteristically intensified by certain movements, such as coughing, sneezing or straining, and is associated with hyperesthesia of the dermatomas involved.
Irradiated pain in the abdomen from the testicles or seminal vesicles is usually accentuated by the smallest pressure on each of these organs, abdominal discomfort having a painful character without being well located.
I will now address abdominal metabolic seizures, with pain of metabolic origin likely to simulate almost any type of intraabdominal disease. So whenever the cause of abdominal pain is obscure, metabolic origin should be considered.
Examples can be listed: pain in porphyria and pain in Saturnic colic that are difficult to distinguish from that of intestinal occlusion (severe hyperperistaltism being an important feature of both). Pain in uremia or diabetes is not specific, and pain and sensitivity frequently change in location and intensity, and examples could continue.
And finally, there's the neurogenic causes of abdominal pain. Causal pain can occur in diseases with sensory nerve damage and is burn-like and is usually limited to the distribution territory of a peripheral nerve. Normal stimuli, such as touch and temperature changes, can be converted into this type of pain.
Although pain can be precipitated by gentle palpation, stiffness of the abdominal muscles is absent and breathing is not influenced, the distension of the abdomen is unusual, and the pain is not related to food consumption.
Pain originating in the spinal nerves or roots appears and disappears suddenly and is of the lancinant type and can be caused by herpes zoster, favored by arthritis, tumors, hernia of the pulpy nucleus, diabetes or syphilis (and this type of pain is not associated with food consumption, abdominal distension or changes in breathing).
Severe muscle spasm, as in gastric bouts of dorsalis tabes, is common but improved or is not accentuated by abdominal palpation, the pain being accentuated by the movement of the spine, limited to a few dermatomas and hyperesthesia is very common.
Psychogenic pain has a hard-to-define mechanism. The most common problem is the hysteria of the young person or adolescent, who complains of abdominal pain and frequently loses an appendix or other organs because of it. Ovulation and any other natural phenomenon that causes mild abdominal discomfort can sometimes be perceived as an abdominal catastrophe.
This pain varies enormously in type and localization and is not usually related to meals, with nausea and vomiting rarely noticed. Spasm is rarely induced in the abdominal muscles and, if present, does not persist, especially if attention can be distracted.
Persistent localized sensitivity is rare and, if any, muscle spasm in the area is inconsistent and often absent. Limiting the depth of breathing is the most common respiratory abnormality, but it is part of the sensation of suffocation and choking, being part of the state of anxiety.
Understanding,
love and gratitude on this Sunday, relaxation and/ or fun!
Dorin, Merticaru