Chronic Abdominal Pain

History

ChloridePP

Character: colicky pain builds and subsides, suggesting hollow organ pain. Sharp, stabbing pain suggests peritoneal involvement.

Colicky pain - coming and going - tends to be visceral, ie gallbladder, ileum, ureter.

A constant, localized pain points towards somatic peritoneal origin, with causes including inflammation or infection - pancreatitis, cholecystitis, or appendicitis.

 

Location

epigastric pain can come from the stomach, duodenum, or pancreas.

right upper quadrant pain can come from the biliary tree or liver (cholecystitis)

periumbilical pain can come from the small intestine, appendix, or colon.

sacral pain can come from the rectum.

hypogastric pain can come from the colon, bladder, or uterus.

 

 

 

 

Onset: sudden onset can accompany

 

Radiation: Pancreatic pain tends to radiate through to the middle of the back. Gallbladder pain tends to radiate around to the right side. Renal pain starts in the flank but can radiate to the groin.

• back pain - retroperitoneal causes: aortic aneurysm, pancreatitis, posterior duodenal ulcer, or pyelonephritis
• sacral or pelvic pain: ovarian cysts, PID, pelvic abscess, ectopic pregnancy

 

 

Intensity: rate from 1-10, with 10 being the most severe pain the patient has experienced.

• Severe pain suggests ischemia or infarction, or generalized peritonitis (ie perforation)

 

Duration: waves of pain suggest rhythmic muscle contractions, such as those of peristalsis, are involved.

 

Events Associated: A pertinent review of systems based on the differential.

 

Provoking and Palliating Factors: The impact of certain behaviours can point to system of origin. Changes with eating, bowel movements, or vomiting suggest pain is GI in origin. Increased pain with exertion suggests cardiac causes.

 

 

Associated Symptoms

• fever and chills: inflammation or sepsis
• distension or bloating: intermittent with IBS, progressive with mass or ascites
• weight loss: malignancy or IBD
• change in bowel habits: malignancy
• rectal bleeding
• nausea/vomiting: pain reflex, gastroenteritis, bowel obstruction
• jaundice: liver, biliary tree, gallbladder or hemolysis
• vaginal discharge: PID

 

past history

• previous episodes
• previous surgery
• medications
• constipation (potentially leading to obstruction)

Physical Exam

The physical exam can reveal important clues, and should be started with simple inspection of the state of the patient. Weight loss, pignmentation, and signs of dehydration are all possible.

Auscultation can be used to assess bowel sounds and discover bruits.

Palpation should be done gently, starting away from area of pain. Percussion can be used to measure organ size and determine presence of ascites. A pulsatile mass suggests aneurysm, and peripheral pulses should be felt.

Peritonitis is an important finding, first suspected with pain, involuntary guarding or rigidity while taking a deep breath (the most sensitive test). Percussion tenderness may be provocative. Absent bowel sounds are usual, as is rebound tenderness (though this is an inhumane test; avoid it).

Right upper quadrant pain can sometimes be associated with a palpable mass in Crohn's disease.

Rectal examination is important to rule out tumour obstruction.

Pelvic examination should be done to rule out pelvic infammatory disease.

Lab Investigations

CBC: signs of infection, anemia, lymphoma

liver labs: hepatic or biliary tract involvement

coagulation profile: especially important for people on anticoagulants

electrolytes, glucose: ketoacidosis, hypercalcemia

amylase and lipase: pancreatitis

b-HCG for pregancy

arterial blood gases: metabolic acidosis in ischemia, peritonitis, pancreatitis

urinalysis and renal function

culture and staining

fecal occult blood test: upper GI bleeds

 

 

Diagnostic Imaging

ECG: MI

CXR: free gas, pneumonia

abdominal X-ray: chronic pancreatitis, constipation

ultrasound: intra-abdominal abscess, gallstones, chronic cholelithiasis, ovarian cyst, AAA, renal tumour

endoscopy: peptic ulcer disease, gastritis, or tumours

colonoscopy: diverticulitis, colonic ischemia

CT: pancreatitis, pancreatic carcinoma, AAA, diverticulitis

IVU: stones, renal tumours

ERCP: chronic pancreatitis, pancreatic carcinoma

small bowel enema: Crohn's disease, Meckel's diverticulum

HIDA scans can be used to evaluate gallbladder conditions, but takes time