Acute Abdominal Pain

Manual descriptions of abdominal pain are of limited use because all people react differently to pain. While some, v. a. older people endure their pain stoically, others tend to exaggerated pain sensations. Children, toddlers and even older people sometimes find it difficult to locate the pain.

Abdominal pain occur frequently and often remain without consequence. However, acute and severe abdominal pain is usually a sign of intra-abdominal disease. They may be the only indication of the need for a surgical procedure and must be clarified immediately: For example, under certain circumstances gangrene or perforation of the bowel in less than 6 hours after the acute pain event develop (eg interruption of intestinal. blood supply through a strangulation or an arterial embolus). Acute abdominal pain are of particular concern in very young or very old patients and in those with HIV infection or immunosuppressive therapy (incl. Corticosteroids). Manual descriptions of abdominal pain are of limited use because all people react differently to pain. While some, v. a. older people endure their pain stoically, others tend to exaggerated pain sensations. Children, toddlers and even older people sometimes find it difficult to locate the pain. The pathophysiology of visceral pain comes from the abdominal viscera, which are innervated by the autonomic nervous system and pain sensations v. a. cause by expansion or muscular contraction – not by cutting, tearing or local irritation. The visceral pain is typically vague, dull and nausea-triggering. It is difficult to pinpoint and is often related to areas corresponding to the embryonic output of the structure in question. So structures generate the embryonic foregut (stomach, duodenum, liver and pancreas) pain in the upper abdomen, the embryonic midgut (small intestine, proximal colon and Appendix) Pain in the Periumbilikalgegend and structures from the embryonic hindgut (distal colon and urogenital tract), pain in lower abdomen , The somatic pain comes from the parietal peritoneum, which is innervated by somatic nerves that respond to infectious, chemical or originating from other inflammatory processes stimuli. Somatic pain is sharp and easy to locate. Radiating pain is removed perceived by its place of origin and arises from the fact that the nerve fibers converge in the spinal cord. Common examples of referred pain are shoulder blade pain when biliary colic, groin pain in renal colic and shoulder pain in diaphragmatic irritation, z. For example, by bleeding or infection. Peritonitis Peritonitis is an inflammation of the abdominal cavity. Their most serious cause is a perforation in Gastrointestinalrakt (Acute perforation), which immediately leads to a chemical inflammation and infection with intestinal pathogens. Peritonitis can occur at any abdominal disease in the sequence that causes severe inflammation (z. B. appendicitis [Appendicitis] diverticulitis [diverticulitis], strangling ileus [ileus], ??pancreatitis [pancreatitis], inflammation in the pelvic area [Pelvic Inflammatory Disease (PID)], Mesenterialarterienischämie [Acute mesenteric ischemia]). Peritoneal irritation with the following peritonitis also by intraperitoneal bleeding of any origin caused (eg. B. ruptured aneurysm, trauma, surgical procedures and ectopic pregnancy [ectopic]). Barium causes severe clumping and peritonitis and should therefore not be given to patients with suspected perforation of the gastrointestinal tract. However, water-soluble contrast agents can be used safely. Peritoneosystemische shunts, drainages and dialysis catheter in the peritoneal cavity predispose well as ascites fluid for infectious peritonitis. Rarely occurs a so-called. Spontaneous bacterial peritonitis, in which the peritoneal cavity is infected by bacteria from the blood. Peritonitis causes fluid shift into the peritoneal cavity and intestines, leading to severe dehydration and electrolyte imbalance. Respiratory distress syndrome can develop rapidly, kidney failure, liver failure and disseminated intravascular coagulation can follow. The patient is given a mask-like face, the “Hippocratic face” the face of a dying man. Death occurs within days. Etiology Many intra-abdominal diseases produce pain (localization of abdominal pain and possible causes.); Some are trivial, but others immediately life-threatening and require immediate diagnosis and surgery. These include ruptured abdominal aortic aneurysms (AAA, abdominal aortic aneurysms (AAA)), perforated viscera, Mesenterialarterienischämie and ruptures in ectopic pregnancy. More are also very serious and almost as urgent (ileus, appendicitis and severe acute pancreatitis). A number of extraabdominellen diseases also cause acute abdominal pain (Extraabdominal causes of abdominal pain). Localization of abdominal pain and possible causes. Extraabdominal causes of abdominal pain abdominal wall hematoma in the rectus abdominis urogenital tract testicular torsion Infectious herpes zoster Metabolically Alcoholic ketoacidosis corticosteroid insufficiency diabetes che ketoacidosis hypercalcemia porphyria sickle cell anemia chest costochondritis myocardial infarction pneumonia pulmonary embolism radiculitis toxic spider bite (Black Widow) heavy metal poisoning Methanol poisoning opioid withdrawal scorpion sting abdominal pain in neonates, infants and young children has numerous causes that do not occur in adults. This causes necrotizing enterocolitis, meconium, pyloric stenosis (hypertrophic pyloric stenosis), volvulus of the intestine with intestinal malrotation (malrotation of the intestine), anal atresia (anal atresia), intussusception (intussusception), and intestinal obstruction by atresia (jejunoileal atresia). Clarification principle is carried out clarification at low or severe pain in the same way, although in severe pain already begun often parallel to the clarification of the therapy and a surgeon is consulted. The history and physical examination exclude all but a few possible causes in general, the final diagnosis is in addition by adequate laboratory tests and imaging procedures. Life-threatening causes should always be excluded before turns his attention to less serious diagnoses. In critically ill patients with severe abdominal pain the most important diagnostic procedure can be a quick surgical exploration. For less ill patients is often attentive watchful waiting and diagnostic evaluation for the best. History A thorough history can lead to the diagnosis (see Fig. Medical history in patients with acute abdominal pain) in many cases. Particularly important is the localization (localization of abdominal pain and possible causes.) And the character of the pain-like symptoms in the history and associated symptoms. Accompanying symptoms such as gastroesophageal reflux, nausea, vomiting, diarrhea, constipation, jaundice, melena, hematuria, hematemesis, weight loss and mucus or blood in the stool lead directly to targeted further clarification. A detailed drug history includes prescription medications, illegal drug use and alcohol abuse. Many medications cause irritation of the gastrointestinal tract. Prednisone and immunosuppressive drugs can have a pronounced inflammatory reaction such. lead example in perforation or peritonitis, prevent and lower pain intensity, tenderness or lower leukocytosis, as one would have expected. Anticoagulants increase the risk of bleeding and bruising. Alcohol predisposes to pancreatitis. Anamnesis in patients with acute abdominal pain Question Possible answers and indications Where is the pain? See localization of abdominal pain and possible causes. What is the nature of the pain? Acute waves of a sharp, associated with Einklemmungsgefühl pain which “robs the breath” (renal or biliary colic) waves of a dull pain with vomiting (bowel obstruction) colic, which merge into continuous pain (appendicitis, strangulation, Mesenterialarterienischämie) Sharp duration pain caused by movement is exacerbated (peritonitis) tearing pain (dissecting aneurysm) Dull pain (appendicitis, diverticulitis, pyelonephritis) Have you previously this pain? “Yes,” suggests a recurrent problem such. B. ulcer disease, gallstone colic, diverticulitis or Mittelschmerz Is the pain suddenly occurred? Suddenly, “such as light flick” Less (perforated ulcer, kidney stone, ectopic pregnancy, ovarian or testicular torsion, some ruptured aneurysms ruptured) suddenly most other causes How strong is the pain? Severe pain (perforated hollow organ, kidney stone, peritonitis, pancreatitis) pain is out of proportion to physical findings (mesenteric ischemia) beam of pain in other body regions? Right scapula (gallbladder pain) left shoulder region (ruptured spleen, pancreatitis) pubis or vagina (kidney pain) back (ruptured aortic aneurysm, pancreatitis, occasionally perforated ulcer) What relieves the pain? Antacids (peptic ulcer) As silent loungers (peritonitis) What other symptoms accompany the pain? Vomiting precedes the pain, and is followed by diarrhea (gastroenteritis) delayed vomiting, lack of bowel sounds and air outlet (acute intestinal obstruction, delay increases, the deeper the bowel obstruction) Heavy vomiting goes vigorous epigastric, left-side thoracic or shoulder pain advance (perforation of the intra-abdominal esophagus by vomiting) It is important to check for known diseases and previous abdominal surgery. Women should be asked if they pregnant sind.Körperliche investigation The general physical condition is important. A happy, satisfied patient rarely has a serious problem, as opposed to patients who are fearful, pale and kaltschweißig and obviously in pain. Blood pressure, pulse, consciousness and other peripheral signs of circulation must be observed. However, the main focus is on the abdomen, beginning with inspection and auscultation, followed by palpation and percussion. Rectal and gynecological (for women) investigation are essential to locate pain, lesions and blood. Palpation begins cautiously, initially far from the pain region; particularly painful regions to be registered, as well as the existence of guarding, hardened abdominal wall and knocking pain (all signs of Peritonealreizung) and of resistance. The guarding is an involuntary contraction of the abdominal muscles, which is slower and more durable than the fast arbitrary flinch in vulnerable and anxious patients. Rebound tenderness is a clear flinch in response to a rapid retraction of the hand of the examiner. The inguinal and all operative scars should be palpated for the presence of hernias werden.Warnhinweise Certain findings suggest a more serious etiology: severe pain symptoms of shock (. Eg tachycardia, hypotension, sweating, confusion) Peritonitissymptome abdominal rigidity interpretation of the findings a distended abdomen, especially if surgical scars, tympany are present in the percussion and superscript peristalsis or stormy borborygmi, justified the suspicion of intestinal obstruction. Severe pain in a patient with a silent abdomen that is as quiet as possible, suggests peritonitis; the localization of the pressure sensitivity allows conclusions about the etiology to (z. B. right upper quadrant suspicious suspicious for cholecystitis, in the lower right quadrant of appendicitis), but is not diagnostic. Back pain with shock steer the ruptured abdominal aortic aneurysm suspected (AAA), particularly if a pressure-sensitive, pulsating mass is present. Shock and vaginal bleeding in a pregnant woman are suspected of ruptured ectopic pregnancy. Ecchymosis at the rib cage (Gray Turner’s sign) or around the navel (Cullen’s sign) suggest a hemorrhagic pancreatitis, but are not very sensitive to this disease. Often the history justified the suspicion (s. Medical history in patients with acute abdominal pain). Mild to moderate pain during active peristalsis with normal bowel sounds create a nonsurgical disease close (z. B. gastroenteritis), but it can also be an early manifestation of a serious illness. A patient that winds back and forth in trying to find a comfortable position is more likely to suffer an obstructive mechanism (z. B. renal or biliary colic). For example, make previous history of surgery on the abdomen, the presence of adhesions likely. A generalized atherosclerosis increases the likelihood of a myocardial infarction, an abdominal aortic aneurysm or Mesenterialarterienischämie. HIV infection makes infectious causes wahrscheinlich.Testsverfahren tests are selected according to the clinical suspicion. Pregnancy test in the urine for all women of childbearing age selected imaging examinations based on the diagnosis standard tests (such as complete blood count, laboratory chemistry, urinalysis) are performed normally, but often due to low specificity of limited relevance. Patients with more serious disease may have normal levels. Pathological findings do not indicate a specific diagnosis towards (as urinalysis, a pyuria or hematuria in a variety of diseases show) and may also be present if no serious illness is. One exception is the serum lipase, which directs the urgent suspected acute pancreatitis. For all women of childbearing age, a pregnancy test should be carried out in the urine, because a negative result rules out the existence of a ruptured ectopic pregnancy. Abdomenübersichtsaufnahmen in a horizontal and an upright position and a chest X-ray (abdomen in the left lateral position or anteroposterior thorax in patients who can not stand) should be performed in suspected perforation or closure. However, this survey radiographs are rare diagnosis of other diseases and therefore have otherwise not be automatically made. Ultrasound examinations should be performed in cases of suspected disease of the bile ducts or ectopic pregnancy (transvaginal probe) and appendicitis in children. The ultrasound can also diagnose an abdominal aortic aneurysm, but not always reliable rupture. A spiral CT is the method of choice for suspected kidney stones. A CT with oral and intravenous contrast agent is diagnostic in 95% of patients with severe abdominal pain and Laparotomiefrequenz has decreased. However, advanced imaging should not delay surgical intervention when symptoms are highly suspicious or clearly. Therapy Some clinicians believe that pain relief before the diagnosis can be confirmed conceal the disease and can complicate the investigation. On the other hand moderate doses of intravenous painkillers not disguise (such. As fentanyl 50-100 micrograms, morphine 4-6 mg) Peritonealzeichen, but often facilitate the study because they take away the fear and pain. Important points after life-threatening causes should be sought first. In women of childbearing age, pregnancy is ruled out. For signs of peritonitis, shock and obstruction to look for. Blood tests are of minimal value.

Health Life Media Team

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