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ACUTE ABDOMEN ( PAIN)

ACUTE ABDOMEN ( PAIN). DR.RAMATE WONGWILAIRAT. MD SOMDEJPHAJAOTAKSIN HOSPITAL. OUTLINE. DIFINITION ACUTE ABDOMEN ANATOMY AND PATHOPHYSIOLOGY ABDOMINAL PAIN ETIOLOGY OF ACUTE ABDOMEN CLINICAL ASSESSMENT HISTORY TAKING PHYSICAL EXAMINATION

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ACUTE ABDOMEN ( PAIN)

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  1. ACUTE ABDOMEN (PAIN) DR.RAMATE WONGWILAIRAT. MD SOMDEJPHAJAOTAKSIN HOSPITAL

  2. OUTLINE • DIFINITION ACUTE ABDOMEN • ANATOMY AND PATHOPHYSIOLOGY ABDOMINAL PAIN • ETIOLOGY OF ACUTE ABDOMEN • CLINICAL ASSESSMENT • HISTORY TAKING • PHYSICAL EXAMINATION • LABORATORY INVESTIGATION • IMAGING STUDY • KEY FEATURES OF COMMON CAUSES OF ACUTE ABDOMINAL PAIN • QUESTION

  3. DIFINITIONdiagnosis and treatment immediatelymedical or surgical conditiontimimg 1-4 wk

  4. pathophysiology Anatomy relate to abdominal pain • Peritoneum visceral and parietal peritoneum • abdominal organ intraabdominal and retroperitoneal organ • Abdominal wall

  5. Intraabdominal organ

  6. NERVE 1.Parietal peritoneum Abdominal wall inferior epigastric a. somatic sipinal nerve T7-L2 2.Intraabdominal organ Visceral peritoneum celiac trunk , SMA , IMA autonomous system

  7. Type of abdominal pain • Visceral pain • Somatic pain • Refered pain • Migratory pain

  8. Visceral pain abdominal organ • parasympathetic and sympathetic • C-fiber ,slow transmitter • dull and crampy not localized • midline pain (bilaterallity) • Stretching , compression , torsion, distention

  9. Visceral pain foregut epigastium midgut periumbilical hindgut suprapubic

  10. Somatic pain Irritate to Parietal peritoneum A-delta fiber , spinal nerve fast transmitters sharp and exquisite localized peritoneal sign : localized tender , guarding

  11. Migratory pain Acute appendicitis

  12. Migratory pain Peptic ulcer perforate

  13. Refered pain • pain feltat asite distant from a disease process Pathophysiology multiple pain afferents in the posterior horn of spinal cord

  14. Common nerve root

  15. Spinal nerve root C4 • Right shoulder diaphragm gall bladder liver capsule peumoperitomeun • Left shoulder diaphragm spleen tail of pancrease stomach splenic flexure of colon

  16. The thoracic affernt T6-T8 • Right scapular gall bladder biliary tree • Left scapular spleen tail of pancrease

  17. Refered pain • Groin/genitalia ureter kidney • Back- midline pancrease duodenum aorta

  18. ETIOLOGY OF ACUTE ABDOMINAL PAIN

  19. INFLAMMATION /INFECTION • PERITONEUM • PRIMARY PERITONITIS ; ASCITES • SCONDARY PERITONITIS: HOLLOW VICUS ORGAN PERFORATE • TERTIALY PERITONITIS : TB • B. HOLLOW VICUS ORGAN • APPENDICITIS , CHOLECYSTITIS , GASTROENTERITIS • DIVERTICULITIS, PEPTIC ULCER • C. SOLID VISCERA • PANCREATITIS , HEPATITIS • D. MESENTERY • LYMPADINITIS • E. PELVIC ORGAN • PID , ENDOMETRIOSIS , TUBOOVARIAN ABSCESS

  20. 2. MECHANICAL ( OBSTRUCTION /ACUTE DISTENTION) • HOLLOW VISCUS ORGAN • GUT OBSTRUCTION ; HERNIA ,TUMOR INTUSSUSCEPTION • BILIARY TRACT OBSTRUCTION: CALCULI TUMOR • SOLID ORGAN • ACUTE HEPATOMEGALY , SPLENOMAGALY • MESENTERY • OMENTAL TORSION • PELVIC ORGAN • OVARIAN CYST , ECTOPIC PREGNANCY

  21. 3. VASCULAR • INTRAPERITONEAL BLEEDING • RUPTURE LIVER AND SPLEEN • RUPTURE AORTA , SPLENIC ANEURYSM • RUPTURE ECTOPIC PREGNANCY • INTRAPERITONEAL ISCHEMIA • MESENTERY THOMBOSIS • HEPATIC INFRACION : TOXIMIA , PURPURA • SPLENIC INFRACTION • OMENATAL INFRACTION

  22. Abdominal pain pathway Intraabdominal organ Parietal peritoneum Somatic pain Visceral pain Refer pain vagus Spinal nerve sympathetic History taking PE investigation Spinothalamic tract Inflammation Infection Obstruction Distention Bleeding infarction

  23. HISTORY TAKING • CLINICAL ASSESSMENT

  24. duration • Site of pain • maximum point of pain • initial location of pain

  25. Nature in onset of pain • Sudden onset hollow viscus organ perforate ischemic process passage stone • Gradual onset inflammmation process

  26. Progression of pain • Intermittent pain Colicky seconds( bowel) minutes (ureteric) tens of minutes (biliary) • Constant pain peptic ulcer, pancreatitis • Subside early colic • More severe late colic

  27. Characteristic of pain • Burning peptic ulcer • Sharp or stabbing ureteric colic • Crampy gut ostruction gastroenteritis

  28. Aggravate or relieve of pain • Posture lying still rolling around • GI function type of food

  29. Associated symptom • Vomitting type of vomitus timing frequent • Anorexia • Bowel habits • fever

  30. Refered pain or radiate pain

  31. HISTORY TAKING age menstruation past illness familial history organ systemic review medication

  32. CLINICAL ASSESSMENT Physical examination

  33. BASIC CONSIDERATION A large number of different structures Small abdominal cavity Pelvic cavity and dome of diaphargm Abdominal wall muscle The brain cannot distinguish depend on tecnique of examination

  34. preparation • The environment warm and private good daylight and oblique • The bed hard bed with a backrest rest head on pillow and flex hip

  35. preparation • Exposure uncover the patients from nipple to knees genitalia and hernia orifices • Get the patients to relax rest his arm on his side breathe regularly and slowly

  36. preparation • The position of the examination right side , hand and forearm horizontal position clean and warm hand short nail

  37. The routine of examination • Inspection • Auscultation • Percussion • palpation

  38. INSPECTATION Look at the whole abdomen symmetry buldging : organomegaly , mass distended : gas , ascitis, fat , mass scaphoid abdomen: malnutrition

  39. inspectation • Scar • Spider nevi , superficial vien dilate • Visible peristalsis • Grey tunner and cullen sign • Hernia • umbilicus

  40. Spider nevi

  41. auscultation • Bowels sound (all quadrants) peritalsis ; gurgling noise…mixture gas and air low pitched , every few seconds no bowel sound over a 15-30 seconds paralytic ileus intestinal obtruction : high pitch , freqent • Systolic bruit aortic or iliac aneurysm • Splashing sounds gastric outlet obstruction

  42. percussion

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