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Simposium 5

Non Surgical Approach of


Abdominal Pain
dr. Putut Bayupurnama, Sp.PD-KGEH
Div. Gastroenterology & Hepatology Bag/SMF Ilmu Penyakit Dalam RSUP Dr Sardjito/FK-UGM

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Non Surgical Approach


Putut BayupurnamaPain
of Abdominal
Div. Gastroenterology & Hepatology
Bag/SMF Ilmu Penyakit Dalam
RSUP Dr Sardjito/FK-UGM,
Yogyakarta

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Introduction

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Abdominal pain
a complaint seen commonly in
the outpatient setting
may often be a symptom of a disease
process with a benign course
it may also herald a severe, life-threatening
condition
demands prompt recognition and
management
general understanding of abdominal
anatomy, physiology, and pathophysiology
is vital

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

The abdominal organs

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Three Types of Abdominal Pain


1. Visceral

Autonomic nerves
Poorly localized
Dull ache, colicky
Location is often midline
Felt in the abdominal wall in the
area of embryonic origin of the pain

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Cont
2. Somatic

Typically sharp
well localized
Irritation of the parietal peritoneum
parietal innervation is unilateral
Felt directly over area of inflammation

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Cont
3. Referred pain
felt in cutaneous site distant from diseased
organ
visceral afferents carrying stimuli from a
diseased organ enter the spinal cord at the
same level as somatic afferents
typically well localized
Awareness of the anatomy and innervation of
the abdominal viscera allows one to formulate
a differential diagnosis of abdominal pain
based on the location and distribution of the
pain

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

History
Where is your pain? Has it always been there?
Does the pain radiate anywhere?
How did the pain begin (sudden vs. gradual
onset)? How long have you had the pain?
What does the pain feel like?
On a scale of 010, how severe is the pain?
Does anything make the pain better or worse?
Have you had the pain before?

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

History cont
Although location of abdominal pain
guides the initial evaluation, associated
signs and symptoms can help narrow
the differential diagnosis
change in bowel habit, blood loss per
rectum
Presence of nausea/vomiting, fullness,
bloating, belching, early satiety, are signs of
an upper GI cause (dyspeptic symptoms)
Respiratory symptoms point to basal
pneumonia causing diaphragmatic irritation
Dysuria or haematuria indicates a renal
cause

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Physical Examination
General appearance
patient with peritonitis often lies completely
a patient with renal colic may writhe in pain

Vital Signs
Abdomen

Inspection
Auscultation
Percussion
Palpation

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Differential Diagnosis
Abdominal Pain based on
Region

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

The position of abdominal pain used


abdomen region

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Peptic Ulcer

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Experimental pain in the stomach


Drewes AM et al. Gut 1997;41-753-757

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Differential Diagnosis: RUQ pain

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Differential Diagnosis: LUQ and


Epigastric pain

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Differential Diagnosis: RLQ Pain

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Gynecologic Causes of RLQ Pain

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Differential Diagnosis: LLQ

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Differential Diagnosis: Periumbilical

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Pain Patterns of
Abdominal Disease

Simposium Kedokteran
Nasional Clinical Updates 2015|14-15
Maret 2015|FK UGM 1983 & 2009
Substernal
Epigastric

Onset

Chronic

Disease /
diagnosis

Refluks
esofagitis

Pain quality

Acute

Acute

Cholecystitis

Pancreatitis

Burning; after Severe, history


meal / at
of chronic ulcer
night
pain

Steady / biliary
colic

Steady

Pain referral

Left arm

back

Tip of scapula

Back

Pain
progression

Upper chest

Rapid, over entire Intensity


peritoneal
abdomen
increases steady sign
over hours to
RUQ

Associated
finding

Perforated
duodenal ulcer

Acute

Guarding ; free
peritonel air

Fever, gall
stone,

Nausea,
vomiting

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Epigastric
Onset

chronic

chronic

chronic

Disease /
diagnosis

Duodenal ulcer

Gastric ulcer

Non ulcer dyspepsia

Pain quality

Gnawing, burning
before meals/ at night

Gnawing,
worsened by food

Same as duodenal
ulcer, bloating

Pain referral

Back

Occasionally to
the back

None

Pain
progression

None

None

None

Associated
finding

Temporary relief with


food or antacids

relief by
antacids

relief with food or


antacid

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Periumbilical

Onset

Acute

Disease /
diagnosis

Appendicitis

Small bowel
obstruction

Intestinal
infarction

Pain
quality

Cramping,
steady

Cramping

Severe,
Cramping,
aching, diffuse aching
in LQ

Colickly,
aching,
diffuse

Pain
referral

Back or
groin

Back

None

None

None

Pain
progressio
n

Localizatio
n to RLQ

None

If Tx is
delayed,
peritonitis

None

Pain relief
1-2 hour

Peristaltic >,
nausea,
vomite,
delated bowel

Unimpressive,
occult blood
stool,
peristaltic -

Diarrhea,
blood+pus
stool,
urgency,
tenesmus

Weight loss

Associated Referred
finding
percusion
tenderness
to RLQ

Acute

Acute

Chronic
Inflammato
ry bowel
disease

Chronic
Intestinal
angina

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Lower Quadrant
Onset

Acute

Acute

Chronic

Chronic

Disease /
diagnosis

Diverticulitis

Colon
obstruction

Dissecting aortic
aneurysm

Irritable bowel
syndrome

Pain quality

Steady, aching,
LLQ

Crampy

Sudden, severe,
tearing, peri
umbilical

Cramping, steady
or itermittent

Pain referral

Back

Back

Flank, inguinal
region

None

Pain
progression

None

None

None

None

Associated
finding

Palpable
inflamatory
mass, fever,
constipation,
leucocytosis

Vomiting,
constipation,
distention,
peristaltic >

Shock,
abdominal bruit,
abdomnal mass

Cosntipation,
diarrhea,
bloating

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Diagnostic Tools :

Laboratory tests
Transabdominal Ultrasonography
Endoscopy : Upper, Lower, and Enteroscopy
Endoscopic Ultrasonography
CT-Scan, MRCP
ERCP : Diagnostic and Therapeutic

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Abdominal pain management :


Dyspeptic Symptoms :
Proton pump inhibitor
Pro kinetic
Antidepressant
Non-dyspeptic symptoms :
based on etiology

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Abdominal pain should be referred :


No improvement after empiric treatment
Abdominal pain with emergency :
Acute appendicitis
Acute pancreatitis (lipase > 3 times normal value)
Ileus
Peritonitis
Decreased body weight, GI tract bleeding, chronic diarrhea

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Take Home Message


Abdominal pain typically, but not always,
has characteristic locations : right upper,
right lower, epigastric, periumbilical, left
upper, left lower, and diffuse
The location of pain is a useful starting
point and will guide further evaluation
Performing a thorough history and physical
evaluation will allow the practitioner to
generate a differential diagnosis that will
guide further laboratory, imaging, and
management decisions

Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009

Terima Kasih

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