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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
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
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
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
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
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
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
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
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
Steady / biliary
colic
Steady
Pain referral
Left arm
back
Tip of scapula
Back
Pain
progression
Upper chest
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
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
relief by
antacids
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
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
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Terima Kasih