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parietal
referred
Visceral peritoneum
Innervated bilaterally by ANS
Described as midline, vague, deep, dull, poorly
localized
Triggered by inflammation, ischemia, geometric
changes (ie distension, pressure)
Innervated unilaterally via the spinal somatic
nerves (also supply abd wall)
Pain well localized, sharp, severe
Triggered by irritation of parietal peritoneum
(ie chemical peritonitis from perforated peptic
ulcer or bacterial peritonitis)
From deep visceral structure but superficial at
presenting site
Central neural pathways common to somatic
nerves and visceral organs
i.e. biliary tract pain – refer to R. inf scapular
area; diaphragmatic irritation to ipsilateral
shoulder
Foregut organs (stomach, duodenum and biliary
tract) produce pain in the epigastric region
Midgut organs (most small bowel, appendix,
cecum) produce periumbilical pain
Hindgut organs (most of colon, including sigmoid)
and intraperitoneal portions of the genitourinary
tract cause pain in the suprapubic or hypogastric
area
Intraperitoneal visceral pain in felt in the midline
because these organs have bilateral innervation
1. Intraabdominal
2. Extraabdominal
GI
GU
GYN
Vascular
Cardiopulmonary
Abdominal wall
Toxic-metabolic
Neurogenic
SUDDEN ONSET OF PAIN (SECONDS)
- Perforated peptic ulcer
- Ruptured abdominal aortic aneurysm
- Infarction (MI or acute mesenteric occlusion)
RAPIDLY ACCLERATING PAIN (WITHIN
MINUTES)
COLIC SYNDROMES
Biliary colic, ureteral colic, small bowel obstruction
INFLAMMATORY PROCESSES
Appendicitis, pancreatitis, diverticulitis
ISCHEMIC PROCESSES
Mesenteric ischemia, strangulated intestinal
obstruction, volvulus
GRADUAL ONSET OF PAIN (SEVERAL
HOURS)
INFLAMMATORY CONDITIONS
Appendicitis, cholecystitis
OBSTRUCTIVE PROCESSES
Nonstrangulated bowel obstruction, urinary retention
Case 1
RUQ
From usmleworld qbank 2007
Differentials Diagnosis??
- Abdominal aortic aneurysm - Gastritis, Acute
- Acute mesenteric ischemia - Gastroesophageal Reflux
- Amebic hepatic abscesses Disease
- Appendicitis - Hepatitis, Viral
- Biliary colic - Myocardial Infarction
- Biliary disease - Nephrolithiasis
- Cholangiocarcinoma - Pancreatitis, Acute
- Cholangitis - Peptic Ulcer Disease
- Choledocholithiasis - RLL Pneumonia
- Cholelithiasis - Pregnancy and Urolithiasis
- GB Cancer - Pyelonephritis, Acute
- GB mucocele - Renal Disease
- Gastric Ulcers - Renal Vein Thrombosis
Inflammation of GB commonly caused by
gallstone obstruction (90%)
Choice B – infection of GB present in 50-70% acute cholecystitis
cases secondary to gallstone impaction in cystic duct
Patho:
Stone obstructs eat fatty food stimulate GB to
contract colicky pain stasis bacterial
overgrowth inflammation gangrene/
perforation/ peritonitis
S/Sx:
epigastric or RUQ pain
nausea and emesis 4-6 hrs after meal
Murphy’s sign
May radiate to right scapula
A. Alcohol cirrhosis
B. Budd-chiari syndrome
C. peritoneal carcinomatosis
D. portal vein thrombosis
E. Right heart failure
A 61 y/o woman comes to her dr. office for steadily increasing abd girth
and fatigue with mild exertion. She has noticed this symptom for the past
few months. She reports a 5kg increase in her weight without making
any change in her regular diet. Her PMH is unremarkable, although she
has not seen a physician for many years. She denies smoking, but admits
drinking a glass of wine with meals on weekends. On physical exam, she
is afebrile and normotensive. Examination of her abd reveals shifting
dullness and a fluid wave, with clear distension. A bedside ultrasound is
performed, which demonstrates a large amount of ascitic fluid. Which of
the following conditions is the most likely cause of this patient’s current
condition?
A. Alcohol cirrhosis
B. Budd-chiari syndrome
C. peritoneal carcinomatosis
D. portal vein thrombosis
E. Right heart failure
Pt. has late ovarian cancer. There are no indications for liver insufficiency, or
cardiac insufficiency.
A 24 y/o white women comes to the physician complaining of 6 months of crampy
abd pain. The pain has been localized to the RLQ, and is made worse by eating.
She has also noted an increase in the number of her bowel movements to
approximately four per day, and the stools have become semi-formed. She denies
any fevers, chills, or night sweats during this period. She has lost 15 lbs from her
baseline weight of 128 lb over the past 6 months. She has also noted aching in her
knees, and ankles during this interval. On physical examination, she is slightly
pale and has two oral ulcers on the inner lower lip that are covered by a gray
exudate and surrounded by an erythematous halo. The abd is soft but tender in
the right lower quadrant. No masses are palpable and there is no
hepatosplenomegaly. Rectal exam reveals brown stool, which is guaiac-positive.
Which of the following diagnostic test would be the most accurate for this patient?
A. Abd CT scan
B. abd sonogram scan
C. barium enema
D. colonoscopy
E. sigmoidoscopy
F. upper GI series
A 24 y/o white women comes to the physician complaining of 6 months of crampy abd pain.
The pain has been localized to the RLQ, and is made worse by eating. She has also noted an
increase in the number of her bowel movements to approximately four per day, and the stools
have become semi-formed. She denies any fevers, chills, or night sweats during this period.
She has lost 15 lbs from her baseline weight of 128 lb over the past 6 months. She has also
noted aching in her knees, and ankles during this interval. On physical examination, she is
slightly pale and has two oral ulcers on the inner lower lip that are covered by a gray exudate
and surrounded by an erythematous halo. The abd is soft but tender in the right lower
quadrant. No masses are palpable and there is no hepatosplenomegaly. Rectal exam reveals
brown stool, which is guaiac-positive. Which of the following diagnostic test would be the
most accurate for this patient?
A. Abd CT scan
B. abd sonogram scan
C. barium enema
D. colonoscopy
E. sigmoidoscopy
F. upper GI series
Pt has Crohns, and colonoscopy with entry into the terminal ileum is the main way of diagnosing
ileocolonic disease, as described in this patient.
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Kluwer, Lippincott Williams & Wilkins, 2010.
Gallagher E. J, "Chapter 72. Acute Abdominal Pain" (Chapter). Tintinalli JE, Kelen GD,
Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive
Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=592077.
Platt Melissa, Doshi Samir, Telfer Eric, "Chapter 13. Abdominal Pain" (Chapter). Stone
CK, Humphries RL: CURRENT Diagnosis & Treatment: Emergency Medicine, 6e:
http://www.accessmedicine.com/content.aspx?aID=3099123.
Klingensmith, Mary, Chen Li Ern, Glasgow Sean, Goers Trudie, Melby Spencer.
“Chapter 11, The Washington Manual of Surgery.” Wolters Kluwer, Lippincott Williams
& Wilkins, 2008.