“'For I know the plans I have for you,' declares the Lord, 'plans to prosper you and not to harm you, plans to give you a hope and a future. '” —
... [Show More] Jeremiah 29:11
1
“'For I know the plans I have for you,' declares the Lord, 'plans to prosper you and not to harm you, plans to give you a hope and a future. '” — Jeremiah 29:11
2
Appendix, colon,
and pelvic viscera
Mesenteric
plexus and lesser
splanchnic nerve
T10-11
Sigmoid colon,
rectum, kidney,
ureters, and
testes
Lowest
splanchnic nerve
T10-11
Bladder &
rectosigmoid
Hypogastric
plexus
S2-4
TOPIC OUTLINE
I. Acute Abdomen
II. Anatomy and Physiology
A. Visceral pain
B. Parietal pain
C. Referred pain
D. Shifting pain
III. History taking
A. Pain
B. Other symptoms associated
C. Regions of the abdomen
IV. Physical Examination
A. Inspection
B. Percussion
C. Palpation
D. Abdominal examination signs
V. Laboratory studies
VI. Imaging studies
VII. Indications for surgical consult
ACUTE ABDOMEN
ANATOMY AND PHYSIOLOGY
VISCERAL PAIN
SENSORY LEVELS ASSOCIATED WITH VISCERAL
STRUCTURES
STRUCTURES NERVOUS
SYSTEM
PATHWAYS
SENSORY
LEVEL
Liver, spleen and
central part of
diaphragm
Phrenic nerve C3-5
Peripheral
diaphragm,
stomach,
pancreas,
gallbladder, and
small bowel
Celiac plexus and
greater
splanchnic nerve
T6-9
DR.
MARAMBA
“'For I know the plans I have for you,' declares the Lord, 'plans to prosper you and not to harm you, plans to give you a hope and a future. '” — Jeremiah 29:11
3
• Refers to signs and symptoms of abdominal pain and
tenderness that often requires emergency surgical
therapy.
• Abdominal pain divided into
A. Visceral
B. Parietal
• Vague and poorly localized to:
• Epigastrium origin primitive foregut
• Periumbilical region origin midgut
• Hypogastrium origin hindgut
• Result of distention of a hollow viscus
PARIETAL PAIN
• Corresponds to the segment nerve roots
innervating the peritoneum.
• Tends to be sharper and better localized.
• Mediated by both C and A delta nerve fibers,
latter being responsible for the transmission of
more acute, sharper, better-localized pain
sensation.
• Direct irritation of the somatically innervated
parietal peritoneum by pus, bile, urine, or
gastrointestinal secretions lead to more precisely
localized pain.
REFERRED PAIN
• Pain perceived at a site distant from the source of
stimulus
• Eg. Irritation of the diaphragm perceives pain in
the shoulder
• Distorted central perception of the site of pain due
to the confluence of afferent nerve fibers from
widely disparate areas within the posterior horn of
the spinal cord.
“'For I know the plans I have for you,' declares the Lord, 'plans to prosper you and not to harm you, plans to give you a hope and a future. '” — Jeremiah 29:11
4
Location and Causes of Referred Pain
Right
shoulder
Liver
Gallbladder
Right hemidiaphragm
Left shoulder Heart
Tail of pancreas
Spleen
Left hemidiaphragm
Scrotum and
testicles
Ureter
SPREADING OR SHIFTING PAIN
• Parallels the course of the underlying conditions
• Site of pain at onset should be distinguished from
the site at presentation.
Acute Appendicitis
• Beginning classically: epigastric or periumbilical
region.
o Visceral pain (appendix distention)
• Shifts to right lower quadrant o Sharper
parietal pain o (overlying peritoneum directly
inflamed)
Perforated Peptic Ulcer
• Pain almost always begin in the epigastrium,
leaked gastric contents
o Track down the right paracolic gutter, may
descend to the right lower quadrant
• Diminution epigastric pain
Peritonitis
• Peritoneal inflammation of any cause
• Physical examination o Severe tenderness o
With or without rebound tenderness &
guarding
• Secondary to an inflammatory insult o Often a
gram-negative infection with an enteric organism
or anaerobe
o Noinfectious inflammation, a common
example being pancreatitis
Primary Peritonitis
• More common among children, caused by: o
Pneumococcus o Hemolytic
Streptococcus spp.
• Adults with end-stage renal disease on
peritoneal dialysis
o Gram (+) cocci (most common)
• Adults with ascites and cirrhosis o Escherichia
coli o Klebsiella spp.
Right Hypochondriac
Region
Cholecystitis Hepatitis
Epigastric Pancreatitis
Right Iliac Region Appendicitis [Show Less]