TABLE 91 Abdominal Pain

Problem

Process

Location

Quality

Peptic Ulcer and

Dyspepsia (These disorders cannot be

Peptic ulcer refers to a demonstrable ulcer, usually in the duodenum or stomach. Dyspepsia causes similar reliably differentiated symptoms but no ulceration. Infection by symptoms and signs.) by Helicobacter pylori is often present.

Epigastric, may radiate to the back

Variable: gnawing burning, boring, aching, pressing, or hungerlike

Cancer of the Stomach

A malignant neoplasm

Epigastric

Variable

Acute Pancreatitis An acute inflammation of the pancreas

Chronic Fibrosis of the pancreas secondary to

Pancreatitis recurrent inflammation

Epigastric, may radiate to the back Usually steady or other parts of the abdomen; may be poorly localized

Epigastric, radiating through to Steady, deep the back

Cancer of the Pancreas

A malignant neoplasm

Epigastric and in either upper Steady, deep quadrant; often radiates to the back

Biliary Colic Sudden obstruction of the cystic duct or Epigastric or right upper quadrant; Steady, aching; not common bile duct by a gallstone may radiate to the right scapula and colicky shoulder

Acute Cholecystitis Inflammation of the gallbladder, usually from obstruction of the cystic duct by a gallstone

Acute Diverticulitis Acute inflammation of a colonic diverticulum, a saclike mucosal outpouching through the colonic muscle

Acute Appendicitis Acute inflammation of the appendix with distention or obstruction

Acute Mechanical

Intestinal

Obstruction

Obstruction of the bowel lumen, most commonly caused by (1) adhesions or hernias (small bowel), or (2) cancer or diverticulitis (colon)

Right upper quadrant or upper Steady, aching abdominal; may radiate to the right scapular area

Left lower quadrant

■ Poorly localized periumbilical pain, followed usually by

■ Right lower quadrant pain

■ Small bowel: periumbilical or upper abdominal

■ Colon: lower abdominal or generalized

May be cramping at first, but becomes steady

■ Mild but increasing, possibly cramping

■ Steady and more severe

Cramping

Mesenteric Ischemia

Blood supply to the bowel and mesentery blocked from thrombosis or embolus (acute arterial occlusion), or reduced from hypoperfusion

May be periumbilical at first, then diffuse

Cramping at first, then steady

Timing

Factors That May Aggravate

Factors That May Relieve

Associated Symptoms and Setting

Intermittent. Duodenal ulcer is Variable more likely than gastric ulcer or dyspepsia to cause pain that

(1) wakes the patient at night, and (2) occurs intermittently over a few weeks, then disappears for months, and then recurs.

The history of pain is typically Often food shorter than in peptic ulcer. The pain is persistent and slowly progressive.

Acute onset, persistent pain Lying supine

Chronic or recurrent course

Alcohol, heavy or fatty meals

Persistent pain; relentlessly progressive illness

Rapid onset over a few minutes, lasts one to several hours and subsides gradually. Often recurrent

Gradual onset; course longer Jarring, deep than in biliary colic breathing

Food and antacids may bring relief, but not necessarily in any of these disorders and least commonly in gastric ulcer.

Not relieved by food or antacids

Leaning forward with trunk flexed

Possibly leaning forward with trunk flexed; often intractable

Possibly leaning forward with trunk flexed; often intractable

Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight loss (more common in gastric ulcer). Dyspepsia is more common in the young (20-29 yr), gastric ulcer in those over 50 yr, and duodenal ulcer in those from 30-60 yr.

Anorexia, nausea, early satiety, weight loss, and sometimes bleeding. Most common in ages 50-70

Nausea, vomiting, abdominal distention, fever. Often a history of previous attacks and alcohol abuse or gallstones

Symptoms of decreased pancreatic function may appear: diarrhea with fatty stools (steatorrhea) and diabetes mellitus.

Anorexia, nausea, vomiting, weight loss, and jaundice. Emotional symptoms, including depression

Anorexia, nausea, vomiting, restlessness

Anorexia, nausea, vomiting, and fever

Often a gradual onset

Fever, constipation. There may be initial brief diarrhea.

■ Depends on intervention

■ Paroxysmal; may decrease as bowel mobility is impaired

■ Paroxysmal, though typically milder

■ Movement or cough

If it subsides temporarily, suspect perforation of the appendix.

Anorexia, nausea, possibly vomiting, which typically follow the onset of pain; low fever

■ Vomiting of bile and mucus (high obstruction) or fecal material (low obstruction). Obstipation develops.

■ Obstipation early. Vomiting late if at all. Prior symptoms of underlying

Usually abrupt in onset, then persistent

Vomiting, diarrhea (sometimes bloody), constipation, shock

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