Abdominal pain – pathogenesis, diagnosis, what diseases may indicate

Abdominal pain is a condition in which it is important to distinguish between somatic (peritoneal) pain and visceral pain. There are three mechanisms for the development of somatic pain, i.e. as a result of 1) physical contact of the inflamed tissue with the parietal peritoneum that is very sensitive to pain (pain receptors), 2) leakage of gastric, intestinal, pancreatic, bile or blood into the peritoneal cavity, and 3) pulling peritoneum due to pressure on the posterior abdominal wall (e.g. by a tumor).

Abdominal pain pathogenesis

The abdominal organs covered with the visceral peritoneum do not show sensitivity to pain stimuli, such as:

1. pressure,
2. pulling,
3. cutting,
4. higher temperature.

This pain insensitivity also applies to the healthy mucosa of the gastrointestinal tract. Visceral pain occurs only when inflammation and / or congestion of the gastric or intestinal mucosa occurs, especially when the mucosa is exposed to mechanical and chemical stimuli. Pain is most likely the result of the release of mediators that contract the smooth muscle of the gastrointestinal tract. Visceral pain is recorded by the patient in the midline of the body, while somatic pain is located in the projection of the lateral surfaces of the abdomen. There is evidence that the same disease is the source of visceral pain initially and then somatic pain.

Pain in acute appendicitis begins in the mesogastrium or even epigastric region and moves to the right iliac fossa after a few hours. Also, pain in acute cholecystitis is first felt in the epigastric region, and then in the right hypochondrium – the place where the gallbladder adheres to the parietal peritoneum.

Check if an appendectomy is necessary

Abdominal pain – diagnosis

In everyday medical practice, abdominal pain or discomfort is a very common symptom reported by patients. In all cases, the frequency of pain should be determined, not satisfied with the patient’s response that pain occurs occasionally. There is a need to clarify whether the intervals between pain episodes are for hours, days, weeks or months. It is also necessary to know the circumstances of the appearance of pain and the factors aggravating and alleviating this ailment. It is especially important to establish the dependence of the occurrence of pain and changes in its intensity on eating, breathing, coughing, trunk movement, physical exertion or the use of gastric antisecretory drugs. Abdominal pain that occurs at night and wakes the patient up from sleep is most often caused by organic diseases, not functional diseases of the digestive tract. The fact that an ambulance is being called by the patient shows that the pain is intense.

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Differential diagnosis

For the differential diagnosis of the causes that provoke the abdominal pain reaction, it is important to identify the location of the pain. Pains in the right epigastrium most often originate from pathology of the liver and biliary tract, and less frequently from intestinal or gastric pathology. Pain in the left abdominal quadrant most often indicates pancreatic disease, but it can also be a symptom of an ulcer located on the greater curvature of the stomach, spleen disease (tumor, hematoma, infarction), gas distension of the splenic flexure of the colon, left-sided pleurisy or disease processes in the kidneys or perirenal space.

Pain felt around the umbilical cord most often originates from diseases of the small intestine and is very rarely the result of pain radiation from the chest. If mid-abdominal or lower abdominal pain is accompanied by diarrhea, it is this symptom that should be considered dominant. Disturbances in the rhythm of bowel movements, the presence of blood or mucus in the stools draw attention to diseases of the rectum and sigmoid colon. In these cases, it is important to remember to perform a digital rectal examination (rectal examination).

Frequent and painful micturition (dysuria), hematuria and pain in the suprapubic or lumbar region suggest changes of urological origin.

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What diseases do stomach pains indicate?

1. Women often have lower abdominal pain gynecological backgroundwhich requires information about menstruation, ovulation and sexual activity in the interview. Lower abdominal pain may be a consequence ectopic pregnancy, ovarian cyst torsion, salpingitis and appendicitis. During pregnancy, the abdominal organs are displaced by the pregnant uterus, hence the location of pain caused by, for example, an inflamed appendix, may be completely unusual.

2. Watery diarrhea suggests gastroenteritiswhile bloody diarrhea is a symptom inflammatory diseases, intestinal ischemia, or bacterial infection. Stool retention is a symptom mechanical bowel obstructionand inflammatory diseases cause paralytic obstruction.

3. Lack of peristaltic sounds after 2 minutes of auscultation suggests paralytic obstruction, while the high tones, intensified indicate mechanical obstruction. The bulging of the abdominal integuments is a symptom of both mechanical and paralytic obstruction. It also occurs when fluid builds up in the abdomen (ascites).

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Symptoms of individual abdominal pain

1. Gallbladder pain (stone, hydrocele, empyema) radiates to the right shoulder blade, but can sometimes cause pain in the right shoulder.
2. Renal colic pain typically appears in the lumbar region and radiates to the groin, testicle or thigh.
3. Pain in acute pyelonephritis or obstruction of the pyeloureteral junction is usually felt in the costo-vertebral angle or side, and much less in the epigastric region.
4. In the case of phlebitis pleurisy, the pain in the abdomen may extend to the side of the abdomen and to the shoulder.
5. Pain from the pelvic organs can radiate to the back.
6. Pain movement during patient observation indicates an inflammatory process.
7. Pain from an ulcer perforation or an abdominal aortic aneurysm rupture is sudden and unbearable.
8. The pain from acute appendicitis builds up over the course of a few hours.
9. The pain from biliary colic wears off after a few hours, and the pain in acute pancreatitis is continuous.

Severe pain that began no earlier than 24 hours before the doctor’s appointment is defined as “gripes” and often requires surgical treatment. Carefully collected history is essential for a proper diagnosis, and additional examinations must be kept to an absolute minimum due to time constraints. Alcoholism points to the pancreas as the cause of pain, while the use of non-steroidal anti-inflammatory drugs (NSAIDs) makes you think about damage to the mucosa of the upper or lower gastrointestinal tract. The risk of cytomegalovirus (CMV) infection is increased in immunocompromised people. This virus can cause hemorrhagic gastroenteritis, neutropenia, fever and jaundice. Chronic estrogen hormone therapy may be an indication that the source of epigastric pain is liver adenoma, which is prone to bleeding inside and outside the tumor.

A patient with peritonitis is pale and anxious, with a sweaty face and shallow breathing. Parietal peritonitis forces you to lie still (pain increases with movement). Patients with peritoneal symptoms usually complain of:

1. high temperature,
2. increased heart rate (tachycardia)
3. rapid breathing (tachypnoea)
4. low blood pressure (hypotension).

Note: Elderly people treated with immunosuppressants and those with diseases that impair the immune response (cirrhosis, chronic renal failure, diabetes, AIDS) may not present the typical symptoms of peritonitis.

Moreover, in patients with spinal cord injury, pain reactions may be absent. Unlike patients with peritonitis, patients with renal colic or ischemic enteritis behave restlessly and frequently change body position. A lumbar-femoral abscess in a patient with Crohn’s disease forces a supine position with the right leg bent in the knee and hip joints.

In the history, information about the surgical procedures performed is important. Abdominal pain immediately following the procedure indicates the possibility of paralytic ileus, abscess, dehiscence or noncital cholecystitis. Earlier laparotomy increases the likelihood of intestinal obstruction due to postoperative adhesions. Traveled cholecystectomy There is some suspicion that epigastric or mid-abdominal pain is a consequence of choledocholithiasis or biliary pancreatitis.

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Source: Abdominal PHYSICAL TEST WITH ELEMENTS OF DIFFERENTIAL DIAGNOSTICS; Czelej Publishing House