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1.
Partcial peritoneal inflammation
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a.
Bacterial contamination,eg., perforated
appendix. Pelvic inflammatory disease
b.
,eg ., perforated ulcer.pan creatitis,mittelschmerz
c.
Primary(spontaneous) peritonitis.this is acute orsubacute bacterial
inflammation of the eritoneum.it occurs in patient with cirrhotic or malignant
ascites,immune deficiency states and in
children with nephroticsyndromeor urinary tract infaction the commonest organismis
Streptocccuus pneumoniae.
d.
Tuberculous peritonitis(seep.600).
e.
Chemical peritonitis develops when asterile but irritant fluide,e.g.
bile,blood or pancreatic secretions,leaks into
the peritoneal cavity
f.
Granulomatous peritonitis can be caused by
infections(berculosis,fungi,parasites), secondary
adenocarcinoma,sarcoidosis,crohn's disease or foreign bodies(e.g.starch).
g.
Vasculties peritonitis occure when
there is gut involvementin
SLE,polyartiritis nodosa,systematic,sclerosis,dematomysities or
Henoch-schonlein perpura.
h.
Familial Mediterranean fever is characterized by recurrent episodes is acute self –limiting ser sitis especially involving the
peritoneum(see p 1101).
2.
Mechanical obstruction of hollow viscrea
a.
Obstruction of the smallor large intense
b.
Obstruction of the biliary tree
c.
Obstructionof the ureter
3.
Vascular disrurbances
a.
Embolism orthrombosis
b.
Vasculer rupture
c.
Pressure or torsional occlusion
d.
Sickle cell anemia
4.
Abdomminal wall
a.Distortion or traction of mesentery
Vascular distrubance Afrequent misconception,
despite abundant experience to the contrary pain associated with intraabdominal
vascular disturbances is sudden and catasrrophic in nature the pain of
embolism of thrombosis of superior mesenteric artery or that of impending rupture
of an abdominal aortic aneurysm certainly may be severe and diffuse .yet.just
as frequently ,the patient with occlussion of the superior mesenteric artery
has only mild continous diffuse pain for
2or3days before vascular collapse or finding of peritoneal inflammation
appear.the early.seemingly insignificant
discomfort is caused by hyper istalsis rather than peritoneal inflammation
.indeed ,absence of tenderness and rigidity
in the presence of continous ,defuse pain in apatient likely to have vascular disease
in quite charachteristic of occulision of superior mesenteric artery.abdominal
pain with radiation to the sacralregion.flank or genetalia should always signal
to the possible presence of a rupturing
abdominal aortoc aneurysm.this pain may persist over operiod of several days before rupture and
collapse occure.
Refered
pain in abdominal disease pain referredto the abdomen from the thorax , spin .or genitalia may
prove avexing diagnostic problem.because diseases of upper part of abdominal cavity
such as acute cholecysitis or
performated ulcer are frequently associated with intrathoracic complication.Amost important ,yet often
forgotten.dictum is that the possibility of intrathoracic disease must be
consideredin every patient with abdominal pain,especially if the pain is in the upper part of the abdomen.systematic
questioning and examinationdirected toward directing myocardial or pulmonary
infraction pneumonia.pericarditis or esophageal disease(the intrathooracic
diseases that most often masquerade as abdominal emergencies)will of tenten
provide sufficient clues to establish the poper
diagnosis.Diaphragmaticpleuritis resulting from pneumonia or pulmonary
infraction may cause pain in the right upper quadrant and pain in the
supraclaicular area the latter radiation to be
pulposus.diabetes,or syphilis.it is nnot associated with food intake .abdominal destination .or changes in perspiration Severe muscle spam.as in the gastric crises of tabes dorsalis.is common but is either relieved or is not accentuated by abdominal palpation .The pain is made worse by movement of the spine and is usually confined to afew dermatomes. hyperesthesia is very common
pulposus.diabetes,or syphilis.it is nnot associated with food intake .abdominal destination .or changes in perspiration Severe muscle spam.as in the gastric crises of tabes dorsalis.is common but is either relieved or is not accentuated by abdominal palpation .The pain is made worse by movement of the spine and is usually confined to afew dermatomes. hyperesthesia is very common
The correct
interpretation of acute abdominal pain is challenging since paper therapy may
require urgent action .the unhurried approach suitable for the study of other condition is some
times denied few other clinical situation demand greater gudgment because the
most catastrophic of events may be for cast the subtlest of symptoms and
signs.Ameticulously executed detailed history and phusical examination are of
great importance .the etiologic classification in Table 13-1,although not
complete,forms ausefull basis for the evaluation of patient s with abdominal pain.
The diagnosis
of "acure of surgical abdomen" is not aacceptable one because of its
often mis leading and erroneous connotation.The most abvious of " acute
abdomens"may not require operative intervention,and the mildest of
abdominal pains may herald an urgently correctable lesion.any patient with
abdominal pain of recent one set requires early and through evaluation and
accurate diagnosis.
SOME MECHANISM OF PAIN ORIGINATING IN THE
ABDOMEN…inflammation of partial peritoneum The pain of partial peritoneal inflammation is stead
and aching in character and is located directly over the inflamed area,is exact
referencebeing
possible because it is transmitted somatic nerves suppling the peritoneal
peritoneum.The intensivity of the pain dependent on the type and amount of material towhich the periotoneal surfaces
are exposed in agiven time period. The pain of peritoneal inflammation is
invarariably accentuated by
pressure or changes in tension of peritoneum.whether produced by
palpation or by movement .as in caughing or sneezing.the patient with peritonitis
lies quietly in bed.preferring to avoid motion. In contrast to the patient with
colic.who may writhe incessantly.
b.Trauma or infection of muscles
5. Dustention of visceral
surfaces,e.g.,hepatic or renal capsules
PAIN REFERRD
FROM EXTRA ABDOMINAL SOURCE
1.Thorax,e.g ., pneumonia, referred pain from coronary
occlusion
2.Spin,eg .,radiculitis from arthritis,herpes zoster
3.Genitalia,e.g.,torsion
of the testicle
METABOLIC
CAUSES
1.Exogenous
a.Black widow spider bite
b.Lead poisoning and others
2.Endogenous
a. Uremia
b. Diabetic
ketoacidosis
c. Porphyria
d. Allergic
factor(C'1 esterase inhibitor deficiency)
NEUROGENIC
CAUSES
1.Organic
a. Tabes dorsalis
b.Herpes zoster
c.Casualgia and others
2. Functional
distinguished
from the referred subscapular pain caused by acute disternation of the
extrahepticbiliary tree.the ultimate decision as to the origin of abdominal
pain may require deliberate and planned observation over a period of several hours ,during which
repeated questioning and examination
will provide the diagnosis or
suggest the appropriate studies.
Referred pain
of thoracic origin is often accompanied by splinting of the involved hemithorax
with respiratory lag and decrease in excursion more marked than that seen in
the presence of intraabdominal
disease.in addition,apparent abdominal muscle spam caused by referred pain will
diminish during the inspiratory phase of
respiration, where as it is persistent throughout both respiratory phase if it
is of abdominal origin.palpation over the area of referred pain in abdomen also
does not usually accentuated the pain and
in many instances actually seems to relieve it.
METABOLIC ABDOMINAL CRISES pain of
metabolic origin may simulate almost any other type of intraabdominal disease.Several
mechanisms may be at work in certain instances, such as hyperlipidemia,the
metabolic disease It self may accompanied by an intraabdominal pracess such as
pan creatitis,which can lead to unnecessary laparatormy unless recognized.C'1 esterase deficiency
associated with angioneurotic edema is often associated with episodes of severe abdominal
pain.whennever the cause of abdominalpain is obsecure.ametabolic origin always
must be considered.Abdominal pain is also the hallmark of familial Mediterrranean
fever
NEUROGENIC CAUSES Causalgic pain
may occur in disease that injure sensory
nerves . it has aburning character and is usually limited to the distribution
of given peripheral nerve.Normal stimuli such as touch or change in temperature may be transformed
into this type of pain which is
frequently present in a patient at rest
Pain arising from spinal nerves or roots comes and
goes suddenly and is of lancinating type.it may caused by herped
zoster,impingement by arthritis.tumors.heriiated nucleus
