PAIN ORIGINATING IN THE ABDOMEN

1.     Partcial peritoneal inflammation

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

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