pain2000.ppt

1、Common Non-surgical Causes of Abdominal Pain,John B. Canio, M.D. Division of Gastroenterology UCDMC,John Canio, MD,Approach to Abdominal Pain,History Location Intensity Character Radiation Setting of pain Aggravating and relieving factors Associated signs and symptoms,John Canio, MD,Approach to Abdo

2、minal Pain,Physical exam Observation Auscultation Percussion Palpation,John Canio, MD,Differential,John Canio, MD,Differential,Huge: Appendicitis, aortic aneurysm, gastroenteritis, intestinal obstruction, diverticulitis, diverticulosis, peritonitis, mesenteric infarction, pancreatitis, IBD, IBS, mes

3、enteric adenitis, metabolic causes: uremia, DKA, lead poisoning, sickle cell crisis, trauma, pneumonia, UTI, PID, porphyria, HSP, adrenal insufficiency, PUD, DU, duodenitis, hepatitis, angina/mi, herpes zoster, cholecystitis, cholangitis, incarcerated hernia, choledocolithiasis, fecal impaction, can

4、cer, renal stones, ectopic pregnancy, endometriosis, cystitis, dyspepsia, GERD, mittelschmerz, familial mediterranean fever, SMA, PAN, abcess, perforation, foreign body ingestion, pseudomyxoma peritonei, pneumocystis coli and etc,John Canio, MD,Location of Pain From Specific Organs,Esophagus Stomach

5、 Duodenal Bulb Small Intestine Colon Splenic Abcess Rectosigmoid Rectum Pancreas Liver/gallbladder,Substernal:jaw, neck, arm, back Epigast:LUQ 1/3 of patients are awakened at night Association w/ food: eating a meal or antacids relieves DU pain; food aggravates GU pain *Pain is episodic, lasting day

6、s to weeks followed by a remission of months,John Canio, MD,Peptic Ulcer Disease,Duodenal ulcer Epigastric Gnawing/ burning/ hunger/, achy Rhythmic: relieved w/ food/antacids/milk and returns 1-3h after eating Awakens patient 1-3am Radiate to back/hypogast Like to snack & increase body wt,Gastric ul

7、cer Epigastric Pain character: same Rhythmic: pain is least or absent during fasting, occurs shortly after eating (5-15 min) Radiates to back/LUQ Avoid food, lose wt,John Canio, MD,Peptic Ulcer Disease,Diagnose: H & P, EGD, Barium study Complication Pain Perforation Obstruction Bleeding Penetration

8、Treatment PPI, H2 Blockers, Anti-HP meds,John Canio, MD,Duodenal Ulcer,Gastric Ulcer,John Canio, MD,Pancreatitis,Etiology: many but two most common Alcohol and gallstones (90%) Symptoms: Epigastric sharp to boring pain w/ patients having radiation to back Alleviated by sitting up or fetal position A

9、ggravated by movement Assoc w/ nausea, vomiting and anorexia,John Canio, MD,Pancreatitis,Exam: Tachycardia, +/- fever Epigastric/LUQ abdominal pain Hypoactive bowel sounds Mass suggestive of pseudocyst or inflammation Hypocalcemia Intra-abdominal bleeding (Cullen, Grey-Turner signs),John Canio, MD,P

10、ancreatitis,Diagnosis: confirmed by Lab: elevated amylase and lipase Abdominal x-ray vs CT scan vs abd us Treatment Conservative: NPO, IV hydration, Pain control, correct electrolytes, NG-tube decompression,John Canio, MD,Pancreatitis,Admit Age 55 WBC 16,000/mm3 Blood glucose 200mg/dl Serum LDH 350I

11、U/L AST 250 IU,Initial 48 hours Hct 10% BUN rise 5 mg/dl Calcium 4mEq/L Fluid retention 6 liter,Ransons Criteria,* If number of risk factor: 1) 7 mortality 100%,John Canio, MD,stones,John Canio, MD,Dysphagia,Dysphagia: Impaired passage of food from the mouth to the stomach. Greek: dys (difficulty/di

12、sordered) & phagia (to eat) Odynophagia: Painful Swallowing Greek: odyno (pain) Globus Sensation of a lump or tightness in throat. Unrelated to swallowing,John Canio, MD,Dysphagia,Oropharyngeal Dysphagia (Transfer) Difficulty in with initiating swallowing or transferring food from the mouth to the u

13、pper esophagus. Esophageal Dysphagia Difficulty in passage of food somewhere from suprasternal notch to xyphoid. Localization of the level of obstruction accurate to w/in 4cm 74% of the time,John Canio, MD,Oropharyngeal dysphagia,Symptoms/Signs: nasal regurgitation, aspiration during swallowing chok

14、ing and coughing nasal speech food sticking in back of throat neurological deficits, h/o CVA dysphagia to solids and liquids Triad: halitosis/regurgitation of undigested food/nocturnal cough,John Canio, MD,Esophageal dysphagia,Symptoms/Signs: sensation that food stops/sticks behind stomach “hanging-

15、up”, “ball of food”, “!#$%&*” solids alone intermittent to solids (esp. steak/bread) suggest esophageal rings progressive initially to solids the to liquids younger: Schatzkis ring older: cancer reflux sxs: risk factor for Barretts Esophagus pyrosis: 40yo, 5-10yrs duration Iron deficiency/esoph web/

16、 (+/-) glossitis,John Canio, MD,Zenkers Diverticulum,Esophageal lumen,Blind pouch,Tic,John Canio, MD,Esophageal dysphagia,Mechanical Peptic strictures Esophageal carcinoma Webs and rings Diverticula Mediastinal tumors Vascular Cervical osteophytes,Motility Achalasia DES Nutcrackers esophagus hyperte

17、nsive UES Chagas disease Scleroderma progressive systemic sclerosis Severe GERD,John Canio, MD,DIFFERENTIAL,John Canio, MD,Foreign Body,Who is at risk? Very young Very old Mentally impaired Intoxicated Prisoners Presence of stricture,John Canio, MD,Foreign Body,What are the symptoms? Usually symptom

18、atic in the esophagus Drooling suggest complete esophageal obstruction Severe abdominal pain suggest obstruction or perforation,John Canio, MD,Foreign Body,Diagnosis By history Never use barium study to diagnose esophageal foreign body X-rays of GI tract in lateral/AP Endoscopy four upper GI tract Diagnosis of underlying lesions such as strictures,John Canio, MD,Foreign Body,How do you treat or manage? Emergency removal for total esophageal obstruction Endoscopy preferred method Never try to dissolve meat or push FB using NG tube Most objects pass sp