Diagnostic ideas for abdominal pain

Abdominal pain is one of the most common clinical symptoms. It is of great significance to promptly and correctly diagnose the cause of abdominal pain and provide reasonable treatment. Because some abdominal pain requires emergency surgery, if the diagnosis is delayed, it will inevitably cause serious consequences and even endanger life.

Key points of medical history taking

1. Age and gender

Intussusception, intestinal parasitic diseases, and mesenteric lymphadenitis are the most common causes in children; peptic ulcer, pancreatitis, and biliary ascariasis are the most common causes in young and middle-aged people; cholelithiasis and cholecystitis are the most common causes in middle-aged and elderly people; urinary stones and renal colic are more common in males; ovarian cyst torsion and corpus luteum rupture are common causes of acute abdomen in women; women of childbearing age should consider ectopic pregnancy.

2. Special attention

Pay special attention to the history of lead exposure in occupations. Lead poisoning can cause abdominal colic due to smooth muscle spasms.

3. History

Past history of abdominal pain similar to the current onset, history of tuberculosis, history of diabetes, and history of abdominal trauma or surgery

4. Onset and causes

Those with acute onset can tell the exact time of onset, while those with chronic onset can only tell the approximate time of onset. Overeating or alcoholism are often the causes of pancreatitis, and fatty meals are often related to cholecystitis and pancreatitis.

5. The location and regularity of abdominal pain.

The location of abdominal pain is mostly consistent with the anatomical location of the internal organs. Persistent pain indicates inflammation, bleeding or hemorrhagic lesions; persistent severe pain is mostly caused by expansion, traction or peritoneal stimulation of the capsule of the abdominal organs; paroxysmal colic indicates spasm or obstructive lesions of the hollow organs; persistent pain with paroxysmal aggravation often indicates the coexistence of obstruction and inflammation. Rhythmic upper abdominal pain may be peptic ulcer; repeated and uncertain abdominal pain should be considered ascariasis and abdominal allergic purpura.

6. Nature

The nature and degree of abdominal pain include dull pain, colic, knife-like pain, and drilling pain. Whether the pain radiates or not, liver and gallbladder diseases radiate to the right shoulder, and ureteral diseases radiate to the perineum. The degree of pain is related to the level of pain threshold and tolerance; biliary colic, renal colic, and intestinal colic are severe and unbearable; the elderly have a high tolerance for pain, so even if the condition is serious, the pain may be mild, so it should be taken seriously.

7. The relationship between abdominal pain and body position:

For patients with gastric mucosal prolapse, the pain can be relieved by lying on the left side; the knee-chest position or prone position can relieve the abdominal pain of duodenal congestion syndrome; the abdominal pain of patients with pancreatic body cancer is severe in the supine position, and is relieved in the forward leaning position or prone position; the burning pain under the xiphoid process of patients with reflux esophagitis is aggravated when the body is bent forward, and is relieved in the upright position.

8. Symptoms associated with abdominal pain

(1) Fever and chills indicate inflammation

(2) Accompanied by jaundice, which may be cause by liver, gallbladder or pancreatic disease; abdominal pain and jaundice may also occur during acute hemolysis.

(3) Hematuria may be cause by urinary system disease

(4) Accompanying vomiting indicates esophageal, stomach, or bile duct diseases. Appendicitis and pancreatitis are often accompanied by vomiting. Large amounts of vomiting indicate gastrointestinal obstruction.

(5) Accompanied by diarrhea, indicating intestinal inflammation or chronic hepatopancreatic disease.

(6) Accompanied by gastrointestinal bleeding, possibly gastrointestinal ulcers, inflammation and tumors.

(7) If accompanied by shock, necrotizing pancreatitis, paralytic ileus, intestinal torsion, rupture of intra-abdominal organs, toxic pneumonia, and myocardial infarction should be considere.

Physical examination focus

During a comprehensive physical examination, pay special attention to the following:

1. Abdominal condition

(1) Whether there is herpes on the abdominal wall; whether there is varicose veins on the abdominal wall and the direction of blood flow; whether there is intestinal type and peristaltic wave.

(2) The location of tenderness and mass is best determine by pointing. Note the size, hardness, smoothness and mobility of the abdominal mass. The presence of the peritonitis triad (tense abdominal muscles, tenderness, rebound pain). Note the size of the liver and spleen and whether they are tender. Note whether the gallbladder can be palpate. Check for Murphy’s sign, McBurney’s point, and the presence of a hernia sac. Pay special attention to the tenderness of the abdominal aorta.

(3) Whether there is percussion pain in the liver and spleen. Percussion pain in the liver area helps diagnose hepatobiliary diseases, such as hepatitis, liver abscess, biliary tract infection, biliary ascariasis, etc. Percussion pain in the spleen area may be cause by inflammation or infarction. The reduction or disappearance of the liver dullness boundary helps diagnose the perforation of hollow organs. Pay attention to the presence or absence of mobile dullness.

(4) Bowel sounds (absent, active, hyperactive, sound of air passing through water) and vascular murmurs.

2. Conditions other than the abdomen: temperature, pulse, blood pressure, heart and lung auscultation for abnormalities, rectal examination

Laboratory and auxiliary examinations

1. Inspections that must be done

(1) Routine blood test: increase white blood cell count and neutrophilia indicate inflammation; increased eosinophilia may be related to parasitic infection and can also be see in Henoch-Schonlein purpura.

(2) Urinalysis and urine porphyrin test: When the red blood cells in the urine increase, it may be urinary stones, tuberculosis or tumors. Urine porphyrin is positive in porphyria or lead poisoning.

(3) Routine stool examination and occult blood test should focus on the examination of parasite eggs and fecal occult blood test.

(4) Blood amylase: Any unexplained upper and middle abdominal pain should be suspect of pancreatitis and amylase should be measure, but attention should be pay to the time of blood collection. Blood amylase reaches its peak 8-12 hours after abdominal pain; if blood is draw too early or too late, it may be normal even if there is pancreatitis.

(5) X-ray abdominal film: whether there is free gas and step-like fluid level under the diaphragm; the former indicates perforation of hollow organs, and the latter indicates intestinal obstruction. X-ray chest film: whether there is pneumonia and pleural effusion. Lobar inflammation of the lungs may manifest as upper abdominal pain; gastrointestinal barium meal and barium enema examination can understand whether there are organic lesions in the gastrointestinal tract (patients suspected of perforation of hollow organs should not undergo this examination).

(6) Abdominal ultrasound, CT, and MRI: the size of the liver, gallbladder, spleen, pancreas, and kidneys, and whether there are space-occupying lesions. Whether the common bile duct and intrahepatic bile duct are dilate, whether there are stones, etc.

(7) Endoscopy (gastroscopy and colonoscopy) has diagnostic value for organic lesions of the stomach and colon (it is not advisable to perform this examination if there is suspect perforation of hollow organs).

(8) Electrocardiogram: whether there is myocardial infarction.

2. Inspections to be performed:

(1) For those suspect of having diabetes, fasting blood sugar and blood ketone bodies should be measure. Diabetic ketoacidosis may cause abdominal pain, and hypoglycemia may also cause severe abdominal pain.

(2) Suspected electrolyte imbalance: measure blood sodium, potassium, calcium, chloride and pH. Hypocalcemia and hyponatremia may cause abdominal pain.

(3) For patients suspect of having liver and kidney diseases, liver and kidney function tests should be perform

(4) For patients suspect of lead poisoning, the blood spot red blood cell count and urine lead or hair lead quantity should be measure.

(5) For patients suspect of having peritoneal effusion, routine, biochemical, bacterial culture and tumor cell examinations should be perform by abdominal puncture. If blood or turbid fluid is draw, it has diagnostic value for abdominal organ rupture and hollow organ perforation. Increased adenosine deaminase is helpful for the diagnosis of tuberculosis.

(6) For those suspect of having a tumor, tumor markers such as AFP, CA199, CEA, etc. can be measure to help diagnose liver cancer, pancreatic cancer, and colon cancer.

(7) For patients suspect of having urinary stones, abdominal plain film or intravenous pyelography can be perform, which can help in the diagnosis of kidney stones, tuberculosis and tumors.

(8) EEG can be perform for patients suspect of having abdominal epilepsy

(9) Patients with suspected bile duct disease or obstructive jaundice may undergo MRCP, percutaneous cholangiography, or endoscopic retrograde pancreaticocholangiography.

(10) Patients suspected of having abdominal vascular disease may undergo vascular Doppler ultrasound, magnetic resonance angiography, or selective angiography.

(11) If abdominal tuberculosis or unexplained ascites is suspected, laparoscopy and peritoneal biopsy may be perform if necessary.

Diagnosis:

Is it acute or chronic abdominal pain? IDoes it an abdominal disease or an extra-abdominal disease? Is it the abdominal wall or the abdominal organs? Which organ? What is the cause (trauma, inflammation, ulcer, stone, tumor, organ rupture, vascular disease, etc.)

Treat:

It includes etiological treatment and symptomatic treatment. However, analgesics and anesthetics are prohibit before the diagnosis is clear, so as not to mask symptoms and delay diagnosis.