Abdominal pain

Chapter 22 Abdominal pain



Case 22.1



1. What information can you elicit from the following observations:
a pain is colicky

Colicky abdominal pain is due to a significant increase in smooth muscle contraction in a hollow organ or duct. This may be due to obstruction of that structure, or due to toxins, infective agents or other stimuli.


b pain is in the central part of the abdomen

This usually indicates pathology in any structure derived from the midgut (ie: small intestine and proximal large intestine). Alternatively, it may be due to trauma or a pathology directly affecting that part of the abdominal wall.


c presence of a scrotal mass

There are a number of causes of scrotal masses, including inguinal herniae. The presence of such a mass in a patient with colicky, central abdominal pain suggests that it is due to a hernia which has strangulated and caused a mechanical bowel obstruction.


d loud, high pitched bowel sounds

This is usually representative of the excessive peristalsis that accompanies a bowel obstruction.


2. What is your differential diagnosis? What will you do now?
• Differential diagnosis 1: strangulated inguinal hernia causing a mechanical bowel obstruction.

• Differential diagnosis 2: other causes of a mechanical bowel obstruction (eg: adhesions).

• Differential diagnosis 3: gastroenteritis or food poisoning (less likely due to absence of diarrhoea).

The patient needs immediate referral to the hospital, due to the possibility of a mechanical bowel obstruction.


3. What type of investigations will be performed which could facilitate the diagnostic considerations?

A plain abdominal X-ray would be the first investigation to be done. In mechanical bowel obstruction, distended loops of bowel are often seen. When the patient is in the standing position, fluid levels would generally be identified.


If X-rays were normal, a stool culture may be required to determine other possible causes of his presentation.


4. Plain abdominal X-ray showed distended loops of bowel with fluid levels. What is your final diagnosis?

Mechanical bowel obstruction.


5. Is it unusual for someone with this disorder to not complain of constipation?

This is not an unusual occurrence, as the bowel distal to the obstruction can still undergo peristalsis, and thus empty. The higher (more proximal) the site of obstruction, the later will be the onset of constipation.


6. What are the possible causes of this disorder? Which of these is most likely in Bill’s case?
• Obstruction within the lumen of the bowel (eg: tumours).

• Obstruction in the wall of bowel (eg: volvulus, strangulated hernia, intusussception).

• Compression from outside the wall (eg: adhesions).

In Bill’s case, a strangulated inguinal hernia is the most likely cause.



Case 22.2



1. What is meant by ‘anorexic’?

A loss of appetite.


2. What is your differential diagnosis based only on this history?

Epigastric pain may relate to pathologies of: stomach; duodenum; pancreas; biliary tract (sometimes). The absence of any previous episodes indicate an acute disorder. Possible diagnoses are:


• differential diagnosis 1: acute gastritis (most likely)

• differential diagnosis 2: peptic ulceration, initial attack

• differential diagnosis 3: acute pancreatitis.

3. Could the spicy meal be the cause of his problem?

It is unlikely that the meal was the sole cause, although the presence of another aetiological agent or predisposing condition may have precipitated the attack.


4. What other pertinent questions should be asked?
• Has this ever occurred before?

• Are you on any medications—prescribed or over-the-counter? (Many drugs may cause acute gastritis.)

• Any recent infections? (Many infective agents may cause acute gastritis: most common is H. pylori.)

• Did anyone else who ate the same meal become ill? (Food poisoning may cause acute gastritis.)

• Do you have any allergies? (Allergies may cause acute gastritis.)

• How much alcohol do you drink?


Case 22.3



1. What information is given by the description of her pain?

It is colicky pain (characterised by episodes of increased severity); that is, there is involvement of hollow viscera with an increase in contraction, either with or without obstruction.


It is likely to originate in the biliary tract/gallbladder region (right hypochondrial pain and radiating around to her back and up between the scapulae).


2. What is your differential diagnosis?
• Differential diagnosis 1: acute cholecystitis.

• Differential diagnosis 2: acute cholangitis.

• Differential diagnosis 3: obstruction of bile duct (eg: with stone) and consequent infection of gallbladder or duct.

3. Describe Murphy’s sign.

In a patient with right hypochondrial tenderness, hook the fingers of your right hand under the right costal margin, at the level where the lateral border of the rectus abdominis muscle intersects. In the presence of acute cholecystitis, the patient will gasp and experience an exacerbation of pain.


4. What is the possible relationship between the three earlier episodes and her current presentation?

It is possible that she has a gall stone which episodically moves from the gallbladder (fundus or body) to obstruct the neck of the gallbladder or the cystic duct. This causes the pain. The return of the stone to its original position results in pain relief. The current presentation indicates that an inflammatory process has occurred as a result of the recurrent obstructive episodes (fever, tachycardia, tenderness and a positive Murphy’s sign).



Case 22.4



1. Given the description of Oscar’s pain, what organ is most likely to be involved? Why?

Stomach — the pain occurs immediately with eating. Duodenal or pancreatic pathology can cause epigastric pain, but usually some time after eating, not immediately.


2. What types of pathologies may be causing his problem? Why?
• Gastric ulceration.

• Gastric carcinoma.

• Chronic gastritis.

In early stages, these disorders present in a similar way. Although weight loss will often alert a practitioner to the possibility of a malignancy, individuals with gastric ulceration tend to avoid eating as this is the trigger for their pain. Hence, weight loss is a common finding in patients with gastric ulcers.


3. Name the most useful investigation that could be done by a medical specialist in order to determine the diagnosis?

Gastroscopy with biopsy.


4. What other tests could be indicated?
• Full blood count to determine if there has been haemorrhage from the lesion, resulting in anaemia.

• Faecal occult blood could be done, but this would not help to distinguish between aetiologies.

• If a gastric carcinoma is diagnosed, liver function tests could indicate possible liver involvement; bone scans could be used to search for bony metastases, and other tests performed as needed.


Case 22.5



1. Compile a differential diagnosis for this scenario.

This is a difficult case, as the symptoms are non-specific. We can be relatively certain that it is a chronic condition, and that it most likely involves the digestive system. Possibilities include:


• chronic gastritis

• chronic pancreatitis

• chronic hepatitis

• chronic cholecystitis.

2. Assume that your full history and physical examination reveal nothing. Describe, in general terms, the steps you would need to follow in order to ‘workup’ this patient.

It is clear that investigations are required to determine the cause of her problem. It is thus necessary to refer the patient to a medical practitioner for further studies.



Case 22.6



1. Using only this information, list the possible causes of the patient’s abdominal pain. Justify your answer.

Possible causes are:


• acute appendicitis

• ovarian cyst complication

• ectopic pregnancy

• ovarian torsion

• acute pelvic inflammatory disease (eg: acute salpingitis).

Justification: all of these disorders can present with right iliac fossa pain. Despite her denial regarding absence of a fever, this needs to be objectively measured, as subjective measures of body temperature may be misleading. Although ectopic pregnancy usually presents at least 5 weeks after the last menstrual period, bleeding can still occur at regular intervals for up to 3 months, thus it would be dangerous to ignore this possibility. The tenderness which she reports when palpating the painful area suggests that there is either irritation of the parietal peritoneum or abdominal wall in that area.


2. Why was she asked about the presence of preceding peri-umbilical pain?

Peri-umbilical pain suggests a pathology in structures derived from the embryonic midgut (ie: jejunum, ileum and proximal part of large intestine). The appendix is derived from midgut, and thus pathology of this organ may refer to the peri-umbilical area.


3. Why do you think she was ill-advised to take OCPs?

OCPs may cause depression as a side effect, believed to be related to the progesterone component. Having a depressive illness is not an absolute contraindication to the use of the OCP, but when alternate modes of contraception are appropriate, it is commonly recommended by health practitioners that patients try those methods first.


4. What do you need to examine in this patient?
• Vitals, especially body temperature and pulse rate.

• Abdominal examination.

• Bimanual pelvic examination and a rectal examination would be done by a medical practitioner, but generally not by a manual therapist (international variations exist).

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Abdominal pain

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