Beruflich Dokumente
Kultur Dokumente
MOSCOW 2010
Visceral
Somatic
Referred
Visceral pain
Stretching of peritoneum or organ capsules by
distension or edema
Diffuse
Poorly localized
May be perceived at remote locations related
to organ’s sensory innervation
Somatic pain
Inflammation of parietal peritoneum or
diaphragm
Sharp
Well-localized
Referred pain
Perceived at distance from diseased organ
Pneumonia
Acute myocardial infarction
Male genitourinary problems
Gastrointestinal Causes:
Peritonitis
Pancreatitis
Early Appendicitis
Mesenteric Adenitis
Gastroenteritis
Colitis
Intestinal Obstruction
Hematologic Causes:
Leukemia
Sickle Cell Crisis
Vascular Causes:
Mesenteric Thrombosis
Abdominal Aortic Aneurysm
Splenic artery aneurysm
Mesenteric Artery aneurysm
Gastrointestinal Causes:
Cholecystitis or Cholelithiasis
Pericarditis
Gastritis or Peptic Ulcer Disease
Pancreatitis
Vascular Causes:
Myocardial Infarction
Aortic Dissection
Mesenteric Ischemia
Gastrointestinal Causes:
Gastritis
Pancreatitis
Miscellaneous Causes:
Splenic enlargement, splenic rupture, splenic
infarction, aneurysm
Renal pain
Cardiopulmonary Causes:
Myocardial Ischemia
Pneumonia
Empyema
Acute Pelvic Pain Causes
Gastrointestinal Causes:
Gall Bladder or Billiary Tract Disease
Hepatitis
Hepatic Abscess
Hepatomegaly due to Congestive Heart Failure
Peptic Ulcer
Pancreatitis
Retrocecal Appendicitis
Miscellaneous Causes:
Renal pain
Pneumonia
Empyema
Gastrointestinal Causes:
Intestinal Obstruction
Constipation
Diverticulitis
Vascular Causes:
Leaking aortic aneurysm
Genitourinary Causes:
Acute Pelvic Pain Causes
Ovarian Cyst or torsion
Ureteral Calculus (Nephrolithiasis)
Renal pain
Seminal vesiculitis
Miscellaneous Causes:
Psoas abscess
Abdominal wall hematoma
Gastrointestinal Causes:
Appendicitis (pain over McBurney's Point)
Intestinal Obstruction
Regional Enteritis
Diverticulitis
Genitourinary Causes:
Acute Pelvic Pain Causes
Ovarian Cyst or torsion
Ureteral Calculus (Nephrolithiasis)
Renal pain
Seminal vesiculitis
Miscellaneous Causes:
Leaking Abdominal Aortic Aneurysm
Abdominal wall hematoma
Inflammation of distal esophagus
Usually from gastric reflux, hiatal hernia
Diverticula
Pouches in colon wall
Typically in older
persons
Usually asymptomatic
Related to diets with
inadequate fiber
Diverticula trap feces, become inflamed
Occasionally result in bright red rectal
bleeding
Rupture may cause peritonitis, sepsis
Signs and Symptoms
Usually left-sided pain
May localize to LLQ (“left-sided
appendicitis”)
Alternating constipation, diarrhea
Bright red blood in stool
Small masses of veins in anus, rectum
Most frequently develop when patients are in
age of 30s or 40s; common past 50
Most are idiopathic, can be associated with
pregnancy, portal hypertension
Cause bright red bleeding, pain on defecation
May become infected, inflamed
Inflammation of abdominal cavity lining
Signs and Symptoms
Generalized pain, tenderness
Abdominal rigidity
Nausea, vomiting
Absent bowel sounds
Patient resistant to movement
Positive Blumberg's sign
Helicobacter Pylori
Nonsteroidal Anti-inflammatory Drug (NSAID)
Tobacco Smoking
Stress
Caffeine
Alcohol
Established Risk Factors Possible Risk Factors
Age over 60 years Questionable Risk
Factors
previous peptic ulcer NSAIDs-related
disease dyspepsia
Cigarette smoking
Previous upper GI Duration of NSAIDs
bleeding use
Concomitant Alcohol consumption
Helicobacter pylori
corticosteroid therapy infection
high-dose and multiple Rheumatoid arthritis
NSAIDs use
Concomitant
anticoagulant use or
coagulopathy
Chronic major organ
impairment (e.g.,
cardiovascular disease)
Duodenal Ulcers Gastric Ulcers
20 to 50 years old > 50 years old
High stress Work at jobs
occupations requiring physical
Genetic predisposition activity
Pain when stomach is Pain after eating or
empty when stomach is full
Pain at night Usually no pain at
night
Men are affected 3-4x more than women.
Damage to mucosa Acid and pepsinogen
with alcohol abuse, release with chronic Infection with
smoking, use of vagal response to Helicobacter Pylori
aspirin and NSAIDs increased stress
Severe Ulcerations:
A damage mucosa could not
secrete enough mucus to act as Signs and Symptoms:
a barrier against gastric acid Epigastric pain
Hematemesis
Dsypepsia
Pyrosis
Symptoms of gastric ulcer disease:
Bleeding
Perforation
Penetration
Pylero-duodenal stenosis
Malignization
NONPHARMACOLOGIC TREATMENT
Life style modifications
Patients with PUD should eliminate or reduce psychological stress,
cigarette smoking, and the use of Nonselective NSAIDs (including
aspirin). If possible, alternative agents such as acetaminophen, a
nonacetylated salicylate (e.g., salsalate), or a COX-2 selective
inhibitor should be used for pain relief.
Although there is no need for a special diet, patients should avoid
foods and beverages that cause dyspepsia or exacerbate ulcer
symptoms (e.g. spicy foods, caffeine, and alcohol).
PHARMACOLOGIC TREATMENT
acid-antisecretory agents,
mucosal protective agents,
agents that promote healing through eradication of H pylori.44
Medicines for peptic ulcer disease
Drug type/mechanism Examples Dose
Acid-suppressing drugs
Antacids Maalox, Tums, 100-140 mg 1
Gaviscon and 3 h after
meals
Bismuth-containing Bismuth
compounds subsalicylate
(BSS)
46
Omeprasol 20 mg twice daily or Ranitidine 400 mg
twice daily.
Bismuth subcitrate (De-Nol) two tablets four times
daily.
Tetracyclin 500 mg four times daily.
Metronidazol 250 mg four times daily.
The most common triple therapy :
• Omeprasol (lanzoprazol) 20 mg bid
• Clarithromycin 500 mg bid
• Amoxicillin 1 g bid for 14 days.
Gastrointestinal Hemorrhage
Intra-abdominal Hemorrhage
Dilated veins in esophageal wall
Occur secondary to hepatic cirrhosis, common in
alcohol abusers
Obstruction of hepatic portal blood flow results
in dilation, thinning of esophageal veins
Portal hypertension
Hepatic scarring slows blood flow
Blood backs up in portal circulation
Pressure rises
Vessels in portal circulation become distended
Signs and Symptoms
Hematemesis (usually bright red)
Nausea, vomiting
Evidence of hypovolemia
Melena (uncommon)
Mallory-Weiss Syndrome
Longitudinal tears at
gastroesophageal junction
Occur as result of
prolonged, forceful
vomiting, retching
Common in alcoholics
May be complicated by
presence of esophageal
varices
Localized dilation due to weakening of aortic wall
Usually older patient with history of hypertension,
atherosclerosis
May occur in younger patients secondary to
Trauma
Marfan’s syndrome
Signs and Symptoms
Unilateral lower quadrant pain; low back or leg pain
May be described as tearing or ripping
Pulsatile palpable mass usually above umbilicus
Diminished pulses in lower extremities
Unexplained syncope
Evidence of hypovolemic shock
Ectopic Pregnancy