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INTRODUCTION

Numerous causes, ranging from acute, life-threatening emergencies to chronic functional disease and disorders of several organ systems, can generate abdominal pain. Evaluation of acute pain requires rapid assessment of likely causes and early initiation of appropriate therapy. A more detailed and time-consuming approach to diagnosis may be followed in less acute situations. Table 37-1 lists the common causes of abdominal pain.

TABLE 37-1SOME IMPORTANT CAUSES OF ABDOMINAL PAIN

APPROACH TO THE PATIENT: Abdominal Pain

History: History is of critical diagnostic importance. Physical examination may be unrevealing or misleading, and laboratory and radiologic examinations delayed or unhelpful.

CHARACTERISTIC FEATURES OF ABDOMINAL PAIN

Duration and pattern: These provide clues to nature and severity, although acute abdominal crisis may occasionally present insidiously or on a background of chronic pain.

Type and location provide a rough guide to nature of disease. Visceral pain (due to distention of a hollow viscus) localizes poorly and is often perceived in the midline. Intestinal pain tends to be crampy; when originating proximal to the ileocecal valve, it usually localizes above and around the umbilicus. Pain of colonic origin is perceived in the hypogastrium and lower quadrants. Pain from biliary or ureteral obstruction often causes pts to writhe in discomfort. Somatic pain (due to peritoneal inflammation) is usually sharper and more precisely localized to the diseased region (e.g., acute appendicitis; capsular distention of liver, kidney, or spleen), exacerbated by movement, causing pts to remain still. Pattern of radiation may be helpful: right shoulder (hepatobiliary origin), left shoulder (splenic), midback (pancreatic), flank (proximal urinary tract), and groin (genital or distal urinary tract).

Factors that precipitate or relieve pain: Ask about its relationship to eating (e.g., upper GI, biliary, pancreatic, ischemic ...

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