Amir ABDELNOUR, FRCS Head of Divison of General Surgery UOB Abdominal Pain

Abdominal Pain
What is pain?
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Abdominal Pain
The purpose of pain
Pain operates as a protective system; it warns us of imminent or actual tissue damage and elicits coordinated reflex and behavioral responses to keep such damage to a minimum. Pain occurs with tissue damage or damage to the nervous system. This could result from surgical trauma or pathological tissue changes

Abdominal Pain
Types of pain
- Nociceptive pain +Somatic pain +Visceral pain - Neuropathic Pain

Abdominal Pain
Physiologically, pain is classified as
nociceptive pain and neuropathic pain. The nociceptive pain can be further classified as somatic and viscera pain. The neuropathic can be classified as centrally or peripherally generated pain.

Abdominal Pain
The somatic pain arises from
-skin, - connective tissue, - muscle, - joint and bone.

The somatic pain sensation is usually described

as
localized, sharp, aching, throbbing, or pressure like

Abdominal Pain
The viscera pain sensation is usually
described as - dull - ill-defined.

Abdominal Pain
The viscera pain could potentially result
from tumors, inflammation , infection or obstructions. The obstruction from hollow organs can cause intermittent cramping or a poorly localized pain.

Abdominal Pain
A neuropathic pain may be due to nerve
injury or damage and resulting in neuropathies which then lead to abnormal processing of sensory input by the peripheral or central nervous system.

Abdominal Pain
The etiology of neuropathic pain includes
- traumatic, - infectious, - metabolic, - ischemic, or - immune mediated. - Nerve compression could also lead to neuropathic pain.

Abdominal Pain
The neuropathic pain sensation in humans
has been described as - electrical, - sharp, - burning, and - jabbing pain.

Abdominal Pain
Duration of pain
- Acute pain - Chronic pain

Abdominal Pain
The acute pain is a normal predicated physiological response to an
adverse - chemical, - thermal - mechanical stimulus. Acute pain is useful and serves as protective purpose. The acute pain frequently associated with - surgery, - trauma or any acute illness. Acute pain frequently lasts from hours to days. tachycardia, fainting etc.

Pain is also associated with other manifestation like sweating,

Abdominal Pain
Chronic pain is defined as pain that
persists longer than the expected time frame for healing or pain associated with progressive, non-malignant disease. Chronic pain has little protective significance and usually persists despite normalization after injury or disease, and ultimately interferes with productive life

Abdominal Pain
How is pain occurring?
- Nociceptor = a receptor for pain - In peripheral tissue, detect potentially damaging stimuli - Activated or sensitized by endogenous substances released in inflammation (prostaglandins, bradykinin, serotonin, histamine, etc.) - Transmit information to spinal cord-dorsal horn cells via :
A (sharp pain, rapid transmission) C fibers (dull, burning pain, slow transmission)

Abdominal Pain
Most of the tissues are rich with specific pain
receptors called nociceptors. Tissue damaged activated these nociceptors and results in two simultaneous pathophysilogical changes -Biochemical changes at the nerve endings and injured tissues - neuronal changes in the peripheral nerves.

Abdominal Pain
The biochemical changes include
- release of prostaglandins, - substance P, - serotonin, K+, and - bradykinin from mast cells, platelets and free nerve endings.

Abdominal Pain
Peripheral sensitization
The inflammatory biochemical substances sensitize the vast population of nociceptors, making them far more sensitive to further stimulation; this is termed "peripheral sensitization". - vasodilatation, - inflammation, - edema in the local tissues and - sending pain signals to specific pain transmission fibers to the spinal cord.

The release of these biochemical substances causes

Abdominal Pain
Pain signals transmission from peripheral to
spinal core Pain signals transmission involves neuronal conduction from the periphery to the dorsal horn cells in the spinal core and the brain, primarily by A-delta and C fibers. - fast pricking pain is transmitted by the myelinated A-delta fibers - slow burning pain is conducted by small unmyelinated C-fibers.

Abdominal Pain
ABDOMINAL PAIN

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Abdominal Pain
What is abdominal pain?
Ordinarily, we are unaware of any of the actions of the organs in the abdomen or any discomfort from activities such as eating, movement of food through the intestines, or bowel movements. Nerves are constantly monitoring activities in the body, and when those messages are transmitted to the brain and come into consciousness as unpleasant sensations, we may sense pain or discomfort

Abdominal Pain
What causes abdominal pain?
Pain can arise from any of the structures within the abdomen or the abdominal wall. In addition, pain messages originating in the chest, back, or pelvis can sometimes be perceived as coming from the abdomen. For example, patients with heart attacks or pneumonia sometimes complain of upper abdominal pain rather than chest pain. There are many possible causes of pain.

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Abdominal Pain
Abdominal pain is traditionally described by its 1.Chronicity (acute or chronic) 2.progression over time 3.nature (sharp, dull, colicky) 4.distribution i.e. Site (by various methods, such as abdominal quadrant (left upper quadrant, left lower quadrant, right upper quadrant, right lower quadrant) or other methods that divide the abdomen into nine sections) 5.characterization of the factors that make it worse, or alleviate it.

Abdominal Pain
Types and mechanisms
1. The pain associated with inflammation of the parietal peritoneum is steady and aching, and worsened by changes in the tension of peritoneum caused by pressure or positional change, and is often accompanied by tension of the abdominal muscles contracting to relieve such tension. 2. The pain associated with obstruction of the hollow viscera is often intermittent or "colicky" 3. The pain associated with abdominal vascular disturbances (thrombosis or embolism) can be sudden or gradual in onset, and can be severe or mild. Pain associated with the rupture of an abdominal aortic aneurysm may radiate to the back, flank, or genitals. 4. Pain that is felt in the abdomen may be "referred" from elsewhere (e.g., a disease process in the chest, like a sub-diaphragmatic abscess, may cause pain in the abdomen), and abdominal processes can cause radiated pain elsewhere (e.g. gall bladder pain-in cholecystitis or cholelithiasis-is often referred to the shoulder).

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Abdominal Pain
NOTES ON VISCERAL SENSATION
1.Sensation from viscera can be crudely divided into "normal" (usually associated with motility and/or distension) and "abnormal" (i.e. painful). (a) "Normal" sensory information from viscera is transmitted through the visceral sensory fibres that accompany the parasympathetic motor fibres supplying that organ. What is the parasympathetic motor supply to:: (i) the fore- and midgut? (ii) the hindgut? (iii) the bladder? (b) "Painful" sensory information from viscera is transmitted through the visceral sensory fibres that accompany the sympathetic motor fibres supplying that organ

Abdominal Pain
What is the sympathetic motor supply to
the abdominal and pelvic viscera? Painful sensations from the viscera are vaguely localized to the median plane, no matter what the location of the viscous. All viscera are invested with a layer of the lining of the body cavity.

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Abdominal Pain Analysis of Pain

Site Radiation Severity Timing & Duration Character Occurrence or aggravation Relief

Abdominal Pain
Region of the Abdomen

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