Diagnosis of abdominal pain

In the presence of acute intensive pain in the abdomen, the general practitioner is faced with the task not only of establishing a nosological diagnosis, but also an immediate assessment of the urgency of the disease and the need for urgent surgical care. The solution of this question is the prerogative of the surgeon, but the preliminary conclusion is made by a general practitioner. If the urgency of the situation is not obvious, it is required to establish a presumptive diagnosis, to help and outline a plan for additional diagnostic measures, possible in an outpatient setting or in a hospital, judging by the patient's condition.

The solution of these questions should, first of all, be conducted on the basis of questioning and physical examination.

When questioning a patient, the following questions should be raised:

1. when there was a pain in the abdomen, their duration;
2. how the disease developed - suddenly or gradually;
3. what are the possible causes of pain - poor quality food, trauma, medication, previous diseases of the abdominal cavity, chest, spine;
4. what are the localization, irradiation and prevalence of abdominal pain (local, diffuse);
5. what are the intensity and nature of abdominal pain: acute, blunt, colic, short-term, prolonged, persistent, etc .;
6. what are the attendant symptoms: fever, vomiting, diarrhea, stool retention, and gas leakage.

In an objective examination, the general condition of the patient should be assessed: position in bed and behavior, face, tongue, skin color, respiratory and pulse frequency, blood pressure; conduct auscultation of the lungs, heart, blood vessels. When examining the abdomen, you need to determine its configuration, size, participation in the act of breathing, soreness, muscle tension, peritoneal symptoms, peristalsis sounds. You should use gentle, careful palpation, using more rational techniques, for example, the symptom of Shchetkin-Blumberg can be replaced by a light percussion of the abdomen, and the detection of muscular protection - coughing. The questioning and objective research make it possible to distinguish visceral pains from diseases of hollow organs, somatic - from irritation of the parietal peritoneum.

When examining a patient, diagnostic methods should be used that ensure sufficient reliability, i.e., the reliability of the results from the position of sensitivity and specificity of the method; small risk for the patient, small time. The latter is especially important in urgent situations. These requirements are met, first of all, by detailed inquiry and objective research, which are considered more valuable than any instrumental and laboratory studies and, in most cases, solve the diagnosis or determine the tactics of the patient's management.

The main, most informative methods of additional examination of such patients are currently endoscopic (with possible biopsy), ultrasound and laboratory studies. The latter include a general blood test (leukocytosis!), Blood for amylase, alkaline phosphatase, sugar, bilirubin. X-ray studies often give only probable data, and therefore it is better to use them for special indications: with suspicion of mechanical ileus (sensitivity of the method 98%), perforation of the hollow organ (60%), stones (64%) - only positive results are taken into account.

Based on the clinical examination of a patient with acute pain in the abdomen, three alternative solutions are possible:

• urgent hospitalization;
• planned hospitalization;
• outpatient monitoring and examination.

Urgent hospitalization in the surgical department is primarily for all patients with signs of peritonitis, intestinal obstruction or mesenteric thrombosis. Followed by patients with severe prolonged or recurrent pain, especially with signs of inflammation and / or cardiovascular disorders, including suspected acute appendicitis, cholecystitis, pancreatitis.

The remaining patients have a lesser degree of "urgency", are subject to planned hospitalization, usually in the therapeutic departments, or, as with chronic pain, are examined on an outpatient basis. This group includes patients with cholelithiasis or urolithiasis, acute gastroenteritis, extra-abdominal diseases, which can cause acute pain, but not an acute abdomen.

To prevent many unnecessary studies, it is important to take into account anamnestic information that allows us to distinguish between organic and functional pathology of the intestine.

In favor of organic disease, the rapid development of symptoms and their progression. Irritable bowel syndrome is significantly more likely than with organic diseases, there is the occurrence of diarrhea or simply rapid defecation with the appearance of pain, as well as visible bloating. On the border of reliability, such symptoms as a feeling of fullness in the abdomen, incomplete emptying, mucus in the feces. Taking into account these signs helps to diagnose the streets of young and middle age. Elderly people always require a complete gastroenterological examination in accordance with the history and examination data.

Differential diagnosis of functional and organic pathology of the intestine

Symptom	Irritable Bowel Syndrome	Organic Bowel Disease
Age	Less than 50 years	Older than 50 years
Duration of anamnesis	Years	Months
Features of pain	Diffuse, volatile localization and intensity	Clearly localized, often paroxysmal, nocturnal, short-term
Connectivity	With psychoemotional factors	With food
Defecation	In the morning	At night
Blood and the feces	No	May be
Weight Loss	No	There is
Psycho-vegetative disorders	There are	Usually not
Blood test	Without features	Anemia, increased ESR

In the presence of signs of organic bowel disease, bowel cancer, ulcerative colitis, terminal ileitis (Crohn's disease), diverticulitis of the large intestine should be excluded. All these diseases have some common symptoms: weakness, weight loss, fever, blood in the stool, anemia, leukocytosis, an increase in ESR.

Nonspecific ulcerative colitis and terminal ileitis have characteristic extra-abdominal manifestations: arthritis, skin lesions (nodal or multiple exudative erythema, exanthema), iritis, enlarged lymph nodes. With ulcerative colitis and diverticulitis, the predominantly descending part of the large intestine is affected, which, when palpated, is painful, thickened, and there are often tenesmus and perianal inflammatory changes. For the diagnosis, finger examination of rectum, rectomo-and irrigoscopy is important. With diverticulitis there may be narrowing of the lumen of the gut, filling defects, which requires a biopsy of the mucosa to exclude the tumor.

Terminal ileitis more often in young people is accompanied by local symptoms from the side of the ileocecal region: a painful conglomerate, fistulas, diarrhea, steatorrhea, malabsorption syndrome. The diagnosis is determined by X-ray examination (rigidity and narrowing of the lumen of the gut) and a colonoscopy with targeted biopsy.

Intestinal tumors show similar symptoms, but are more common in elderly patients and require a detailed radiographic and endoscopic examination.

Differential diagnosis of abdominal pain includes the following diseases: gastric and duodenal ulcer, esophagitis, stomach cancer, pancreatitis, pancreatic carcinoma, gall bladder disease, helminthic invasion, abuse of laxatives, small and large intestine tumors.

When differential diagnosis of chronic pain in the abdomen must take into account their location, as well as the presence or absence of dyspepsia, intestinal disorders, other associated symptoms.

It should be emphasized that the benchmark for selecting and prioritizing diagnostic tests for bowel diseases is the history and objective research data that each doctor should possess, regardless of specialty.

When diagnosing pain in the abdomen, one should not forget about the existence of pain associated with viscerovisceral, visceromuscular and viscero-cuffed reflexes. They arise as a result of switching afferent impulses from sympathetic fibers from the affected organ to the corresponding segments of the somatic nervous system. The diagnostic significance of the appearance of such reflected pains was first described by A. Zakharin and G. Ged (1989) and presented their zones in the form of a diagram. Establishing zones of pain and comparing their boundaries with the above scheme, we can make an assumption about which internal organ is affected. However, the pain of the same zones can occur in diseases of various organs.

Thus, diagnosis, differential diagnosis of abdominal pain syndrome is a very difficult task.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12],