Abdominal Pain - 2

Lower Abdominal Pain
13.10.06

Irritable bowel syndrome
Epidemiology
• IBS affects 9-20% of population.
• Very dependent on criteria.
• In 1year, 38% will resolve and 8% develop new IBS.
• Female: male ratio = 1.1 to 2.6.
• Age and race have no consistent effect on incidence of symptoms.

Presentation
• Only small fraction seen by gastroenterologists.
• 50% do not seek medical advice.
• Large spectrum of severity.
• Often referred to other specialties.

Abdominal symptoms
• Almost universal symptoms.
• Colicky abdominal pain.
• Bloating.
• Sensation of increased flatus production.
• Rectal dissatisfaction.
• Often upper GI symptoms of heartburn, early satiety.

Associated symptoms
• Increased urinary frequency.
• Urinary dissatisfaction.
• Headaches.
• Atypical chest pain.
• Fibromyalgia.
• Chronic fatigue.
• Menorrhagia, dyspareunia.

Rome II criteria
At least 12 weeks in last 12 months of abdominal discomfort/pain that has 2 out 3 of following features:
• Relieved by defaecation.
• Onset associated with change in frequency of stool.
• Onset associated with change in form of stool.
Supportive symptoms
• <3 bowel movements per week.
• >3 bowel movements per day.
• Straining during bowel movement.
• Hard/lumpy stools.
• Urgency.
• Etc.

Approach to diagnosis
• Positive diagnosis and minimise investigation.
• Typical symptoms without alarm symptoms - weight loss, nocturnal symptoms.
• Normal UEC, LFT, FBC, CRP, TFT.
• Screen for coeliac disease.
• Search for depression.

Pathogenesis
• Abnormal bowel motility.
• Visceral hypersensitivity.
• Psychological factors.
• Post-infective.
• Post-surgical.
• Abnormal colonic fermentation and gas production.
• Food intolerances.

Treatment
• Careful explanation - benign nature.
• Normal diet.
• ?Increase fibre.
• Antispasmodics helpful - mebeverine, alverine.
• Tricyclic antidepressants.
• Relaxation therapy.
• Hypnotherapy.

Problems with trials in IBS
• High placebo response.
• High drop out rate.
• Safety issues.

Appendicitis
• Appendectomy most common abdominal operation.
• Diagnosis difficult at extremes of life.
• 20% normal and up to 40% misdiagnosis especially in women.
• No such thing as grumbling appendix.

Signs
• Fever.
• Guarding.
• Rebound tenderness.
• Indirect tenderness.
• Psoas sign.

Symptoms
• RLQ pain.
• Nausea.
• Vomiting.
• Onset of pain before vomiting.
• Anorexia.

3 most predictive signs
• Pain in RIF.
• Abdomen rigidity.
• Migration of pain from periumbilical region to RIF.
Other factors
• Short duration of pain than with other disorders.
• Atypically presents with back pain, LIF pain.

RIF pain in women
• Most common misdiagnoses in women with:
Pelvic inflammatory disease.
-Gastroenteritis.
-UTI.
-Ruptured ovarian follicle, ectopic pregnancy.

PID more likely if:
• History of PID.
• Vaginal discharge.
• Urinary symptoms.
• Tenderness outside RIF.

Laboratory tests
• b-HCG level.
• 70-90% increased WCC, but not specific.
• MSSU.
• 40% of acute appendicitis have pyuria, haemuturia or bacteriuria.
• CT more accurate and better at identifying other diagnoses and complications that ultrasound scan.

Crohn's disease
• Idiopathic inflammatory bowel disease.
• Occurs anywhere from mouth to rectum.

Signs/symptoms
• Young Caucasian.
• Diarrhoea (80%).
• Abdominal pain (70%) - usually colicky lower abdomen.
• Occasionally obstructive symptoms.
• Weight loss (50%).
• Extra-GI symptoms.
• Examination - usually normal.
• RIF mass/fullness.

Smoking
• Probably most important intervention: stopping smoking.
• Smokers with CD have:
-More relapses.
-More pain.
-More operations.

Extra-GI manifestation
• Arthralgia.
• Mouth ulcers.
• Iritis.
• Etc.

Diagnosis
• Clinical.
• Raised inflammatory markers.
• Endoscopy.

PID
• Usually caused by invasion of either gonorrhoea/chlamydia from cervix up to uterus and tubes.
• Bacteria and neutrophils fill tubes.

Risk factors
• Low socioeconomic status.
• Multiple/high-risk sexual partners.
• Intrauterine contraceptive device.
• Previous episode.

Symptoms/signs
• Lower abdominal/pelvic pain.
• Dyspareunia.
• Dysuria.
• Abnormal uterine bleeding.
• Nausea and vomiting.
• Fever.
• Etc.

Investigation
• Increased WCC, ESR and CRP - non-specific.
• USS and CT.
• Laparoscopy.

Management
• Oral/IV antibiotic regimes.
• Ofloxacin.
• Ceftriaxone and doxycycline.

Ectopic pregnancy
• Most common location: Fallopian tubes.
• Pregnancy outgrows tube, tube wall ruptures.
• Haemorrhage into pelvic cavity occurs.

• Suspect in females of child-bearing age with:
-Abdominal pain.
-Unexplained shock.
• When was LNMP?
-Does not necessarily cause missed period.

Conclusions
• Pattern of pain and associated symptoms vital in making diagnosis.
• Functional pain most likely cause in younger adults.
• Important to think of PID, but difficult to diagnose.
• RIF pain in females most difficult.