stomach ache
Introduction
Introduction to abdominal pain Abdominal pain (abdominalpain) is a common clinical symptom and the cause of the patient's visit. Abdominal pain is caused by some strong stimulation or injury of the intra-abdominal tissues or organs. It can also be caused by chest diseases and systemic diseases. In addition, abdominal pain is a subjective feeling. The nature and intensity of abdominal pain are not only affected by the lesions and The degree of stimulation is affected by factors such as nerves and psychology. That is, the sensitivity of the patient to pain stimuli is different, and the stimulation of the same lesion differs in nature, intensity, and duration of abdominal pain caused by different patients or different periods of the same patient. Therefore, only by analyzing the pathophysiology, neurophysiology, psychology and clinical aspects of the disease, it is possible to have a correct understanding of abdominal pain. Abdominal pain is often divided into acute and chronic clinical categories. basic knowledge The proportion of illness: 0.003% Susceptible people: no special people. Mode of infection: non-infectious Complications: electrolyte imbalance shock
Cause
Cause of abdominal pain
Acute abdominal pain (35%):
(1) Abdominal organ diseases:
1 acute inflammation of abdominal organs: acute gastroenteritis, acute corrosive gastritis, acute cholecystitis, acute pancreatitis, acute appendicitis, acute cholangitis.
2 perforation or rupture of abdominal organs: perforation of gastric and duodenal ulcer, perforation of typhoid, liver rupture, rupture of spleen, renal rupture, rupture of ectopic pregnancy, rupture of ovary, etc.
3 abdominal organ obstruction or dilation: gastric mucosal prolapse, acute intestinal obstruction, inguinal hernia incarceration, intussusception, biliary ascariasis, cholelithiasis, kidney and ureteral stones.
4 abdominal organ torsion: acute gastric torsion, ovarian cyst torsion, omental torsion, intestinal torsion and so on.
5 intra-abdominal vascular obstruction: acute obstruction of mesenteric artery, acute portal vein thrombosis, dissecting abdominal aortic aneurysm.
(2) abdominal wall disease: abdominal wall contusion, abdominal wall abscess and abdominal wall banded sores.
(3) chest disease: acute myocardial infarction, acute pericarditis, angina pectoris, pneumonia and pulmonary infarction.
(4) systemic diseases and other: rheumatic fever, uremia, acute lead poisoning, hematoporphyria, abdominal allergic purpura, abdominal epilepsy.
Chronic abdominal pain (35%):
(1) Abdominal organ diseases:
1 chronic inflammation: reflux esophagitis, chronic gastritis, chronic cholecystitis, chronic pancreatitis, tuberculous peritonitis, inflammatory bowel disease.
2 stomach, duodenal ulcer and gastrinoma.
3 torsion or obstruction of intra-abdominal organs: chronic gastrointestinal torsion, intestinal adhesions, omental adhesion syndrome.
4 organ capsule tension increased: liver congestion, hepatitis, liver abscess, liver cancer, splenomegaly and so on.
5 gastrointestinal dysfunction: gastroparesis, functional dyspepsia, liver varicose and splenic syndrome, irritable bowel syndrome.
6 tumor compression and infiltration: gastric cancer, pancreatic cancer, colorectal cancer.
(2) Poisoning and metabolic disorders: chronic lead poisoning, uremia, etc.
(3) chest, lumbar lesions: such as spinal tuberculosis, abscess and so on.
(4) organic neuropathy: spinal tuberculosis, spinal cord tumors, etc.
Pathogenesis
Any form of stimulation (physical or chemical) that reaches a certain level of intensity can cause abdominal pain. It is currently believed that in the case of inflammation, tissue necrosis, ischemia, hypoxia, etc., tissue can release some hormones or body fluids to activate pain receptors. Body, causing pain, these substances include acetylcholine, serotonin, histamine, bradykinin and its like peptides, prostaglandins, potassium ions, hydrogen ions and acidic products produced by tissue damage, etc., of which bradykinin is Strong irritants of pain, in addition, these chemicals may also trigger the contraction of local smooth muscles and cause pain.
1. The pain receptor is a free nerve ending, distributed in various tissues and organs of the body. The receptors related to pain in the abdominal cavity include:
(1) The receptor or tension receptor in the wall of the hollow organ mainly affects the tension, the tension and the strong contraction of the muscle.
(2) The serosal membrane, the peritoneal wall layer and the intra-abdominal parenchyma receptor and mesangial receptors, and the mechanical stimulation of stretching, twisting and the like.
(3) mucosal receptors, sensing the stimulation of chemical substances, such as gastric acid, intestinal fluid, etc. After the pain receptors are stimulated, the impulse signals are transmitted to the cerebral cortex via three levels of neurons.
Grade I neurons (from the abdomen to the spinal cord): The afferent nerves of the abdomen are from the spinal nerves and splanchnic nerves. The former is responsible for the conduction of the abdominal wall, the latter is responsible for the conduction of the visceral sensation, and the painful afferent nerve fibers of the abdominal tissues and organs. The local splanchnic nerve enters the sympathetic chain and rises to a certain segment of the spinal cord. The sensory nerve fibers from the abdominal wall transmit information of pain to the respective neurons located in the dorsal root ganglia of the spinal cord.
Class II neurons (connected to the spinal cord and brainstem): Synapses of grade I neurons are in the gray matter at the posterior horn of the spinal cord. After replacement neurons (level II neurons), the pain information is transferred to the white matter on the opposite side of the spinal cord. And along two pathways: the spinal thalamus bundle and the spinal cord reticular bundle, respectively send information to the thalamus or pons and the medullary reticular formation.
Class III neurons (connected to the brainstem and cortex): Some neuronal cells in the thalamus receive information from the synapses of the spinal thalamus and transmit them to the somatosensory region of the cerebral cortex, which accepts the neural cells of the reticular structure. Information transmitted by synapses of the reticular tract of the spinal cord and transmitted to the frontal and marginal systems.
Due to the above-mentioned special nerve conduction, the pain of the abdomen and pelvic organs is reflected on the body surface, and often has a certain segmental distribution of the spinal cord. Generally speaking, the spinal cord segment that governs the abdominal skin feels from the chest to the waist 1, such as the esophagus. Distal, stomach and duodenal proximal, liver, gallbladder, pancreas, its afferent nerve into the spinal cord of the chest 5 ~ chest 9, the abdominal pain caused by these organs mainly between the ventral midline xiphoid and the umbilicus.
The small intestine, appendix, ascending colon and transverse colon are 2/3 in the proximal segment, and the afferent spinal cord 8 to chest 11 and waist 1 are mainly expressed around the umbilicus.
In addition, most of the organs in the abdomen, such as the stomach, small intestine, liver, gallbladder, and pancreas, have bilateral symmetry, and the pain is mostly in the midline of the abdomen; while the nerves of the kidney, ureter, and ovary are mainly distributed on the side, and the abdominal pain is mostly One side.
2. Peripheral stimulation is perceived as pain and is affected by different levels of regulation.
(1) The intensity of local stimuli needs to exceed the threshold of the receptor.
(2) The interaction between intraspinal stimulation and inhibitory factors. In the gray matter in the posterior horn of the spinal cord, there is a spinal cord regulation center, where a nerve cell is called a "transmission cell" (T cell), a T cell. The activity becomes a "valve" that controls the transmission of pain, directly affecting the transmission of pain information into the gray matter; another cell is called "intermediary neuron" (I-cell), which stimulates I cells to inhibit T cell activity. Closing the "valve" prevents the transmission of pain; inhibiting I cells opens the "valve" and accelerates the transmission of pain.
(3) Internal factors of the cerebral cortex: The nerve fibers of some neurons in the midbrain and cerebral reticular formation can be transmitted to the gray matter in the posterior horn of the spinal cord, releasing some neurotransmitters or hormones, such as releasing endorphins, and activating I. Cells that inhibit the transmission of pain, such neurons and their descending nerve fibers are called pain-relieving "downward suppression systems," which exemplify the regulation of low-level nerve centers by the high-grade nerve center in pain.
3. From the neural mechanism of pain, abdominal pain can be divided into the following three types:
(1) Visceral abdominal pain: The pain signal is transmitted through the sympathetic nerve pathway, and the spinal nerves are basically not involved. The characteristics of the pain are:
1 The pain is more blurred, and it is usually more widely shuttled to the midline of the abdomen.
2 The feeling of pain is mostly sputum, discomfort, dull pain or burning.
3 often accompanied by nausea, vomiting, sweating and other symptoms of autonomic nervous system excitability, without local muscle tension and skin hypersensitivity.
(2) Body-induced abdominal pain: also known as "peritoneal skin reflex pain", only the body or spinal nerves without the involvement of visceral nerves, pain characteristics:
1 The positioning is more accurate, often appear in the peritoneal area adjacent to the affected organ, and has a clear distribution of segmental nerve distribution of the spinal cord.
2 degree is intense and continuous.
3 Pain can occur on one side of the abdomen and can be aggravated by coughing or changing body position.
4 can be accompanied by local abdominal muscle stiffness, tenderness and rebound tenderness.
(3) Involving pain: refers to the pain caused by the abdominal organs appearing in the area away from the splanchnic nerve conduction of the organ, and the visceral nerve and the body nerve participate in such pain mechanism, the pain characteristics:
More than 1 is sharp pain, the degree is more severe.
2 positions are clearly on one side.
3 local may have muscle tension or skin hyperesthesia.
Prevention
Abdominal pain prevention
The main reason for prevention and adjustment of abdominal pain is diet, cold and warm, and emotional. People with cold pain should pay attention to heat preservation. Those who suffer from pain should eat easily digestible foods. People with hot pain should avoid eating sweet and mellow taste and alcoholic wine. Those who eat food should pay attention to diet. People with qi stagnation should keep their mood comfortable.
Prevention of abdominal pain during exercise should avoid mental stress, fully prepare for activities, pay attention to step by step to increase the amount of exercise, and do what you can. In addition, before strenuous exercise, do not eat too much, do not eat food that is not used to, and do not go to the hungry to participate in sports, usually exercise after 1 hour after a meal as well.
Complication
Abdominal pain complications Complications electrolyte disorder shock
When the abdominal pain is severe, there will be a disorder of water and electricity balance, shock and so on.
Symptom
Symptoms of abdominal pain Common symptoms The eggs are found in the feces... After violent exercise, vomiting, phlegm, diarrhea, menstruation, anterior and posterior period, abdominal pain, dysmenorrhea, premature knee pain, diffuse after eating... Dizziness, postpartum, postpartum abdominal pain
1. The nature and extent of abdominal pain: The nature of abdominal pain is related to the nature of the organ and lesion in which the lesion is located. For example, colic is often indicative of obstruction of the hollow organ; pain is often caused by increased visceral capsule tension, mesangial traction or The degree of pain is sometimes consistent with the severity of the lesion, but due to individual differences, sometimes the degree of pain does not reflect the extent of the lesion.
2. Abdominal pain site: The body surface position of abdominal pain is often related to the segmental distribution of the spinal cord. Usually, the site of the pain is the site of the lesion, but some lesions cause pain to be radiated to a fixed area, such as acute cholecystitis. Radiation to the right scapula and back, pain caused by appendicitis can be transferred from the umbilicus to the right lower abdomen.
3. Accompanying symptoms: abdominal pain accompanied by fever, inflammation, connective tissue disease, malignant tumor, etc.; accompanied by vomiting, suggesting esophagus, stomach or biliary tract disease; vomiting is more likely to have gastrointestinal obstruction; accompanied by diarrhea, suggesting intestinal inflammation, malabsorption, pancreatic disease With shock, while anemia suggests rupture of abdominal organs (such as liver or spleen rupture or rupture of ectopic pregnancy), myocardial infarction, pneumonia may also have abdominal pain with shock, should be particularly vigilant; with urgency, frequent urination, dysuria, hematuria Etc., indicating urinary tract infections or stones; accompanied by gastrointestinal bleeding, such as tar-like stool or hematemesis suggestive of peptic ulcer or gastritis; such as bloody stools or dark red bloody stools, often suggesting ulcerative colitis, colon cancer, intestines Tuberculosis, etc.
Examine
Abdominal pain check
Physical examination
Abdominal examination
(1) visual examination: pay attention to whether there is abdominal distension, intestinal type, intestinal peristalsis and abdominal breathing.
(2) Auscultation: pay attention to bowel sounds.
(3) percussion: those with obvious abdominal distension should check whether the liver dullness disappears, whether there is mobile dullness, and the drum sound is obvious, suggesting that the intestine is inflated, and there may be obstruction.
(4) palpation: the examination should start from the non-pain area, gradually move to the pain site, find the tenderness and tension, the extent and extent, observe the facial expression of the child, partially refuse to press, and the degree of crying is serious.
2. Other inspections
Pay attention to skin bleeding points, ecchymosis, jaundice, cardiopulmonary examination, groin, anal finger examination.
Laboratory inspection
1. Blood, urine, fecal routine, ketone body and serum amylase are the most commonly used laboratory tests.
2. For peritonitis, internal bleeding, abdominal abscess and certain abdominal masses, a diagnostic puncture is feasible, and the puncture is routinely smeared, bacterial culture or pathological examination.
Film degree exam
1. X-ray examination: When the diagnosis is difficult, suspected and chest and abdomen have lesions, it is feasible to see the chest and abdomen, the purpose is to observe whether there is any lesion in the chest, whether there is free gas under the armpit, changes in diaphragmatic movement, presence or absence of intestinal gas and liquid level Etc., abnormal cases should be routinely filmed, when suspected sigmoid torsion or low intussusception, barium enema examination is feasible; patients with suspected intestinal obstruction, internal hemorrhoids or perforation should not be barium meal examination.
2. B-ultrasound: mainly used for the examination of biliary and urinary calculi, bile duct dilatation, pancreas and hepatosplenomegaly, etc., also has a good diagnostic value for a small amount of effusion in the abdominal cavity, intra-abdominal cysts and inflammatory masses.
3. Endoscopy: Endoscopy has become an important means of finding the cause of abdominal pain. Retrograde cholangiopancreatography, cystoscopy and laparoscopy can also be performed if the patient's condition permits.
4. CT, magnetic resonance and radionuclide scanning examination: for intra-abdominal and retroperitoneal lesions, such as liver, spleen, pancreatic lesions and some intra-abdominal masses and abdominal abscesses, effusion, gas accumulation, etc. Diagnostic value should be selected according to the condition.
5. Electrocardiogram examination: For older patients, ECG should be performed to understand myocardial blood supply and exclude myocardial infarction and angina pectoris.
Diagnosis
Diagnosis and identification of abdominal pain
diagnosis
Abdominal pain is often the cause of patients' treatment. The nature of the lesion may be organic or functional. Some abdominal pains are acute and severe, some have slow onset and mild pain. Because of the complicated pathogenesis, patients with abdominal pain It is necessary to meticulously ask about the medical history, conscientious and comprehensive physical examination and reasonable auxiliary examination, and comprehensive analysis to determine the location and nature of the lesion and make a correct diagnosis of the cause.
1. Medical history: Ask whether there is a similar episode in the past, whether there is a history of surgery and a history of allergies, etc., women of childbearing age should be asked about menstruation, in addition to the past and the current situation of the drug use and response to treatment.
2. Course of disease: including the time of abdominal pain, urgency, continuous or intermittent episodes, etc. The time of abdominal pain combined with the patient's health status is crucial for judging the severity of the condition.
3. Inducing factors: such as drinking or greasy, cold, unclean food, etc.; often have a history of eating fatty food before cholecystitis or cholelithiasis; acute pancreatitis often has a history of alcoholism or overeating before the onset of acute pancreatitis.
4. Physical examination:
(1) General examination: Pay attention to the general condition, observe the patient's mind, mental state, body temperature, breathing, pulse, blood pressure, posture, posture, activity, with or without anemia or jaundice; in addition, check the heart and lungs, spine and so on.
(2) Abdominal examination:
1 with or without bulging, with or without diffuse or localized flatulence, with or without intestinal type, stomach type and peristaltic wave.
2 palpation: whether there is tenderness, rebound tenderness and muscle tension in the abdomen, if the sputum and mass should be known, its location, size, shape, boundary, texture, activity and tenderness.
3 percussion: whether there is mobile dullness, drum sound, liver dullness and so on.
4 auscultation: should pay attention to whether the bowel sounds increase, hyperthyroidism, reduce or disappear, the change of bowel sounds should be observed for many long time.
(3) rectal, vaginal examination: for lower abdominal pain, those with abnormal bowel movements should do anal examination, and those who are suspected of having pelvic lesions in married women should be examined by a gynecologist.
5. Surgical exploration: If the diagnosis is unknown, the medical treatment is invalid and the condition is critical, laparotomy can be considered.
Differential diagnosis
1. Acute abdominal pain: Acute abdominal pain is one of the common clinical symptoms, and its etiology is complex and diverse, but its common features are acute onset, rapid change and serious condition. It is necessary to make rapid and accurate diagnosis and differential diagnosis.
(1) Acute inflammation of the abdominal organs:
1 acute gastroenteritis: can occur in any age group, mostly after eating unclean food or drinking contaminated water or overeating, persistent and paroxysmal abdominal pain, accompanied by nausea, vomiting, diarrhea, postprandial abdominal pain can be alleviated or relieved Can be accompanied by chills, fever, etc., upper abdominal and umbilical tenderness is obvious, no rebound pain, auscultation of bowel sounds hyperthyroidism, laboratory examination of white blood cells and neutrophils can be increased.
2 cholecystitis, cholelithiasis: more common in women, the age of onset is 20 to 40 years old, the infection of bacteria is mainly Escherichia coli, mostly caused by eating fatty food or cold, clinical manifestations of persistent right upper quadrant pain Intermittent aggravation, radiation to the right shoulder and right back, accompanied by chills, fever, nausea and vomiting, etc., 40% to 50% of patients have skin mucosal yellow staining, most patients have right upper quadrant tenderness and local muscle tension, there are One-third of patients can reach the enlarged gallbladder under the right costal margin, Murphy sign positive, white blood cells and neutrophils increased, B-ultrasound and CT examination can be found that the enlarged gallbladder and stone signs filled with fluid can be diagnosed .
3 acute pancreatitis: acute onset, more drinking, overeating, high-fat meal and mental agitation and other incentives, the main clinical manifestations of persistent upper abdomen or left upper abdomen pain, and to the left back waist radiation; Pain is relieved when bending over or sitting forward, accompanied by fever, nausea, vomiting, vomiting occurs soon after the onset of abdominal pain, more severe, but not persistent; a small number of jaundice; severe cases of respiratory and circulatory failure, upper abdominal tenderness, Anti-jumping pain and localized muscle tension, obvious in the left upper abdomen, sometimes with mobile dullness; elevated white blood cells and neutrophils, elevated serum and urine amylase, and increased blood glucose, blood calcium, B Ultra-CT examination can be seen in pancreatic enlargement, sometimes abdominal puncture can extract yellow or bloody ascites, ascites amylase increase can help diagnosis; gastric and duodenal ulcer perforation, intestinal obstruction, cholecystitis, cholelithiasis, etc. There may be mild blood, increased urinary amylase, and no change in blood calcium and blood sugar. Repeated detection of urinary amylase may be differentiated from the above diseases.
4 acute appendicitis: can be seen at any age, but more common in 20 to 50 years old, clinical manifestations of umbilical or mid-abdominal pain, gradually worsening, and transferred to the right lower abdomen, persistent or paroxysmal aggravation or sudden all Abdominal pain, accompanied by nausea and vomiting, diarrhea or constipation, severe fever may occur, physical examination: Mai's point tenderness, rebound tenderness and local abdominal muscle tension, colon aeration test positive; if the cecum is posterior, appendix can appear psoas muscle Positive test, white blood cells and neutrophils increased, acute appendicitis needs to be differentiated from acute non-specific appendicitis, because its clinical manifestations are similar to acute appendicitis; female acute appendicitis also needs acute right salpingitis, right ectopic pregnancy rupture , ovarian cysts are reversed, ovarian corpus luteum or follicular rupture is identified.
5 acute hemorrhagic necrotizing enterocolitis: mostly children and adolescents, the onset is acute, the cause is still unclear, may be related to the production of B-toxin C-type Bacillus licheniformis infection, clinical manifestations suddenly acute abdominal pain, pain Mostly located in the umbilical and upper abdomen, can spread to the whole abdomen, mostly persistent paroxysmal aggravation, accompanied by fever, nausea, vomiting, diarrhea and bloody stools; severe cases may have toxic shock, intestinal paralysis, intestinal perforation, etc.; Bulging, abdominal muscle tension, umbilical and upper abdomen tenderness, no rebound pain, early bowel sounds hyperthyroidism, decreased bowel sounds; the total number of white blood cells increased significantly, up to (2 ~ 30) × 109 / L, feces The occult blood is strongly positive or bloody; the abdominal X-ray shows small intestine flatulence, the liquid level or small intestinal wall of different sizes is thickened, and the mucosa is irregular.
6 acute mesenteric lymphadenitis: can occur in any age group, but more common in children aged 8 to 12 years old, some people think it is caused by viral infection, clinical manifestations: abdominal pain often occurs with upper respiratory tract infection, mostly persistent right Pain in the lower abdomen or umbilical cord, short-term abdominal pain can be reduced or disappeared, accompanied by fever, nausea and vomiting, some patients have diarrhea or constipation; lower abdomen has tenderness, rebound tenderness and mild muscle tension, tenderness is more extensive, not fixed The total number of white blood cells is slightly increased, and the disease needs to be differentiated from acute appendicitis.
(2) rupture of abdominal organs, perforation:
1 acute perforation of gastroduodenal ulcer: a history of gastroduodenal ulcer or a history of recurrent episodes of stomach pain, the vast majority of pain suddenly occurs, the nature of the pain is inconsistent, usually manifested as sudden and severe upper abdominal pain, and then Persistent or paroxysmal full abdominal pain, accompanied by nausea and vomiting, pale, cold limbs, palpitation, weak pulse, decreased blood pressure or shock state, physical examination of total abdominal tenderness, rebound tenderness and slab-like abdomen The upper abdomen or the right upper abdomen is heavy, the abdomen may have mobile dullness, the total number of white blood cells and neutrophils are elevated, and the abdominal X-ray and fluoroscopy see the free gas under the armpit. It is feasible for the suspected disease and the diagnosis is unclear. Abdominal puncture examination.
2 acute intestinal perforation: acute intestinal perforation can occur in intestinal ulcer, intestinal necrosis, trauma, intestinal typhoid, inflammatory bowel disease, acute hemorrhagic necrotic enteritis and amoebic bowel disease, acute intestinal perforation often occurs suddenly, abdominal pain is Persistent knife-cutting pain, mostly in the lower abdomen or affecting the whole abdomen, the pain is often unbearable, and is exacerbated by deep breathing and coughing, often accompanied by fever, bloating and toxic shock; physical examination of abdominal breathing movement weakened or disappeared, Abdominal tenderness and rebound tenderness, abdominal muscle tension, may have mobile dullness, bowel sounds weakened or disappeared; total white blood cells and neutrophils increased, abdominal X-ray or fluoroscopy showed visible free air under the arm.
3 liver rupture: more occurs under the inducement of increased abdominal pressure or trauma, manifested as sudden severe abdominal pain, extending from the right upper abdomen to the whole abdomen, showing persistent pain, if the traumatic liver rupture or hepatic hemangioma rupture, More often accompanied by hemorrhagic shock symptoms, such as pale, rapid pulse, blood pressure, etc.; liver cancer rupture also has hemorrhagic shock, physical examination of abdominal muscle tension, total abdominal tenderness, rebound pain, abdominal breathing restriction, abdominal mobility Voiced sound; the total number of red blood cells and hemoglobin decreased, the total number of white blood cells increased; abdominal X-ray examination of left iliac elevation, limited movement, abdominal puncture to extract non-coagulated blood and bile, abdominal puncture found that blood ascites is conducive to differentiation with gastrointestinal perforation Sometimes it is necessary to undergo surgical exploration to determine if there is a liver rupture.
4 spleen rupture: spleen rupture occurs on the basis of splenomegaly, trauma is the direct cause, manifested as severe abdominal pain, spread from the left upper abdomen to the full abdomen, sometimes to the left shoulder, accompanied by nausea and vomiting, bloating, palpitation , sweating, pale and other symptoms of hemorrhagic shock, physical examination of total abdominal tenderness, rebound tenderness, abdominal muscle tension, percussion with mobile dullness; total red blood cell count and hemoglobin reduction; abdominal X-ray examination of left diaphragmatic muscle elevation, exercise Restricted, abdominal puncture to extract non-coagulated blood is helpful for diagnosis.
5 ectopic pregnancy rupture: the age of onset is more than 26 to 35 years old, about 80% of ectopic pregnancy rupture occurs within 2 months of pregnancy, the main symptoms are abdominal pain, vaginal bleeding and menopause, mostly for one side of the lower abdomen Severe pain, then spread to the whole abdomen, showing persistent pain, sometimes tearing pain, about 80% of patients with irregular vaginal bleeding, most of them are small, dark brown, dripping, lasting for a long time, with palpitation , sweating, pale and other signs of shock, some patients may have anal swelling, abdominal examination of the lower abdomen or the whole abdomen has tenderness, rebound tenderness, abdominal muscle tension, abdominal muscle tension can be absent when the amount of bleeding is large, percussion has movement Vaginal examination; vaginal examination found that the posterior cervix of the cervix is full and bulging, obvious tenderness; positive pregnancy test, abdominal or posterior iliac puncture can extract non-coagulated blood, abdominal B-ultrasound, endometrial disease and laparoscopy can help For diagnosis.
6 ovarian rupture: mostly occurred in women aged 14 to 30 years old, mostly caused by factors such as squeezing, sexual intercourse, puncture, etc., manifested as sudden onset of severe pain in one side of the lower abdomen, and spread to the whole abdomen, accompanied by nausea and vomiting, irritability, Severe cases may have shock, but less common; abdominal examination has tenderness, rebound tenderness and muscle tension in the lower abdomen, some patients may have no abdominal muscle tension, one side attachment tenderness is obvious, there may be mobile dullness; vaginal examination finds The cervix is firm, no tenderness, and the pregnancy test is negative. The disease must be differentiated from acute appendicitis, ruptured ectopic pregnancy and other diseases.
(3) Abdominal organ obstruction, torsion and vascular disease:
1 acute intestinal obstruction: acute intestinal obstruction is divided into three types: mechanical, paralytic and spontaneous; from local pathological changes, it is divided into simple and strangulated, only the intestinal lumen is not smooth and no blood Supply disorders are simple, such as the blood supply disorder is strangulated, clinically acute mechanical intestinal obstruction is the most common, the main reasons are: torsion, intussusception, aphids, tumors, tuberculosis, incarceration, etc. Among them, intestinal adhesions are the most common. The main clinical manifestations of acute mechanical intestinal obstruction are persistent abdominal pain and paroxysmal colic, accompanied by abdominal distension, nausea and vomiting, constipation or cessation of exhaust; abdominal examination is often an expanded bowel contour. Even the bowel type is visible, sometimes the whole abdomen is tender, the bowel sounds are hyperthyroidism, and the bowel movement sounds are high-pitched metal sounds during the flatulence; abdominal X-ray examination is helpful for diagnosis. Patients with mechanical intestinal obstruction should consider the following conditions. intestinal obstruction:
A. Abdominal pain is acute and intense, with persistent paroxysmal aggravation and persistent vomiting.
B. The course of disease progresses rapidly, and early symptoms of shock occur, and the treatment effect is not good.
C. There is obvious peritoneal irritation, asymmetry on both sides of the abdomen, palpation of the abdomen or anal fingering touches a tender mass, body temperature, pulse, white blood cells have an increasing trend; X-ray examination found that there is persistence, stand alone Inflated intestinal fistula.
D. vomiting or discharge of bloody fluid from the anus, abdominal hemorrhagic fluid by diagnostic puncture, treated by gastrointestinal decompression, etc., although abdominal distension is reduced, but abdominal pain is not significantly improved.
2 ovarian cyst pedicle torsion: the most common in 20 to 50 years old, mostly occurred in small volume, large mobility, long pedicle cyst, body position change as its incentive, clinical manifestations of sudden onset of one side of the lower abdomen severe pain, presented Sustained, accompanied by nausea and vomiting, sometimes consciously abdomen mass swelling; abdominal examination of the affected side of the abdominal tenderness, abdominal muscle tension; vaginal examination can touch a round, smooth, active and obvious tender mass, sometimes can be affected The tender tibial pedicle has a definite significance for diagnosis; B-ultra-visible circular dark liquid area on the side of the uterus, smooth borders, CT examination, laparoscopy, etc. are helpful for diagnosis.
3 biliary mites: more common children and adolescents, mites into the biliary tract is the cause of this disease, the clinical manifestations of sudden upper abdominal or xiphoid paroxysmal cramps, accompanied by nausea and vomiting, fever, jaundice and other symptoms, intermittent The pain was completely relieved. Some patients had a history of discharge of mites from the stool. Abdominal examination: soft belly, mild tenderness under xiphoid, no rebound pain; B-ultrasound, X-ray venography, ERCP examination, etc. are helpful for diagnosis. The dip intestinal bile drainage test found aphid eggs, and the mites were found to have yellow stains or ring indentations in the feces, which were evidence that the mites had drilled into the biliary tract.
4 kidney, ureteral stones: more common in 20 to 40 years old young adults, its occurrence and urinary tract infections, obstruction, foreign body, diet, fungus, high calcium urine, high oxalic acid, clinical manifestations of the affected side of the abdomen, upper abdomen or lower Persistent dull pain or paroxysmal cramps, often radiated to the lower abdomen or genital area, accompanied by nausea and vomiting, frequent urination, urgency, dysuria, hematuria, pyuria and fever, physical examination of the affected kidney area, ureteral area Tenderness and snoring pain; X-ray examination can be found in the kidney area or ureteral stone shadow, B-ultrasound can be found in the X-ray can not show positive stones, urography can be found in the stone site and hydronephrosis, where the kidney or ureteral area found Diagnosis can be confirmed by stone shadows.
(4) Chest disease:
1 acute myocardial infarction: a small number of patients with acute myocardial infarction only showed upper abdominal pain, accompanied by nausea, vomiting, and even abdominal muscle tension, upper abdominal tenderness, etc., such patients are easily misdiagnosed, so for the elderly, especially high blood pressure, Atherosclerosis or past history of angina pectoris should be highly valued, electrocardiogram, echocardiography, and serum enzymology have a definite diagnosis.
2 acute pericarditis: acute pericarditis is more common in young adults, the reasons are non-specific, rheumatic, suppurative, tuberculous and malignant tumors, myocardial infarction sequelae, etc., clinically can have upper abdominal pain, abdominal muscle tension, tenderness Excessive sweating, pale complexion, etc.; abdominal pain is persistent or paroxysmal, mostly in the middle and upper abdomen, sometimes in the right lower abdomen or full abdomen, physical examination: jugular vein engorgement, liver enlargement, odd pulse, pericardial friction sound and heart sound distant Etc.; laboratory examination of the total number of white blood cells increased, ESR increased; X-ray examination of the heart is triangular or trapezoidal; echocardiography suggesting pericardial effusion, pericardial puncture fluid and pericardoscopy are helpful for diagnosis.
3 pneumococcal pneumonia: more common in young adults, the above respiratory infections, fatigue, rain and so on as the incentive, the clinical manifestations of persistent pain in the upper abdomen, radiation to the affected side of the shoulder, accompanied by high fever, chills, cough, chest pain, breathing Difficulties and coughing rust, etc. Physical examination: the respiratory movement of the affected side is weakened, the vocal fibrillation is enhanced, and the pathological breath sounds can be heard; the abdomen may have tenderness and abdominal muscle tension; the total number of white blood cells and neutrophils are elevated, And blood smear smear, culture can determine the pathogenic bacteria; X-ray examination of the early stage of the lesion is the shadow of the distribution of the lung segment, and later a large piece of uniform dense shadow can be confirmed.
2. Chronic abdominal pain: chronic abdominal pain is slow onset, long course of disease, pain is mostly intermittent or delayed after abdominal pain, abdominal pain is prolonged, pain is mostly dull or painful, there is also burning pain or cramps, the cause of chronic abdominal pain More complicated, often intersects with the cause of acute abdominal pain, causing difficulties in diagnosis and differential diagnosis.
(1) Esophageal hiatus: The incidence of hiatal hiatus hernia increases with age, more common after 30 years old, the main causes include late pregnancy, obesity, severe cough, tight belt, frequent vomiting, massive ascites, huge abdomen Internal tumor, chronic constipation, esophagitis, esophageal ulcer, etc., its main clinical manifestations are middle and upper abdominal discomfort or burning pain, pain to the shoulder and back, with hernia, acid reflux, anti-feeding and other symptoms; Symptoms, especially before bedtime, can make the symptoms relieve after walking. The diagnosis of this disease mainly depends on X-ray barium meal examination and gastroscopy in special position.
(2) Lower esophageal cancer: It is more common in middle-aged and elderly people. The pathogenesis of the disease is still unclear. It is mainly caused by pain in the back of the sternum or under the xiphoid during early eating. It is burning, acupuncture or pulling. Like, with nausea and vomiting, loss of appetite, fatigue; late dysphagia, hematemesis, black feces, etc., physical examination: late cases of the upper abdomen often hard and hard, fixed, surface is not smooth and tender mass; X Line sputum examination, esophageal mucosal exfoliative cytology, gastroscopy and lesion biopsy found that cancer cells have a diagnostic value.
(3) peptic ulcer: upper abdominal pain is the most prominent symptom of ulcer disease, characterized by: chronic upper abdominal pain, repeated periodic attacks, obvious rhythm, gastric ulcer pain located in the middle or left of the upper abdomen, 0.5 after meal ~1h occurs, until the next meal remission; duodenal ulcer pain is mostly located in the middle and upper abdomen or right, 2 to 3 hours after the meal, hunger pain or night pain, re-education pain can be relieved; accompanied by acid reflux , nausea and vomiting, hernia, if there is no complication, the general condition has no obvious effect, physical examination: gastric ulcer has tenderness in the middle and upper abdomen, and duodenal ulcer has tenderness in the right upper quadrant. Jumping pain and muscle tension; gastric juice analysis, fecal occult blood test are helpful for diagnosis, X-ray barium meal examination or gastroscopy found that ulcers have a diagnostic value.
(4) Chronic gastritis: Helicobacter pylori infection, smoking, drinking, duodenal reflux is the main cause of chronic gastritis, its clinical manifestations are upper abdominal discomfort or dull pain, fullness after eating, pain has no obvious rhythm, Accompanied by nausea and vomiting, loss of appetite, abdominal distension, diarrhea, weight loss, and even anemia, the diagnosis of this disease is mainly based on gastroscopy and direct observation of gastric mucosal biopsy; other auxiliary examinations, such as gastric acid determination, Hp examination, serum gastric secretion Determination of the content of the hormone helps to understand the functional status of the stomach and establish the cause.
(5) Gastric cancer: more common in men over 40 years old, the etiology and pathogenesis of the disease are not very clear, the clinical manifestations of early abdominal pain or discomfort, severe pain in the late stage, pain irregularity and rhythm, with fatigue, Loss of appetite, abdominal distension, weight loss, fever, anemia, etc., physical examination: upper abdominal tenderness, 1/3 of patients can touch hard, irregular, tender mass, diagnosis based on gastroscopy and biopsy, found that cancer cells have a diagnosis value.
(6) Functional dyspepsia: Indigestion is a group of symptoms such as acid reflux, hernia, anorexia, nausea and vomiting, upper abdominal discomfort and pain, and B-ultrasound, X-ray barium meal, endoscopy, CT, etc. Symptoms of sexual lesions, in addition, patients are often accompanied by dizziness, headache, insomnia, palpitations, chest tightness, inattention and other symptoms, physical examination: upper abdominal tenderness, but the site is not fixed, the diagnosis mainly depends on B-ultrasound, barium meal, gastroscope Etc. Check for abnormal lesions.
(7) Intestinal tuberculosis: more common in people under 40 years old, can be caused by tuberculosis, miliary tuberculosis, tuberculous peritonitis, tuberculous annexitis, divided into ulcer type and proliferative type, the main clinical manifestations of abdominal pain, diarrhea, Constipation or diarrhea, constipation alternately, abdominal pain in the right lower abdomen or umbilical circumference, dull pain, dull pain or paroxysmal pain, can be aggravated by eating, accompanied by low fever, night sweats, weight loss, bloating, anemia, poor appetite; Proliferative type may have intestinal obstruction performance, physical examination: tenderness in the lower abdomen, no rebound pain and muscle tension, proliferative type can be phlegm and mass; erythrocyte sedimentation rate is significantly increased, fecal acid-fast bacilli examination, tuberculin test, etc. Diagnosis; X-ray barium meal examination can establish the lesion; colonoscopy and mucosal biopsy at the lesion is conducive to diagnosis and differential diagnosis.
(8) Crohn's disease (segmental enteritis): is a chronic, recurrent, granulomatous enteritis, the incidence of more than 21 to 40 years old, the main clinical manifestations of abdominal pain, diarrhea, abdominal mass, abdominal pain often Occurred after a meal, located in the right lower abdomen or umbilical circumference, usually a spasm pain, sometimes persistent abdominal pain: initial intermittent, followed by persistence, about 2 to 6 times a day, a paste, usually no Pus or blood, may be associated with fever, nausea, vomiting, loss of appetite, fatigue, weight loss, abdominal distension, anemia, etc.; abdominal examination: tenderness in the whole abdomen or right lower abdomen, no rebound pain and abdominal muscle tension, intestinal obstruction and When the fistula is formed, the right lower abdomen can be covered with a tender mass. The gastrointestinal X-ray barium meal or barium enema shows:
1 The intestine is narrow, and there is a line-like sign on the X-ray.
2 There is a normal bowel between the diseased intestines.
3 The contour of the diseased intestine is asymmetrical, one side is stiff and the other side is inflated.
4 multiple nodular lesions and cobblestone signs.
5 fistula or sinus sacral shadows are helpful for diagnosis, colonoscopy:
A. Longitudinal fissure ulcers.
B. The surrounding mucosa is normal or paving stone is uneven.
C. The intestines disappear and flatten into a water-tubular, narrow, pseudopolyp.
D. The lesions are segmentally distributed. Tissue biopsy found non-caseous necrotizing granuloma and a large number of lymphocyte aggregates have diagnostic value.
(9) Ulcerative colitis: The etiology and pathogenesis of ulcerative colitis have not yet been fully elucidated. The age of onset is 20 to 30 years old, and the number of men is slightly more than that of women. The clinical manifestations are abdominal pain, diarrhea and diarrhea. Repeated episodes, long-term unhealed, several times a day to dozens of times, more often accompanied by urgency, or diarrhea and constipation alternately, feces have pus and mucus; abdominal pain often in the lower left abdomen or lower abdomen with paroxysmal spasm After defecation, relieve abdominal pain in the attack period, no abdominal pain or only mild abdominal pain during remission, may be associated with weight loss, anemia, physical strength; abdominal examination has left lower abdomen or total abdominal tenderness, no rebound pain and abdominal muscle tension; Blood routine examination of hemoglobin reduction; fecal routine for blood, pus and mucus; X-ray barium enema examination: early mucosa can be found to have a granular change, late tube tube ductal stiffness, short, colonic bag disappearance; colonoscopy The extent of the lesion, severity, and mucosal biopsy have diagnostic value.
(10) Colorectal cancer: The age of onset is 40 to 50 years old. The etiology and pathogenesis are still unclear. The main clinical manifestations are persistent pain in the left lower abdomen or right lower abdomen. It is aggravated after eating, and relieves after defecation. If intestinal obstruction occurs. Or perforation can cause acute abdominal pain; some patients have diarrhea or constipation, or alternating between the two, stool with blood or mucus; rectal cancer with urgency and heavy; often accompanied by loss of appetite, abdominal distension, weight loss, anemia, ascites can occur in the late stage , cachexia, etc., no obvious positive signs in the early stage of abdominal examination, can be touched in the late stage, the mass is hard, fixed, tender; serum carcinoembryonic antigen, CAl9-9 and other intestinal cancer-related antigens have screening value; X-ray Barium enema can detect the extent of the lesion and its relationship with the surrounding organs. Colonoscopy, biopsy found that cancer cells have a diagnostic value.
(11) Chronic appendicitis: Mostly caused by repeated episodes of leftovers after remission of acute appendicitis, it may also be caused by stomach (intestine) stones, grains, eggs and other foreign bodies in the appendix cavity. The clinical manifestation is right. Intermittent or persistent pain in the lower abdomen, often caused by strenuous exercise, improper diet or aggravation, accompanied by upper abdominal discomfort, indigestion, loss of appetite, abdominal distension, diarrhea or constipation; abdominal examination of the lower right abdomen has limitations, fixed tenderness The blood routine of acute attack, the total number of white blood cells and the increase of neutrophils are helpful for diagnosis.
(12) chronic pancreatitis: more than 30 to 50 years old, mostly by biliary calculi, biliary ascariasis combined with biliary tract infection leading to recurrent episodes of pancreatitis, can also be caused by the prolongation of acute pancreatitis, the main clinical manifestations are related to eating Repeated episodes of dull pain, pain or cramps, can be radiated to the lower back, shoulders, accompanied by hernia, nausea and vomiting, steatorrhea, sometimes jaundice, physical examination can sometimes touch the mass; patients during remission Asymptomatic, or only general symptoms of dyspepsia, X-ray abdominal plain film can be found in pancreatic stones and pancreatic calcification shadow; gastrointestinal barium X-ray examination of some patients can be found in adjacent organs shift, degeneration, etc.; B-ultrasound can show pancreatic swelling Large, pancreatic duct protection, chronic pancreatitis diagnosis based on repeated episodes of abdominal pain and associated with diabetes, diarrhea and other evidence of pancreatic internal and external dysfunction, and abdominal X-ray film can be seen pancreatic calcification or stone shadow, B-ultrasound And ERCP check is very helpful for diagnosis.
(13) Pancreatic cancer: Most occur in people aged 40-60 years. The etiology and pathogenesis are still unclear. The main clinical manifestations are persistent dull pain or paroxysmal severe pain in the upper abdomen, and to the lower back, chest and Radiation on the right shoulder, increased at night and in the lying position, relieved when sitting and leaning forward, often accompanied by fatigue, loss of appetite, nausea, vomiting, diarrhea, bloating, weight loss, etc.; those with jaundice are more common in pancreatic head cancer, mostly(Courvoisier)BBXERCPCT
