Persistent pain in the upper and middle abdomen
Introduction
Introduction It refers to the lesions of the internal and external organs caused by various reasons, and it is manifested as pain in the abdomen. Sustained pain in the upper abdomen is more common in acute pancreatitis, stomach, duodenal ulcer, intestinal obstruction.
Cause
Cause
Abdominal pain can be divided into acute and chronic. The cause is extremely complex, including inflammation, tumors, bleeding, obstruction, perforation, trauma, and dysfunction.
Examine
an examination
Related inspection
General radiography examination of liver, gallbladder, spleen CT examination of gastrointestinal CT examination
History
(1) Gender and age: The common causes of abdominal pain in children are ascariasis, mesenteric lymphadenitis and intussusception. Young adults are more likely to have ulcer disease, gastroenteritis, and pancreatitis. In the middle-aged and elderly people, there are many cholecystitis and gallstones. In addition, the possibility of gastrointestinal tract, liver cancer and myocardial infarction should be noted. Renal colic is more common in men, and ovarian cyst torsion and corpus luteum rupture are common causes of acute abdomen in women. For women of childbearing age, ectopic pregnancy should be considered.
(2) Onset: Insidious onset is more common in ulcer disease, chronic cholecystitis, mesenteric lymphadenitis. The onset of sudden onset is more common in gastrointestinal perforation, biliary calculi, and ureteral stones. Mesenteric artery embolization, ovarian cyst torsion, liver cancer nodule rupture, ectopic pregnancy rupture. The possibility of cholecystitis and pancreatitis should be considered for a meal or excessive fat meal before the onset of illness.
(3) Past medical history: biliary colic and renal colic have a similar history in the past. Those with a history of abdominal surgery have the possibility of intestinal adhesions. Mesenteric vascular embolization and the like should be considered in the history of atrial fibrillation.
2. Clinical manifestations
(1) Characteristics of abdominal pain itself: The location of abdominal pain often indicates the location of the lesion, which is an important factor in differential diagnosis. However, many visceral pains are often ambiguous. Therefore, the site of tenderness is more important than the location where the patient feels pain. The diagnosis of the radiation site of pain also has a certain role, such as biliary tract disease often has pain in the right shoulder and back, pancreatitis pain often radiated to the left waist. Renal colic is often radiated to the perineum.
The degree of abdominal pain reflects the severity of the condition in a certain sense. In general, gastrointestinal perforation, liver and spleen rupture, acute pancreatitis, biliary colic, renal colic and other pains are more intense, while ulcers, mesenteric lymphadenitis and other pains are relatively mild. However, the feeling of pain varies from person to person, especially in the elderly, sometimes feeling dull, such as acute appendicitis, even until the perforation is painful. The nature of pain is roughly related to the degree. Severe pain is often described by patients as knife-like pain and cramps, while milder pain may be described as soreness and pain. Pain in patients with biliary ascariasis is often described as drill-like pain, which is more characteristic.
The abdominal pain rhythm has a strong effect on the diagnosis. The lesions of the substantive organs are mostly persistent pain, and the lesions of the hollow organs are mostly paroxysmal. Persistent pain with paroxysmal aggravation is more common in both inflammation and obstruction, such as cholecystitis with biliary obstruction, late intestinal obstruction with peritonitis.
(2) Accompanying symptoms: The accompanying symptoms of abdominal pain are very important in differential diagnosis. The suggestion of fever is inflammatory lesions. Commonly associated with vomiting and diarrhea, food poisoning or gastroenteritis, intestinal infection with diarrhea, vomiting may be gastrointestinal obstruction, pancreatitis. With jaundice prompted biliary tract disease. The possibility of blood in the stool may be intussusception and mesenteric thrombosis. With hematuria may be ureteral stones. The possibility of abdominal distension is intestinal obstruction, and most of the shock is visceral rupture, gastrointestinal perforation and peritonitis. For example, abdominal pain with fever, cough, etc. need to consider the possibility of pneumonia, upper abdominal pain with heart rhythm disorder, blood pressure decreased, myocardial infarction also need to be considered.
(3) Body pressure: The signs of the abdomen are the focus of the examination. First of all, it should be ascertained whether it is total abdominal tenderness or local tenderness. Abdominal tenderness indicates that the lesion is diffuse, such as McPhee point tenderness is a sign of appendicitis. Check the tenderness fashion to pay attention to whether there is muscle tension and rebound tenderness. Muscle tension is often prompted by inflammation, while rebound pain means that the lesion (usually inflammation - including chemical inflammation) involves the peritoneum. Unscheduled attention should be paid to check for abdominal masses, such as abdominal masses that have tenderness and blurred borders.
There is no obvious tenderness, and the border is also relatively clear, suggesting the possibility of a tumor. The tumor mass is harder. Intussusception, intestinal torsion, and intestinal obstruction can also affect the intestinal curvature of the disease. The mites in the small intestine of the small intestine and the feces in the colon of the elderly may also be treated as "abdominal masses".
The stomach type and intestinal type are seen on the abdominal wall, which is a typical sign of pyloric obstruction and intestinal obstruction. Hearing bowel sounds suggesting intestinal obstruction, while bowel sounds disappear, suggesting intestinal paralysis.
Diagnosis
Differential diagnosis
There are many diseases that cause abdominal pain. The most common and more representative ones are as follows:
Acute gastroenteritis
Pain above the abdomen and the umbilical part of the main, often persistent acute pain with paroxysmal aggravation. Often accompanied by nausea, vomiting, diarrhea, or fever. During the physical examination, you can find tenderness in the upper abdomen or the umbilicus, no muscle tension, no rebound pain, and a slight bowel sound. It is not difficult to diagnose if you have an unclean diet before the onset of illness.
2. stomach, duodenal ulcer soup
Occurs in young and middle-aged people, abdominal pain is mainly in the upper and middle abdomen, mostly persistent pain, more on the fasting, eating or taking acid can relieve its characteristics. Physical examination may have tenderness in the upper abdomen, but no muscle tension or rebound tenderness. Frequent seizures may be associated with a positive stool test. Gastrointestinal barium examination or endoscopy can establish a diagnosis.
If the history of the original stomach or duodenal ulcer or similar symptoms, sudden upper abdominal pain, such as knife cut, and quickly spread to the whole abdomen, the whole abdominal tenderness during examination, abdominal muscle tension, "plate-like rigidity "There is rebound tenderness, disappearance of bowel sounds, pneumoperitoneum and transplanted dullness, and the dullness or disappearance of the liver dullness area suggests gastric and duodenal perforation." Abdominal X-ray film confirmed the diagnosis of inflammatory effusion with free gas and abdominal puncture.
3. Acute appendicitis
Most patients have persistent pain in the middle of the abdomen onset, and after a few hours, they metastasize to the right lower abdomen, showing persistent pain and paroxysmal aggravation. There are also a small number of patients who feel right lower abdominal pain when they are onset. A few hours after the mid-abdominal pain in the lower abdomen, the right lower abdominal pain was characterized by acute appendicitis pain. May be associated with fever and malignancy. Examination can be tender at the point of Mai's point, and there may be muscle tension, which is a typical sign of appendicitis. Combined with the total number of white blood cells and increased neutrophils, the diagnosis of acute appendicitis can be clarified. If acute appendicitis is not diagnosed and treated in time, after 1 to 2 days, there is persistent pain in the right lower abdomen. The tenderness, muscle tension and rebound tenderness around the Mai's point are obvious. The total number of white blood cells and neutrophils are significantly increased. Gangrenous appendicitis. If the mass in the right lower abdomen and the edge are blurred, a mass of the appendix has been formed.
4. Cholecystitis, gallstones
The disease occurs in middle-aged and older women. Chronic cholecystitis often feels pain in the right upper abdomen, increases after eating a fat meal, and radiates to the right shoulder. Acute cholecystitis often occurs after a fat meal, with persistent severe pain in the right upper quadrant, radiation to the right shoulder, and more with fever and malignant vomiting. Many people with cholelithiasis have chronic cholecystitis. When the gallstone enters the cystic duct or moves in the bile duct, it can cause paroxysmal cramps in the right upper quadrant and also radiate to the right shoulder and back. Also often accompanied by malignancy. Physical examination showed significant tenderness and muscle tension in the right upper abdomen, and Murphy sign positive was characteristic of cystitis. If there is jaundice, it indicates that the biliary tract has obstruction. If it can be sputum and gallbladder, the obstruction is more complete. The number of white blood cells and neutrophils were significantly increased in the onset of acute cholecystitis. Ultrasound and X-ray examination can confirm the diagnosis.
5. Acute pancreatitis
Suddenly after a meal, sudden onset of severe pain in the upper abdomen, often accompanied by malignant vomiting and fever. Deep tenderness, muscle and kidney and rebound tenderness in the upper abdomen are not obvious. A significant increase in serum amylase can confirm the disease. However, the increase of serum amylase is often 6 to 8 hours after the onset of the disease, so if the serum amylase is not high in the early stage of the disease, the disease may not be queued. If abdominal pain spreads to the whole abdomen, and symptoms of shock appear rapidly, the examination reveals full abdominal tenderness, muscle tension and rebound tenderness, and even found ascites and umbilical and ventral skin spots, suggesting hemorrhagic necrotizing pancreatitis. At this time, the blood stasis amylase is significantly increased or not increased. X-ray plain film shows that the stomach and small intestine are fully expanded and the colon is not filled with gas and collapses. CT examination showed that the pancreas was swollen and the surrounding fat layer disappeared.
6. Intestinal obstruction
Intestinal obstruction can be seen in patients of all ages, and children are caused by ascariasis, intussusception and so on. Adults are caused by sputum or intestinal adhesions, and the elderly can be caused by colon cancer. The pain of intestinal obstruction is mostly in the umbilical cord, showing paroxysmal colic, accompanied by vomiting and stopping defecation. Signs of the bowel, abdominal tenderness, bowel sounds, and even "gas over water" sound. If abdominal pain is persistent pain with paroxysmal aggravation, abdominal tenderness is marked with muscle tension and rebound tenderness, or ascites is more common, and those who present with shock quickly suggest a strangulated intestinal obstruction. X-ray plain film examination, if the intestinal lumen is inflated, and the diagnosis of intestinal obstruction in most fluids can be established.
7. Abdominal organ rupture
Common spleen rupture caused by external force, liver cancer nodules due to external force or spontaneous rupture, spontaneous rupture of ectopic pregnancy. Sudden onset, persistent severe pain involves the whole abdomen, often accompanied by shock. During the examination, it was found to be full of tenderness, muscle tension, and rebound tenderness. Signs of abdominal hemorrhage can often be found. Abdominal puncture and blood accumulation can be confirmed as abdominal organ rupture. Ectopic pregnancy rupture, such as in the abdominal cavity can not puncture the puncture site after the puncture, often have a positive result. Real-time ultrasonography, a protein assay, CT examination, gynecological examination, etc. can help the differential diagnosis of common organ rupture.
8. Ureteral stones
Abdominal pain often occurs suddenly, often in the left or right abdomen with paroxysmal cramps and radiation to the perineum. Abdominal tenderness is not obvious. The onset of pain can be seen as a characteristic of hematuria as a disease, and it can be clearly diagnosed by abdominal X-ray and intravenous pyelography.
9. Acute myocardial infarction
Found in middle-aged and elderly people, the infarcts are in the face, especially those with larger areas. The pain is sudden after a tired, nervous or full meal, with persistent cramps and radiating to the left shoulder or the inside of the arms. Often accompanied by nausea, there may be shock. At the time of physical examination, there was mild tenderness, no muscle tension and rebound tenderness in the upper abdomen, but heart auscultation often had arrhythmia. An electrocardiogram can confirm the diagnosis.
10. Lead poisoning
People who have been exposed to lead dust or smoke for a long time are occasionally seen as a result of accidental exposure to large amounts of lead compounds. Lead poisoning has acute and chronic points. However, both acute and chronic, paroxysmal abdominal cramps are characterized. Its onset is sudden, mostly in the umbilicus. Often accompanied by abdominal distension, constipation and loss of appetite. Abdominal signs were not obvious during the examination, there was no fixed tenderness point, and the bowel sounds were weakened. In addition, the lead line is visible at the edge of the gum, which is a characteristic sign of lead poisoning. The basophilic red blood cells can be seen in the surrounding blood, and the increase in blood lead and urine lead can establish a diagnosis.
