Abdominal pain has a complex etiology, involves multiple organs in the thoracic and abdominal cavities and systemic diseases, and has a variety of manifestations, making it the most common and sometimes the most difficult disease to diagnose. Among them, acute abdomen refers to abdominal diseases with abdominal pain as the main symptom, often requiring emergency surgery. Its occurrence is characterized by rapid onset, central development, multiple changes, and seriousness of the disease. Once misdiagnosed, the danger is great. The common clinical features of acute abdominal disease are: abdominal pain, vomiting, abdominal distension, constipation, blood in stool, and even shock. These symptoms are not unique to surgical acute abdominal disease, so they should be carefully distinguished from.
First, the classification of abdominal pain (can be distinguished according to the following three methods)
1, somatic N pain: accurate localization, often accompanied by local pressure pain and muscle tightness. The manifestations are sharp pain, burning pain and dull pain.
2, visceral N pain: poor localization, no abdominal muscle tension. The manifestations are: hidden pain, distension, colic, and drilling pain.
3.Radiation pain (involvement pain): refers to the pain in another part caused by the lesion in one part, for example, when the kidney ureteral stone causes pain in the perineal area, inner thigh and other parts.
According to the nature of abdominal pain: (three types)
1, persistent pain: often caused by the stimulation of inflammation, cavity organ contents, blood, etc. If it is the stimulation of gastroduodenal contents or bile, etc., it is manifested as persistent severe knife-like pain, accompanied by plate-like abdomen.
2, paroxysmal abdominal pain: caused by obstruction or spasm of cavity organs.
3, persistent pain with paroxysmal intensification: for cavity organ obstruction with infection, such as cholelithiasis with infection, etc.
Second, diagnosis and differentiation: (must clarify the following issues)
1.Is it a medical emergency abdomen, gynecological emergency abdomen, or surgical emergency abdomen.
(1) Acute abdominal disease of internal medicine.
Usually abdominal pain appears after other symptoms (e.g., fever, cough, nausea, vomiting, diarrhea, etc.), the site is not fixed, the degree is mild or light from severe, the signs of peritoneal irritation are not obvious, the abdomen likes to press, and abdominal breathing is present.
Common medical acute abdominal disorders are: acute gastroenteritis, angina pectoris, pleurisy, lobar pneumonia, allergic purpura, bacillary dysentery, etc.
(2) Gynecological acute abdominal disorders: often have some relationship with the menstrual cycle or vaginal secretions, such as
a. Dysmenorrhea: it is cyclical and occurs before or within a few days of the menstrual flow.
b. Ectopic pregnancy: with a history of menopause or irregular vaginal bleeding after menopause.
c. Uterine adnexitis: often accompanied by increased vaginal discharge with foul odor.
d. Luteal rupture: Mostly occurs more than 20 days after menstruation.
e. Follicular rupture: mostly occurs during ovulation and is more likely to occur in young women.
f. Ovarian cyst torsion: often in the lower abdomen with a mass, etc.
(3) Surgical emergency abdomen.
Generally abdominal pain appears before other symptoms, the location is determined, the degree is heavy or from light to heavy, peritoneal irritation signs are obvious, abdomen refuses to press, abdominal breathing is weakened or disappears.
2, surgical emergency abdominal diseases belong to which type of acute abdominal diseases, different types of acute abdominal diseases, often have their own characteristics.
(1) inflammatory acute abdomen: such as: peritonitis, appendicitis, cholecystitis, pancreatitis, etc. These diseases have a slow onset, abdominal pain from mild to severe, localization from vague to clear, persistent pain, prominent signs of peritoneal irritation, elevated body temperature and WBC count.
(2) Perforated acute abdomen: for example, ulcer perforation, traumatic intestinal perforation, etc., with sudden and persistent abdominal pain, obvious peritoneal irritation signs, positive mobile turbid sounds, often with pneumoperitoneum signs, etc.
(3) Hemorrhagic acute abdominal signs: for example, liver and spleen rupture, often with a history of trauma, manifested as internal bleeding signs and shock, while abdominal pain and peritoneal irritation signs are mild. However, if bile is mixed with it, abdominal pain is increased and peritoneal inflammation is heavy. When the volume of blood accumulation exceeds 600 ML, there may be mobile turbid sounds, and non-coagulable blood may be withdrawn by abdominal puncture.
(4) Obstructive acute abdomen: such as: intestinal obstruction, cholelithiasis, ureteral stones, etc. These diseases often have an acute onset, paroxysmal abdominal colic, and generally no evidence of peritoneal irritation, except for strangulated intestinal obstruction, perforation. In addition to abdominal pain, these diseases are accompanied by corresponding symptoms and signs.
(5) Organ ischemic acute abdominal disease: for example, mesenteric vascular embolism, ovarian cyst torsion, etc., often sudden severe abdominal pain with shock, local pressure pain, early without muscle tightness, but when organ ischemic necrosis secondary to peritonitis, peritonitis signs only obvious.
3. What organs or systems are damaged; analyze and diagnose according to the location of the organs and the accompanying symptoms.
(1) Biliary tract disease: the site is in the right quarter rib area, often accompanied by xanthogranuloma, etc.
(2) Gastrointestinal perforation: there is often a history of ulcer disease or trauma, and there is often free gas in the abdominal cavity, etc.
(3) Urinary tract disease: often accompanied by hematuria.
(4) Female genital diseases: there are often menstrual changes or vaginal bleeding, etc.
(4) What kind of disease causes pain: Commonly, there are
(1) Acute appendicitis: with metastatic abdominal pain and fixed pressure pain in the right lower abdomen.
(2) Acute diffuse peritonitis: with persistent abdominal pain and peritoneal inflammation, shifting turbidity, loss of bowel sounds, elevated T and WBC, and purulent exudate can be extracted by laparotomy.
(3) Acute perforation of ulcer: there is often a history of ulcer or overeating, abdominal pain in the form of severe knife-like pain, plate-like abdomen, with clouding and pneumoperitoneum signs (the disease is easily confused with appendicitis).
(4) Acute cholecystitis and cholelithiasis: the lesion is confined to the right upper abdomen, often with a history of recurrent attacks, and the pain may radiate to the right shoulder, and the enlarged gallbladder may be palpated or the Charcot’s triad (abdominal pain, chills and high fever, jaundice) may appear.
(5) Intestinal obstruction: signs and symptoms of intestinal obstruction are present.
(6) Ureteral stone: sudden onset of abdominal or lumbar colic with radiating pain, no signs of peritoneal irritation, often with microscopic hematuria.
(7) Ascariasis: severe abdominal colic or drilling-like pain is present. For example: biliary ascariasis, appendicular ascariasis, ascariasis intestinal obstruction, etc.
(8) Acute pancreatitis: often develops after overeating, with persistent severe pain in the left side of the epigastrium, radiating to the lower back, ineffective general analgesics, prone to shock, and increased blood and urine amylase.
(9) Ectopic pregnancy: with history of menopause and early pregnancy symptoms, shock is not easily corrected once it occurs.
(10) Ovarian cyst torsion, abdominal examination can reveal the mass, gynecological examination can clearly diagnose.
III. Principles of management.
1, basic principles.
(1) systemic supportive therapy
(2) Control of infection
(3) Prevention and control of shock
2, the treatment of unknown diagnosis.
(1) monitoring: T, P, R, BP mental and abdominal pain conditions, etc.
(2) Commonly used examination methods: such as: inguinal area examination, rectal finger examination, abdominal puncture, abdominal cavity cleaning, laboratory tests, ultrasound, X-rays, abdominal cavity. The three routines.
(3) During the observation period: fasting, diarrhea, enema, morphine-based pain relief, etc. are prohibited.
(4) If the condition worsens during observation, peritoneal inflammation gradually becomes obvious or active bleeding is suspected, etc., the abdomen should be immediately dissected and explored.
Abdominal pain that can be easily misdiagnosed
1. Ectopic pregnancy: sometimes it is easily misdiagnosed as appendicitis. Some ectopic pregnancies are also manifested as right lower abdominal pain, but ectopic pregnancy is often accompanied by pallor, decreased blood pressure and other shock manifestations, anemia and low white blood cell count in the routine blood check. For women of childbearing age, we should carefully inquire about menstrual history and do relevant tests if necessary to avoid misdiagnosis.
2. Upper gastrointestinal perforation: sometimes it is not easy to diagnose, especially the perforation of the duodenal bulb. Early abdominal fluoroscopy is often without subdiaphragmatic free gas, and repeated fluoroscopy is needed. It also needs to be distinguished from acute pancreatitis and heart attack. Do relevant examinations when necessary.
3. Appendicitis: early stage is easily misdiagnosed. Because the site of pain is not fixed in the early stage. Sometimes it is in the epigastrium, sometimes in the periumbilical region, but eventually shifts to the right lower abdomen.