Page 143 - Medicine and Surgery

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Gastrointestinal system 4

Clinical, 139 Disorders of the stomach, 160 Disorders of the rectum and anus,
Gastrointestinal infections, 148 Disorders of the small bowel and 172
Disorders of the abdominal wall, appendix, 163 Vascular disease of the bowel, 175
154 Disorders of the large bowel and Gastrointestinal oncology, 177
Disorders of the oesophagus, 156 inflammatory bowel disease, 167

Pain arising from the hindgut, which continues to the

Clinical dentate line, is felt in the suprapubic region.
Pain may begin in one area, then become localised as
the peritoneum overlying the organ is involved, e.g. in
Symptoms
appendicitis the pain is often initially felt around the
umbilicus, then localises to the right iliac fossa.
Abdominal pain
The causes of abdominal pain are diverse, frequently in- Radiation
volving inflammation, ischaemia and/or obstruction in Pain radiating to the back is often due to retroperitoneal
different organs. structures such as the pancreas, aorta and kidneys. If
The characteristics of abdominal pain should be the disease is sub-diaphragmatic, then pain can be re-
clearlydefinedwhentakingahistory.Ausefulmnemonic ferred to the shoulder-tip because of innervation of the
is SOCRATES (Site, Onset, Character, Radiation, Alle- diaphragm by C4.
viating factors, Timing, Exacerbating factors and Symp-
toms associated with the pain). Onset, character and timing
Acute onset of pain suggests infarction, or an acute ob-
Site struction of the biliary tree or urinary tract. The pain
Well-localised pain suggests involvement of the parietal may then last for hours. Other gastrointestinal pathol-
peritoneum, which has somatic innervation. However, ogy tends to cause a gradual onset of pain. The relation-
abdominal pain is often ‘referred’ pain due to the pattern ship of pain to posture, meals (including the type of food
of visceral innervation derived from the embryological and timing of onset related to eating) and the pattern of
development. severity should also be noted.
Disease of the embryonic foregut causes pain to be Obstruction of any part of the gut tends to cause ‘col-

felt in the epigastrium or upper third of the abdomen. icky’ pain, i.e. pain that comes in waves caused by con-
This includes the stomach, proximal duodenum (to tractions (peristalsis). Constant pain may be burning,
the opening of the common bile duct), the liver, pan- dull, sharp, mild or severe. It may be recurrent, e.g. the
creas and biliary tree. The lower respiratory system nocturnal pain of peptic ulcer disease.
and oesophagus are also derived from the foregut, so
that occasionally abdominal pain can be due to disease Alleviating and exacerbating factors
in the chest. If movement exacerbates the pain, this is suggestive
Pain arising from the midgut, which continues down of peritoneal inflammation. Patients with colic tend to

to two thirds of the way along the transverse colon, is roll around in pain, whereas those with appendicitis lie
felt in the paraumbilical region. absolutely still. Eating may relieve the pain of peptic

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