So let's talk about a case of abdominal pain.
So this is the 41-year-old woman
who's presenting to her family physician
with abdominal pain
localized to her right upper quadrant.
She says, it's episodically occurring over the last two weeks,
and it's gradually worsening.
So, when we're thinking about abdominal pain,
it's important to first anchor ourselves
to the different regions in the abdomen,
and how they correlate with certain disease processes.
There's two primary systems for mapping out the abdomen.
The first is the abdominopelvic regions,
which are depicted here.
And then the abdominopelvic quadrants,
which is perhaps the more common language that we use.
Thinking about the right upper quadrant,
which would also be the hypochondriac area,
we're thinking about disease of the gallbladder
like cholelithiasis, cholecystitis, and colangitis.
We're thinking potentially about liver: hepatitis,
like alcohol related hepatitis.
Certainly stomach,
while it's more midline, and epigastric, and location
can have pain radiating to either side.
And then disease of the duodenum,
like peptic ulcer disease can also manifest
up in the right upper quadrant.
Moving over to the left upper quadrant,
we're again thinking about peptic ulcer disease,
particularly gastric ulcers,
and much, much less commonly a splenic infarction
can cause pain in that area as well.
Moving down to the right lower quadrant,
certainly in younger patients we think about appendicitis
so that can occur in older folks as well.
Disease of the reproductive tract in women,
lots of things can cause pain regarding the ovaries,
whether it's cysts that are rupturing or torsion itself
and certainly in young sexually active women
were worried about ectopic pregnancies as well.
And the left lower quadrant mirrors a lot of these
same disease processes
with the exception of diverticulitis,
which can absolutely cause a subacute to acute pain
in that area.
Another way of dividing up the abdomen
is just into thirds
with upper, middle, and lower abdominal pain.
Patients with upper abdominal pain,
you always have to think about the thorax,
and potentially the patient is actually having
acute coronary syndrome,
gastroesophageal reflux disease with that burning sensation
that may start all the way up here at the base of the neck
and can burn all the way down towards the epigastrium.
And of course, aortic dissection,
while it usually radiates to the back,
it can certainly cause anterior pain as well.
In terms of mid-abdominal pain, pancreatitis,
again, usually radiating to the back,
but nonetheless can cause
burning abdominal pain and tenderness, anteriorly.
And then lower abdominal pain,
anybody can have a urinary tract infection,
prostatitis in men, and then pelvic inflammatory disease in women
can be particularly severe and is an emergent condition.
I also want to highlight here something we often overlook,
which is abdominal wall pain.
While a lot of things can cause pain, intra-abdominally
it's important to recognize that the abdominal wall musculature itself
can cause pain and often does after a period of vomiting.
Also, remember that there are cutaneous nerves
that are diving or coming out
adjacent to the rectus abdominis muscles
and those nerves can get trapped
and that can also cause very focal pain
in the abdominal wall.
And we'll talk about during our exam lecture
how to tease apart intra-abdominal versus abdominal wall pain.
And don't forget about shingles.
Lastly, it's important to think about
is this a chronic, indolent diffuse pain
or is it acute and diffuse?
People with diffuse pain can't quite localize
where their pain is coming from.
Classically irritable bowel syndrome and simply having constipation.
Inflammatory bowel disease
is kind of a waxing and waning disease process
that may have nonspecific, non-localizing pain.
And then acute painful conditions
that can also present with diffuse pain
would be a bowel obstruction,
mesenteric ischemia,
where there's pain that's out of proportion
to the physical exam.
Bowel perforations
can have very nonspecific findings because of peritonitis,
where the entire peritoneum is inflamed.
So, looking back at the case we'd mentioned earlier,
there's a lot of different things that this patient could have
whether it's cholecystitis, choledocholithiasis,
hepatitis, peptic ulcer disease,
irritable bowel syndrome, or inflammatory bowel disease.
And we're really going to have to rely upon
some really good physical exam skills
to tease apart this differential diagnosis.