ABDOMINAL PAIN
Titong Sugihartono
Abdominal Pain affects Quality of Life
FAP= functional abdominal pain GERD=gastroesophageal reflux disease IBD= inflammatory bowel disease HC=health children
Youssef, N.N, et al. Pediatrics.2006;117(1):54-59
ABDOMINAL PAIN Location Work-up Acute pain syndromes Chronic pain syndromes
Epigastric Pain • PUD • GERD • MI • AAA- abdominal aortic aneurysm • Pancreatic pain • Gallbladder and common bile duct obstruction
Right Upper Quadrant Pain • Acute Cholecystitis and Biliary Colic • Acute Hepatitis or Abscess • Hepatomegaly due to CHF • Perforated Duodenal Ulcer • Herpes Zoster • Myocardial Ischemia • Right Lower Lobe Pneumonia
Left Upper Quadrant Pain – Acute Pancreatitis – Gastric ulcer – Gastritis – Splenic enlargement, rupture or infarction – Myocardial ischemia – Left lower lobe pneumonia
Right lower Quadrant Pain • Appendicitis • Regional Enteritis • Small bowel obstruction • Leaking Aneurysm • Ruptured Ectopic Pregnancy • PID • Twisted Ovarian Cyst • Ureteral Calculi • Hernia
Left Lower Quadrant Pain • Diverticulitis • Leaking Aneurysm • Ruptured Ectopic pregnancy • PID • Twisted Ovarian Cyst • Ureteral Calculi • Hernia • Regional Enteritis
Periumbilical Pain • Disease of transverse colon • Gastroenteritis • Small bowel pain • Appendicitis • Early bowel obstruction
Diffuse Pain • Generalized peritonitis • Acute Pancreatitis • Sickle Cell Crisis • Mesenteric Thrombosis • Gastroenteritis • Metabolic disturbances • Dissecting or Rupturing Aneurysm • Intestinal Obstruction • Psychogenic illness
Referred Pain Pneumonia (lower lobes) Inferior myocardial infarction Pulmonary infarction
TYPES OF ABDOMINAL PAIN Visceral originates in abdominal organs covered by peritoneum Colic crampy pain Parietal from irritation of parietal peritoneum Referred produced by pathology in one location felt at another location
WORK UP Historical element Physical examination Laboratory test Diagnostic study
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Historical Elements O- onset P-provocation /palliation Q- quality/quantity R- region/radiation S- severity/scale T- timing/time of onset
Physical Exam General Appearance and Vitals (sick vs Not sick) Abdominal exam Inspection (scars, masses, ecchymosis, distention) Auscultation (bowel sounds, bruits), Percussion (organomegaly, dullness) Palpation (tenderness, guarding, rebound, referred pain, masses) Don't forget GU, Rectal and Pelvic
Laboratory tests CBC Urinalysis Routine Fecal examination Additional depending on rule outs – amylase, lipase, LFT’s, etc
Diagnostic Studies Plain X-rays (flat plate) Contrast studies - barium (upper and lower GI series) Ultrasound CT scanning Endoscopy Sigmoidoscopy, colonoscopy
Common Acute Pain Syndromes Appendicitis Acute diverticulitis Cholecystitis Pancreatitis Perforation of an ulcer Intestinal obstruction Ruptured AAA Pelvic disorders
CHRONIC PAIN SYNDROMES Irritable bowel syndrome Chronic pancreatitis Diverticulosis Gastroesophageal reflux disease (GERD) Inflammatory bowel disease Duodenal ulcer Gastric ulcer
IRRITABLE BOWEL SYNDROME GI condition classified as functional as no identifiable structural or biochemical abnormalities Affects 14%-24% of females and 5%-19% of males Onset in late adolescence to early adulthood Rare to see onset > 50 yrs old
SYMPTOMS Pain described as nonradiating, intermittent, crampy located lower abdomen Usually worse 1-2 hrs after meals Exacerbated by stress Relieved by BM Does not interrupt sleep
Critical to diagnosis of IBS
ROME DIAGNOSTIC CRITERIA 3 month minimum of following symptoms in continuous or recurrent pattern Abdominal pain or discomfort relieved by BM & associated with either: Change in frequency of stool and/or Change in consistency of stools
ROME DIAGNOSTIC CRITERIA Two or more of following symptoms on 25% of occasions/days: Altered stool frequency >3 BMs daily or <3BMs/week Altered stool form Lumpy/hard or loose/watery Altered stool passage Straining, urgency, or feeling of incomplete evacuation Passage of mucus Feeling of bloating or abdominal distention
Gejala IBS
Berdasarkan penelitian di Jakarta (2013) didapatkan keluhan nyeri abdomen lebih dominan (hampir sama dengan di negara Barat) sebesar 91% dari kasus IBS.
Konsensus Penatalaksanaan Irritable Bowel Syndrome (IBS) di Indonesia. PGI. 2013.
Antispasmodik, terapi Nyeri Perut pada IBS
Konsensus Penatalaksanaan Irritable Bowel Syndrome (IBS) di Indonesia. PGI. 2013.
Antispasmodik, terapi Nyeri Perut pada IBS
Konsensus Penatalaksanaan Irritable Bowel Syndrome (IBS) di Indonesia. PGI. 2013.
Antispasmodik, terapi Nyeri Perut pada IBS
Konsensus Penatalaksanaan Irritable Bowel Syndrome (IBS) di Indonesia. PGI. 2013.
Studi (terbaru-tahun 2013): randomized, double-blind, placebo-controlled, two-arm parallel group; 175 pasien dengan nyeri dan kram perut; selama 4 minggu
Pain intensity – Numerical Pain Rating Scale (NPRS) Pain intensity decrease during one episode of pain
9 8 7
CEPAT*
6 5 4
Redakan nyeri perut sejak 15 menit pertama
3 2 1 0 0
2 ** 00:30 00:45 4 01:00 01:30 6 02:00 02:30 8 10 04:00 00:00 00:15 03:00 03:30
**P=0.0137
Time after Plasebo (n=87)
1st
12
dose Buscopan® (n=88)
*Penurunan nyeri pada pengobatan dengan Buscopan® berbeda bermakna (p=0,0156) secara statistik vs plasebo pada episode 1.
Diadaptasi dari: Lacy BE, et al. Scand J Gastroenterol. 2013; 48: 926–935
Role of Hyoscine-N-Butyl Bromide (HBB) in ACP&D Aliment Pharmacol Ther 23, 2006, 1741–1748
Studi double-blind, acak, multicenter, four arm parallel group (hyoscine 10 mg t.d.s, parasetamol 500 mg t.d.s, kombinasi 10 mg HBB + 500 mg PAR t.d.s, plasebo)
Pengamatan dilakukan pada hari -8 (dimulai dengan plasebo), hari 1 (awal fase double-blind), hari 8, dan hari 21 (akhir dari fase double-blind)
Role of Hyoscine-N-Butyl Bromide (HBB) in ACP&D Aliment Pharmacol Ther 23, 2006, 1741–1748
Role of Hyoscine-N-Butyl Bromide (HBB) in ACP&D Aliment Pharmacol Ther 23, 2006, 1741–1748
Setelah minggu 1, 2 dan 3, seluruh kelompok uji menunjukkan skor yang lebih baik secara signifikan dibandingkan dengan plasebo (P < 0.001).
Sekitar 90% pasien memberikan skor tolerabilitas umum dengan skala “baik” untuk kelompok uji (zat aktif), tidak ada perbedaan dengan plasebo.
Studi: Prospective, randomized, double-blind, placebo-controlled, crossover; 125 pasien dengan nyeri dan kram perut; selama 8 hari (3 hari sebelum dan 5 hari selama periode menstrual).
4
Penilaian Pasien pada Intensitas Nyeri
3.5 3
Plasebo
2.5
Parasetamol+HBB
*
2
* 1.5 1 0.5 0 Hari 1
Hari 2
Hari 3
Hari 4
*p<0.002 vs plasebo
Penggunaan kombinasi Hyoscine-N-Butylbromide dan parasetamol lebih efektif dibandingkan plasebo pada terapi nyeri menstrual dan gejala lain akibat dysmenorrhea primer serta dapat ditoleransi dengan baik.
Diadaptasi dari: De los Santos AR, et al. Int. J. Clin. Pharm. Res. 2001; XXI(1):21-29
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