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Distention reddit


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In a simple obstruction there is a single point of obstruction, whereas a closed-loop obstruction is caused by two distinct points of distention reddit. A complete obstruction is present if there is no passage of intestinal contents beyond the point of obstruction, whereas a partial obstruction allows for the passage of some contents distal to the obstruction. Compromised blood flow to the bowel causing ischemic necrosis is referred to as strangulated obstruction. This almost always occurs in the setting of complete obstruction and is more frequently seen with closed-loop obstructions. Dehydration and its sequelae are the central systemic pathology in intestinal obstruction. As the stomach and small intestine proximal to the obstruction dilate, patients experience nausea and vomiting and cease oral intake.

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Abdominal pain in general is perhaps one of the most difficult symptoms to evaluate.

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Distention reddit a diagnostician, making an effort to ascertain location of the pain during history taking is helpful in establishing a provisional diagnosis at the bedside and will also aid in guiding further evaluation. In that respect, abdominal pain can be classified into 3 varieties visceral pain, parietal pain and referred pain :. Caused by inflammation or ischemia of a visceral organ, obstruction and distension of a hollow viscus or stretching of a capsule. Oftenlocated at the midline because visceral innervation of abdominal organs is typically bilateral.

Parietal peritoneal afferents are A delta fibers with a rapid conduction velocity and hence parietal pain isSHARP in nature. Occurs when visceral afferents carrying stimuli from a diseased organ enter the spinal cord at the same level as somatic afferents from a remote anatomic location e. Right lower quadrant abdominal painis pain that develops in the area of the abdomen just superior to the right inguinal ligament.

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It may be acute in onset of a few hours to a few days duration or subacute or chronic, having developed over weeks to months. The etiology of RLQ pain is most commonly related to disease processes such as infection, inflammation, perforation, obstruction, neoplasia, vascular events, etc.

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The quality, intensity and duration of pain also depends upon the pathophysiology of the process as discussed later in the chapter. In creating a differential diagnosis for right lower quadrant RLQ pain, the very first step would be to divide the causes into the following :. A useful way to think of abdominal pain to establish its etiology is to subclassify it as arising from either one or a combination of the following layers from exterior towards the interior:. In considering the etiologies under this heading, the key concept would be to think of the RLQ in anatomic terms.


This area primarily overlies the Ileocecal junction and appendix and disease states affecting these organs are a common cause of RLQ pain. Other relevant intra-abdominal viscera in this location include the proximal half of the ascending colon, lower pole of right kidney, right ureter and in females — the right ovary and fallopian tube and certain conditions affecting these organs should be considered in the differential. Femoral hernias — occur through the femoral canal inferior to the inguinal ligament and can cause referred pain to the RLQ.

Right hip pathology — osteoarthritis, intertrochanteric or acetabular fracture can cause referred pain to RLQ. Make sure pain is non-traumatic i. Age, gender, prior abdominal surgical history and abdominal medical history is important. Note any prior history of appendectomy, bowel surgery e. In elderly patients, keep a high index of suspicion for vascular distention reddit such as mesenteric ischemia or aortic aneurysm rupture. Data — check relevant labs and order appropriate abdominal imaging Kidney scan [KUB] or computed tomography [CT] abdomen and pelvis.

A KUB may also pick up a radio-opaque ureteric stone. If there is any concern for acute distention reddit ischemia or evidence of an acute abdomen with peritoneal s in the hospital setting would directly go to a CT abdomen for imaging. Acuity, intensity and duration of pain may be helpful in assessing severity of disease. A sudden onset of pain suggests a serious intra-abdominal event such as an organ perforation appendiceal rupture, colonic diverticular perforation or Ischemia ischemic colitis or obstruction of a small tubular structure ureteric stone. The pain of acute appendicitis may start in the periumbilical area visceral pain and then a few hours later localize in the RLQ as the peritoneum overlying the inflamed appendix gets affected parietal pain.

A positive response would suggest a chronic intermittent problem e. Any family history of IBD? Any prior abdominal surgeries — specifically appendectomy, bowel surgery e. This line of specific questioning helps rule out certain possibilities and make some more likely. Any intra-abdominal medical devices e.

Approach to the patient with intestinal obstruction

Though a non-specific complaint, in the presence of abdominal distension and constipation may indicate intestinal obstruction. Not specific but puts infectious and inflammatory conditions higher on the list acute appendicitis, diverticulitis, IBD and in females pelvic inflammatory disease. If yes, then any recent antibiotic use within the past weeks or recent consumption of restaurant or stale food? Think C. If no bowel movement, are you passing flatus? Any abdominal bloating or distension? Think intestinal obstruction if constipation or obstipation present.

Any black or maroon stools or bright red blood per rectum? If bright red blood, was it associated with straining on defecation or rectal pain during defecation? In the acute setting this may suggest ischemic colitis; in the sub-acute or chronic setting it may suggest colon malignancy. Bloody diarrhea may be suggestive of an infectious enterocolitis or inflammatory bowel disease. Presence of bleeding raises suspicion for possible ectopic pregnancy and a discharge may indicate pelvic inflammatory disease PID.

When was your last menstrual period? Any history of ectopic pregnancies or prior miscarriages? This may be a harbinger of a malignancy e. Expose the abdomen from the xiphisternum to the upper third of both thighs so that both inguinal areas are well in view. Does the abdominal wall move normally with respiration?

Lack of movement whether localized or diffuse may indicate peritonitis. Other distention reddit to look for in females would be in the midline and suprapubic area from a prior distention reddit and salpingo-oophorectomy.

Look for any obvious swelling or fullness in the RLQ asymmetric abdominal enlargement — suggests an abdominal wall mass or intra-abdominal mass.


Look for any inguinal or inguinoscrotal in males swelling — suggestive of an inguinal or femoral hernia. Place your hand flat over the abdomen using the flexor surface of all the fingers during palpation. Be careful not to use the tip of the fingers during palpation i.

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Palpate gently and as you are palpating ask the patient to take deep breaths in and out. Unlike true rigidity involuntary muscle guardingvoluntary muscle guarding will disappear during expiration. Hernias: s of strangulation — redness, tenderness, loss of cough impulse and irreducibility. To confirm the abdominal wall as distention reddit cause of pain as opposed to an intra-abdominal organ palpate and find point of maximum tenderness. While palpating with abdomen relaxed have patient tense abdominal wall by doing half a sit-up with the arms crossed or by having them flex their neck to make the chin touch the chest.

Psoas : Pain in the RLQ when the right hip t is passively extended with the patient lying on their left side. Positive in cases of a retrocecal appendix.

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Obturator : Pain elicited when the examiner passively performs internal rotation with the flexed right thigh. May be positive in cases of a pelvic appendix. Proceed to examine the right hip t and inguinal area more carefully; point tenderness over these locations suggest hip t or pubic rami pathology.

Difficile toxin, ova and parasites when appropriate.

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Acute onset crampy abdominal pain usually begins in periumbilical area and then migrates to RLQ ; in pelvic appendix dysuria, urinary frequency, diarrhea or tenesmus may be prominent symptoms. Inflammatory diarrhea — bloody, small volume associated with lower quadrant cramps, patients may be febrile and toxic. Non-inflammatory diarrhea — large volume and watery, associated with nausea, vomiting and diffuse abdominal cramps. Abdominal distension. Usually occurs over days but will be acute in two-thirds patients with colonic volvulus. Patients with cecal volvulus often have a past history of abdominal surgeries and a history of chronic constipation and laxative use.

KUB will show a massively dilated cecum with distended loops of small distention reddit indicating the proximal small bowel obstruction. Acute to subacute onset — may begin with a dull ache in the RLQ and right flank progressing to intense pain which begins to wax and wane and occurs in paroxysms ureteric colic. As the stone migrates down the renal pelvis and ureter the pain may radiate to the scrotum in males and labia in females.

Distention reddit patient uncomfortable due to pain, tender Right flank but typically soft unless there is voluntary guarding. Labs: Urinalysis may show evidence of hematuria or pyuria; CBC — may have a leukocytosis; BMP may show an elevated BUN and creatinine if patient dehydrated or there is ificant ureteral obstruction. Occurs in sexually active women of reproductive age group whether or not they are using contraceptives or have undergone tubal sterilization. Most common symptom — abdominal pain, absence of menses interval of amenorrhea usually 6 weeks or more and irregular vaginal bleeding.

Before rupture occurs, pain may be vague soreness or colicky and may be generalized or unilateral. Pain intense during rupture of fallopian tube. Other symptoms following rupture — dizziness and urge to defecate.

Right-lower quadrant abdominal pain

Vaginal bleeding usually characterized as spotting and rarely as heavy as in spontaneous abortion. Pregnancy predisposes women to torsion with an incidence of 1 in 5 women being pregnant when the condition is diagnosed. Lower abdominal tenderness on exam or on pelvic exam evidence of cervical motion tenderness, distention reddit adnexal tenderness. Quick focused history to rule out trauma blunt or otherwise as a cause of RLQ pain.

If evidence of a GI Bleed melena or stool occult blood positive consider possibility of mesenteric ischemia. If toxic appearing female patient with high fever, chills and mucopurlent vaginal discharge suspect — PID. In cases where the initial exam was unrevealing and symptoms persist, conduct serial abdominal exams to assess for development of any peritoneal s. This population does not always present with the classic s and symptoms associated with different acute abdominal syndromes. In addition, historical information may be difficult to obtain and typical physical exam findings may be absent or hard to elicit.

For example, fever and leucocytosis may not be a prominent finding in the presence of intra-abdominal infection in these patients.

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