用户:Kumokumo0310/腹痛

腹痛
同义词	肚子痛
腹痛的位置可根据其影响的器官而定。
病因	严重病因：阑尾炎、, 胃溃疡、胃穿孔、胰腺炎、憩室炎破裂、卵巢扭转、肠扭转、主动脉瘤破裂、肝脏或脾脏破裂、缺血性肠炎、缺血性心脏病 常见病因：肠胃炎、大肠激躁症
分类和外部资源
医学专科	胃肠学、普通外科

腹痛（Abdominal pain）是指腹部疼痛的症状，其背后可能的原因可能有严重与非严重的成因。常见的腹痛原因包含肠胃炎或大肠激躁症。约15%的腹痛原因可能是由更严重的病因引起，诸如阑尾炎、腹主动脉瘤破裂、憩室炎，或是异位妊娠。其中约三分之一的患者腹痛的成因不明。

由于多种疾病皆可能造成不同形式的腹痛，因此对患者进行系统性地检查及进行鉴别诊断仍然相当重要。

鉴别诊断

最常见的腹痛成因为肠胃炎（13%）、大肠激躁症（8%）、泌尿道问题（5%）、胃炎（5%），或便秘（5%）等等。30%的案例原因不明。约10%的病人则是缘自于较严重的疾病，诸如胆道（胆结石或胆道收缩障碍）、胰脏（4%）相关问题、憩室炎（3%）、阑尾炎（2%），或癌症（1%）。在年长病患中较常见的病因包含缺血性肠炎、肠系膜缺血、腹主动脉瘤，或其他病因。

腹部急症

腹部急症的定义是指在短时间内发生剧烈而持续的疼痛，且可能必须进行紧急外科手术治疗。相关症状可能会伴随恶心、呕吐、腹胀、发热，或休克的症状。急性阑尾炎最常见的腹部急症之一。

部分可能病因

• 创伤性因素：胃部、肠、脾脏、肝脏、肾脏钝挫伤或穿刺伤。
• 发炎性因素：
  • 阑尾炎、胆囊炎、胰脏炎、肾盂肾炎、腹膜炎、骨盆腔发炎、肝炎、肠系膜淋巴腺炎，或横膈下脓疡。
  • 胃溃疡并发穿孔、憩室炎、或盲肠炎
  • 发炎性肠病及其并发症：如克隆氏症或溃疡性结肠炎
• 器质性因素：
  • 先前手术造成的肠道粘连，造成小肠阻塞、肠套叠、疝气、恶性或良性肿瘤
  • 大肠癌导致的大肠阻塞、发炎性肠病、肠扭转、粪便阻塞或疝气
• 血管性：血栓阻塞血管造成肠系膜缺血，其中最常阻塞的为上肠系膜动脉

依系统分类

更详细的鉴别诊断胪列如下：

依系统分类的鉴别诊断
消化道性	消化道	发炎性		肠胃炎、阑尾炎、胃炎、食管炎、憩室炎、克隆氏症、溃疡性结肠炎、microscopic colitis
		阻塞性		疝气、肠套叠、肠扭转、术后粘连、肿瘤、严重便秘、痔疮
		血管性		栓塞、血栓形成、出血, 镰刀型红血球疾病、腹绞痛、血管压迫综合症（如腹腔动脉综合症）、superior mesenteric artery syndrome, postural orthostatic tachycardia syndrome
		消化性		peptic ulcer, lactose intolerance, celiac disease, food allergies
	分泌腺	胆道系统	发炎性	cholecystitis, cholangitis
			阻塞性	cholelithiasis, tumours
		肝脏	发炎性	hepatitis, liver abscess
		胰脏	发炎性	pancreatitis
泌尿系统	发炎性			pyelonephritis, bladder infection, indigestion
	阻塞性			kidney stones, urolithiasis, urinary retention, tumours
	血管性			left renal vein entrapment
妇女生殖系统	发炎性			pelvic inflammatory disease
	器质性			ovarian torsion
	内分泌性			menstruation, Mittelschmerz
	肿瘤性			endometriosis, fibroids, ovarian cyst, ovarian cancer
	妊娠相关			ruptured ectopic pregnancy, threatened abortion
腹壁	肌肉性			muscle strain or trauma
	发炎性			muscular infection
	神经性			herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES), tabes dorsalis
Referred pain	thorax			pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
	spine			radiculitis
	genitals			testicular torsion
Metabolic disturbance				uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal
Blood vessels				Blood vessels
Immune system				sarcoidosis vasculitis familial Mediterranean fever
Idiopathic				irritable bowel syndrome (IBS)(affecting up to 20% of the population, IBS is the most common cause of recurrent and intermittent abdominal pain)

By location

The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include:

• Diffuse
  • Peritonitis
  • Vascular: mesenteric ischemia, ischemic colitis, Henoch-Schonlein purpura, sickle cell disease, systemic lupus erythematosus, polyarteritis nodosa
  • Small bowel obstruction
  • Irritable bowel syndrome
  • Metabolic disorders: ketoacidosis, porphyria, familial Mediterranean fever, adrenal crisis
• Epigastric
  • Heart: myocardial infarction, pericarditis
  • Stomach: gastritis, stomach ulcer, stomach cancer
  • Pancreas: pancreatitis, pancreatic cancer
  • Intestinal: duodenal ulcer, diverticulitis, appendicitis
• Right upper quadrant
  • Liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess
  • Gallbladder and biliary tract: inflammation, gallstones, worm infection, cholangitis
  • Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer
  • Other: pneumonia, Fitz-Hugh-Curtis syndrome
• Left upper quadrant
  • Splenomegaly
  • Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer
• Peri-umbilical (the area around the umbilicus, aka the belly button)
  • Appendicitis
  • Pancreatitis
  • Inferior myocardial infarction
  • Peptic ulcer
  • Diabetic ketoacidosis
  • Vascular: aortic dissection, aortic rupture
  • Bowel: mesenteric ischemia, Celiac disease, inflammation, intestinal spasm, functional disorders, small bowel obstruction
• Lower abdominal pain
  • Diarrhea
  • Colitis
  • Crohn's
  • Dysentery
  • Hernia
• Right lower quadrant
  • Colon: intussusception, bowel obstruction, appendicitis (McBurney's point)
  • Renal: kidney stone (nephrolithiasis), pyelonephritis
  • Pelvic: cystitis, bladder stone, bladder cancer, pelvic inflammatory disease, pelvic pain syndrome
  • Gynecologic: endometriosis, intrauterine pregnancy, ectopic pregnancy, ovarian cyst, ovarian torsion, fibroid (leiomyoma), abscess, ovarian cancer, endometrial cancer
• Left lower quadrant
  • Bowel: diverticulitis, sigmoid colon volvulus, bowel obstruction, gas accumulation, Toxic megacolon
• Right low back pain
  • Liver: hepatomegaly
  • Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection
• Left low back pain
  • Spleen
  • Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection
• Low back pain
  • kidney pain (kidney stone, kidney cancer, hydronephrosis)
  • Ureteral stone pain

Pathophysiology

Region	Blood supply	Innervation	Structures
Foregut	Celiac artery	T5 - T9	Pharynx Esophagus Lower respiratory tract Stomach Proximal duodenum Liver Biliary tract Gallbladder Pancreas
Midgut	Superior mesenteric artery	T10 - T12	Distal duodenum Cecum Appendix Ascending colon Proximal transverse colon
Hindgut	Inferior mesenteric artery	L1 - L3	Distal transverse colon Descending colon Sigmoid colon Rectum Fever Superior anal canal

Abdominal pain can be referred to as visceral pain or peritoneal pain. The contents of the abdomen can be divided into the foregut, midgut, and hindgut. The foregut contains the pharynx, lower respiratory tract, portions of the esophagus, stomach, portions of the duodenum (proximal), liver, biliary tract (including the gallbladder and bile ducts), and the pancreas. The midgut contains portions of the duodenum (distal), cecum, appendix, ascending colon, and first half of the transverse colon. The hindgut contains the distal half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal canal.

Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord, traveling with the autonomic sympathetic nerves. The visceral sensory information from the gut traveling to the spinal cord, termed the visceral afferent, is non-specific and overlaps with the somatic afferent nerves, which are very specific. Therefore, visceral afferent information traveling to the spinal cord can present in the distribution of the somatic afferent nerve; this is why appendicitis initially presents with T10 periumbilical pain when it first begins and becomes T12 pain as the abdominal wall peritoneum (which is rich with somatic afferent nerves) is involved.

Diagnosis

A thorough patient history and physical examination is used to better understand the underlying cause of abdominal pain.

The process of gathering a history may include:

• Identifying more information about the chief complaint by eliciting a history of present illness; i.e. a narrative of the current symptoms such as the onset, location, duration, character, aggravating or relieving factors, and temporal nature of the pain. Identifying other possible factors may aid in the diagnosis of the underlying cause of abdominal pain, such as recent travel, recent contact with other ill individuals, and for females, a thorough gynecologic history.
• Learning about the patient's past medical history, focusing on any prior issues or surgical procedures.
• Clarifying the patient's current medication regimen, including prescriptions, over-the-counter medications, and supplements.
• Confirming the patient's drug and food allergies.
• Discussing with the patient any family history of disease processes, focusing on conditions that might resemble the patient's current presentation.
• Discussing with the patient any health-related behaviors (e.g. tobacco use, alcohol consumption, drug use, and sexual activity) that might make certain diagnoses more likely.
• Reviewing the presence of non-abdominal symptoms (e.g., fever, chills, chest pain, shortness of breath, vaginal bleeding) that can further clarify the diagnostic picture.
• Using Carnett's sign to differentiate between visceral pain and pain originating in the muscles of the abdominal wall.

After gathering a thorough history, one should perform a physical exam in order to identify important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung exam, thorough abdominal exam, and for females, a genitourinary exam.

Additional investigations that can aid diagnosis include:

• Blood tests including complete blood count, basic metabolic panel, electrolytes, liver function tests, amylase, lipase, troponin I, and for females, a serum pregnancy test.
• Urinalysis
• Imaging including chest and abdominal X-rays
• Electrocardiogram

If diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include:

• Computed tomography of the abdomen/pelvis
• Abdominal or pelvic ultrasound
• Endoscopy and/or colonoscopy

Management

The management of abdominal pain depends on many factors, including the etiology of the pain. In the emergency department, a person presenting with abdominal pain may initially require IV fluids due to decreased intake secondary to abdominal pain and possible emesis or vomiting. Treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and opioid medications (morphine, fentanyl). Choice of analgesia is dependent on the cause of the pain, as ketorolac can worsen some intra-abdominal processes. Patients presenting to the emergency department with abdominal pain may receive a "GI cocktail" that includes an antacid (examples include omeprazole, ranitidine, magnesium hydroxide, and calcium chloride) and lidocaine. After addressing pain, there may be a role for antimicrobial treatment in some cases of abdominal pain. Butylscopolamine (Buscopan) is used to treat cramping abdominal pain with some success. Surgical management for causes of abdominal pain includes but is not limited to cholecystectomy, appendectomy, and exploratory laparotomy.

Emergencies

Below is a brief overview of abdominal pain emergencies.

Condition	Presentation	Diagnosis	Management
Appendicitis	Abdominal pain, nausea, vomiting, fever Periumbilical pain, migrates to RLQ	Clinical (history & physical exam) Abdominal CT	Patient made NPO (nothing by mouth) IV fluids as needed General surgery consultation, possible appendectomy Antibiotics Pain control
Cholecystitis	Abdominal pain (RUQ, radiates epigastric), nausea, vomiting, fever, Murphy's sign	Clinical (history & physical exam) Imaging (RUQ ultrasound) Labs (leukocytosis, transamintis, hyperbilirubinemia)	Patient made NPO (nothing by mouth) IV fluids as needed General surgery consultation, possible cholecystectomy Antibiotics Pain, nausea control
Acute pancreatitis	Abdominal pain (sharp epigastric, shooting to back), nausea, vomiting	Clinical (history & physical exam) Labs (elevated lipase) Imaging (abdominal CT, ultrasound)	Patient made NPO (nothing by mouth) IV fluids as needed Pain, nausea control Possibly consultation of general surgery or interventional radiology
Bowel obstruction	Abdominal pain (diffuse, crampy), bilious emesis, constipation	Clinical (history & physical exam) Imaging (abdominal X-ray, abdominal CT)	Patient made NPO (nothing by mouth) IV fluids as needed Nasogastric tube placement General surgery consultation Pain control
Upper GI bleed	Abdominal pain (epigastric), hematochezia, melena, hematemesis, hypovolemia	Clinical (history & physical exam, including digital rectal exam) Labs (complete blood count, coagulation profile, transaminases, stool guaiac)	Aggressive IV fluid resuscitation Blood transfusion as needed Medications: proton pump inhibitor, octreotide Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology)
Lower GI Bleed	Abdominal pain, hematochezia, melena, hypovolemia	Clinical (history & physical exam, including digital rectal exam) Labs (complete blood count, coagulation profile, transaminases, stool guaiac)	Aggressive IV fluid resuscitation Blood transfusion as needed Medications: proton pump inhibitor Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology)
Perforated Viscous	Abdominal pain (sudden onset of localized pain), abdominal distension, rigid abdomen	Clinical (history & physical exam) Imaging (abdominal X-ray or CT showing free air) Labs (complete blood count)	Aggressive IV fluid resuscitation General surgery consultation Antibiotics
Volvulus	Sigmoid colon volvulus: Abdominal pain (>2 days, distention, constipation) Cecal volvulus: Abdominal pain (acute onset), nausea, vomiting	Clinical (history & physical exam) Imaging (abdominal X-ray or CT)	Sigmoid: Gastroenterology consultation (flexibile sigmoidoscopy) Cecal: General surgery consultation (right hemicolectomy)
Ectopic pregnancy	Abdominal and pelvic pain, bleeding If ruptured ectopic pregnancy, the patient may present with peritoneal irritation and hypovolemic shock	Clinical (history & physical exam) Labs: complete blood count, urine pregnancy test followed with quantitative blood beta-hCG Imaging: transvaginal ultrasound	If patient is unstable: IV fluid resuscitation, urgent obstetrics and gynecology consultation If patient is stable: continue diagnostic workup, establish OBGYN follow-up
Abdominal aortic aneurysm	Abdominal pain, flank pain, back pain, hypotension, pulsatile abdominal mass	Clinical (history & physical exam) Imaging: Ultrasound, CT angiography, MRA/magnetic resonance angiography	If patient is unstable: IV fluid resuscitation, urgent surgical consultation If patient is stable: admit for observation
Aortic dissection	Abdominal pain (sudden onset of epigastric or back pain), hypertension, new aortic murmur	Clinical (history & physical exam) Imaging: Chest X-Ray (showing widened mediastinum), CT angiography, MRA, transthoracic echocardiogram/TTE, transesophageal echocardiogram/TEE	IV fluid resuscitation Blood transfusion as needed (obtain type and cross) Medications: reduce blood pressure (sodium nitroprusside plus beta blocker or calcium channel blocker) Surgery consultation
Liver injury	After trauma (blunt or penetrating), abdominal pain (RUQ), right rib pain, right flank pain, right shoulder pain	Clinical (history & physical exam) Imaging: FAST examination, CT of abdomen and pelvis Diagnostic peritoneal aspiration and lavage	Resuscitation (Advanced Trauma Life Support) with IV fluids (crystalloid) and blood transfusion If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy
Splenic injury	After trauma (blunt or penetrating), abdominal pain (LUQ), left rib pain, left flank pain	Clinical (history & physical exam) Imaging: FAST examination, CT of abdomen and pelvis Diagnostic peritoneal aspiration and lavage	Resuscitation (Advanced Trauma Life Support) with IV fluids (crystalloid) and blood transfusion If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy and possible splenectomy If patient is stable: medical management, consultation of interventional radiology for possible arterial embolization

Epidemiology

Abdominal pain is the reason about 3% of adults see their family physician. Rates of emergency department (ED) visits in the United States for abdominal pain increased 18% from 2006 through to 2011. This was the largest increase out of 20 common conditions seen in the ED. The rate of ED use for nausea and vomiting also increased 18%.

外部链接

Category:症状和体征：消化系统及腹部 Category:急性疼痛