Western Diagnosis:

Etiology

1. appendicitis, perforated peptic ulcer, intestinal obstruction, peritonitis, perforated diverticulitis, twisted ovarian cyst, ectopic pg, leaking abdominal aneurysm, mesenteric embolism or thrombosis
2. biliary tract disease, pancreatitis, renal calculi usually need urgent care

History

1. acute or chronic: chronic usually functional or need long dx work-up
2. sudden onset: perforation, pancreatitis, ruptured aneurysm
3. length of attack: if gone now, biliary or renal colic
4. severity
5. location
6. radiation: along nerves of same spinal segment
7. type of pain
---severe, knife-like - emergency
---burning - functional, ulcers
---waves of sharp, constricting pain - biliary or renal colic
---tearing - dissecting aneurysm
---colicky pain that becomes steady - appendicitis, obstruction, vascular accident
8. what ameliorates it
9. associated sx: immediately before onset of pain
10. past hx of sx
11. drug hx

Signs & Symptoms

1. vital signs - T, HR, BP
2. shock, pallor, sweating
3. abdominal peristalsis
4. distention, masses
5. tenderness, rebound tenderness
6. Grey Turner’s sign: extravasation of hemorrhagic exudate to the flanks
7. Cullen’s sign: extravasation of hemorrhagic exudate to the umbilical region

Diagnosis

1. every test available
2. exploratory laparotomy is the most important diagnostic measure in pts. with severe abd pain


TCM Pathology:

Abdominal Pain (Fù Tòng)

Any subjective, unpleasant and painful sensation in the abdominal region.
Defined as the area below the epigastrium to the suprapubic margin.

-Abdominal pain can be a symptom of many disorders involving various organs.
-Gynecologic pathology, traumatic injuries, and surgical conditions can all cause abdominal pain.
-Proper identification of situations requiring urgent referral is crucial (e.g., ectopic pregnancy, bowel obstruction, perforated ulcers, acute peritonitis, necrotic pancreatitis, and acute appendicitis).
-Improper treatment due to misdiagnosis will mask symptoms and place the patient at risk for serious complications and even death

Relevant Biomedical Diseases

-Enteritis
-Intestinal Tumor
-Pancreatitis
-Cholecystitis
-Appendicitis
-Fecal Impaction
-Diverticulitis

Etiology and Pathology

Invasion of Exogenous Pathogens: pathogenic cold, summer-heat, or damp heat -> obstruction in SP/ST & intestines -> abdominal pain
Improper Diet: excessive consumption of cold or raw foods, excessive intake of fatty, greasy, or spicy foods, over eating -> food retention in the middle jiao & failure of SP to transform & transport abdominal pain
Emotional Disturbance -> Liver Qi stagnation causing Qi stagnation -> Blood stasis, or Liver and SP/ST disharmony -> Qi stagnation and Blood stasis -> abdominal pain
Miscellaneous: surgery or traumatic injury -> Qi stagnation and Blood stasis -> abdominal pain
Constitutional yang vacuity, chronic illness, or taxation fatigue -> lack of warmth and nourishment in fu organs -> abdominal pain

Differential Dx of Abdominal Pain

Abdominal Pain (Fù Tòng): Pain is usually felt lower (between/around umbilicus and pubic bone)
Epigastric Pain (Wèi Tòng): Pain is usually felt higher (between umbilicus and sternocostal angle)

Dysentery, abdominal masses, intestinal abscess, and hernia may all present with abdominal pain. However, they also exhibit unique and characteristic symptoms by which they can be differentiated from abdominal pain.
-Dysentery: manifests with abdominal pain and tenesmus as well as severe diarrhea with purulent blood and mucus in the stool.
-Abdominal masses: abdominal pain will be accompanied by visible or palpable abdominal masses which may be hard or soft
-Intestinal abscess: characterized by pain in the right lower quadrant, rebound tenderness, muscle guarding and rigidity, and flexing of right lower extremity with pressure to the abdomen
-Hernia: lower abdominal pain that radiates from the inguinal region to the genitalia; pain may be relieved by warmth; protrusion of abdominal wall may be evident

Distinguishing Vacuity Patterns from Repletion Patterns
Vacuity Patterns: Pain decreases with pressure, Pain increases with hunger
Repletion Patterns: Pain aggravated by pressure, Pain aggravated by pressure or after meals

Distinguishing Cold Patterns from Heat Patterns
Cold Patterns: Pain alleviated by warmth
Heat Patterns: Pain alleviated by cold

Distinguishing Qi Stagnation from Blood Stasis Patterns
Qi Stagnation Patterns: Distending, migrating pain
Blood Stasis Patterns: Fixed, stabbing pain

Abdominal Pain: Determining Organ Involvement

Pain localized at the lower flank radiating to the hypochondria: Liver and Gallbladder
Pain in the the suprapubic area and periumbilical region: Spleen, Kidney, and Bladder

TCM Pattern Differentiation

Obstruction by Cold Evil in the Middle Jiao

Signs: sudden and severe abdominal pain relieved by warmth and aggravated by cold
Symptoms: no thirst, usually loose stools but possibly constipation, copious, clear urine
Tongue: white, greasy tongue coating
Pulse: deep, tight
Treatment Principles: Warm the Middle Jiao, disperse Cold, regulate Qi, relieve pain
Herbal Treatment: Liang Fu Wan (Lesser Galangal and Cyperus Pill)
[Gao liang jiang (10g), Xiang fu (10g)]

Obstruction by Damp-Heat

Signs: abdominal pain and distention that is aggravated by pressure, constipation or incomplete/difficult defecation with sticky stools, fullness and oppression in the chest
Symptoms: irritability, thirst, scanty dark urine, possible fever or sweating
Tongue: yellow, greasy tongue coating
Pulse: slippery, rapid
Treatment Principle: Clear Heat, transform Dampness, promote bowel movement
Herbal Treatment: Da Cheng Qi Tang (Great Order the Qi Decoction)
[Da huang (10g), Mang xiao (10g), Zhi shi (10g), Hou po (10g)]

Obstruction by Food Stagnation

Signs: abdominal and distention that increases with pressure and after eating, acid regurgitation
Symptoms: anorexia, nausea/vomiting, belching with foul breath, abdominal pain that occurs prior to and is relieved by defecation, loose stools/diarrhea or constipation
Tongue: greasy coating
Pulse: replete, slippery
Treatment Principle: Disperse food, abduct stagnation, relieve pain
Herbal Treatment: Bao He Wan (Harmony Preserving Pill)
[Ban Xia (10g), Fu Ling (10g), Chen Pi (10g), Shan Zha (10g), Shen Qu (10g), Lai Fu Zi (10g), Lian Qiao (10g), Zhi Gan Cao (10g)

Stagnation of Liver Qi

Signs: abdominal pain and distention that tends to migrate and fluctuate with emotional state; may involve the epigastric and costal regions, hypochondrium and groin
Symptoms: pain relieved by belching or passing gas, chest oppression, frequent sighing
Tongue: thin, white coating,
Pulse: wiry
Treatment Principle: Soothe the Liver, regulate the flow of Qi, relieve pain
Herbal Treatment: Chai Hu Shu Gan San (Bupleurum Course the Liver Decoction)
[Chai Hu (10g), Xiang Fu (10g), Zhi Ke (10g), Chen Pi (10g), Bai Shao (10g), Chuan Xiong (10g), Zhi Gan Cao (3g)

Blood Stasis

Signs: stabbing abdominal pain with fixed location that increases with pressure
Symptoms: chronic history of condition in most cases
Tongue: purple
Pulse: choppy
Treatment Principle: Quicken the Blood, eliminate stasis, warm the channels, and relieve pain
Herbal Treatment: Shao Fu Zhu Yu Tang (Lesser Abdomen Stasis Expelling Decoction)
[Dang Gui (10g), Chuan Xiong (10g), Chi Shao Yao (10g), Pu Huang (10g), Wu Ling Zhi (10g), Mo Yao (5g), Yan Hu Suo (10g), Rou Gui (4g), Gan Jiang (5g), Xiao Hui Xiang (5g.)]

Yang vacuity of the Stomach and the Spleen

Signs: mild, dull and intermittent abdominal pain that is relieved by warmth and pressure and increases with hunger or fatigue (improves with eating and rest)
Symptoms: loose stool, lusterless complexion, listlessness, aversion to cold, shortness of breath
Tongue: pale tongue with possible tooth-marks, thin, white coating
Pulse: deep, fine and slow pulse
Treatment Principle: Warm and supplement Yang, relieve pain
Herbal Treatment: Xiao Jian Zhong Tang (Minor Center Fortifying Decoction)
[Yi tang (30g), Gui Zhi (6g), Bai Shao Yao (10g), Zhi Gan Cao (3g), Da Zao (10 pc.), Sheng jiang (6 slices)]

Acupuncture for Abdominal Pain

Cold Evil: CV 12, LI 4, CV 8, ST 25, ST 34, ST 36, SP4, SP 15 + moxa
Damp-Heat: LI 11, ST 25, ST 37, BL 25, SP 9
Food Stagnation: CV 12, ST 21, ST 25, ST 36
LV Qi Stag.: LV 3, PC 6, CV 17, GB 34, CV 10, LV 14
Blood Stasis: LV 3, CV 17, BL 17, SP 6, SP 10
Yang Vacuity: BL 20, BL 21, CV 12, CV 6, ST 36, SP 6 + moxa

Clinical Tips for Treating Abdominal Pain

It is important to rule out all possible non-medical diagnoses before treatment. Abdominal pain can be a symptom of many disorders involving various organs. Gynecologic pathology, surgical conditions, and traumatic injuries all can induce abdominal pain and confuse the diagnosis. Prompt diagnosis and identification of urgent and critical pathology are important to guide the treatments. Improper treatments due to misdiagnosis will mask symptoms, placing the patient at serious risk for complications or even death.

Conservative medical measures are not adequate for gynecological, obstetrical, or surgical conditions such as ectopic pregnancy, bowel obstruction, perforated peptic ulcers, acute peritonitis, necrotic pancreatitis, and acute appendicitis.