Abdominal+Pain

//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

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

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

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

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

Obstruction by Cold Evil in the Middle Jiao
[Gao liang jiang (10g), Xiang fu (10g)]
 * 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)

Obstruction by Damp-Heat
[Da huang (10g), Mang xiao (10g), Zhi shi (10g), Hou po (10g)]
 * 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)

Obstruction by Food Stagnation
[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)
 * 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)

Stagnation of Liver Qi
[Chai Hu (10g), Xiang Fu (10g), Zhi Ke (10g), Chen Pi (10g), Bai Shao (10g), Chuan Xiong (10g), Zhi Gan Cao (3g)
 * 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)

Blood Stasis
[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.)]
 * 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)

Yang vacuity of the Stomach and the Spleen
[Yi tang (30g), Gui Zhi (6g), Bai Shao Yao (10g), Zhi Gan Cao (3g), Da Zao (10 pc.), Sheng jiang (6 slices)]
 * 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)

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.