01/11/2023
PAIN IN RIGHT ABDOMEN
"It Hurts Right Up"
Pain in the upper right side of the abdomen can be caused by a number of conditions. The patient's age, s*x, and general condition determine the list of possible diagnoses. History and physical examination also help to choose one of the different diagnoses (differential diagnosis). Evidence such as sudden or gradual onset of pain, weight loss, fever, general weakness, and bowel or urinary symptoms can also help make a correct diagnosis. It is important to decide if there is a case of a serious intra-abdominal problem (acute abdomen).
Doctor S.C.Hirides will first ask you some questions about the pain: where is the pain? can you point to the point of the pain with one finger or is it more diffuse and where does it spread? When did it start? Did it start suddenly or gradually? Is it continuous or does it come and go? Does it feel like a stab, a burn, or is it deeper? Are there factors that make it better or worse? Remember to tell your doctor about accompanying symptoms such as fever, cough or stinging when urinating. Also report any anorexia, change in your body weight, bowel habits, color and consistency of urine. State whether you are a smoker or a frequent drinker of alcohol. Remember to list all medications you are taking. Finally, remember if there are chronic illnesses in the family.
Pain in the right upper abdomen may be related to problems with the liver (liver) or bile (gallbladder): Finding a stone (stone) or multiple stones inside the gallbladder (often called "bile") is very common . Usually gallstones do not cause symptoms, but they can at any time cause pain or severe inflammation (cholecystitis) and require removal of the 'bile' - cholecystectomy. Gallbladder polyps should be monitored with frequent ultrasounds unless they grow larger than 5mm, in which case a cholecystectomy should also be discussed with your doctor. Gallbladder malignancy is very rare. If the pain is accompanied by fever with chills and jaundice then the doctor should investigate the possibility of cholangitis (inflammation of the bile ducts, i.e. the vessels that carry bile from the liver to the intestine). Don't forget to report any injuries to the liver area. If the liver has larger dimensions than normal it should be checked for various hematological and autoimmune diseases of the bile ducts. Cardiac problems may be associated with liver congestion and should be reported.
Although every physician should be aware of the above diagnoses, they should first rule out the more common causes of pain. In addition to the liver and bile ducts, sometimes pain must be sought in other systems, such as the gastrointestinal, genitourinary, cardiovascular and even respiratory systems. Endocrine (hormone-secreting) causes, microbial infections, and special pregnancy and pediatric problems should also be considered.
Intestinal causes of pain in the right upper abdomen include severe constipation or irritable bowel syndrome (spastic colitis), diverticulae (pathological stretching of the intestinal wall), problems with intestinal perfusion, masses and inflammatory bowel diseases (eg Crohn's disease). In some cases the pain is due to appendicitis, i.e. inflammation of the appendix (the small appendix that hangs from the beginning of the large intestine, the "cecum"), especially when it is in an unusual position. In this case, the surgical removal of the appendix (appendicectomy) should not be delayed. Similarly, inflammation of another, large diverticulum usually found in the terminal small intestine may be responsible for the pain (Meckel's diverticulum). This condition is usually detected during surgery and may be accompanied by blood in the stools.
Inflammation, stones or masses in the kidney or ureter (tube that carries urine from the kidneys to the bladder) that block the urinary tract and lead to hydronephrosis (enlarged kidney) can cause pain in the upper right abdomen.
Pain caused by an abdominal aortic dissection aneurysm (severe damage to the wall of the aorta) is usually worse in the back and may radiate from the chest down to the legs. Aneurysms can also occur in other arteries of the body. Upper abdominal pain can rarely originate from cardiac causes. Congestive heart failure can lead to liver pain.
Even the lung can cause pain on the right, as for example in the case of pneumonia of the lower lobe of the right lung or in the rare case of a pulmonary embolism event caused by a thrombus becoming wedged in the pulmonary vessels (usually accompanied by thrombosis in the large veins of the legs).
Endocrine causes of upper abdominal pain are diabetic ketoacidosis (a serious complication of diabetes mellitus), diseases of the adrenal glands (glands located at the upper pole of the kidneys). Pancreatic pain (the pancreas is the large gland located behind the stomach) is usually located more centrally with a backward reflection between the shoulder blades.
The pain may also be due to contamination by a microorganism (infection). Shingles can often present with pain before the skin blisters. This pain is typically located in the skin. Abscesses (collection of pus) under the diaphragm (the large vaulted muscle that separates the abdomen from the chest) create similar pain. Similar discomfort is reported by patients after laparoscopy (where dioxide is introduced into the abdomen). This pain is characteristically reflected in the shoulder.
Pregnant patients with abdominal pain need special treatment, which should also be examined by a gynecologist. Special treatment is also required in pediatric patients, who readily complain of "tummy" pain without giving specific descriptions or cooperating during physical examination. Mesenteric lymphadenitis involves swelling of the lymph nodes around the intestine and often causes pain similar to that of appendicitis. Endurance runners experience pain that returns intermittently and is very difficult to diagnose.
In order to help with the diagnosis, your doctor will order certain tests, which usually include: complete blood count, erythrocyte sedimentation rate, CRP, liver enzymes, complete urinalysis, and an upper abdominal ultrasound. Depending on the findings, your doctor may order a chest x-ray, abdominal CT scan and/or colonoscopy. If biliary problems are suspected, magnetic cholangiography and ERCP can help significantly. The last examination can be in addition to diagnostic and therapeutic.
"It Hurts Down Right"
Pain in the right lower abdomen accounts for 50% of all cases of acute abdomen (very severe abdominal pain). Pain in the right lower abdomen immediately raises the suspicion of appendicitis. Appendicitis is more common in men and can manifest in a variety of ways, as a result of which its surgical treatment (appendicectomy) is often delayed. However, there are many other diagnoses that the physician should consider in the patient who presents with pain in the right side of the abdomen. Assessing abdominal pain in children can be extremely difficult. Abdominal pain during pregnancy also causes problems due to changes in normal anatomy and displacement of organs from the pregnant uterus.
And in this case the surgeon will isolate the cause based on the history, clinical examination and any laboratory or imaging tests. Appendicitis pain can start around the navel and then move down to the right iliac fossa. When did it start? Did it start suddenly or gradually? Is it continuous or does it come and go? Does it feel like a stab, a burn, or is it deeper? Are there factors that make it better or worse? Does it extend to the back, to the ge****ls (renal colic), or to the shoulder (diaphragmatic irritation from splenic rupture)? Remember to tell your doctor about accompanying symptoms such as anorexia, nausea or vomiting. Also report any fevers, change in your body weight, bowel habits, stool color and consistency, any urinary symptoms and if you are a woman any vaginal discharge. State whether you are a smoker or a frequent drinker of alcohol. Describe your health history. Remember to list all medications you are taking. Finally, remember if there are chronic illnesses in the family. After taking a history the doctor will examine you and look for signs that will lead him to the diagnosis.
Gastrointestinal causes of right abdominal pain include acute appendicitis, Crohn's disease, mesenteric lymphadenitis, diverticulitis, Meckel's diverticulum, perforated stomach ulcer, right inguinal or femoral hernia, certain colon neoplasms leading to rupture. It is not always easy to diagnose these diseases. for example in acute appendicitis the pain may not be typical if the appendix has a retrocaecal position (ie when it is 'hidden' behind the large intestine). An inflamed appendix needs urgent treatment (appendicectomy) because if it ruptures, we may have germs spread throughout the abdomen (generalized peritonitis). The terminal ileum (the end of the small intestine before the large intestine) is a common site of ulceration of Crohn's disease and therefore may mimic appendicitis. Mesenteric lymphadenitis affects children more often. It is caused by viruses and some bacteria. It can also be found in adults but is more common in patients under 15. It is often accompanied by fever, swollen lymph nodes in the neck and high white blood cell counts. If a laparoscopy is performed, swollen lymph nodes in the mesentery (fatty 'curtain' that supports and supplies the intestine) are found without any other pathology. Diverticulitis most often affects the left colon, but on the one hand it can also be found in the right colon, on the other hand it can involve a long sigmoid extending into the right abdomen. Diverticulae may rupture causing peritonitis. Meckel's diverticulum is a conge***al anomaly that occurs in 2% of the population. When the diverticulum becomes inflamed it can mimic appendicitis. A perforated peptic ulcer usually causes pain in the upper abdomen, but the release and accumulation of gastric fluids in the right abdomen can cause pain in the lower right. A tight right inguinal hernia or femoral hernia causes severe pain in the lower right. In these cases the pain is accompanied by a swelling above the mouth of the hernia and there may be symptoms of intestinal obstruction such as gas and stool retention, abdominal distension and vomiting. These patients should be taken directly to the operating room for surgical reduction and plastic repair of the hernia. Some colon neoplasms may present with lower right pain due to rupture and peritonitis. Patients with irritable bowel (spastic colitis) usually have chronic discomfort.
The gynecological causes of pain in the lower abdomen must always be taken into account and a gynecologist's opinion should be sought in case of strong suspicion. Pelvic inflammatory disease - salpingitis - pelvic abscess usually presents with increased vaginal discharge. Patients at increased risk of pelvic inflammatory disease are those with a history of multiple s*xual partners, previous pelvic inflammatory disease, and a history of intrauterine device placement. Ectopic pregnancy in the right fallopian tube more often causes pain and less vaginal bleeding. These women should be taken directly to the operating room for laparoscopic exploration because bleeding in ectopic pregnancy must be controlled immediately. Torsion is usually caused when an o***y becomes too large due to a cyst. Diagnosis can be difficult. There will be tenderness in the internal ge***al area. Ovarian pathology can be seen on ultrasound. Miscarriage in a pregnant woman may be accompanied by abdominal pain, and in this case, the patient should be checked with a pregnancy test and ultrasound. Ectopic pregnancy should be ruled out in this case as well. Many women experience severe pain in the middle of the menstrual cycle (Mittelschmerz). Other gynecological causes of right abdomino-pelvic pain are degenerating uterine fibroids, multiple adhesions from previous operations, and certain pelvic tumors. Patients with endometriosis usually have chronic discomfort.
Urological diseases that cause pain in the right lower abdomen are usually accompanied by transient and sudden pain. An impacted stone can cause microscopic hematuria. 70% of these stones are visible on plain abdominal x-ray. Ultrasound remains a valuable diagnostic tool. UTIs cause frequent urination, dysuria, hematuria, urge to urinate, and foul-smelling urine. Testicular torsion and epididymitis or orchitis can cause lower abdominal pain. The testicle will have intense sensitivity in these cases.
Other causes of pain in the lower right abdomen are various microbes that cause inflammation of the ileum. Shingles infection can cause pain accompanied by a characteristic rash. Abdominal aortic aneurysm can present with atypical symptoms. The doctor will look for a pulsating mass in the abdomen on palpation.
A history of groin surgery may be associated with chronic pain and should always be considered.
Dr. Hirides and his scientific team with 21 years of experience in surgery, are able to treat almost all surgical diseases related to abdominal pain with minimally invasive techniques (laparoscopic and robotic surgery) with excellent results. The correct diagnosis and the appropriate indication for the rational use of these techniques by experienced hands are important.
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