Case Answers:
Case answers will be presented after review of the HPI.
Answer 1
The student should be able to discuss the three sources of abdominal pain:
Visceral, Somatoparietal, and Referred. Visceral pain comes from the solid and the hollow
viscera of the GI tract. Pain from a solid organ like the liver is described as dull,
constant and associated with a variety of autonomic symptoms like nausea. Pain from the
hollow viscera is described as colicky and intermittent. The pain is not localized. A good
example is that of bowel obstruction. Somatoparietal pain is usually steady and aching in
character and located over the area that is inflamed. Examples would be appendicitis in
the RLQ and diverticulitis in the LLQ. This type of pain is accentuated by sudden change
in tension of the peritoneum as caused by cough, sneeze, or movement. The patient with
peritoneal irritation lies quietly and usually does not writhe around. Referred pain
describes pain in remote areas from where the primary disease process is located. The
cutaneous dermatomes are involved in this process. Examples would be right shoulder and
scapular pain in gall bladder disease.
Answer 2
Impress upon the student the need for careful, accurate medical histories in the
patient with abdominal pain. A reasonable differential diagnosis should be arrived at
after a careful history.
Answer 3
Students should be able to discuss the difference between the acute abdominal
presentation and patients with acute/chronic abdominal pain that is not of an emergent
nature. Stress to the students that acute abdominal pain should never be evaluated over
the telephone.
Answer 4
The patient has gallbladder/biliary tract pain and the differential diagnosis
should focus on this etiology.
Answer 5
The patient should have an ultrasound examination of the gallbladder/biliary tree
which should reveal the diagnosis and should be referred for cholecystectomy
(laprascopic). ERCP and Nuclear Medicine biliary scans are not necessary for this patient.
ERCP considered for those patients with suspected common duct stones and nuclear scans for
those with cholecystitis when ultrasound is not revealing.