Site & Sign of Abdomen Pain

Site & Sign of Abdomen Pain

हिंदी के लिए यहां क्लिक करें

    <h4><strong><img src="" alt="" width="150" height="150" />Definition: </strong>Discomfort or pain in the region of the abdominal wall or abdominal cavity.</h4><h4><b>Aetiology</b></h4><ul><li>Oesophageal : Hiatus Hernia, Reflux, Oesophagitis, Tumours, Ulcers</li><li>Gastro-duodenal : Gastritis, Ulcers, Tumours</li><li>Pancreatic : Pancreatitis, Malignancy</li><li>Hepatobiliary : Cholelithiasis, Infection (e.g.Hepatitis, Cholecystitis), Biliary Tract Obstruction, Tumours (benign or malignant)</li><li>Cardiorespiratory : Inflammation (e.g.Pneumonia, Pleurisy), Ischaemic heart disease, Carcinoma, Pneumothorax, Pulmonary Embolism</li><li>Intestinal : Inflammatory (e.g.ulcerativecolitis, Crohn's disease, Appendicitis, Diverticulitis), Tumours, Intestinal obstruction, Irritable Bowel Syndrome, Malabsorption syndromes</li><li>Renal : Ureteric Calculus, Pyelonephritis, Cystitis, Tumours</li><li>Gynaecological : Endometriosis, Infections (e.g.Salpingitis, Endometritis), Dysmenorrhoea, Ectopic Pregnancy, Ovarian Cysts (from haemorrhage, Torsion, Rupture, Infection), Tumours</li><li>Testes/Epididymis : Epididymitis, Orchitis, Epididymo-orchitis, Torsion of Testes</li></ul><h4><b>Pathophysiology:  </b>Abdominal pain may be a result of either:</h4><ul><li>Stimulation of pain receptors in the abdominal wall</li><li>Neural irritation.</li><li>Referred pain from another source.</li><li>Pathological processes which cause stimulation of pain receptors in the parietal peritoneum.</li><li>The parietal peritoneum is innervated by somatic sensory fibres. Therefore, pain arising from damaged or inflamed parietal</li><li>Pathological processes which cause stimulation of pain receptors in an abdominal viscus.</li><li>Visceral pain is caused by stretching or inflammation of intra-abdominal organs such as gut, gallbladder, bile duct, pancreas, ureters and uterus. Stimulation of pain receptors does not occur with every type of pathology. Common stimuli causing visceral pain include: Distension of the wall of a hollow viscus; a build-up to metabolites in a tissue as a result of ischaemia; acute stretching of the capsule of a solid viscera; tension on the mesentery;or exaggerated contraction of a hollow viscus.</li></ul>Depending on the cause, visceral pain can be described as deep. continuous, dull ache/gnawing or intermittent cramping sensation. Visceral pain tends to be perceived near the midline, irrespective of the location of the organ.This is because the afferent fibres of the autonomic nervous system that carry pain impulses into the brain from the abdominal organs and visceral peritoneum are poorly mapped in the brain.This explains why the pain can usually(but not always)be localised to the epigastric, periumbilical or suprapubic areas.

Pain arising from:

  • Foregut(stomach and duodenum)is felt in the Epigastrium
  • Midgut(small intestine and proximal colon)is felt in the peri-umbilical region
  • Hindgut(distal colon)in felt in the suprapubic area.

Discriminating features





Pain in iliac fossa in middle of menstrual cycle

‘Ovulatory pain


Pain worse on movement,coughing.sneezing.etc.

Inflamed peritoneum or abdominal wall pathology or referred pain from vertebrae


Pain accompanied by constant writhing and movement of patient

Obstruction of a hollow viscera


Burning pain,in a dermatomal distribution,with sensitivity of skin to touch.

Neurogenic cause of pain (e.g.herpes zoster)or referred pain from vertebrae


Pain accompanied by dysuria, frequency,pyuria,etc.

Urinary tract disorder


Localised pain with tenderness on palpation,guarding and rigidity

Localised inflammation of parietalperitoneum (e.g.appendicitis)


Pain over entire abdomen plus tenderness,guarding and rigidity

Generalised peritonitis


Pain improved by leaning forward

pancreatic pathology or musculoskeletal disorder


Pain better with lying still

Inflamed peritoneum


Pain prior to or accompanying menses



Upper abdominal pain in conjunction with respiratory symptoms,no tenderness, but worse on deep inspiration

Referred pain from                 thorax (e.g.pneumonia)


Pain in abdomen and pain or discomfort in scrotum/testes

Referred pain from genitalia                                                          

(e.g.torsion of testes)


Pain around umbilicus

Small intestinal pathology or pathology from parts of the large intestine that are

derived from the midgut (i.e.proximal parts)


Pain in upper abdomen radiating through to the back.                                

Pancreatic disease


Pain in upper abdomen on right side radiating around to the back and between

the scapulae

Gall bladder/biliary tract disease


Miscarriage (Spontaneous Abortion)

Miscarriage (Spontaneous Abortion)


miscarriage is the loss of your products of conception before the twentieth week of pregnancy. The loss of products of conception after 20 weeks is called a stillbirth. About 20-30% of women bleed or have cramping at some time during the first 20 weeks of pregnancy and half of these women have a spontaneous miscarriage. About 85% of spontaneous abortions occur in the first trimester and tend to have fetal causes; those occurring in the second trimester are more likely to have maternal causes.


  • Abnormalities in embryo or foetus.
  • Inadequate level of maternal hormones needed to assure fetal viability

  • Maternal factors:

    • Autoimmune disorders
    • Systemic disease: e.g.Diabetes Mellitus, Thyroid disorders, Coeliac disease, Polycystic ovarian syndrome
    • Blood Dyscrasias
    • Nutritional, e.g. vitamin deficiencies (especially vitamin D)
    • Maternal chromosomal anomalies, e. g. Translocations, deletions
    • Incompetent, amputated or lacerated cervix
    • Uterine Abnormalities
    • acute infections
    • Specific viral illnesses, e. g. Rubella, herpes, cytomegalovirus, toxoplasmosis
    • Severe emotional shock
    • Physical trauma.


  • Early- Loss of fetus before 12 weeks of pregnancy.
  • Late-Loss of the fetus between 12 and 20 weeks of preg.
  • spontaneous- Loss of foetus without induction or instrumentation.
  • Induced- termination of pregnancy for medical or elective reasons
  • Therapeutic- Termination of pregnancy to preserve the woman life or health or because of foetal malformations incompatible with life.
  • Threatened- Any vaginal bleeding or lower abdominal cramping in the first 20 weeks of pregnancy.
  • Inevitable- Bleeding or rupture of the membranes accompanied by pain and dilation of the cervix.
  • Incomplete- Expulsion of part of the products of conception.
  • Complete- Expulsion of all the products of conception.
  • Habitual- Three or more consecutive spontaneous abortions.
  • Missed- Prolonged delay in the expulsion of a dead fetus.
  • Septic- Infection of the contents of the uterus before, during or after a spontaneous abortion.
Hypertension: Causes & Classification

Hypertension: Causes & Classification


               Hypertension is defined as an abnormal, persistent, elevation of systolic and/or diastolic blood pressure above the generally accepted normal level of up to 140/90 mmHg for adults.

Note:   Exercise, anxiety, discomfort and unfamiliar surroundings can all lead to a transient rise in blood pressure, and measurements should be repeated when the patient is resting and relaxed. For example, office or white coat hypertension refers to blood pressure that is consistently elevated in the physician’s surgery, but normal when measured at home. Patients who have high blood pressure on the first examination, but who subsequently settles with rest, may not require treatment. However, they should be kept under review because they are more likely to develop sustained hypertension. It has been estimated that approximately 15% of the general population can be regarded as hypertensive, although only a proportion of these will be diagnosed or receive treatment.

Factors influencing blood pressure

Blood pressure (BP) is influenced by three major factors: blood volume, cardiac output, and peripheral resistance.

Blood pressure=Cardiac output x peripheral resistance

Cardiac output = heart rate x stroke volume


Aetiological classification:  90 Percent of cases are primary hypertension (aka essential hypertension, idiopathic hypertension) i.e. the cause is unknown, many risk factors have been identified. These include-

  • Genetic influences
  • Environmental factors,e.g. salt intake, inactivity, cigarette smoking, obesity
  • Hormonal influences
  • Neurogenic influences, e.g, anxiety.

10% of cases are secondary hypertension, Aetiology is unknown.

Clinical classification:

  • 95%of cases are benign hypertension: long course and generally compatible with a long life.
  • 5% of cases are malignant hypertension: short course and may kill a patient in months.

Common Causes

  • Stress
  • Anxiety.

Other causes

  • Endocrine Disease e.g. Cushing’s disease, Conn’s syndrome, phaeochromocytoma, hyperthyroidism.
  • Renal diseases, e.g, glomerulonephritis, chronic pyelonephritis, diabetic nephropathy, polycystic disease, renal vascular disease, obstruction, collagen diseases
  • Pregnancy, e.g. pre-eclampsia, eclampsia
  • Co-arctation of the aorta.
  • Neurogenic causes, e.g. increased intracranial pressure, hypothalamic lesions, head injury, brain stem disorders
  • Some insect and spider bites
  • Concurrent use of medication e.g. anti-inflammatories, steroids, salt tablets, etc.
  • High salt diet.




Back pain: Causes

Any pain in the posterior part of the trunk. Pain in the cervical spine region is referred to as neck pain, pain in the thoracic region is referred to as upper back pain, and pain in the lumbosacral region is known as lower back pain.

Aetiology: Classified by pathologies

  • Traumatic -e.g.Muscle strain, joint damage, fractures, ligamentous sprains
  • Structural Alterations-e.g. Scoliosis, Degenerative changes
  • Inflammatory-e.g. Pancreatitis, Acute pyelonephritis, Arthritides
  • Infections- e.g. Osteomyelitis, spinal abscesses, pelvic infection, Renal infections
  • Degenerative- e.g. Osteoarthritis
  • Hormonal- e.g. Dysmenorrhoea, premenstrual syndrome
  • Metabolic Alterations- e. g. osteoporosis, osteomalacia, Paget disease
  • Activity related: Prolonged periods of recumbency or inactivity
  • Psychogenic- e. g. Stress-related muscle contraction

Classified by Anatomy:

  • Disorders of the vertebral column- Disc protrusion, Fractures, Spondylosis, Spondylolisthesis, Intervertebral disc disease, Spinal stenosis, Inadequacies of the vertebral column supporting structures (e. g. Ligaments, bones), bony tumors, Scheuermann’s disease, ankylosing spondylitis, osteomyelitis, other arthritides (e.g.osteo- arthritis, rheumatoid arthritis), facet joint disorders, disorders of sacrum (e. g. sacroiliitis), disorders of the coccy× (e. g. coccydynia)
  • Disorders of Paravertebral muscle and/or myofascial tissue: strains, sprains, muscle spasm, myositis, inflammation of fascial attachments
  • Disorders of Anterolateral Abdominal wall e. g. Trauma, postsurgical
  • Disorders of Anterior Thoracic structures: see Upper back pain
  • Disorders of the digestive system- Oesophageal, gastric/duodenal, pancreatic, gall bladder, intestinal, severe constipation or feacal impaction, following prolonged vomiting or diarrhea
  • Disorders of urinary system calculi, neoplasms, infections
  • Disorders of cardiovascular system ischaemic heart disease
  • Disorders of the nervous system.
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Tuberculosis: RNTCP

Tuberculosis: RNTCP

Tuberculosis and Revised National TB Control Programme (RNTCP)

TB is one of the most prevalent chronic infection in our country and is responsible for high morbidity and mortality.
TB is caused by Mycobacterium tuberculosis and affects the lungs most commonly. in one third or more, extrapulmonary involvement is seen.
tubercular lymphadenopathy is the commonest form of extrapulmonary tuberculosis.
all cases of TB is a notifiable disease should be reported to the local /district/ State Health authorities, as it is a notifiable disease.


  • pulmonary TB usually presents with fever, malaise, chronic cough with sputum production, anorexia, and weight loss.
    *sometimes chest pain and hemoptysis may be the presenting symptoms.
    *extrapulmonary tuberculosis presents most commonly as prolonged FEVER and cervical, mediastinal or mesenteric lymphadenopathy.
    *abdominal tuberculosis may present as Ascites, chronic abdominal pain, diarrhea, recurrent subacute intestinal obstruction, etc.
    *CNS tuberculosis presents as irritability, headache, vomiting, chronic meningitis, seizures or focal neurological deficits, altered sensorium.
  • skeletal tuberculosis they present as POTT’s spine, tuberculous osteomyelitis, monoarticular arthritis.
    *Tubercular constrictive pericarditis presents with edema/ ascites.
    *symptoms Of genitourinary TB include tubo-ovarian masses, secondary amenorrhea
    in women, chronic epididymo orchitis in men and painless hematuria in both the sexes.
  • definite diagnosis is made an only by the demonstration of AFB on smear or culture of the bottom of bronchial secretions.
    chest cardiograph nearly localised the site of Pathology and does not define an aetiology.
    there are no pathognomonic radiological signs of Tuberculosis.the test is sensitive but less specific with higher inter and intra reader variation, should be used judiciously. definitely diagnosis of extrapulmonary Tuberculosis is made on the basis of FNAC or findings of TCS granuloma with the presence of FB in the tissue, fluid cystology, biochemical analysis and smear examination; although ultrasonography and radiological examination of the system involved are useful investigations. CT scan is rarely necessary and is not caused and radiation effective. chest CT scan, however, may offer and opportunity for CT guided biopsy for tissue diagnosis. Tests not recommended in the diagnosis of Tuberculosis are BCG test, serology (IgM, IgG, IgA antibodies against MTB antigens), PCR test and gene expert.
    childhood tuberculosis is suspected, when an ill child has the history of chronic illness that includes cough and fever, weight loss or failure to thrive, and inability to return to normal health after measles or whooping cough, and history of contact with an adult case of Pulmonary tuberculosis. the diagnosis of Tuberculosis in children is extremely challenging due to relative inability to demonstrate AFB the gold standard.




New case

A patient who has never taken treatment for TB or has taken ATT for less than 1 month.


A patient declared cured of TB by a physician, but who reports back to the

health service and is found to be bacteriologically Positive.


A Patient who received ATT for one month or more from any source and

who returns to treatment after having defaulted, 1. e., not taken ATT

consecutively for two months or more and found to be smear positive.

Treatment failure

A smear-positive patient, who continues to be smear-positive at 5 months

or more after starting treatment. The failure also includes a patient who was initially smear-negative but becomes smear-positive during treatment.

Chronic case

A patient who remains smear-positive after completing the treatment regimen for previously treated but not initiated on MDR-TB treatment.

Other cases

Includes patients who do not fit into the above- mentioned categories.

The reasons for putting a patient in this category must be specified.

Treatment Outcome Cured

Initially, smear-positive who has completed treatment and had negative sputum smears, on at least two occasions one of which was at the completion of treatment.

Treatment completed

Sputum smear-positive case who has completed.





Smear-positive pulmonary TB(PTB)

TB in a patient with at least two initial sputum smear examinations (direct smear microscopy) Positive for AFB,


TB in a patient with one sputum examination positive for AFB and radiographic abnormalities consistent determined by the treating medical officer.


TB in a patient with one sputum specimen positive for AFB and culture positive for M tuberculosis.

Smear-negative pulmonary tuberculosis

TB in a patient with symptoms suggestive oF TB with at least 3 sputum examinations negative for AFB, and radiographic abnormalities consistent

with active pulmonary TB as determined by an MO, followed by a decision to treat the patient with a full course of anti-tubercular therapy (ATT),

Or :

Diagnosis based on a positive culture but the existence of negative AFB sputum examinations.

Extrapulmonary tuberculosis (EPTB)

TB of organs other than the lungs, such as the pleura (TB pleurisy), lymph nodes, abdomen,

genitourinary tract, skin, joints and bones, tubercular meningitis,

tuberculoma of the brain, etc. The diagnosis should be based on one culture-positive specimen for an extra-pulmonary site, or histological evidence, or strong clinical evidence consistent with active extrapulmonary TB, followed by MO’s decision to treat with a full course of anti-TB therapy. A patient diagnosed with both pulmonary and extrapulmonary TB should be classified as a case of pulmonary TB. pleurisy is classified as an extrapulmonary TB.





An initially smear-positive Patient, who has completed the treatment and has negative sputum smears On at least 2 occasions (one of which is at completion of treatment.

Treatment completed

A sputum smear-positive case who has completed the treatment, with negative smears at the end of intensive phase but none at the end of


Or :

A sputum smear-negative smears at the end of the intensive phase but none at the end of treatment.


An extrapulmonary TB patient who has received a full course of treatment

and has not become smear-positive during or at the end of treatment


A patient who died during treatment, regardless of the cause.


A smear-positive patient who continues to be smear positive at 5 months or more after starting treatment. The failure also includes a patient who

was initially smear-negative but becomes smear-positive during treatment.


A patient who, at any time after registration has not taken ATT for two months or more consecutively.

Transferred out

A patient has been transferred to another tuberculosis unit/district and Ms/her treatment results are not known.

Switched over to MDR-TB treatment

A patient who has been diagnosed as having MDR-TB by an RNTCP-MDR-TB

Accredited lab prior to being declared as”failure” and is placed on MDR treatment.

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