Abdominal syndrome: causes, symptoms and treatment features. Abdominal ischemic syndrome: causes, symptoms, principles of treatment

Abdominal syndrome is one of the most important and frequent clinical manifestations of most diseases of the gastrointestinal tract. But unlike many other pathologies, it is impossible to “get sick” in the usual sense of the word. After all, abdominal syndrome is actually the pain that we feel. It can be different (for details, see the relevant section): acute, blunt, pulling, cramping, girdle and point. Unfortunately, it is impossible to consider pain as an objective criterion. Therefore, the attending physician often faces the need not only to explain the causes of its occurrence, but also to alleviate the patient's condition in the absence of a confirmed diagnosis.

However, in addition to the obvious difficulties associated with subjective sensations, abdominal syndrome (AS) differs from other similar conditions in a confusing and difficult to understand classification. Firstly, the validity of such a diagnosis in any acute conditions (appendicitis, ulcer perforation, cholecystitis attack) is rather doubtful. Secondly, it should be clearly understood: AS, which we will talk about today, is not at all the same as abdominal ischemic syndrome (AIS, chronic abdominal ischemia syndrome). After all, AIS is a long-term developing, chronic insufficiency of blood supply in various parts of the abdominal aorta. Thirdly, many domestic doctors treat AS with some prejudice, not considering it an independent nosological unit. The main argument is the interpretation of the subjective complaints of the patient, because many of them (especially when the issue concerns children) are unable to explain in words what worries them. Yes, and “concerned” mothers who demand (!) To diagnose their child with “abdominal syndrome”, if it has eaten too much sweets or unripe apples, are unlikely to cause a surge of positive emotions in the doctor.

The topic “ARVI and abdominal pain syndrome in children” deserves special mention. What could be the connection between an acute respiratory viral infection and pain caused by pathology of the gastrointestinal tract, you ask? To be honest, we ourselves did not immediately understand this. But after digging through specialized forums, we found out that such a diagnosis in our area is very popular. Formally, he has the right to life, but most practicing doctors who are responsible for their work are sure that in this case, district pediatricians are trying to avoid mentioning acute intestinal infection (AII) in the medical record. It is also possible that such an "ARVI" means hidden appendicitis. “Treatment”, of course, will give a result. The patient will most likely stop coughing, but will be on the operating table very soon.

The reasons

There are quite a lot of diseases that can provoke the occurrence of AS, because pain can be accompanied by almost any violation of the normal functioning of the gastrointestinal tract. But before proceeding directly to the causes of the syndrome, an important clarification should be made regarding pain receptors located in the abdominal cavity. The fact is that their sensitivity is quite selective, because many types of irritating effects can be completely invisible to the patient. But cuts, ruptures, stretching or squeezing of the internal organs lead to a surge in pain.

What does it say? Unfortunately, in the case of AS, it is no longer possible to perceive pain as an indicator of the state of the body, since the nature and type of “pleasant” sensations in the general case do not depend much on the cause that causes them. Because of this, with a superficial, formal examination of many patients (especially for children), the doctor can “look through” a life-threatening condition, limiting himself to prescribing harmless antispasmodics. Which, as you might guess, in the case of appendicitis or intestinal obstruction, will not be able to bring any real benefit. The reasons themselves are divided into two types:

Intra-abdominal (located in the abdominal cavity)

1. Generalized peritonitis, which developed as a result of damage to the membrane (perforation) of a hollow organ or an ectopic pregnancy

2. Inflammation of organs caused by:

cholecystitis;
diverticulitis;
pancreatitis;
colitis;
pyelonephritis;
endometriosis;
appendicitis;
peptic ulcer;
gastroenteritis;
pelvic inflammation;
regional enteritis;
hepatitis;
lymphadenitis.

3. Obstruction (obturation) of a hollow organ

intestinal;
biliary;
uterine;
aortic;
urinary tract.

4. Ischemic pathologies

heart attacks of the intestines, liver and spleen;
mesenteric ischemia;
organ torsion.

5. Other reasons

retroperitoneal tumors;
IBS - irritable bowel syndrome;
hysteria;
withdrawal after drug withdrawal;
Munchausen syndrome.

Extra-abdominal (located in the abdominal cavity)

1.Diseases of the chest organs

myocardial ischemia;
pneumonia;
pathology of the upper esophagus.

2. Neurogenic diseases

shingles (Herpes zoster);
syphilis;
various problems with the spine;
metabolic disturbances (porphyria, diabetes mellitus).

Symptoms

The main (and perhaps the only) manifestation of AS is pain. Adults can still more or less clearly describe their feelings, but with regard to children (especially small ones), one cannot count on such “cooperation”. And if a child is brought to a pediatrician in a district clinic, whose only complaint is “it hurts somewhere in the tummy”, it can be quite difficult to identify the root cause of the problem. As a result, parents receive a medical card with the entry “abdominal syndrome in ARVI” (we talked about this a little higher) in their hands and are taken to treat a cold.

The nature of pain in AS and possible causes of their occurrence

1. The attack occurs and develops rapidly, the pain is very intense

rupture of an aneurysm of a large vessel;
myocardial infarction (sometimes it happens in children);
renal or biliary colic (occur during the passage of stones).

2. The level of pain syndrome reaches its maximum in a few minutes, remaining at the peak for a long time

total intestinal obstruction;
acute pancreatitis;
thrombosis of mesenteric vessels.

3. The attack develops quite slowly, but can last for many hours

diverticulitis;
acute cholecystitis or appendicitis.

4. Colicky or intermittent abdominal pain

small bowel mechanical obstruction;
subacute pancreatitis in the early stages.

Approximate localization of the attack and the organs that could provoke it

1. Right hypochondrium

gallbladder;
12 duodenal ulcer;
hepatic angle of the colon;
ureter and right kidney;
liver;
bile ducts;
head of the pancreas;
abnormally located appendix;
pleura and right lung.

2. Left hypochondrium

tail of the pancreas;
splenic angle of the colon;
ureter and left kidney;
stomach;
spleen;
pleura and left lung.

3. Epigastric region (area under the xiphoid process)

liver;
stomach;
lower parts of the esophagus;
pancreas;
esophageal opening of the diaphragm;
bile ducts;
stuffing box;
organs located directly in the chest;
celiac plexus.

4. Right iliac region

terminal portion of the ileum;
ureter and right kidney;
appendix;
terminal section of the ascending and blind colon;
right uterine appendages.

5.Left iliac region

ureter and left kidney;
sigmoid and descending colon;
left uterine appendages.

6. Umbilical area

transverse colon;
pancreas;
small intestine;
appendix in the medial location;
peritoneal vessels.

7. Pubic and inguinal areas

pelvic organs;
bladder;
rectum.

Possible types of pain

1. Colic (spastic pain)

arise due to spasm of the smooth muscles of the excretory ducts and hollow organs (stomach, gallbladder, pancreatic duct, esophagus, intestines, bile ducts);
can manifest itself in various pathologies of internal organs (colic and spasms of various etiologies), poisoning or functional diseases (IBS - irritable bowel syndrome);
appear and disappear suddenly, the use of antispasmodics significantly reduces the intensity of the attack;
may radiate to the back, lumbar region, shoulder blades, or legs;
the patient shows signs of nervous excitement and anxiety;
forced, often unnatural, position of the body;
the most characteristic clinical manifestations: vomiting, rumbling in the abdomen, nausea, flatulence, fever, chills, discoloration of feces and urine, constipation, diarrhea;
after the passage of gases and bowel movements, the pain often decreases or disappears.

2. Arising due to tension of the ligamentous apparatus of hollow organs and their stretching

rarely when they have a clear localization;
are distinguished by a pulling, aching character.

3. Dependent on various disorders of local circulation (congestive and ischemic pathologies in the vessels of the abdominal cavity)

paroxysmal nature of the pain syndrome with a slow increase in severity;
the most likely causes: spasm, stenotic lesion of the abdominal aorta (most often congenital or atherosclerotic), embolism and thrombosis of intestinal vessels, stagnation of blood in the inferior vena cava and portal veins, microcirculation disorders.

4. Peritoneal pain (the so-called "acute abdomen": peritonitis, acute pancreatitis)

because of the transience they pose a real threat to the life of the patient;
are explained by severe structural changes in internal organs (ulcers, inflammation, malignant and benign neoplasms);
the level of pain is exceptionally high, even more aggravated by coughing, palpation and any change in body position;
characteristic symptoms: unsatisfactory general condition, tension in the muscles of the anterior abdominal wall, severe vomiting.

5. Reflected (mirror) pain

the approximate localization of the attack cannot be "tied" to any organ;
diseases and pathologies that can provoke referred pain: pneumonia, pulmonary embolism, pleurisy, porphyria, poisoning, myocardial ischemia, pneumothorax, insect bites;
in some cases, they can mean the terminal stage of the development of malignant neoplasms (the so-called neoplastic syndrome).

6. Psychogenic pain

objectively not associated with any problems in the internal organs;
most often such pains are explained by psycho-emotional stress, severe nervous exhaustion or even chronic fatigue;
the intensity of the attack to a greater extent depends on the psychological state of the patient, and not on the individual characteristics of his body;
the nature of the pain is long and monotonous, and often unpleasant sensations remain after the elimination of the causes that caused them.

Symptoms requiring emergency hospitalization

Diagnostics

AS is a classic example of how a formal approach to a patient can lead to big problems. When the only complaint is pain (especially for children), the doctor is faced with a difficult task: he is forced to explain to the patient that the appointment of certain painkillers is not a cure, but only relief of symptoms. The correct approach will be, as we have already found out, in the search for the causes that caused the pain. But the realities of our life are such that from the clinic the patient most often goes to the pharmacy for analgesics or antispasmodics.

What measures can be taken to make the correct diagnosis?

1. Laboratory research

clinical analysis of urine is not the main one in this case, but, nevertheless, it will help to identify pyelonephritis, infection of the urinary tract and urolithiasis;
a blood test may indicate a possible leukocytosis (a frequent companion of diverticulitis and appendicitis), but even normal test results are not able to exclude infection or inflammation;
liver tests will give an idea about the state of the liver, pancreas and gallbladder (the most informative indicators are the level of lipase and amylase).

2. Instrumental methods

Differential Diagnosis

AS should be distinguished from acute conditions similar in clinical manifestations:

perforated ulcer of the duodenum or stomach (sudden sharp pain in the epigastrium);
acute cholecystitis (systematic pain attacks in the right hypochondrium);
acute pancreatitis (girdle pain, accompanied by uncontrollable vomiting);
renal and hepatic colic (sharp cramping pains);
acute appendicitis (at first - pain without a pronounced localization, but after 2-3 hours it migrates to the inguinal region);
thromboembolism of mesenteric vessels (sudden onset of pain without clear localization);
exfoliating aneurysm of the abdominal aorta (sharp pain in the epigastrium against the background of severe atherosclerosis);
pleurisy and lower lobe pneumonia (signs of acute pneumonia).

Treatment

Therapy of abdominal syndrome is a rather complicated task. If the underlying cause of AS cannot be identified (this sometimes happens), doctors have to look for ways to stop the pain attack. It should be taken into account that the use of traditional analgesics is generally not recommended due to the high probability of blurring the clinical picture of the disease. Therefore, the following groups of drugs are considered the most effective means of treatment today:

Any pain is a warning signal that indicates the appearance of some kind of malfunction in the body. Accordingly, this kind of discomfort should not be ignored. This is especially true of the symptoms that develop in children, since it can indicate the most serious violations of the body's activity, including those that require emergency care. A fairly common symptom of this kind is considered to be abdominal pain, in other words, abdominal pain. Let's talk about the diversity and specificity of complaints of this kind in a little more detail.

Abdominal pain syndrome in children often causes parents to visit doctors, and may be an indication for hospitalization in an inpatient department. The appearance of such an unpleasant phenomenon can be explained by a variety of factors - from SARS and up to surgical pathologies.

Diagnostics

In the last ten years, the main assistance in clarifying and even establishing the correct diagnosis for abdominal pain syndrome in pediatric practice has been an ultrasound examination of the peritoneal organs, as well as the retroperitoneal space.

No special preparatory measures are needed for the implementation of ultrasound. Children usually skip one feeding. Young children should pause for three to four hours, schoolchildren under ten years old will have to fast from four to six hours, and older ones - about eight hours. In the event that it is not possible to carry out an ultrasound scan in the morning on an empty stomach, it is allowed to be performed later. However, at the same time, certain foods should be excluded from the child’s diet - butter and vegetable oil, eggs, fruits and vegetables, sour-milk products, seeds and various frankly unhealthy foods. In the morning, you can give the patient a little lean boiled meat or fish, buckwheat porridge and some unsweetened tea.

The reasons

Abdominal syndrome in children at an early age can be triggered by excessive gas formation - flatulence, which causes intestinal colic. In rare cases, such a nuisance is fraught with the development of intestinal intussusception, requiring immediate hospitalization. In addition, at an early age, ultrasound helps to detect abnormalities in the structure of organs.

In school-age children, complaints of abdominal pain are often a sign of a chronic variety of gastroduodenitis. In addition, they may indicate dyskinesia and reactive changes in the pancreas. In this case, the doctor will select the appropriate treatment for the child, which will eliminate the symptoms and lead to recovery.

Among other things, quite often abdominal pain syndrome in children develops due to acute or chronic diseases of the kidneys or bladder. Accordingly, an important role is played by the examination of the urinary system. Ultrasound of these organs is carried out twice - with a well-filled bladder and shortly after emptying it.

It is also necessary to take into account the fact that abdominal pain may be a consequence of the formation of the menstrual cycle. In this case, their appearance is often explained by the occurrence of functional ovarian cysts, which require systematic monitoring by ultrasound, and usually disappear on their own.

Acute pain in the abdomen that develops at night often causes the child to be hospitalized in the surgery department, where he is already undergoing a mandatory ultrasound. So a similar symptom is often explained by the appearance of an acute surgical pathology, for example, acute appendicitis, intestinal obstruction (mechanical or dynamic type), intestinal intussusception, etc. Such conditions require immediate surgical intervention.

Sometimes nocturnal abdominal pain syndrome indicates the appearance of changes in internal organs that can be corrected by conservative methods and do not require hospitalization.

In rare cases, the occurrence of pain may also indicate the development of neoplasms. Such diseases require prompt diagnosis and immediate treatment. Again, ultrasound and a number of other studies will help to identify them.

Treatment

Therapy of abdominal pain syndrome in children depends directly on the causes of its development. Parents are strongly discouraged from making their own decision and giving the child some painkillers, antispasmodics, etc., since such a practice is fraught with serious consequences. It is better to play it safe and once again seek medical help.

Additional Information

With the development of abdominal pain syndrome in pediatric practice, the main difficulty for correct diagnosis is the difficulty in describing the child's sensations, localization of pain, their intensity and irradiation. According to doctors, little children very often describe any discomfort that occurs in the body as abdominal pain. A similar situation is observed when trying to describe a feeling of dizziness, nausea, painful sensations in the ears or head that the child does not understand. At the same time, it is extremely important to take into account that many pathological conditions can also manifest as pain in the abdomen, such as diseases of the lungs or pleura, heart and kidneys, as well as lesions of the pelvic organs.

abdominal pain it is pain in the abdomen, a very common complaint in patients. Abdominal pain is one of the most common complaints of patients. It can be completely different: after all, in the abdominal cavity next to each other there are many organs: the stomach, liver, gallbladder, pancreas, intestines, and very close - the kidneys and ovaries. Each of them hurts in its own way and requires its own treatment. In some cases, you can get by with home remedies, and sometimes you need to urgently call an ambulance.

Causes of abdominal pain

There are two most common type of pain:

Spasmodic (convulsive) abdominal pain (colic). It usually manifests itself in undulating attacks, the intensity of which increases or decreases. The pain is caused by deformations in the intestine (stretching or compression), and, as a rule, is a consequence of hyperactive peristalsis. Such pain is caused by excessive gas formation in the intestines, infectious inflammatory processes or stress.

Constant abdominal pain. This type of abdominal pain is characterized by a relatively constant and steady course. Patients often describe it as "burning in the abdomen", sharp, cutting or "hungry" pain. This type of pain is the result of severe inflammation of the abdominal organs, ulcerative lesions, gallstone attacks, abscesses, or acute pancreatitis.

The most dangerous and unpleasant conditions are united in the concept of "acute abdomen" ( acute pancreatitis, peritonitis). The pain is most often intense, diffuse, general health: poor, often the temperature rises, severe vomiting opens, the muscles of the anterior abdominal wall are tense. In this situation, you should not give any painkillers before the doctor's examination, but urgently call an ambulance and be hospitalized in a surgical hospital.

Appendicitis in the early stages is usually not accompanied by very severe pain. On the contrary, the pain is dull, but rather constant, in the lower right abdomen (although it can begin in the upper left), usually with a slight rise in temperature, it can be single vomit. The state of health may worsen over time, and as a result, signs of an “acute abdomen” will appear.

There are also such abdominal pain that are not associated with diseases of the intestines or other internal organs: neurotic pain. A person may complain of pain when he is afraid of something or does not want to, or after some psycho-emotional stress, shocks. At the same time, it is not at all necessary that he feigns, the stomach can really hurt, sometimes even the pain is very strong, resembling an “acute stomach”. But they don't find anything on examination. In this case, you need to consult a psychologist or neurologist. You can also visit a cardiologist if abdominal pain is part of vegetative-vascular dystonia, while the child, in addition to abdominal pain, may have sweating, fatigue, increased heart rate.

Often, abdominal pain is accompanied by other unpleasant symptoms, such as:

sweating;

rumbling (especially when taking a horizontal position or changing position).

Symptoms are important factors indicative of bowel dysfunction, stomach, biliary tract or inflammatory processes in the pancreas. Chills and fever usually accompany dangerous intestinal infections or blockage of the bile ducts. A change in the color of urine and feces is also a sign blockage of the bile ducts. In this case, the urine, as a rule, acquires a dark color, and the feces lighten. Intense cramping pain accompanied by black or bloody stools indicates the presence of internal bleeding and requires immediate hospitalization.

abdominal pain

Intense abdominal pain that keeps you awake at night. It may appear before or after meals. Pain often precedes bowel movements, or manifests itself immediately after the act of defecation. "Cutting" pain, characteristic of intestinal ulcer, manifests itself immediately before eating. Intense pain due to gallstone disease, like pain in pancreatitis, usually develops after eating. The most common causes of abdominal pain are irritable bowel syndrome and biliary dyskinesia.

For people suffering from irritable bowel syndrome, the onset of pain immediately after eating is characteristic, which is accompanied by bloating, increased peristalsis, rumbling, diarrhea, or a decrease in stool. The pain subsides after defecation and the passage of gases and, as a rule, do not disturb at night. Pain syndrome in irritable bowel syndrome is not accompanied by weight loss, fever, anemia.

Inflammatory Bowel Disease, accompanied by diarrhea (diarrhea), can also cause cramping and pain, usually before or after a bowel movement. Among the sick psychogenic disorders gastrointestinal tract abdominal pain as the leading symptom occurs in 30% of cases.

Diagnostics

The location of the pain is one of the main factors in the diagnosis of the disease. Pain centered in the upper abdomen is usually caused by disorders in the esophagus, intestines, bile ducts, liver, pancreas. The pain that occurs with cholelithiasis or inflammatory processes in the liver is localized in the upper right part of the peritoneum; (may radiate under the right shoulder blade). Ulcer pain and pancreatitis, usually radiates through the entire back. Pain caused by disorders in the small intestine is usually concentrated around the navel, while pain caused by large intestine, are recognized in the middle of the peritoneum and below the navel. Pelvic pain is usually felt as pressure and discomfort in the rectal area.

At abdominal pain syndrome, pain, as a rule, of low intensity, is concentrated in the upper middle part of the abdominal cavity, or in its lower left section. Pain syndrome is characterized by a variety of manifestations: from diffuse dull pain to acute, spasmodic; from permanent to paroxysms pain in the abdomen. Duration of painful episodes from several minutes to several hours. In 70% of cases, the pain is accompanied intestinal motility disorder(diarrhea or constipation).

Treatment

The most common cause of abdominal pain is the food we eat. You should contact gastroenterologist If you:

often experience severe abdominal pain;

observe the loss of your usual weight;

lose your appetite;

suffer from chronic gastrointestinal diseases.

Irritation of the esophagus(pressive pains) caused by salty, too hot or cold food. Certain foods (fatty, cholesterol-rich foods) stimulate the formation or movement of gallstones, causing gallstone attacks. colic. It is no secret that many people have intolerances to certain types of foods, such as milk, milk sugar, or lactose. Eating them leads to spasmodic pains in the abdomen, bloating and diarrhea.

Pain is one of the most frequent and important symptoms of clinical gastroenterology. The biological meaning of pain, according to I.P. Pavlov, is "to reject everything that threatens the life process." As you know, in diseases of the abdominal organs (and, above all, the digestive system), pain occurs due to such causes as spasm of the smooth muscles of the hollow organs and excretory ducts of the glands, stretching of the walls of the hollow organs and tension of their ligamentous apparatus, stagnation in the system of the lower hollow and portal vein, ischemic disorders in the vessels of the abdominal organs, thrombosis and embolism of mesenteric vessels, morphological damage, penetrations, perforations. Often a combination of these symptoms can be observed. Abdominal pain syndrome is the leading in the clinic of most diseases of the digestive system.

Mechanisms of pain perception

Pain is a spontaneous subjective sensation that occurs as a result of pathological impulses from the periphery entering the central nervous system (in contrast to pain, which is determined during examination, for example, during palpation). Pain is the most important sign that signals the action of a factor that damages the tissues of the body. It is the pain, depriving a person of peace, that leads him to the doctor. Proper treatment of patients with an apparent limited process (eg, bone fracture) relieves pain in most cases. In many patients, however, the pain syndrome requires careful investigation and evaluation before its cause is clarified and a treatment approach determined. In some patients, the cause of the pain cannot be determined.

The type of pain, its character does not always depend on the intensity of the initial stimuli. The abdominal organs are usually insensitive to many pathological stimuli, which, when exposed to the skin, cause severe pain. Rupture, incision or crushing of the internal organs are not accompanied by noticeable sensations. At the same time, stretching and tension of the wall of a hollow organ irritate pain receptors. So, tension of the peritoneum by a tumor, stretching of a hollow organ (for example, biliary colic) or excessive muscle contraction cause abdominal pain. Pain receptors of the hollow organs of the abdominal cavity (esophagus, stomach, intestines, gallbladder, bile and pancreatic ducts) are localized in the muscular membrane of their walls.

Similar receptors are present in the capsule of parenchymal organs, such as the liver, kidneys, spleen, and their stretching is also accompanied by pain. The mesentery and parietal peritoneum are sensitive to pain stimuli, while the visceral peritoneum and the greater omentum are devoid of pain sensitivity.

Classification of abdominal pain syndrome

Clinically, there are two types of pain: acute and chronic. This subdivision is extremely important for understanding the phenomenon of pain itself. Acute and chronic pain have different physiological meanings and clinical manifestations, they are based on different pathophysiological mechanisms, and various pharmacological and non-pharmacological methods of treatment are used for their relief.

The doctor can start pain treatment only after it becomes clear whether the patient's pain is acute or chronic. Abdominal pain is divided into acute, which usually develop quickly or, less often, gradually and have a short duration (minutes, rarely several hours), as well as chronic, which is characterized by a gradual increase. These pains persist or recur for weeks or months.

acute pain

Acute pain is characterized, as a rule, by short duration, combined with hyperactivity of the sympathetic nervous system (pallor or reddening of the face, sweating, dilated pupils, tachycardia, increased blood pressure, shortness of breath, etc.), as well as emotional reactions (aggressiveness or anxiety).

The development of acute pain is directly related to damage to superficial or deep tissues. The duration of acute pain is determined by the duration of the damaging factor. Thus, acute pain is a sensory reaction followed by the inclusion of emotional-motivational, vegetative-endocrine, behavioral factors that occur when the integrity of the body is violated. Acute pains are most often local in nature, although the intensity and characteristics of pain, even with a similar local pathological process that caused them, may be different. Individual differences are determined by a number of hereditary and acquired factors. There are people who are highly sensitive to pain stimuli and have a low pain threshold. Pain is always emotionally colored, which also gives it an individual character.

chronic pain

The formation of chronic pain depends more on psychological factors than on the nature and intensity of the damaging effect, so such prolonged pain loses its adaptive biological significance. Gradually develop vegetative disorders, such as fatigue, sleep disturbance, loss of appetite, weight loss.

Chronic pain is pain that has ceased to depend on the underlying disease or damaging factor and develops according to its own laws. The International Association for the Study of Pain defines pain as "pain that continues beyond the normal healing period" and lasts more than 3 months. According to DSM-IV criteria, chronic pain lasts at least 6 months. The main difference between chronic pain and acute pain is not the time factor, but qualitatively different neurophysiological, biochemical, psychological and clinical relationships. The formation of chronic pain is more dependent on a complex of psychological factors than on the nature and intensity of peripheral exposure. So, for example, the intensity of post-traumatic chronic headache (CH) does not correlate with the severity of the injury, and in some cases even inverse relationships are noted: the milder the traumatic brain injury (TBI), the more persistent chronic pain syndrome can form after it.

Features of chronic pain

A variant of chronic pain is psychogenic pain, where peripheral effects may be absent or play the role of a triggering or predisposing factor, determining the localization of pain (cardialgia, abdominalgia, GB). Clinical manifestations of chronic pain and its psychophysiological components are determined by personality characteristics, the influence of emotional, cognitive, social factors, and the patient's past "pain experience". The main clinical characteristics of chronic pain are their duration, monotony, and diffuse character. Patients with such pain often have combinations of different localizations: headache, pain in the back, abdomen, etc. “The whole body hurts,” is how they often characterize their condition. Depression plays a special role in the occurrence of chronic pain, and this syndrome is referred to as depression-pain. Often depression is hidden and is not realized even by the patients themselves. The only manifestation of latent depression may be chronic pain.

Causes of chronic pain

Chronic pain is a favorite mask for hidden depression. The close relationship between depression and chronic pain is explained by common biochemical mechanisms.

Insufficiency of monoaminergic mechanisms, especially serotonergic mechanisms, is a common basis for the formation of chronic algic and depressive manifestations. This position is confirmed by the high effectiveness of antidepressants, especially serotonin reuptake inhibitors, in the treatment of chronic pain.

Not all chronic pain is due to mental disorders. Oncological diseases, joint diseases, coronary heart disease, etc. are accompanied by chronic pain, but more often of limited localization.

However, one should take into account the possibility of the occurrence of depression-pain syndrome against this background. The prevalence of chronic pain in the population reaches 11%. In addition to depression, the incidence of which in chronic pain reaches 60-100%, chronic pain is associated with anxiety and conversion disorders, as well as with features of personal development and family upbringing. Panic disorder is a disease that can occur both in combination with chronic pain (up to 40% of cases) and without it.

An important role in the pathogenesis of chronic pain is played by the previous saturation of the patient's life with pain-related stresses: 42% of patients with chronic pain had a history of "pain situations" - severe stress associated with a threat to life and intense pain. Significantly higher scores on the "pain education" and "pain/vital fear" scales in patients with a combination of chronic pain and panic disorder are noteworthy than in patients without chronic pain.

Mental features of chronic pain

Patients with chronic pain syndrome in panic disorder are characterized by:

Greater significance in the course of the disease of depression than anxiety;

Atypical panic disorder, reflecting the predominance of functional neurological disorders;

High level of somatization;

Significant saturation of life with stress associated with pain.

Factors preventing chronic pain

There are a number of factors that prevent chronic pain:

Relatively high severity and significance in the course of the disease of phobic anxiety;

Typical panic disorder;

Less "saturation" of the patient's life with pain;

Expressed restrictive behavior. The latter is not favorable for the prognosis of panic disorder in general, since it contributes to the intensification of agoraphobia.

Pathophysiological classification of pain

In accordance with another classification based on the alleged pathophysiological mechanisms of pain syndrome development, nociceptive, neuropathic and psychogenic pains are distinguished.

nociceptive pain, probably arises from the activation of specific pain fibers, somatic or visceral. When somatic nerves are involved in the process, the pain usually has an aching or pressing character (for example, in most cases of malignant neoplasms).

neuropathic pain caused by damage to the nervous tissue. This kind of chronic pain may be associated with a change in the function of the efferent link of the sympathetic nervous system (sympathetically mediated pain), as well as with primary damage to either the peripheral nerves (for example, with nerve compression or the formation of a neuroma) or the central nervous system (deafferent pain).

Psychogenic pain occurs in the absence of any organic lesion that would explain the severity of pain and associated functional impairment.

Etiological classification of abdominal pain

I. Intra-abdominal causes:

Generalized peritonitis, which developed as a result of perforation of a hollow organ, ectopic pregnancy or primary (bacterial and non-bacterial);

Periodic illness;

Inflammation of certain organs: appendicitis, cholecystitis, peptic ulcers, diverticulitis, gastroenteritis, pancreatitis, pelvic inflammatory disease, ulcerative or infectious colitis, regional enteritis, pyelonephritis, hepatitis, endometritis, lymphadenitis;

Obstruction of a hollow organ: intestinal, biliary, urinary tract, uterine, aorta;

Ischemic disorders: mesenteric ischemia, infarcts of the intestines, spleen, liver, torsion of organs (gall bladder, testicles, etc.);

Others: irritable bowel syndrome, retroperitoneal tumors, hysteria, Munchausen's syndrome, drug withdrawal.

II. Extra-abdominal causes:

Diseases of the chest cavity: pneumonia, myocardial ischemia, diseases of the esophagus;

Neurogenic: herpes zoster, diseases of the spine, syphilis;

Metabolic disorders: diabetes mellitus, porphyria. Note. The frequency of diseases in rubrics is indicated in descending order.

Abdominal pain is a spontaneous subjective sensation of low intensity arising from the entry of pathological impulses from the periphery into the central nervous system. Most often concentrated in the upper and middle part of the abdominal cavity.

The type and nature of pain does not always depend on the intensity of the factors that cause it. The abdominal organs are usually insensitive to many pathological stimuli, which, when exposed to the skin, cause severe pain. Rupture, incision or crushing of the internal organs is not accompanied by noticeable sensations. At the same time, stretching and tension of the wall of a hollow organ irritate pain receptors. Thus, tension in the peritoneum (tumors), stretching of a hollow organ (such as biliary colic), or excessive muscle contraction cause pain and cramps in the abdomen (abdominal pain). Pain receptors of the hollow organs of the abdominal cavity (esophagus, stomach, intestines, gallbladder, bile and pancreatic ducts) are localized in the muscular membrane of their walls. Similar receptors are present in the capsule of parenchymal organs, such as the liver, kidneys, spleen, and their stretching is also accompanied by pain. The mesentery and parietal peritoneum respond to pain stimuli, while the visceral peritoneum and greater omentum are devoid of pain sensitivity.

Abdominal syndrome is the leader in the clinic of most diseases of the abdominal organs. The presence of abdominal pain requires an in-depth examination of the patient to clarify the mechanisms of its development and the choice of treatment tactics.

Abdominal pain (abdominal pain) subdivided into acute pain and cramps in the abdomen (Table 1), developing, as a rule, quickly, less often - gradually and having a short time duration (minutes, rarely several hours), and chronic abdominal pain, which is characterized by a gradual increase or recurrence over weeks or months.

Table 1.

Chronic pain (cramps) in the stomach periodically disappear, then reappear. Such abdominal pain usually accompanies chronic diseases of the gastrointestinal tract. If such pains are noted, you need to consult a doctor and be ready to answer such questions: are the pains related to food (ie, do they always occur before or always after eating, or only after a certain meal); how often the pains occur, how strong they are; whether pain is associated with physiological functions, and in older girls with menstruation; where it usually hurts, is there any specific localization of pain, does the pain spread somewhere; it is desirable to describe the nature of the pain (“pulls”, “burns”, “pricks”, “cuts”, etc.); what activities usually help with pain (medication, enema, massage, rest, cold, heat, etc.).

Types of abdominal pain

1. Spasmodic abdominal pain (colic, cramps):

caused by spasm of smooth muscles of hollow organs and excretory ducts (esophagus, stomach, intestines, gallbladder, bile ducts, pancreatic duct, etc.);
can occur with pathology of internal organs (hepatic, gastric, renal, pancreatic, intestinal colic, spasm of the appendix), with functional diseases ( irritable bowel syndrome), in case of poisoning (lead colic, etc.);
arise suddenly and often stop just as suddenly, i.e. have the character of a pain attack. With prolonged spastic pain, its intensity changes, after the application of heat and antispastic agents, its decrease is observed;
accompanied by typical irradiation: depending on the place of its occurrence, spastic abdominal pain radiates to the back, shoulder blade, lumbar region, lower limbs;
the patient's behavior is characterized by excitement and anxiety, sometimes he rushes about in bed, takes a forced position;
often the patient has accompanying phenomena - nausea, vomiting, flatulence, rumbling (especially when taking a horizontal position or changing position). These symptoms are important factors that indicate dysfunction of the intestines, stomach, biliary tract, or inflammatory processes in the pancreas. Chills and fever usually accompany dangerous intestinal infections or blockages in the bile ducts. A change in the color of urine and feces is also a sign of blockage of the biliary tract. In this case, the urine, as a rule, acquires a dark color, and the feces lighten. Intense cramping pain accompanied by black or bloody stools indicates the presence of gastrointestinal bleeding and requires immediate hospitalization.

Cramping pains in the stomach area are an excruciating, squeezing type of sensation that disappears after a few minutes. From the moment of its onset, the pains take on an increasing character and then gradually decrease. Spasmodic phenomena do not always occur in the stomach. Sometimes the source is located much lower. As an example one can refer to irritable bowel syndrome These digestive disorders of unknown origin can cause pain, cramps, loose stools, and constipation. For people suffering from IBS, the appearance of pain immediately after eating is characteristic, which is accompanied by bloating, increased peristalsis, rumbling, the intestines hurt with diarrhea or a decrease in stool. Pain after or during the act of defecation and the passage of gases and, as a rule, do not bother at night. Pain in irritable bowel syndrome is not accompanied by weight loss, fever, anemia.

Inflammatory bowel disease ( celiac disease, Crohn's disease , ulcerative colitis (UC) may also cause abdominal cramps and pain, usually before or after a bowel movement, and may be accompanied by diarrhea (diarrhea).

A common cause of abdominal pain is the food we eat. Irritation of the esophagus (pressive pain) causes salty, too hot or cold food. Some foods (fatty, cholesterol-rich foods) stimulate the formation or movement of gallstones, causing attacks of biliary colic. The use of poor-quality products or food with improper cooking usually ends in food poisoning of bacterial origin. This disease is manifested by cramping abdominal pain, vomiting and sometimes loose stools. Inadequate amounts of dietary fiber in the diet or water are also among the leading causes of both constipation and diarrhea. Both disorders are also often accompanied by cramping pains in the abdomen.

In addition, cramping pains in the abdomen appear with lactose intolerance, inability to digest the sugar contained in dairy products, with an autoimmune inflammatory disease of the small intestine - celiac disease, when the body is intolerant of gluten.

Diverticulosis is a disease that is associated with the formation of small pockets filled with intestinal contents and bacteria. They cause irritation of the walls of the small intestine and, as a result, not only spasmodic phenomena and pains of a cramping nature can occur, but also intestinal bleeding.

Another disorder leading to pain may be a viral infection.

2. Pain from stretching of hollow organs and tension of their ligamentous apparatus(they differ in aching or pulling character and often do not have a clear localization).

3. Abdominal pain depending on local circulatory disorders (ischemic or congestive circulatory disorders in the vessels of the abdominal cavity)

Caused by spasm, atherosclerotic, congenital or other origin, stenosis of the branches of the abdominal aorta, thrombosis and embolism of the intestinal vessels, stagnation in the portal and inferior vena cava, impaired microcirculation, etc.

Angiospastic pains in the abdomen are paroxysmal;

For stenotic pain in the abdomen, a slower manifestation is characteristic, but both of them usually occur at the height of digestion (“abdominal toad”). In the case of thrombosis or embolism of the vessel, this type of abdominal pain acquires a severe, growing character.

4. Peritoneal pain the most dangerous and unpleasant conditions united in the concept of "acute abdomen" (acute pancreatitis, peritonitis).

They occur with structural changes and damage to organs (ulceration, inflammation, necrosis, tumor growth), with perforation, penetration and the transition of inflammatory changes to the peritoneum.

The pain is most often intense, diffuse, the general state of health is poor, the temperature often rises, severe vomiting opens, the muscles of the anterior abdominal wall are tense. Often the patient assumes a resting position, avoiding minor movements. In this situation, it is impossible to give any painkillers before the doctor's examination, but it is necessary to urgently call an ambulance and be hospitalized in a surgical hospital. Appendicitis in the early stages is usually not accompanied by very severe pain. On the contrary, the pain is dull, but fairly constant, in the lower right abdomen (although it can begin in the upper left), usually with a slight rise in temperature, there may be a single vomiting. The state of health may worsen over time, and as a result, signs of an “acute abdomen” will appear.

Peritoneal abdominal pain occurs suddenly or gradually and lasts more or less a long time, subsides gradually. This type of pain in the abdomen is more distinct localization; palpation can detect limited pain areas and points. When coughing, moving, palpation, the pain intensifies.

5. Referred abdominal pain(we are talking about the reflection of pain in the abdomen with a disease of other organs and systems). Reflected abdominal pain can occur with pneumonia, myocardial ischemia, pulmonary embolism, pneumothorax, pleurisy, diseases of the esophagus, porphyria, insect bites, poisoning).

6. Psychogenic pain.

This type of abdominal pain is not associated with diseases of the intestines or other internal organs, neurotic pain. A person may complain of pain when he is afraid of something or does not want to, or after some kind of psycho-emotional stress, shock. At the same time, it is not at all necessary that he feigns, the stomach can really hurt, sometimes even the pain is very strong, resembling an “acute stomach”. But they don't find anything on examination. In this case, you need to consult a psychologist or neurologist.

Of particular importance in the occurrence of psychogenic pain is depression, which often proceeds hidden and is not realized by the patients themselves. The nature of psychogenic pain is determined by the characteristics of the individual, the influence of emotional, cognitive, social factors, the psychological stability of the patient and his past "pain experience". The main features of these pains are their duration, monotony, diffuse nature and combination with pains of other localization (headache, back pain, throughout the body). Often, psychogenic pain persists after relief of other types of pain, significantly transforming their character.

Localization of pain in the abdomen (Table 2)

In what cases does the intestine hurt and it is already necessary to visit a proctologist?

Diagnosis for abdominal pain (intestinal pain)

All women of reproductive age should have a biochemical test to determine pregnancy.
Urinalysis helps diagnose urinary tract infection, pyelonephritis, and urolithiasis, but is nonspecific (eg, pyuria may be detected in acute appendicitis).
Inflammation usually has leukocytosis (eg, appendicitis, diverticulitis), but a normal blood count does not rule out an inflammatory or infectious disease.
The results of the study of functional liver tests, amylase and lipase may indicate pathology of the liver, gallbladder or pancreas.
Visualization methods:

If biliary tract disease, abdominal aortic aneurysm, ectopic pregnancy, or ascites is suspected, abdominal ultrasound is the method of choice;

CT of the abdominal organs quite often allows you to make the correct diagnosis (nephrolithiasis, abdominal aortic aneurysm, diverticulitis, appendicitis, mesenteric ischemia, intestinal obstruction);

Plain radiography of the abdominal cavity is used only to exclude perforation of a hollow organ and intestinal obstruction;

ECG to rule out myocardial ischemia

Fibroesophagogastroduadenoscopy to exclude diseases of the esophagus, stomach, duodenum;

The location of abdominal pain is one of the main factors in the diagnosis of the disease. Pain that is concentrated in the upper abdominal cavity is usually caused by disorders in the esophagus, intestines, biliary tract, liver, pancreas. Abdominal pain arising from cholelithiasis or inflammatory processes in the liver is localized in the upper right abdomen and may radiate under the right shoulder blade. Pain with ulcers and pancreatitis, as a rule, radiates through the entire back. Pain caused by disorders in the small intestine is usually centered around the navel, while pain due to the large intestine is recognized below the navel. Pelvic pain is usually felt as tightness and discomfort in the rectal area.

In what cases is it necessary to visit a proctologist for pain in the abdomen?

If you answered yes to at least one of the following questions, you should contact your doctor:

Do you often experience abdominal pain?
Does the pain you experience interfere with your daily activities and performance at work?
Are you experiencing weight loss or decreased appetite?
Are you seeing changes in bowel habits?
Do you wake up with intense abdominal pain?
Have you suffered from diseases such as inflammatory bowel disease in the past?
Do the medications you take have gastrointestinal side effects (aspirin, non-steroidal anti-inflammatory drugs)?
Diagnosis of abdominal pain (abdominal pain).

If a standardized patient with abdominal pain fails to establish a diagnosis (in case of abdominal pain of unknown origin), it is recommended to perform capsule endoscopy, since in this case, abdominal pain may be due to the pathology of the small intestine (ulcers, tumors, celiac disease, Crohn's disease, diverticulosis, etc.). Difficulties in diagnosing lesions of the small intestine are primarily due to the difficult accessibility of this section of the digestive tract for standard methods of instrumental diagnostics, the locality of the emerging pathological changes, and the absence of specific symptoms. Capsule endoscopy solves this problem and in most clinical cases helps to establish the diagnosis in patients with abdominal pain of unknown origin.

Differential diagnosis of abdominal pain (abdominal pain).

Perforated ulcer of the stomach or duodenum- the patient suddenly feels extremely sharp pain in the epigastric region, which is compared with pain from a dagger. Initially, the pain is localized in the upper abdomen and to the right of the midline, which is typical for perforation of a duodenal ulcer. Soon, the pain spreads throughout the right half of the abdomen, capturing the right iliac region, and then throughout the abdomen. The characteristic posture of the patient: lies on his side or on his back with the lower limbs brought to the stomach, bent at the knees, clasping his stomach with his hands, or takes a knee-elbow position. Pronounced tension of the muscles of the anterior abdominal wall, in a later period - the development of local peritonitis. Percussion is determined by the absence of hepatic dullness, which indicates the presence of free gas in the abdominal cavity.

Acute cholecystitis- characterized by recurring attacks of acute pain in the right hypochondrium, which are accompanied by fever, repeated vomiting, and sometimes jaundice, which is uncharacteristic of a perforated stomach ulcer. When the picture of peritonitis develops, differential diagnosis is difficult, video endoscopic technique helps to recognize its cause during this period. However, with an objective examination of the abdomen, it is possible to palpate tense muscles only in the right iliac region, where an enlarged, tense and painful gallbladder is sometimes determined. There are positive Ortner's symptom, phrenicus-symptom, high leukocytosis, frequent pulse.

Acute pancreatitis- the onset of the disease is preceded by the use of fatty plentiful food. The sudden onset of acute pains are girdle in nature, accompanied by indomitable vomiting of gastric contents with bile. The patient cries out in pain, does not find a quiet position in bed. The abdomen is swollen, muscle tension as in a perforated ulcer, peristalsis is weakened. There are positive symptoms of Resurrection and Mayo-Robson. In biochemical blood tests - a high rate of amylase, sometimes - bilirubin. Video endolaparoscopy reveals plaques of fatty necrosis on the peritoneum and in the greater omentum, hemorrhagic effusion, pancreas with black hemorrhages.

Hepatic and renal colic- acute pains are cramping in nature, there are clinical manifestations of cholelithiasis or urolithiasis.

Acute appendicitis must be differentiated from a perforated ulcer. Since, with a perforated ulcer, the gastric contents descend into the right iliac region, it causes sharp pain in the right iliac region, epigastrium, tension of the anterior abdominal wall and symptoms of peritoneal irritation.

Thromboembolism of the mesenteric vessels- characterized by a sudden attack of pain in the abdomen without a specific localization. The patient is restless, tossing about in bed, intoxication and collapse develop rapidly, loose stools appear mixed with blood. The abdomen is swollen without tension of the anterior abdominal wall, there is no peristalsis. The pulse is frequent. A heart disease with atrial fibrillation is detected. Quite often in the anamnesis there is an indication of embolism of the peripheral vessels of the branches of the aorta. During diagnostic video endolaparoscopy, hemorrhagic effusion and necrotic changes in intestinal loops are detected.

Dissecting abdominal aortic aneurysm- occurs in elderly people with severe atherosclerosis. The onset of stratification is manifested by sudden pain in the epigastrium. The abdomen is not swollen, but the muscles of the anterior abdominal wall are tense. Palpation in the abdominal cavity is determined by a painful tumor-like pulsating formation, over which a rough systolic murmur is heard. The pulse is quickened, blood pressure is reduced. The pulsation of the iliac arteries is weakened or absent, the extremities are cold. When the aorta and the mouth of the renal arteries are involved in the process of bifurcation, signs of acute ischemia are revealed, anuria sets in, and the phenomena of heart failure rapidly increase.

Lower lobe pneumonia and pleurisy- sometimes they can give a clinical picture of the abdominal syndrome, but the examination reveals all the signs of an inflammatory lung disease.

Dangerous symptoms that require a solution to the issue of urgent surgical intervention for abdominal pain include:

dizziness, weakness, apathy;
arterial hypotension, tachycardia;
visible bleeding;
fever;
repeated vomiting;
increasing increase in the volume of the abdomen;
lack of discharge of gases, peristaltic noises;
increased pain in the abdomen;
muscle tension of the abdominal wall;
positive Shchetkin-Blumberg symptom;
vaginal discharge;
fainting and pain during the act of defecation.

Clinical cases of Crohn's disease using capsule endoscopy in the examination and

Patient A., 61, female. She was on a capsule endoscopy study in May 2011. Was admitted with complaints of chronic abdominal pain, flatulence. Sick for 10 years, the patient repeatedly underwent colonoscopies, gastroscopy, MRI with contrast and CT. The patient was observed and treated by doctors of various specialties - a gastroenterologist, a surgeon, a therapist, a neuropathologist, a psychiatrist ...

In the study of capsule endoscopy, the patient revealed erosion of the small intestine with places without villousness. As well as hyperemic mucosa of the ileum.

The patient was diagnosed with Crohn's disease. small intestine and prescribed a course of conservative therapy with mesalazines, diet therapy. During the month, the intensity and severity of pain decreased in the patient after 3 months, the pain stopped.

Patient O female 54 year. She was admitted to the Department of Proctology of the Regional Clinical Hospital with complaints of intermittent pain in the left iliac region, nausea, loose stools 2-3 times a day. Sick for 7 years. Previously, colonoscopy and gastroscopy were performed without pathology. When conducting capsule endoscopyin June 2011 the patient revealed an altered mucosa of the ileum.

During our colonoscopy with a biopsy from the terminal part of the small intestine, we received a histological conclusion of Crohn's disease small intestine. The patient was prescribed a basic course of conservative therapy, mesalazines, diet therapy for two months, the patient's stool returned to normal and the pain in the abdomen stopped. She is now under observation.