Abdominal syndrome. Abdominal pain

Localization of pain orients the clinician to the topography of a possible pathological process. The epigastric region includes three sections: the right and left hypochondrium, and the epigastrium itself. Pain in the right hypochondrium often signals diseases of the gallbladder, bile ducts, head of the pancreas, duodenum, hepatic angle of the colon, right kidney, and abnormally high located appendix. Hepatomegaly manifests itself less intensely. In the left hypochondrium, pain is recorded with lesions of the stomach, pancreas, spleen, left kidney, left half of the large intestine, and left lobe of the liver. The epigastrium is directly connected to the cardiac part of the esophagus, stomach, duodenum, diaphragm, pancreas, abdominal wall hernia, dissecting aneurysm of the abdominal aorta. The mesogastrium in its central umbilical region reflects the condition of the small intestine, abdominal aorta, hernial changes in the abdominal wall, omentum, mesentery, lymph nodes and vessels. The right iliac region is traditionally associated with changes in the appendix, the cecum, the terminal part of the small intestine with the Bauginean valve, the right kidney, the ureter, and the right ovary. Left iliac region - left half of the colon, left kidney, ureter, left ovary. Only the suprapubic region narrows the list of possible lesions to the genitourinary system and inguinal hernias. Widespread (diffuse) pain over the entire surface of the abdominal cavity is characteristic of diffuse peritonitis, intestinal obstruction, damage to the vessels of the abdominal cavity, ruptures of parenchymal organs, capillary toxicosis, and ascites.
Pathogenetically, there are 3 types of abdominal pain.
True visceral pain is provoked by changes in pressure in organs when they are stretched (both parenchymal and hollow organs) or a sharp contraction of the muscles of hollow organs, or a change in blood supply.
From a clinical point of view, true visceral pain includes three types of sensations: spastic, distensional and vascular pain. Spasmodic pain is characterized by paroxysmal pain, pronounced intensity, and clear localization. They have a clear irradiation (refers to the second type of abdominal pain, but we have no right not to mention this when describing the clinical characteristics of pain), which is associated with the anatomical proximity in the spinal and thalamic centers of the afferent pathways of innervation of the affected organ and the area to which the pain irradiates. Examples include pain in the case of damage to the biliary system “up and to the right”, the right shoulder blade, shoulder, right arm, in case of damage to the pancreas - pain of a “girdling” nature, etc. Spasmodic pain is often called “colic,” although the term “colic” translated from Greek (“colikos”) means only “pain in the colon.” In practice, the use of combinations of biliary colic, renal colic, gastric colic, and intestinal colic occurs constantly. Activation of nociceptors (pain receptors) can be carried out by various stimulants: high and low temperature, strong mechanical effects, release of biologically active substances (bradykinin, histamine, serotonin, prostaglandins) at the site of inflammation or damage. The latter either reduce the threshold of sensitivity to other stimuli or directly activate pain receptors. The spastic mechanism of pain suggests a positive effect when taking antispasmodics. Concomitant phenomena may be vomiting, which often does not bring relief, fever of reflex origin and local muscle tension of the anterior abdominal wall.
The occurrence of visceral pain can be caused by both organic and functional disorders. However, in any case, they are a consequence of primarily a violation of the motor function of the gastrointestinal tract. The motor function of the gastrointestinal tract has regulatory mechanisms from external and internal innervation. External innervation is carried out through the autonomic nervous system (sympathetic and parasympathetic). The submucosal and muscular plexus of the gastrointestinal tract are united by the concept of internal innervation. The presence of intramural neurons in the Auerbach (muscular) plexus allows for autonomous control of the motor activity of the gastrointestinal tract even when the autonomic nervous system is turned off.
The contractility of the gastrointestinal tract is determined by the activity of smooth muscle cells, which is directly dependent on the ionic composition, where the dominant role is played by calcium ions, which cause contraction of the muscle fiber. The opening of calcium channels for the entry of Ca2+ ions into the cell correlates with an increase in the concentration of sodium ions in the cell, which characterizes the beginning of the depolarization phase. Intramural mediators play a significant role in the regulation of transport ion flows and direct motility of the gastrointestinal tract. Thus, the binding of acetylcholine to M receptors stimulates the opening of sodium channels.
Serotonin activates several subtypes of receptors, which causes diametrically opposite effects: connection with 5-MT-3 receptors promotes relaxation, with 5-MT-4 - contraction of muscle fiber.
New mediators currently include: substance P, enkephalins, vasoactive interstitial polypeptide, somatostatin.
Substance P (separated into a separate group from the group of tachykinins), contacting directly with the corresponding receptors of myocytes, increases their motor function due to direct activation and due to the release of acetylcholine.
Enkephalins modulate the activity of intramural neurons operating at the level of the Auerbach (muscular) plexus. Enkephalinergic receptors are widely represented in the gastrointestinal tract and are localized in gastrointestinal effector cells of smooth muscle fibers.
Endorphins also play a certain role in the regulation of gastrointestinal motor activity: when they interact with m and D-opioid receptors of myocytes, stimulation occurs, and when connected with k receptors, they slow down the motor activity of the digestive tract.
Somatostatin can both stimulate and inhibit intramural neurons, leading to similar motor changes.
The direct effect of motilin polypeptide on stimulating receptors of muscle cells has been proven, which increases the tone of the lower esophageal sphincter, accelerates gastric emptying and enhances the contractile activity of the large intestine.
Vasoactive intestinal peptide (VIP) (the predominant area of ​​secretion is the submucosal and muscular plexus in the large intestine) is able to relax the muscles of the lower esophageal sphincter, the muscles of the fundus of the stomach, and the colon.
The basis of functional disorders of the gastrointestinal tract is an imbalance of neurotransmitters and regulatory peptides (motilin, serotonin, cholecystokinin, endorphins, enkephalins, VIP), and changes in motor activity are considered the leading component of pathogenesis. Functional disorders (FD) are a set of symptom complexes on the part of the digestive system, the occurrence of which cannot be explained by organic causes - inflammation, destruction, etc. Due to the high prevalence of this pathology, guidelines have been developed (“Rome III criteria”) on the pathogenesis, diagnosis and treatment of this nosological form. Table 1 shows the classification of risk factors of the digestive system.
Analysis of the above conditions proves that the basis for the pathogenesis of functional disorders is a change in motor activity in combination with disturbances in the central, peripheral and humoral regulation of the digestive tract, and hyperalgesia of the digestive organs.
The distensional nature of pain occurs when the volume of internal organs (both hollow and parenchymal) changes and the tension of their ligamentous apparatus. Complaints are described by patients as low-intensity, gradually occurring, long-lasting, without clear localization and irradiation of pain; taking antispasmodics does not have a positive effect, sometimes giving the opposite effect. The syndrome of flatulence, gastrointestinal dyspepsia with secretory insufficiency, hepatomegaly, splenomegaly are manifested by the clinical complaints described above. If the blood supply to the abdominal organs is disrupted (arterial embolism, mesanterial thrombosis, atherosclerosis of the abdominal aorta and its branches - “abdominal toad”), pain occurs suddenly, diffusely, usually intense, gradually increasing.
The next category of pain is parietal pain. Mechanism: irritation of the cerebrospinal nerve endings of the parietal peritoneum or the root of the mesentery, as well as perforation of the wall of hollow organs. The pathogenesis of peritonitis can be of inflammatory origin (appendicitis, cholecystitis are considered as a result of perforation). Depending on the etiology, the onset of peritoneal pain transforms from gradual to sudden acute, with a pain syndrome continuously increasing in intensity up to unbearable pain. An obligatory companion is symptoms of inflammation, intoxication, and the possible presence of acute vascular insufficiency.
Reflex (radiating, reflected) pain. The description of pain is associated with the names of G.A. Za-har-i-na and Geda, who for the first time proved the relationship between internal organs and areas of increased skin sensitivity, which occurs as a result of the interaction of visceral fibers and somatic dermatomes in the dorsal horns of the spinal cord. For example, visceral afferentation from the liver capsule, spleen capsule and pericardium enters the central nervous system via the phrenic nerve from nerve segments (dermatomes) C3-5. Afferentation from the gallbladder and small intestine passes through the solar plexus, the main celiac trunk and enters the spinal cord at the T6-T9 level. The appendix, colon and pelvic organs correspond to the T6-T9 level through the mesenteric plexus and the minor branches of the celiac trunk. Level T11-L1 is connected through the lower branches of the celiac nerve to the sigmoid colon, rectum, renal pelvis and capsule, ureter and testicles. The rectum, sigmoid colon and bladder enter the spinal cord at the S2-S4 level. In addition to areas of increased skin sensitivity (Zakharyin-Ged zones), pain is detected in deeper tissues. For example, pain caused by intestinal distension at the initial stage is perceived as visceral, but as it progresses it radiates to the back.
Treatment of pain syndrome. Domestic medicine is characterized by etiological and pathogenetic approaches to the treatment of any disease. Treatment carried out in connection with only one of the stated complaints cannot be taken as a basis, especially since there are many reasons for its occurrence, firstly, and secondly, the pain syndrome itself is diverse in the mechanisms of its development. However, the humane desire to alleviate the patient’s suffering gives us the right, with a correct assessment of all collected complaints and the patient’s status, to offer approaches to the treatment of abdominal pain. The most common mechanism for this is smooth muscle spasm. Based on the reasons for its occurrence, drugs are used that act on different parts of the reflex chain (Table 2).
Of the drugs presented in the table, myotropic antispasmodics are the most widely used. The mechanism of their action is reduced to the accumulation of c-AMP in the cell and a decrease in the concentration of calcium ions, which inhibits the connection of actin with myosin. These effects can be achieved by inhibition of phosphodiesterase or activation of adenylate cyclase, or blockade of adenosine receptors, or a combination of these effects. Due to the selectivity of pharmacological effects, myotropic antispasmodics do not have the undesirable systemic effects inherent in cholinomimetics. However, the antispastic effect of drugs in this group is not powerful and fast enough. Myotropic antispasmodics are prescribed mainly for functional diseases of the gastrointestinal tract (non-ulcer dyspepsia, irritable bowel syndrome), as well as for secondary spasms caused by organic disease.
Of the non-selective myotropic antispasmodics, papaverine and drotaverine are currently the most studied, but the latter is more preferable in the choice of a clinician. Drotaverine (Spazmonet) is highly selective. The selectivity of its action on smooth myocytes of the gastrointestinal tract is 5 times higher than papaverine. The frequency of undesirable side effects, including those from the cardiovascular system (arterial hypotension, tachycardia), is significantly lower when taking the drug. Spasmonet does not penetrate the central nervous system and has no effect on the autonomic nervous system.
A significant advantage of drotaverine, in contrast to anticholinergics, is safety of use.
Spasmonet is ideal for long-term use to ensure a long-term spasmolytic effect. In gastroenterology, the indications are: spastic dyskinesia of the biliary tract, pain relief from gastric and duodenal ulcers, pylorospasm, irritable bowel syndrome, and kidney stones.
Spasmonet reduces blood viscosity, platelet aggregation and prevents thrombus formation. This property may be useful in treating patients with intestinal ischemia.
However, in chronic pathologies such as IBS or biliary disorders, oral administration of these drugs in therapeutic doses is often insufficient, and there is a need to increase their dose or parenteral administration. In order to enhance the therapeutic effect, drugs with a higher dosage of the active substance are produced. An example is the tablet form of the drug Spasmonet-forte (KRKA). 80 mg of drotaverine in 1 tablet allows you to obtain a more pronounced antispasmodic effect while reducing the frequency of administration, as well as reducing the number of dosage forms taken.
Although drotaverine and papaverine are usually well tolerated, in large doses or when used intravenously they can cause dizziness, decreased myocardial excitability, and impaired intraventricular conduction.
Despite the fact that monotherapy for abdominal pain syndrome is not a complete treatment for both functional and organic lesions of the gastrointestinal tract, it can serve as one of the areas of complex treatment of the patient.

Literature
1. Belousova E.A. Antispasmodics in gastroenterology: comparative characteristics and indications for use // Pharmateka. 2002, No. 9, p. 40-46.
2. Grigoriev P.Ya., Yakovenko A.V. Clinical gastroenterology. M.: Medical Information Agency, 2001. P. 704.
3. Grossman M. Gastrointestinal hormones and pathology of the digestive system:.- M.: Medicine, 1981. - 272 p.
4. Ivashkin V.T., Komarova F.I., Rapoport S.I. A short guide to gastroenterology. - M.: LLC M-Vesti, 2001.
5. Ivashkin V.T. Metabolic organization of gastric functions. - L.: Science, 1981.
6. Menshikov V.V. Gastrointestinal hormones: a scientific review. Moscow, 1978.
7. Parfenov A.I. Enterology. 2002.
8. Frolkis A.V. Pharmacological regulation of intestinal functions. - L.: Science, 1981.
9. Henderson J. M. Pathophysiology of the digestive organs. 2005.
10. Khramova Yu A Therapeutic syndromes. GASTROENTEROLOGY 2007-2008.
11. Drossman DA. The Functional Gastrointestinal Disorders and the Rome III Process. Gastroenterology 2006; 130 (5): 1377-90.
12. Thompson WG, Longstreth GF, Desman DA, et al. Functional bowel disorders and functional abdominal pain. Gut 1999; 45(suppl. II):43-7.

Any pain is an alarming signal that indicates the appearance of some problems in the body’s functioning. Accordingly, this kind of unpleasant sensation should not be ignored. This is especially true for symptoms that develop in children, since they can indicate serious disturbances in the body’s functioning, including those that require emergency care. Abdominal pain syndrome, in other words abdominal pain, is considered to be a fairly common symptom of this kind. Let's talk about the variety and specificity of complaints of this kind in a little more detail.

Abdominal pain syndrome in children often causes parents to contact 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 ARVI 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 provided by ultrasound examination of the peritoneal organs, as well as the retroperitoneal space.

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

Causes

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 can lead to the development of 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 type 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 ailments of the kidneys or bladder. Accordingly, an examination of the urinary system also plays an important role. Ultrasound of these organs is performed twice - with a well-filled bladder and soon 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 emergence of functional ovarian cysts, which require systematic ultrasound monitoring, and usually disappear on their own.

Acute painful sensations in the abdomen that develop at night often cause the child to be hospitalized in the surgery department, where he undergoes a mandatory ultrasound. So, such a symptom is often explained by the appearance of acute surgical pathology, for example, acute appendicitis, intestinal obstruction (mechanical or dynamic type), intussusception, etc. Such conditions require immediate surgical intervention.

Sometimes nighttime 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. Ultrasound and a number of other studies will again help to identify them.

Treatment

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

Additional Information

With the development of abdominal pain syndrome in pediatric practice, the main difficulty for correct diagnosis is the difficulty of the baby describing his sensations, localization of pain, their intensity and irradiation. According to doctors, young children very often describe any discomfort occurring in the body as abdominal pain. A similar situation occurs when trying to describe a feeling of dizziness, nausea, or pain in the ears or head that is incomprehensible to a child. It is extremely important to take into account that pain in the abdominal area can also manifest itself in many pathological conditions, such as diseases of the lungs or pleura, heart and kidneys, as well as lesions of the pelvic organs.

Pain syndrome is one of the most common and important symptoms of clinical gastroenterology. The biological meaning of pain, according to I. P. Pavlov, is “the discarding of everything that threatens the life process.” As is known, in diseases of the abdominal organs (and, above all, the digestive system), pain occurs due to reasons such 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 lower hollow system 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 clinical symptom for most diseases of the digestive system.

Mechanisms of pain perception

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

The type of pain and its nature do not always depend on the intensity of the initial stimuli. The abdominal organs are usually insensitive to many pathological stimuli that, when applied to the skin, cause severe pain. Rupture, cut or crushing of internal organs is not accompanied by noticeable sensations. At the same time, stretching and tension of the wall of the hollow organ irritate pain receptors. Thus, 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 lining of their walls.

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

Classification of abdominal pain syndrome

Clinically, there are two types of pain: acute and chronic. This division 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 treatment methods are used to relieve them.

The doctor can begin pain treatment only after it becomes clear whether the patient’s pain is acute or chronic. Abdominal pain is divided into acute, which usually develops quickly or, less often, gradually and has 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, combination with hyperactivity of the sympathetic nervous system (pallor or redness of the face, sweating, dilated pupils, tachycardia, increased blood pressure, shortness of breath, etc.), as well as emotional reactions (aggression 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 action of the damaging factor. Thus, acute pain is a sensory reaction with the subsequent inclusion of emotional-motivational, vegetative-endocrine, and behavioral factors that arise when the integrity of the body is violated. Acute pain is most often local in nature, although the intensity and characteristics of pain, even with a similar local pathological process that caused it, may be different. Individual differences are determined by a number of hereditary and acquired factors. There are people who are highly sensitive to painful stimuli and have a low pain threshold. Pain is always emotionally charged, 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, therefore such prolonged pain loses its adaptive biological significance. Autonomic disorders gradually develop, such as fatigue, sleep disturbances, decreased appetite, and 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 it 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 depends to a greater extent on a complex of psychological factors rather than on the nature and intensity of peripheral influence. For example, the intensity of post-traumatic chronic headache (CH) does not correlate with the severity of the injury, and in some cases even the opposite relationship is 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 location of pain (cardialgia, abdominalgia, headache). 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 nature. Patients with such pain often experience combinations of different localizations: headache, back pain, abdominal pain, 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 occurs hidden and is not recognized even by the patients themselves. The only manifestation of hidden depression may be chronic pain.

Causes of chronic pain

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

The insufficiency of monoaminergic mechanisms, especially serotonergic ones, is the 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 caused by 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 frequency of which in chronic pain reaches 60-100%, chronic pain is associated with anxiety and conversion disorders, as well as with characteristics 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 patient’s previous saturation of life with pain-related stress: 42% of patients with chronic pain had a history of “painful situations” - severe stress associated with a threat to life and intense pain. Noteworthy are the significantly higher scores on the “pain education” and “pain/vital fear” scales in patients with a combination of chronic pain and panic disorder than in patients without chronic pain.

Mental characteristics of chronic pain

Patients with chronic pain syndrome due to panic disorder are characterized by:

Depression is more important in the course of the disease than anxiety;

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

High level of somatization;

Significant saturation of life with stress associated with pain.

Factors that prevent pain from becoming chronic

There are a number of factors that prevent pain from becoming chronic:

Relatively greater severity and significance during the course of the disease of phobic anxiety;

Typical characteristics of panic disorder;

Less “saturation” of the patient’s life with pain;

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

Pathophysiological classification of pain

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

Nociceptive pain probably occurs when specific pain fibers are activated, somatic or visceral. When somatic nerves are involved in the process, the pain is usually aching or pressing in nature (for example, in most cases of malignant neoplasms).

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

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

Etiological classification of abdominal pain

I. Intra-abdominal causes:

Generalized peritonitis that 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 inflammation, 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, infarction of the intestine, spleen, liver, torsion of organs (gallbladder, testicles, etc.);

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

II. Extra-abdominal causes:

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

Neurogenic: herpes zoster, spinal diseases, syphilis;

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

Abdominal syndrome is one of the most common diseases of the digestive system nowadays. Severe pain in the abdominal area is a warning sign. If this continues for some time, you should immediately contact a specialist. The fact is that this disease most often occurs as a secondary disease. That is, it stems from problems with the gastrointestinal tract. The course of therapy for the syndrome is part of a complex treatment aimed at restoring the digestive organs.

Classification

Abdominal pain can be divided into two main types:

• short-lived, but characterized by rapid development;
• chronic, which progress gradually as the condition worsens.

In addition, there is another classification of syndromes according to the type of appearance. The following are distinguished:

1. Visceral. Abdominal syndrome is formed as a result of tension, which contributes to irritation of the receptors. This type of pain is characterized by an increase in pressure inside the organ due to tension in the walls.
2. Parietal. Here the nerve endings come to the fore. This deviation occurs as a result of damage to the abdominal walls.
3. Reflected. This is more of a subtype of visceral pain. If it passes with great tension, it develops into a reflected one.
4. Psychogenic. The development of the syndrome in this case occurs secretly. Usually this type of pain occurs due to depression. Often the patient does not even realize there is a problem, as he simply does not notice it. Abdominal pain is accompanied by other unpleasant sensations in the back or head.

Signs of the disease

Abdominal syndrome most often occurs in children and young people. It is characterized by painful sensations in the abdomen, which intensify during physical activity. Sometimes this becomes unbearable and some patients stop eating. As a result, artificial vomiting is induced, and the person loses significant weight. Often before pain appears, the patient feels heaviness and discomfort in the abdominal area.

Abdominal pain syndrome causes belching and indigestion. The discomfort subsides after taking validol and nitroglycerin. However, these medications do not eliminate the problem; they simply numb the pain for a while. To correctly diagnose the disease, you should pay attention to the systolic murmur. If it is found in the navel area (a couple of centimeters above), this indicates damage to the visceral arteries.

The most dangerous symptoms

The general signs of the disease were discussed above; if they appear, you just need to see a doctor. However, abdominal pain syndrome is characterized by the fact that sometimes its manifestations require emergency surgical intervention. Alarming symptoms:

• increased heart rate (tachycardia);
• apathy, indifference;
• severe dizziness;
• repeated vomiting;
• fainting;
• the pain intensifies several times;
• bleeding.

If such signs are detected, in no case should they be ignored, citing the fact that “they will go away on their own.” This is already a serious stage of the disease, and only a specialist can help in this situation.

Abdominal ischemic syndrome

This disease is characterized by impaired blood supply to the digestive organs. This syndrome occurs most often due to damage to the abdominal cavity. Lesions can be caused by both internal narrowing and external pressure. The disease proceeds quite calmly, gradually developing. The syndrome is characterized by severe abdominal pain, weight loss, and other symptoms of gastrointestinal tract abnormalities.

It is worth noting that identifying this disease is a difficult task. This is due to the fact that its symptoms are similar to those of other digestive ailments. In most cases, it is possible to diagnose the disease only at autopsy. Therapy is aimed at eliminating the causes that contributed to its occurrence. Improving blood circulation is the main goal of the fight against ischemic syndrome.

Causes of illness in children

This disease mainly affects children. At an early age, almost all babies experience colic, which can cause the formation of the disease. It is recommended to periodically do ultrasound to identify possible abnormalities in the structure of organs.

Abdominal syndrome in children develops due to acute ailments of the kidneys or bladder. In this case, ultrasound examination will also be useful. Moreover, it should be carried out twice: with a full bladder and soon after emptying.

Children often experience night pain in the abdominal area. They often cause the child to be hospitalized. As a result of surgical examination, pathologies such as appendicitis or intestinal obstruction are revealed. Less commonly, night pain is characterized by conservative correction of internal organs. In this case, doctor intervention is not required.

Sometimes discomfort in the abdomen indicates the development of tumors. Then urgent hospitalization and immediate intervention by specialists are required. ARVI with abdominal syndrome has been occurring quite often lately. In this case, the main thing is to make the correct diagnosis so that the doctor prescribes the most effective treatment.

Diagnosis of the disease

In fact, there is one most effective way to detect abdominal syndrome - ultrasound. For about 10 years, doctors have been using this method to diagnose the disease. Even now, nothing better has yet been invented.

No special preparation is required to perform an ultrasound. You must skip meals and come for the procedure after a certain amount of time. This depends on the age of the patient: for example, for small children it is enough to take a pause of 3-4 hours, and for adults - about 8 hours. It is advisable to perform an ultrasound in the morning, on an empty stomach. However, if this is not possible, it can be done during the day.

Treatment of abdominal syndrome

Therapy for this disease directly depends on the reasons that provoked its appearance. There can be a huge number of them, so you need to clearly determine the source of the disease. The most commonly used drugs in treatment are those that affect the reflex circuit. Among these medications are antispasmodics. They are prescribed to patients who have problems with the digestive system.

In many situations, abdominal pain syndrome is not a disease, but a symptom. Accordingly, it must be eliminated as a sign. That is, the first thing to do is to pay attention to the normalization of the functioning of the digestive organs and nervous system. This approach will prevent the formation of new pathologies and eliminate old ones.

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

The type and nature of pain do not always depend on the intensity of the factors that cause it. The abdominal organs are usually insensitive to many pathological stimuli that, when applied to the skin, cause severe pain. A rupture, cut or crush of internal organs is not accompanied by noticeable sensations. At the same time, stretching and tension of the wall of the hollow organ irritate pain receptors. Thus, tension of the peritoneum (tumor), stretching of a hollow organ (for example, 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 lining 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 painful stimuli, while the visceral peritoneum and greater omentum lack pain sensitivity.

Abdominal syndrome is the leading specialist in the clinic for 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 choose treatment tactics.

Abdominal pain (stomach pain) are divided into acute pain and cramps in the abdomen (Table 1), usually developing quickly, less often - gradually and having a short 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 (spasms) in the stomach periodically disappear and then appear again. Such abdominal pain usually accompanies chronic diseases of the gastrointestinal tract. If such pain is noted, you need to consult a doctor and be prepared to answer the following questions: are the pains associated with food (that is, do they always occur before or always after eating, or only after a specific meal); how often the pain occurs, how severe it is; whether the pain is associated with physiological functions, and in older girls with menstruation; where does it usually hurt, is there any specific localization of pain, does the pain spread somewhere; it is advisable to describe the nature of the pain (“pulling”, “burning”, “stabbing”, “cutting”, etc.); what activities usually help with pain (medicines, enema, massage, rest, cold, heat, etc.).

Types of abdominal pain

1. Spasmodic pain in the abdomen (colic, cramps):

• caused by spasm of the smooth muscles of hollow organs and excretory ducts (esophagus, stomach, intestines, gall bladder, biliary tract, pancreatic duct, etc.);
• may occur with pathologies 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 painful attack. With prolonged spastic pain, its intensity changes; after the use of heat and antispastic agents, its decrease is observed;
• accompanied by typical irradiation: depending on the location 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 experiences accompanying phenomena - nausea, vomiting, flatulence, rumbling (especially when taking a horizontal position or changing position). These symptoms are important factors indicating dysfunction of the intestines, stomach, biliary tract or inflammatory processes in the pancreas. Chills and fever usually accompany dangerous intestinal infections or blockage of the bile ducts. Changes in the color of urine and feces are also a sign of blockage of the bile ducts. In this case, urine, as a rule, becomes dark in color, and feces become lighter. Intense cramping pain accompanied by black or bloody stools indicates the presence of gastrointestinal bleeding and requires immediate hospitalization.

Cramping pain in the stomach is an excruciating, squeezing sensation that goes away after a few minutes. From the moment of its onset, the pain takes on an increasing character and then gradually decreases. Spasmodic phenomena do not always occur in the stomach. Sometimes the source is located much lower. As an example, reference can be made to Irritable bowel syndrome These digestive system disorders of unknown origin can cause pain, cramping, loose stools and constipation. People suffering from IBS are characterized by the appearance of pain immediately after eating, which is accompanied by bloating, increased peristalsis, rumbling, intestinal pain with diarrhea or loss of stool. Pain after or during the act of defecation and passage of gases and, as a rule, does not bother you at night. The pain syndrome of irritable bowel syndrome is not accompanied by weight loss, fever, or anemia.

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

A common cause of abdominal pain is the food we eat. Irritation of the esophagus (pressing pain) is caused by salty, too hot or cold food. Certain foods (fatty, cholesterol-rich foods) stimulate the formation or movement of gallstones, causing attacks of biliary colic. Consumption of poor quality products or food that has been improperly cooked usually results in food poisoning of bacterial origin. This disease is manifested by cramping abdominal pain, vomiting and sometimes loose stools. Insufficient dietary fiber or water can also be considered a leading cause of both constipation and diarrhea. These and other disorders are also often accompanied by cramping abdominal pain.

In addition, cramping abdominal pain appears with lactose intolerance, inability to digest sugar contained in dairy products, with autoimmune inflammatory disease of the small intestine - Celiac disease, when the body cannot tolerate 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 cramping pain can occur, but also intestinal bleeding.

Another disorder that leads to pain can be a viral infection.

2. Pain from stretching of hollow organs and tension of their ligamentous apparatus(distinguished by an 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 intestinal vessels, stagnation in the portal and inferior vena cava system, impaired microcirculation, etc.

Angiospastic pain in the abdomen is paroxysmal;

Stenotic abdominal pain is characterized by a slower onset, but both usually occur at the height of digestion (“abdominal toad”). In the case of thrombosis or embolism of a vessel, this type of abdominal pain becomes severe and increasing in nature.

4. Peritoneal pain the most dangerous and unpleasant conditions combined into 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, general health is poor, the temperature often rises, severe vomiting occurs, and the muscles of the anterior abdominal wall are tense. Often the patient assumes a resting position, avoiding minor movements. In this situation, you cannot give any painkillers until examined by a doctor, but you must 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 quite constant, in the right lower abdomen (although it can begin in the upper left), usually with a slight rise in temperature, and there may be a single vomiting. The state of health may worsen over time, and eventually signs of an “acute abdomen” will appear.

Peritoneal abdominal pain occurs suddenly or gradually and lasts for a more or less long time, subsiding gradually. This type of abdominal pain is more clearly localized; upon palpation, limited painful areas and points can be detected. When coughing, moving, or palpating, the pain intensifies.

5. Referred abdominal pain(we are talking about the reflection of pain in the abdomen with diseases of other organs and systems). Referred 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 doesn’t want to, or after some kind of psycho-emotional stress or shock. At the same time, it is not at all necessary that he is faking it; the stomach can really hurt, sometimes even the pain is very strong, reminiscent of an “acute stomach”. But during the examination they find nothing. In this case, you need to consult a psychologist or neurologist.

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

Locations of abdominal pain (Table 2)

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

Diagnosis of abdominal pain (intestinal pain)

1. All women of reproductive age must undergo a biochemical test to determine pregnancy.
2. Urinalysis helps diagnose genitourinary tract infection, pyelonephritis and urolithiasis, but is nonspecific (for example, in acute appendicitis, pyuria may be detected).
3. With inflammation, as a rule, there is leukocytosis (for example, with appendicitis, diverticulitis), but a normal blood test does not exclude the presence of an inflammatory or infectious disease.
4. Results of liver function tests, amylase and lipase may indicate pathology of the liver, gallbladder or pancreas.
5. Imaging methods:

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

CT scan of the abdominal cavity quite often makes it possible 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 exclude myocardial ischemia

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

The location of abdominal pain is one of the main factors in diagnosing the disease. Pain concentrated in the upper abdominal cavity is usually caused by disorders in the esophagus, intestines, biliary tract, liver, and pancreas. Abdominal pain that occurs due to cholelithiasis or inflammatory processes in the liver is localized in the upper right abdomen and can radiate under the right shoulder blade. Pain from ulcers and pancreatitis usually radiates through the entire back. Pain caused by problems in the small intestine is usually concentrated around the navel, while pain caused by the large intestine is recognized below the navel. Pelvic pain usually feels like pressure and discomfort in the rectal area.

In what cases should you visit a proctologist for abdominal pain?

If the answer to at least one of the following questions is positive, you should consult a doctor:

• Do you often experience stomach pain?
• Does your pain affect your daily activities and work responsibilities?
• Are you experiencing weight loss or decreased appetite?
• Are you seeing changes in your 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 side effects on the gastrointestinal tract (aspirin, non-steroidal anti-inflammatory drugs)?
• Diagnosis of abdominal pain (stomach pain).

If it is not possible to establish a diagnosis in a patient with abdominal pain examined according to the standards (for abdominal pain of unknown origin), it is recommended that capsule endoscopy, since in this case abdominal pain may be caused by pathology of the small intestine (ulcers, tumors, celiac disease, Crohn's disease, diverticulosis, etc.). Difficulties in diagnosing lesions of the small intestine are due, first of all, to the difficult accessibility of this part of the digestive tract for standard instrumental diagnostic methods, the locality of the pathological changes that occur, and the lack of specific symptoms. Capsule endoscopy solves this problem and in most clinical cases helps to establish a diagnosis in patients with abdominal pain of unknown origin.

Differential diagnosis of abdominal pain (stomach pain).

Perforated ulcer of the stomach or duodenum- the patient suddenly feels extremely sharp pain in the epigastric region, which is compared to the pain of being hit by 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, affecting the right iliac region, and then throughout the entire abdomen. The characteristic position of the patient is: 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. Severe tension in the muscles of the anterior abdominal wall, in a later period - the development of local peritonitis. Percussion determines the absence of hepatic dullness, which indicates the presence of free gas in the abdominal cavity.

Acute cholecystitis- characterized by repeated attacks of acute pain in the right hypochondrium, which are accompanied by elevated body temperature, repeated vomiting, and sometimes jaundice, which is not typical for a perforated gastric ulcer. When the picture of peritonitis develops, differential diagnosis is difficult; video endoscopic technology 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 detected. Positive Ortner's symptom, phrenicus symptom, high leukocytosis, rapid pulse are noted.

Acute pancreatitis- the onset of the disease is preceded by the consumption of rich fatty foods. Sudden onset of acute pain is of a girdling nature, accompanied by uncontrollable vomiting of gastric contents with bile. The patient screams in pain and cannot find a restful position in bed. The abdomen is swollen, muscle tension is like a perforated ulcer, peristalsis is weakened. Positive Voskresensky and Mayo-Robson symptoms are observed. Biochemical blood tests show a high level of amylase, and sometimes bilirubin. Video endolaparoscopy reveals plaques of fat necrosis on the peritoneum and in the greater omentum, hemorrhagic effusion, and the pancreas with black hemorrhages.

Hepatic and renal colic- acute pain is 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, gastric contents descend into the right iliac region, it causes sharp pain in the right iliac region, epigastrium, tension in the anterior abdominal wall and symptoms of peritoneal irritation.

Thromboembolism of mesenteric vessels- characterized by a sudden attack of abdominal pain without a specific localization. The patient is restless, tosses about in bed, intoxication and collapse quickly develop, and loose stools mixed with blood appear. The abdomen is distended without tension of the anterior abdominal wall, peristalsis is absent. Pulse is frequent. A heart defect with atrial fibrillation is detected. Often there is an indication in the anamnesis of embolism of peripheral vessels of the aortic branches. During diagnostic video endolaparoscopy, hemorrhagic effusion and necrotic changes in intestinal loops are detected.

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

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

Dangerous symptoms that require urgent surgical intervention for abdominal pain include:

• dizziness, weakness, apathy;
• arterial hypotension, tachycardia;
• visible bleeding;
• fever;
• repeated vomiting;
• increasing increase in abdominal volume;
• absence of gas discharge, peristaltic noise;
• increased abdominal pain;
• abdominal wall muscle tension;
• positive Shchetkin-Blumberg symptom;
• vaginal discharge;
• fainting and pain during bowel movements.

Clinical cases of Crohn's disease using capsule endoscopy techniques in examination And

Patient A.61 female. I was undergoing a capsule endoscopy study in May 2011. She was admitted with complaints of chronic abdominal pain and flatulence. The patient has been ill for 10 years and has undergone multiple colonoscopies, gastroscopy, MRI with contrast and CT. The patient was observed and treated by doctors of various specialties: gastroenterologist, surgeon, therapist, neurologist, psychiatrist...

A capsule endoscopy study revealed erosions of the small intestine in the patient with local villousness. As well as hyperemic ileal mucosa.

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

Patient O wives 54. She was admitted to the proctology department of the Regional Clinical Hospital with complaints about periodic pain in the left iliac region, nausea, loose stools 2-3 times a day. She has been ill for 7 years. Previously, colonoscopy and gastroscopy were performed without pathology. When conducting capsule endoscopyin June 2011 The patient was found to have altered ileal mucosa.

When we performed a 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, mesalazine, and diet therapy for two months; the patient's stool returned to normal and the abdominal pain stopped. She is now under observation.