Understanding stomach pain

Understanding stomach pain

When I was a surgical registrant, one of the local GPs was able to diagnose acute appendix over the telephone with instructions; “Stand on your right leg and hop.” When the light exercise made the pain worse, he contacted the hospital and said he was sending in a patient with appendicitis and a “positive hops test.”

I know it sounds strange, but for a time he was so uncannily accurate that hopping on one leg was a popular test among juniors in the A&E department.

Presumably the family doctor has long since recovered and his eccentric diagnostic method seems to have been forgotten, but in retrospect I now realize that he unknowingly taught me a lotstomach pain, especially the simplicity of diagnosis. In fact there are only two types.

• Koliken sind quälende, wälzende Schmerzen, die in Wellen kommen. Es wird durch eine abnormal starke Peristaltik eines Hohlvirus aufgrund von Obstruktion, wie Stein, Tumor oder Hernie, oder Reizung, möglicherweise in Verbindung mit Enteritis, Hühnervindaloo oder Abführmitteln, produziert.
• Kontinuierlich. Anhaltende Schmerzen im Liegen, die durch Bewegung noch schlimmer werden, werden durch Entzündungen aufgrund einer Infektion, Peritonitis oder Ulzeration oder Ischämie in Verbindung mit einem Infarkt oder einer Mesenterialembolie verursacht.

Forget all about burning, stinging, excruciating, horrible, and any other adjectives that can be used. Your ears and your eyes will tell you whether or not the patient describes colicky or persistent pain. Or perhaps you could ask if it causes them to roll around or lie still. In any case, it has to be colic or constant colic, and once that's established, you're halfway there - you'll know whether the pain is due to constipation or irritation or inflammation. There is nothing else to consider.

Next is, where exactly is the pain felt? This requires a little knowledge of embryology.

No! Please don't give up at this point just because I mentioned embryology. To keep you interested, I want you to think back to the last time you suffered from “gastroenteritis,” or in some cases, a beer and curry overdose. Those teeth marks you left on the toilet door handle were the result of the suprapubic colic you felt the next morning when your intestines exploded.

The point is that afferent visceral impulses reach the brain via the pouches and splanchnic nerves and are perceived simply as foregut (epigastric), midgut (periumbilical), or hindgut (suprapubic) pain in the midline. Typically, a patient places their hand on the appropriate area when describing their viscelial pain or does so when prompted.

So, at the risk of becoming boring, let's restate the facts. Foregut, midgut and hindgut, coupled with colic or continuous colic, receive the diagnosis almost every time. Now we just need to know which bits are which:

• Vorderdarm: Magen, erstes und zweites Herz des Zwölffingerdarms, der Gallenblase, des Billardbaums und der Bauchspeicheldrüse.
• Mitteldarm: Dritter und vierter Teil des Duodenums zu zwei Dritteln über dem Colon transversum.
• Hinterdarm: Letztes Drittel des Colon transversum, des Colon descendens, Rektum und der gynäkologischen Bereiche (das letzte stammt aus dem Kloakensack).

Let's use an example commonly encountered in the clinic or on war rounds - an anemic 60-year-old with weight loss and a few months of periumbilical (midgut) colicky abdominal pain.

Based on the history alone, it only has to be a right or transverse colon cancer, and if you're lucky, a hand on your stomach will feel a right-sided mass. Light.

Inspired by Seto El Kahfi