Clinical Approach to Colic Pain
Dr. dr. Syifa Mustika, SpPD-KGEH, FINASIM
Divisi Gastroenterohepatologi, Departemen Ilmu Penyakit Dalam
RS dr. Saiful Anwar – Fakultas Kedokteran Universitas Brawijaya
Malang 2024
Curriculum Vitae
• Nama : Dr. dr. Syifa Mustika, SpPD-KGEH-FINASIM
• Tempat, tanggal lahir : Banyuwangi, 30-4-1978
• Perhimpunan :
• Anggota Ikatan Dokter Indonesia (IDI)
• Pengurus Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI) Cabang
Malang
• Anggota Perhimpunan Peneliti Hati Indonesia (PPHI)-Perkumpulan Gastroenterologi
Indonesia (PGI)-Perhimpunan Endoskopi Gastrointestinal Indonesia (PEGI)
• Member of Asian Pacific Association for The Study of The Liver (APASL)
• American Association for the Study of Liver Diseases (AASLD)
• Perhimpunan Dokter Nahdlatul Ulama (PD NU)
• World Endoscopy Organization (WEO)
• Alamat : Jl. Raya Permata Jingga I/9 Blok AA-2, Malang, Jawa Timur
• Pekerjaan saat ini :
• Dosen Fakultasi Kedokteran Universitas Brawijaya, Malang
• Staff di Divisi Gastroenterohepatologi, Departemen Ilmu Penyakit Dalam RS. Saiful
Anwar, Malang
• Dokter Spesialis Penyakit Dalam Konsultan Gastroenterohepatologi di RS. Saiful Anwar
Malang, RS Hermina Tangkuban Perahu Malang, RS Lavalette Malang
• Riwayat Pendidikan:
S1 Fakultas Kedokteran Universitas Brawijaya 2001
Sp-1 Fakultas Kedokteran Universitas Brawijaya 2012
SP-2 Fakultas Kedokteran Universitas Brawijaya 2018
S3 Fakultas Kedokteran Universitas Brawijaya 2024
OUTLINE
1 Colicky Abdominal Pain at A Glance
2 Diagnostic Approach
3 Treatment Approach
4 Conclusion
Colicky Abdominal Pain at A Glance
Introduction
A myriad of conditions can cause acute abdominal pain,
ranging from life-threatening to self-limiting.
Abdominal colicky pain is one of the pain characteristics
frequent in daily practice
The diagnosis of diseases as the cause of acute abdominal
colicky pain is various.
The differential diagnoses need to be established through a
thorough history and physical examination.
Colic Pain Definition
• Colic pain) is associated with numerous diseases of hollow viscera. the
mechanism of pain is thought to be smooth muscle contraction proximal to a
partial or complete obstruction (e.g., gall stone, kidney stone, small bowel
obstruction).
• There is pain-free intervals reflecting intermittent peristalsis
• Sharp or dull intermittent pain
• Sharp colicky pain : ureters or uterine tube obstruction
• Dull colicky pain : bowel obstruction
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Description of Abdominal pain
General
Local
or diffuse
Referred
Colicky
Am Fam Physi cian. 2008;77(7):971-978.
Types of Abdominal Pain
Visceral
• Crampy, achy, diffuse
• Colicky abdominal pain is the major symptom
Somatic Parietal
• Sharp, lancinating
• Weel localized
Referred
• Distant from site of generation
• Symptoms, but no signs
Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set, 11th Edition
Patterns of Acute Abdominal Pain
A. Subside spontaneously with time (e.g gastroenteritis)
B. Colicky pain (i.e. the pain progresses and remits over
time); e.g. intestinal, renal, and biliary pain (colic)
C. Commonly, acute abdominal pain s progressive, as in
acute appendicitis or diverticulitis
D. Certain conditions have catastrophic onset, such as
ruptures abdominal aortic aneurysm
Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set, 11th Edition
Diagnostic Approach
History Taking
Location,
Spread,
Onset, Duration
Intensity,
Characteristic
Conditions that Other
trigger and accompanying
reduce pain circumstances
Am Fam Physi cian. 2008;77(7):971-978.
History Taking: Onset
Gradually: acute
Sudden: Colic biliary, Colic
cholecystitis, acute
ureteral, perforated ulcer,
cholangitis, acute hepatitis,
Acute pancreatitis,
appendicitis, diverticulitis,
strangulated bowel,
IBD, Small Bowel
Miocard infarct
obstruction
Am Fam Physi cian. 2008;77(7):971-978.
Gradual Progressive Colic, cramping, intermittent Sudden, severe pain
History Taking: Pain
Characteristics
Referred pain
Acta Med Indones. 2012 Oct;44(4):344-50
History Taking: Aggravating and
Alleviating Factors
Conditions that trigger and reduce pain Other accompanying circumstances
Influenced by food (abnormalities in the stomach and small intestine) Changes in the pattern of defecation (from the process of the colon
and IBS)
Lower abdominal pain decreases with flatus and bowel movements Vomiting or upper abdominal distention (small bowel obstruction)
(abnormalities in the rectum or increased rectal sensitivity)
Pain medication that reduce abdominal pain (Paracetamol is effective Hematuria (renal colic)
for solid organs, musculoskeletal and antispasmodic is effective for
viscus organ)
Pain when tapped (abdominal wall disturbance)
Pain aggravated by stress (Functional or Organic disturbance)
Am Fam Physi cian. 2008;77(7):971-978.
Comparison of Common Causes of Acute Abdominal
Pain
Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set, 11th Edition
Assess General condition and Airway,
Breathing, Circulation
Vital Sign: Blood pressure, pulse,
respiratory rate, temperature, VAS
Physical Inspection
Examination
Auscultation
Palpation and percussion: from the
painless area to the painful area
Useful Findings in the Evaluation of Abdominal Pain
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Imaging
Early Secondary
Chest X-ray: pneumonia, free air under the Location Imaging
diaphragm Right Upper quadrant Ultrasonography
Plain abdominal radiographs: intestinal Left Upper quadrant CT
obstruction, air fluid level, intestinal cystoid Right Lower quadrant Ct scan with IV contrast
pneumatosis or thumb image
Left Lower quadrant Ct scan with oral and IV contrast
Suprapubic Ultrasonography
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Imaging
Computerized
Abdominal ultrasound: tomography(CT) abdomen:
Magnetic resonance
gallstones, cholecystitis, pancreatitis, pancreatic
imaging(MRI): the same
appendicitis or ruptured cancer, appendicitis,
with CT.
ovarian cysts. diverticulitis, abscesses of
abdomen.
Barium X-rays: ulcers, Computerized Capsule enteroscopy:
inflammation, intestinal tomography(CT) of the small Crohn’s disease, small bowel
obstruction. intestine: Crohn’s disease. tumors, bleeding lesions.
Am Fam Physi cian. 2008;77(7):971-978.
Endoscopy
Esophagogastroduodenoscopy (EGD): ulcers, gastritis, gastric cancer
Colonoscopy or flexible sigmoidoscopy: infectious colitis, ulcerative
colitis, colon cancer
Endoscopic ultrasound(EUS): pancreatic cancer, gallstones.
Laboratory Test
General Specific Disease
• Routine blood • Pancreas: Amylase, lipase
• Electrolyte • ACS: troponin T, CPK-MB
• Liver Function: SGOT, SGPT, ALP, LDH • Coagulation: PT, APTT, D-dimer
• Kidney Function: BUN, Creatinine • Unconscious: NH3 ammonia, vitamin
• Inflammation: LED, CRP, Creatinine B12, alcohol
Kinase (CK) • Infection: HBsAg, anti HCV, HIV, syphilis
• Blood Sugar • Blood gas analysis
• Urinalysis • Culture
Differential Diagnosis for Abdominal Pain Based On
Location
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Algorithm of
Evaluation
Approach in
Abdominal Pain
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Treatment Approach
Early Management Analgesic/Antispasmodic
Treatment
Approach
Antibiotic as indicated Surgical Consultation
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• Fluid resuscitation: Crystalloid fluid
• Electrolyte replacement
Early • Blood transfusion if needed
Management • Identification of Surgical Emergencies
Pharmacologic Management
Symptomatic: Treatment of the causes:
Antispasmodic, Analgetic, antibiotic/anti parasitic for
Combination infections, Anti
antispasmodic+analgetic, inflammatory drugs for
opioid inflammation
Pharmacologic Management
• Several studies reported that early treatment by administering
analgesics may provide pain relief and does not obscure diagnosis.
• Appropriate antibiotics should be provided in accordance with the
indication, e.g. for peritonitis.
• In some conditions, empirical antibiotic treatment may be given
when establishing the working diagnosis of abdominal pain without
waiting for the results of culture tests
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Surgical Management
• The management of patient with acute abdomen ultimately includes the
determination whether the case is surgical case which requires surgical
treatment.
• Acute appendicitis: Appendictomy
• Peritonitis or perforation of Peptic ulcer: operation/laparotomy.
• Acute cholecystitis: Laparoscopic Cholecystectomy.
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Conclusion
Conclusion
Abdominal Pain is frequent in daily Diagnosis of the causes of abdominal The treament of abdominal pain
practice. pain is made according history taking, include non-pharmacologic,
physical examination, laboratory pharmacologic and surgery.
examination and supporting examination.
