Chronic Abdominal Pain

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Introduction

• Chronic abdominal pain is a common presentation.
• Reported prevalence ranges from 8% to 54%.
• Women are more likely than men to report chronic abdominal pain.
• The prevalence of paediatric functional abdominal pain is 13.5%.

​

• Majority of them do not have serious disorders

​

• Very important not to miss the red flags which could be challenging for the paramedics and medical officers.

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Definition

Chronic abdominal pain is defined:

​

• as continuous or intermittent abdominal discomfort lasting for 3 to 6 months ^1,2.

​

• The pain can be originated from any system, such as the gastrointestinal, genitourinary and gynaecological tracts ¹.

​

¹Jonathan Gotfried. Chronic Abdominal Pain and Recurrent Abdominal Pain. Merck Manuals.2022 Sept. Available: http://www.msdmanuals.com/professional/gastrointestinal-disorders/symptoms-of-gi-disorders/chronic-and-recurrent-abdominal-pain

²Assessment of chronic abdominal pain. BMJ Best Practise. 2022 Mar. Available: https://bestpractice.bmj.com/topics/en-gb/767

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Classification

Chronic abdominal pain is divided into organic and functional aetiologies.

​

• Organic aetiologies have a clear anatomical, physiological, or metabolic cause and can also arise from the abdominal wall, nerve or fascia ³.

​

• A more challenging condition and common is called functional chronic abdominal pain when there is no clear source of pain, despite thorough investigations ³.

​

³Tolba, R., Shroll, J., Kanu, A., Rizk, M.K. (2015). The Epidemiology of Chronic Abdominal Pain. In: Kapural, L. (eds) Chronic Abdominal Pain. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1992-5_2

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Epidemiology

​

Epidemiological data suggest that the incidence of unspecified abdominal pain is 22.9 per 1000 person-years ³.

​

A cross-sectional survey among adult population reported as high as 25% have abdominal pain at one time ³. In a systemic review of chronic abdominal pain in children and adolescents, the prevalence rate ranged is 4 to 53% ⁴.

​

³Tolba, R., Shroll, J., Kanu, A., Rizk, M.K. (2015). The Epidemiology of Chronic Abdominal Pain. In: Kapural, L. (eds) Chronic Abdominal Pain. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1992-5_2

⁴Banez GA. Recurrent abdominal pain in children and adolescents: Classification, epidemiology and etiology/conceptual models.

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Epidemiology

​

Diagnosis and management is often challenging at primary health care setting.

​

Factors that contribute to this include:

• poor sensitivity of the history and physical examination,
• a broad differential diagnosis that crosses several specialties, and
• an often negative diagnostic work ².

​

²Assessment of chronic abdominal pain. BMJ Best Practise. 2022 Mar. Available: https://bestpractice.bmj.com/topics/en-gb/767

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Common 10 diagnosis of chronic abdominal pain at primary health care level

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

It is important to rule out any red flag:

​

1. Acute Coronary Syndrome

2. Malignancy

3. MARK’s Quadrant Score > 10

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Flow chart management of chronic abdominal pain in primary health care

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

It is important to rule out any red flag:

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Thank You

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Functional Dyspepsia

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Functional Dyspepsia

Prevalence: 10-30% ⁷

Clinical Features

• ROME IV : Presence of at least one of the following:

• Postprandial fullness ( 3 days per week)

• Early satiety ( 3 days per week)

• Epigastric pain (1 day per week)

• Epigastric burning ( 1 day per week)

AND

• No evidence of structural disease

* Criteria must be present for at least the past three months, with symptoms starting at least six months before diagnosis.

​

⁷ Theodor A, Roxana G et al. Functional Dyspepsia Today. Maedica (Buchar). 2013 Mar; 8(1): 68–74

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Functional Dyspepsia

Functional dyspepsia accounts for 70% of dyspepsia.

​

Diagnosis of exclusion, therefore, evaluation for a more serious disease eg malignancy is warranted.

​

Medication history should be taken to assess for any drugs that are associated with dyspepsia.

e.g. Acarbose, Antibiotics, Bisphosponates, Corticosteroids, Iron, Metformin, NSAIDs, Orlistat, Theophylline, Potassium chloride

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Functional Dyspepsia

Physical Examination/ Investigations:

• Normal physical findings

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Functional Dyspepsia

Management

• Dietary Modification

• Limit foods associated with functional dyspepsia e.g. foods high in fat, wheat, FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols), and naturally occurring food chemicals such as caffeine.

• Avoid drugs associated with dyspepsia

• H2 Receptors Antagonist (Ranitidine) / PPI (Pantoprazole) (Epigastric pain syndromes)

• Prokinetics (Metoclopramide/ Domperidone) for 4 weeks (Post- prandial distress syndrome)

• Psychological therapy (e.g. Cognitive Behaviour Therapy)

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Functional Dyspepsia

​

Refer Surgical or Gastro if

• No response to treatment for 4 weeks

• Alarm symptoms (profound weight loss, anemia, epigastric mass, enlarged supraclavicular lymph node)

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gastroesophageal Reflux Disease (GERD)

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gastroesophageal Reflux Disease (GERD)

Prevalence

• SEA and West Asia: 6.3-18.3% ⁸

​

Clinical Features

• Typical symptoms: Heartburn, regurgitation, dysphagia ⁹

• Atypical symptoms: dyspepsia, epigastric pain, nausea, bloating and belching may be indicative to GERD ⁹

• Extra oesophageal symptoms: chronic cough, asthma and chronic laryngitis

​

⁸Hye-Kyung Jung. Epidemiology of Gastroesophageal Reflux Disease in Asia: A systemic review (JNM) Journal Neurogastroenterology Motil, Vol. 17 No.1 January, 2011

⁹Philip O, Lauren B, Marcelo F. Guidelines for the Diagnosis and Management of GERD. Am J Gastroenterol 2013;108:308-328

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gastroesophageal Reflux Disease (GERD)

Physical Examination/Investigations

• Normal physical findings

​

Investigations – not needed ¹¹

​

¹¹John Murtagh. John Murtagh’s general practice. Dyspepsia (indigestion).4^th edition. Chap 47:511-520

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gastroesophageal Reflux Disease (GERD)

Management

• Exclude cardiac cause

• Extra oesophageal symptoms; need careful evaluation for non-GERD causes ⁹

• Non-pharmacotherapy

• Lifestyle modification

• Avoid drugs (11): Anticholinergics, Theophylline, CCB.

• If taking drugs like Tetracycline, Slow Release Potassium, Iron sulphates, Corticosteroids and NSAIDS - use ample fluids to swallow medications.

• Pharmacotherapy

• PPI for 8 weeks

⁹Philip O, Lauren B, Marcelo F. Guidelines for the Diagnosis and Management of GERD. Am J Gastroenterol 2013;108:308-328

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gastroesophageal Reflux Disease (GERD)

Refer for endoscopy if

• Failed treatment with PPI after 2 months

• Presence of red flag

• High risk group

• History of Barret’s oesophagus

• Dysphagia

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gastroesophageal Reflux Disease (GERD)

Refer for endoscopy if

• Failed treatment with PPI after 2 months

• Presence of red flag

• High risk group

• History of Barret’s oesophagus

• Dysphagia

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Peptic Ulcer Disease (PUD)

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Peptic Ulcer Disease (PUD)

Prevalence

• 1-year prevalence based on physician diagnosis was 0.12–1.50% ¹³

Clinical Features

• History of smoking, NSAIDS, Aspirin, H.pylori infection ¹⁴

• Epigastric pain; gnawing or burning sensation especially after meal ¹⁴

• Fullness, bloatedness, nausea, vomit a few hours after meal, dyspepsia, heartburn, chest discomfort, hematemesis, melena or symptoms of anaemia ¹⁴

Physical Examination/Investigations

• Epigastric tenderness, melena

• FBC for anaemia

​

¹³Sung JJY, Kuipers EJ et al. Alimentary Pharmacology & Therapeutics. Vol 29, Issue 9, Article first published online: 10 FEB 2009 Systematic review: the global incidence and prevalence of peptic ulcer disease

¹⁴BS Anand et al. Peptic Ulcer Disease. Medscape 2021 Apr.

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Peptic Ulcer Disease (PUD)

Management

• Stop NSAIDS ¹⁵ Aspirin

Prevention:

• If NSAIDS is needed, choose COX-2 selective inhibitor at the lowest efficacy dose plus daily PPI ¹⁶

• If Aspirin is needed as secondary CVD prevention, consider long term PPI therapy ¹⁶

• If Aspirin was given for primary prevention, antiplatelet should not be resumed

• Quit smoking

• Offer full dose PPI eg. Pantoprazole 40mg OD or H2RA therapy for 8 weeks ¹⁵

Refer SOPD/ Gastro for OGDS

RED FLAG: Anaemia, Early satiety, Unexplained weight loss, dysphagia/ odynophagia, recurrent vomiting, Family history GI cancer

¹⁵Sung JJY, Kuipers EJ et al. Alimentary Pharmacology & Therapeutics. Vol 29, Issue 9, Article first published online: 10 FEB 2009 Systematic review: the global incidence and prevalence of peptic ulcer disease

¹⁶Laine, Loren; Jensen, Dennis M. Management of Patients With Ulcer Bleeding. American Journal of Gastroenterology 107(3):p 345-360, March 2012.

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Irritable Bowel Syndrome (IBS)

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Irritable Bowel Syndrome (IBS)

Prevalence: 7-10% in the world ¹⁷

Clinical Features

• Diagnosis-ROME III Criteria: Recurrent abdominal pain or discomfort at least 3 months associated with≥ 2 of the following:

• Improvement with defecations

• Onset associated with a change in frequency of stool

• Onset associated with a change in form(appearance) of stool

• Should be accompanied by at least 2 of the following 4 symptoms: ¹⁹

• Altered stool passage (straining, urgency, incomplete evacuation)

• Abdominal bloating, distension, tension or hardness

• Symptom made worse by eating

• Passage of mucus

• Age onset 20-30y

​

¹⁷ Lisa G. Practice Guidelines. ACG Releases Recommendations on the Management of Irritable Bowel Syndrome; Am Fam Physician. 2009 Jun; 79 (12):1108 – 1117.

¹⁹ Irritable bowel syndrome in adults: diagnosis and management Clinical guideline [CG61]Published: 23 February 2008 Last updated: 04 April 2017

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Irritable Bowel Syndrome (IBS)

Physical Examination/Investigations

• Overall healthy or maybe tense or anxious

• May have sigmoid tenderness or palpable sigmoid cord ²⁰

​

No Investigations for age <50year old with typical IBS sign and symptoms ¹⁹

​

¹⁹ Irritable bowel syndrome in adults: diagnosis and management Clinical guideline [CG61]Published: 23 February 2008 Last updated: 04 April 2017

²⁰ Jenifer K Lehrer et al. Irritable Bowel Syndrome (IBS). Medscape Feb 15, 2022.

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Irritable Bowel Syndrome (IBS)

Management

• Lifestyle advice: Increase physical activity & Dietary advice ¹⁹

Pharmacotherapy ¹⁹:

• Consider antispasmodic agent; to take as required

• Laxative for constipation, not lactulose (specific laxative)

• Loperamide for diarrhoea

• Antidepressant if all above not help

​

Refer surgical or gastro if having alarm features such as:

• Loss of weight

• Anaemia

• Family History of GI organic disease eg IBD, Colon Cancer

​

¹⁹ Irritable bowel syndrome in adults: diagnosis and management Clinical guideline [CG61]Published: 23 February 2008 Last updated: 04 April 2017

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gallbladder Disease

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gallbladder Disease

Pain due to

• a gallstone which blocks the bile duct (biliary colic)

• it may become chronic if it recurs for more than 3 months

• Pain Quality: severe colicky pain, short lived with associated sweating.

• the pain goes away if the stone passes into the small intestine and unblocks the duct.

• Pain especially after fatty meal.

Site

• Right upper quadrant, but also epigastrium and other parts of the abdomen.

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gallbladder Disease

Factors that may increase risk of gallstones

• Female

• Age 40 or older

• Overweight or obese

• Sedentary

• Pregnant

• Eating a high-fat diet

• Eating a high-cholesterol diet

• Eating a low-fibre diet

• Having a family history of

gallstones

​

​

• Having diabetes

• Having certain blood disorders, such as sickle cell anaemia or leukaemia

• Losing weight very quickly

• Taking medications that contain estrogenic, such as oral contraceptives or hormone therapy drugs

• Having liver disease

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gallbladder Disease

Radiology

• Abdominal x-ray has limited use to diagnose gallstone.

• Ultrasound Abdomen is the best imaging test for detecting gallstones. (only rarely are cholecystograms needed).

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Gallbladder Disease

Management:

• Pain relief with antispasmodics (Hyoscine)

• IM Diclofenac in patients with severe pain

• Refer surgery

• The usual treatment for chronic gallstones with pain is removal of the gallbladder.

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Nephrolithiasis

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Nephrolithiasis

Clinical Features

• History of recurrent renal colic pain-severe pain from flank and radiate inferiorly and anteriorly

• History of urinary tract calculi

• UTI

• Haematuria

• Urinary symptoms – stones lodged at ureterovesical junction (frequency, dysuria), stones lodged at intramural ureter (suprapubic pain, frequency, urgency, dysuria, stranguria, pain tip of penis)

• Asymptomatic in small, non-obstructing stone or staghorn calculi

• Family history of renal calculi ²⁵

​

²⁵Chirag N Dave. Nephrolithiasis. Medscape Sep 16, 2021 .

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Nephrolithiasis

Physical Examination/ Investigations

• Abdomen – unremarkable

• UFEME, Renal profile, Serum Uric Acid

• Serum calcium/ phosphate and ± Serum parathyroid

• Plain KUB Xray

• KUB USG

• CT Urogram (CTU)-indicated if USG and KUB x rays negative for stone despite strong suspicion of urolithiasis/ persistent haematuria

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Nephrolithiasis

Management

• Dietary modifications-increase fluid intake (8 glasses/day), Low salt and protein diet

• Dietary calcium: 600 – 800mg/day

• Medications: Alkalizing agent

• Allopurinol if evidence of uric acid stones

​

Refer urologist if

• Stones >6 mm ²⁵

• Deranged renal profile(urgent referral)

• USG showed obstructive uropathy (urgent referral)

​

​

​

²⁵Chirag N Dave. Nephrolithiasis. Medscape Sep 16, 2021 .

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Primary Dysmenorrhea

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Primary Dysmenorrhea

90% common cause of dysmenorrhea

​

Clinical features

• Onset menarche, Duration 48-72 hours

• Cramping or labor like pain

• Constant lower abdominal pain, radiating to the back or thigh

​

PE/Ix

• Normal pelvic examination

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Primary Dysmenorrhea

Management

• Reassurance

• Non-medical therapy: High frequency TENS, Acupuncture

• Medical therapy

• NSAID

• Oral contraceptive

• Depot medroxyprogesterone/ levonorgestrel intrauterine system

​

Refer gynae if indication for surgery or suspected secondary cause

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Pelvic Inflammatory Disease (PID)

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Pelvic Inflammatory Disease (PID)

Prevalence

• The number of visits to physicians for PID among women aged 15–44 was 39.8% (29)

​

Clinical Features

• History of high-risk sexual behaviour

• History of instrumentation of uterus insertion

• Abnormal vaginal or cervical discharge

• Lower abdominal pain

• Abnormal vaginal bleeding: Intermenstrual bleeding, Post-Coital Bleeding, Menorrhagia

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Pelvic Inflammatory Disease (PID)

Physical Examination/ Investigations

• Febrile (>38 °C), lower abdominal tenderness, Adnexal or Cervical motion tenderness

​

Ix:

• Tests for Gonorrhoea and Chlamydia (Gram stain, Culture & Sensitivity), FBC, UFEME

• Ultrasound, Diagnostic Laparoscopy

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Pelvic Inflammatory Disease (PID)

Management

• Safe sex

• Educate on long term complication

• Appropriate analgesia (WHO Analgesic Ladder approach)

• Broad spectrum antibiotic to cover N.Gonorrhoea, C. Trachomatis and anaerobic infection

​

Referral if diagnosis uncertain, severe symptoms, presence of a tubo- ovarian abscesses, inability to tolerate an oral regime and pregnancy.

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Chronic Abdominal Wall Pain

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Chronic Abdominal Wall Pain

Prevalence:

• 10-90%

• Common causes of Abdominal Wall pain

• Nerve entrapment

• Hernia

• Surgical and procedural complication

​

Clinical Features

• Pain more common at right side of abdomen

• Usually sharp to extreme tenderness on upon gentle stroking or pinching.

• Exacerbated by tight clothing, obesity or post-operative scarring

• Relief by sitting, lying or relatively frequently by hand-splinting the affected area

• Aggravated by standing, lifting, stretching, eating, defecation and coughing

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Chronic Abdominal Wall Pain

Physical examination/Investigations

• Proper physical examination including Carnett’s test and investigation to find out the cause

• Diagnosis by exclusion

• Assess severity by Trigger Point Injection (TPI) by trained specialist (FMS / Pain Specialist)

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Chronic Abdominal Wall Pain

Management

• Reassurance

• Breathing exercises

• Mild pain

• minimizing activities that aggravate the pain

• An abdominal binder.

​

For moderate to severe pain:

• Modification of physical activities

• Local nerve blocks or trigger point injections using anaesthetic/ steroid injections by trained specialist (FMS / Pain Specialist)

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Infective Gastroenteritis

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Infective Gastroenteritis

Clinical Features

• history of travel to endemic areas;

• greasy, foul-smelling stools;

• diarrhoea (may be bloody, depending on organism, but most chronic forms are nonbloody);

• tenesmus,

• fever, chills

• immunosuppressed patients at higher risk

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Infective Gastroenteritis

Physical examination/Investigations

• Nonspecific physical examination

• Stool culture: positive culture for Escherichia coli, Shigella , Salmonella , or Campylobacter

• Stool ova and parasites: positive

• Stool assay for Clostridium difficile toxin: positive (Indicated if there is a history of recent antibiotic use or in hospitalized patients).

• Sigmoidoscopy/ colonoscopy with biopsy: microbiologic and/or histologic confirmation of infection

• Endoscopic exam is not required in the vast majority of patients with gastroenteritis.

• In patients with negative cultures, or persistent diarrhoea and no improvement with conservative management, sigmoidoscopy should be performed to exclude other causes of diarrhoea.

• Colonoscopy is rarely required, and is usually postponed until colonic inflammation has resolved.

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA

Infective Gastroenteritis

Management

• Treat according to causative organism.

• Do not use anti-diarrheal agent.

• Hydration

• Antimuscuranic (Hyoscine Butylbromide)

​

​

​

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA