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Disorders of the thoracic cage and abdomen - sharp pain in lower right abdomen

Disorders of the thoracic cage and abdomen-sharp pain in lower right abdomen

Disorders of the thoracic cage and
Referred pain . . . . . . . . . . . . . . . . . . . . . . . e185
Pain referred from visceral structures . . . . . . . e185 Ischaemic heart disease
Pain referred from musculoskeletal structures not The innervation of the heart is derived from the C8-T4 seg-
belonging to the thoracic cage . . . . . . . . . . . e191 ments. Pain is therefore not only felt in the chest but can also
Disorders of the thoracic cage and abdomen . . . . . e191 be referred to the ulnar side of both upper limbs, though more
Disorders of the inert structures . . . . . . . . . . e191 commonly to the left.
It is traditionally accepted that pain felt in the chest radiat-
Disorders of the contractile structures . . . . . . . e193 ing into the left arm is indicative of myocardial ischaemia,
especially when the patient reports it as pressure, constriction,
squeezing or tightness. However, none of these descriptions,
Pain in the thorax or abdomen can be the result of a local
which are usually regarded as characteristic of ischaemia, is of
problem of either the thoracic wall or the abdominal muscles
definitive aid in the differential diagnosis from other non-
but it is more often referred from a visceral structure or
cardiogenic problems in the thorax. Even relief of pain after
from another musculoskeletal source, most frequently a disc
the intake of glyceryl trinitrate does not offer absolute confir-
protrusion. Therefore, it is wise to remember the only safe
mation of coronary ischaemia. For clinical diagnosis, a combina-
approach in this area is to achieve a diagnosis by both positive
tion of several elements must be present, of which the most
confirmation of the lesion and exclusion of other possible
important is pain spreading to both arms and shoulders initi-
ated by walking, especially after heavy meals or on cold days.1
Mitral valve prolapse
This condition usually gives rise to mild pain located in the left
Referred pain submammary region of the chest and sometimes also subster-
nally. Occasionally it mimics typical angina pectoris and is
sometimes accompanied by palpitations.
Pain referred from visceral
structures Pericarditis
Pain that arises from the pericardium is the consequence of
All visceral structures belonging to the thorax or abdomen irritation of the parietal surface, mainly from infectious peri-
may give rise to pain felt in this area (see Ch. 25). In that carditis, seldom from a myocardial infarction or in association
the discussion of these disorders is principally the province with uraemia. When pericarditis is the outcome of one of the
of internal medicine, only major elements in the history latter two causes it is usually only slight. Pain is normally
that are helpful in differential diagnosis from musculoskeletal located at the tip of the left shoulder, in the anterior chest or
disorders are mentioned here. Acute chest pain is summarized in the epigastrium and the corresponding region of the back.
in Box 1. Three different types of pain can be present. First and most
? Copyright 2013 Elsevier, Ltd. All rights reserved.
The Thoracic Spine
When aortic dissection involves the vessels that supply the
Box 1 spinal cord, neurological changes and even paraplegia may
Summary of acute chest pain
Severe chest pain of abrupt onset should arouse suspicion of: Pleuritic pain
Myocardial infarction
Dissecting aneurysm
Pneumothorax Pleuritic chest pain is a common symptom and has many
Pulmonary embolus causes, which range from life-threatening to benign, self-
Rupture of the oesophagus limited conditions. Because neither the lungs nor the visceral
Acute thoracic disc protrusion pleura have sensory innervation, pain is only present if the
parietal pleura is involved, which may occur in inflammation
or in pleural tumour. Invasion of the chest wall by a pulmonary
neoplasm also provokes pain.
Clinical presentation
Pleuritic pain is localized to the area that is inflamed or along
predictable referred pain pathways. Parietal pleurae of the
outer rib cage and lateral aspect of each hemidiaphragm are
innervated by intercostal nerves. Pain is therefore referred to
their respective dermatomes. The central part of each hemidia?
phragm belongs to the C4 segment and therefore the pain is
referred to the ipsilateral neck or shoulder.
The classic feature is that forceful breathing movement,
Fig 1 ? Referred pain in lesions of the heart. such as taking a deep breath, coughing, or sneezing, exacerbates
the pain. Patients often relate that the pain is sharp and is made
worse with movement. Typically, they will assume a posture
obvious, but rarely encountered, is pain synchronous with the that limits motion of the thorax. Movements of the trunk
heartbeat. Second is a steady, crushing substernal ache, indis- which stretch the parietal pleura may increase the pain.
tinguishable from ischaemic heart disease. Third and most During auscultation the typical `friction rub' is heard. The
common is pain caused by an associated localized pleurisy, normally smooth surfaces of the parietal and visceral pleurae
which is sharp, usually radiates to the interscapular area, is become rough with inflammation. As these surfaces rub against
aggravated by coughing, breathing, swallowing and recum- one another, a rough scratching sound, or friction rub, may be
bency, and is alleviated by leaning forward.2 heard with inspiration and expiration. This friction rub is a
classic feature of pleurisy.
Aorta Aetiologies
Aneurysm of the thoracic aorta Pneumonia
This is most frequently the result of arteriosclerosis but is rare Although the clinical presentation of pneumonia may vary,
by comparison with the same condition below the diaphragm. classically the patient is severely ill with high fever, pleuritic
The majority of small aneurysms remain asymptomatic, but if pain and a dry cough.4
they expand a boring pain results, usually from displacement
of other visceral structures or erosion of adjacent bone. Com- Carcinoma of the lung
pression of the recurrent nerve may result in hoarseness and In carcinoma of lung, pain is consequent upon involvement of
compression of the oesophagus in dysphagia. When acute pain other structures such as the parietal pleura, the mediastinum
and dyspnoea supervene, this usually indicates that the aneu- or the chest wall. Invasion of the chest wall may cause spasm
rysm has ruptured, with a likely fatal outcome. of the pectoralis major muscle, which subsequently leads to a
limitation of both passive and active elevation of the arm.
Dissecting aneurysm of the thoracic aorta Pleural tumour
This is an exceptional cause of chest pain, occurring mainly in Malignant mesothelioma is a diffuse tumour arising in the
hypertensive patients. The process usually starts suddenly in pleura, peritoneum, or other serosal surface. The most fre-
the ascending aorta, giving rise to severe substernal or upper quent site of origin is the pleura (>90%), followed by perito-
abdominal pain. Radiation to the back is common and back neum (6-10%), and only rarely other locations. Mesothelioma
pain may sometimes be the only feature, expanding along the is closely associated with asbestos exposure and has a long
area of dissection as it progresses distally. The patient often latency (range 18-70). There is no efficient treatment and
describes the pain as tearing. In most cases, it is not changed the overall survival from malignant mesothelioma is poor
by posture or breathing. (8.8 months).5,6
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Disorders of the thoracic cage and abdomen
This is characterized by a sharp superficial and well-localized
pain in the chest, made worse by deep inspiration, coughing
and sneezing. Viral infection is one of the most common causes
of pleuritic pain.7 Viruses that have been linked as causative
agents include influenza, parainfluenza, coxsackieviruses, respi-
ratory syncytial virus, mumps, cytomegalovirus, adenovirus,
and Epstein-Barr virus.8
Pulmonary embolism
Pulmonary embolism is the most common potentially life-
threatening cause, found in 5-20% of patients who present to
the emergency department with pleuritic pain.9,10
Predisposing factors for pulmonary embolism are: phlebo?
thrombosis in the legs, prior embolism or clot, cancer, immo-
bilization, prolonged sitting (aeroplane), oestrogen use or
recent surgery.11
Symptoms and signs are mainly dependent on the extent
of the lesion. A small embolus may give rise to effort
dyspnoea, abnormal tiredness, syncope and occasionally to
cardiac arrhythmias. A medium-sized embolus may lead to Fig 2 ? The clinical symptoms of a superior sulcus tumour of the
pulmonary infarction, so provoking dyspnoea and pleuritic lung are produced by local extension into the chest wall, the base
pain. In a massive pulmonary embolus, the patient complains of the neck and the neurovascular structures at the thoracic inlet.
of severe central chest pain and suddenly shows features of
shock with pallor and sweating, marked tachynoea and tachy-
cardia. Syncope with a dramatically reduced cardiac output sternocleidomastoid muscles. On examination of the shoulder
may follow. This is a medical emergency: death may follow girdle, a restriction of both active and passive elevation of the
rapidly. scapula may be present. More positive signs are detected
during examination of the shoulder.15 Both active and passive
Acute pneumothorax elevations of the arm are limited because of spasm of the
This is characterized by a sudden dyspnoea and unilateral pain pectoralis major muscle. Passive shoulder movements may be
in the chest, radiating to the shoulder and arm on the affected considerably limited in a non-capsular way. Some resisted
side and often described as a tearing sensation. Breathing movements are weak.
and activity increase the pain. The typical features of pneu- The neurological examination of the upper limb shows
mothorax are tachycardia, hyperresonance on percussion and weakness and atrophy of the muscles on which consequent is
decreased breath sounds on auscultation. extension of the tumour to the lower trunks of the brachialis
Superior sulcus tumour of the lung plexus (Fig. 2). The only abnormal finding during thoracic
(Pancoast's tumour) examination is pain and limitation on lateral flexion towards
This warrants special attention because 90% of patients suffer-
the unaffected side explained by putting the affected thoracic
ing from this disorder complain of musculoskeletal pain.12,13 It
wall under stretch.
The clinical picture of Pancoast's tumour may be completed
is frequently mistaken for a shoulder lesion or even for thoracic by some typical findings that are caused by an ingrowth of
outlet syndrome, an error which leads to a delay in diagnosis neurological and vascular structures at the apex of the lung.16
and treatment.14
The superior pulmonary sulcus is the groove in the lung
These include:
formed by the subclavian artery as it crosses the apex of the ? Horner's syndrome: this is characterized by an ipsilateral
lung. Because most apical tumours have some relation to the slight ptosis of the upper lid, miosis of the pupil and
sulcus, they are often called superior sulcus tumours. They enophthalmos, together with decreased sweating on the
frequently involve the brachial plexus and the sympathetic same side of the face. It is the outcome of involvement of
ganglia at the base of the neck and may destroy ribs and the ascending sympathetic pathway at the stellate ganglion
vertebrae. on the side of the tumour.17
Pain around the shoulder, radiating down the arm and ? Hoarseness: this is the result of involvement of the
towards the upper and lateral aspect of the chest is usual and recurrent laryngeal nerve, which innervates the voice
is often worse at night. cords. The hoarseness is unusual and unlike that caused by
Orthopaedic clinical examination produces an unusual local laryngeal problems.
pattern of clinical findings. There is often a complicated ? Oedema and discoloration of the arm: this occurs if the
mixture of cervical, shoulder and thoracic signs. Passive and subclavian vein is obliterated by the tumour.
resisted movements of the cervical spine may be limited and/ All the symptoms and signs mentioned (summarized in Box 2),
or painful, the result of involvement of the scaleni and either singly or in combination, call for careful clinical chest
? Copyright 2013 Elsevier, Ltd. All rights reserved.

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