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Oleh :

Radityo Budi Leksono (DIT)

dr. Syaiful Mukhtar Sp.B (K) BD

The definition of pain according to the
International Association for the Study of
Pain (IASP, 1979) is an unpleasant sensory
and emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage
Pain is not always associated with the
degree of the damaged tissue
Pain is an unpleasant phenomenon that is
uniquely experienced by each individual, it
cannot be adequately defined, identified, or
measured by an observer
Pain threshold and pain tolerance
The pain threshold is the point at which a stimulus is perceived
as pain
It does not vary significantly among healthy people or in the same
person over time
Perceptual dominance- intense pain at one location may cause
an increase in the pain threshold in another location
The pain tolerance is expressed as duration of time or the
intensity of pain that an individual will endure before initiation
overt pain responses.
It is influenced by - persons cultural prescriptions
- expectations
- role behaviours
- physical and mental health
Pain tolerance is generally decreased:
- with repeated exposure to pain,
- by fatigue, anger, boredom, apprehension,
- sleep deprivation

Tolerance to pain may be increased:
- by alcohol consumption,
- medication, hypnosis,
- warmth, distracting activities,
- strong beliefs or faith
Pain tolerance varies greatly among people and in
the same person over time
A decrease in pain tolerance is also evident in the elderly,
and women appear to be more tolerant to pain than men
Age and perception of pain

Children and the elderly may experience or express pain
differently than adults
Infants in the first 1 to 2 days of life are less sensitive to pain
(or they simply lack the ability to verbalise the pain experience).
A full behavioural response to pain is apparent at 3 to 12 month of
Older children, between the ages of 15 and 18 years,
tend to have a lower pain threshold than do adults
Pain threshold tends to increase with ageing
This change is probably caused by peripheral neuropathies and
changes in the thickness of the skin
Pain categories

1. Somatogenic pain is pain with cause (usually known)
localised in the body tissue
a/ nociceptive pain
b/ neuropatic pain

2. Psychogenic pain is pain for which there is no known
physical cause but processing of sensitive information
in CNS is dysturbed
Acute and chronic pain

Acute pain is a protective mechanism that alerts the
individual to a condition or experience that is immediately
harmful to the body
Onset - usually sudden
Relief - after the chemical mediators that stimulate the
nociceptors, are removed
This type of pain mobilises the individual to prompt action
to relief it
Stimulation of autonomic nervous system can be observed
during this type of pain (mydriasis, tachycardia, tachypnoe,
sweating, vasoconstriction)
Responses to acute pain
- increased heart rate - diaphoresis
- increased respiratory rate - blood sugar
- elevated blood pressure - gastric acid secretion
- pallor or flushing, - gastric motility
dilated pupils - blood flow to the viscera,
kidney and skin
- nausea occasionally
Psychological and behavioural response to acute pain
- fear
- general sense of unpleasantness or unease
- anxiety
Chronic pain is persistent or intermittent usually defined as
lasting at least 6 months
The cause is often unknown, often develops insidiously, very
often is associated with a sense of hopelessness and
helplessness. Depression often results
Psychological response to chronic pain
Intermittent pain produces a physiologic response similar to
acute pain.
Persistent pain allows for adaptation (functions of the body are
normal but the pain is not reliefed)
Chronic pain produces significant behavioural and
psychological changes
The main changes are:
- depression
- an attempt to keep pain - related behaviour to a minimum
- sleeping disorders
- preoccupation with the pain
- tendency to deny pain
Acute Pain or Nociceptive Pain is pain that
elicited by activation of nociceptors

There are 4 distinct process involved:
1. Transduction
2. Transmission
3. Modulation and
4. Perception

Pain Perception
Dorsal Root
Dorsal Horn
Spinal Cord
Gottschalk A et al. Am Fam Physician. 2001;63:1979-84.
Fields HL et al. Harrisons Principles of Internal Medicine. 1998:53-8.
Transduction Conversion of noxious stimuli
(mechanical, thermal, chemical into
electrical activation
Transmission Communication of the nerve impulse
from the periphery to the spinal cord,
up to spinothalamic track to the
thalamus and cerebral cortex
Modulation Process by which impulse travel from
the brain back down to the spinal cord
to selectiveley inhibit (or sometimes
amlpify) pain impulse
Perception Net result of three events the
subjective experience of pain
An alarm protection tell us that something wrong in our
Accompanied by emotional reaction like nausea, fear,
anxiety, and discomfort
There is an urgency feeling for relieving the pain in the right
upper abdominal area
The Location of pain
The quality and intensivity of pain
Duration of pain
What time did the pain appear
Refered pain
Accompanying symptoms Symptom yang menyertai
Physical examination Pemeriksaan fisik
Laboratorium valuesLaboratorium

Biliary Colic,
The Result from stimulation of the autonomic
nerve in the visceral peritoneum surrounding the
internal organs.
The Pain/noxius stimuli will be transferred to the
spinal cord through the symphatetic route.
The pain is hard to localize
Intermittent, cramp dan colicy pain
Usually accompanied with nausea, vomitting,
and diaphoresis
Stimuli occur from the iritation of the parietal
Somatic pain impulses is conducted through
the peripheral nerve system, therefore it could
be better localized.
The somatic pain characteristic are continous,
constant, and usually worsen by cough or
changing of the body position. Nyeri terus
menerus, konstan, memburuk dengan
perubahan posisi, batuk

It is elicited by firmly placing a hand at the costal
margin in the right upper abdominal quadrant and
asking the patient to breathe deeply. If the gallbladder
is inflamed, the patient will experience pain and catch
their breath as the gallbladder descends and contacts
the palpating hand.
A positive Murphy's sign is seen in acute cholecystitis.
In cholecystitis, the gallbladder becomes inflamed
secondary to blockage of the cystic duct, usually by a
gallstone. Subsequently, this inflammation causes the
release of prostaglandins, which cause more
inflammation of the gallbladder. Patients with acute
cholecystitis experience discomfort with the Murphys
sign maneuver because the inflamed gallbladder
descends toward the examiners fingers, which
irritates the peritoneum, thereby causing pain.