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Referred Shoulder Tip Pain — FRCA Final MCQ

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EasyGeneral AnaesthesiaReferred Shoulder Tip PainFRCA Final

A 30-year-old woman undergoes an uncomplicated diagnostic laparoscopy. In the recovery room she reports bilateral shoulder-tip pain. Her observations are normal and she has no chest pain or respiratory symptoms. What is the most likely mechanism of this pain?

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Correct answer: A — Irritation of diaphragmatic afferents in the phrenic nerves by CO2 pneumoperitoneum

The correct answer is A. CO2 pneumoperitoneum irritates and stretches the diaphragmatic peritoneum. Sensory afferents from the central diaphragm travel in the phrenic nerves to spinal segments C3–C5. Convergence with somatic afferents from the shoulder-tip region, principally through the C3–C4 supraclavicular nerves, causes the brain to mislocalise the stimulus as shoulder-tip pain. Brachial plexus injury would more typically produce upper-limb pain, sensory loss or weakness. Pneumothorax and pulmonary embolism would usually be accompanied by respiratory or cardiovascular features. A subphrenic abscess is a delayed infective complication rather than a cause of pain immediately after an uncomplicated laparoscopy.

Reference: Sao CH et al. Pain after laparoscopic surgery: Focus on shoulder-tip pain after gynecological laparoscopic surgery. Journal of the Chinese Medical Association. 2019;82(11):819–826. https://pubmed.ncbi.nlm.nih.gov/31517775/