The Acute Abdomen

Andrew Wright MDDepartment of Surgery

What is an acute abdomen?

What is an acute abdomen?

New onset abdominal pain

Usually abdominal pain as main symptom

Often seen by primary physician

Signifies need for prompt diagnosisDoes not necessarily imply need for surgical intervention

How do you diagnose an acute abdomen?

How do you diagnose an acute abdomen?

History and Physical

History

Exact time and onset

Most slowCan guide prognosis – i.e. timing of appendicitis

AcuteColic

Bowel strangulation

Rupture of viscera

Torsion

FaintingAbdominal apoplexy

Perforated ulcer, ruptured aortic aneurysm, ruptured ectopic

What was patient doing at time of onset?i.e. “minor” trauma

Location

Initial location

Shifting of painTransition from visceral to parietal pain

What is visceral pain?

Intestines are:Insensitive to touch

Sensitive to stretch, distension, or excessive contraction against resistance

Location:Small intestine – umbilicus

Large intestine – hypogastrium

Biliary – RUQ, R subscapular

Kidney – Loin, occ radiates to ipsilateral testicle

What is visceral pain?

CharacterParoxysmal

Often excruciating

Patients will writhe, twist, attempt to find a comfortable position

In contrast to peritonitis – where patients will lie still to avoid further irritation

Character

CharacterBurning – i.e. ulcer

Agony- i.e. pancreatitis

Sharp, constricting – i.e. biliary colic

Tearing – i.e. dissecting aneurysm

Gripping – i.e. obstruction

Aching – i.e. appendicitis

Dull, fixed – i.e. pyonephrosis

Radiation

Referred painDiaphragm – shoulder

Biliary tract – tip of shoulder

Pancreas – mid back

Kidney – mid back

Rectum- coccyx

Uterus – coccyx

Exacerbating factors

Relationship to food

RespirationPleuritic pain usually worse on deep inspiration

MicturationUTI

Bladder obstruction

Nephrolithiasis

Peri-bladder abscess

RecliningOften retroperitoneal origon

Vomiting

CauseObstruction

Severe irritation of nerves of peritoneumi.e. pain, pancreatitis

Frequency

Relationship with pain

Character

Nausea and/or lack of appetite

Bowel Movements

Regularity

DiarrheaTrue diarrhea vs. passage of several small loose stools

Blood

Mucusi.e. intussusception

Menstruation

Regularity

Exact timing

Pain

History

Prior similar episodes

Prior illnesses that may relateh/o peritonitis, appendicitis, pneumonia, etc.

Previous attacks of jaundice, melena, hematemesis, hematuria

Travel history

PMH

PSH

Examination

General appearance

General gestalt – is he (or she) sick?

Vitals

Pulse

Respiratory rate

TempNormal or mildly elevated typical

High fever unusual – suspect kidney or thorax

Hypothermic – suspect shock

Blood Pressure

Inspection

Determine exact location of pain first

InspectionDistension

Bulge

HerniaAll potential orifices – including femoral

MovementRigidity with inspiration

Palpation

Keys to successGentleness

Thighs flexed

Thorough exam

Include back

Guarding

Rebound

Iliopsoas rigidity

Percussion

Liver dullness

Free-fluid

Rectal exam

Pelvic exam

Should pain meds be given prior to diagnosis?

Diagnostic Testing

Diagnostic Testing

CBC with dif

Electrolytes, BUN, creatinine, and glucose

Aminotransferases, alkaline phosphatase, and bilirubin

Lipase

Urinalysis

Pregnancy test in women of childbearing potential

Imaging

Imaging

ImagingPlain XRays

Flat and UprightLeft Lateral Decubitus if not able to stand)

Chest

Ultrasound

CT

Additional TestingGuide by Differential

Causes of Abdominal Pain

Extra-abdominal

Herpes Zoster

MI

Pneumonia

Biliary Disease

Cholelithiasis

Cholecystitis

Cholangitis

Pancreatitis

Biliary Dyskinesia

GI

GERD

Gastritis

Peptic Ulcer Disease

Irritable Bowel

Constipation

Diabetic Gastroparesis

Infectious

Appendicitis

Diverticulitis

GastroenteritisViral

Eosinophilic

Yersinia

Hepatitis

Typhlitis

Tropical infectious diseases (helminthic)

Tuberculosis

Typhlitis

Appendicitis

Normal Acute Appendicitis

Appendicolith

Appendiceal Phlegmon

Peri-appendiceal Abscess

Diverticulosis

Diverticulitis

Diverticular Abscess

Bowel Obstruction

Hernia

Adhesion

Malignancy

Intussuception

Inflammatory

Crohn’s

Ulcerative Colitis

Malignancy

Epiploic appendagitis

Epiploic appendagitis

Gynecologic

PID

Adnexal Torsion

Cyst

Neoplasm

Endometriosis

Ectopic pregnancy

Endometritis

Leiomyomas

Urologic

UTI

Nephrolithiasis

Bladder distension

Vascular

Aneurysm

Dissection

Mesenteric IschemiaAcute

Chronic

Sickle Cell Crisis

Colonic Ischemia

Other

Psychiatric Disease

SpleenAbscess

Infarct

Wandering Spleen

MusculoskeletalAbdominal wall pain

Painful rib syndrome (chostochondritis)

Hernia

Other

Celiac artery compression

Abdominal Migraine

Fitz-Hugh-Curtis syndrome

Familial Mediterranean fever

Hereditary angioedema

Heavy Metal Poisoning

MetabolicDiabetic Ketoacidosis

Porphyria

Lactose Intolerance

Pediatric

Henoch-Schönlein purpura

Intussuception

Malrotation with midgut volvulus

Recurrent Abdominal Pain – diagnosis of exclusion