Ashley Esdaile MSIII
Byron Baptist MSIII
Mike Pothen MS III

Acute abdomen
Recent or sudden onset of abdominal pain
 Either new pain, or increase in chronic pain
 Pain of less than 1 week duration


visceral

parietal

referred

Visceral peritoneum
Innervated bilaterally by ANS
 Described as midline, vague, deep, dull, poorly
localized
 Triggered by inflammation, ischemia, geometric
changes (ie distension, pressure)




Innervated unilaterally via the spinal somatic
nerves (also supply abd wall)
Pain well localized, sharp, severe
Triggered by irritation of parietal peritoneum
(ie chemical peritonitis from perforated peptic
ulcer or bacterial peritonitis)



From deep visceral structure but superficial at
presenting site
Central neural pathways common to somatic
nerves and visceral organs
i.e. biliary tract pain – refer to R. inf scapular
area; diaphragmatic irritation to ipsilateral
shoulder




Foregut organs (stomach, duodenum and biliary
tract) produce pain in the epigastric region
Midgut organs (most small bowel, appendix,
cecum) produce periumbilical pain
Hindgut organs (most of colon, including sigmoid)
and intraperitoneal portions of the genitourinary
tract cause pain in the suprapubic or hypogastric
area
Intraperitoneal visceral pain in felt in the midline
because these organs have bilateral innervation

1. Intraabdominal

2. Extraabdominal

GI

GU

GYN

Vascular

Cardiopulmonary

Abdominal wall

Toxic-metabolic

Neurogenic

SUDDEN ONSET OF PAIN (SECONDS)
Perforated peptic ulcer
- Ruptured abdominal aortic aneurysm
- Infarction (MI or acute mesenteric occlusion)
-

RAPIDLY ACCLERATING PAIN (WITHIN
MINUTES)

COLIC SYNDROMES
 Biliary colic, ureteral colic, small bowel obstruction

INFLAMMATORY PROCESSES
 Appendicitis, pancreatitis, diverticulitis

ISCHEMIC PROCESSES
 Mesenteric ischemia, strangulated intestinal
obstruction, volvulus

GRADUAL ONSET OF PAIN (SEVERAL
HOURS)

INFLAMMATORY CONDITIONS
 Appendicitis, cholecystitis

OBSTRUCTIVE PROCESSES
 Nonstrangulated bowel obstruction, urinary retention

Case 1
RUQ
From usmleworld qbank 2007
Differentials Diagnosis??
-
Abdominal aortic aneurysm
Acute mesenteric ischemia
Amebic hepatic abscesses
Appendicitis
Biliary colic
Biliary disease
Cholangiocarcinoma
Cholangitis
Choledocholithiasis
Cholelithiasis
GB Cancer
GB mucocele
Gastric Ulcers
-
-
Gastritis, Acute
Gastroesophageal Reflux
Disease
Hepatitis, Viral
Myocardial Infarction
Nephrolithiasis
Pancreatitis, Acute
Peptic Ulcer Disease
RLL Pneumonia
Pregnancy and Urolithiasis
Pyelonephritis, Acute
Renal Disease
Renal Vein Thrombosis



Inflammation of GB commonly caused by
gallstone obstruction (90%)
Choice B – infection of GB present in 50-70% acute cholecystitis
cases secondary to gallstone impaction in cystic duct
Patho:

Stone obstructs  eat fatty food  stimulate GB to
contract  colicky pain  stasis  bacterial
overgrowth  inflammation  gangrene/
perforation/ peritonitis

S/Sx:
epigastric or RUQ pain
 nausea and emesis 4-6 hrs after meal
 Murphy’s sign
 May radiate to right scapula


Labs: leukocystosis, slight elevation of liver
enzymes, increased bilirubin

RADIOLOGY:


UTZ – shows gallstones, gallbladder thickening,
pericholecystic fluid, sonographic Murphy’s sign
TREATMENT:


Supportive: NPO, IV antibiotics, IV hydration, pain
medication
Laparoscopic cholecystectomy – consider if
perforation or gangrene
http://sites.google.com/site/drjoea/calculi-multiple-1e.jpg

Ascending Cholangitis
Infection of bile ducts secondary to ductal
obstruction
 Life threatening
 S/Sx:

 Charcot’s triad: jaundice, fever, RUQ tenderness
 Reynold’s pentad: add hypotension and mental status
change

Labs
 Leukocytosis, increased bilirubin, increased ALP,
increased LFTs, blood cultures positive

UTZ and CT
 Biliary duct dilatation from obstructing gallstones

Tx
 Initially supportive: hydration and IV antibiotics
 If no response: ERCP or PTC for emergency bile duct
decompression




Most common presentation of symptomatic
cholelithiasis
S/Sx: constant RUQ pain to epigastric
Exception to “colicky pain” which typically
waxes and wanes due to hyperpreristalsis of
smooth muscle against mechanical site of
obstruction
UTZ: gallstones but no GB wall thickening or
pericholecystic fluid
http://emedicine.medscape.com/article/171256-overview


Stone in the common bile duct
s/sx: RUQ pain worse with fatty meals,
juandice

UTZ: common bile duct dilatation

Labs: increase LFTs, increase bilirubin
http://emedicine.medscape.com/article/172216-overview
From usmleworld qbank 2007
From usmleworld qbank 2007






Pancreatitis
Ruptured Abdominal Aortic Aneurysm
Perforated Peptic Ulcer
GERD
MI
Gastroenteritis



MCC – alcohol and gallstones
S/Sx: severe epigastric pain radiating to
patient’s back, N/V, and varying degrees of
tachycardia, fever, hypotension (signs of
hypovolemia due to “third spacing,” decreased
bowel sounds
Hemorrhagic pancreatitis

Grey turner’s sign – ecchymotic appearing skin
findings in flank; Cullen’s sign – skin findings
around periumbilical area




Labs  leukocytosis, increase serum amylase
and lipase
X-ray: dilated small bowel or transverse colon
adjacent to the pancreas called “sentinal loop”
CT  phlegmon, pseudocyst, necrosis, abscess
Tx: IV hydration, NPO, pain control





Sudden onset of abdominal pain,
radiating to flank, back or both
may present as shock (hypotension)
Exam findings possible palpable
pulsatile abdominal mass
Plain Xray – may find calcification in
aortic wall; CT scan gold standard (if pt
hemodynamically stable)
If hypotension + known aneurysm 
OR





Duodenal more common than gastric
Ass. w/ chronic NSAID use
Sudden onset severe epigastric pain that
progresses to peritonitis
PE remarkable for diffuse abdominal
tenderness, rigidity, and peritoneal signs
Plain XR may reveal free intraperitoneal air
http://emedicine.medscape.com/article/367878imaging&usg

HPI: A 21 year old African American female presents
to the ER with the sudden onset of acute abdominal
pain. The patient says that the pain began suddenly
while she was sitting at home watching television. She
localizes the source of the pain to the RLQ and
describes it as sharp and continuous with no radiation
to any other part of her body. She rates the severity a
10/10 and denies any aggravating or alleviating
factors. She says that the pain was so severe it caused
her to vomit twice and she currently feels nauseas. She
says that she had noticed some crampy abdominal
discomfort 2 days prior but attributed it to her getting
her period soon. She denies having ever experienced
this type of pain in the past.




PMHx: Chlamydia 2009, no chronic illness
PSHx: None
FHx: HTN (both parents), DMII (father), MI
(mother)
SocHx: She is a college student and lives with a
roommate. She is currently sexually active with
one male partner and uses condoms
occasionally. She has had five sexual partners
in her life. She drinks alcohol socially and
denies smoking tobacco or doing any drugs.


Meds: None
Allergies: NKDA









Gen: patient feels weak and tired.
HEENT: nml
CVA: nml
Resp: nml
GI: she has vomited twice and feels nauseas.
GU: nml
Genital: G0P0; 11/28/5 regular flow; LMP
4/29/10; uses condoms irregularly, no other form
of birth control; Chlamydia ‘09, took doxycycline
for 2 days
Hematologic: nml
Psych: nml






Gen: The patient is in extreme pain
Vitals: BP 90/63
R 20
P 54
T 97.8
SaO2 98%
CVA: S1S2 present, no murmurs heard,
bradycardia.
Resp: Lungs clear, no wheezing/crackles/rales.
Abd: soft and tender in RLQ, guarding present.
GU: right adnexal mass palpated, cervical motion
tenderness present. Vaginal bleeding present.






Ectopic pregnancy
Appendicitis
Ovarian torsion
Salpingitis/tubo-ovarian abscess
Endometriosis
Yersinia enterocolitis





RLQ pain or tenderness at first diffuse then
migrates to McBurney’s point
Fever
Diarrhea
PE: rectal exam to check for retroperitoneal
appendicitis
Labs: high leukocyte count, fecalith present on
abd CT or x ray






Acute, sharp unilateral abd pain that may be
intermittent
Pain is related to change in position
Nausea
Fever
Tender adnexal mass
Confirm via ultrasound and laparoscopy






Constant to crampy or sharp to dull, lower abd
pain
Purulent vaginal discharge
Cervical motion tenderness
Adnexal mass
Wet mount: WBCs, endocervical culture
positive for N. gonorrhoeae or Chlamydia
Confirm via ultrasound, CT can rule out
appendicitis






Gradual or sudden onset of lower abd pain
History of dysmenorrhea or cyclic attacks of
pain in lower abd
More painful with menses
Dyspareunia, dyschezia
Mild pain: analgesics and referral to OB/GYN
Severe pain: hospitalization and possible
surgery





Severe RLQ pain
Fever
Diarrhea
Difficult to distinguish from appendicitis
Labs: fecal culture



CBC – WBC 5.2
HGB 10.1 g/dL
HCT 33% PLT: 236
Urine pregnancy test -beta hCG 5 459
Transabdominal ultrasound: no products of
conception detected in uterine cavity

Ruptured ectopic pregnancy




Diagnostic laparoscopy
Salpingostomy/Salpingectomy
Iron therapy for anemia
In a stable patient with early ectopic pregnancy
can treat with methotrexate 50 mg/m2
intramuscularly as a single dose or multiple
doses. Criteria for use: pregnancy < 3.5 cm
diameter, unruptured, no fetal heart tones and
no active bleeding.
28y/o Caucasian male comes to the ER complaining of left sided
abdominal pain.
Types of pain presentation
Visceral - caused when the nerves on an organ sense an acute
stretching of that structure's wall
ache
poorly localized
Parietal/somatic - caused by irritation to the parietal peritoneal
wall
sharp
pinpoint, localized
Referred - pain that is felt at a place in the body different from the
injured or diseased part where the pain would be expected

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



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

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
Skin – trauma, shingles
Muscle – trauma, strain
Ribs – coastochondritis
Aorta – AAA
Spleen – injury, tumor
Stomach – ulcer, tumor
Renal – pylonephritis left kidney, stones, tumor
Adrenal - tumor
Bowl – inflammation, tumor, crohns, UC, IBS, celiac
disease, constipation, infectious process
Fallopian tube – ectopic pregnancy, tumor
Ovary – abscess, cyst
Type of pain is achy and cramping. It began 4
days ago and has not let up. The pain varies in
intensity from 6 to 8/10. The Patient states
multiple previous episodes for 11 years with
severe instances, such as this, causing
hospitalization. Patient has diarrhea with
blood, and has 9 to 10 bowel movements per
day. Patient also complains of pressure in his
eyes, fever, weight loss, fatigue, and ulcers in
his mouth.











Skin – trauma, shingles
Muscle – trauma, strain
Ribs – coastochondritis
Aorta – AAA
Spleen – injury, tumor
Stomach – ulcer, tumor
Renal – pylonephritis left kidney, stones, tumor
Adrenal - tumor
Bowl – inflammation, tumor, crohns, UC, IBS, celiac
disease, constipation, infectious process
Fallopian tube – ectopic pregnancy, tumor
Ovary – abscess, cyst






Crohns
Ulcerative colitis
IBS
Toxic megacolin
Celiac disease
Colon cancer

Crohns - is an inflammatory
disease of the intestines that may
affect any part of the
gastrointestinal tract from mouth
to anus, causing a wide variety of
symptoms. It primarily causes
abdominal pain, diarrhea (which
may be bloody), vomiting, or
weight loss, but may also cause
complications outside of the
gastrointestinal tract such as skin
rashes, arthritis, inflammation of
the eye, tiredness, and lack of
concentration.

Ulcerative Colitis (UC) – is a relatively
common disease that causes
inflammation of the large intestine.
The cause is unknown. The rectum is
always involved. When the
inflammation is limited to the rectum,
it is called ulcerative proctitis. The
inflammation may extend to varying
degrees into the upper parts of the
colon. When the entire colon is
involved, the terms pancolitis or
universal colitis are used. Intermittent
rectal bleeding, crampy abdominal
pain and diarrhea can be symptoms of
ulcerative colitis. Ulcerative colitis
characteristically waxes and wanes.
Many patients experience long
remissions, even without medication.
Crohns
UC
Terminal Ileum
Common
Seldom
Colon
involvement
Usually
Always
Anus
Common
Seldom
Bile duct
No change in
rate PSC
Higher rate
PSC
Distribution
Skip lesion
continuous
Depth
Transmural
Mucosal
Fistulae
Common
Seldom
Stenosis
Common
Seldom
Surgical cure
Usually returns
Usually curative
Smoking
Higher risk
Lower risk

IBS - is a diagnosis of exclusion.
It is a functional bowel disorder
characterized by chronic
abdominal pain, discomfort,
bloating, and alteration of bowel
habits in the absence of any
detectable organic cause. In some
cases, the symptoms are relieved
by bowel movements. Diarrhea
or constipation may predominate,
or they may alternate (classified
as IBS-D, IBS-C or IBS-A,
respectively). IBS may begin after
an infection (post-infectious, IBSPI), a stressful life event, or onset
of maturity without any other
medical indicators.

Toxic megacolon is a life-threatening
complication of
other intestinal
conditions. It is
characterized by a
very dilated colon
(megacolon),
accompanied by
bloating, and
sometimes fever,
abdominal pain, or
shock.

Celiac Disease - is an
autoimmune disorder of the
small intestine that occurs in
genetically predisposed people
of all ages from middle infancy
onward. Symptoms include
chronic diarrhea, failure to
thrive (in children), and
fatigue. Upon exposure to
gliadin, and certain other
prolamins, the enzyme tissue
transglutaminase modifies the
protein, and the immune
system cross-reacts with the
small-bowel tissue, causing an
inflammatory reaction. That
leads to villous atrophy which
results in the interference of
absorption of nutrients

Colon Cancer – includes
cancerous growths in the
colon, rectum and
appendix. Signs and
symptoms can be broken
down into local (reduction
in stool diameter, blood in
stool), constitutional (iron
deficiency anemia may
occur; this may be
experienced as fatigue,
palpitations and noticed as
pallor, weight loss), and
metastatic (most commonly
spreads to liver which
could present with
jaundice, biliary
obstruction, pale stools).




H/o UC
H/o apthus ulcers
H/o erythema nodosum
H/o DVT and PE








Surgical hx – tissue biopsy 1999 no
complication
Family hx – no pertinent history
Social hx – works in retail, lives alone,
Tobacco – 1 pack/day
ETOH – no
Drugs – no
Allergies- NKDA
Medications – Sulfasalizine, dexamethasone



Redness in the eyes
CVS – tachycardia
Abdomen – distended, general tenderness,
negative for bowl sounds














BP 100/70 T 101.4 P 90 RR 20 sO2 98% rm air
ESR - elevated
C-reactive protein – elevated
WBC – 15k
HGB – 10
HCT – 34%
Plt – 470k
Na - 138
K - 2.9
Cl – 100
CO2 – 24
BUN – 40
Creatinine – 1
Gluc - 100

Tx - objective of treatment is to decompress the bowel and to prevent swallowed
air from further distending the bowel





Complications






Fluid and electrolyte replacement to help prevent dehydration, and shock
Corticosteroids for inflammatory reaction
Antibiotics to prevent sepsis
If decompression is not achieved and patient does not improve within 24 hours, a
colectomy is indicated
Sepsis
Shock
Perforation of the colon
Prognosis - If the condition does not improve, there is a significant risk of death. In
case of poor response to conservative therapy a colectomy is usually required. This
may involve all or part of the colon being removed, with the resulting option of
anastomosis or colostomy.
Emergency action may be required if severe abdominal pain develops, particularly
if it is accompanied by fever, rapid heart rate, tenderness when the abdomen is
pressed, bloody diarrhea, frequent diarrhea, or painful bowel movements.
Tx for Iritis – prednisalone 1-2 gtts q1-8hrs






A 61 y/o woman comes to her dr. office for steadily increasing abd girth
and fatigue with mild exertion. She has noticed this symptom for the past
few months. She reports a 5kg increase in her weight without making
any change in her regular diet. Her PMH is unremarkable, although she
has not seen a physician for many years. She denies smoking, but admits
drinking a glass of wine with meals on weekends. On physical exam, she
is afebrile and normotensive. Examination of her abd reveals shifting
dullness and a fluid wave, with clear distension. A bedside ultrasound is
performed, which demonstrates a large amount of ascitic fluid. Which of
the following conditions is the most likely cause of this patient’s current
condition?
A. Alcohol cirrhosis
B. Budd-chiari syndrome
C. peritoneal carcinomatosis
D. portal vein thrombosis
E. Right heart failure

A 61 y/o woman comes to her dr. office for steadily increasing abd girth
and fatigue with mild exertion. She has noticed this symptom for the past
few months. She reports a 5kg increase in her weight without making
any change in her regular diet. Her PMH is unremarkable, although she
has not seen a physician for many years. She denies smoking, but admits
drinking a glass of wine with meals on weekends. On physical exam, she
is afebrile and normotensive. Examination of her abd reveals shifting
dullness and a fluid wave, with clear distension. A bedside ultrasound is
performed, which demonstrates a large amount of ascitic fluid. Which of
the following conditions is the most likely cause of this patient’s current
condition?
A. Alcohol cirrhosis

B. Budd-chiari syndrome

C. peritoneal carcinomatosis

D. portal vein thrombosis

E. Right heart failure
Pt. has late ovarian cancer. There are no indications for liver insufficiency, or
cardiac insufficiency.








A 24 y/o white women comes to the physician complaining of 6 months of crampy
abd pain. The pain has been localized to the RLQ, and is made worse by eating.
She has also noted an increase in the number of her bowel movements to
approximately four per day, and the stools have become semi-formed. She denies
any fevers, chills, or night sweats during this period. She has lost 15 lbs from her
baseline weight of 128 lb over the past 6 months. She has also noted aching in her
knees, and ankles during this interval. On physical examination, she is slightly
pale and has two oral ulcers on the inner lower lip that are covered by a gray
exudate and surrounded by an erythematous halo. The abd is soft but tender in
the right lower quadrant. No masses are palpable and there is no
hepatosplenomegaly. Rectal exam reveals brown stool, which is guaiac-positive.
Which of the following diagnostic test would be the most accurate for this patient?
A. Abd CT scan
B. abd sonogram scan
C. barium enema
D. colonoscopy
E. sigmoidoscopy
F. upper GI series

A 24 y/o white women comes to the physician complaining of 6 months of crampy abd pain.
The pain has been localized to the RLQ, and is made worse by eating. She has also noted an
increase in the number of her bowel movements to approximately four per day, and the stools
have become semi-formed. She denies any fevers, chills, or night sweats during this period.
She has lost 15 lbs from her baseline weight of 128 lb over the past 6 months. She has also
noted aching in her knees, and ankles during this interval. On physical examination, she is
slightly pale and has two oral ulcers on the inner lower lip that are covered by a gray exudate
and surrounded by an erythematous halo. The abd is soft but tender in the right lower
quadrant. No masses are palpable and there is no hepatosplenomegaly. Rectal exam reveals
brown stool, which is guaiac-positive. Which of the following diagnostic test would be the
most accurate for this patient?
A. Abd CT scan

B. abd sonogram scan

C. barium enema

D. colonoscopy

E. sigmoidoscopy

F. upper GI series
Pt has Crohns, and colonoscopy with entry into the terminal ileum is the main way of diagnosing
ileocolonic disease, as described in this patient.



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


Ayala Carlos, Spellberg Brad, “Chapter 2. Surgery”. Boards and Wards, 4e. Wolters
Kluwer, Lippincott Williams & Wilkins, 2010.
Gallagher E. J, "Chapter 72. Acute Abdominal Pain" (Chapter). Tintinalli JE, Kelen GD,
Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive
Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=592077.
Krause Richard S, Janicke David M, "Chapter 103. Ectopic Pregnancy" (Chapter).
Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, 6e:
http://www.accessmedicine.com/content.aspx?aID=594594.
Platt Melissa, Doshi Samir, Telfer Eric, "Chapter 13. Abdominal Pain" (Chapter). Stone
CK, Humphries RL: CURRENT Diagnosis & Treatment: Emergency Medicine, 6e:
http://www.accessmedicine.com/content.aspx?aID=3099123.
Klingensmith, Mary, Chen Li Ern, Glasgow Sean, Goers Trudie, Melby Spencer.
“Chapter 11, The Washington Manual of Surgery.” Wolters Kluwer, Lippincott Williams
& Wilkins, 2008.
Usmleworld qbank 2007