ACUTE ABDOMINAL PAIN
Victor Politi, M.D., FACP
Medical Director, SVCMC School of Allied Health,
Physician Assistant Program
Abdominal Pain
• Most common cause of hospital admission
in the US
• Accounts for 5-10% of all ED visits
• In 35-40% of all hospital admissions due to
abdominal pain - the pain is nonspecific
Epidemiology
• Gastroenteritis is the most common cause of
abdominal pain not requiring surgery
• In patients age 60 and older, biliary disease
and intestinal obstruction are the most
common cause of acute abdominal pain that
is surgically correctable
Epidemiology
• Appendicitis is the most common cause of
abdominal pain requiring surgery in patients
< age 60
• Appendicitis is the leading cause of acute
abdominal pain in children
– accounts for 32% of children admitted w/acute
abdominal pain
Patient History
• The term “acute abdomen” implies the
sudden onset of abdominal pain for which a
surgically correctable cause is likely
Patient History
• Besides the age of the patient - key elements
of the patient history include:
• Time of pain onset
• Location/character of pain
• Pattern of pain radiation
• Associated symptoms
Key Points in History
• Reproductive
 Sexual Activity, Contraception, Last Menstrual Period
 Always Consider Pregnancy in Reproductive Age Women
 Have a Low Threshold for Pregnancy Testing
• Bowel and Bladder
– Nausea, Vomiting, Diarrhea, Constipation
– Frank Blood, "Coffee Grounds" Emesis, Black Stools
– Urinary Frequency, Urgency, Discomfort
AGE
• Age of patient - crucial
• Differential diagnosis of abdominal pain in
children - differs from dx in elderly patient
• Common conditions that cause abdominal
pain in most age groups
– acute appendicitis, intestinal obstruction,
incarcerated hernias
AGE
• Intussusception is most likely the cause of
intestinal obstruction in children
• Adhesions are most likely the cause of
intestinal obstruction in adults
• In older patients, pain from a MI can be
referred to the upper abdomen
Time of Onset
• Pain sudden in onset, awakens a patient from sleep
- suggests a viscus
• Knowing the timing of associated nausea and
vomiting is essential to narrow the diagnostic
possibilities
• Pain precedes vomiting when abdominal pain is
from surgically correctable causes, whereas the
reverse is true for medical conditions such as
gastroenteritis
Location
• Abdomen divided into 4 quadrants, which
are further divided (with some overlap) into
the epigastric, periumbilical, and suprapubic
regions
Location of Abdominal Pain
 Four quadrants:
 Right Upper Quadrant
 Right Lower Quadrant
 Left Upper Quadrant
 Left Lower Quadrant
 Three central areas:
 Epigastric
 Periumbilical
 Suprapubic
Location
• RUQ pain – duodenal ulcers, acute pancreatitis, acute cholecystitis,
and acute hepatitis
• LUQ pain – gastritis, gastric ulcer, acute pancreatitis, and splenic
infarct or rupture
• RLQ pain – acute appendicitis,
• LLQ pain – diverticulitis
• GYN and urologic causes of acute abdominal pain can also
present with lower quadrant abdominal pain
Radiation of Abdominal Pain
Perforated Ulcer
Biliary Colic
Renal Colic
Dysmenorrhea/Labor
Renal Colic (Groin)
Character
• Implies all the features of the pain
• Usually can be determined by asking the
patient to describe the quality of the pain
• Most often described as
– sharp or dull
– cramping (colicky)
Character
• Colicky pain - rhythmic pain resulting from
intermittent spasms - most commonly
associated with
– biliary disease, nephrolithiasis, intestinal
obstruction
• Pain that begins as dull, poorly localized
ache and progresses to a constant, well
localized sharp pain indicates a surgically
correctable cause
Physical Examination of the Abdomen
Inspection
Auscultation
Percussion
Palpation
Inspection
• General observation
• Look at abdominal contour, note location of
any scars, rashes or lesions
Inspection
• Patient writhing in agony - likely has
colicky abdominal pain caused by ureteral
lithiasis
• Patient lying very still - more likely to have
peritonitis
• Patient leaning forward to relieve pain may have pancreatitis
Inspection
• The abdominal wall is a commonly
overlooked source of abdominal pain
• Other parts of the body should also be
inspected. For example, the eyes should be
inspected for evidence of scleral icterus
which may indicate hepatobiliary disease
Auscultation
• Useful in assessing peristalsis
• Bowel sounds are widely transmitted through the
abdomen - therefore, it is not necessary to listen in
all 4 quadrants
• Auscultation should last at least 1 minute
• Bowel sounds typically highly pitched so the
diaphragm of the stethoscope should be used
Auscultation
• ? Bowel soundsnormal/hyperactive/hypoactive
• Auscultation should precede percussion and
palpation
• ? Abdominal bruits – listen over aortic,iliac and
renal arteries
Auscultation
• Hypoactive bowel sounds - associated with
ileus, intestinal obstruction, peritonitis
• Intestinal obstruction can produce
hyperactive bowel sounds which are high
pitched tinkling sounds occurring at brief
intervals; very audible
Percussion
• Technique - performed by firmly pressing
the index finger of one hand on the
abdominal wall while striking the
abdominal wall with the other index finger
• Percussion note can be described as dull,
resonant, or hyperresonant
Percussion
• Dull/resonant or hyperresonant
• Tympany normally present in
supine position
• ? Unusual dullness
– ? Clue to underlying abdominal mass
Percussion
• Gastric region – percussion over the gastric region will
generate a hyperresonant note because
of usual presence of a gastric air bubble
• Liver – percussion over the liver will generate
a dull note
– A normal liver span is 6 to 12 cm in
the midclavicular line
Percussion
• Generalized percussion is a useful method
for detecting the presence of ascites or
intestinal obstruction in a distended
abdomen
• In ascites - a dull percussion note would be
generalized
• In intestinal obstruction - a hyperresonant
note would be heard
Percussion
• If ascites is suspected, then a test for
shifting dullness can be performed
• Ascites typically sinks with gravity,
percussion of the flanks generates a dull
note and percussion of the periumbilical
region generates a resonant note in the
supine patient
Percussion
• The test for shifting dullness involves
having the patient shift to a lateral decubitus
position and then performing percussion
again; the area of resonance should shift
upward
Shifting Dullness
• If dullness on percussion shifts when the patient is rolled
on the side, peritoneal fluid (ascites) may be present.
Percussion
• Splenic Enlargement
A change from tympany to dullness suggests splenic enlargement
Palpation
• Before palpating the abdomen the examiner
should ask the patient to point directly to
the area that hurts most and avoid palpating
that area until absolutely necessary
• May be difficult in patient who has
guarding (voluntary or involuntary)
Palpation
• Voluntary guarding - conscious elimination
of muscle spasms
• Involuntary guarding - reported when the
spasm response cannot be eliminated, which
usually indicates diffuse peritonits
Palpation
• Where is pain ? Begin with light palpation
• Guarding - voluntary/involuntary
• Rebound tenderness
Palpation
• Rebound tenderness is elicited by pressing on the
abdominal wall deeply with the fingers and then
suddenly releasing the pressure
• Pain on the abrupt release of steady pressure
indicates the presence of peritonitis
• Asking the patient to cough is another method of
eliciting signs of peritonitis
Rebound Tenderness
• This is a test for peritoneal irritation. Palpate deeply and
then quickly release pressure. If it hurts more when you
release, the patient has rebound tenderness
Deep Palpation
• ? Areas of deep tenderness/masses
Liver Palpation
Palpation of Aorta
• Easily palpable on most
• Pulsate with deep palpation of central
abdomen
• Enlarge aorta – ? Sign of aortic aneurysm
Palpation of Spleen
• Not normally palpable
Costovertebral Angle Tenderness
• CVA tenderness is often associated with renal disease. Use
the heel of your closed fist to strike the patient firmly over
the costovertebral angles
Specific Disorders
• Upper abdominal pain - common causes of
acute abdominal pain in the upper abdomen
include: acute cholecystitis, acute
pancreatitis, perforated ulcers
• Pain usually overlaps the left and right
upper quadrants
Classic Presentations - Acute Cholecystitis
Localized or diffuse RUQ pain
Radiation to right scapula
Vomiting and constipation
Low grade fever
Cholecystitis
• Murphy’s sign (have patient take a deep breath while right subcostal
area is palpated) abrupt cessation of inspiration secondary to pain is
considered a positive Murphy’s sign
• Disease of adulthood
• More common in women
• Bacteria invasion can develop into ascending
cholangitis
– Charcot’s triad
• Right upper quadrant pain
• Fever
• Jaundice
Acute pancreatitis
• Retroperitoneal dissection of blood can result in bluish
discoloration of the flanks (Turner’s sign) or of the
periumbilical region (Cullen’s sign)
– Biliary pancreatitis secondary to cholelithiasis is most common
women > age 50 in community hospital setting
– Alcoholic pancreatitis is most common in men ages 30-45 years in
urban hospital setting
• Symptoms-epigastric pain,nausea,vomiting,pain is constant
& boring in nature
• Bowel sounds decrease - lack of rigidity or rebound
tenderness
Perforated Peptic Ulcer
• Sudden onset - severe epigastric pain
– Pain becomes generalized after a few hours to involve
the entire abdomen
– Perioperative mortality rate of 23%
• Patient usually lying quietly and breathing
shallow.
– Abdomen rigid,board-like, guarding - maximal at site
of perforation
• Upright chest x-ray - detection of free
intraperitoneal air
Specific Disorders
• Midabdominal pain - common causes of
midabdominal pain include
– intestinal obstruction, mesenteric ischemia and
early appendicitis
– dissecting aortic aneurysm
– myocardial infarction
Intestinal Obstruction
• Mechanical - results from
– gallstones, adhesions, hernias, volvulus,
intussuseption, tumors
• Non-mechanical- results from
– intestinal infarction or occurs after surgery as a
paralytic ileus, pain medication
Intestinal Obstruction
• Obstruction high in small intestine
– results in severe abdominal pain in epigastric or
umbilical region with bilious vomiting,
distention of abdomen not an early feature
• Obstruction located lower in small intestine
– results in less severe pain
– Vomiting late feature and may be feculent
Intestinal Obstruction
• Differential Diagnosis of obstruction of
small intestine
–
–
–
–
strangulated hernia
volvulus
mesenteric thrombus
gallstone ileus
– Abdominal x-ray of distal obstruction of small
intestine will show a dilated loop
Large Intestine Obstruction
• Pain less severe than small intestine
obstruction
• Vomiting infrequent
• Distention of abdomen - common
• Main Causes of Large Intestine Obstruction
• Ca of colon (change bowel habits, wt loss, rectal
bleeding)
• diverticulitis (fixed,tender, LLQ mass)
• volvulus (sigmoid volvulus most common)
Mesenteric Ischemia
• Presents with acute, diffuse, midabdominal pain, vomiting,
decreased bowel sounds and distention resulting from
intestinal obstruction
• Abdominal pain is out of proportion to physical
examination findings
• Abdominal distention is a late sign indicative of gangrene signs of peritoneal irritation also indicative of gangrene
Specific Disorders
• Lower abdominal pain - common causes of
lower abdominal pain include
–
–
–
–
Acute appendicitis (typically RLQ pain)
Sigmoid diverticulitis (typically LLQ pain)
Gynecologic causes
Urologic causes
Diverticulitis
• Lower Left Quadrant Pain
• Cramping sensation
• Possible fever
Appendicitis
• Peak incidence in 2nd decade of life
• Differential diagnosis is broad and errors in
diagnosis are common
– Diagnostic error rate
• Men 23%
• Women 42%
Appendicitis
• Patients seen in first few hours - report
poorly defined constant pain in
periumbilical region
• As disease progresses - pain shifts to RLQ
in a region known as McBurney’s point
(located 2/3 of the distance along a line
drawn from the umbilicus to the right
anterior superior iliac spine)
Appendicitis
• Pain relieved somewhat when patient
assumes a right lateral decubitus position
with slight hip flexion
• Abdominal tenderness - most likely
physical finding
• Voluntary guarding in RLQ is common
Appendicitis
• Rovsing’s sign can be elicited by palpating
deeply in the left iliac area and observing
for referred pain in the right iliac fossa
• When present, the psoas and obturator signs
are also helpful in establishing a diagnosis
of appendicitis
Appendicitis
• Psoas sign - the psoas sign is pain elicited
by extending the right hip while the patient
is in the left lateral decubitus position • alternatively, while in the supine position,
the patient can lift the right thigh against the
examiners hand, which is placed above the
knee
Psoas Sign
• The psoas sign. Pain on passive extension of the
right thigh. Patient lies on left side. Examiner
extends patient's right thigh while applying
counter resistance to the right hip (asterisk).
Appendicitis
• Obturator sign - the obturator sign is pain
elicited by flexing the patient’s right thigh at
the hip with the knee flexed and then
internally rotating the hip
• Right sided rectal tenderness may also be
elicited on rectal exam of patients with
acute appendicitis
Obturator Sign
• The obturator sign. Pain on passive internal
rotation of the flexed thigh. Examiner moves
lower leg laterally while applying resistance to the
lateral side of the knee (asterisk) resulting in
internal rotation of the femur.
Classic Presentations - Acute Appendicitis
Diffuse periumbilical pain and anorexia early
Pain localizes to RLQ as peritonitis develops
Low grade fever, nausea and vomiting may not be present
Xrays and other tests are often negative
Remember that the position of the appendix is highly variable!
Other Causes of Abdominal Pain
• Abdominal aortic aneurysm
–
–
–
–
abdominal pain/backache
hypotension
71% perioperative mortality rate
Physical exam of abdomen - detect pulsatile
mass
– unequal femoral pulses
Abdominal Aortic Aneurysm
Other Causes of Abdominal Pain
• Nephrolithiasis
– ureteral colic 4% of patients w/acute abdominal
pain
– Colicky pain - Upper lumbar region radiates
laterally to inguinal region
– Patient writhing in pain
Classic Presentations - Acute Renal Colic
Severe flank pain
Radiation to groin
Vomiting and urinary symptoms
Blood in the urine
Other Causes of Abdominal Pain
•
•
•
•
•
•
•
•
•
Cardiac Origin
Gastritis
GERD
Esophageal disease
Hiatal hernia
Liver abscess/subdiaphragmatic abscess
Pulmonary origin
Herpes Zoster
Hernia
Other Causes of Abdominal Pain
• Gynecologic
– Ovarian cyst
– Ectopic pregnancy
– PID
Gynecologic Causes
• In the absence of a positive pregnancy test
result – fresh blood suggests a corpus luteum
hemorrhage
– old blood suggests a ruptured endometrioma
(chocolate cyst)
– purulent fluid suggests acute pelvic
inflammatory disease (PID)
– sebaceous fluid indicates a dermoid cyst.
Ectopic Pregnancy
• Unruptured ectopic pregnancy - localized pain due to
dilatation of the fallopian tube.
• Ruptured ectopic - pain tends to be generalized due to
peritoneal irritation
• Symptoms of rectal urgency due to a mass in the pouch of
Douglas may also be present
• Syncope, dizziness, and orthostatic changes in blood
pressure are sensitive signs of hypovolemia in these
patients
Ectopic Pregnancy
• Abdominal examination findings include
tenderness and guarding in the lower
quadrants.
• Once hemoperitoneum has occurred,
distension, rebound tenderness, and
sluggish bowel sounds may develop.
Corpus luteum hematoma
• Slow leakage produces minimal pain
• Frank hemorrhage can lead to
hemoperitoneum and hypovolemic shock
• Generalized abdominal pain and syncope
are features of such a presentation.
Ruptured Ovarian Cyst
• The most common causes are dermoid cyst,
cystadenoma, and endometrioma
• Blood loss is minimal, hypovolemia does not
supervene
• Peritoneal irritation due to leakage of cyst fluid
can lead to significant tenderness, rebound
tenderness, abdominal distension, and
hypoperistalsis
Ovarian Torsion
• Frequently - resolves spontaneously - only presenting
symptom -lower abdominal pain
• Persistent torsion leads to congestion, ovarian
enlargement, thickening of the ovarian capsule, and
subsequent infarction.
• Pain becomes severe -accompanied by nausea,
vomiting, and restlessness
• Infarction also leads to fever and mild leukocytosis
PID
• Acute salpingo-oophoritis is a polymicrobial
infection that is transmitted sexually.
• Neisseria gonorrhoeae and Chlamydia
trachomatis are usually identified in patients with
PID, and both organisms often coexist in the same
patient.
• Gonococcal disease tends to have a rapid onset,
while chlamydial infection has a more insidious
onset
Diagnostic Criteria for PID
 Lower abdominal tenderness
 Cervical motion tenderness
 Adnexal tenderness
• Diagnosis may also be supported by any of the
following criteria:
 Temperature greater than 101°F (38.3°C)
 Abnormal cervical or vaginal discharge
 Laboratory evidence of C trachomatis or N gonorrhoeae
 Elevated erythrocyte sedimentation rate or elevated Creactive protein value
Tubo-ovarian abscess
• A ruptured abscess can lead to gram-negative
endotoxic shock; therefore, this condition is a
surgical emergency.
• The most common presentation is bilateral,
palpable, fixed, tender masses.
• Patients often present with generalized abdominal
pain and rebound tenderness caused by peritoneal
inflammation
Fibroids
• A pedunculated subserous fibroid may twist
and undergo necrosis, causing acute
abdominal pain
• A pedunculated submucous fibroid may
present with cramping pain and vaginal
bleeding
Endometriosis
• Pain associated with endometriosis may
worsen premenstrually or during menses.
• Patients experience generalized lower
abdominal tenderness, and associated
complaints include dysmenorrhea,
dyschezia, and dyspareunia
Things to Remember
• Inguinal/rectal examination in males.
• Pelvic/rectal examination in females.
• Disorders in the chest will often manifest with abdominal
symptoms.
• It is always wise to examine the chest and cardiovascular
system when evaluating an abdominal complaint
• Consider mesenteric ischemia in diabetic patients and
patients with vascular disease and vasculitis
Questions ???