The Acute Abdomen
Andrew Wright MD
Department 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 diagnosis
Does 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 slow
Can guide prognosis – i.e. timing of appendicitis
Acute
Colic
Bowel strangulation
Rupture of viscera
Torsion
Fainting
Abdominal 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 pain
Transition 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?
Character
Paroxysmal
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
Character
Burning – 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 pain
Diaphragm – shoulder
Biliary tract – tip of shoulder
Pancreas – mid back
Kidney – mid back
Rectum- coccyx
Uterus – coccyx
Exacerbating factors
Relationship to food
Respiration
Pleuritic pain usually worse on deep inspiration
Micturation
UTI
Bladder obstruction
Nephrolithiasis
Peri-bladder abscess
Reclining
Often retroperitoneal origon
Vomiting
Cause
Obstruction
Severe irritation of nerves of peritoneum
i.e. pain, pancreatitis
Frequency
Relationship with pain
Character
Nausea and/or lack of appetite
Bowel Movements
Regularity
Diarrhea
True diarrhea vs. passage of several small loose stools
Blood
Mucus
i.e. intussusception
Menstruation
Regularity
Exact timing
Pain
History
Prior similar episodes
Prior illnesses that may relate
h/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
Temp
Normal or mildly elevated typical
High fever unusual – suspect kidney or thorax
Hypothermic – suspect shock
Blood Pressure
Inspection
Determine exact location of pain first
Inspection
Distension
Bulge
Hernia
All potential orifices – including femoral
Movement
Rigidity with inspiration
Palpation
Keys to success
Gentleness
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
Imaging
Plain XRays
Flat and Upright
Left Lateral Decubitus if not able to stand)
Chest
Ultrasound
CT
Additional Testing
Guide 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
Gastroenteritis
Viral
Eosinophilic
Yersinia
Typhlitis
Hepatitis
Typhlitis
Tropical infectious diseases (helminthic)
Tuberculosis
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 Ischemia
Acute
Chronic
Sickle Cell Crisis
Colonic Ischemia
Other
Psychiatric Disease
Spleen
Abscess
Infarct
Wandering Spleen
Musculoskeletal
Abdominal 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
Metabolic
Diabetic Ketoacidosis
Porphyria
Lactose Intolerance
Pediatric
Henoch-Schönlein purpura
Intussuception
Malrotation with midgut volvulus
Recurrent Abdominal Pain – diagnosis of exclusion