Introduction

Complaints related to abdominal pain comprise
between 7- 9 % of all visits to the ED.

Of those, the most common discharge diagnosis is
Abdominal Pain NOS.

Although most abdominal pain is non-emergent and
self-limited in nature, attention must be paid to not
miss medical and/or surgical emergencies.
Important Factors
 Patients rarely present with the classical
signs/symptoms of acute abdominal pain.
 Three important factors to consider are age,
gender, and co-morbidities.
Definition

The term acute abdomen refers to a sudden, severe
abdominal pain that is less than 24 hours in duration. It is in
many cases a medical emergency, requiring urgent and specific
diagnosis. Several causes need surgical treatment.
Don’t forget about the chronic pain that has acutely
worsened.
Basic Principles
 Proper evaluation and management requires one to recognize:
1. Does this patient need surgery?
2. Is it emergent, urgent, or can wait?
• In other words, is the patient unstable or stable?
 Remember medical causes of abd pain
 > 100 causes exist
1.
2.
3.
4.
5.
6.
7.
8.
NSAP (34%)
Acute appendicitis (28%)
Acute chlecystitis (10%)
SBO (4%)
Perforated PU (3%)
Pancreatitis (3%)
Diverticular disease (2%)
Others (13%)
In children
Acute appendicitis
UTI
Mesenteric adenitis
GE
Constipation
 50-65% inaccurate initial diagnosis
 50% of surgical admissions are emergencies, and of
those 50% present with acute abdomen.
Types of Pain
 Visceral Pain: caused by stretching of fibers
innervating the walls of hollow organs or
capsules of solid organs, described as cramp or
dull pain
 Parietal Pain: caused by irritation of fibers that
innervate the parietal peritoneum, pain is more
sharp and localized
 Referred Pain: pain at a location distant to the
diseased organ based on embryological origin
Visceral pain
I. Parietal pain
 Is localised to the dermatome above
the site of the stimulus.
 Character:
I. sharp and localized pain.
II. somatic nerve distribution (T7-L2,
umbilicus at T12). The exception to this is
the diaphragmatic portion, which is supplied
centrally by the phrenic nerve (C3-C5), and
peripherally by the lower six intercostal and
subcostal nerves.
III.sensitive to mechanical stimuli
(stretching, pinprick , pinch), heat,
electrical shock, chemical stimulus,
infection-inflammation.
I. Referred pain
 It’s pain perceived distant from its
source and results from convergence
of nerve fibers at the spinal cord.
 produces symptoms, not signs e.g.
tenderness
Causes of Acute Abdomen
I. Surgical
II. Gynecological
III. Medical
Think Broad categories for
DDx surgical Causes
o Inflammation
o Obstruction
o Ischemia
o Perforation (any of above can end here)
 Offended organ becomes distended
 Lymphatic/venous obstruction due to ↑ pressure
 Arterial pressure exceeded → ischemia
 Prolonged ischemia → perforation
Inflammation versus Obstruction
Organ
Lesion
Stomach
Gastric Ulcer
Duodenal Ulcer
Biliary
Tract
Acute cholecystitis
Acute cholangitis
Pancreas
Acute, recurrent, or
chronic pancreatitis
Small
Intestine
Large
Intestine
Crohn’s disease
Meckel’s
diverticulum
Appendicitis
Diverticulitis
Location
Lesion
Small Bowel
Obstruction
Adhesions
Hernia
Cancer
Crohn’s disease
Gallstone ileus
Intussusception
Volvulus
Large Bowel
Obstruction
Malignancy
Volvulus: cecal
or sigmoid
Diverticulitis
Biliary colic
Ureteric colic
Acute retention
Ischemia versus Perforation
Acute
mesenteric
ischemia
Usually acute
occlusion of the
SMA from
thrombus or
embolism
Perforated PU
Chronic
mesenteric
ischemia
Typically smoker,
vasculopathy
with severe
atherosclerotic
vessel disease
Perforated appendix
Ischemic colitis
Torsion of a viscus
Perforated diverticular
disease
Acute chlolecystitis with
Perforation
Ruptured AAA
Perforated bladder
GYN Causes
Organ
Lesion
Ovary
Torsion of ovary
Ruptured graafian follicle
Tubo-ovarian abscess (TOA)
Fallopian tube
Ectopic pregnancy
Acute salpingitis
Pyosalpinx
Uterus
Uterine rupture
Endometritis
Non-Surgical (Medical) Causes
System
Cardiac
Disease
Myocardial infarx
Acute pericarditis
Pulmonary Pneumonia
System
Disease
Endocrine
Diab ketoacidosis
Addisonian crisis
Metabolic
Acute porphyria
Mediterranean fever
Hyperlipidemia
Pulmonary infarx
PE
GI
Acute pancreatitis
Gastroenteritis
Acute hepatitis
Musculoskeletal
Rectus muscle
hematoma
GU
Pyelonephritis
CNS
PNS
Tabes dorsalis (syph)
Nerve root
compression
Vascular
Aortic dissection
Hematological
Sickle cell crisis
Generalized AP
Perforation
Mesenteric ischemia
AAA
Acute pancreatitis
Central AP
Early appendicitis
SBO
Acute pancreatitis
Ruptured AAA
Mesenteric thrombosis
Acute gastritis
Epigastric pain
DU / GU
 Recurrent, relationship to meals,
relationship to posture
Oesophagitis
Acute pancreatitis
 History of alcohol consumption,
history of similar event, elevated
labs
AAA
RUQ pain
Acute cholecystitis
Recurrent attacks, tender over gall bladder
area
DU
Acute pancreatitis
Retrocecal appendicitis
Shift of pain, tenderness
R L Pneumonia
Fever, tachypnea, bronchial breathing
Subphrenic abscess
LUQ pain
 Pneumonia
 Acute pancreatitis
 Splenic rupture
 Splenic abscess
 Acute perinephritis
 Subphrenic abscess
RIF pain
 Acute appendicitis
Shift of pain, anorexia, localized tenderness
 Mesenteric adenitis (young)
Fever, inconstant signs




Perf DU
Diverticulitis
Salpingitis
Ureteric colic
Colicky pain, hematuria




Meckel’s diverticulum
Ectopic pregnancy
Crohn’s disease
Biliary colic (low-lying GB)
LIF pain
 Diverticulitis
 Constipation
 IBS
 PID
 Rectal Ca
 UC
 Ectopic pregnancy
Suprapubic pain
 Acute urinary retention
Palpable bladder, difficulty passing urine
 UTI
 Cystitis
 PID
 Ectopic pregnancy
 Diverticulitis
Loin pain
Muscle strain
UTIs
Renal stones
Pyelonephritis
Approach to Acute Abdomen
Take a proper Hx and Ex, do not work to the
diagnosis given to you by the referring doctor.
History is THE MOST IMPORTANT part of the
diagnostic process:
 Location , onset, nature , severity, radiation, aggravating or
relieving factors, associated symptoms
 A good medical history
 A good social history, including alcohol, drugs, domestic
abuse, stressors, etc.
 Family history is important (IBD, cancers, etc)
 MEDICATION INVENTORY
CLUES in Hx.
Was onset of pain gradual or sudden?
Sudden
perforation, hemorrhage, infarct
Gradual
inflammation, peritoneal irrigation, hollow organ distension
What does nature of pain?
Steady pain
inflammatory process
Colicky pain
Biliary colic ,obstruction
Stabbing
AAA
Does pain radiate anywhere?
Right shoulder, angle of right scapula
Around flank to groin
kidney, ureter
In Females ?
Last menstrual period?
Abnormal bleeding?
GB
Progression of Pain
Associated symptoms
•
•
•
•
Fever
Genitourinary
Gynaecological
Vascular
PMSH
•
•
•
•
•
Previous episodes of AP
Investigations
Operations
Chronic disease
Medications (NSAIDs)
Physical examination
Administration of analgesics prior to surgical
consultation does not obscure the diagnosis,
but improves accuracy.
 Observation
Bending Forward: Chronic Pancreatitis
Jaundiced: CBD obstruction
Dehydrated: Peritonitis, SBO
 Inspection






Not move with respiration in peritonitis
Scaphoid or flat in peptic ulcer
Distended in ascites or intestinal obstruction
Visible peristalsis in a thin or obstruction
Scars : relevant previous illness or adhesions
Hernia : intestinal obstraction
 Palpation
 Check for Hernia sites
 Tenderness
 Rebound tenderness.
 Guarding.
 Rigidity.
 Rebound tenderness, considered the clinical indicator of
peritonitis, has a high (25%) false -ve rate
 Rigidity, referred tenderness & cough pain are sufficient
evidence for peritonitis
 Local Right Iliac Fossa tenderness:
 Acute appendicitis
 Acute Salpingitis in females
 Low grade, poorly localized tenderness:
 Intestinal Obstruction
 Tenderness out of proportion to examination:
 Mesenteric Ischemia
 Acute Pancreatitis
 Flank Tenderness:
 Perinephric Abscess
 Retrocaecal Appendicitis
Important Signs in Patients with Abdominal Pain
Sign
Finding
Association
Cullen's sign
Bluish periumbilical discoloration
Kehr's sign
referd left shoulder pain
McBurney's sign
Tenderness located 2/3 distance from
anterior iliac spine to umbilicus on right side
Murphy's sign
Abrupt interruption of inspiration on palpation
of right upper quadrant
Iliopsoas sign
Hyperextension of right hip causing abdominal pain
Appendicitis
Obturator's sign
Internal rotation of flexed right hip causing
abdominal pain
Appendicitis
Grey-Turner's
Discoloration of the flank
Chandelier sign
Manipulation of cervix causes patient to lift
buttocks off table
PID
Rovsing's sign
Right lower quadrant pain with palpation of
the left lower quadrant
Appendicitis
Retroperitoneal
haemorrhage
Splenic rupture
Ectopic pregnancy
rupture
Appendicitis
Acute cholecystitis
Retroperitoneal
hemorrhage
 Percussion
 Resonance : intestinal obstruction
 Loss of liver dullness: gastrointestinal perforation
 Dullness : free fluid , full bladder
 Shifting dullness : free fluid
 Auscultation
 NR Bowel sounds 5-30/min
 > 2min to confirm absent
 High pitched, hyperactive or tinkling
caused by powerful peristaltic action , partial obstruction , abdominal cramping
 Hypoactive bowel sounds
indicates Peritonitis , non-mechanical obstruction , Inflammation , gangrene
 Bruit in epigastrium indicates AAA
Systemic Examination
PR Examination:
 Tenderness
 Induration
 Mass
 Frank blood
Systemic Examination
PV Examination
 Bleeding
 Discharge
 Cervical motion tenderness
 Adnexal masses or tenderness
 Uterine Size or Contour
Investigations
 Beware of misleading by investigations
A.Blood tests
 CBC (Hb & WBC) & U&E
 Amylase (Pancreatitis) but remember 20% have NR values
 LFTs
 CRP & ESR (inflammatory markers)
 ABG
 Serum calcium (Abnormal GI motility PU, Pancreatitis)
 Clotting (acute pancreatitis, sepsis, DIC, liver disease)
 Blood glucose
 ECG
 Attention to the WBC as a screening test only if
substantially elevated.
 25% of patients with elevated WBC do not have
different outcomes from those with a normal WBC.
 CBC has a limited clinical utility
 In RLQ pain to rule in or rule out Acute Appendicitis
wbc count (n>70%)
< 8,000
very unlikely
8,000-10,000 unlikely
10,000-12000 equivocal
12,000-15,000 suggestive
15,000-20,000 highly suggestive
>20,000
probably ruptured
B. Urinalysis
Cheap
Simple & available test
High yield when results fit with the clinical scenario
Pregnancy test
C. Radiology
Erect CXR
Supine AXR
USS
 Biliary trees , Mass , fluid , Retroperitoneal organs
 Ultrasound in Acute Appendicitis +!?
Causes of free sub-
IVU (renal/ureteric colic)
CT scan




Similar benefit as in U/S but
more time consumed , more accurate
more expensive
more risk
diaphragmatic gas
Perforation of viscus
Gas-forming infection
Pleuroperitoneal fisula
Iatrogenic
Interposition of bowel
b/t liver & diaphragm
 Plain X-rays have limited utility in the
evaluation of AAP
Low diagnostic yield
High incidence of misleading incidental
findings
Lack of impact on management
Exception: Bowel obstruction or perforation
Labs & Imaging
Test
CBC w diff
Reason
Left shift can be
very telling
ABG
N/V, acidosis,
dehydration
Amylase
Pancreatitis,
perf DU, bowel
ischemia
LFT
Jaundice,
hepatitis
UA
GU- UTI, stone,
hematuria
Beta-hCG
Ectopic
Test
KUB
Reason
Flat & Upright
SBO/LBO,
free air,
stones
Ultrasound
Chol’y, jaundice
GYN pathology
CT scan
Anatomic dx
Case not
straight forward
Diagnostic
accuracy
Findings in plain X-ray abdomen
 in case of Biliary disease :
1. radioopaque shadow for stone
2. pneumobilia
3. calcification of porcelain gallbladder
 In case of pancreatic disease :
1. calcification in chronic pancreatitis
2. sentinel loop : dilatation of a segment of large or small intestine, indicative
of localised ileus from nearby inflammation.
 In case of appendicitis:
1. Fecalith: a hard stony mass of feces
2. Phlebolith : is a small local, usually rounded, calcification within a vein
3. Abscent of psoas muscle shadow
calcification of porcelain gallbladder
Pneumoperitoneum
Findings in plain X-ray abdomen
Intestinal obstruction
Erect
(air fluid level)
Step ladder
Central
Small
multiple
Supine
(dilatation of bowel)
>3cm
plicae circulares
Erect
(air fluid level)
Peripheral
Large
Few
Supine
(dilatation of bowel)
> 5cm in sigmoid
> 10 cm in cecum
Peripheral haustration
SBO
LBO
ultrasound
.
Hepatobiliray tree(stones,mass,thickining of the
wall)
*pancreases
*kidney
*pelvic organ
*intrabdominal fluid collection
Gall stone\ appendicolith
CT scan
.
Helpful in case of abdominal pain without clear
etiology better in evaluation of abdominal aortic
aneurysm.
5.helical CT_scan
Provide rapid cost effective diagnostic tool.
CT scan
What is the diagnosis?
Acute appendicitis
Acute pancreatitis
D. Laparoscopy
 Early diagnostic laparoscopy may result in:
 accurate,
 prompt,
 efficient management of AAP
 Reduces the rate of unnecessary laparotomy
 Increases the diagnostic accuracy
 May be a key to solving the diagnostic dilemma of
NSAP.
Immediate Treatment of the Acute
Abdomen
I.
Start large bore IV with either saline or lactated Ringer’s
solution
II. IV pain medication
III. Nasogastric tube if vomiting or concerned about obstruction.
IV. Foley catheter to follow hydration status and to obtain
urinalysis.
V. Antibiotic administration if suspicious of inflammation or
perforation.
VI. Definitive therapy or procedure will vary with diagnosis.
VII. Reassess patient on a regular basis.
Decision to operate
• Proper management requires a timely decision about
the need for surgical operation.
 Peritonitis
Tenderness w/ rebound, involuntary guarding
 Severe / unrelenting pain
 “Unstable” (hemodynamically, or septic)
Tachycardic, hypotensive, white count
 Intestinal ischemia, including strangulation
 Pneumoperitoneum
 Complete or “high grade” obstruction
Take Home Massage
 Careful history (pain, other GI symptoms)
 Remember DDx in broad categories
 Narrow DDx based on hx, exam, labs, imaging
 Always perform ABC, Resuscitate before Dx
 If patient’s sick or “toxic”, get to OR (surgical
emergency)
Ideally, resuscitate patients before going to the OR
 Don’t forget GYN/medical causes, special situations
 For acute abdomen, think of these commonly (below)
Perf DU
Appendicitis +/perforation
Diverticulitis +/perforation
Bowel
obstruction
Cholecystitis
Ischemic or perf
bowel
Ruptured
aneurysm
Acute
pancreatitis