Acute Abdominal Pain by Dr.Iraqi

7/30/2019 Acute Abdominal Pain by Dr.Iraqi

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Acute Abdominal Pain Chap. 72

DR/Mohamed Eraki

Lecturer of general and pediatric surgery


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OutlineAcute Abdominal Pain

Definition

Epidemiology

Pathophysiology

Visceral

Referred

History / Physical Exam of Abdominal Pain

Labs / Radiographic Test for Abd Pain


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OutlineAcute Abdominal Pain

Intra-abdominal Diagnosis by Organ System : Gastrointestinal Gynecologic Pain

Appendicitis Acute PID

Biliary Tract Disease Ectopic Preg

Small Ball Obstruction Diverticulitis Vascular

Acute Pancreatitis AAA

Genitourinary Mesenteric Ischemia

Renal Colic Ischemic Colitis

Acute Urinary Retention / UTI

Treatment

Disposition


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Acute Abdominal Pain

Define as:

pain less than one week duration.

The principal reason for an ED visit in 2000.

Annual incidence approx. 63/1000 ED visits

Admission rate varies (high as 63% in pts >

65 yrs old.)


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Types of Abdominal Pain:

Three types of pain exist:

1. Visceral

2. Parietal

3. Referred


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1. Visceral Pain

Due to stretching of fibers innervating the

walls of hollow or solid organs.

It occurs early and poorly localized

It can be due to early ischemia orinflammation.


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2. Parietal Pain

Caused by irritation of parietal peritoneum

fibers.

It occurs late and better localized.

Can be localized to a dermatome superficial

to site of the painful stimulus.


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3. Referred Pain

Pain is felt at a site away from the

pathological organ.

Pain is usually ipsilateral to the involvedorgan and is felt midline if pathology is

midline.

Pattern based on developmental embryology.


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Two approaches to evaluate pts with acute

abdominal pain:

1. Classification of abd pain into systems

2. Abdominal Topography (4 quadrants)


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Classification on Abdominal Pain

Three main categories of abdominal pain:

1. Intra-abdominal (arising from within the abd

cavity / retroperitoneum) involves: GI (Appendicitis, Diverticulitis, etc, etc, etc)

GU (Renal Colic, etc, etc, etc)

Gyn (Acute PID, Pregnancy, etc)

Vascular systems (AAA, Mesenteric Ischemia, etc)


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Classification on Abdominal Pain

2. Extra-abdominal (less common) involves:

Cardiopulmonary (AMI, etc)

Abdominal wall (Hernia, Zoster etc)

Toxic-metabolic (DKA, OD, lead, etc) Neurogenic pain (Zoster, etc)

Psychic (Anxiety, Depression, etc)

3. Nonspecific Abd pain not well explained or

described.


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Abdominal Topography

RUQ LUQ

RLQ LLQ

UPPER ABDOMEN LOWER ABDOMEN

CENTRAL

GENERALIZED


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Historical features of Abd Pain

Location, quality, severity, onset, and

duration of pain, aggravating and alleviating

factors

GI symptoms (N/V/D) GU symptoms

Vascular symptoms (A. fib / AMI / AAA)

Can overlap i.e. Nausea seen in both GI / GUpathologies.


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Historical features of Abd Pain

PMH

Recent / current medications

Past hospitalizations

Past surgery

Chronic disease

Social history

Occupation / Toxic exposure (CO / lead)


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Physical Examination of the Abdomen

Note pts general appearance. Realize thatthe intensity of the abdominal pain may haveno relationship to severity of illness.

One of the initial steps of the PE should beobtaining and interpreting the vitals.

Pts with visceral pain are unable to lie still.

Pts with peritonitis like to stay immobile.


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Physical Examination of the Abdomen

INSPECT for distention, scars, masses, rash.

AUSCULATE for hyperactive, obstructive,absent, or normal bowel sounds.

PALPATION to look for guarding, rigidity,rebound tenderness, organomegally, orhernias.

Women should have pelvic exam (check FHR

if pregnant).Anyone with a rectum should have rectal

exam (If no rectum check the ostomy).


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Radiographic Test

Plain abdominal radiographs or abdominal

series has several limitations and is subject to

reader interpretation.

CT scan in conjunction with ultrasound is

superior in identifying any abnormality seen

on plain film.


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Specific Diagnoses

In patients above fifty years of age the top four

reasons for acute abdominal pain are: Biliary Tract

Disease (21%,) NSAP (16%), Appendicitis(15%), and

Bowel Obstruction (12%).

In patients under fifty years of age the top three

reasons for acute abdominal pain are: NSAP (40%,)

Appendicitis (32%,) and Other (13%.)


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Acute Appendicitis

In spite of a large number of algorithms and

decision rules incorporating many different

clinical and laboratory features, an accuratepreoperative diagnosis of appendicitis has

remain elusive for more than a century.


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Acute Appendicitis

Clinical features with some predictive value

include:

Pain located in the RLQ

Pain migration from the periumbilical area to theRLQ

Rigidity

Pain before vomiting

Positive psoas sign Note: Anorexia is not a useful symptom (33% pts

not anorectic preoperatively.)


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Acute Appendicitis

Ultrasound can be used for detection, but CTis preferred in adults and non-pregnantwomen.

The CT scan can be with and without contrast(oral & IV.)

A neg. CT does not exclude diagnosis, but apositive scan confirms it.


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Biliary Tract Disease

Most common diagnosis in ED of pts > 50.

Composed of:

Acute Cholecystitis (acalculus / calculus)

Biliary Colic Common Duct Obstruction (Ascending

Cholangitis painful jundice / fever / MS).

Of those patients found to have acutecholecystitis, the majority lack fever and 40%

lack leukocytosis.


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Patients may complain of:

Diffuse pain in upper half of abdomen

Generalized tenderness throughout belly

RUQ or RLQ pain.


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Sonography (US) is the initial test of choice for

patients with suspected biliary tract disease. More

sensitive than CT scan to detect CBD obstruction.

CT scan is better in the identification of cholecystitis

than in the detection of CBD obstruction.

Cholescintigraphy (radionclide / HIDA scan) of the

biliary tree is a more sensitive test than US for the

diagnosis of both of these conditions.


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Small Bowel Obstruction

SBO may result from previous abdominal surgeries.

Patient may present with intermittent, colicky pain,

abdominal distention, and abnormal BS.

Only 2 historical features (previous abd surgery andintermittent / colicky pain) and 2 physical findings

(abd distention and abn BS) appear to havepredictive value in diagnosing SBO.


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Plain abd films has a large number of

indeterminate readings and can be very

limited due to the following:

Pt is obese

Pt is bedridden / contracted (limited lateral

decub / upright view)

Technical limitations


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CT scan is better than plain film in detecting high

grade SBO.

CT scan can also give more info that might notbe seen on plain film (i.e. ischemic bowel)

Low grade SBO may require small bowel followthrough.


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Acute Pancreatitis

80% of cases are due to ETOH abuse or gallstones.

Other common causes:

Drugs ( Valproic acid, Tetracycline, Hydrochlorothiazide, Furosemide)

Pancreatic cancer

Abdominal trauma/surgery Ulcer with pancreatic involvement

Familial pancreatitis (Hypertriglycerides / Hypercalcemia)

Iatrogenic (ERCP) In Trinidad, the sting of the scorpion Tityus trinitatis is the most common cause of

acute pancreatitis

Definition :

Inflammation of the pancreas

Associated with edema, pancreatic autodigestion, necrosis andpossible hemorrhage


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Acute Pancreatitis

Only a minority number of pts present with pain

and tenderness limited to the anatomic area ofthe pancrease in the upper half of the abdomen.

50% of pts present with c/o pain extending well

beyond the upper abd to cause generalized

tenderness.


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Acute Pancreatitis

The inflammatory process around the

pancreas may cause other signs and

symptoms such as:

Pleural effusion Grey Turner's sign ( flank discoloration )

Cullen's sign ( discoloration around the

umbilicus )

Ascites

Jaundice


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Acute Pancreatitis

Should consider ICU admission for pts with

high Ransons Criteria.

When making the diagnosis of AcutePancreatitis, it maybe necessary to assess

the pt for the following:

1. Biliary pancreatitis

2. Peripancreatic complications


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Acute Pancreatitis

Biliary pancreatitis-Due to CBD obstruction.

-Can lead to Ascending Cholangitis

Clinical findings: May have a fever, MS, jaundice / icterus

Lab findings:AST / ALT, Total Bilirubin

Radiological std:

MRCP- Test of choice to get clear images of the pancrease and CBD.

Double contrast CT- can also be use, may have limited view of the CBD 2nd

most common test to be ordered in ED

Ultrasound 1st most common test to be order in ED to evaluate for CBD

obstruction. More sensitive than CT scan to evaluate the CBD. Its use is safer in

pregnancy.


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Acute Pancreatitis

Peripancreatic complications: Necrosis (Necrotizing Pancreatitis)

Hemorrhage (Hemorrhagic Pancreatitis)

Drainable fluid collections (Ruptured PancreaticPseudocyst)

Clinical findings: May have a distended Abd, appearseptic, Cullens sign, and / or Grey Turners Sign.

Lab findings:No definite lab test will help in thediagnosis. May see decrease Hg or Lactic Acid level.

Radiological test: of choice to evaluate for the abovecomplications is a double contrast CT scan.


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Acute Diverticulitis

Less than of pts present with LLQ pain.

1/3 of pts present with pain to the lower half of theabdomen.

20% of elderly pts with operatively confirmeddiverticulitis lacked abdominal tenderness.

Elderly pts are at risk for a severe and often fatalcomplication of diverticulitis.(Free perforation of the colon)


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Acute Diverticulitis

CT with contrast:

Test of choice for Acute Diverticulitis.

Can identify abscesses, other complications,and inform surgical management strategies.

US:

Relies on identification of an inflamed

diverticulum to make the diagnosis which isoften obscured in pts with complicateddiverticulitis.


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Renal Colic

Pts may present with abrupt, colicky, unilateral flank painthat radiates to the groin, testicle, or labia.

Hematuria and plain abd films can be helpful however do

not provide a strong support in the diagnostic evaluation ofsuspected renal colic.

Noncontrast helical CT is standard for the diagnosis. IVP

has poor sensitivity and time consuming in ED setting.

Must rule out AAA.


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Acute Pelvic Inflammatory Disease

Patient may complain of pain / tenderness in

lower abdomen, adnexal or cervix.

Most importantly patient may complain of

abnormal vaginal discharge (most commonfinding).

Fever, palpable mass, WBC have been

inconsistently associated with PID.

The best noninvasive test is transvaginal

ultrasound.


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Ectopic Pregnancy

Symptoms include abdominal pain (most

common) and vaginal bleeding (maybe the

only complaint).

Female pts (child bearing age) that present

with these symptoms automatically get a

pregnancy test and HCG quantitative level.


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Ectopic Pregnancy

If the pt is pregnant, then order a transvaginal

US to evaluate for ectopic pregnancy.

Clear view of an IUP in 2 perpendicular viewsessentially excludes an ectopic pregnancy.

If an IUP is not seen, this must be interpretedin the context of the discriminatory zone (DZ)

of the quantitative HCG.


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Ectopic Pregnancy

The DZ (1500 mlU/ml) is the threshold level ofserum HCG, above which a normal IUP should beseen on sonography.

Although there is a broad range of normal variationin HCG, failure of levels to increase by about 66%within 48 h in 1st trim pregnancy suggests anabnormal gestation (either a threatenedmiscarriage or blighted pregnancy from an

ectopic.)

If the diagnosis is not made with US and there isstill a high suspicion for ectopic than laparoscopy isindicated.


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Abdominal Aortic Aneurysm

Dissections produce chest or upper back pain thatcan migrates to abdomen as the dissection extend

distally.

AAA rather than dissect, it enlarge, leak, and

rupture.


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Abdominal Aortic Aneurysm

Palpation is an important part of physical exam.

Maybe able to detect an enlarged aorta.

Any stable pt > 50 yrs old presenting with recent

onset of abd / flank / low back pain should have a CT

scan to exclude AAA from the differential diagnosis.

Can use bedside ultrasound FAST scan, but this will

not provide information about leakage or rupture.

MRI is limited in its ability to identify fresh bleeding. It

is not an appropriate emergency procedure.


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Mesenteric Ischemia (MI)

2. Venous Mesenteric Venous Thrombosis

Occurs in hypercoagulable states.

Usually is found in younger pts.

Has a lower mortality.

Can be treated with immediate anticoagulation.


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Mesenteric Ischemia

Pt is usually older, has significant co-morbidity,and with visceral type abdominal pain poorlylocalized without tenderness.

Pt may have a diversion for food or weight loss.

Elevated Lactate level may help in the diagnosis.Abd films may have findings of perforated viscus

and / or obstruction.

May find pneumotosis intestinalis, free fluid,dilated bowel consistent with an ileus and / orobstructive pattern on CT scan.

Angiography is the diagnostic and initial

therapeutic procedure of choice.


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Ischemic Colitis

It is a diagnosis of an older patient.

Pain described as diffuse, lower abdominal pain in

80% of pts. Can be accompanied by diarrhea often mixed with

blood in 60% of patients.

Compares to mesenteric ischemia, this is not due tolarge vessel occlusive disease.

Angiography is not indicated. If it is performed it is

often normal.


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Ischemic Colitis

Can be seen post Abd Aorta surgery

The diagnosis is made by colonoscopy.

A color doppler ultrasound can also be used.

In most cases only segmental areas of the mucosa

and submucosa are affected.

Chronic cases can lead to colonic stricture. Treatment may include conservative management

or if bowel necrosis occurs surgery may be needed

for colectomy.

E bd i l Di f A


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Extrabdominal Diagnoses of Acute

Abdominal Pain: Cardiopulmonary

Pain is usually in upper half of abdomen.

A chest film should be done to look for pneumonia,

pulmonary infarction, pleura effusion, and / orpnemothorax.

A neg. film plus pleuritic pain could mean PE.

If epigastric pain is present one should inquireabout cardiac history, get and ECG, and considerfurther cardiac evaluation .

E bd i l Di f A


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Abdominal Pain: Abdominal Wall

Carnetts sign: The examiner finds point of

maximum abdominal tenderness on patient.

Patient asked to sit up half way, and if

palpation produces same or increasedtenderness than test is positive for an

abdominal wall syndrome.

Abd wall syndrome overlaps with hernia,neuropathic causes of acute abdominal pain

E bd i l Di f A


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Abdominal Pain: Hernias

Characterized by a defect through whichintraabdominal contents protrude during increases

in the intraabdominal pressure

Several types exist: inguinal, incisional,periumbilical, and femoral (common in Female).

Uncomplicated hernias can be asymptomatic,

aching / uncomfortable, and reducible on exam.

Significant pain could mean strangulation (bloodsupply is compromised) / incarceration (not

reducible).

T i f


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Toxic causes for


Pt may present with symptoms of N/V/D and/or +/- fever to

suggest a gastroenteritis or enterocolitis.

Most of these infections are confine to the mucosa of the

GI tract, therefore, pts may not present with significant

tenderness.

Other Infectious etiology that can cause abd pain includes:

Gp A Beta Hem. Strep Pharyngitis, Henoch-Schonlein

purpura, Rocky Mountain spotted fever, Scarlet fever,

early toxic shock syndrome.

Oth T i f


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Other Toxic causes for


Other toxic cause includes poisoning and OD

Black Widow Spider Abd muscle spasm

Cocaine induced intestinal ischemia

Iron poisoning Lead toxicity

Mercury salts

Electrical injury

Opoid withdrawal

Mushroom toxicity

Isopropranol induced hemorrhagic gastritis

M t b li f


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Metabolic causes for


DKA

AKA (ETOH)

Note both AKA / DKA can be a cause or aconsequence of acute pancreatitis.

Adrenal crisis

Thyroid storm

Hypo / hypercalcemia

Sickle cell crisis consider these causes for painsplenomegaly / heptomegaly, splenic infarct,cholecystitis, pancreatitis, Salmonella infect, ormesenteric venous thrombosis.

N i f


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Neurogenic causes for


Hover Sign the pt show signs of

discomfort when the examining hand is

hovering just above or is passed very lightly

over the area of dysesthesia. Zosteriform Radiculopathy- follows

dermatome distribution and is characterized

by shooting or continuous burning sensation.

May be due to diabetic neuropathicinvolvement of root, plexus, or nerve.

NSAP f


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NSAP causes for


A good portion of ER patients will have

nonspecific abdominal pain.

Patients may have nausea, midepigastric

pain, or RLQ tenderness. The lab workup is usually normal.

WBC may be elevated.

Diagnosis should be confirm with repeatedexam.


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Special Considerations

In pts >50 you must consider mesenteric ischemia,

ischemic colitis, and AAA.

In an elderly patient symptoms do not manifest in

the same manner as those younger. Compared to young pts, only 20% of elderly pts

with abdominal pain will be diagnose with NSAP

Assume an elderly patient has a surgical cause of

pain unless proven otherwise.

40% of those > 65 yrs old that present to ED with

abdominal pain need surgery.


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HIV/AIDS

Enterocolitis with diarrhea and dehydration is

most common cause of abdominal pain.

CMV related large bowel perforation is

possible. Watch for obstruction due to Kaposi

Sarcoma, lymphoma, or atypical

mycobacteria.

Watch for biliary tract disease (CMV,

Cryptosporidium.)


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Treatment of Acute Abdominal Pain

Hypotension:

In younger pts probably due to volume

depletion from vomiting, diarrhea, decreased

oral intake or third spacing. Treatment would be isotonic crystalloid.

Younger patients may also have abdominal

sepsis (septic shock).

Treatment would include isotonic crystalloid,antibiotics, and vasopressors (levophed or

dopamine).


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Hypotension:

In older patients CV disease should be added

to the differential.

If AMI is the diagnosis, a aortic balloon pump maybe needed until angioplasty or bypass is done. If

CHF is diagnosed than dobutamine with isotonic

crystalloid may be used

Must also consider hemorrhage as a cause:

Initiate treatment with isotonic crystalloid then

consider blood transfusion


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Analgesics:

Though in past ER physicians did not treat

acute abdominal pain with analgesics for fear

of altering or obscuring the diagnosis, currentliterature favors the use of opoids judiciously

in such patients.


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Antibiotics:

Must be consider when treating suspected

abdominal sepsis or diffuse peritonitis. Coverage should be aimed at anaerobes and

aerobic gram negatives.

If SBP suspected, must cover for gram positive

aerobes.

Examples of mononotherapy are cefoxitin,

cefotetan, ampicillin-sulbactam, or ticarcillin-

clavulanate.


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Disposition of Acute Abdominal Pain

Indications for admissions: Pts who appear ill.

Very young / Elderly

Immunocompromised

Unclear diagnosis

Intractable pain, nausea, or vomiting

Altered mental status

Those using drugs, alcohol, or that lack socialsupport.

Pts with poor follow-up and/or noncompliant.


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Disposition of Acute Abdominal Pain

Non-specific abdominal pain

If this is the working diagnosis, patients must

be re-examined in 24 hours. This may be done

in the outpatient setting.


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??? QUESTION #1 ???

A 45 year-old male patient presents with severe abdominalpain which is worse with movement. He has fever,

tachycardia, tachypnea and a narrow pulse pressure. There is

guarding, and rebound tenderness in the right lower quadrant.

Which of the following is the most likely diagnosis?

A. Perforated appendicitis

B. Acute unperforated appendicitis

C. Perforated gallbladder

D. Ruptured diverticulumE. Acute cholecystitis


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??? QUESTION #2 ???

A 45 year-old male with peptic ulcer disease (PUD) presents tothe ED with an abrupt onset of severe epigastric pain 1 hourprior to arrival. Abd exam leads you to suspect an early acutesurgical abdomen. Describe the findings and treatment withthis complication of PUD. Physical examination findingssuggestive of perforation include all of the following except?

A. A reactive pleural effusion is frequent seen with gastricperforation.

B. Tympany may indicate free air, confirmed by upright chestx-ray or lateral decubitus film

C. Acute pancreatitis may result from posterior perforation.

D. Chemical peritonitis progresses to abdominal rigidity,bacterial peritonitis and sepsis.


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??? QUESTION #3 ???

Acute pancreatitis may range from mild inflammation to severehemorrhagic pancreatitis with extensive necrosis of the gland.

Serum amylase and lipase are elevated. Laboratory findings

suggesting a poor prognosis include all of the following except:

A. Elevated blood glucose

B. Elevated hematocrit (due to dehydration)

C. Elevated LDH

D. Elevated WBC

E. Elevated AST


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??? QUESTION #4 ???

Most hernias are asymptomatic, but signs and symptoms mayinclude all of the following except:

A. Chronic postprandial pain and belching.

B. Nausea and vomiting with pain, inflammation and toxicity,

progressing to perforation, peritonitis and sepsis with

strangulated hernias.

C. Abdominal or focal pain and tenderness, possibly with signs of

obstruction with incarceration. Possibly tachycardia and fever,

leukocytosis and left shift.

D. Local swelling; intermittent "dragging" sensation or minor

aching discomfort.


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??? QUESTION #5 ???

All of the following are true regarding the plain radiographicevaluation of bowel obstruction except:

A. A stepladder pattern of air-fluid levels suggests obstruction.

B. Gas in the rectum or sigmoid excludes obstruction.

C. A dilated loop may terminate abruptly at the site of

obstruction.

D. Obtain an upright chest x-ray to exclude free air in the

abdomen.

E. Obtain flat and upright abdominal films or decubitus films tolook for air fluid levels.

F. Dilated loops without stepladder air-fluid levels may be due

to ileus.


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ANSWERS

1. A -These findings are highly suggestive of bacterial peritonitisand sepsis.

2. A

3. B

4. A

5. A -With complete obstruction, distal gas will usually be

absent. Gas may still be present early in obstruction, however,

or may be introduced during the rectal examination.

Acute Abdominal Pain by Dr.Iraqi

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