The Acute Abdomen

Jason E. Davis, MD

Abdominal Pain

• A leading cause for hospital admissions• Most self-limited and of little consequence• Subset of serious acute pathology may require

acute medical and/or surgical intervention– This latter group referred to as ‘acute abdomen’

• Not all acute abdomens = surgical abdomen– Renal colic, gastroenteritis, infectious colitis*, PID– Mesenteric ischemia, ruptured AAA, appendicitis,

perforated bowel, perf’d peptic ulcer, inc’d hernia

Broad Differential Dx

Anatomic Considerations

• Embryonic origin & Blood supply– Foregut: esophagus, stomach, proximal

duodenum, pancreas, liver, biliary tract, spleen• Celiac artery

– Midgut: distal duodenum, jejunem, ileum, cecum, appendix, proximal 2/3 transverse colon

• Superior mesenteric artery

– Hindgut: remaining colon and rectum• Inferior mesenteric artery

Anatomic Considerations

• Innervation– Visceral pain: autonomic, dull, cramping, poorly

localized, often assoc with nausea and diaphoresis• Often midline secondary to embryonic origin

– Parietal pain: somatic, sharp, severe, persistent, loc

• Referred visceral sensation– Foregut pain: Epigastric– Midgut pain: Peri-umbilical– Hindgut pain: Hypogastrium

Anatomic Considerations

Anatomic Considerations

Approach to Acute Abdomen

• Age• Location and character of pain• Pain duration and progression• Associated symptoms

– Nausea– Emesis– Anorexia– Constipation/Diarrhea

Approach to Acute Abdomen

Most important symptom is PAIN. Accordingly, history should include all of the following:1. Onset2. Severity3. Type of pain4. Radiation of pain5. Change in nature of pain6. Associated bowel or urinary symptoms7. Aggravating or relieving factors

Approach to Acute Abdomen

• Diagnosis according to onset of pain:– Sudden– Rapid– Gradual– Chronic

(exacerbation)

Sudden onset (full pain in seconds)Perforated ulcer Mesenteric infarction Ruptured AAARuptured ectopic pregnancyOvarian torsion or ruptured cystPulmonary embolismAcute myocardial infarction

Rapid onset(initial sensation to fullpain over minutes or hours) Strangulated herniaVolvulusIntussusceptionAcute pancreatitisBiliary colicDiverticulitisUreteral and renal colic

Gradual onset(hours)AppendicitisStrangulated herniaChronic pancreatitisPeptic ulcer diseaseInflammatory bowel diseaseMesenteric lymphadenitisCystitis and urinary retentionSalpingitis and prostatitis

Stereotypes of Pain Onset and Associated Pathology

• Position of patient (motionless vs. writhing in pain vs. rolling restlessly appendicitis/peritonitis vs. mesentary ischemia vs. ureteral/intestinal colic)

Approach to Acute Abdomen

Diaphragmatic Supraclavicular area (Kehr’s sign)

Ureteral Hypogastrium, groin, inner thigh

Cardiac pain Epigastrium, jaw, shoulder

Appendix Periumbilical via T10 nerve

Duodenum Umbilical region via greater thoracic splanchnic nerve

Hiatal hernia Epigastrium via T7 and T8 nerves

Pancreas or gallbladder Epigastrium

Gallbladder and bile duct Epigastric pain, wraps around scapula

Structure irritated Location of referred pain

Named Exam Findings

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Cullen's sign Bluish periumbilicaldiscoloration

Retroperitoneal hemorrhage(hemorrhagic pancreatitis, abdominal aortic aneurysm rupture)

Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture

McBurney's sign Tenderness located2/3 distance fromanterior iliac spine toumbilicus on right side

Appendicitis

Murphy's sign Abrupt interruption ofinspiration on palpationof right upper quadrant

Acute cholecystitis

Iliopsoas sign Hyperextension of right hipcausing abdominal pain

Appendicitis

Obturator's sign Internal rotation offlexed right hip causingabdominal pain

Appendicitis

Grey-Turner's sign Discoloration of the flank Retroperitoneal hemorrhage(hemorrhagic pancreatitis, abdominal aortic aneurysm rupture)

Chandelier sign Manipulation of cervixcauses patient to liftbuttocks off table

Pelvic inflammatory disease

Rovsing's sign Right lower quadrantpain with palpation of the left lower quadrant

Appendicitis

Sign Finding Association

Imaging and Laboratory Studies

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• Laboratory examinations– CBC with differential, type & screen– Chem-10, amylase, LFT’s, urinanalysis

• X-rays of the chest and abdomen (upright/supine)– Distended loops of bowel, kidney stones, perf free gas

• Ultrasound: cholelithiasis, bile duct obstruction, AAA

• Abdominal CT: AAA, abdominal abscess, severe diverticulitis

• Endoscopy: perforated peptic ulcer, SBO, gastric cancer

• Colonoscopy: carcinoma of the colon

• Angiography: mesenteric ischemia

• Radionuclide scans

Appendiceal Disease• Appendicitis

– 7% lifetime risk of appendicitis– Most common cause of acute abdominal surgery in the U.S.

• Though living in Lehigh Valley appears to be risk for gallbladder disease

– Must be considered in every patient with acute abdomen– Especially common during pregnancy (also important to consider

ectopic pregnancy in women of reproductive age)

• Constipation: “the great imitator”• Less common among differential diagnoses

– Mucocele, carcinoid, appendiceal carcinoma

Special Considerations

• Elderly patients– May not mount febrile response– Atypical pain presentation (severity/location)

• Immunosuppressed patients– Opportunistic infections, lymphomas– Corticosteroids may mask pain

• Obese patients– May be more difficult to palpate

• Patients taking pain medications– Opioids may cause constipation and mask/distort pain

• Pregnant women– Distorted abdomen & pregnancy may mimic Sx’s

Beyond Appendicitis

Beyond Appendicitis• Appendiceal Neoplasms

– Carcinoid• Marjority of appendiceal neoplasms• Derived from neural crest cells• <2cm (90%) appendectomy• >2cm (10%) right hemicolectomy• Slow mets, 5 yr survival >50% w/ mets

• Primary Adenocarcinoma– Mucinous more favorable than Colonic– Assoc with colon and ovarian CA (15 – 30%)

• Lymphoma (often AIDS-associated)

Acute Abdomen

Algorhithm adopted from Vanderbilt Medical Center

RLQ Pain

Adopted from Vanderbilt Medical Center

Case 1: Ms. Jones

• 27 years old, pregnant female• ED presentation

– Crampy peri-umbilical pain– Nausea, emesis and anorexia x 12 hours– Pain has ‘migrated’ to RLQ over past several

hours, becoming constant and intense

• Urinanalysis: mild hematuria and pyuria• CT scan – deferred for preg

Case 1: Ms. Jones revisited

• Appendicitis– Classic chronologic presentation– Especially common during pregnancy

• 1 out of every 1750 pregnancies!• May be in RUQ due to enlarged uterus

– Mild hematuria and pyuria are common in appendicitis with pelvic inflammation

– Radiopaque fecalith present only 5% x’s

• Open or Laparoscopic appendectomy

Case 2: Mr. Smith

• 42 year-old male• ED presentation

– Fever, vomiting and diarrhea– Constant abdominal pain 4hrs, radiates to back

• Last bowel movement yesterday, flatus unsure• FUA: non-specific bowel gas pattern

Case 2: Mr. Smith revisited

• Gastroenteritis– Classic presentation– Pain often follows N/V

• Non-surgical, medical management

Summary

• Differential diagnosis for acute abdomen is lengthy

• Many presentations will not require admission or surgery

• Ischemic colitis, ruptured AAA, intestinal or ulcer perforation, and ectopic pregnancy are important causes not to be missed

• Common differentials include appendicitis, cholecystitis, obstruction, and ischemia, but will vary per population

Thank you