ACUTE ABDOMINAL PAIN

Abdominal pain

Acute abdominal pain: 7 days

usually seek attention within the first 24 to 48 hours

Subacute abdominal pain: 7 days but 6 months

Chronic abdominal pain : > 6 months

constantly or intermittently
 Acute abdominal pain
Emergency department patient with abdominal pain

25 50%: no specific disease identified

50 %: more serious disorders that warrants further evaluation and

treatment

small proportion of patients has a life-threatening disease

Evaluation of acute abdominal pain accurate diagnosis early in

the presentation:
treatment of patients who are seriously ill should not be delayed

patients with self-limited disorders are not overtreated

 Clinical evaluation
Initial - rapid assessment of the patient's overall physiologic state:
unstable? / require expedited treatment?
Airway
Breathing
Circulation

If hemodynamic instability
early hemodynamic resuscitation: should precede diagnostic
imaging death begins in radiology
immediate surgical consultation
need for endotracheal intubation?
 Clinical evaluation: history

1. The rapidity of onset of pain

2. Progression

3. Duration

4. Location

5. Intensity and Character

6. Aggravating and Alleviating Factors

7. Past Medical History

 Clinical evaluation:history

1. The rapidity of onset of pain

2. Progression

3. Duration

4. Location

5. Intensity and Character

6. Aggravating and Alleviating Factors

7. Past Medical History

 The rapidity of onset of pain

Often a measure of the severity of the underlying disorder:

sudden in onset, severe, and well localized likely of an intra-

abdominal catastrophe
perforated viscus
mesenteric infarction
ruptured aneurysm
 Clinical evaluation: history

1. The rapidity of onset of pain

2. Progression

3. Duration

4. Location

5. Intensity and Character

6. Aggravating and Alleviating Factors

7. Past Medical History

 Progression

gastroenteritis: pain is self-limited

appendicitis: pain is progressive

colicky pain (renal colic): crescendo-decrescendo pattern

 Clinical evaluation: history

1. The rapidity of onset of pain

2. Progression

3. Duration

4. Location

5. Intensity and Character

6. Aggravating and Alleviating Factors

7. Past Medical History

 Duration

abdominal pain for an extended period (e.g., weeks) less

likely to have an acute life-threatening illness

abdominal pain - onset within hours to days likely a serious

pathology
 Clinical evaluation: history

1. The rapidity of onset of pain

2. Progression

3. Duration

4. Location

5. Intensity and Character

6. Aggravating and Alleviating Factors

7. Past Medical History

 Location

Changes in location may represent:

progression from visceral to parietal irritation : appendicitis

development of diffuse peritoneal irritation: perforated ulcer

 Clinical evaluation: history

1. The rapidity of onset of pain

2. Progression

3. Duration

4. Location

5. Intensity and Character

6. Aggravating and Alleviating Factors

7. Past Medical History

 Intensity and character
Three patterns of acute abdominal pain

1. Prostrating pain: severe, life-threatening disease

perforated viscus, ruptured aneurysm, or severe pancreatitis

2. Colicky pain: sinusoidal pattern of intense pain alternating with a

period of relief
nausea and vomiting are characteristic symptoms associated with this
group of disorders (vagal reflexes)

cause: obstruction of a hollow viscus intestinal obstruction, renal

colic, or biliary pain

3. Gradually increasing discomfort (vague and poorly localized at the

start more localized as the pain intensifies)
caused by inflammation: acute appendicitis or diverticulitis
 Clinical evaluation: history

1. The rapidity of onset of pain

2. Progression

3. Duration

4. Location

5. Intensity and Character

6. Aggravating and Alleviating Factors

7. Past Medical History

 Aggravating and Alleviating Factors
Positional changes

patient with peritonitis: lies motionless

renal colic: writhes in an attempt to find a comfortable position

Relationship with meals or medications

intake of fatty foods biliary pain

history of chronic nonsteroidal anti-inflammatory drug use peptic
ulcer disease
pain alleviated by meals associated with duodenal ulcer
exacerbation of pain with eating patients with gastric ulcer or
chronic mesenteric ischemia
 Clinical evaluation:history

1. The rapidity of onset of pain

2. Progression

3. Duration

4. Location

5. Intensity and Character

6. Aggravating and Alleviating Factors

7. Past Medical History

 Past Medical History

history of similar symptoms a recurrent problem

partial small bowel obstruction, renal calculi, or pelvic inflammatory
disease

systemic illness abdominal pain as a manifestation of the

underlying disorder
systemic lupus erythematosus, porphyria, or sickle cell disease
 Physical examination
A surgical abdomen is a clinical diagnosis!

presence of bowel sounds - intestinal obstruction

initial stage: intense bowel sounds

late stage: absent bowel sounds

palpate the abdomen: tenderness detected assess for rebound

tenderness = evidence of peritonitis
jarr the patient's bed or stretcher
finger percussion
Laboratory data establish a firm diagnosis!
complete blood count, with a differential count
leukocytosis, particularly when associated with immature band forms

patient's fluid and acid-base status, renal function, and metabolic

state
metabolic acidosis/ high serum lactate level/ depressed bicarbonate
bicarbonate level associated with tissue hypoperfusion and shock
patients likely to require urgent surgical intervention or intensive care
serum electrolyte, blood urea nitrogen, creatinine, and glucose levels

patients with upper abdominal pain or with jaundice liver

biochemical tests and serum amylase/lipase levels
urinalysis

in all women of reproductive age with abdominal pain/ in women of

childbearing potential urine or serum pregnancy testing
 Imaging
Abdominal radiographs= plain radiograph: upright or lateral
decubitus radiograph
bowel distension + air-fluid levelsintestinal obstruction,
free intraperitoneal air hollow organ perforation

Computed tomography
suspected partial or complete intestinal obstruction test of choice
a negative CT scan in the setting of acute abdominal pain
considerable value in excluding common serious disorders
CT should not be routine in all patients with acute abdominal pain
acute cholecystitis and cholangitis relatively invisible on CT
ultrasound examination of the right upper quadrant as the primary
diagnostic test
radiation exposure
 Imaging

Ultrasonography

clinical signs of peritonitis abdominal ultrasound is the test of

choice
effectively assess for appendicitis and abdominal abscess /intrapelvic
pathology

FAST (the focused abdominal sonogram for trauma) detect fluid

in the abdominal cavity
presence of shock and fluid in the abdomen is an indication for
immediate laparotomy
 Other diagnostic imaging modalities
take a secondary role in the evaluation of the patient with acute
abdominal pain use of these tests is generally guided by the
results of CT or ultrasound

MRI biliary pathology

endoscopy
angiography: establishing a diagnosis of visceral ischemia
delivering therapy aimed at improving or reestablishing blood flow
paracentesis
leukocytes in the lavage effluent in an unstable patient may in extreme
circumstances, sufficient grounds for laparotomy

patient who is unstable and deteriorating and has signs of an acute

abdomen imaging may be is considered prohibitively risky (delayed
treatment) laparotomy as a diagnostic maneuver should be considered
Imaging
 I.Nonabdominal etiologies of
upper abdominal pain
possible extension of cardiac pain: acute coronary syndrome with
referred pain:
exertional symptoms
shortness of breath

electrocardiogram

pleural or pulmonary pathology arising in the lower thorax

lower lobe pulmonary pathologies (eg, pneumonia, pulmonary embolism)
inflammatory pleural effusions (empyema,pulmonary infarction)

chest radiographs
Nonabdominal etiologies of
abdominal pain
 II. Right upper quadrant pain

most pain in the right upper quadrant = related to the biliary tree

hepatic pain: only when capsule of the liver is "stretched"

 Right upper quadrant pain. Initial assessment
Clinical
fever and jaundice ascending cholangitis
systemically unwell patient with low-grade fever acute cholecystitis

Laboratory
1.Aminotransferases/alkaline phosphatase/ bilirubin
acute aminotransferases (+/- acute in bilirubin)
choledocholithiasis
alkaline phosphatase does not rise for many hours after pain onset
2. Amylase/ lipase

Abdominal ultrasound -test of choice:

1.sensitivity for detecting gallstones / biliary dilatation > CT scanning
2.unable to visualize the distal common bile duct (duodenal air)

MR cholangiopancreatography ( MRCP) when therapeutic intervention

is not immediately necessary

ERCP most cases of ascending cholangitis will require endoscopic

treatment
 Acute biliary disease

caused by transient obstruction of the cystic duct by a gallstone

biliary cholic
persistent obstruction of the cystic duct by a gallstone acute
cholecystitis
obstruction of the bile duct by a gallstone ascending cholangitis

right upper quadrant or epigastric pain (dull pain)usually postprandial

may radiate around the back to the right scapula
nausea, vomiting, and low-grade fever are common
self-limited, generally lasting less than 6 hours
persistent pain acute cholecystitis
right upper quadrant pain, fever and chills, and jaundice (Charcot's triad)
ascending cholangitis

On examination diagnostic of acute cholecystitis

right upper quadrant tenderness

guarding

Murphy's sign (inspiratory arrest on palpation of the right upper quadrant)

 Acute biliary disease

key diagnostic test : ultrasound evaluation of

the right upper quadrant
gallstones
finding of stones with gallbladder wall
thickening, pericholecystic fluid, and pain on
compression of the gallbladder with the
ultrasound probe (sonographic Murphy's sign)
- essentially diagnostic of acute cholecystitis
 Acute biliary disease
Treatment
Acute cholecystitis
best managed with cholecystectomy within 48 hours
diabetic, particularly those with a leukocyte count over
15,000/mm3 high risk for gangrenous cholecystitis and should
have immediate surgical consultation likely to require an
emergent open cholecystectomy

Ascending cholangitis
intravenous fluids
antibiotics,
bile duct drainage usually by endoscopy ( ERCP)
 III.Epigastric pain
1. Acute pancreatitis
acute pain in the epigastrium:
constant, unrelenting
frequently described as boring through to the back or left scapular region
fever, anorexia, vomiting

more comfortable sitting upright, leaning forward slightly

tachycardic and tachypneic
extremities are often cool and cyanotic (underperfusion)
abdominal examination:
hypoactive bowel sounds
marked tenderness to percussion and palpation in the epigastrium
sometimes abdominal rigidity
 Acute pancreatitis

pancreatic necrosis with hemorrhage (rarely)

flank or periumbilical ecchymoses (Grey-Turner's or Cullen's sign)
 Acute pancreatitis
Laboratory findings
White blood cell counts = 12,000 - 20,000/mm3

Elevated serum lipase and urine amylase levels: usually present

within the first few hours of pain lipase levels persist longer
chronic pancreatitis may present with exacerbations suggestive of
recurrent acute pancreatitis may not exhibit impressive rises in
lipase or amylase CT or US : crucial role in diagnosis

Aminotransferases / alkaline phosphatase / bilirubin

in patients with elevated transaminases and pancreatitis - biliary
etiology

Ultrasonography identifying gallstones as a potential cause

CT
more sensitive for the diagnosis of pancreatitis
Complications of pancreatitis
 Epigastric pain
2. Perforated peptic ulcer
sudden onset of severe diffuse abdominal pain able to specify
the precise moment of the onset of symptoms

abdominal examination:
peritonitis, with rebound tenderness, guarding, or abdominal
muscular rigidity distinguishing other causes of a perforated
viscus

older or debilitated patients : less dramatic symptoms perforation

detected by imaging
abdominal radiograph= pneumoperitoneum: 75% of patients
laparotomy is acceptable as the primary diagnostic maneuver

endoscopy - not advisable when the diagnosis of a perforated

peptic ulcer is suspected: insufflation of the stomach can convert
a sealed perforation into a free perforation
 IV.Lower abdominal pain
Acute right lower quadrant pain + fever + white blood cell
count appendicitis

Acute left lower quadrant pain + fever + white blood cell

count diverticulitis abdominal CT scan to assist in diagnosis

Left and/or right lower quadrant pain

constipationdiverticulitis
diarrhea colitis and/or ileitis:
infectious
ischemic
medication-associated history of NSAID use
inflammatory bowel disease extraintestinal manifestations of IBD
colon cancer risk factors for colon cancer (particularly age and
family history)
- older patients
- weight loss
- change in bowel habits
 Lower abdominal pain

Cystitis ( suprapubic pain) urinary symptoms

frequency
urgency
dysuria

Retroperitoneal pathology= renal colic:

pain that begins in the flank and migrates through the abdomen to
the groin, testes, or labia ureteric obstruction: CT scanning
 Lower abdominal pain

Diagnostic evaluation

CBC : iron-deficiency anemia in the elderly suspicion for

gastrointestinal malignancy

Diarrhea
stool for

culture for enteric pathogens,

microscopy for ova and parasites

measurement of Clostridium difficile toxin

Diarrhea exceeding two weeks with negative cultures

flexible sigmoidoscopy

Urinalysis (urine culture if urinalysis shows leukocytes)

 Lower abdominal pain
1.Acute appendicitis

Remember the classic progression of symptoms in appendicitis

(mnemonic PANT)pain followed by anorexia followed by nausea
followed by temperature elevation.

prodromal symptoms in the beginning: anorexia, nausea, and vague

periumbilical pain
within 6 to 8 hours: the pain migrates to the right lower quadrant
peritoneal signs develop

In uncomplicated appendicitis, a low-grade fever to 38 C and mild

leukocytosis are usually present higher temperature and white blood
cell count are associated with perforation and abscess formation
 Acute appendicitis

clinical signs of peritonitis are present abdominal ultrasound is

the test of choice effectively assesses for:
appendicitis
abdominal abscess
intrapelvic pathology

CT has dramatically improved the accuracy of diagnosis:

appendiceal diameter larger than 6 mm has positive and negative
predictive values of 98%
other findings: fat inflammation, presence of fluid in the right lower
quadrant, and failure of contrast dye to fill the appendix
 Lower abdominal pain
2. Acute diverticulitis

a spectrum of disease: from mild abdominal discomfort gross fecal

peritonitis
constant, dull, left lower quadrant pain and fever
may complain of constipation

left lower quadrant tenderness and, in some cases, a left lower quadrant
mass
localized peritoneal signs frequent
generalized peritonitis may be present

CT confirms the diagnosis

performed routinely in the emergency evaluation of patients with
diverticulitis
the severity of diverticulitis - Hinchey grading system
 Acute diverticulitis

Treatment
mild disease
no CT findings of perforation
in the absence of limiting comorbid disease

treated as an outpatient

localized pericolic abscess (Hinchey grade I ) hospitalization for

intravenous antibiotics

pelvic, intra-abdominal, or retroperitoneal abscess (Hinchey grade II ): CT-

guided drainage of the abscess + a course of broad-spectrum intravenous
antibiotics

generalized peritonitis (Hinchey III and IV ) emergency surgery

 3.Lower abdominal pain in women
Additional history :
regularity and timing of menstrual periods

possibility of pregnancy

presence of vaginal discharge or bleeding

recent history of dyspareunia or dysmenorrhea

Common etiologies:
pelvic inflammatory disease (PID)

anexal cysts or masses with bleeding, torsion, or rupture;

ectopic pregnancy

uterine pain

infection (endometritis)

degeneration / infarction / torsion of leiomyomas.

pelvic examination
 Lower abdominal pain in women
Diagnostic evaluation
A pregnancy test should be performed in women of childbearing
potential, even when pregnancy is felt to be unlikely.

Microscopic exam in saline (wet mount) of abnormal vaginal

discharge

tests for Chlamydia and Gonococcus :

Women with risk factors for STD

mucopurulent cervical discharge

suspected PID

pelvic US examination:
Leiomyomas, adnexal masses, and intrauterine pregnancy
Fluid in the cul-de-sac ruptured ovarian cyst or ectopic pregnancy
infection: often normal / accumulation of fluid and debris in the uterine
cavity or thickened, fluid-filled oviducts with or without free pelvic flu
 V.Generalized abdominal pain

Severe generalized abdominal pain

unstable or exhibits signs of shock evaluated by a surgeon

before any imaging study is considered
additional evaluation only proceed once a process requiring
emergency surgery has been excluded.

the focused abdominal sonogram for trauma (FAST) preferable

approach.
presence of shock and fluid in the abdomen is an indication for
immediate laparotomy

further diagnostic maneuvers (including CT) add little value to the

patient's care
 1.Acute mesenteric ischemia

hallmark of the diagnosis: abrupt onset of intense cramping epigastric and

periumbilical pain out of proportion to the findings on abdominal examination

on physical examination: most patients appear acutely ill

shock is present in about 25% of cases
 Acute mesenteric ischemia

Diagnostic tests
CTis the best initial diagnostic test
mesenteric angiography:

determining the cause of intestinal ischemia and defining the extent

of vascular disease
transcatheter vasodilator therapy for patients who are found to
have vasospasm on visceral arteriography

Treatment:
acute embolic or thrombotic intestinal ischemia immediate revascularization
and bowel resection
nonocclusive mesenteric ischemia (hypoperfusion) treatment of the
underlying shock state persistent symptoms laparotomy for resection of
infarcted intestine may be necessary
 Generalized abdominal pain
2.Abdominal aortic aneurysm
sudden onset of acute, severe tearing abdominal pain
localized to the midabdomen or paravertebral or flank areas.
associated: prostration, lightheadedness, and diaphoresis shock is the most
common presentation

physical examination:a pulsatile, tender abdominal mass - 90% of cases.

the classic triad (75% of cases) = hypotension, a pulsatile mass, and abdominal
pain immediate surgical intervention.

unstable patients with suspected aneurysm rupture surgical referral

stable patients:
abdominal ultrasound is the preferred investigation

CT scanning is also acceptable

 Generalized abdominal pain

3.Small bowel obstruction

adults:
about 70% of cases are caused by postoperative adhesions

incarcerated hernias make up most of the remainder

 Small bowel obstruction

sudden, sharp, periumbilical abdominal pain

soon after the onset of pain nausea and vomiting provide temporary
relief of discomfort
bilious emesis with epigastric pain: suggestive of high (proximal)
intestinal obstruction
cramping periumbilical pain with infrequent feculent emesis :distal
intestinal obstruction

Examination
acutely ill, restless patient
fever, tachycardia, and orthostatic hypotension - common
abdominal distention is usual
diffuse tenderness to percussion and palpation, but peritoneal signs are
absent, unless a complication such as ischemia or perforation has occurred
auscultation : hyperactive bowel sounds and audible rushes absent bowel
sounds
 Small bowel obstruction
Laboratory

Plain radiographs of the abdomen diagnostic:

dilated loops of small intestine with air-fluid levels and decompressed distal
small bowel and colon

CT - superior for establishing the diagnosis and location of intestinal

obstruction > plain abdominal radiographs
 Small bowel obstruction

Treatment
partial small intestinal obstruction - initial treatment:
bowel rest

intravenous fluids

nasogastric decompression

Close observation

failure of conservative management

evidence of complete obstruction
if ischemia is suspected

Surgery
 Generalized abdominal pain

4.Infectious enteritis or colitis

(viral/bacterial/ toxin-mediated food poisoning)

pain with vomiting and/or diarrhea

self-limited illness
contacts developing a similar illness

toxin-mediated illnesses can occur within hours of ingestion

bacterial colitis generally requires 24 to 48 hours to develop

upper respiratory tract involvement or myalgias viral etiology

watchful waiting for spontaneous recovery

 Generalized abdominal pain

5.Metabolic disease
(diabetic ketoacidosis and Addison's disease)

fairlyindolent / undiagnosed until triggered by an acute

precipitant (infection, dehydration, surgical stress, or alcohol or drug
use)
patient with diabetes + intra-abdominal infection precipitate DKA

associated systemic illness or signs and symptoms of

endocrinopathies
diffuse and nonprogressive abdominal pain without focal tenderness
or other peritoneal features
 Metabolic disease
(diabetic ketoacidosis and Addison's disease)

acid-base status, calculation of an anion gap

metabolic acidosis and an elevated blood glucose diabetic

ketoacidosis (DKA)

Electrolytes:
hyponatremia or hyperkalemia: adrenal insufficiency
should be considered
 Generalized abdominal pain
6.Hematologic etiologies of generalized abdominal
pain

severe hemolysis
sickle cell anemia

acute leukemia

complete blood count and differential

 Acute abdominal pain
Principles of treatment
appropriate opioid analgesics early in care:

patients comfort
no delay in diagnosis

immunocompetent patient - antibiotic therapy: not before a likely

source is identified antibiotic given as soon as a putative diagnosis
is reached aimed at the likely causative pathogens

immunocompromised patients or neutropenic : broad-spectrum

antibiotics early in the course of management for acute abdominal
pain

Watchful waiting: no firm diagnosis after initial assessment careful

observation of the patient's course will be the most important
factor in their management:
severe pathology typically becomes more obvious with time
benign conditions may spontaneously improve