ACUTE ABDOMINAL PAIN Victor Politi, M.D., FACP Medical

ACUTE ABDOMINAL PAIN Victor Politi, M.D., FACP Medical

ACUTE ABDOMINAL PAIN Victor Politi, M.D., FACP Medical Director, SVCMC School of Allied Health, Physician Assistant Program Abdominal Pain Most common cause of hospital admission in the US

Accounts for 5-10% of all ED visits In 35-40% of all hospital admissions due to abdominal pain - the pain is nonspecific Epidemiology Gastroenteritis is the most common cause of abdominal pain not requiring surgery In patients age 60 and older, biliary disease

and intestinal obstruction are the most common cause of acute abdominal pain that is surgically correctable Epidemiology Appendicitis is the most common cause of abdominal pain requiring surgery in patients < age 60

Appendicitis is the leading cause of acute abdominal pain in children accounts for 32% of children admitted w/acute abdominal pain Patient History The term acute abdomen implies the sudden onset of abdominal pain for which a

surgically correctable cause is likely Patient History Besides the age of the patient - key elements of the patient history include: Time of pain onset Location/character of pain Pattern of pain radiation

Associated symptoms Key Points in History Reproductive Sexual Activity, Contraception, Last Menstrual Period Always Consider Pregnancy in Reproductive Age Women Have a Low Threshold for Pregnancy Testing

Bowel and Bladder Nausea, Vomiting, Diarrhea, Constipation Frank Blood, "Coffee Grounds" Emesis, Black Stools Urinary Frequency, Urgency, Discomfort AGE Age of patient - crucial Differential diagnosis of abdominal pain in children differs from dx in elderly patient

Common conditions that cause abdominal pain in most age groups acute appendicitis, intestinal obstruction, incarcerated hernias AGE Intussusception is most likely the cause of intestinal obstruction in children

Adhesions are most likely the cause of intestinal obstruction in adults In older patients, pain from a MI can be referred to the upper abdomen Time of Onset Pain sudden in onset, awakens a patient from sleep suggests a viscus Knowing the timing of associated nausea and vomiting

is essential to narrow the diagnostic possibilities Pain precedes vomiting when abdominal pain is from surgically correctable causes, whereas the reverse is true for medical conditions such as gastroenteritis Location Abdomen divided into 4 quadrants, which are further divided (with some overlap) into

the epigastric, periumbilical, and suprapubic regions Location of Abdominal Pain Four quadrants: Right Upper Quadrant

Right Lower Quadrant Left Upper Quadrant Left Lower Quadrant Three central areas: Epigastric Periumbilical Suprapubic

Location RUQ pain duodenal ulcers, acute pancreatitis, acute cholecystitis, and acute hepatitis LUQ pain gastritis, gastric ulcer, acute pancreatitis, and splenic infarct or rupture RLQ pain acute appendicitis, LLQ pain diverticulitis GYN and urologic causes of acute abdominal pain can also present with

lower quadrant abdominal pain Radiation of Abdominal Pain Perforated Ulcer Biliary Colic Renal Colic Dysmenorrhea/Labor Renal Colic (Groin)

Character Implies all the features of the pain Usually can be determined by asking the patient to describe the quality of the pain Most often described as sharp or dull cramping (colicky)

Character Colicky pain - rhythmic pain resulting from intermittent spasms - most commonly associated with biliary disease, nephrolithiasis, intestinal obstruction Pain that begins as dull, poorly localized ache and

progresses to a constant, well localized sharp pain indicates a surgically correctable cause Physical Examination of the Abdomen Inspection Auscultation Percussion

Palpation Inspection General observation Look at abdominal contour, note location of any scars, rashes or lesions

Inspection Patient writhing in agony - likely has colicky abdominal pain caused by ureteral lithiasis Patient lying very still - more likely to have peritonitis Patient leaning forward to relieve pain may have pancreatitis

Inspection The abdominal wall is a commonly overlooked source of abdominal pain Other parts of the body should also be inspected. For example, the eyes should be inspected for evidence of scleral icterus which may indicate hepatobiliary disease

Auscultation Useful in assessing peristalsis Bowel sounds are widely transmitted through the abdomen - therefore, it is not necessary to listen in all 4 quadrants Auscultation should last at least 1 minute Bowel sounds typically highly pitched so the diaphragm of the stethoscope should be used

Auscultation ? Bowel soundsnormal/hyperactive/hypoactive Auscultation should precede percussion and palpation ? Abdominal bruits listen over aortic,iliac and renal arteries

Auscultation Hypoactive bowel sounds - associated with ileus, intestinal obstruction, peritonitis Intestinal obstruction can produce hyperactive bowel sounds which are high pitched tinkling sounds occurring at brief intervals; very audible

Percussion Technique - performed by firmly pressing the index finger of one hand on the abdominal wall while striking the abdominal wall with the other index finger Percussion note can be described as dull, resonant, or hyperresonant

Percussion Dull/resonant or hyperresonant Tympany normally present in supine position ? Unusual dullness ? Clue to underlying abdominal mass Percussion

Gastric region percussion over the gastric region will generate a hyperresonant note because of usual presence of a gastric air bubble Liver percussion over the liver will generate a dull note A normal liver span is 6 to 12 cm in the midclavicular line

Percussion Generalized percussion is a useful method for detecting the presence of ascites or intestinal obstruction in a distended abdomen In ascites - a dull percussion note would be generalized In intestinal obstruction - a hyperresonant

note would be heard Percussion If ascites is suspected, then a test for shifting dullness can be performed Ascites typically sinks with gravity, percussion of the flanks generates a dull note and percussion of the periumbilical region

generates a resonant note in the supine patient Percussion The test for shifting dullness involves having the patient shift to a lateral decubitus position and then performing percussion again; the area of resonance should shift

upward Shifting Dullness If dullness on percussion shifts when the patient is rolled on the side, peritoneal fluid (ascites) may be present. Percussion Splenic Enlargement

A change from tympany to dullness suggests splenic enlargement Palpation Before palpating the abdomen the examiner should ask the patient to point directly to the area that hurts most and avoid palpating that area until absolutely necessary May be difficult in patient who has

guarding (voluntary or involuntary) Palpation Voluntary guarding - conscious elimination of muscle spasms Involuntary guarding - reported when the spasm response cannot be eliminated, which usually indicates diffuse peritonits

Palpation Where is pain ? Begin with light palpation Guarding - voluntary/involuntary Rebound tenderness Palpation Rebound tenderness is elicited by pressing on the

abdominal wall deeply with the fingers and then suddenly releasing the pressure Pain on the abrupt release of steady pressure indicates the presence of peritonitis Asking the patient to cough is another method of eliciting signs of peritonitis Rebound Tenderness

This is a test for peritoneal irritation. Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness Deep Palpation ? Areas of deep tenderness/masses Liver Palpation

Palpation of Aorta Easily palpable on most Pulsate with deep palpation of central abdomen Enlarge aorta ? Sign of aortic aneurysm Palpation of Spleen

Not normally palpable Costovertebral Angle Tenderness CVA tenderness is often associated with renal disease. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles Specific Disorders

Upper abdominal pain - common causes of acute abdominal pain in the upper abdomen include: acute cholecystitis, acute pancreatitis, perforated ulcers Pain usually overlaps the left and right upper quadrants Classic Presentations - Acute Cholecystitis

Localized or diffuse RUQ pain Radiation to right scapula Vomiting and constipation Low grade fever Cholecystitis Murphys sign (have patient take a deep breath while right subcostal area is palpated) abrupt cessation of inspiration secondary to pain is considered a positive Murphys sign

Disease of adulthood More common in women Bacteria invasion can develop into ascending cholangitis Charcots triad Right upper quadrant pain Fever Jaundice

Acute pancreatitis Retroperitoneal dissection of blood can result in bluish discoloration of the flanks (Turners sign) or of the periumbilical region (Cullens sign) Biliary pancreatitis secondary to cholelithiasis is most common women > age 50 in community hospital setting Alcoholic pancreatitis is most common in men ages 30-45 years in urban

hospital setting Symptoms-epigastric pain,nausea,vomiting,pain is constant & boring in nature Bowel sounds decrease - lack of rigidity or rebound tenderness Perforated Peptic Ulcer Sudden onset - severe epigastric pain

Pain becomes generalized after a few hours to involve the entire abdomen Perioperative mortality rate of 23% Patient usually lying quietly and breathing shallow. Abdomen rigid,board-like, guarding - maximal at site of perforation

Upright chest x-ray - detection of free intraperitoneal air Specific Disorders Midabdominal pain - common causes of midabdominal pain include intestinal obstruction, mesenteric ischemia and early appendicitis dissecting aortic aneurysm

myocardial infarction Intestinal Obstruction Mechanical - results from gallstones, adhesions, hernias, volvulus, intussuseption, tumors Non-mechanical- results from

intestinal infarction or occurs after surgery as a paralytic ileus, pain medication Intestinal Obstruction Obstruction high in small intestine results in severe abdominal pain in epigastric or umbilical region with bilious vomiting, distention of abdomen not an early feature

Obstruction located lower in small intestine results in less severe pain Vomiting late feature and may be feculent Intestinal Obstruction Differential Diagnosis of obstruction of small intestine

strangulated hernia volvulus mesenteric thrombus

gallstone ileus Abdominal x-ray of distal obstruction of small intestine will show a dilated loop Large Intestine Obstruction

Pain less severe than small intestine obstruction Vomiting infrequent Distention of abdomen - common Main Causes of Large Intestine Obstruction Ca of colon (change bowel habits, wt loss, rectal

bleeding) diverticulitis (fixed,tender, LLQ mass) volvulus (sigmoid volvulus most common) Mesenteric Ischemia Presents with acute, diffuse, midabdominal pain, vomiting, decreased bowel sounds and distention resulting from intestinal obstruction

Abdominal pain is out of proportion to physical examination findings Abdominal distention is a late sign indicative of gangrene signs of peritoneal irritation also indicative of gangrene Specific Disorders Lower abdominal pain - common causes of lower abdominal pain include

Acute appendicitis (typically RLQ pain) Sigmoid diverticulitis (typically LLQ pain) Gynecologic causes Urologic causes

Diverticulitis Lower Left Quadrant Pain Cramping sensation Possible fever Appendicitis Peak incidence in 2nd decade of life

Differential diagnosis is broad and errors in diagnosis are common Diagnostic error rate Men 23% Women 42% Appendicitis Patients seen in first few hours - report poorly

defined constant pain in periumbilical region As disease progresses - pain shifts to RLQ in a region known as McBurneys point (located 2/3 of the distance along a line drawn from the umbilicus to the right anterior superior iliac spine) Appendicitis

Pain relieved somewhat when patient assumes a right lateral decubitus position with slight hip flexion Abdominal tenderness - most likely physical finding Voluntary guarding in RLQ is common Appendicitis

Rovsings sign can be elicited by palpating deeply in the left iliac area and observing for referred pain in the right iliac fossa When present, the psoas and obturator signs are also helpful in establishing a diagnosis of appendicitis Appendicitis

Psoas sign - the psoas sign is pain elicited by extending the right hip while the patient is in the left lateral decubitus position alternatively, while in the supine position, the patient can lift the right thigh against the examiners hand, which is placed above the knee Psoas Sign

The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk). Appendicitis Obturator sign - the obturator sign is pain elicited by flexing the patients right thigh at

the hip with the knee flexed and then internally rotating the hip Right sided rectal tenderness may also be elicited on rectal exam of patients with acute appendicitis Obturator Sign The obturator sign. Pain on passive internal

rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur. Classic Presentations - Acute Appendicitis Diffuse periumbilical pain and anorexia early Pain localizes to RLQ as peritonitis develops

Low grade fever, nausea and vomiting may not be present Xrays and other tests are often negative Remember that the position of the appendix is highly variable! Other Causes of Abdominal Pain Abdominal aortic aneurysm

abdominal pain/backache hypotension 71% perioperative mortality rate Physical exam of abdomen - detect pulsatile

mass unequal femoral pulses Abdominal Aortic Aneurysm Other Causes of Abdominal Pain Nephrolithiasis ureteral colic 4% of patients w/acute abdominal

pain Colicky pain - Upper lumbar region radiates laterally to inguinal region Patient writhing in pain Classic Presentations - Acute Renal Colic Severe flank pain Radiation to groin

Vomiting and urinary symptoms Blood in the urine Other Causes of Abdominal Pain

Cardiac Origin Gastritis

GERD Esophageal disease Hiatal hernia Liver abscess/subdiaphragmatic abscess Pulmonary origin Herpes Zoster Hernia

Other Causes of Abdominal Pain Gynecologic Ovarian cyst Ectopic pregnancy PID Gynecologic Causes In the absence of a positive pregnancy test

result fresh blood suggests a corpus luteum hemorrhage old blood suggests a ruptured endometrioma (chocolate cyst) purulent fluid suggests acute pelvic inflammatory disease (PID) sebaceous fluid indicates a dermoid cyst. Ectopic Pregnancy

Unruptured ectopic pregnancy - localized pain due to dilatation of the fallopian tube. Ruptured ectopic - pain tends to be generalized due to peritoneal irritation Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these

patients Ectopic Pregnancy Abdominal examination findings include tenderness and guarding in the lower quadrants. Once hemoperitoneum has occurred, distension, rebound tenderness, and

sluggish bowel sounds may develop. Corpus luteum hematoma Slow leakage produces minimal pain Frank hemorrhage can lead to hemoperitoneum and hypovolemic shock Generalized abdominal pain and syncope are features of such a presentation.

Ruptured Ovarian Cyst The most common causes are dermoid cyst, cystadenoma, and endometrioma Blood loss is minimal, hypovolemia does not supervene Peritoneal irritation due to leakage of cyst fluid can lead to significant tenderness, rebound tenderness, abdominal distension, and hypoperistalsis

Ovarian Torsion Frequently - resolves spontaneously - only presenting symptom lower abdominal pain Persistent torsion leads to congestion, ovarian enlargement, thickening of the ovarian capsule, and subsequent infarction. Pain becomes severe -accompanied by nausea, vomiting, and restlessness Infarction also leads to fever and mild leukocytosis

PID Acute salpingo-oophoritis is a polymicrobial infection that is transmitted sexually. Neisseria gonorrhoeae and Chlamydia trachomatis are usually identified in patients with PID, and both organisms often coexist in the same patient. Gonococcal disease tends to have a rapid onset,

while chlamydial infection has a more insidious onset Diagnostic Criteria for PID Lower abdominal tenderness Cervical motion tenderness Adnexal tenderness

Diagnosis may also be supported by any of the following criteria: Temperature greater than 101F (38.3C) Abnormal cervical or vaginal discharge Laboratory evidence of C trachomatis or N gonorrhoeae Elevated erythrocyte sedimentation rate or elevated C-reactive protein value

Tubo-ovarian abscess A ruptured abscess can lead to gram-negative endotoxic shock; therefore, this condition is a surgical emergency. The most common presentation is bilateral, palpable, fixed, tender masses. Patients often present with generalized abdominal pain and rebound tenderness caused by peritoneal inflammation

Fibroids A pedunculated subserous fibroid may twist and undergo necrosis, causing acute abdominal pain A pedunculated submucous fibroid may present with cramping pain and vaginal bleeding

Endometriosis Pain associated with endometriosis may worsen premenstrually or during menses. Patients experience generalized lower abdominal tenderness, and associated complaints include dysmenorrhea, dyschezia, and dyspareunia

Things to Remember Inguinal/rectal examination in males. Pelvic/rectal examination in females. Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest and cardiovascular system when evaluating an abdominal complaint

Consider mesenteric ischemia in diabetic patients and patients with vascular disease and vasculitis Questions ???

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