The Acute Abdomen

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The Acute Abdomen

• Andrew Wright MD
• Department of Surgery

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What is an acute abdomen?
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What is an acute abdomen?

• New onset abdominal pain
• Usually abdominal pain as main symptom
• Often seen by primary physician
• Signifies need for prompt diagnosis
• Does not necessarily imply need for surgical
  intervention

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How do you diagnose an acute abdomen?
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How do you diagnose an acute abdomen?

• History and Physical

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History
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Exact time and onset

• Most slow
• Can guide prognosis i.e. timing of appendicitis
• Acute
• Colic
• Bowel strangulation
• Rupture of viscera
• Torsion
• Fainting
• Abdominal apoplexy
• Perforated ulcer, ruptured aortic aneurysm,
  ruptured ectopic
• What was patient doing at time of onset?
• i.e. minor trauma

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Location

• Initial location
• Shifting of pain
• Transition from visceral to parietal pain

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What is visceral pain?

• Intestines are
• Insensitive to touch
• Sensitive to stretch, distension, or excessive
  contraction against resistance
• Location
• Small intestine umbilicus
• Large intestine hypogastrium
• Biliary RUQ, R subscapular
• Kidney Loin, occ radiates to ipsilateral
  testicle

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What is visceral pain?

• Character
• Paroxysmal
• Often excruciating
• Patients will writhe, twist, attempt to find a
  comfortable position
• In contrast to peritonitis where patients will
  lie still to avoid further irritation

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Character

• Character
• Burning i.e. ulcer
• Agony- i.e. pancreatitis
• Sharp, constricting i.e. biliary colic
• Tearing i.e. dissecting aneurysm
• Gripping i.e. obstruction
• Aching i.e. appendicitis
• Dull, fixed i.e. pyonephrosis

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Radiation

• Referred pain
• Diaphragm shoulder
• Biliary tract tip of shoulder
• Pancreas mid back
• Kidney mid back
• Rectum- coccyx
• Uterus coccyx

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Exacerbating factors

• Relationship to food
• Respiration
• Pleuritic pain usually worse on deep inspiration
• Micturation
• UTI
• Bladder obstruction
• Nephrolithiasis
• Peri-bladder abscess
• Reclining
• Often retroperitoneal origon

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Vomiting

• Cause
• Obstruction
• Severe irritation of nerves of peritoneum
• i.e. pain, pancreatitis
• Frequency
• Relationship with pain
• Character
• Nausea and/or lack of appetite

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Bowel Movements

• Regularity
• Diarrhea
• True diarrhea vs. passage of several small loose
  stools
• Blood
• Mucus
• i.e. intussusception

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Menstruation

• Regularity
• Exact timing
• Pain

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History

• Prior similar episodes
• Prior illnesses that may relate
• h/o peritonitis, appendicitis, pneumonia, etc.
• Previous attacks of jaundice, melena,
  hematemesis, hematuria
• Travel history
• PMH
• PSH

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Examination
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General appearance

• General gestalt is he (or she) sick?

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Vitals

• Pulse
• Respiratory rate
• Temp
• Normal or mildly elevated typical
• High fever unusual suspect kidney or thorax
• Hypothermic suspect shock
• Blood Pressure

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Inspection

• Determine exact location of pain first
• Inspection
• Distension
• Bulge
• Hernia
• All potential orifices including femoral
• Movement
• Rigidity with inspiration

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Palpation

• Keys to success
• Gentleness
• Thighs flexed
• Thorough exam
• Include back
• Guarding
• Rebound
• Iliopsoas rigidity

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Percussion

• Liver dullness
• Free-fluid

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Rectal exam
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Pelvic exam
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Should pain meds be given prior to diagnosis?
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Diagnostic Testing
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Diagnostic Testing

• CBC with dif
• Electrolytes, BUN, creatinine, and glucose
• Aminotransferases, alkaline phosphatase, and
  bilirubin
• Lipase
• Urinalysis
• Pregnancy test in women of childbearing potential

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Imaging
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Imaging

• Imaging
• Plain XRays
• Flat and Upright
• Left Lateral Decubitus if not able to stand)
• Chest
• Ultrasound
• CT
• Additional Testing
• Guide by Differential

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Causes of Abdominal Pain
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Extra-abdominal

• Herpes Zoster
• MI
• Pneumonia

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Biliary Disease

• Cholelithiasis
• Cholecystitis
• Cholangitis
• Pancreatitis
• Biliary Dyskinesia

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GI

• GERD
• Gastritis
• Peptic Ulcer Disease
• Irritable Bowel
• Constipation
• Diabetic Gastroparesis

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Infectious

• Appendicitis
• Diverticulitis
• Gastroenteritis
• Viral
• Eosinophilic
• Yersinia
• Hepatitis
• Typhlitis
• Tropical infectious diseases (helminthic)
• Tuberculosis

Typhlitis
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Appendicitis
Acute Appendicitis
Normal
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Appendicolith
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Appendiceal Phlegmon
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Peri-appendiceal Abscess
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Diverticulosis
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Diverticulitis
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Diverticular Abscess
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Bowel Obstruction

• Hernia
• Adhesion
• Malignancy
• Intussuception

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Inflammatory

• Crohns
• Ulcerative Colitis
• Malignancy
• Epiploic appendagitis

• Epiploic appendagitis

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Gynecologic

• PID
• Adnexal
• Torsion
• Cyst
• Neoplasm
• Endometriosis
• Ectopic pregnancy
• Endometritis
• Leiomyomas

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Urologic

• UTI
• Nephrolithiasis
• Bladder distension

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Vascular

• Aneurysm
• Dissection
• Mesenteric Ischemia
• Acute
• Chronic
• Sickle Cell Crisis

Colonic Ischemia
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Other

• Psychiatric Disease
• Spleen
• Abscess
• Infarct
• Wandering Spleen
• Musculoskeletal
• Abdominal wall pain
• Painful rib syndrome (chostochondritis)
• Hernia

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Other

• Celiac artery compression
• Abdominal Migraine
• Fitz-Hugh-Curtis syndrome
• Familial Mediterranean fever
• Hereditary angioedema
• Heavy Metal Poisoning
• Metabolic
• Diabetic Ketoacidosis
• Porphyria
• Lactose Intolerance

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Pediatric

• Henoch-Schönlein purpura
• Intussuception
• Malrotation with midgut volvulus
• Recurrent Abdominal Pain diagnosis of exclusion