Nearly everyone has experienced sudden abdominal pain at some time in their life.

Whether self-limited, as in gastroenteritis, or imminently life-threatening, as in perforated peptic ulcer or colon cancer, the physical and psychosocial impacts may be overwhelming. About 25 , people miss wor! each day because of digestive or abdominal problems. "n the #nited $tates, abdominal pain accounts for more hospital admissions than any other disease category.% &owever, the term acute abdomen applies to only a small number of these. "t implies a pathophysiologic process that has a sudden onset and may be corrected by surgical manipulation. $ymptoms are the sub'ective manifestations of a disturbance in function and represent pathophysiologic states rather than specific diseases.2 "n the gastrointestinal tract, numerous alterations in physiologic function can be implicated. (hese include changes in secretion, absorption, motility, synthesis, digestion, and transport. (he resultant symptoms can include abdominal )or extraabdominal* pain, dysphagia or odynophagia, anorexia, weight loss, nausea and vomiting, bloating or distention, constipation, flatulence, and diarrhea.+ $igns of disease are the ob'ective demonstrations of a pathologic process. (hese include tenderness, rigidity, masses, altered bowel sounds, bleeding, malnutrition, 'aundice, and stigmata of hepatic dysfunction.2,, (he case history remains one of the most useful tools in the diagnosis of digestive diseases.5 (he surgical consultant should thoroughly review every detail of the illness with the patient. (he art of physical examination is also of great importance in the diagnosis of abdominal pain. -ombining the elicited symptoms from a complete history and the signs from a comprehensive physical examination allows the surgeon to establish a differential diagnosis. "t is important to formulate a thorough but cost-effective diagnostic evaluation that may re.uire blood tests, radiographs, and histologic confirmation./ 0ain 0ain, from the 1atin poena, meaning punishment, penalty, or torment, is the singular sensory experience that humans use to identify disease within themselves. "t is one of the greatest motivational drives !nown to man.2 3ost diseases of the abdominal viscera are associated with pain sometime during their course )4ig. 5,-%*. A brief review of abdominal embryology and pain physiology will assist the clinician in evaluating the patient with acute or chronic abdominal pain. (he gastrointestinal tract consists of a foregut, midgut, and hindgut. 5ach segment has its own blood supply and innervation and retains these relations throughout development and into adulthood. (he foregut extends from the oropharynx to the duodenum at the level of the entrance of the common bile duct. "t includes the pancreas, liver, biliary tree, and spleen. (he midgut is composed of the distal duodenum, 'e'unum, ileum, appendix, ascending colon, and proximal two thirds of the transverse colon. (he hindgut consists of the remainder of the colon and rectum down to the cloacal bulge, which constitutes the interface between the surface ectoderm and endoderm of the cloaca, corresponding to the dentate line.2,/ (he peritoneum is a continuous visceral and parietal layer. Although both layers are mesodermally derived, they develop separately and have separate nerve supplies. (his is important for diagnostic reasons. (he visceral layer )ie, the layer surrounding all intraabdominal organs* is supplied by autonomic nerves )sympathetic and parasympathetic*, and the parietal peritoneum is supplied by somatic innervation )spinal

nerves*.% (he pathways relaying the sensation of pain differ for each layer. (hey also differ in .uality. 6isceral pain is characteristically dull, crampy, deep, or aching, and it may involve sweating and nausea. 0arietal pain is sharp, severe, and persistent./ 6isceral organs have very little pain sensation, but stretching of the mesentery and stimulation of the parietal peritoneum cause severe pain. Normal embryologic development of the abdominal viscera proceeds with bilateral autonomic innervation, resulting in visceral pain that is usually perceived as arising from the midline. (he location of pain in the midline is determined by the embryologic origin of the involved viscus. 5pigastric pain is typical of foregut origin. 0eriumbilical pain signifies pain emanating from the midgut. &ypogastric or lower abdominal midline pain indicates a hindgut origin. 0elvic pain is more typical of disease originating in structures derived from the cloaca.2 4or abdominal pain to be recogni7ed by the patient, nociceptors, or pain receptors, must be noxiously stimulated. (wo types of neuronal fibers are involved. A-d fibers are rapid transmitters and give rise to sharp, well-locali7ed pain sensations. (hese fibers are distributed to muscle and s!in and are involved with somatic pain transmission through spinal nerves. - fibers are slow transmitters. (hey generate the sensation of dull, poorly locali7ed pain that is gradual in its onset and of long duration./ (hese fibers are located intramurally in hollow viscera and in the capsule of solid organs. (hey are found in muscle, periosteum, and the parietal peritoneum and are involved in visceral pain transmission through the autonomic nervous system.2 8ifferent neural pathways are responsible for pain mediation, depending on whether the source of the pain is the parietal peritoneum or the visceral peritoneum. (he anterior and lateral abdominal walls are supplied by nerves arising from spinal segments (-2 to 1-%. (he posterior abdominal wall is innervated from spinal segments 1-2 to 1-5. 0ain arising from the abdominal wall is relayed to the spinal cord through the spinal nerves. 9ecause these pain fibers enter the spinal cord ipsilaterally, pain is perceived as originating from that side. Also, such pain locali7es to the area of the abdomen from which it originates. "n contrast, pain arising from intraabdominal viscera is perceived to arise in the midline because sensory input from such viscera enters the spinal cord on both sides. Abdominal pain can be divided into three categories: visceral, somatic, and referred. (he aforementioned intramural sensory receptors of the abdominal organs are responsible for visceral pain. $ome destructive stimuli to the abdominal viscera are painless. 4or example, almost all abdominal organs are insensitive to pinching, burning, stabbing, cutting, and electrical and thermal stimulation. (he same is true for the application of acid and al!ali to normal mucosa./ (he four general classes of visceral stimulation that result in abdominal pain are the following: ; $tretching and contraction ; (raction, compression, and torsion ; $tretch alone ; -ertain chemicals (he mediating receptors for these responses are located intramurally in hollow organs, on serosal structures such as the visceral peritoneum and capsule of solid organs, within the mesentery )especially associated with large mesenteric vessels and ligaments*, and within the mucosa. (hese receptors are polymodal )responsive to both mechanical and chemical

stimuli*. 3ucosal receptors respond primarily to chemical stimulation./ (he ma'or forces that evo!e visceral pain arise from geometric forces )such as stretching and distention* that result in increased wall tension. <ther factors responsible for visceral pain include ischemia and inflammation.% 6isceral pain almost always heralds intraabdominal disease but may not indicate the need for surgical therapy. When visceral pain is superseded by somatic pain, the need for surgical intervention becomes li!ely.= $omatic or visceral pain arises from irritation of the parietal peritoneum. 3ediated mainly by spinal nerve fibers that supply the abdominal wall, somatic pain is locali7ed and perceived as arising from one of the four .uadrants of the abdominal wall. "n contrast to visceral pain, in which geometric changes are responsible for the stimulation of nerve endings, somatic pain arises as a response to acute changes in p& or temperature, as seen in bacterial or chemical inflammation./,2 "n addition, somatic pain is felt in response to sudden increases in pressure, as with a surgical incision. $omatic pain is perceived as sharp and pric!ing and is usually constant. "n many clinical situations it is probable that the perception of pain results from multiple stimuli. (he pain of pancreatic cancer probably arises from the combination of serosal stretch, vascular and mesenteric compression, and direct neural infiltration. (he sensitivities of visceral receptors are also affected by circumstances. 0ressure on or chemical application to normal gastric mucosa is usually painless, but if the mucosa is inflamed, these same stimuli are .uite painful./ >eferred pain is felt in an area of the body other than the site of its origin and is one of the characteristic .ualities of abdominal pain. >eferred pain usually arises from a deep structure, is superficial at its distant presenting location, and often is sharp, locali7ed, and persistent at the distant site. "t occurs secondary to the existence of shared central pathways for afferent neurons arising from different sites.= (wo associated features of referred pain are s!in hyperalgesia and increased muscle tone of the abdominal wall. A classic example is the ruptured spleen that results in irritation of the left hemidiaphragm, which is innervated by the same cervical nerves. "n this setting, referred pain is perceived as arising in the left shoulder )?ehr sign*, which is also supplied by those nerve roots. A !nowledge of referred pain and its patterns may be of diagnostic assistance when other evidence of disease is lac!ing or absent )(able 5,-%*. Acute Abdominal 0ain Acute abdominal pain is loosely defined as pain present for less than = hours. (he !ey to the management of patients with acute abdominal pain is early diagnosis. No aspect of diagnosis is more important than a careful and thorough history. "f possible, it is best to allow the patient to give his or her entire current history before as!ing specific .uestions. (his should include a past medical history and information concerning associated illnesses. A history of prior similar symptoms is also sought, as is the presence of any prodromal symptoms.= (he character and onset of the pain are important. -olic!y pain usually indicates some type of obstructive process, such as bowel obstruction, ureteral calculus, or acute biliary colic. -olic represents hyperperistalsis of the smooth muscle during an attempt to move fluid or an ob'ect past the obstruction. 9etween attac!s, the pain lessens or disappears. 8uring attac!s, the pain is persistent and unrelenting. (he pain seen with infectious processes such as appendicitis or diverticulitis is sustained and gradually worsens over time. -lues to the underlying cause of pain can be deduced by the type of onset. 0ancreatitis is usually gradual in onset and commonly follows an episode of alcohol abuse. "n contrast, a perforated hollow viscus produces a sudden onset of pain

that the patient may be able to time precisely. (he location of the pain is very helpful in establishing the diagnosis. (his is especially true with somatic pain that results from irritation of the parietal peritoneum )see 4ig. 5,-%*. <ther factors must also be considered in the evaluation of the patient with abdominal pain. (hese include any previous history of intraabdominal disease, previous abdominal surgery, and current medications. 4amilial or concomitant diseases in family members should also be sought. A woman@s precise menstrual history should be obtained because this may be the sole clue to the presence of gynecologic pathology.A (he first and most important step in the physical examination of the patient with an acute abdomen is careful observation of the patient@s body habitus and facial expression. #nwillingness to change body position suggests an underlying peritonitis. &ip flexion with the !nees drawn up to maintain comfort suggests abdominal wall and possibly peritoneal irritation.= >estriction of diaphragmatic excursion with respiration, as noted by shallow breathing and the use of accessory respiratory muscles, is also consistent with peritoneal irritation. "n contrast, colic!y pain is often manifested by intense movement in an effort to alleviate pain, followed by restful intervals between colic!y periods. "nspection of the abdomen for hernial bulges, masses, distention, or areas of inflammation should be performed. -areful auscultation of the abdominal cavity for the presence or absence and .uality of bowel sounds is performed. (he presence and location of bruits should be noted. A careful auscultation of the chest, particularly in the diaphragmatic area, should be underta!en to document diaphragmatic movement and to search for a basilar pneumonia that may simulate an acute abdominal condition. Bentle palpation of all .uadrants of the abdomen should be performed last. Bentle, rather superficial, palpation of the abdomen should be performed initially, proceeding from the .uadrant with the least symptomatology to the most painful area. 0eritoneal signs or masses, suggested by the superficial examination, may then be confirmed by a deeper, still gentle palpation. -lassic rebound tenderness is fraught with examiner errorC a percussion test is !inder and more specific.2 &aving the patient cough, laugh, or maximally distend the abdomen may locali7e the disease, especially in children.% 0atients in pain who were previously examined by an uns!illed physician are often .uite sensiti7ed to the manipulations that are used to elicit rebound. (herefore, a s!illed examiner must use other diversions to confirm peritonitis. (he so-called stethoscope test, which consists of using a stethoscope to depress and release the abdomen, is useful. $imilarly, sha!ing the pelvis from side to side may elicit true rebound tenderness. &yperesthesia is uncommonly present but is defined as s!in that is ex.uisitely sensitive to gentle touch. &yperesthesia exists because the dermatome is supplied by the same nerve roots as an area of parietal peritoneum. 3any laboratory tests offer useful information in the evaluation of patients with an acute abdominal condition. 3inimally, a complete blood count, urinalysis, serum amylase, and, for women with lower abdominal pain, a b-human chorionic gonadotropin, or pregnancy test, should be re.uested. $erum electrolytes, blood urea nitrogen, creatinine, and glucose are useful in determining the patient@s hydration status, renal function, and basic metabolic state. 1iver chemistries are helpful in patients with upper abdominal pain or stigmata of liver disease. "n general, laboratory tests should not be performed unless their results will alter the need for additional tests or therapy.%% 4re.uently, at the time of

venipuncture, an intravenous cannula can be inserted and used for hydration or administration of medication. 4our radiologic views of the chest and abdomen are essential in patients with abdominal pain and no obvious diagnosis.%2 (he physician must be aware of the stress of a trip to the radiology suite on the patient and of the time involved and must therefore ensure stability of the patient@s hemodynamic status before this endeavor ta!es place. An upright and supine film of the abdomen and an upright and lateral radiograph of the chest are then performed. Although only % D of patients with an acute abdomen have abnormalities on screening roentgenography, radiographs are still suggested in patients unless a clear-cut diagnosis is established.%+ 0neumoperitoneum, gasEfluid levels, fecaliths, gallstones, ascites, and obliteration of the psoas shadows are all helpful diagnostic findings that can be seen on the four screening films.%, -ontrast gastrointestinal studies, ultrasonography, computed tomography )-(* scans, and arteriography may be suggested or re.uired given the specific findings and clinical suspicions of the evaluating physician.%5,%/ No laboratory or radiologic maneuver should be performed unless its result will alter the need for additional tests or treatment. "f the patient appears to have appendicitis and an operation is planned, it serves no purpose to obtain an abdominal series to loo! for a fecalith. Also, test results should not duplicate previous tests. Ballstones delineated by ultrasound do not re.uire additional radiologic examinations. A balance should be sought, ta!ing into consideration cost, yield, morbidity, and accuracy. 4inally, one must resist the F3ount 5verestG syndrome,%2 wherein a test is performed because the facilities exist for its performance. Numerous surgical causes exist for the patient presenting with acute abdominal pain. (hese are covered individually in the chapters dealing with specific organ systems. A review of nearly %2 patients presenting for emergency evaluation of abdominal pain affords some interesting findings.%= (he most common diagnosis was nonspecific abdominal pain, occurring in +5D of patients. Appendicitis )%2D*, intestinal obstruction )%5D*, urologic problems )/D*, and gallstones )5D* were the leading surgical causes. (he largest number of admissions consisted of patients % to 2A years of age )+%D* and patients / to 2A years of age )2AD*. $urgical procedures were re.uired in ,2D of patients. (he increased proportion of elderly patients in this study mirrors the rise in the elderly population. 1arge series of elderly patients presenting with acute abdominal pain have found the leading diagnoses to be cholelithiasis, nonspecific pain, malignancy, incarcerated hernia, ileus, and gastroduodenal ulcer.2 (he presence of comorbid processes, especially cardiovascular disease, stresses the need for rapid diagnosis and timely operative surgery if appropriate.%A Bynecologic -auses of the Acute Abdomen <rgan systems other than those classically associated with the alimentary tract must also be considered. Bynecologic causes of acute abdominal pain include pelvic inflammatory disease )0"8*, ectopic pregnancy, tuboovarian cysts, torsion, hemorrhage or abscess, and mittelschmer7.A 0"8 must be considered in virtually every woman of reproductive age with lower abdominal pain. "t includes tuboovarian abscess with or without rupture. Whereas 0"8 is usually appreciated bilaterally, an abscess is unilateral in over 2 D of cases. Acute pain is reported in A D of patients, fever and chills in 5 D, fever in / D, and leu!ocytosis in /=D.A 0elvic examination usually reveals extreme pelvic tenderness

and increased pain on cervical motion.2 0eritoneal signs in the upper abdomen suggest lea!age or rupture of a pelvic abscess, usually re.uiring surgical intervention. 8ifferentiation of 0"8 from acute appendicitis is particularly difficult, especially in women of childbearing age, and the rate of false-positive explorations approaches , D. (able 5,-2 outlines a few of the salient differences. 5ctopic pregnancy occurs once in 2 conceptions, leading to 5 , cases per year in the #nited $tates. >is! factors include prior salpingitis, tubal ligation, prior tubal repair, presence of an intrauterine device, and prior ectopic pregnancy. 0ain and abnormal uterine bleeding are seen in A2D and =/D of patients, respectively.2% &uman chorionic gonadotropin )h-B* testing and culdocentesis are essential for diagnosis. &emorrhage from functional ovarian cysts can also simulate an acute surgical abdomen. $ymptoms typically begin at or around the time of ovulation. 0ain is classically severe, abrupt in onset, and often bilateral. 0regnancy testing by serum h-B should distinguish this process from ectopic pregnancy. <peration is rarely re.uired to treat hemorrhage associated with rupture of a follicular ovarian cyst. Adnexal torsion presents with lower abdominal, laterali7ed pain that may be colic!y. As with other pelvic conditions, ultrasonography and laparoscopy are helpful tools in diagnosis and management.%% #rologic -auses of the Acute Abdomen #rologic conditions that may simulate an acute surgical abdominal condition include renal, perirenal, or bladder infectionsC obstructions of the ureter, renal pelvis, or bladderC and acute intrascrotal events. #ncomplicated pyelonephritis is rarely a diagnostic problem and does not often present as an acute abdominal event. "n contrast, renal and perirenal abscesses may present acutely and may mimic appendicitis, diverticulitis, or cholecystitis. An intravenous pyelogram )"60* is abnormal in most cases, as is urinalysis. Acute ureteral or renal pelvis obstruction is the most common condition to be confused with nonurologic causes of the acute abdomen. #rinalysis, plain abdominal radiography, and "60 are usually confirmatory.22 Acute testicular torsion and other intrascrotal events present with prominent abdominal pain in 25D to 5 D of cases. A careful examination of the scrotum usually reveals an elevated testicle on the affected side, along with profound tenderness.22 (he Acute Abdomen in $pecific -onditions Nonsurgical conditions that simulate the acute abdomen include a number of pulmonary, cardiac, neurologic, metabolic, toxic, infectious, and hematologic problems, as described in (able 5,-+. (he differential diagnosis of acute abdominal pain in the pediatric patient is outlined in (able 5,-,. "n the first few years of life, congenital abnormalities are the most common source of abdominal symptoms of surgical importance.2+ &istories are difficult to obtain, and the physical examination in the newborn or infant can be extremely misleading in that no discernible tenderness may be present. 0lain abdominal films should be used more liberally in the pediatric population. "n older children, the history and physical findings are more easily elicited, and diagnosis is generally more clear. -ertain features in children should be mentioned. Anorexia is often absent in children with appendicitis or other intraabdominal inflammatory conditions.% (he sigmoid colon is often redundant in children. "f it is ad'acent to an inflamed appendix, diarrheal symptoms may predominate, leading to a false diagnosis of gastroenteritis. "n children, microscopic hematuria and pyuria are often seen with appendicitis, whereas leu!ocytosis is less common.2+

Acute abdominal conditions after cardiac surgery occur in only %D of patients. &owever, abdominal complications are responsible for 2D to % D of the total postoperative mortality rate for cardiac surgery because of their associated 25D to / D mortality rate. Bastrointestinal bleeding, acute cholecystitis, mesenteric ischemia, pancreatitis, and acute colitis are the diagnoses most commonly reported.2, "mmunocompromised patients constitute a heterogeneous group that includes those receiving allografts, chemotherapy, or immunosuppressive drugs for autoimmune disorders, and individuals with the ac.uired immunodeficiency syndrome )A"8$*.25E2= 5ach of these groups has specific abdominal complications that must be appreciated and suspected by the evaluating physician )(able 5,-5*. Acute, nonspecific abdominal pain is a fre.uent final diagnosis. "t accounts for up to ,+D of patients with abdominal pain presenting for emergency evaluation.2A <ne retrospective study found this to be the /th and % th most common cause of hospital admission for women and men, respectively.%= A long-term study found that 22D of these patients remained healthy and symptom-free at 5 years@ follow-up, 2D had been readmitted )one third of whom had acute appendicitis*, and the rest had diagnosed recurrences of acute nonspecific abdominal pain. 3alignancy was found in only % of 2+ patients, or ,D of patients over the age of 5 years.2A Abdominal wall pain is a diagnosis to be considered in patients with acute abdominal pain. -auses to be evaluated include iatrogenic peripheral nerve in'uries, hernia, myofascial pain syndromes, the rib tip syndrome, abdominal pain of spinal origin, and spontaneous rectus sheath hematomas.+ 5ach year about % , new spinal cord in'ury patients are added to the nearly 2 , paraplegics residing in the #nited $tates. Acute abdominal conditions are common but difficult to diagnose in these patients. <ne excellent review of 2% such patients found that the interval between the spinal cord in'ury and hospitali7ation for the acute abdominal complaint averaged %5 years. (he average patient was ,+ years old. 8iseases most commonly seen were acute cholecystitis )+/D*, perforated peptic ulcer )%,D*, and renal disease )AD*. 0hysical examination was fre.uently not helpful. 1eu!ocytosis was seen in 52D, and radiologic studies )plain radiographs, -( scans, oral cholecystograms, sonograms, and barium studies* led to the correct diagnosis in 22D of cases. (he overall mortality rate was % D, and there was a +=D operative morbidity rate.+% Acute abdominal pain in the patient on oral anticoagulation is another difficult clinical situation. "n a recent review of 5% patients with this presentation from the literature,+2 nausea and vomiting were seen in 2=D, fever occurred in 2AD, and decreased bowel sounds were present in 2/D of patients. (he most common diagnosis was intramural hematoma of the bowel )=/D of all patients*. 3ost hematomas )/2D* were found in the 'e'unumC the next most common site was the ileum )2=D*. <ther diagnoses reported were bowel infarction in /D of patients, volvulus in ,D, and miscellaneous causes in /D. (he overall mortality rate was %,D. (he challenge for the surgeon is to differentiate patients with intramural hematoma from the minority of patients who will re.uire surgery. 1aparotomy or laparoscopy is recommended for patients who fail to improve or who worsen over a 2,- to +/-hour observation period.