Acute medical abdomen

Features:

• severe abdominal pain, with brutal onset

• local and general signs

• EMERGENCY:
- establish immediate diagnosis
- take immediate action
- prevent fatal event
Two forms:
- the medical acute abdomen
- the surgical acute abdomen

It is necessary for the practitioner to know

the etiopathogenic classification in order to
formulate a correct diagnosis an soon as
possible and to establish the appropriate
therapeutic attitude.
 DIAGNOSIS

• History
• Physical examination
• Limited lab tests
 IS THE PAIN ACUTE OR
CHRONIC?
Did the pain recently start or has it occured for
weeks,months or years?
• Chronic: mild chronic discomfort localized to
one area (perforated duodenal ulcer or perforated
diverticulum)
• Acute: recurrent attacks of severe colic
(gallstones, kidney stones, mild intestinal
obstruction caused by a benign tumor, such as a
carcinoid).
 WAS THE ONSET SUDDEN?

•Pain that is sudden in onset, severe or explosive,

progressive, continuous, and lasts more than 6
hours generally indicates surgical etiology

•Pain that is gradual in onset, mild to moderate in

intensity, intermittent, recurrent, or resolves
partially or completely in less than 6 hours favors
a nonsurgical diagnosis.
 HOW WAS THE ONSET?

Persistent pain that awakens

surgical
the patient or
solution
begins during relative inactivity

Pain that occurs during

Strenuous activity
nonsurgical
or after eating
diagnosis
 WHERE IS THE PAIN?
• Epigastric pain:
• stomach, duodenum, intestine, gallbladder, or
pancreas
• Appendicitis: usually it is the initial site before the
pain shifts to the right lower quadrant.

• Pain in periumbilical area arising from midgut derivatives:

• jejunum, ileum, proximal third of the colon, and
appendix.

• Pain in the hypogastrium arising from the embryonic

hindgut
• distal two-thirds of the colon
• internal reproductive organs (ovaries, fallopian tubes,
uterus, seminal vesicles, and prostate)
• the urinary bladder
 Location of Abdominal Pain
•Four quadrants:
oRight Upper Quadrant
oRight Lower Quadrant
oLeft Upper Quadrant
oLeft Lower Quadrant

•Three central areas:

oEpigastric
oPeriumbilical
oSuprapubic
 
 
 
Digestive system
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 DOES THE PAIN RADIATE?

• Gallbladder pain → beneath the right scapula

• Left diaphragmatic irritation → the left shoulder

• Renal pain → the region of pubis or vagina

• Ruptured aortic aneurysm: severe pain beginning in the

midback → rapidly spreading to the abdomen
Radiation of Abdominal Pain

•Perforated Ulcer

•Biliary Colic

•Renal Colic

•Dysmenorrhea/Labor

•Renal Colic (Groin)

 HOW IS THE PAIN DESCRIBED?

• Severe, knifelike pain:

– associated with shock → EMERGENCY!
• Burning pains:
– Peptic ulcers
• Acute waves of sharp constricting pain (“take the breath away”):
– Renal or biliary colic
• Tearing pain:
– Dissecting aneurysm
• Ache:
– Appendicitis
• Dull ache in the region of the kidney:
– Pyelonephritis
• Colicky pain that becomes steady:
– Appendicitis, strangulating intestinal obstruction, or a very
serious vascular accident.
 WHAT GIVES RELIEF?

• Antacids:
– Peptic ulcer

• During the acute attack:

– Walking the floor → biliary colic
– The patient lies as quietly as possible → peritonitis
 ARE OTHER SYMPTOMS ASSOCIATED WITH THE
PAIN?

• Vomiting:
– If it precedes pain and esp. if it is followed shortly by diarrhea →
gastroenteritis
– 3 mechanisms:
• Severe irritation of local peritoneum or mesentery
• Obstruction of a muscular tube (bile duct, intestine, ureter)
• Absorbed toxin or drug stimulation of CNS centers controlling the
vomiting reflex
– Severe vomiting that precedes an intense epigastric, left chest, or
shoulder pain → emetic perforation of intra-abdominal esophagus.
– 1 or 2 times/hour after the onset of pain → appendicitis
– Acute intestinal obstruction: the lower the site of obstruction, the more
delayed is the vomiting

• Shock, pallor, sweating, fainting

ARE OTHER SYMPTOMS ASSOCIATED WITH THE
PAIN?

• nausea
• anorexia
• fever
• chills
• constipation
• diarrhea.

In surgical conditions: pain may be followed by nausea,

vomiting, and anorexia.

In nonsurgical conditions nausea, vomiting, and anorexia

typically precede pain.
ARE OTHER SYMPTOMS ASSOCIATED WITH THE
PAIN?

• Anorexia is uncommon in:

• athletes
• especially in obese individuals

• Fever is a common finding

• This combination suggests infection in the urinary
tract, respiratory system, etc.
ARE OTHER SYMPTOMS ASSOCIATED WITH THE
PAIN?

• Constipation may accompany any abdominal condition

that causes an illness

•Obstipation-nonpassage of both stool and gas--

however, always suggests a surgical problem

• Diarrhea, especially with cramps:

• gastroenteritis
• other non-surgical conditions (inflammatory bowel
disease).
 WHAT AGGRAVATES THE PAIN?

• Coughing,
• sneezing, peritoneal irritation
• rapid movements,
• walking, especially down stairs

• Musculoskeletal pain is often relieved by changing

position.

• A bowel movement often eases the pain of

gastroenteritis, but the pain may promptly recur.
 HISTORY OF PRECEDING SYMPTOMS

• Previous symptoms and history of:

– Ulcer disease
– Gallstone colic
– Diverticular disease
– Esophageal reflux
– Diarrhea
– Constipation Can help establish
– Jaundice the diagnosis
– Melena
– Hematuria
– Hematemesis
– Weight loss
– Mucus or blood in stool
 DRUG HISTORY

• Details concerning drugs, both therapeutic and addictive:

– K tablets: highly irritating to the intestin → perforation and peritonitis
– Prednisone or immunosuppresive → increase the chance of perforation
of some portion of the GI tract
– Anticoagulants → bleedings.

FAMILY HISTORY OF CERTAIN DISEASES

• Pain
• Vomiting In other family members → gastroenteritis
• Diarrhea
 GENERAL PHYSICAL EXAMINATION

• Must not be neglected

• BP, pulse, state of consciousness, degree of shock
• PERISTALSIS:
– Active peristalsis of normal pitch → nonsurgical disease
(gastroenteritis)
– High-pitched peristalsis or borborygmi in rushes → intestinal
obstruction
– Severe pain and absolutely silent abdomen → IMMEDIATE
EXPLORATION!
GENERAL PHYSICAL EXAMINATION

• Tenderness
• Rebound tenderness
• Degree of distention
• Palpable masses
• Operative scars → adhesions and intestinal
obstructions
• Orifices → external hernias
 Tip to remember
• Pain arising in a hollow, tubular
structure, such as the ureter, intestine,
biliary tract, or fallopian tubes, may be
continuous or intermittent

• The severity of such pain is inversely

proportional to the diameter of the
tubular structure involved
 GENERAL PHYSICAL EXAMINATION

• Rectal and pelvic examinations

• Jaundice or evidence of bleeding in subcutaneous
tissues
– Retroperitoneal bleeding from
• hemorrhagic pancreatitis
• Dissecting bluish discoloration
• Frank ecchymoses of the costovertebral angles (Grey
Turner’s sign) or around the umbilicus (Cullen’s sign)
 Murphy’s Sign

Technique
A.Maneuver: Deep subcostal palpation of
right upper quadrant on inspiration
B.Positive: Worsened pain
Suggests
Acute Cholecystitis
 Carnett's Sign
Interpretation of abdominal muscle wall pain
1. Intra-abdominal pain source = Negative Carnett's Sign
(abdominal pain decreases with tensing abdomen)
2. Abdominal Muscle Wall Pain = Positive Carnett's Sign
(pain increases or remains unchanged)

Technique
A. Patient lies supine
B. Patient tenses abdominal wall by
1. Lifting head off table
2. Lifting shoulder off table
 Laboratory studies

Confirmation only

CBC, UA, Blood chemistries

Serum and urinary amylase

Use lab only as needed, not as a “Shotgun”
 Radiographic and Endoscopic
studies

Confirmation only
Start with simple and inexpensive studies
- x-rays
- IVU
- US
- CT
Common Causes of Acute Abdominal
Pain
*Condition requires urgent surgery
Gastrointestinal Tract
Appendicitis, acute*
Meckel's diverticulitis*
Perforated bowel*
Perforated peptic ulcer*
Small and large bowel obstruction*
Strangulated hernia*
Diverticulitis
Gastritis
Gastroenteritis
Inflammatory bowel disease
Mesenteric lymphadenitis
Liver, Spleen, and Biliary Tract

Cholangitis, acute*
Cholecystitis, acute*
Hepatic abscess*
Ruptured hepatic tumor*
Ruptured spleen*
Biliary colic
Hepatitis, acute
Splenic infarct
Peritoneum
Intra-abdominal abscess*
Primary peritonitis
Tuberculous peritonitis

Pancreas
Acute pancreatitis

Urinary Tract
Cystitis, acute
Pyelonephritis, acute
Renal infarct
Ureteral or renal colic
Female Reproductive System
Ruptured ectopic pregnancy*
Ruptured ovarian follicular cyst*
Twisted ovarian tumor*
Dysmenorrhea
Endometriosis
Salpingitis, acute

Vascular System
Ischemia, acute*
Mesenteric thrombosis*
Ruptured arterial aneurysm*

Retroperitoneum
Retroperitoneal hemorrhage
 Generalized Abdominal Pain Causes

• Peritonitis • Gastroenteritis
• Pancreatitis • Abdominal Aortic
• Leukemia aneurysm
• Sickle Cell Crisis • Splenic artery
• Early Appendicitis aneurysm
• Mesenteric Adenitis • Mesenteric Artery
aneurysm
• Mesenteric
Thrombosis • Colitis
• Intestinal obstruction
Left Lower Quadrant Pain Causes

• Appendicitis
• Intestinal obstruction
• Constipation
• Diverticulitis
• Leaking aneurysm
• Abdominal wall hematoma
• Ovarian cyst or torsion
• Ureteral calculus
(Nephrolitiasis)
• Renal pain
• Seminal vesiculitis
• Psoas abscess
 Left Upper Quadrant Abdominal Pain Causes

                     Gastritis
                          Pancreatitis
                          Splenic enlargement, rupture, infarction, aneurysm
                          Renal pain
                          Herpes Zoster
                          Myocardial Ischemia
                          Pneumonia
                          Empyema
 Right Lower Quadrant Pain Causes

Appendicitis
Intestinal obstruction
Regional enteritis
Diverticulitis
Cholecystitis
Perforated Ulcer
Leaking aneurysm
Abdominal wall hematoma
Ovarian cyst or torsion
Ureteral calculus (Nephrolithiasis)
Renal pain
Seminal vesiculitis
Psoas abscess
 
 Right Upper Quadrant Pain Causes

Gall Bladder or Billiary Tract Disease

Hepatitis
Hepatic abscess
Hepatomegaly due to Congestive heart failure
Peptic Ulcer
Pancreatitis
Retrocecal Appendicitis
Renal pain
Herpes Zoster
Myocardial Ischemia
Pericarditis
Pneumonia
Empyema
 Extraperitoneal Abdominal Pain Causes

I.Cardiopulmonary Causes
A.Cardiopulmonary Causes
B.Pneumonia
C.Empyema
D.Myocardial Infarction
E.Active Rheumatic Heart Disease
F.Aortic Dissection
II.Hematologic Causes
A.Leukemia
B.Sickle Cell Crisis
III. Neurologic Causes
A.Spinal cord tunor
B.Spinal Osteomyelitis
C.Tabes dorsalis
D.Herpes Zoster
E.Abdominal Epilepsy
F.Abdominal Migraine
IV. Genitourinary and Renal Causes
A.Pyelonephritis
B.Perinephric abscess
C.Nephrolithiasis or other Ureteral obstruction
D.Prostatitis
E.Seminal vesiculitis
F.Epididymitis
V. Metabolic Causes
A.Uremia
B.Diabetic acidosis
C.Porphyria
D.Addison's Disease in crisis
VI. Toxins
A.Bacterial Infection
B.Insect Bites
C.Snake Bite Venoms
D.Spider Bite Venoms (e.g. Black Widow Spider Bite)
E.Drugs
F.Lead poisoning
 Things to Remember

•Consider inguinal/rectal examination in males

•Consider pelvic/rectal examination in females
•Inflammatory bowel disease can mimic acute
apendicitis
•Herpes zoster – confusing pain if located in right lower
quadrant
•Pneumonia-diffuse radiated abdominal pain, no
tenderness
• Acute MI – diffuse abdominal pain
•Drug addicts – severe colicky pain
• Spinal/CNS disease – radiculitis, reffered pain
• Psychogenic somatoform disorders