01 dr. nurcahya acut abdomen

Acute Abdominal Pain

dr. Nurcahya Setyawan, SpB-KBD, FinaCS, FICS

Sub. Bagian Bedah DigestifFK-UGM/RSUP dr. Sardjito, Yogyakarta

Definisi :

Sudden severe abdominal pain(maximum VAS).

One of the most common presenting complaints in the emergency department(5-10% of all ED visits).

Terminology:

• Pain ?• Sign or symptom ?

Signs

• SIGNS are objective and reproducible findingsD TendernessD RigidityD MassesD Altered bowel soundsD Evidence of malnutrit ionD BleedingD Jaundice

Symptoms

• SYMPTOMS reflect a subjective change from normal function

D PainD Appetite: anorexia, nausea, vomiting,

dysphagia, weight lossD Bowel habits: bloating, diarrhea,

constipation, flatulence

Visceral pain.

Somatic pain.

Referred pain.

Physiology of Abdominal Pain

Visceral PainD Stimuli•Distention of the gut or other hollow abdominal organ•Traction on the bowel mesentery•Inflammation•Ischemia

D Sensation•Corresponds to the embryologic origin of the diseased organ (foregut, midgut, hindgut)

foregu

t

midguthindgut

Somatic Pain

D Stimuli• Irritation of the

peritoneumD Sensation

• Sharp, localized pain• Easily described

D Cardinal signs• Pain• Guarding• Rebound• Absent bowel sounds

Example: McBurney’s point in late appendicitis

Referred Pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Biliary colicPancreatic and renal pain

Uterine and rectal pain

Diaphragmatic irritation

Common causes of acute abdominal pain:conditions in italic type often require surgery.

Gastrointestinal tract disorders• Nonspecific abdominal pain• Appendicitis• Small and large bowel obstruction• Incarcerated hernia• Perforated peptic ulcer• Bowel perforation• Meckel's diverticulitis• Boerhaave's syndrome

• Diverticulitis• Inflammatory bowel disorders• Mallory-Weiss syndrome• Gastroenteritis• Acute gastritis• Mesenteric adenitis

Liver, spleen, and biliary tract disordersAcute cholecystitis Acute cholangitis Hepatic abscess Ruptured hepatic tumorSpontaneous rupture of the spleenSplenic infarct Biliary colic Acute hepatits

Pancreatic disordersAcute pancreatitis

Urinary tract disorders Ureteral or renal colic Acute pyelonephritis Acute cystitisRenal infarct

Gynecologic disorders Ruptured ectopic pregnancy Twisted ovarian tumor Ruptured ovarian follicle cyst Acute salpingitis Dysmenorrhea Endometriosis

Vascular disordersRuptured aortic and visceral aneurysms Acute ischemic colitisMesenteric thrombosis

Peritoneal disorderslntra-abdominal abscesses Primary peritonitis Tuberculous peritonitis

Retro-peritoneal disordersRetro-peritoneal hemorrhage

Extra-Abdominal Causes of the Acute Abdomen

Supra-diaphragmaticD Myocardial infarctionD PericarditisD Left lower lobe pneumoniaD PneumothoraxD Pulmonary infarction

HematologicD Sickle cell diseaseD Acute leukemia

• Drugs• Metabolic• Nervous System

D Herpes ZosterD Tabes dorsalisD Nerve root compression

• EndocrineD Diabetic ketoacidosisD Addisonian crisis

How to approach the patient with acute abdominal pain ?

Detailed history and Careful physical examination alone.

the correct diagnosis can be established(in most cases)

Laboratory tests orother investigation are

usually needed for diagnostic confirmation.

How to approach the patient with acute abdominal pain ?

• Question key• Physical examination key point• Laboratory investigation• Radiology investigation• Other investigation• Planning

Question key point :

What are the patient’s vital signs?where is the location of pain?Does the pain radiate?What is the quality of pain ?When did the pain begins?What relieves the pain or makes it worse?Are there any associated symptoms?For women, what is the patients menstrual history?What is the patient’s past history?

Physical examination key points :

• Vital sign & general exam• Lung• Heart• Abdomen• Rectum• Female genitalia

Laboratory investigations points :

• Hemology• Electrolit & Serum creatinin• LFT• Amylase lipase• Pregnancy test• Urine analysis• Cervical culture

Radiology investigations :

• Erect and supine abdominal films• Chest X-ray• USG• CT Scan• Barium study• IVP

Other investigations :

• ECG• Paracentesis• Endoscopy• Arteriography

Planning:

• Observation• Surgery / indication ?

The Questions key points :1. What are the patient’ vital signs?

Tachycardia and hypotension suggest circulatory or septic shock from perforation, hemorrhage or fluid loss into the intestinal lumen or peritoneal cavity.

Fever occurs in inflammatory conditions such as cholecystitis and appendicitis.

Fever may not be present in: elderly patients, patients oncorticosteroids and patients who are immunocompromised.

2. where is the location of pain?

• Visceral pain is dull pain located in the midline and poorly localized.

• Unilateral pain: is caused by organs unilateral innervation such the kidney, ureter, or ovary

Mid epigastric pain: is caused by diseases inthe stomach, duodenum, pancreas, liver andbiliary tract.

Periumbilical pain: is caused bydiseases in the small intestine, appendix, upperureters, testes and ovaries.

Lower abdominal pain is caused bydiseases in the colon, bladder, lowerureters and uterus.

Parietal peritoneum inflammation resultsin more severe pain well localized to the area ofinflammation.

The Quadrants

Differential Diagnosis: RUQ Pain

CONDITION CLUESBiliary colic, acute cholecystitis

Recurrent attacks, tender over gall bladder area

Acute hepatitis Alcohol history, jaundice, medications

Right pyelonephritis Dysuria, fever, costovertebral angle tenderness

Congestive heart failure Edema, dyspnea, elevated JVPRetrocecal appendicitis Shift of pain, tendernessRight lower lobe pneumonia

Fever, tachypnea, bronchial breathing

Differential Diagnosis: LUQ and Epigastric Pain

CONDITION CLUES

Splenic rupture History of trauma or splenic disease

Fractured ribs History of trauma, gross deformity, extreme tenderness on palpation

Pancreatitis History of alcohol consumption, history of similar event, elevated labs

Gastritis / Peptic ulcer disease

Recurrent, relationship to meals, relationship to posture

Pneumonia Fever, XR findings, bronchial breathing

Differential Diagnosis: RLQ Pain

CONDITION CLUESAcute appendicitis Shift of pain, anorexia, localized tendernessMesenteric adenitis Fever, inconstant signsRight renal colic Colicky pain, hematuriaTorsed right testis Tender swollen testis, usually young age

Crohn’s disease Recurrent, several days historyGynecologic causes …see next

Gynecologic Causes of RLQ Pain

CONDITION CLUESRuptured follicle Fever, cervical excitation, dischargeTorsion of ovary Midcycle, sudden onsetRuptured ectopic pregnancy

Severe pain, vomiting

Pelvic inflammatory disease

Sudden onset, amenorrhea, shock

Differential Diagnosis: LLQ Pain

CONDITION CLUESDiverticular disease Elderly patient, recurrent

Acute urinary retention Palpable bladder, difficulty passing urineUrinary tract infection Dysuria, frequencyInflammatory bowel disease Recurrent attacks, diarrhea (+/- mucus, blood)Large bowel obstruction Colicky pain, obstipationLeft renal colic Colicky pain, hematuria

Torsion of testis Tender, swollen testis, young age

Gynecologic causes as for RLQ pain

Differential Diagnosis: Periumbilical Pain

CONDITION CLUES

Gastroenteritis Vomiting and diarrheaConstipation Colicky pain, hard stoolInflammatory bowel disease

Recurrent diarrhea, +/- mucus and blood

Early appendicitis Nausea, short historySmall bowel obstruction

Colicky pain, vomiting, no flatus

Ischemic bowel Severe pain, tenderness less marked, rectal bleeding

3. Does the pain radiate?

Biliary pain can radiate from the right upper quadrant to the right inferior scapula.

Pancreatic and abdominal aneurysmal pain may radiate to the back.

Ureteral colic classically is referred to the groin and thigh.

Diaphragmatic irritation due to subphreniccollections of pus or blood often radiatesto the supraclavicular area.

Pain that becomes rapidly generalized meansperforation and leakage of fluid into theperitoneal cavity.

Referred Pain

4. When did the pain begins?

Sudden onset suggests: perforated ulcer

mesentric occlusion

ruptured aneurysm.

ruptured ectopic pregnancy

More gradual onset (>1hour) suggests an inflammatory cond.appendicitis, cholecystitis diverticulitis, bowel obstruction.

Intestinal colic is cramping abdominal pain interposed with pain-free intervals.

Biliary colic is not a true colicky but it is usually sustained persistent pain.

The terms sharp, burning, dull and tearingseldom assist in diagnosis.

5. what is the quality of pain?

6. What relieves the pain or makes it worse?

Pain with deep inspiration is assosiated with diaphragmatic irritation is assosiated with pleuricy upper abdominal inflammation.

Coughing increases the abdominal paindue to peritonitis.

Patients with peritonitis take some relief ofpain by avoiding all motions whereas patientswith intestinal or ureteral colic are usuallyrestless and active.

7. Are there any associated symptoms?

• Vomiting : intestinal obstruction. visceral reflex due to the pain

In acute surgical conditions, the vomiting follows the onset of pain.

• Haematemesis : gastritis or peptic ulcer disease

• Diarrhea : Gastro enteritis Ischemic colitis Inflammatory bowel disease.

• Absolute constipation : Mechanical intestinal obstruction.

• Haematuria : Urinary tract disease.• Coughing and sputum : lower lobe pneumonia.

8. For women, what is the patients menstrual history?

• Missed period : disturbed ectopicpregnancy .

• Foul vaginal discharge : pelvicinflammatory disease.

9. What is the patient’s past history?

medical

• Peptic ulcer disease, gall stones, diverticulosis,alcohol abuse, abdominal operations suggesting adhesions.

• Abdominal aortic aneurysm or cardiac disease may suggest embolization.

Physical examination key points :

• Vital sign & general exam• Lung• Heart• Abdomen• Rectum• Female genitalia

Physical examination key points :

1 Vital signs & general exam:• Tachycardia• Hypotension• Fever• Posture• Jaundice

2. Lungs:• Evidence of consolidation.• Friction rub.• Effusion.

3. Heart:• Arrhythmias.• Valvular lesion.• Heart failure.

4. Abdomen:

a. Inspection:

• Distension : obstruction, ileus, ascites.• Ecchymoses : haemorrhgic pancreatitis.• Surgical scars : adhesions.

b. Palpation:• Tenderness & rigidity• Organomegaly.

c. Percussion:• Tympany : distended bowel loops.• Shifting dullness : suggests ascites with

peritonitis

d. Auscultation : bowel sounds

• Absent : ileus.

• Hyper peristaltic : gastroenteritis.

• High pitched rushes : small bowel obstruction.

e. Other sign:

• Psoas sign.• Obturator sign• Rovsing’s sign

Acute appendicitis

5. Rectum

• Mass

• Lateral tenderness.

• If stool is present, evaluate for occult blood.

6. Female genitalia

• Pain with cervical motion• Cervical discharge

• Adnexal masses : ectopic pregnancyovarian abscess cystneoplasm

Pelvic inflammatory diseases

Laboratory investigations points :

• Value :• In cases in which the etiology is unclear.

• Preoperative assessment.

Laboratory investigations points :

• Hemology• Electrolit & Serum creatinin• LFT• Amylase lipase• Pregnancy test• Urine analysis• Cervical culture

1. Hemology :

• ↑ Hematocit suggests hemoconcentration from volume loss as in cases of pancreatitis.

• ↓ Hematocit suggests intra abdominal or acuteG.I hemorrhage.

• ↑ WBCS suggests an inflammatory process as acute appendicitis and cholecystitis.

2. Electrolytes and S. creatinine

• Bowel obstruction : hypokalemia, azotemia and alkalosis

• Volume depletion and G.I bleeding : ↑ s.creatinine.

3. liver function tests

Including bilirubin, transaminases andkaline phosphatase.

The results are elevated in cases ofacute hepatitis, cholecystitis, andother biliary tract diseases.

4- Amylase / lipase :Elevated in cases of acute pancreatitis.In up to 30% of patients with acute pancreatitis, amylase may be normal.

S. amylase is also elevated in cases of• Perforated peptic ulcer.

• Strangulated small bowel.

• Ruptured ectopic pregnancy

S.Lipase will help differentiate pancreatitis from

other causes of hyperamylasemia.

5 Pregnancy test

6. Urine analysis for haematuria and/or pyuria.

7. Cervical culture � PID.

Radiology investigations :

• Erect and supine abdominal films• Chest X-ray• USG• CT Scan• Barium study• IVP

Radiology investigation :1 Erect and supine abdominal films: looking for :

• Air-fluid levels

• Evidence of bowel dilation.

• Pancreatic, biliary or renal calcifications.• Loss of psoas margin suggesting retro peritoneal

bleeding.

• Aortic calcification.

• Presence or absence of air in the biliary tract.

2. Chest x ray : looking for

• Lower lobe pneumonia• Pleural effusion.• Elevation of a hemidiaphragm.• Free air under the diaphragm.

3. Ultra sound : looking for

• Gall stones or biliary tract dilatation.• Ectopic pregnancy.

• Free fluid in the peritoneal cavity.

4 CT: very sensitive in many possible diagnoses.

5 Barium studies.

6 I.V.P

Other investigations :

• ECG• Paracentesis• Endoscopy• Arteriography

• ECG: in patients with acute upper abdominal pain to rule out acute myocardial infarction or pericarditis.

• paracentesis.• Endoscopic studies: upper or lower G.I endoscopy

or ERCP.• Arteriography in cases of suspected acute

mesenteric artery ischemia.

Other investigation

Management / plan :

• The initial goal is :

to determine whether surgical treatment is needed or not.

Indication for urgent operation

• Physical findings• Involuntary guarding or rigidity, especially if

spreading.• Increasing or severe localized tenderness.• Tense or progressive distension.

• Tender abdominal or rectal mass with high fever or hypotension.

• Rectal bleeding with shock or acidosis.

Indication for urgent operation

• Radiologic findings• Pneumoperitoneum• Gross or progressive bowel distension• Free extravasation of contrast material• Space-occupying lesion on CT scan with fever• Mesenteric occlusion on angiography

• Endoscopic findings• Perforated or uncontrollably bleeding lesion

• Paracentesis findings• Blood, bile, pus, bowel contents, or urine

Management / plan :• observation: include

• Serial clinical examinations by the same clinician.• I.V fluids in cases of septic shock or fluid loss• Use of antibiotics an analgesics• Gastric decompression : in cases of mechanical

intestinal obstruction.

Referral (when ?)

• Surgical / non surgical consultation

Algorithm.

Algorithm.

Abdominal Pain Referral

file:///C:/Users/nurcahya/Downloads/Abdominal%20Pain%20Referral.html 1/1

When to Refer to :

Surgeon Acute abdomen on physical examination Hemodyn instabilityFree intraperitoneal air on radiographs Suspected b obstruction Suspected acute mesenteric ischemia Suspected a appendicitisSuspected acute cholecystitis or biliary colic

Abdominal Pain Referral

file:///C:/Users/nurcahya/Downloads/Abdominal%20Pain%20Referral.html 1/1

When to Refer to :

Urologist Nephrolithiasis with fever or complete ureteral obstructionNephrolithiasis with solitary kidney or failure to pass stone within 6 weeks Nephrolithiasis with stone > 7 mm diameter

Gynecologist Suspected adnexal torsionLower abdominal pain and positive pregnancy test Suspected pelvic inflammatory diseaseSuspected endometriosis

Abdominal Pain Referral

file:///C:/Users/nurcahya/Downloads/Abdominal%20Pain%20Referral.html 1/1

When to Refer to : Gastroenterologist

Unable to make a definitive diagnosisNeed for endoscopic procedure for diagnosisIrritable bowel syndrome refractory to standard therapy Suspected ischemic bowel (chronic)Suspected diverticulitisSuspected ulcerative colitis or Crohn's disease Suspected pancreatitisSuspected pancreatic carcinoma

Undiagnosed (non specific) acute abdominal pain (NSAP)

In a large proportion of patients with acute abdomena specific diagnosis can not be reached.

The incidence of these patients varies considerablyin different studies (varying from 15-42%).

The psychological results demonstrated thatthe NSAP group had the same level of anxiety anddepression as the control group and also had no evidenceof increased preceding life events.

• The majority of these patients will be recovered.However, some patients will worsen and require subsequent hospitalization & surgery.

• The emergency physician should avoid labelingnon specific abdominal pain as gastritis orgastroenteritis or other similar terms.

• Scheduled out-patient follow up & reassesment is necessary.

• Patients should not be told that nothing is wrongor that they are not having pain. But, they shouldbe reassured and advised that by meansavailable today, it is not possible to identify thecause of their pain.

• Patients may be better managed by referralto a pain clinic as the pain has an impact on thequality of life.