the acute abdomen andrew wright md department of surgery
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The Acute Abdomen
Andrew Wright MDDepartment 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 diagnosisDoes 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 slowCan guide prognosis – i.e. timing of appendicitis
AcuteColic
Bowel strangulation
Rupture of viscera
Torsion
FaintingAbdominal 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 painTransition 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?
CharacterParoxysmal
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
CharacterBurning – 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 painDiaphragm – 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
RespirationPleuritic pain usually worse on deep inspiration
MicturationUTI
Bladder obstruction
Nephrolithiasis
Peri-bladder abscess
RecliningOften retroperitoneal origon
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Vomiting
CauseObstruction
Severe irritation of nerves of peritoneumi.e. pain, pancreatitis
Frequency
Relationship with pain
Character
Nausea and/or lack of appetite
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Bowel Movements
Regularity
DiarrheaTrue diarrhea vs. passage of several small loose stools
Blood
Mucusi.e. intussusception
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Menstruation
Regularity
Exact timing
Pain
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History
Prior similar episodes
Prior illnesses that may relateh/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
TempNormal 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
InspectionDistension
Bulge
HerniaAll potential orifices – including femoral
MovementRigidity with inspiration
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Palpation
Keys to successGentleness
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
ImagingPlain XRays
Flat and UprightLeft Lateral Decubitus if not able to stand)
Chest
Ultrasound
CT
Additional TestingGuide 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
GastroenteritisViral
Eosinophilic
Yersinia
Hepatitis
Typhlitis
Tropical infectious diseases (helminthic)
Tuberculosis
Typhlitis
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Appendicitis
Normal Acute Appendicitis
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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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Diverticular Abscess
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Bowel Obstruction
Hernia
Adhesion
Malignancy
Intussuception
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Inflammatory
Crohn’s
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 IschemiaAcute
Chronic
Sickle Cell Crisis
Colonic Ischemia
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Other
Psychiatric Disease
SpleenAbscess
Infarct
Wandering Spleen
MusculoskeletalAbdominal 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
MetabolicDiabetic Ketoacidosis
Porphyria
Lactose Intolerance
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Pediatric
Henoch-Schönlein purpura
Intussuception
Malrotation with midgut volvulus
Recurrent Abdominal Pain – diagnosis of exclusion