ACUTE ABDOMINAL PAIN Victor Politi, M.D., FACP Medical Director, SVCMC School of Allied Health, Physician Assistant Program

Abdominal Pain Most common cause of hospital admission in the US Accounts for 5-10% of all ED visits In 35-40% of all hospital admissions due to abdominal pain - the pain is nonspecific

Epidemiology Gastroenteritis is the most common cause of abdominal pain not requiring surgery In patients age 60 and older, biliary disease and intestinal obstruction are the most common cause of acute abdominal pain that is surgically correctable

Epidemiology Appendicitis is the most common cause of abdominal pain requiring surgery in patients < age 60 Appendicitis is the leading cause of acute abdominal pain in children accounts for 32% of children admitted w/acute abdominal pain

Patient History The term “acute abdomen” implies the sudden onset of abdominal pain for which a surgically correctable cause is likely

Patient History Besides the age of the patient - key elements of the patient history include: Time of pain onset Location/character of pain Pattern of pain radiation Associated symptoms

Key Points in History Reproductive Bowel and Bladder Sexual Activity, Contraception, Last Menstrual Period Always Consider Pregnancy in Reproductive Age Women Have a Low Threshold for Pregnancy Testing Bowel and Bladder Nausea, Vomiting, Diarrhea, Constipation Frank Blood, "Coffee Grounds" Emesis, Black Stools Urinary Frequency, Urgency, Discomfort

AGE Age of patient - crucial Differential diagnosis of abdominal pain in children - differs from dx in elderly patient Common conditions that cause abdominal pain in most age groups acute appendicitis, intestinal obstruction, incarcerated hernias

AGE Intussusception is most likely the cause of intestinal obstruction in children Adhesions are most likely the cause of intestinal obstruction in adults In older patients, pain from a MI can be referred to the upper abdomen

Time of Onset Pain sudden in onset, awakens a patient from sleep - suggests a viscus Knowing the timing of associated nausea and vomiting is essential to narrow the diagnostic possibilities Pain precedes vomiting when abdominal pain is from surgically correctable causes, whereas the reverse is true for medical conditions such as gastroenteritis

Location Abdomen divided into 4 quadrants, which are further divided (with some overlap) into the epigastric, periumbilical, and suprapubic regions

Location of Abdominal Pain Four quadrants: Right Upper Quadrant Right Lower Quadrant Left Upper Quadrant Left Lower Quadrant Three central areas: Epigastric Periumbilical Suprapubic Location of Abdominal Pain

Location RUQ pain - duodenal ulcers, acute pancreatitis, acute cholecystitis, and acute hepatitis LUQ pain - gastritis, gastric ulcer, acute pancreatitis, and splenic infarct or rupture RLQ pain - acute appendicitis, LLQ pain - diverticulitis GYN and urologic causes of acute abdominal pain can also present with lower quadrant abdominal pain

Radiation of Abdominal Pain Perforated Ulcer Biliary Colic Renal Colic Dysmenorrhea/Labor Renal Colic (Groin)

Character Implies all the features of the pain Usually can be determined by asking the patient to describe the quality of the pain Most often described as sharp or dull cramping (colicky)

Character Colicky pain - rhythmic pain resulting from intermittent spasms - most commonly associated with biliary disease, nephrolithiasis, intestinal obstruction Pain that begins as dull, poorly localized ache and progresses to a constant, well localized sharp pain indicates a surgically correctable cause

Physical Examination of the Abdomen Inspection Auscultation Percussion Palpation

Inspection General observation Look at abdominal contour, note location of any scars, rashes or lesions

Inspection Patient writhing in agony - likely has colicky abdominal pain caused by ureteral lithiasis Patient lying very still - more likely to have peritonitis Patient leaning forward to relieve pain - may have pancreatitis

Inspection The abdominal wall is a commonly overlooked source of abdominal pain Other parts of the body should also be inspected. For example, the eyes should be inspected for evidence of scleral icterus which may indicate hepatobiliary disease

Auscultation Useful in assessing peristalsis Bowel sounds are widely transmitted through the abdomen - therefore, it is not necessary to listen in all 4 quadrants Auscultation should last at least 1 minute Bowel sounds typically highly pitched so the diaphragm of the stethoscope should be used

Auscultation ? Bowel sounds- normal/hyperactive/hypoactive Auscultation should precede percussion and palpation ? Abdominal bruits - listen over aortic,iliac and renal arteries

Auscultation Hypoactive bowel sounds - associated with ileus, intestinal obstruction, peritonitis Intestinal obstruction can produce hyperactive bowel sounds which are high pitched tinkling sounds occurring at brief intervals; very audible

Percussion Technique - performed by firmly pressing the index finger of one hand on the abdominal wall while striking the abdominal wall with the other index finger Percussion note can be described as dull, resonant, or hyperresonant

Percussion Dull/resonant or hyperresonant Tympany normally present in supine position ? Unusual dullness ? Clue to underlying abdominal mass

Percussion Gastric region - Liver - percussion over the gastric region will generate a hyperresonant note because of usual presence of a gastric air bubble Liver - percussion over the liver will generate a dull note A normal liver span is 6 to 12 cm in the midclavicular line

Percussion Generalized percussion is a useful method for detecting the presence of ascites or intestinal obstruction in a distended abdomen In ascites - a dull percussion note would be generalized In intestinal obstruction - a hyperresonant note would be heard

Percussion If ascites is suspected, then a test for shifting dullness can be performed Ascites typically sinks with gravity, percussion of the flanks generates a dull note and percussion of the periumbilical region generates a resonant note in the supine patient

Percussion The test for shifting dullness involves having the patient shift to a lateral decubitus position and then performing percussion again; the area of resonance should shift upward

Shifting Dullness If dullness on percussion shifts when the patient is rolled on the side, peritoneal fluid (ascites) may be present.

Percussion Splenic Enlargement A change from tympany to dullness suggests splenic enlargement

Palpation Before palpating the abdomen the examiner should ask the patient to point directly to the area that hurts most and avoid palpating that area until absolutely necessary May be difficult in patient who has guarding (voluntary or involuntary)

Palpation Voluntary guarding - conscious elimination of muscle spasms Involuntary guarding - reported when the spasm response cannot be eliminated, which usually indicates diffuse peritonits

Palpation Where is pain ? Begin with light palpation Guarding - voluntary/involuntary Rebound tenderness

Palpation Rebound tenderness is elicited by pressing on the abdominal wall deeply with the fingers and then suddenly releasing the pressure Pain on the abrupt release of steady pressure indicates the presence of peritonitis Asking the patient to cough is another method of eliciting signs of peritonitis

Rebound Tenderness This is a test for peritoneal irritation. Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness

Deep Palpation ? Areas of deep tenderness/masses

Liver Palpation

Palpation of Aorta Easily palpable on most Pulsate with deep palpation of central abdomen Enlarge aorta - ? Sign of aortic aneurysm

Palpation of Spleen Not normally palpable

Costovertebral Angle Tenderness CVA tenderness is often associated with renal disease. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles

Specific Disorders Upper abdominal pain - common causes of acute abdominal pain in the upper abdomen include: acute cholecystitis, acute pancreatitis, perforated ulcers Pain usually overlaps the left and right upper quadrants

Classic Presentations - Acute Cholecystitis Localized or diffuse RUQ pain Radiation to right scapula Vomiting and constipation Low grade fever

Cholecystitis Murphy’s sign (have patient take a deep breath while right subcostal area is palpated) abrupt cessation of inspiration secondary to pain is considered a positive Murphy’s sign Disease of adulthood More common in women Bacteria invasion can develop into ascending cholangitis Charcot’s triad Right upper quadrant pain Fever Jaundice

Acute pancreatitis Retroperitoneal dissection of blood can result in bluish discoloration of the flanks (Turner’s sign) or of the periumbilical region (Cullen’s sign) Biliary pancreatitis secondary to cholelithiasis is most common women > age 50 in community hospital setting Alcoholic pancreatitis is most common in men ages 30-45 years in urban hospital setting Symptoms-epigastric pain,nausea,vomiting,pain is constant & boring in nature Bowel sounds decrease - lack of rigidity or rebound tenderness

Perforated Peptic Ulcer Sudden onset - severe epigastric pain Pain becomes generalized after a few hours to involve the entire abdomen Perioperative mortality rate of 23% Patient usually lying quietly and breathing shallow. Abdomen rigid,board-like, guarding - maximal at site of perforation Upright chest x-ray - detection of free intraperitoneal air

Specific Disorders Midabdominal pain - common causes of midabdominal pain include intestinal obstruction, mesenteric ischemia and early appendicitis dissecting aortic aneurysm myocardial infarction

Intestinal Obstruction Mechanical - results from gallstones, adhesions, hernias, volvulus, intussuseption, tumors Non-mechanical- results from intestinal infarction or occurs after surgery as a paralytic ileus, pain medication

Intestinal Obstruction Obstruction high in small intestine results in severe abdominal pain in epigastric or umbilical region with bilious vomiting, distention of abdomen not an early feature Obstruction located lower in small intestine results in less severe pain Vomiting late feature and may be feculent

Intestinal Obstruction Differential Diagnosis of obstruction of small intestine strangulated hernia volvulus mesenteric thrombus gallstone ileus Abdominal x-ray of distal obstruction of small intestine will show a dilated loop

Large Intestine Obstruction Pain less severe than small intestine obstruction Vomiting infrequent Distention of abdomen - common Main Causes of Large Intestine Obstruction Ca of colon (change bowel habits, wt loss, rectal bleeding) diverticulitis (fixed,tender, LLQ mass) volvulus (sigmoid volvulus most common)

Mesenteric Ischemia Presents with acute, diffuse, midabdominal pain, vomiting, decreased bowel sounds and distention resulting from intestinal obstruction Abdominal pain is out of proportion to physical examination findings Abdominal distention is a late sign indicative of gangrene - signs of peritoneal irritation also indicative of gangrene

Specific Disorders Lower abdominal pain - common causes of lower abdominal pain include Acute appendicitis (typically RLQ pain) Sigmoid diverticulitis (typically LLQ pain) Gynecologic causes Urologic causes

Diverticulitis Lower Left Quadrant Pain Cramping sensation Possible fever

Appendicitis Peak incidence in 2nd decade of life Differential diagnosis is broad and errors in diagnosis are common Diagnostic error rate Men 23% Women 42%

Appendicitis Patients seen in first few hours - report poorly defined constant pain in periumbilical region As disease progresses - pain shifts to RLQ in a region known as McBurney’s point (located 2/3 of the distance along a line drawn from the umbilicus to the right anterior superior iliac spine)

Appendicitis Pain relieved somewhat when patient assumes a right lateral decubitus position with slight hip flexion Abdominal tenderness - most likely physical finding Voluntary guarding in RLQ is common

Appendicitis Rovsing’s sign can be elicited by palpating deeply in the left iliac area and observing for referred pain in the right iliac fossa When present, the psoas and obturator signs are also helpful in establishing a diagnosis of appendicitis

Appendicitis Psoas sign - the psoas sign is pain elicited by extending the right hip while the patient is in the left lateral decubitus position - alternatively, while in the supine position, the patient can lift the right thigh against the examiners hand, which is placed above the knee

Psoas Sign The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk).

Appendicitis Obturator sign - the obturator sign is pain elicited by flexing the patient’s right thigh at the hip with the knee flexed and then internally rotating the hip Right sided rectal tenderness may also be elicited on rectal exam of patients with acute appendicitis

Obturator Sign The obturator sign. Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur.

Classic Presentations - Acute Appendicitis Diffuse periumbilical pain and anorexia early Pain localizes to RLQ as peritonitis develops Low grade fever, nausea and vomiting may not be present Xrays and other tests are often negative Remember that the position of the appendix is highly variable!

Other Causes of Abdominal Pain Abdominal aortic aneurysm abdominal pain/backache hypotension 71% perioperative mortality rate Physical exam of abdomen - detect pulsatile mass unequal femoral pulses

Abdominal Aortic Aneurysm

Other Causes of Abdominal Pain Nephrolithiasis ureteral colic 4% of patients w/acute abdominal pain Colicky pain - Upper lumbar region radiates laterally to inguinal region Patient writhing in pain

Classic Presentations - Acute Renal Colic Severe flank pain Radiation to groin Vomiting and urinary symptoms Blood in the urine

Other Causes of Abdominal Pain Cardiac Origin Gastritis GERD Esophageal disease Hiatal hernia Liver abscess/subdiaphragmatic abscess Pulmonary origin Herpes Zoster Hernia

Other Causes of Abdominal Pain Gynecologic Ovarian cyst Ectopic pregnancy PID

Gynecologic Causes In the absence of a positive pregnancy test result - fresh blood suggests a corpus luteum hemorrhage old blood suggests a ruptured endometrioma (chocolate cyst) purulent fluid suggests acute pelvic inflammatory disease (PID) sebaceous fluid indicates a dermoid cyst.

Ectopic Pregnancy Unruptured ectopic pregnancy - localized pain due to dilatation of the fallopian tube. Ruptured ectopic - pain tends to be generalized due to peritoneal irritation Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients

Ectopic Pregnancy Abdominal examination findings include tenderness and guarding in the lower quadrants. Once hemoperitoneum has occurred, distension, rebound tenderness, and sluggish bowel sounds may develop.

Corpus luteum hematoma Slow leakage produces minimal pain Frank hemorrhage can lead to hemoperitoneum and hypovolemic shock Generalized abdominal pain and syncope are features of such a presentation.

Ruptured Ovarian Cyst The most common causes are dermoid cyst, cystadenoma, and endometrioma Blood loss is minimal, hypovolemia does not supervene Peritoneal irritation due to leakage of cyst fluid can lead to significant tenderness, rebound tenderness, abdominal distension, and hypoperistalsis

Ovarian Torsion Frequently - resolves spontaneously - only presenting symptom -lower abdominal pain Persistent torsion leads to congestion, ovarian enlargement, thickening of the ovarian capsule, and subsequent infarction. Pain becomes severe -accompanied by nausea, vomiting, and restlessness Infarction also leads to fever and mild leukocytosis

PID Acute salpingo-oophoritis is a polymicrobial infection that is transmitted sexually. Neisseria gonorrhoeae and Chlamydia trachomatis are usually identified in patients with PID, and both organisms often coexist in the same patient. Gonococcal disease tends to have a rapid onset, while chlamydial infection has a more insidious onset

Diagnostic Criteria for PID Lower abdominal tenderness Cervical motion tenderness Adnexal tenderness Diagnosis may also be supported by any of the following criteria: Temperature greater than 101°F (38.3°C) Abnormal cervical or vaginal discharge Laboratory evidence of C trachomatis or N gonorrhoeae Elevated erythrocyte sedimentation rate or elevated C- reactive protein value

Tubo-ovarian abscess A ruptured abscess can lead to gram-negative endotoxic shock; therefore, this condition is a surgical emergency. The most common presentation is bilateral, palpable, fixed, tender masses. Patients often present with generalized abdominal pain and rebound tenderness caused by peritoneal inflammation

Fibroids A pedunculated subserous fibroid may twist and undergo necrosis, causing acute abdominal pain A pedunculated submucous fibroid may present with cramping pain and vaginal bleeding

Endometriosis Pain associated with endometriosis may worsen premenstrually or during menses. Patients experience generalized lower abdominal tenderness, and associated complaints include dysmenorrhea, dyschezia, and dyspareunia

Things to Remember Inguinal/rectal examination in males. Pelvic/rectal examination in females. Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest and cardiovascular system when evaluating an abdominal complaint Consider mesenteric ischemia in diabetic patients and patients with vascular disease and vasculitis

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