Andrew Wright MD Department of Surgery The Acute Abdomen Andrew Wright MD Department of Surgery

What is an acute abdomen?

What is an acute abdomen? New onset abdominal pain Usually abdominal pain as main symptom Often seen by primary physician Signifies need for prompt diagnosis Does not necessarily imply need for surgical intervention

How do you diagnose an acute abdomen?

How do you diagnose an acute abdomen? History and Physical

History

Exact time and onset Most slow Acute Can guide prognosis – i.e. timing of appendicitis Acute Colic Bowel strangulation Rupture of viscera Torsion Fainting Abdominal apoplexy Perforated ulcer, ruptured aortic aneurysm, ruptured ectopic What was patient doing at time of onset? i.e. “minor” trauma

Location Initial location Shifting of pain Transition from visceral to parietal pain

What is visceral pain? Intestines are: Location: 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

What is visceral pain? Character Paroxysmal 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

Character Character Burning – 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

Radiation Referred pain Diaphragm – shoulder Biliary tract – tip of shoulder Pancreas – mid back Kidney – mid back Rectum- coccyx Uterus – coccyx

Exacerbating factors Relationship to food Respiration Micturation Pleuritic pain usually worse on deep inspiration Micturation UTI Bladder obstruction Nephrolithiasis Peri-bladder abscess Reclining Often retroperitoneal origon

Vomiting Cause Frequency Relationship with pain Character Obstruction Severe irritation of nerves of peritoneum i.e. pain, pancreatitis Frequency Relationship with pain Character Nausea and/or lack of appetite

Bowel Movements Regularity Diarrhea Blood Mucus True diarrhea vs. passage of several small loose stools Blood Mucus i.e. intussusception

Menstruation Regularity Exact timing Pain

History Prior similar episodes Prior illnesses that may relate h/o peritonitis, appendicitis, pneumonia, etc. Previous attacks of jaundice, melena, hematemesis, hematuria Travel history PMH PSH

Examination

General appearance General gestalt – is he (or she) sick?

Vitals Pulse Respiratory rate Temp Blood Pressure Normal or mildly elevated typical High fever unusual – suspect kidney or thorax Hypothermic – suspect shock Blood Pressure

Inspection Determine exact location of pain first Inspection Movement Distension Bulge Hernia All potential orifices – including femoral Movement Rigidity with inspiration

Palpation Keys to success Guarding Rebound Iliopsoas rigidity Gentleness Thighs flexed Thorough exam Include back Guarding Rebound Iliopsoas rigidity

Percussion Liver dullness Free-fluid

Rectal exam

Pelvic exam

Should pain meds be given prior to diagnosis?

Diagnostic Testing

Diagnostic Testing CBC with dif Electrolytes, BUN, creatinine, and glucose Aminotransferases, alkaline phosphatase, and bilirubin Lipase Urinalysis Pregnancy test in women of childbearing potential

Imaging

Imaging Imaging Additional Testing Plain XRays Ultrasound CT Flat and Upright Left Lateral Decubitus if not able to stand) Chest Ultrasound CT Additional Testing Guide by Differential

Causes of Abdominal Pain

Extra-abdominal Herpes Zoster MI Pneumonia

Biliary Disease Cholelithiasis Cholecystitis Cholangitis Pancreatitis Biliary Dyskinesia

GI GERD Gastritis Peptic Ulcer Disease Irritable Bowel Constipation Diabetic Gastroparesis

Infectious Appendicitis Diverticulitis Gastroenteritis Hepatitis Viral Eosinophilic Yersinia Hepatitis Typhlitis Tropical infectious diseases (helminthic) Tuberculosis Typhlitis

Appendicitis Acute Appendicitis Normal

Appendicolith

Appendiceal Phlegmon

Peri-appendiceal Abscess

Diverticulosis

Diverticulitis

Diverticular Abscess

Bowel Obstruction Hernia Adhesion Malignancy Intussuception

Epiploic appendagitis Inflammatory Crohn’s Ulcerative Colitis Malignancy Epiploic appendagitis Epiploic appendagitis

Gynecologic PID Adnexal Endometriosis Ectopic pregnancy Endometritis Torsion Cyst Neoplasm Endometriosis Ectopic pregnancy Endometritis Leiomyomas

Urologic UTI Nephrolithiasis Bladder distension

Vascular Aneurysm Dissection Mesenteric Ischemia Sickle Cell Crisis Acute Chronic Sickle Cell Crisis Colonic Ischemia

Other Psychiatric Disease Spleen Musculoskeletal Abscess Infarct Wandering Spleen Musculoskeletal Abdominal wall pain Painful rib syndrome (chostochondritis) Hernia

Other Celiac artery compression Abdominal Migraine Fitz-Hugh-Curtis syndrome Familial Mediterranean fever Hereditary angioedema Heavy Metal Poisoning Metabolic Diabetic Ketoacidosis Porphyria Lactose Intolerance

Pediatric Henoch-Schönlein purpura Intussuception Malrotation with midgut volvulus Recurrent Abdominal Pain – diagnosis of exclusion