M Grant Ervin MD,MHPE,FACEP ACUTE ABDOMEN Clinical Application Presented April 23, 2002 HUCM By M Grant Ervin MD,MHPE,FACEP

Objectives List at least 5 etiologies of abdominal pain for each quadrant of the abdomen Describe 3 types of pain and correlate with anatomical location Discuss the physiology of the peritoneum Delineate 3 symptoms that may be seen with visceral pain Delineate difference between somatic pain and visceral pain

Background Acute abdominal pain accounts for ~10% of ED visits 40% of patients discharged with diagnosis of nonspecific abdominal pain Elderly Women of reproductive age

Elderly More likely to have a life threatening cause Atypical presentation May be more rapidly progressive Decreased diagnostic accuracy with increased probability of severe disease results in increased mortality

Women of Reproductive Age Ectopic pregnancy Pain in pelvic organs often perceived as pain in abdomen

Three Types of Pain Visceral Somatic Referred

Visceral Pain Results from stimulation of autonomic nerves in the visceral peritoneum which surrounds internal organs Stimuli may be hollow organ distension or capsular stretching of solid organs Pain is perceived from abdominal region that originated from the embryonic somatic portion

Embryology Foregut structures cause upper abdominal pain (stomach,liver, duodenum, pancreas) Midgut structures cause periumbilical pain (small bowel, appendix, proximal colon Hindgut structures cause lower abdominal pain (distal colon, GU tract)

Clinical Presentation Pain poorly localized Intermittent, crampy, or colicky pain Nausea, vomiting, diaphoresis

Somatic Pain Stimuli occurs with irritation of parietal peritoneum Sensations conducted along peripheral nerves which can localize pain better

Clinical Presentation Pain described as intense, constant May be caused by infection, chemical irritation, or other inflammatory process

Referred Pain Pain felt at a distance from its source May be visceral or somatic Epigastric pain felt with inferior wall Myocardial infarction Left shoulder pain felt with splenic rupture

Right Upper Quadrant Pain Acute cholecystitis and biliary colic Acute hepatitis Perforated duodenal ulcer Right lower lobe pneumonia Hepatic abscess

Left Upper Quadrant Pain Gastritis Acute pancreaaatitis Splenic enlargement, rupture Myocardial infarction Left lower lobe pneumonia

Right Lower Quadrant Pain Appendicitis Leaking Aneurysm Ruptured ectopic pregnancy Psoas abscess Cecal diverticulitis

Left Lower Quadrant Pain Sigmoid diverticulitis Leaking aneurysm Ureteral calculi PID Incarcerated strangulated hernia

Diffuse Pain Peritonitis Acute pancreatitis Sickle cell crsis Early appendicitis Mesenteric thrombosis Gastroenteritis Dissecting or rupturing aneurysm Intestinal obstruction Diabetes Mellitus

Extraabdominal Causes of Abdominal Pain Systemic Toxic Thoracic Genitourinary Abdominal Wall

In summary, understanding the anatomy and physiology are key to deciphering the pathophysiology of abdominal pain and managing patients with this presentation