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

2. 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

3. 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

4. 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

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

6. Three Types of Pain
Visceral
Somatic
Referred

7. 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

8. 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)

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

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

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

12. 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

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

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

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

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

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

18. Extraabdominal Causes of Abdominal Pain
Systemic
Toxic
Thoracic
Genitourinary
Abdominal Wall

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