1. Approach to the patient with acute abdominal pain
Asisst. Prof. Dr.Özlem Tanrıöver Yeditepe University
Medical Faculty
Department of Family Medicine

2. Abdominal Anatomy Four quadrants: Three central areas:
Right Upper Quadrant
Right Lower Quadrant
Left Upper Quadrant
Left Lower Quadrant
Three central areas:
Epigastric
Periumbilical
Suprapubic

3. Abdominal Anatomy Right upper quadrant
Liver, Head of Pancreas, Kidney and Lung
Right lower quadrant Appendix, Ureter, Bladder, Colon, Gonads
Left upper quadrant
Heart, Spleen, Body of pancreas, Kidney, Stomach, Lung
Left lower quadrant
Ureter, bladder, colon, gonads

4. The History and Physical in Perspective
70% of diagnoses can be made based on history alone.
90% of diagnoses can be made based on history and physical exam.
Expensive tests often confirm what is found during the history and physical.

5. Types of Abdominal Pain
Pain from Hollow Viscera
crampy/paroxismal
often poorly localized
related to peristalsis
patient writhing on exam table
Pain from Peritoneal Irritation
steady/constant
often localized
patient lies still with knees up

6. Key Historical Points - Bowel and Bladder
Nausea, Vomitting, Diarrhea, Constipation
Frank Blood, "Coffee Grounds" Emesis, Black Stools
Urinary Frequency, Urgency, Discomfort

7. Key Historical Points - Reproductive
Sexual Activity, Contraception, Last Menstrual Period
Always Consider Pregnancy in Reproductive Age Women
Have a Low Threshold for Pregnancy Testing

8. Gastrointestinal Review of Systems
Trouble swallowing
Heartburn
Loss of appetite
Nausea
Change in bowel habits
Blood in stool
Dark tarry stools
Constipation
Diarrhea
Abdominal pain
Jaundice
Fever or chills

9. Ask the following questions:
Where is the pain?
Has the pain changed its location since it started?
Do you feel the pain in any part of your body?
How long have you had the pain?
Have you had recurrent episodes of abdominal pain?

10. Ask the following questions:
Did the pain start suddenly?
Can you describe the pain? Is it sharp, burning, cramping?
Is the pain continuous?
What makes it worse, or better?
Is the pain associated with nausea, vomiting, sweating, constipation, diarrhea, bloody stools, abdominal distention, fever, chills, eating?
If the patient is a woman;
When was your last period?

11. Abdominal Pain Location Other symptoms Character Factors that
aggravate or
alleviate
Timing
Environment
Severity

12. Common causes of acute abdominal pain
Peptic Ulcer Disease
Cancer of Stomach
Pancreas, Colon
Biliary Colic
Acute Cholecystitis
Acute Appendicitis
Acute Diverticulitis
Intestinal Obstruction
Mesenteric Ischemia
Irritable Bowel Syndrome
Inflammatory Bowel Dis.
Hepatitis
Gastroenteritis

13. Peptic Ulcer Disease or Dispepsia
Ulcer begins in lining
of stomach or duodenum.
Helicobacter pylori
infection is often present.
Dyspepsia more
common ages ,
gastric ulcer in those
over 50 and duodenal
ulcer ages 30 – 60.

14. Peptic Ulcer Disease or Dispepsia
Pain is epigastric and may radiate to the back.
Variable, gnawing, burning, boring, aching or hungerlike.
Timing is intermittent. Duodenal ulcer
more likely nocturnal.
Food and antacids may relieve duodenal ulcer pain.
Accompaning symptoms include nausea, vomiting, belching, bloating, heartburn
and weight loss.

15. Pancreatitis Inflammation of the pancreatic tissue often
due to gallstones or
alcohol abuse.
Pain is epigastric and
may radiate to the back.
Pain onset is acute and
pain is steady.
Pain may be worse when
supine and relieved with
leaning forward.
Associated with nausea,
vomiting, abdominal
distention and fever.

16. Biliary Colic and Acute Cholecystitis
Due to obstruction of the
cystic duct or common bile
duct by a gallstone.
Pain is epigastric or right
upper quadrant and may
radiate to the right scapula
or shoulder.
The pain is steady and
aching.
Biliary colic may start
suddenly and subside then
recur whereas cholecystitis
is more steady.
Associated with anorexia,
nausea, vomiting and
fever.

17. Classic Presentations – Acute Cholecystitis
Localized or diffuse RUQ pain
Radiation to right scapula
Vomitting and constipation
Low grade fever

18. Acute Diverticulitis colonic saclike mucosal
Inflammation of a
colonic saclike mucosal
Outpouching through the colonic
muscle.
Pain is in the left
lower quadrant.
The pain may begin
as cramps then
become steady.
It is associate with
fever, constipation and
sometimes, brief diarrhea.

19. Acute Appendicitis Acute distention or obstruction of the appendix.
Pain often begins as poorly
localized periumbilical pain followed by right lower quadrant pain.
Becomes more steady and
severe with time.
Pain is worse with
movement or cough.
Pain is associated with
anorexia, nausea, and
possibly vomiting which
typically follow the onset of
pain.

20. Classic Presentations - Acute Appendicitis
Diffuse periumbilical pain and anorexia early
Pain localizes to RLQ as peritonitis develops
Low grade fever, nausea and vomitting may not be present
Xrays and other tests are often negative

21. Psoas Sign This is a test for appendicitis.
Place your hand above the patient's right knee.
Ask the patient to flex the right hip against resistance.
Increased abdominal pain indicates a positive psoas sign.

22. Obturator Sign This is a test for appendicitis.
Raise the patient's right leg with the knee flexed.
Rotate the leg internally at the hip.
Increased abdominal pain indicates a positive obturator sign

23. Rovsing's Sign
Tenderness felt in the RLQ when palpation is performed on the left is called Rovsing’s sign and suggests appendicitis.

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

25. Inflammatory Bowel Disease Ulcerative Colitis
Inflammation of colon
Soft bloody stools
Insidious onset
Associated with crampy lower or
generalized abdominal pain, anorexia,
weakness and fever
Often begins in young people

26. Inflammatory Bowel Disease Crohn’s Disease
Chronic inflammation of the bowel wall,
typically involving the terminal ileum and/or
proximal colon
Stools loose but not as bloody
Insidious onset
Associated with crampy periumbilical or right
lower quadrant pain with anorexia, low fever
and/or weight loss.
Perianal or perirectal abcesses and fistulas
common
May begin in youth or later.

27. Physical Examination Pelvic Genital Rectal exam on every patient
with severe abdominal pain

28. Laboratory Evaluation
CBC, Urine Analysis, Electrolytes
Urine and serum pregnancy test in all women of reproductive age with lower abdominal pain
Liver Function Tests , amylase/lipase on all with upper abdominal pain

29. Radiographic Evaluation
Plain radiograph
upright and supine abdomen and chest x-ray
Ultrasound on patients with biliary and pelvic symptoms
CT Abdomen and Pelvis
evaluates vasculature, inflammation and solid organs

30. The differential diagnosis
Acute Cholecystitis
cystic duct obstructed, RUQ pain ? R scapula
LFTS, amylase
Acute Appendicitis
anorexia, N/V and vague periumbilical pain
6-8 hrs pain migrates to RLQ, fever
Progresses to localized peritoneal irritation
CT useful in diagnosis

31. The differential Pancreatits Acute Diverticulitis
most commonly in sigmoid colon
symptoms related to inflammation or obstruction
CT useful early to r/o absess, Endoscopy contraindicated ? wait 4-6 wks
Rx bowel rest, IV abx, surgery for failures

32. appendicitis, cholecystitis, pyelonephritis,
Pregnancy
appendicitis, cholecystitis, pyelonephritis,
adnexal problems (ovarian torsion, ovarian cyst rupture)
appendicitis 7/1000 pregnancies
3% fetal loss with surgery, but 20% with perforated appendix

33. Summary Obtain detailed history Careful exam
Consider patient circumstances (diabetes, age, previous ab surgery)
Early thorough work-up (labs/x-rays)
Frequent evaluation of progression

34. Rebound Tenderness This is a test for peritoneal irritation.
Warn the patient what you are about to do.
Press deeply on the abdomen with your hand.
After a moment, quickly release pressure.
If it hurts more when you release, the patient has rebound tenderness

35. Psoas Sign This is a test for appendicitis.
Place your hand above the patient's right knee.
Ask the patient to flex the right hip against resistance.
Increased abdominal pain indicates a positive psoas sign.

36. Obturator Sign This is a test for appendicitis.
Raise the patient's right leg with the knee flexed.
Rotate the leg internally at the hip.
Increased abdominal pain indicates a positive obturator sign

37. Rovsing's Sign
Tenderness felt in the RLQ when palpation is performed on the left is called Rovsing’s sign and suggests appendicitis.