1. Acute abdomen first aid
高醫外傷科
林杏麟

2. 外科? 內科?
The critical distinction, then, is not between acute and nonacute pain, but between surgical and nonsurgical conditions.

3. 外科
serious condition : arises suddenly and is continuous, progressively worse, and long lasting, begins during inactivity; and is not near the umbilicus

4. Gastrointestinal Tract
Appendicitis, acute* Meckel's diverticulitis* Perforated bowel* Perforated peptic ulcer* Small and large bowel obstruction* Strangulated hernia* Diverticulitis Gastritis Gastroenteritis Inflammatory bowel disease Mesenteric lymphadenitis

5. Liver, Spleen, and Biliary Tract
Cholangitis, acute* Cholecystitis, acute* Hepatic abscess* Ruptured hepatic tumor* Ruptured spleen* Biliary colic Hepatitis, acute Splenic infarct

6. Peritoneum
Intra-abdominal abscess* Primary peritonitis Tuberculous peritonitis

7. Pancreas
Pancreatitis, acute

8. Urinary Tract
Cystitis, acute Pyelonephritis, acute Renal infarct Ureteral or renal colic

9. Female Reproductive System
Ruptured ectopic pregnancy* Ruptured ovarian follicular cyst* Twisted ovarian tumor* Dysmenorrhea Endometriosis Salpingitis, acute

10. Vascular System
Ischemic colitis, acute* Mesenteric thrombosis* Ruptured arterial aneurysm

11. Retroperitoneum
Retroperitoneal hemorrhage

12. Miscellaneous
Precompetition anxiety Trauma

13. Appendicitis, acute
Constant pain, progressively more severe; begins in periumbilical region, moves to right lower quadrant; nausea, vomiting, and anorexia follow pain; low-grade fever; patient appears ill

14. Cholecystitis, acute
Constant pain in right upper quadrant, onset often postprandial; nausea and vomiting; tenderness in right upper quadrant and right shoulder; splinting on right side

15. Perforated peptic ulcer
Sudden onset of pain in midepigastrium that spreads and is aggravated by movement; patient appears acutely ill and is reluctant to move; rigid abdomen; grunting respiration; bowel sounds absent

16. Ectopic pregnancy
Pain sudden, severe, and persistent, generally following a missed or abnormal period, typically epigastric; often associated with hypotension and tachycardia

17. Ovarian cyst
Pain constant with sharp, sudden onset; usually in ipsilateral hypogastrium; may have nausea and vomiting following the pain

18. Pelvic inflammatory disease
Pain at end of or shortly after normal menstrual period; bilateral lower quadrant pain aggravated by cervical manipulation; anorexia, nausea, and vomiting rare; possible cervical discharge; fever

19. Urinary calculus
Pain location changes with movement of stone, may radiate to testicle, groin of involved side; pain very severe; patient cannot get comfortable

20. History and PE

21. Mode of onset, progression, character, and severity of pain
surgical etiology: sudden in onset, severe or explosive, progressive, continuous, and lasts more than 6 hours generally.
nonsurgical diagnosis: gradual in onset, mild to moderate in intensity, intermittent, recurrent, or resolves partially or completely in less than 6 hours.

22. Colic pain
Pain arising in a hollow, tubular structure, such as the ureter, intestine, biliary radicles, or fallopian tubes, may be continuous or intermittent

23. Activity during which pain was first noted
Surgical etiology: awakens the patient or begins during relative inactivity
Nonsurgical diagnosis: during or closely following strenuous activity--or after eating

24. Initial location of pain
the farther from the umbilicus the pain localizes, the greater the chance that a surgical condition exists.
Epigastrium: foregut derivatives (stomach, duodenum, biliary tract, and pancreas) or the spleen presents.
periumbilical area: midgut derivatives (jejunum, ileum, proximal third of the colon, and appendix).
Hypogastrium: embryonic hindgut (distal two-thirds of the colon), internal reproductive organs (ovaries, fallopian tubes, uterus, seminal vesicles, and prostate), and the urinary bladder.

25. Shifting pain
When the original inflammation extends to the parietal peritoneum.
Appendicitis initially causes pain in the periumbilical area. Then, after 4 to 6 hours, the inflammation extends to the regional peritoneal surface and is perceived in the right lower quadrant.

26. Associated symptoms
In surgical conditions, pain may be followed by nausea, vomiting, and anorexia.
In nonsurgical conditions nausea, vomiting, and anorexia typically precede pain.
Clinical experience: vomiting in the obese patient is an ominous symptom and suggests serious abnormalities.

27. Fever is a common finding in patients who have abdominal pain.
However, fever and chills is rarely seen in surgical processes. This combination suggests infection in the urinary tract, respiratory system, etc.

28. Obstipation--nonpassage of both stool and gas--however, always suggests a surgical problem.
Diarrhea, especially with cramps, indicates gastroenteritis and other nonsurgical conditions like inflammatory bowel disease.

29. What aggravates the pain
Always ask first about which activities aggravate the pain. (One can generally assume that the opposite will ease the pain.)
If the patient hears questions about what eases the pain, he or she may perceive it as minimizing the problem and become defensive.
Coughing, sneezing, rapid movements, and walking, especially down stairs, can cause peritoneal irritation. Musculoskeletal pain is often relieved by changing position. A bowel movement often eases the pain of gastroenteritis, but the pain may promptly recur.

30. Men who do experience abdominal pain have a higher incidence of surgical disease.

31. Medications and supplements
Aspirin and other nonsteroidal anti-inflammatory drugs, erythromycin, potassium, and salt tablets commonly cause gastric irritation and abdominal pain.

32. nonsurgical diagnosis
Previous episodes, family history of similar problems, peers with the same symptoms, food intolerance, allergies, sudden changes in training or diet, and travel to regions with endemic disease.

33. Physical Exam Pointers
vital signs, inspection, auscultation, light touch, palpation, percussion, and rectovaginal exam

34. keys to the physical exam
tell the patient
Auscultation should precede other modalities
farthest from the site of maximal pain
ask the patient questions and have him or her answer during palpation
rebound tenderness
Any pain elicited in the obese patient is significant