1. ACUTE ABDOMINAL PAIN Victor Politi, M.D., FACP
Medical Director, SVCMC School of Allied Health, Physician Assistant Program

2. Abdominal Pain Most common cause of hospital admission in the US
Accounts for 5-10% of all ED visits
In 35-40% of all hospital admissions due to abdominal pain - the pain is nonspecific

4. Epidemiology
Gastroenteritis is the most common cause of abdominal pain not requiring surgery
In patients age 60 and older, biliary disease and intestinal obstruction are the most common cause of acute abdominal pain that is surgically correctable

5. Epidemiology
Appendicitis is the most common cause of abdominal pain requiring surgery in patients < age 60
Appendicitis is the leading cause of acute abdominal pain in children
accounts for 32% of children admitted w/acute abdominal pain

6. Patient History
The term “acute abdomen” implies the sudden onset of abdominal pain for which a surgically correctable cause is likely

7. Patient History
Besides the age of the patient - key elements of the patient history include:
Time of pain onset
Location/character of pain
Pattern of pain radiation
Associated symptoms

8. Key Points in History Reproductive Bowel and Bladder
Sexual Activity, Contraception, Last Menstrual Period
Always Consider Pregnancy in Reproductive Age Women
Have a Low Threshold for Pregnancy Testing
Bowel and Bladder
Nausea, Vomiting, Diarrhea, Constipation
Frank Blood, "Coffee Grounds" Emesis, Black Stools
Urinary Frequency, Urgency, Discomfort

9. AGE Age of patient - crucial
Differential diagnosis of abdominal pain in children - differs from dx in elderly patient
Common conditions that cause abdominal pain in most age groups
acute appendicitis, intestinal obstruction, incarcerated hernias

10. AGE
Intussusception is most likely the cause of intestinal obstruction in children
Adhesions are most likely the cause of intestinal obstruction in adults
In older patients, pain from a MI can be referred to the upper abdomen

11. Time of Onset
Pain sudden in onset, awakens a patient from sleep - suggests a viscus
Knowing the timing of associated nausea and vomiting is essential to narrow the diagnostic possibilities
Pain precedes vomiting when abdominal pain is from surgically correctable causes, whereas the reverse is true for medical conditions such as gastroenteritis

12. Location
Abdomen divided into 4 quadrants, which are further divided (with some overlap) into the epigastric, periumbilical, and suprapubic regions

13. Location of Abdominal Pain
Four quadrants:
Right Upper Quadrant
Right Lower Quadrant
Left Upper Quadrant
Left Lower Quadrant
Three central areas:
Epigastric
Periumbilical
Suprapubic
Location of Abdominal Pain

14. Location
RUQ pain -
duodenal ulcers, acute pancreatitis, acute cholecystitis, and acute hepatitis
LUQ pain -
gastritis, gastric ulcer, acute pancreatitis, and splenic infarct or rupture
RLQ pain -
acute appendicitis,
LLQ pain -
diverticulitis
GYN and urologic causes of acute abdominal pain can also present with lower quadrant abdominal pain

15. Radiation of Abdominal Pain
Perforated Ulcer
Biliary Colic
Renal Colic
Dysmenorrhea/Labor
Renal Colic (Groin)

16. Character Implies all the features of the pain
Usually can be determined by asking the patient to describe the quality of the pain
Most often described as
sharp or dull
cramping (colicky)

17. Character
Colicky pain - rhythmic pain resulting from intermittent spasms - most commonly associated with
biliary disease, nephrolithiasis, intestinal obstruction
Pain that begins as dull, poorly localized ache and progresses to a constant, well localized sharp pain indicates a surgically correctable cause

18. Physical Examination of the Abdomen
Inspection
Auscultation
Percussion
Palpation

19. Inspection General observation
Look at abdominal contour, note location of any scars, rashes or lesions

20. Inspection
Patient writhing in agony - likely has colicky abdominal pain caused by ureteral lithiasis
Patient lying very still - more likely to have peritonitis
Patient leaning forward to relieve pain - may have pancreatitis

21. Inspection
The abdominal wall is a commonly overlooked source of abdominal pain
Other parts of the body should also be inspected. For example, the eyes should be inspected for evidence of scleral icterus which may indicate hepatobiliary disease

22. Auscultation Useful in assessing peristalsis
Bowel sounds are widely transmitted through the abdomen - therefore, it is not necessary to listen in all 4 quadrants
Auscultation should last at least 1 minute
Bowel sounds typically highly pitched so the diaphragm of the stethoscope should be used

23. Auscultation ? Bowel sounds- normal/hyperactive/hypoactive
Auscultation should precede percussion and palpation
? Abdominal bruits -
listen over aortic,iliac and renal arteries

24. Auscultation
Hypoactive bowel sounds - associated with ileus, intestinal obstruction, peritonitis
Intestinal obstruction can produce hyperactive bowel sounds which are high pitched tinkling sounds occurring at brief intervals; very audible

25. Percussion
Technique - performed by firmly pressing the index finger of one hand on the abdominal wall while striking the abdominal wall with the other index finger
Percussion note can be described as dull, resonant, or hyperresonant

26. Percussion Dull/resonant or hyperresonant
Tympany normally present in supine position
? Unusual dullness
? Clue to underlying abdominal mass

27. Percussion Gastric region - Liver -
percussion over the gastric region will generate a hyperresonant note because of usual presence of a gastric air bubble
Liver -
percussion over the liver will generate a dull note
A normal liver span is 6 to 12 cm in the midclavicular line

28. Percussion
Generalized percussion is a useful method for detecting the presence of ascites or intestinal obstruction in a distended abdomen
In ascites - a dull percussion note would be generalized
In intestinal obstruction - a hyperresonant note would be heard

29. Percussion
If ascites is suspected, then a test for shifting dullness can be performed
Ascites typically sinks with gravity, percussion of the flanks generates a dull note and percussion of the periumbilical region generates a resonant note in the supine patient

30. Percussion
The test for shifting dullness involves having the patient shift to a lateral decubitus position and then performing percussion again; the area of resonance should shift upward

31. Shifting Dullness
If dullness on percussion shifts when the patient is rolled on the side, peritoneal fluid (ascites) may be present.

32. Percussion Splenic Enlargement
A change from tympany to dullness suggests splenic enlargement

33. Palpation
Before palpating the abdomen the examiner should ask the patient to point directly to the area that hurts most and avoid palpating that area until absolutely necessary
May be difficult in patient who has guarding (voluntary or involuntary)

34. Palpation Voluntary guarding - conscious elimination of muscle spasms
Involuntary guarding - reported when the spasm response cannot be eliminated, which usually indicates diffuse peritonits

35. Palpation Where is pain ? Begin with light palpation
Guarding - voluntary/involuntary
Rebound tenderness

36. Palpation
Rebound tenderness is elicited by pressing on the abdominal wall deeply with the fingers and then suddenly releasing the pressure
Pain on the abrupt release of steady pressure indicates the presence of peritonitis
Asking the patient to cough is another method of eliciting signs of peritonitis

37. Rebound Tenderness
This is a test for peritoneal irritation. Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness

38. Deep Palpation
? Areas of deep tenderness/masses

39. Liver Palpation

40. Palpation of Aorta Easily palpable on most
Pulsate with deep palpation of central abdomen
Enlarge aorta -
? Sign of aortic aneurysm

41. Palpation of Spleen
Not normally palpable

42. Costovertebral Angle Tenderness
CVA tenderness is often associated with renal disease. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles

43. Specific Disorders
Upper abdominal pain - common causes of acute abdominal pain in the upper abdomen include: acute cholecystitis, acute pancreatitis, perforated ulcers
Pain usually overlaps the left and right upper quadrants

44. Classic Presentations - Acute Cholecystitis
Localized or diffuse RUQ pain
Radiation to right scapula
Vomiting and constipation
Low grade fever

45. Cholecystitis
Murphy’s sign (have patient take a deep breath while right subcostal area is palpated) abrupt cessation of inspiration secondary to pain is considered a positive Murphy’s sign
Disease of adulthood
More common in women
Bacteria invasion can develop into ascending cholangitis
Charcot’s triad
Right upper quadrant pain
Fever
Jaundice

46. Acute pancreatitis
Retroperitoneal dissection of blood can result in bluish discoloration of the flanks (Turner’s sign) or of the periumbilical region (Cullen’s sign)
Biliary pancreatitis secondary to cholelithiasis is most common women > age 50 in community hospital setting
Alcoholic pancreatitis is most common in men ages years in urban hospital setting
Symptoms-epigastric pain,nausea,vomiting,pain is constant & boring in nature
Bowel sounds decrease - lack of rigidity or rebound tenderness

47. Perforated Peptic Ulcer
Sudden onset - severe epigastric pain
Pain becomes generalized after a few hours to involve the entire abdomen
Perioperative mortality rate of 23%
Patient usually lying quietly and breathing shallow.
Abdomen rigid,board-like, guarding - maximal at site of perforation
Upright chest x-ray - detection of free intraperitoneal air

49. Specific Disorders
Midabdominal pain - common causes of midabdominal pain include
intestinal obstruction, mesenteric ischemia and early appendicitis
dissecting aortic aneurysm
myocardial infarction

50. Intestinal Obstruction
Mechanical - results from
gallstones, adhesions, hernias, volvulus, intussuseption, tumors
Non-mechanical- results from
intestinal infarction or occurs after surgery as a paralytic ileus, pain medication

51. Intestinal Obstruction
Obstruction high in small intestine
results in severe abdominal pain in epigastric or umbilical region with bilious vomiting, distention of abdomen not an early feature
Obstruction located lower in small intestine
results in less severe pain
Vomiting late feature and may be feculent

52. Intestinal Obstruction
Differential Diagnosis of obstruction of small intestine
strangulated hernia
volvulus
mesenteric thrombus
gallstone ileus
Abdominal x-ray of distal obstruction of small intestine will show a dilated loop

53. Large Intestine Obstruction
Pain less severe than small intestine obstruction
Vomiting infrequent
Distention of abdomen - common
Main Causes of Large Intestine Obstruction
Ca of colon (change bowel habits, wt loss, rectal bleeding)
diverticulitis (fixed,tender, LLQ mass)
volvulus (sigmoid volvulus most common)

54. Mesenteric Ischemia
Presents with acute, diffuse, midabdominal pain, vomiting, decreased bowel sounds and distention resulting from intestinal obstruction
Abdominal pain is out of proportion to physical examination findings
Abdominal distention is a late sign indicative of gangrene - signs of peritoneal irritation also indicative of gangrene

55. Specific Disorders
Lower abdominal pain - common causes of lower abdominal pain include
Acute appendicitis (typically RLQ pain)
Sigmoid diverticulitis (typically LLQ pain)
Gynecologic causes
Urologic causes

56. Diverticulitis Lower Left Quadrant Pain Cramping sensation
Possible fever

57. Appendicitis Peak incidence in 2nd decade of life
Differential diagnosis is broad and errors in diagnosis are common
Diagnostic error rate
Men 23%
Women 42%

58. Appendicitis
Patients seen in first few hours - report poorly defined constant pain in periumbilical region
As disease progresses - pain shifts to RLQ in a region known as McBurney’s point (located 2/3 of the distance along a line drawn from the umbilicus to the right anterior superior iliac spine)

59. Appendicitis
Pain relieved somewhat when patient assumes a right lateral decubitus position with slight hip flexion
Abdominal tenderness - most likely physical finding
Voluntary guarding in RLQ is common

60. Appendicitis
Rovsing’s sign can be elicited by palpating deeply in the left iliac area and observing for referred pain in the right iliac fossa
When present, the psoas and obturator signs are also helpful in establishing a diagnosis of appendicitis

61. Appendicitis
Psoas sign - the psoas sign is pain elicited by extending the right hip while the patient is in the left lateral decubitus position -
alternatively, while in the supine position, the patient can lift the right thigh against the examiners hand, which is placed above the knee

62. Psoas Sign
The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk).

63. Appendicitis
Obturator sign - the obturator sign is pain elicited by flexing the patient’s right thigh at the hip with the knee flexed and then internally rotating the hip
Right sided rectal tenderness may also be elicited on rectal exam of patients with acute appendicitis

64. Obturator Sign
The obturator sign. Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur.

65. Classic Presentations - Acute Appendicitis
Diffuse periumbilical pain and anorexia early
Pain localizes to RLQ as peritonitis develops
Low grade fever, nausea and vomiting may not be present
Xrays and other tests are often negative
Remember that the position of the appendix is highly variable!

66. Other Causes of Abdominal Pain
Abdominal aortic aneurysm
abdominal pain/backache
hypotension
71% perioperative mortality rate
Physical exam of abdomen - detect pulsatile mass
unequal femoral pulses

67. Abdominal Aortic Aneurysm

68. Other Causes of Abdominal Pain
Nephrolithiasis
ureteral colic 4% of patients w/acute abdominal pain
Colicky pain - Upper lumbar region radiates laterally to inguinal region
Patient writhing in pain

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

70. Other Causes of Abdominal Pain
Cardiac Origin
Gastritis
GERD
Esophageal disease
Hiatal hernia
Liver abscess/subdiaphragmatic abscess
Pulmonary origin
Herpes Zoster
Hernia

71. Other Causes of Abdominal Pain
Gynecologic
Ovarian cyst
Ectopic pregnancy
PID

72. Gynecologic Causes
In the absence of a positive pregnancy test result -
fresh blood suggests a corpus luteum hemorrhage
old blood suggests a ruptured endometrioma (chocolate cyst)
purulent fluid suggests acute pelvic inflammatory disease (PID)
sebaceous fluid indicates a dermoid cyst.

73. Ectopic Pregnancy
Unruptured ectopic pregnancy - localized pain due to dilatation of the fallopian tube.
Ruptured ectopic - pain tends to be generalized due to peritoneal irritation
Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present
Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients

74. Ectopic Pregnancy
Abdominal examination findings include tenderness and guarding in the lower quadrants.
Once hemoperitoneum has occurred, distension, rebound tenderness, and sluggish bowel sounds may develop.

75. Corpus luteum hematoma
Slow leakage produces minimal pain
Frank hemorrhage can lead to hemoperitoneum and hypovolemic shock
Generalized abdominal pain and syncope are features of such a presentation.

76. Ruptured Ovarian Cyst
The most common causes are dermoid cyst, cystadenoma, and endometrioma
Blood loss is minimal, hypovolemia does not supervene
Peritoneal irritation due to leakage of cyst fluid can lead to significant tenderness, rebound tenderness, abdominal distension, and hypoperistalsis

77. Ovarian Torsion
Frequently - resolves spontaneously - only presenting symptom -lower abdominal pain
Persistent torsion leads to congestion, ovarian enlargement, thickening of the ovarian capsule, and subsequent infarction.
Pain becomes severe -accompanied by nausea, vomiting, and restlessness
Infarction also leads to fever and mild leukocytosis

78. PID
Acute salpingo-oophoritis is a polymicrobial infection that is transmitted sexually.
Neisseria gonorrhoeae and Chlamydia trachomatis are usually identified in patients with PID, and both organisms often coexist in the same patient.
Gonococcal disease tends to have a rapid onset, while chlamydial infection has a more insidious onset

79. Diagnostic Criteria for PID
Lower abdominal tenderness
Cervical motion tenderness
Adnexal tenderness
Diagnosis may also be supported by any of the following criteria:
Temperature greater than 101°F (38.3°C)
Abnormal cervical or vaginal discharge
Laboratory evidence of C trachomatis or N gonorrhoeae
Elevated erythrocyte sedimentation rate or elevated C- reactive protein value

80. Tubo-ovarian abscess
A ruptured abscess can lead to gram-negative endotoxic shock; therefore, this condition is a surgical emergency.
The most common presentation is bilateral, palpable, fixed, tender masses.
Patients often present with generalized abdominal pain and rebound tenderness caused by peritoneal inflammation

81. Fibroids
A pedunculated subserous fibroid may twist and undergo necrosis, causing acute abdominal pain
A pedunculated submucous fibroid may present with cramping pain and vaginal bleeding

82. Endometriosis
Pain associated with endometriosis may worsen premenstrually or during menses.
Patients experience generalized lower abdominal tenderness, and associated complaints include dysmenorrhea, dyschezia, and dyspareunia

83. Things to Remember Inguinal/rectal examination in males.
Pelvic/rectal examination in females.
Disorders in the chest will often manifest with abdominal symptoms.
It is always wise to examine the chest and cardiovascular system when evaluating an abdominal complaint
Consider mesenteric ischemia in diabetic patients and patients with vascular disease and vasculitis

84. Questions ???