Diagnosis and Management of Diagnosis and Management of Acute Abdominal PainAcute Abdominal Pain

Dimitri Raptis and Alec EngledowDimitri Raptis and Alec Engledow

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Definition1

• Acute abdominal pain (AAP):– Presentation of previously undiagnosed

abdominal pain– Lasting 1/52 or < – Prior to a clinical encounter in 10 or 20 care

1De Dombal FT. Diagnosis of acute abdominal pain. New York: Churchill Livingstone; 1991.

Introduction• > 1000 causes exist2

– NSAP (34%)– Acute appendicitis (28%)– Acute chlecystitis (10%) – SBO (4%)– Perforated PU (3%)– Pancreatitis (3%)– Diverticular disease (2%) – Others (13%)

• 20-40% admission rates• 50-65% inaccurate initial diagnosis

2De Dombal FT, Margulies M. Acute abdominal pain. Surgery1996;

Pathophysiology• Visceral pain

– Distention, inflammation or ischaemia in hollow viscous & solid organs

– Localisation depends on the embryologic origin of the organ:

• Forgut to epigastrium• Midgut to umbilicus• Hindgut to the hypogastric

region• Parietal pain

– is localised to the dermatome above the site of the stimulus.

• Referred pain – produces symptoms, not signs

e.g. tenderness

Generalized AP• Perforation

• AAA

• Acute pancreatitis

• DM

• Bilateral pleurisy

Central AP• Early appendicitis

• SBO

• Acute gastritis

• Acute pancreatitis

• Ruptured AAA

• Mesenteric thrombosis

Epigastric pain• DU / GU

• Oesophagitis

• Acute pancreatitis

• AAA

RUQ pain• Gallbladder disease

• DU

• Acute pancreatitis

• Pneumonia

• Subphrenic abscess

LUQ pain• GU• Pneumonia• Acute pancreatitis • Spontaneous splenic

rupture• Acute perinephritis• Subphrenic abscess

Suprapubic pain• Acute urinary retention• UTIs • Cystitis • PID• Ectopic pregnancy • Diverticulitis

RIF pain• Acute appendicitis• Mesenteric adenitis (young)• Perf DU• Diverticulitis • PID• Salpingitis• Ureteric colic • Meckel’s diverticulum • Ectopic pregnancy • Crohn’s disease• Biliary colic (low-lying gall

bladder)

Loin pain• Muscle strain• UTIs• Renal stones• Pyelonephritis

LIF pain• Diverticulitis• Constipation• IBS• PID• Rectal Ca• UC• Ectopic pregnancy

Limitations

• Limitations based on the relationship between – Overlying tenderness – Underlying surgical disease

• 35% of intra-operative diagnoses are considered to have had atypical presentations3

3Staniland, JR, Br Med J 3:393, 1972

Key points on history

• Site• Nature & character • Duration• Intensity • Precipitating & relieving factors• Associated symptoms

Classification by nature

• Colicky pain– Baseline of no pain in true colic– IBS– Bowel obstruction

Nagging & Grumbling

• Biliary colic

• Cholecystitis

• PID

• UTI

Stabbing

• AAA

Burning or boring

• PUD

• Oesophagitis

Gnawing

• Pancreatitis

• Pancreatic Ca

Associated symptoms

• Fever

• Genitourinary

• Gynaecological

• Vascular

PMSH

• Previous episodes of AP

• Investigations

• Operations

• Chronic disease

• Immunosuppression

• Medications (NSAIDs)

Physical examination

• OBS are important

• Observation– Bending Forward: Chronic Pancreatitis– Jaundiced: CBD obstruction– Dehydrated: Peritonitis, Small Bowel

obstruction

Systemic Examination

Abdomen:• Inspection

- Scaphoid or flat in peptic ulcer- Distended in ascites or intestinal

obstruction- Visible peristalsis in a thin or malnourished

patient (with obstruction)

Systemic Examination

Palpation • Check for Hernia sites• Tenderness• Rebound tenderness• Guarding- involuntary spasm of muscles

during palpation• Rigidity- when abdominal muscles are tense

& board-like. Indicates peritonitis.

Systemic Examination

• Local Right Iliac Fossa tenderness:– Acute appendicitis– Acute Salpingitis in females

• Low grade, poorly localized tenderness:– Intestinal Obstruction

• Tenderness out of proportion to examination:– Mesenteric Ischemia– Acute Pancreatitis

• Flank Tenderness:– Perinephric Abscess– Retrocaecal Appendicitis

Important Signs in Patients with Abdominal Pain

Sign Finding Association

Cullen's sign Bluish periumbilicaldiscoloration

Retroperitoneal haemorrhage

Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture

McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side

Appendicitis

Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant

Acute cholecystitis

Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis

Obturator's sign Internal rotation of flexed right hip causingabdominal pain

Appendicitis

Grey-Turner's sign

Discoloration of the flank Retroperitoneal haemorrhage

Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table

Pelvic inflammatory disease

Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant

Appendicitis

Physical examination

• Auscultation – BS– > 2min to confirm absent – High pitched, hyperactive or tinkling– Bruit in epigastrium

Systemic Examination

PR Examination:

- tenderness

- induration

- mass

- frank blood

Systemic Examination

PV Examination

- Bleeding

- Discharge

- Cervical motion tenderness

- Adnexal masses or tenderness

- Uterine Size or Contour

Surgical Myths• Rebound tenderness, considered the clinical indicator

of peritonitis, has a high (25%) false -ve rate4 • Rigidity, referred tenderness & cough pain are

sufficient evidence for peritonitis5 • Except for detection of blood, routine PR exams add

little to clinical assessment6

• Administration of analgesics prior to surgical consultation does not obscure the diagnosis, but

improves accuracy7

4Liddington, MI and Thomson, WH, Br J :795, 19915Bennett, DH Br Med J 308:1336, 19946Manimaran, N et al. Ann Roy Col Surg Engl 86:292 20047Brewster, GS et al. 2000 West J Med 172:209

Initial management

• 1st 20 sec there are only 3 diagnoses: – Very ill:

• Going to die? • ask for help & resus

– ill: • stable for couple h? • Urgent investigations, initial diagnosis & management

– Reasonably well: • Investigate as appropriate • formulate diagnosis.

Initial management

• ABCDE

• Resuscitation & analgesia (opioid IV)

• Full monitoring (including UO)

• Low threshold in seeking senior help

Investigations

• FBC (Hb & WCC) • Amylase (Pancreatitis) • U&Es, LFTs • Clotting (acute pancreatitis, sepsis, DIC, liver disease) • Glucose (BM) • G&S (X-match if necessary) • ABG • ECG • Cardiac enzymes (if appropriate)

Investigations

• Attention to the WCC as a screening test only if substantially elevated. – 25% of patients with elevated WCC do not

have different outcomes from those with a normal WCC8

• FBC has a limited clinical utility

Investigations

• Urinalysis– Cheap– Simple & readily available test– High yield when results fit with the clinical

scenario – MSU

• Pregnancy test

Investigations

• Radiology– Erect CXR– Supine AXR– USS (?gynae pathology) – IVU (renal/ureteric colic)

Investigations

• Plain X-rays have limited utility in the evaluation of AAP – Low diagnostic yield– High incidence of misleading incidental

findings– Lack of impact on management – Exception: Bowel obstruction or perforation

CT scanning• No significant

advantage in DD of AAP

• Delay of necessary treatment

• Routine use not justified

• Hx taking & physical examination are the basis of correct diagnosis8

• Hx, physical examination & lab investigations are often non-specific

• CT is now 1st-line imaging modality in pts with APP.

• MDCT is now faster with thinner slices

• High diagnostic accuracy9

8Keeman JN, New diagnostic imaging technology offten offers no advantage in the differential diagnosis of acute abdomen. Ned Tijdschr Geneeskd. 1999. Nov. 6:143(45):2225-9

9Leschka et al,Multi-detector computer tomography of acute abdomen. Eur Radiol. Dec;15(12):2435-47. 2005

Laparoscopy10,11 • Early diagnostic laparoscopy may result in:

– accurate, – prompt, – efficient management of AAP

• Reduces the rate of unnecessary laparotomy • Increases the diagnostic accuracy• May be a key to solving the diagnostic

dilemma of NSAP.

10Golash and Willson. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1320 patients. Surg Endosc. 2005 Jul;19(7):882-511Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5

Suggestions

• Audit of all patients referred with AAP to assess: – Initial diagnosis – Choice & diagnostic efficacy of

investigations– Treatment– Timing (length of stay) – Cost effectiveness

Thank you