Approach to the patient with acute abdominal pain

Asisst. Prof. Dr.Özlem Tanrıöver Yeditepe University Medical FacultyDepartment of Family Medicine

Abdominal Anatomy

Four quadrants: – Right Upper Quadrant – Right Lower Quadrant – Left Upper Quadrant – Left Lower Quadrant

Three central areas: – Epigastric – Periumbilical – Suprapubic

Abdominal Anatomy

Right upper quadrant Liver, Head of Pancreas,

Kidney and Lung Right lower quadrant

Appendix, Ureter, Bladder, Colon, Gonads

Left upper quadrantHeart, Spleen, Body of

pancreas, Kidney, Stomach, Lung

Left lower quadrantUreter, bladder, colon, gonads

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.

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

Key Historical Points - Bowel and Bladder

Nausea, Vomitting, Diarrhea, Constipation Frank Blood, "Coffee Grounds" Emesis,

Black Stools Urinary Frequency, Urgency, Discomfort

Key Historical Points - Reproductive

Sexual Activity, Contraception, Last Menstrual Period

Always Consider Pregnancy in Reproductive Age Women

Have a Low Threshold for Pregnancy Testing

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

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?

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?

Abdominal Pain

Location Other symptoms Character Factors that aggravate or alleviate Timing Environment Severity

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

Peptic Ulcer Disease or Dispepsia

Ulcer begins in liningof stomach or duodenum. Helicobacter pyloriinfection is often present. Dyspepsia morecommon ages 20- 29,gastric ulcer in thoseover 50 and duodenalulcer ages 30 – 60.

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.

Pancreatitis

Inflammation of thepancreatic tissue oftendue to gallstones oralcohol abuse. Pain is epigastric andmay radiate to the back. Pain onset is acute andpain is steady. Pain may be worse whensupine and relieved withleaning forward. Associated with nausea,vomiting, abdominaldistention and fever.

Biliary Colic and Acute Cholecystitis

Due to obstruction of thecystic duct or common bileduct by a gallstone. Pain is epigastric or rightupper quadrant and mayradiate to the right scapulaor shoulder. The pain is steady andaching. Biliary colic may startsuddenly and subside thenrecur whereas cholecystitisis more steady. Associated with anorexia,nausea, vomiting andfever.

Classic Presentations – Acute Cholecystitis

Localized or diffuse RUQ pain

Radiation to right scapula

Vomitting and constipation

Low grade fever

Acute Diverticulitis

Inflammation of acolonic saclike mucosalOutpouching through the colonicmuscle. Pain is in the leftlower quadrant. The pain may beginas cramps thenbecome steady. It is associate withfever, constipation andsometimes, brief diarrhea.

Acute Appendicitis

Acute distention orobstruction of the appendix. Pain often begins as poorly localized periumbilical pain

followed by right lower quadrant pain.

Becomes more steady andsevere with time. Pain is worse withmovement or cough. Pain is associated withanorexia, nausea, andpossibly vomiting whichtypically follow the onset ofpain.

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

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.

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

Rovsing's Sign

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

Classic Presentations - Acute Renal Colic

Severe flank pain Radiation to groin Vomitting and urinary

symptoms Blood in the urine

Inflammatory Bowel DiseaseUlcerative 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

Inflammatory Bowel DiseaseCrohn’s Disease

Chronic inflammation of the bowel wall,typically involving the terminal ileum and/orproximal colon Stools loose but not as bloody Insidious onset Associated with crampy periumbilical or rightlower quadrant pain with anorexia, low feverand/or weight loss. Perianal or perirectal abcesses and fistulascommon May begin in youth or later.

Physical Examination

Pelvic Genital Rectal exam on every patient with severe abdominal pain

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

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

The differentialdiagnosis

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

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

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

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

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

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.

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

Rovsing's Sign

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