RMO Training – Acute Abdomen

July 19, 2018

James Roring, M.D.

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Outline

Outline

• Types of abdominal pain

• History and physical examination

• Labs and imaging

• Clinical pearls

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Types of Abdominal Pain

Types of Abdominal Pain

Visceral
–Involves hollow or solid organs; midline pain due to bilateral innvervation
–Steady ache or vague discomfort to excruciating or colicky pain
–Poorly localized: Sensitive to stretch, distension, or excessive contraction against resistance. Insensitive to touch
–Epigastric region: stomach, duodenum, biliary tract
–Periumbilical: small bowel, appendix, cecum
–Suprapubic: colon, sigmoid, GU tract
Parietal
–Involves parietal peritoneum
–Localized pain
–Causes tenderness and guarding which progress to rigidity and rebound as peritonitis develops
Referred
–Produces symptoms not signs
–Based on developmental embryology
•Ureteral obstruction → testicular pain
•Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain
•Gynecologic pathology → back or proximal lower extremity
•Biliary disease → right infrascapular pain
•MI → epigastric, neck, jaw or upper extremity pain

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Outline

Outline

• Types of pain

• History and physical examination

• Labs and imaging

• Clinical pearls

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History and Physical

History and Physical

• O = Onset Review of Systems

• L = Location
• D = Duration  GI symptoms
• C = Characteristics of pain Nausea, vomiting, hematemesis, anorexia, diarrhea,
• A = Alleviating/aggravating factors
• R = Relieving factors/Radiations?
constipation, bloody stools, melena stools
• T = Timing  GU symptoms
• S = Severity
Dysuria, frequency, urgency, hematuria,
• O = Onset and Duration incontinence
• P = Provoking and alleviating
factors  Gyn symptoms
• Q = Quality of pain (sharp, dull, Vaginal discharge, vaginal bleeding
throbbing)
• R = Radiation?  General
• S = Severity of pain (1-10)
• T = Timing and progression
Fever, lightheadedness
(constant, intermittent)
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History and Physical

History and Physical

Medical History
 GI
 Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD
 GU
 Past surgeries, h/o kidney stones, pyelonephritis, UTI
 Gyn
 Last menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological
surgeries, pregnancies
 Vascular
 h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA
 Other medical history
 DM, organ transplant, HIV/AIDS, cancer
 Social
 Tobacco, drugs – Especially cocaine, alcohol
 Medications
 NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin

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History and Physical

History and Physical

Physical Exam
 General
 Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bed
 Vital Signs
 Orthostatic VS when volume depletion is suspected
 Cardiac
 Arrhythmias
 Lungs
 Pneumonia
 Abdomen
 Look for distention, scars, masses
 Auscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise not very helpful
 Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity
 Percuss for tympany
 Look for hernias!
 rectal exam
 Back
 CVA tenderness
 Pelvic exam
 CMT
 Vaginal discharge – Culture
 Adenexal mass or fullness

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History and Physical

History and Physical

Focused Abdominal Exam
 Guarding
 Voluntary
 Contraction of abdominal musculature in anticipation of palpation
 Diminish by having patient flex knees
 Involuntary
 Reflex spasm of abdominal muscles
 aka: rigidity
 Suggests peritoneal irritation
 Rebound
 Present in 1 of 4 patients without peritonitis
 Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is
suggestive of peritonitis
 Rovsing’s sign in appendicitis
 Rectal exam
 Little evidence that tenderness adds any useful information beyond abdominal examination
 Gross blood or melena indicates a GIB
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History and Physical

Differential Diagnosis

It’s Huge!
 Use history and physical exam to narrow it down
 Rule out life-threatening pathology
 Half the time you will send the patient home with a diagnosis of nonspecific abdominal pain (NSAP or
Abdominal Pain – NOS)
 90% will be better or asymptomatic at 2-3 weeks

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History and Physical

Differential Diagnosis
Gastritis, ileitis, colitis, esophagitis Hemilith infestation
Ulcers: gastric, peptic, esophageal Porphyrias
Biliary disease: cholelithiasis, cholecystitis ACS
Hepatitis, pancreatitis, Cholangitis Pneumonia
Splenic infarct, Splenic rupture Abdominal wall syndromes: muscle strain, hematomas,
Pancreatic psuedocyst trauma,
Neuropathic causes: radicular pain
Hollow viscous perforation
Non-specific abdominal pain
Bowel obstruction, volvulus
Group A beta-hemolytic streptococcal pharyngitis
Diverticulitis Rocky Mountain Spotted Fever
Appendicitis Toxic Shock Syndrome
Ovarian cyst Black widow envenomation
Ovarian torsion Drugs: cocaine induced-ischemia, erythromycin, tetracyclines,
Hernias: incarcerated, strangulated NSAIDs
Kidney stones Mercury salts
Pyelonephritis Acute inorganic lead poisoning
Hydronephrosis Electrical injury
Inflammatory bowel disease: crohns, UC Opioid withdrawal
Gastroenteritis, enterocolitis Mushroom toxicity
pseudomembranous colitis, ischemia colitis AGA: DKA, AKA
Tumors: carcinomas, lipomas Adrenal crisis
Meckels diverticulum Thyroid storm
Testicular torsion Hypo- and hypercalcemia
Epididymitis, prostatitis, orchitis, cystitis Sickle cell crisis
Constipation Vasculitis
Abdominal aortic aneurysm, ruptures aneurysm Irritable bowel syndrome
Aortic dissection Ectopic pregnancy
PID
Mesenteric ischemia
Urinary retention
Organomegaly
Ileus, Ogilvie syndrome
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History and Physical

Differential Diagnosis

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History and Physical

Differential Diagnosis
Most Common Causes in Abdominal Pain in the UGD

 Non-specific abd pain 34%

 Appendicitis 28%
 Biliary tract dz 10%
 SBO 4%
 Gyn disease 4%
 Pancreatitis 3%
 Renal colic 3%
 Perforated ulcer 3%
 Cancer 2%
 Diverticular dz 2%
 Other 6%
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History and Physical

Differential Diagnosis
Most Common Causes in Abdominal Pain in the UGD

 Non-specific abd pain 34%

 Appendicitis 28%
 Biliary tract dz 10%
 SBO 4%
 Gyn disease 4%
 Pancreatitis 3%
 Renal colic 3%
 Perforated ulcer 3%
 Cancer 2%
 Diverticular dz 2%
 Other 6%
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Outline

Outline

• Types of abdominal pain

• History and physical examination

• Labs and imaging

• Clinical pearls

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Labs and imaging

Labs and Imaging

Imaging
 Abdominal series Laboratory
 3 views: upright chest, flat view of abdomen,  CBC
upright view of abdomen
 Limited utility: restrict use to patients with  Chemistries
suspected obstruction or free air  Liver function tests, Lipase
 Ultrasound
 Coagulation studies
 Good for diagnosing AAA but not ruptured
AAA  Urinalysis, urine culture
 Good for pelvic pathology  GC/Chlamydia swabs
 CT abdomen/pelvis
 Lactate
 Noncontrast for free air, renal colic, ruptured
AAA, (bowel obstruction)
 Contrast study for abscess, infection,
inflammation, unknown cause
 MRI
 Most often used when unable to obtain CT
due to contrast issue

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Outline

Outline

• Types of abdominal pain

• History and physical examination

• Labs and imaging

• Clinical pearls

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Clinical Perils

Clinical Perils
 Significant abdominal tenderness should never be attributed to gastroenteritis
 Incidence of gastroenteritis in the elderly is very low
 In older patients with renal colic symptoms, exclude AAA
 Severe pain should be taken as an indicator of serious disease
 Pain awakening the patient from sleep should always be considered significant
 Sudden, severe pain suggests serious disease
 Pain almost always precedes vomiting in surgical causes; converse is true for
most gastroenteritis and NSAP
 Acute cholecystitis is the most common surgical emergency in the elderly
 A lack of free air on a chest x-ray does NOT rule out perforation
 Signs and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia have
significant overlap
 If the pain of biliary colic lasts more than 6 hours, suspect early cholecystitis

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