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Ma and Mateer's Emergency Ultrasound, 4e

Chapter 10: Sonographic Approach to Acute Abdominal Pain

Timothy Jang; Eleanor Ross Oakley; O. John Ma

INTRODUCTION
The purpose of this chapter is to provide an overview of the ultrasound approach for the acute abdomen.
The discussion is organized by generalized pain versus localized pain and outlines conditions where point-
of-care ultrasound (POCUS) may be helpful. The reader is referred to specific chapters of the book for more
detailed discussion of these findings.

CLINICAL CONSIDERATIONS
Abdominal pain is a common presenting complaint in the acute care setting, comprising 5–10% of adult
visits.1–5 Patients presenting with acute, nontraumatic abdominal pain can pose a diagnostic challenge to
clinicians, as many causes are serious or immediately life threatening (Table 10-1). The most frequent
diagnoses for patients presenting to the emergency department (ED) with abdominal pain vary widely by
country but consistently show high rates of nonspecific abdominal pain, renal and biliary colic,
appendicitis, bowel obstruction, and diverticulitis.4,6,7 Older patients account for a higher percentage of
visits and have a higher mortality than younger patients.8–10 One study showed that 50–65% of adults over
the age of 65 years presenting with abdominal pain required hospitalization and nearly 20% required
surgery.11

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TABLE 10-1.
SERIOUS OR LIFE-THREATENING CAUSES OF ABDOMINAL PAIN

Abdominal aortic aneurysm

Appendicitis
Cholecystitis
Diverticulitis
Ectopic pregnancy
Mesenteric ischemia
Myocardial infarction
Perforated viscus
Placental abruption
Splenic rupture
Volvulus

Evaluation of acute, nontraumatic abdominal pain has evolved over the last 30 years.12 Before the ubiquity
of advanced imaging and rapid turnaround for laboratory tests, many patients were admitted to the
hospital for observation and serial examinations. In modern practice, there is a greater impetus to
determine a diagnosis and to obtain a definitive disposition.

The workup of abdominal pain typically begins with a careful history and physical examination, which
guides the clinician in choosing further lab tests or diagnostic imaging. Historically, clinicians have used
conventional radiography as an initial imaging modality; however, plain radiographs have limited utility
apart from revealing free air under the diaphragm or bowel gas patterns suggestive of bowel obstruction.
With the rare exception of revealing undisclosed radio-opaque foreign bodies, radiographs rarely provide
insight into etiology and may not add much value to clinical assessment.

In the last the last 30 years, sonography and computed tomography (CT) have become much more readily
available. CT is an excellent imaging modality to diagnose not only intraperitoneal pathology, but also
findings in the retroperitoneum. However, CT is relatively contraindicated in pregnant patients, children,
and younger adults due to ionizing radiation exposure. Other disadvantages include time, expense, and use
of nephrotoxic dye. Magnetic resonance imaging (MRI) is an alternative, but has limited availability and is
expensive, time intensive, and requires the patient to remain completely still for a prolonged period of
time.

In contrast, sonography does not expose patients to ionizing radiation and is noninvasive, readily available,
repeatable at the point of care, and less expensive. Studies have shown that POCUS by physicians in the ED
serves as an adjunct to the physical examination and may help to refine diagnostic testing and decision-
making in ED patients with nonspecific abdominal pain.7,13–15

Additional advantages of sonography include higher spatial resolution and dynamic real-time evaluation of
fetal movements, peristalsis, or blood flow. POCUS helps the clinician localize the area of pain, view the
underlying structures, and determine whether the pain is reproducible compared to other areas.

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Ultrasound o ers mobility and flexibility, and can be utilized in multiple clinical settings, particularly with
the development of newer handheld, battery-powered units. Sonography also o ers the advantage of real-
time, guided approach to sampling fluid pockets to distinguish between blood, ascites, pus, bile, chymic,
or stomach contents.

GETTING STARTED
As with any patient, begin the assessment of a patient presenting with abdominal pain with a rapid
determination of stability and initiation of resuscitative measures if indicated.

While these measures are undertaken, POCUS may be utilized to rapidly assess for free intraperitoneal fluid
with the same examination that is used in trauma patients, the focused assessment with sonography for
trauma (FAST) (Figure 10-1; see Chapter 9, “Trauma”). In a patient with nontraumatic abdominal pain,
sonographic evidence of free intraperitoneal fluid can indicate a benign condition, such as underlying
ascites, or reveal a life-threatening one, such as intraperitoneal hemorrhage from a ruptured abdominal
aortic aneurysm (AAA) or ectopic pregnancy. The clinical presentation will help di erentiate between
benign and serious conditions, and determine the urgency of subsequent workup and interventions. Rapid
detection of free intraperitoneal fluid is essential since intraperitoneal hemorrhage may be severe enough
to produce hypovolemic shock. While CT is the gold standard for detecting intraperitoneal hemorrhage and
retroperitoneal hematoma, it is not the initial modality of choice for hemodynamically unstable patients.
Sonography can be used to estimate not only the amount, but also the rate of intraperitoneal hemorrhage
through serial examinations, thus supplementing clinical findings in evaluating whether the hemorrhage is
active or not. At times it is challenging to di erentiate hemoperitoneum from ascites (see Figure 9-36) even
with a careful history and physical examination. If required, ultrasound-guided paracentesis can be applied
for the definitive diagnosis of hemoperitoneum (see Chapter 27, “Additional Ultrasound-Guided
Procedures”).

Figure 10-1.
Ultrasound transducer positions for the focused assessment with sonography for trauma (FAST)
examination.

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The etiology of intraperitoneal hemorrhage can also be evaluated with abdominal sonography. Common
causes of intraperitoneal hemorrhage are rupture of a hepatoma, AAA, splenic artery aneurysm, ectopic
pregnancy, or ovarian cyst. Abdominal sonography is an excellent screening tool for hepatoma and AAA.
Early recognition of these etiologies is beneficial in selecting further imaging tests and strategizing on
treatment options, such as immediate surgery or interventional radiology procedures. In young women
who present with hypotension and associated lower abdominal pain, consider rupture of an ectopic
pregnancy (Figure 10-2) or hemorrhagic ovarian cyst. Although transabdominal sonography may
demonstrate only nonspecific findings, massive hemorrhage warrants immediate surgical intervention.

Figure 10-2.
Ectopic pregnancy. Transverse probe placement. Ultrasound shows le adnexal echogenic mass (tubal
ectopic) and moderate cul-de-sac fluid containing partially clotted hemorrhage.

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Retroperitoneal hemorrhage is di icult to recognize on abdominal ultrasound, but may be delineated as an

anechoic or heterogenous hypoechoic space (see Figure 11-32). Common atraumatic causes of
retroperitoneal hemorrhage are rupture of an AAA (Figure 10-3) or an iliac artery aneurysm (see Chapter 11,
“Aortic Emergencies”).

Figure 10-3.
Abdominal aortic aneurysm. Transverse probe placement and ultrasound findings.

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UPPER QUADRANTS
The benefits of using POCUS in a patient with upper quadrant abdominal pain primarily lie in rapidly
confirming or excluding biliary disease, identifying occult pulmonary or renal causes, and quickly initiating
antibiotic therapy.

Right upper quadrant pain. Right upper quadrant pain can indicate any number of pathologies, including
hepatobiliary, renal, pulmonary, and cardiac. Sonography of the right upper quadrant can assist the
clinician in confirming suspicions of hepatobiliary disease or can suggest a broader di erential diagnosis,
allowing one to tailor next management steps.

For right upper quadrant pain, begin by scanning the biliary system to evaluate for cholecystitis or
cholelithiasis (Figure 10-4) (see Chapter 12, “Hepatobiliary”). If the gallbladder is normal, check for
perihepatic fluid or hepatic masses or anomalies. Next, assess for less common etiologies of right upper
quadrant pain, such as pleural fluid or occult pneumonia (see Chapter 7, “Thorax”). If the clinical picture is
more suggestive of renal colic, scan the kidneys for hydronephrosis (Figure 10-5) (see Chapter 13, “Renal”).
Acute pyelonephritis is generally a clinical diagnosis; however, using the ultrasound probe to locate and
percuss directly over the kidney is a useful technique. Also, the finding of hydronephrosis in patients with
pyelonephritis is always important, and allows early aggressive management in patients who need surgical
intervention.16

Pain from a duodenal ulcer or perforation (see Figure 14-7) may localize to the right upper quadrant but
presents more typically as a gnawing pain in the epigastrium or radiating to the back. It can be evaluated
by a more focused examination of the gastroduodenal portion of the GI tract (see Chapter 14,
“Gastrointestinal and Abdominal Wall”).

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Epigastric and le upper quadrant pain. Consider the gastroduodenal organs and pancreas when the pain
is localized to the epigastrium or le upper quadrant. POCUS of the pancreas is o en underutilized in the
acute care setting, possibly because the pancreas is perceived as di icult to locate and sonographic images
are o en of limited clinical utility. However, with experience, the pancreas is located by its vascular
landmarks as it crosses over the aorta and the inferior vena cava (see Figures 14-5 and 14-9). The splenic
vein is also a useful landmark running along the posterior surface of the pancreas. Sonographic findings
suggestive of pancreatic neoplasm, necrosis, or pseudocyst can guide the radiologist in choosing ideal
acquisition protocols if CT is indicated (see Chapter 14, “Gastrointestinal and Abdominal Wall”).

In patients who are at risk of systemic thromboembolism or who have symptoms of monouncleosis, severe
le upper quadrant pain may be an indication of splenomegaly (see Figure 12-27) with splenic infarction or
rupture; these can be quickly uncovered sonographically.17 Also, sonographic evaluation of le upper
quadrant pain may reveal unexpected findings, such as occult pneumonia, plural fluid (see Figure 7-10),
hydronephrosis, or other renal pathology.

Figure 10-4.
Acute cholecystitis. Longitudinal right subcostal view shows the gallbladder with significant thickening of
the anterior wall due to inflammation.

Figure 10-5.
Hydronephrosis. Use longitudinal anterior or coronal views to image the kidney in long axis. Ultrasound
findings show moderate hydronephrosis.

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LOWER QUADRANTS
For lower quadrant abdominal pain, focus the ultrasound examination based on patient demographics,
pregnancy status, and the history and physical examination. Sharp pain in the lower quadrants may arise
from irritation of the peritoneal tissues suggesting inflammation of tissues around structures such as the
appendix (Figure 10-6; see Figures 14-38 to 14-42), colonic diverticula, or an infected or ruptured salpinx.
Diverticulitis (see Figure 14-28) is typically associated with le lower quadrant pain, but should be
considered as well in patients with right lower quadrant pain, particularly those of East Asian descent
where right-sided diverticulitis is more common.18 Dull non-localizing pain or pain associated with nausea
or vomiting may suggest more visceral causes such as a distended bladder (see Figure 13-25), sigmoid
volvulus, dilated loops of bowel (see Figures 14-16, 14-17, 14-18, 14-19, 14-20, 14-21), uterine, or adnexal
pathology (see Chapter 18, “Gynecologic Concepts”).

Figure 10-6.
Appendicitis. Transverse view of the appendix is performed using a high-frequency linear array probe to
look for enlargement (>6 mm diameter).

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GENERALIZED ABDOMINAL PAIN

Generalized abdominal pain can pose a particular diagnostic challenge, especially in patients who are
unable to provide a good history. Elderly or diabetic patients may have vague or nonspecific complaints,
particularly in cases of biliary disease. CT is not always the optimal imaging modality, particularly in the
case of cholelithiasis where ultrasound is superior to CT. A brief sonographic examination to assess for the
most common causes of abdominal pain can be invaluable in saving time and resources when the pain is
generalized or the history and physical examination are equivocal.

Begin by evaluating for free fluid or free air (see Figure 14-6), followed by a systematic evaluation of the
most common entities, including gallbladder disorders, dilated bowel (Figure 10-7), hydronephrosis, AAA,
or severe bladder distention. Early POCUS may spark the acute care clinician to rapidly initiate lifesaving
measures in the case of an AAA or to conserve resources in the setting of an altered patient with a severely
distended, painful bladder.

Figure 10-7.
Fluid-filled dilated small bowel.

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In the proper clinical context, consider mesenteric ischemia in the di erential diagnosis of abdominal pain.
Sonography may reveal signs of infarcted bowl or superior mesenteric artery occlusion (see Figures 14-29
and 14-30).

ABDOMINAL WALL
Abdominal pain may be due to a lesion or defect within the abdominal wall and an associated incarcerated
hernia (see Figure 14-24). Since the area of anatomic interest is quite superficial and free of shadowing
artifacts, it is well suited to sonographic evaluation with a linear array transducer (see Figures 14-50 and 14-
51). When a palpable or indistinct abdominal wall mass is found on physical examination, or when a focal
area of abdominal wall tenderness is encountered, a POCUS examination of the a ected area may help
provide immediate answers to a number of clinical questions (Table 10-2). Armed with the additional
anatomic knowledge of the site and character of the sonographic findings, the acute care clinician can then
pursue a more targeted workup (see Chapter 14 “Gastrointestinal and Abdominal Wall”).

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TABLE 10-2.
CLINICAL QUESTIONS THAT POCUS MAY HELP ANSWER

Is the region of tenderness due to a lesion within the abdominal wall or an underlying structure?
Is the lesion solid, cystic, hypo, or hyperechoic?
Is there a fascial defect in the abdominal wall, and is there a loop of bowel within the defect?
Is there blood flow within or around the lesion or defect?

POCUS = point-of-care ultrasound.

PEARLS AND PITFALLS

1. An unfocused approach. Utilize patient demographics, history, and physical examination to focus
clinical approach, and then use POCUS to answer specific questions.

2. Anchoring or misinterpretation of findings. Ensure that the ultrasound findings are consistent with the
clinical picture. For example, in evaluating the abdominal wall, consider a malignant etiology for any
homogeneously hypoechoic solid lesion, especially in the groin. Similarly, rule out a vascular etiology
before aspiration or incision and drainage of an anechoic lesion is considered.

3. Overreliance on negative or equivocal sonographic findings. Positive findings o en help the clinician
save time and resources in choosing further diagnostic modalities; however, if the ultrasound
examination presents equivocal or negative findings, its limitations must be recognized. Abdominal CT,
other radiographic procedures using contrast media, or endoscopy should not be delayed.

4. Body habitus. Patients who are obese or who have an immense amount of gas in the GI tract may make
abdominal ultrasonography particularly di icult, limiting its utility in these cases.

REFERENCES

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