Professional Documents
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ABDOMINAL PAIN
INTRODUCTION
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
ABDOMEN- QUADRANTS
ABDOMEN- ORGANS
ABDOMINAL PAIN- CAUSES
ABDOMINAL PAIN- CAUSES
Inflammation of a viscus
Perforation of a viscus
Obstruction of a viscus
Infarction of a viscus
Intra-abdominal hemorrhage or retroperitoneal hemorrhage
Extra-abdominal or medical causes for acute abdominal pain like lower lobe
pneumonia and inferior wall MI
ABDOMINAL PAIN- HISTORY
SOCRATES = Nemonic
SOCRATES = Nemonic
“E” represents “exacerbating” factors; grouped
S - site within this is also alleviating factors. The
O - onset patient should be probed as to what makes their
C - characteristics pain better or worse. Certain physical positions,
R - radiation medications, etc. These factors can all provide
A – associated symptoms & historical clues about the root cause.
signs “S” stands for “severity”. In most hospitals this
T - timing is formulated on a 1 to 10 scale with 10 being
E - exacerbating/ the most severe pain they’ve ever experienced.
alleviating
S - severity
ABDOMINAL PAIN
ABDOMINAL PAIN
RLQ PAIN
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
ABDOMINAL PAIN-RLQ PAIN
A 28-year-old female presents with a 2-day hx of vague periumbilical
pain. Today the patient has lower abdominal pain (right greater than left), which is
associated with new onset of urinary frequency. She also vomited twice today. She is
sexually active and her menstrual cycle tends to be irregular. Her last menstrual period was
6 weeks ago (2 weeks late).
D/D in Females
D/D in Children
ABDOMINAL PAIN-RLQ PAIN
This patient has the characteristic prodrome for appendicitis with periumbilical pain
migrating to the RLQ and associated with localized peritoneal findings.
Check the β-hCG before proceeding with appendectomy particularly in light of the patient’s
delayed menstrual period. Ectopic pregnancy must be r/o.
The abnormal U/A result may relate to bladder irritation from an inflamed appendix or
represent the additional problem of a UTI.
Though the clinical picture is most consistent with appendicitis, preoperative USG/CT Abd
should be done if the β-hCG is normal.
CT Abdomen:
Thickened appendix
Fecolith
Fat stranding
ALVARADO SCORING
Ac. Appendicitis-Algorithm
CASE BASED LEARNING
ABDOMINAL PAIN
RUQ PAIN-1
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
ABDOMINAL PAIN-RUQ PAIN
HISTORY:
A 40-year-old moderately obese female presents to the emergency department with a 1-day
history of constant epigastric and right upper quadrant (RUQ) pain. She describes the severity of
the pain as a 7 out of 10. The pain began after eating fried pork. She reports that the pain also
seems to affect the right side of her back near her scapula. She feels nauseated and has vomited
twice. She has had similar pain, but of lesser severity, about once a month for the past year. The
pain comes on after eating fried or spicy foods, but previously it has resolved after an hour. She
is gravida six and para six.
ABDOMINAL PAIN-RUQ PAIN
On physical examination, her temperature is 100 °F, heart rate is 110/min, and her blood
pressure is 120/80 mmHg. She has marked tenderness in the RUQ of the abdomen to palpation.
When the RUQ is palpated while she is taking a deep breath, she abruptly ceases inspiration
secondary to pain Murphy’s Sign+ve
Laboratory values are significant for WBC count of 14 × 10 3 /μL (normal 4.1–10.9 × 10 3 /μL),
Total Bilirubin 1.0 mg/dL (0.1–1.2 mg/dl),
Alkaline phosphatase70 units/L (33–131 u/L),
Amylase 60 units/L (30–110 u/L), and Lipase 30 units/L (7–60 u/L).
With her current history of severe persistent abdominal pain following ingestion of fatty
foods, nausea and vomiting, and associated right upper quadrant tenderness to palpation, the
etiology is most likely of biliary origin.
The patient’s prior history is consistent with symptomatic cholelithiasis
With a positive Murphy’s sign, fever, tachycardia, and elevated WBC count, the most likely
current diagnosis is acute cholecystitis.
With a normal total bilirubin and alkaline phosphatase, choledocholithiasis and acute
cholangitis are less likely.
Similarly, a normal amylase and lipase rule out gallstone pancreatitis.
RUQ PAIN-Ac. Cholecystitis
History
• RUQ pain in obese, multiparous female
Physical Exam
• Murphy’s sign for acute cholecystitis
Pathology/Pathophysiology
• Acute cholecystitis triggered by persistent cystic duct obstruction by gallstone
Diagnosis
• RUQ US: gallstones, pericholecystic fluid, thickened gallbladder wall, and sonographic
Murphy’s sign
• HIDA scan if RUQ ultrasound is nondiagnostic
• KUB not helpful: only 10 % of gallstones are radio-opaque
RUQ PAIN-Ac. Cholecystitis
Manifestations of Gall Stones
RUQ PAIN-Ac. Cholecystitis
USG Abdomen:
Hyperechoic Gall stone shadow
Posterior acoustic shadowing
GB wall thickness > 3mms
Pericholecystic fluid collection
HIDA Scan:
Fig 1: Visualisation of GB
Fig 2: Non visualization of GB-
Acute Cholecystitis
CASE BASED LEARNING
ABDOMINAL PAIN
RUQ PAIN-2
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
ABDOMINAL PAIN-RUQ PAIN
HISTORY:
A 40-year-old female presents with a 24 hour history of right upper quadrant (RUQ) and
epigastric pain, associated with nausea and vomiting. She has had similar pain in the past,
particularly after eating greasy foods. According to her family, over the last few hours, the
patient has become slightly confused. Past medical history is negative.
PHYSICAL EXAM:
Temperature of 102.5 °F, a heart rate of 110 beats/min, respiratory rate of 16/min, and a blood
pressure of 90/60mmHg. She is moderately tender in the RUQ to deep palpation. She has slight
scleral icterus. She has noted dark- colored Urine. The remainder of her abdominal exam is
negative.
ABDOMINAL PAIN-RUQ PAIN
Laboratory Values:
White blood count of 15 × 10 3 /μL (normal 4.1–10.9 × 10 3 /μL),
Total bilirubin of 4.0 mg/dl (0.1–1.2 mg/dl),
Alkaline phosphatase (AP) of 350 μ/L (33–131 μ/L),
Aspartate aminotransferase (AST) of 300 μ/L (5–35 μ/L)
Alanine aminotransferase (ALT) of 280 μ/L (7–56 μ/L),
Gamma-glutamyl transpeptidase (GGT) of 330 μ/L (8–88 μ/L),
Amylase of 100 μ/L (30–110 μ/L).
Urine is positive for bilirubin.
Additionally, she has leukocytosis, hypotension, altered mental status, elevated bilirubin,
and deranged liver function tests, all of which are consistent with the suppurative
cholangitis Reynold’s Pentad
The Tokyo guidelines have been proposed as diagnostic criteria for acute cholangitis.
Patients should have evidence of systemic inflammation (fever and/or leukocytosis),
cholestasis (jaundice and/or abnormal liver enzymes), and biliary obstruction (dilated bile
ducts on ultrasound).
RUQ PAIN-Ascending Cholangitis
History and Physical
• Charcot’s triad RUQ pain, fever and jaundice
• Reynold’s pentad + hypotension and altered mental status
• Look for evidence of SIRS
• Elderly patients may be hypothermic and leukopenic (are relatively immunosuppressed)
Etiology/Pathophysiology
• Biliary obstruction with bacterial infection
• Bacteria enter bile either via bloodstream from the portal vein or retrograde from the
duodenum
• Most commonly caused by gallstone obstruction of the distal CBD
• Other causes: biliary stricture, cancer, parasites
• Suppurative cholangitis: acute cholangitis complicated by septic shock
RUQ PAIN-Ascending Cholangitis
Diagnosis
• Elevated WBC
• AP, ALT, AST, GGT rise proportion
• US: dilated CBD
Management
• Aggressive IV fluids, blood cultures, broad-spectrum antibiotics
• Admit to ICU
• Urgent biliary decompression via ERCP
• PTC if ERCP fails PTBD
• Open surgery (insert T-tube into CBD) if PTC fails
• Cholecystectomy after sepsis resolves to prevent further biliary complications
Watch Out
• The diagnosis of acute cholangitis may be missed in the elderly and immunosuppressed (e.g.
steroids)
• Think sclerosing cholangitis if also having symptoms of IBD
RUQ PAIN-Ascending cholangitis
RUQ PAIN-Ascending Cholangitis
ERCP ERCP- Stone Extraction
PTBD
ABDOMINAL PAIN
EPIGASTRIC PAIN- 1
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
ABDOMINAL PAIN-
EPIGASTRIC PAIN- 1
HISTORY:
✓ The free air under the diaphragm indicates that the patient has a perforated
viscus.
✓ This is supported by evidence of diffuse peritonitis on physical exam.
✓ The most common causes of free air under the diaphragm are perforated ulcers
and perforated diverticulitis.
✓ Given the longstanding history of epigastric pain relieved by antacids, the most
likely diagnosis is a perforated ulcer
Epigastric Pain- DU perforation
✓ History and Physical:
✓ Sudden onset severe epigastric pain that becomes diffuse
✓ History of peptic ulcer disease (PUD), H. pylori, smoking, chronic NSAID use
✓ Evidence of SIRS
✓ Patient lying motionless in bed
✓ Abdominal guarding, rigidity, and rebound tenderness
✓ Pathophysiology:
✓ Acid hypersecretion, defective mucosal defense or H.Pylori infection
✓ Five types of gastric ulcers- Modified Johnson’s classification
✓ Type I ulcers are on the lesser curve of the stomach
✓ Type II ulcers are in the stomach and duodenum
✓ Type III ulcers are pre-pyloric
✓ Type IV ulcers are located proximally near the cardia
✓ Type V ulcers are anywhere secondary to NSAID use
Epigastric Pain- DU perforation
✓ Workup:
✓ Leukocytosis with left shift
✓ Upright CXR: free air under diaphragm
✓ CT with oral gastrografin
✓ Management:
✓ Duodenal perforation
✓ – Primary closure with an omental patch
✓ Gastric perforation
✓ – Primary closure, biopsy, omental patch vs. wedge resection
✓ – Must rule out malignancy
✓ Triple therapy: clarithromycin, amoxicillin, and a PPI for 14 days (if H. pylori
positive)
✓ Additional acid reduction surgery rarely needed
Epigastric Pain- DU perforation
Pneumoperitoneum DU Perforation Graham’s Patch- Omentopexy
CASE BASED LEARNING
ABDOMINAL PAIN
EPIGASTRIC PAIN- 2
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
ABDOMINAL PAIN-Epigastric Pain
HISTORY:
A 41-year-old woman presents to the emergency department complaining of severe
and continuous epigastric pain for the past 24 hours. The pain radiates straight
through to her back. She has had progressive nausea with vomiting. The vomitus is
bile stained without blood. She has had similar but less severe episodes in the past,
usually after eating heavy meals, but they always resolved within a few hours. She is
married, with two children, and does not consume any alcohol.
PHYSICAL EXAM:
On exam, she is afebrile, heart rate is 115/min, blood pressure is 128/86 mmHg, and
she has a normal respiratory rate. Her abdomen is not distended. She has no
surgical scars on her abdomen and no obvious masses visible. She has no bruising
around her umbilicus or along her flank. Bowel sounds are hypoactive. She has
marked tenderness to palpation in her epigastrium, without guarding or rebound.
The remainder of her abdomen is soft and non-tender to palpation. No masses or
organomegaly are appreciated.
ABDOMINAL PAIN-Epigastric Pain
Laboratory Values:
WBC count of 17.2 × 10 3 cells/μL (normal 4.1–10.9 × 10 3 cells/uL),
Amylase of 1,545 u/L (normal 30–110 u/L),
Lipase of 1,134 u/L (normal 7–60 u/L),
ALT of 245 u/L (7–56 u/L), AST of 263 u/L (5–35 u/L),
Serum glucose of 156 mg/dl (65–110 mg/dL), and LDH 180 u/L (0–250 u/L)
An abdominal series demonstrates gas throughout the small and large bowel,
and a focal dilated loop of proximal small bowel without air fluid levels- sentinel
loop++. There is no free air under the diaphragm.
Pathophysiology
• The initial event in pancreatitis is the inappropriate activation of pancreatic
enzymes
• Gallstones and alcohol are the most common causes of acute pancreatitis
Epigastric Pain-Acute Pancreatitis
Diagnosis
• Most cases can be diagnosed with just a history, physical, and abnormal
amylase/lipase
• Ranson criteria are used to predict severity based on parameters during initial
admission and at 48 hours after
Workup
• Amylase/lipase levels do not correlate with severity of pancreatitis
• In the absence of a history of alcohol abuse, start with a RUQ ultrasound to look
for gallstones
Epigastric Pain-Acute Pancreatitis
Management
• Patients should initially be managed conservatively with IV fluids, NPO, and
narcotic analgesia
• Gallstones
– urgent ERCP if concomitant cholangitis
– early cholecystectomy if mild pancreatitis
– late cholecystectomy if severe pancreatitis
• If patients do not clinically improve after 3 days of conservative management, get
a CT scan with contrast to look for any underlying complications (i.e., necrosis)
• Begin enteral nutrition in patients with prolonged NPO status or in severe acute
pancreatitis
• Refractory persistent abdominal pain is the main indication for surgery in chronic
pancreatitis
Epigastric Pain-Acute Pancreatitis
Etiology Complications
“I GET SMASHED”: • Systemic
Idiopathic – Early (1st week)
Gallstones – Multi-organ failure
Ethanol • Local
Trauma – Late (3 weeks)
Scorpion bite – Pancreatic abscess
Mumps (viruses) – Pancreatic pseudocyst
Autoimmune – Pancreatic necrosis
Steroids
Hyperlipidemia
ERCP
Drugs
Acute Pancreatitis- Ranson’s Scoring
At Admission After 48 hrs
“GA LAW (Georgia law)”: “C HOBBS (Calvin and
Glucose >200 Hobbes)”:
Age > 55 Calcium <8 mg/dL
LDH > 350 Hct drop of >10%
AST > 250 O2 <60 (PaO2)
WBC > 16,000 Base deficit >4
Bun >5 increase
Sequestration >6 L
Acute Pancreatitis-
Glasgow- Imrie Scoring
Acute Pancreatitis-
Balthazar Scoring
Acute Pancreatitis-
BISAP Scoring
Acute Pancreatitis- AXR
Acute Pancreatitis- CECT
ABDOMINAL PAIN
LLQ Pain -1
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
ABDOMINAL PAIN-LLQ Pain
HISTORY:
A 55-year-old obese female presents with a 2-day history of left lower quadrant pain, nausea,
anorexia, and low-grade fever. The patient states that the pain is constant, moderately severe, and
does not radiate anywhere. No H/O aggravating/relieving factors. She denies vomiting and bloody
or black stools and has no recent change in bowel habits, though she says she’s been constipated
most of her life. She has noted similar pain in the past,but never this severe, and has never sought
medical attention before. She has never had a screening colonoscopy or prior surgery.
PHYSICAL EXAM:
Abdominal exam reveals mild distention, no surgical scars, and no masses. Bowel sounds are
absent. The left lower quadrant is moderately tender to palpation with guarding and no rebound
tenderness. Rectal exam is unremarkable. Pelvic exam reveals no cervical motion tenderness and
no adnexal masses.
LABS: TWBC- 16,000; Hb-13Gm; Hct- 39%
What would be your differential dx and plan for further evaluation?
LLQ PAIN-
Differential Diagnosis
ABDOMINAL PAIN-LLQ Pain
Diagnosis most probably Acute Diverticulitis
Given the patient’s left lower quadrant (LLQ) pain and tenderness on exam, associated with
fever and leukocytosis, acute diverticulitis is the most likely diagnosis.
Obesity, diet low in fiber and high in fat and red meat, and advanced age are risk factors for the
formation of diverticulosis.
Rectal diverticula are extremely rare. It is hypothesized that they almost never occur because
the taenia coli, the longitudinal bands of smooth muscle along the colon, unite into a
circumferential band around the rectum, thereby eliminating points of weakness that precede a
diverticulum.
LLQ Pain-Acute Diverticulitis
History and Physical
• Major risk factors are obesity, advanced age, and diet low in fiber, high in fat and red meat
• Diverticulitis is a clinical diagnosis (LLQ pain and tenderness, fever, leukocytosis)
Pathophysiology
• The sigmoid colon is the most common site
• Complicated diverticulitis: abscess, free perforation, fistula, stricture, and obstruction
Diagnosis
• CT scan is the first-line imaging modality
• Avoid barium enema and colonoscopy in acute presentation because of increased risk of
perforation
• Determine if complicated or uncomplicated and with or without SIRS
LLQ Pain-Acute Diverticulitis
Management
• Uncomplicated diverticulitis without SIRS
– Treated as outpatient
– Oral antibiotics and clear liquids
• Uncomplicated diverticulitis with SIRS
– Admit to hospital
– NPO, IV fluids, IV antibiotics, and
analgesia
– Follow up with colonoscopy 4–6 weeks
after acute episode to rule out malignancy and
Inflammatory Bowel Disease.
LLQ Pain-Acute Diverticulitis
Management
• Complicated diverticulitis usually requires
surgery
– Resect the affected colon and construct end
colostomy if urgent
– Sigmoid colectomy with primary
anastomosis if not urgent
LLQ Pain-Acute Diverticulitis
-Etiopathogenesis
• l .Colonic diverticula are mucosal out pouchings through the
submucosa and the muscular layer of the colon.
• 2 .They occur most commonly in the sigmoid colon, and in
10% of patients, they involve the entire colon.
• 3.A disorder of modern civilization and is associated with
consumption of refined food products. It is rare in rural
African and Asian populations where dietary fiber is high.
• 4. Long standing constipation increases the stool transit time
and intraluminal pressure and causes diverticulosis.
• 5. They arise between antimesenteric taenia and the mesenteric
taenia at the site of entry of the blood vessels.
CASE BASED LEARNING
ABDOMINAL PAIN
LLQ PAIN-2
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
ABDOMINAL PAIN-LLQ Pain
HISTORY:
An 80-year-old male presents with severe abdominal distention and no bowel movement or gas
per rectum for 3 days, as well as recent onset of vomiting. He has Parkinson’s disease and chronic
constipation and lives in a nursing home. His medications include levodopa and benztropine,
which he has been taking for several years.
PHYSICAL EXAM:
Patient’s vital signs are T 37°C, heart rate 90/min, blood pressure 116/70 mmHg, and respiratory
rate 22/min. Patient is tachypnic but nontoxic, with mental status unaltered. His abdomen is
severely distended. He does not have any abdominal surgical scars. He is tympanitic but has no
significant tenderness to palpation. There are no palpable hernias, and rectal exam demonstrates
an absence of stool
with no palpable masses or strictures.
ABDOMINAL PAIN-LLQ Pain
LABS:
BUN 26 mg/dL; Creatinine 1.4 mg/dL, Electrolytes within
normal limits, TWBC:6800/dL; ABG- pH 7.48//PaCO2
30//PaO2 80//HCO3 24//SpO2 99 %.
IMAGING:
Plain upright abdominal radiograph shows a massively
dilated loop of sigmoid with the apex pointing toward the
right upper quadrant, consistent with the “coffee bean” or
“bent-inner tube” sign; upright chest radiograph shows no
free air under the diaphragm.
What would be your differential dx and plan for further
evaluation?
LLQ PAIN-
Differential Diagnosis
ABDOMINAL PAIN-LLQ Pain
Management
• Therapy differs based on the location and severity of complication
– Uncomplicated sigmoid volvulus – endoscopic detorsion followed by semi-elective resection
– Complicated sigmoid volvulus – no detorsion attempted; emergent laparotomy with resection
– Cecal volvulus – no detorsion attempted; take to OR for right colectomy
• Complications of surgery – wound infection, anastomotic leak, and recurrence. Without
detorsion or resection – ischemia,
perforation, and sepsis