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Evaluation of Acute

Abdominal Pain

KAMINSKY OLEG, M.D.

Department of Surgery A
Rabin Medical Center
Acute Abdomen -
Conundrum
• If I operate and the problem is not
surgical, patient exposed to unnecessary
risk, anesthetic, etc.
• Risks greater with concomitant illness,
older age

• If I do not operate and problem is surgical,
patient at risk because of wrong therapy.
• Again the older patient is under greater
burden.
A Caricature - Surgery
• Acute pain
• Septic & toxic
• Board-like abdomen
• Absent bowel sounds
• WBC 25,000
• Free air under diaphragm
A Caricature - No Surgery
• Trivial pain
• Robust appearance
• Soft abdomen with no guarding
• Normal bowel sounds
• Normal WBC
• Normal pain and upright films of
abdomen
ABDOMINAL LANDMARKS
• Xyphoid Process
• Costal Margin
• Abdominal Midline
• Umbilicus
• Anterior Superior
Iliac Spine
• Inguinal Ligament
• Symphysis Pubis
ABDOMINAL AREAS
• Four quadrants:
• Right Upper Quadrant (RUQ)
• Right Lower Quadrant (RLQ)
• Left Upper Quadrant (LUQ)
• Left Lower Quadrant (LLQ)
• Three central areas:
• Epigastric
• Periumbilical
• Suprapubic
Anatomy of the GI Tract

liver spleen

stomach
gallblader

Large bowell Small bowell
Acute Abdomen
• Definition: abdominal condition,
typically of sudden onset,
associated with abdominal pain
due to inflammation, perforation,
obstruction, infarction, or rupture
of intra-abdominal organs.
Emergency surgical intervention is
often required.
Common Causes of Abdominal Pain

of Surgery, 16th ed.
Anatomy of Abdominal Pain
• Autonomic response
• Poorly localized, deep pain
• Sweating, nausea
• Visceral pain
• Parasympathetic/Sympathetic routes
Viscera- “dull”
Mesentery- “sharp”
Peritoneum- “sharp and localized”
Pain of Sudden Onset-DDx
• Perforated peptic ulcer
• Rupture of abscess or hematoma
• Ruptured ectopic pregnancy
• Rupture of esophagus
• Infarction of abdominal organ, ht,
lung
• Spontaneous pneumothorax
• Ruptured or expanding aortic
aneurysm
Pain of Gradual Onset
(hours)
• Appendicitis
• Strangulated • Peptic ulcer
hernia • Gastritis
• Low mechanical • Mesenteric
small bowel lymphadenitis
obstruction • Terminal ileitis
• Cholecystitis (Crohn’s)
• Pancreatitis
• Meckel’s
Diverticulitis
Acute Abdominal Pain
Non-surgical Emergencies
• Mesenteric Adenitis
• Acute Enteric Infections
• Acute Enteric Poisonings
• Inflammatory Bowel Disease
• Pancreatitis (usually)
Acute Abdominal Pain
Metabolic Causes
• Diabetic Ketoacidosis
• Heavy Metal Poisoning
• Acute Porphyria
• Tabes
• Sickle Cell Crisis
History
• Provocative and Palliative Factors
• Quality
• Region
• Severity
• Temporal characteristics (onset,
duration, frequency)
Physical Examination
• 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.
• Physical examination of the
abdomen
Palpation

palpation of liver palpation of spleen
Physical Examination
• Percussion:
• Tenderness
– No sudden moves
– Take your time
– Rigidity and guarding
– “Board-like abdomen”
• Tympanitic
• Dull
Tenderness

rebound tenderness CVA tenderness
Shifting Dullness
Referred Pain : Anterior
Referred Pain : Posterior
Routine Lab Studies
• Glucose, electrolytes, Bun,
Creatinine
• CBC and Differential
• Amylase, Lipase
• Alkaline Phos, T Bili, SGOT(AST),
SGPT(ALT)
Routine Lab Studies
• Urine HCG (female of reproductive
age)
• UA (up to 10% of stones without
RBC’s)
• Always do CXR to rule out
pneumonia/effusion
• Always do EKG to rule out
myocardial process
Diagnostic Imaging
Chest X-ray

• Indication
• suspected perforation
• suspected aspiration
• suspected foreign body
Chest X-ray

pneumoperitoneum
Plain Abdominal Film
• Indication
• intestinal obstruction
• calcification
• suspected ischemia
• intestinal transit study
• inflammatory bowel
disease
Plain Films
• Upright CXR
• “Free” air
• KUB (kidney/ureter/bladder)
• Calcifications
• Air/ Fluid levels
• Reactive bowel patterns
• Foreign bodies
Abdominal x-rays
• Valuable in diagnosis in only 10% of
cases
• 20% of perforated peptic ulcers do
not demonstrate “free air” in
abdominal films
• Up to 80% of AAA’s will show
calcium in the wall on plain film
• Diagnostic in 60% with sigmoid
volvulus
Hydropneumoperitoneum
Plain Abdominal Film

normal small bowel obstruction
Barium Study
• Endoscopy has obviated the need for
many conventional GI barium studies.
• Assess motility disorders more
accurately than endoscopy
• Useful in small bowel disease
Upper GI Series

normal stomach cancer B-IV, antrum
Barium Enema

normal colon cancer
Sonography/CT/MRI
• Useful in evaluation of solid organs or
delineation of abdominal masses
• Sonography
• relatively cheap
• effective in the evaluation of GB & biliary tract
• assess the blood flow of major vessels in
combination with Doppler
• CT
• more effective in the evaluation of lower abdomen
• MRI
• the role remains to be delineated
Ultrasound
• Rapid, safe, low cost
– Operator dependent
• Fluid, inflammation, air in walls, masses
• Liver, GB, CBD, Spleen, Pancreas,
Appendix, Kidney, Ovaries, Uterus
Ultrasound Scan
• Establish a precise diagnosis
• Aid in planning appropriate approach of
treatment
• Ultrasound useful in many abdominal
pathologies including
- acute cholecystitis/biliary colic
- renal colic
- appendicitis
- pancreatitis
- ectopic pregnancy
- AAA
Ultrasound

Textbook of Sabiston, 16th ed.
Sonography

gallstone
CT Scans
• Better than plain films and US for
evaluation of solid and hollow organs
– Intravenous contrast
– Oral contrast
– Per rectal contrast
• High use in appendicitis, diverticulitis,
abscess, pancreatitis
CT Scan
• Unenhanced helical CT in the acute abdomen
for diagnosis of
- acute appendicitis
- renal colic
- sigmoid diverticulitis
- pancreatitis
- small bowel obstruction
- abdominal aortic aneurysms
• CT improves accuracy of diagnosis
• Reduces mortality and hospital stay
Abdominal CT
Acute diverticulitis

normal abdominal CT
MRI
Angiography

normal NOMI
Acute Abdomen and Peritonitis
• Symptoms linked to visceral distention
or ischemia
• Inflammation of the peritoneum
• Parietal component provides localization
• End result of a process involving viscera
• Early diagnosis means understanding
the patterns that lead up to peritoneal
irritation
Peritonitis
Peritoniti
• Primary: No obvious source
– E. coli and Klebsiella in adults, cirrhosis, ascites.
• Secondary:
– Fecal
– Chemical
– Infectious
• Tertiary:
Tertiary
• Peritonitis- like syndrome
– Disturbance in immune response
– No pathogens identified
Peritoneal cavity

Acute peritonitis

any perforation,
pancreatitis
abdominal pain, tenderness
guarding, silent abdomen
shock
Treatment – underlying condition
Biliary colic/Cholecystitis
• Biliary colic when gallstones obstruct cystic duct or
pass into CBD
• Cholecystitis when cystic duct or CBD obstructed,
causing inflammation
• Bacterial infection a consequence of cholecystitis.
Common organisms are E. coli, Klebsiella,
enterococci
• CBD stones primary or secondary
• Perforation of GB in 3-15% of cholecystitis gives 60%
mortality
• USS best modality for cholecystitis and cholelithiasis
Gall bladder/Biliary Tract
Acute Cholecystitis
Presentation
Acute RUQ pain
+/- Pyrexia
+/- Rigors
Diagnosis – FBC, WBCC,
USS
Treatment – Antibiotics,
analgesics
Early surgery
Gall bladder/Biliary Tract
Obstructive Jaundice
Yellow skin, sclerae
Pale stools, dark urine
+/- Pain
+/- Courvoisier’s sign
CT – dilated bile ducts

Establish diagnosis
Gallstones
Ca Head of Pancreas
Appropriate treatment
ERCP
Small Intestine

Meckel’s Diverticulum
rare
diverticulum of terminal ileum
can be lined by gastric epithelium
can perforate
can present like appendicitis
Small Intestine

Intestinal obstruction
May arise due to
adhesions, hernia, tumour
Presentation
colicky abdominal pain,
vomiting, constipation
Treatment
resuscitate/operate
Small Intestine

Mesenteric infarct

Sudden occlusion of small
bowel arterial supply
Sudden onset of abdominal pain,
shock
Peritonitis
Treatment
resuscitate/operate
Small bowel obstruction
• Causes: post-op. adhesions, malignancy, Crohn’s
disease and hernias
• Partial or complete, simple or strangulated
• Obstruction of small bowel leads to proximal
dilatation of intestine due to GI secretions and air
• Accumulation of fluid causes increased peristalsis
above and below obstruction
• Increasing bowel distension leads to increasing intra-
luminal pressures
• Increased hydrostatic pressures in capillary beds
result in 3rd spacing of fluid, electrolytes and proteins
into intestinal lumen
SMALL BOWEL
OBSTRUCTION
Large bowel

Acute diverticulitis

Maximal in (L) colon
Presentation LIF pain,
fever, tenderness,
leukocytosis
Middle aged or elderly
Treatment – conservative
antibiotics, fluids, bed rest
Large bowel
Perforation
Diverticulum, colitis,
sudden severe abdominal pain,
rigidity
Faecal peritonitis
Pyrexia, shock
Free gas on X-ray

Treatment
resuscitate, operate
Large Bowel
Ulcerative colitis

Presents – bloody
diarrhoea, pyrexia
leukocytosis
may develop toxic megacolon

Treatment – steroids
Surgery on failure
Inflammatory Bowel Disease

Recurrent regeneration
Increased risk of tumour formation
14.8 X
Appendicitis
• 7-12% lifetime risk of appendectomy
• ~500,000 performed yearly
• 15% misdiagnosed
• 47,000 appys/year
• 1 in 4 women will have a “negative
appendectomy”
• $740 million dollars spent/yr on
misdiagnosis
Pathophysiology
• Obstruction of the appendiceal lumen
• Lymphoid hyperplasia
• Fecalith
– Inspissated stool
– Not always present
• Foreign body
Pathophysiology of
Appendicitis
• obstruction • inflammation
• bacterial overgrowth • edema
• mucous secret • ischemia
• distention • necrosis
• Increased intraluminal • perforation
pressure • abscess or localized
• lymphatic obstruction peritonitis
• venous obstruction • diffuse peritonitis
History and Physical Exam
Table 6 --Clinical Features of Appendicitis

Symptoms

Duration of symptoms (hrs, median) 22.0 hrs
Abdominal pain (% of cases) 100.0
Nausea or vomiting (% of cases) 67.5
Anorexia (% of cases) 61.0
Fever by history (% of cases) 17.9
Dysuria or frequency (% of cases) 10.6
Physical Findings

Right lower quadrant tenderness (% 95.9
of cases)
Rebound tenderness (% of cases) 69.5
Rectal tenderness (% of cases) 41.5

Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.
Distinguishing Appendiceal
Perforation
Appendicitis Appendicitis
With Perforation w/o Perforation

N=70 N=176
Duration of symptoms (hrs, 48.5 hrs 18.0 hrs
median)
Fever as presenting 34.3 11.4
complaint (% of cases)
Nausea or vomiting (% of 60.0 70.5
cases)
Anorexia (% of cases) 52.9 64.2
Urinary symptoms (% of 10.0 10.8
cases)
Rebound tenderness (% of 64.3 71.6
cases)
Rectal tenderness (% of 41.4 41.5
cases)
Impression of a mass (% of 21.4 6.2
cases)

Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.
Signs and Symptoms
• Umbilical then migrates towards the RLQ
• Tenderness, then rebound
• Rovsing
• Psoas
– Extension of leg-pt on left
• Obturator
– Rotation of flexed thigh-pt supine
• Rectal
• Perforation related symptoms
Differential Diagnosis
• Preschool-age
• Intussusception, acute gastroenteritis, Meckel’s diverticulum
• School-age
• Acute GE, constipation, Sickle cell
• Young males
• Crohn’s, UC, epididymitis

• Young females
• Crohn’s, PID, ovarian cysts, UTI, pregnancy
• Older adults
• Malignancies of GI and GU
• Diverticulitis
• Perforated ulcers
• Cholecystitis
Labs
• WBC: 12,000-18,000
• left shift important
• HCG negative
• UA
• mild pyuria possible
Radiographics
• Plain films
• fecolith, ileus
• CT scan
• Distention of appendix, thickened > 5-7
mm walls, target sign
• US
• Non-compressible, 7 mm, fluid, mass
• Nuclear MD: Tc 99 WBC Ig G
Appendicitis
U/S
Appendicitis
CT Scan
Treatment
• Urgent appendectomy
• Antibiotics
• Only preoperative abx needed for
uncomplicated cases
• For complicated appendicitis 7-10 days
Appendectomy

Textbook of Sabiston, 16th ed.
Laparoscopic Appendectomy
Postoperative Complications
• Infection: < 5 % to 60 %
• Wound Closure
• Primary
• Delayed primary
• Secondary
• Bowel obstruction
• Infertility-no longer suspected
Normal appearing appendix?
• Remove appendix anyway?
• Especially if the pt has a RLQ incision
• Negative predictive value of macroscopic
judgments of the appendix are low
• Check for ovarian pathology
• Check for Meckel’s diverticulum
• Rule of 2’s
– 2% incidence
– 2 types of mucosa
– 2 feet from ileocecal valve
– 2-4% (now 6%) with Meckel’s develop symptoms
– >50% of pts with sxs are less than 2 yrs old (bleeding)
Infarcted/Ischemic Bowel
Mesenteric Infarction/Ischemia
• Always consider in patient with atypical
presentation of abdominal pain-
• Older patients
• Hx of arrhythmias or previous emboli
• Pain out of proportion to exam
• Evidence of visceral complaints without peritonitis
• Systemic complications
• Acidosis
Infarction by Endoscopy
Anatomy of the SMA
Occlusion of the SMA
• Source
• Embolic (>50%)
• Venous, Atherosclerotic (thrombotic), NOMI
• Chronic
• Mesenteric/intestinal angina
• 30-60 minutes post eating
• Voluntary anorexia/wt loss
• Acute (>60% mortality)
• “Abdominal apoplexy”
• Variable symptoms at first with progression
• System collapse
Arteriogram of Normal SMA
Occluded SMA
Treatment of Acute SMA
Occlusion
• High index of suspicion
• Arteriogram
• Medical therapy
• Papavarin
• Heparin
• Surgical intervention
Perforated Viscous
Perforated Viscous
• Sudden onset of pain
• “Set your watch to it”
– Epigastric/shoulder/RLQ-often DU
– Lower quadrant-often diverticulum
• Often pre-existing history of ulcer or
diverticular disease
Diagnosis
• Plain x-rays often demonstrate
• Upright CXR
• 75% of perforated DU will have free air
• Sensitive to 5 cc
• CT scan
• Sensitive to <2 cc air
Perforated peptic ulcer
• Most with pre-existing dyspepsia
• 10% no previous symptoms
• 80% perforated DU H. pylori positive
• 10% associated episode of melaena
• 10% not shown on erect CXR
• Can have raised amylase
• Gastric ulcers (posterior) perforate into lesser sac
• Duodenal ulcers (anterior) perforate into main
peritoneal cavity
Perforated peptic ulcer
• Free air under diaphragm – rt.
Oesophagus – Perforation

High mortality

May follow endoscopy
Presentation – acute
chest/abdominal pain
Air in mediastinum and soft
tissues
Treatment -
surgery - benign
intubation - malignant
Stomach/duodenum – Perforation

Presentation –
abdominal pain
rigidity
peritonism, shock
Air under diaphragm on X-
ray
Treatment
antibiotics, resuscitate
repair
Management
• Acute perforation of a viscous requires
emergent exploration
• Delayed presentations are more
complex
• Can avoid operation if the perforation is
contained
• May require delayed interventions
Ischemic Bowel Dis
• 60% acute colonic ischemia
30% acute mesenteric ischemia
5% focal segmental small bowel ischemia
5% chronic mesenteric ischemia
• Arterial Anatomy of Gut
Celiac Axis- supplies Liver, Spleen, Biliary
tree,stomach, duodenum, and pancreas
SMA- duodenum, pancreas, entire small bowel,
ascending and partial transverse colon
IMA- partial transverse colon, descending colon
and rectum
Acute Mesenteric vs. Acute Colonic
Risk factors-cardioemboli, Risk Factors- Vasculitis(SLE,
hypotension, CHF, MI, PN), Sickle cell dis,
Digoxin, diuretics, hypercoag hypercoag, Dig, Gold,
states psychotropic drugs,
Cocaine, post surgical(AAA
repair, AVR), obstruction
due to CA, radiation, fecal
impaction,salmonella,
shigella, E.Coli O157:H7,
age >60
Presentation- sudden severe abd
pain in pt with risk factors. Presentation- sudden, crampy
Exam is nonspecific early mild LLQ pain with urge to
then right sided abd defecate and passage of
tenderness and maroon stool, BRB within 24hrs. Exam
and ultimatley peritoneal reveals mild tenderness
signs with infarction most common over sigmoid
or rectum.
X-ray- negative early then
thumbprinting of SI and Rt X-ray- normal to thumbprinting
Colon of colon
Dx- Angiography required Dx-colonoscopy for mucosal
bx; angio if Rt colon only
Rx- papaverine infusion vs
involved
surgery
Rx- supportive;infarction/toxi
Course-mortality 10% if Rx prior
megacolon rare
Volvulus
• 80% sigmoid
• Classic presentation in elderly with
chronic constipation that presents with 1-
2 day hx of anorexia, N/V, pain,
obstipation, distention
• Pain is often sudden in onset and crampy
• Prior episodes of similar pain that
resolved with BM is a common hx
• Plain film diagnostic in 60%
• Treatment includes BE or endoscopic
decompression vs surgery
• High risk of recurrence
Sigmoid and Cecal volvulus
• Caecal volvulus less than sigmoid volvulus
• Caecal volvulus 25% of volvulus cases
• Incomplete midgut rotation a predisposing factor
• Inadequate fixation of caecum to posterior abdominal
wall
• Caecal volvulus clockwise around ileocolic vessels
• Involves terminal ileum and ascending colon
• May attempt decompression by colonoscopy but
main treatment is laparotomy
LARGE BOWEL VOLVULUS
Acute pancreatitis(1)
• Inflammatory process in which pancreatic enzymes
autodigest gland
• Inflammatory process cause systemic effects due to
cytokines.
• Fat necrosis cause hypocalcaemia
• Pancreatic B cell injury cause hyperglycaemia
• In severe form manifest as ARDS, ARF, cardiac
depression, haemorrhage, hypotensive shock
• Causes: GET SMASHED
Acute pancreatitis(2)
• Serum amylase low sensitivity & specificity. Serum
lipase more sensitive
• 20% cases have normal amylase (alcohol cause)
• amylase raised in cholecystitis, hepatitis, peritonitis
• CT scan most reliable imaging modality
- Criteria for diagnosis divided into 5 grades
• Ranson’s criteria
Age>55, WCC>16, LDH>600, AST>120, Glu>10
• APACHE II score
Acute pancreatitis
Constant pain, vomiting,
shock
Pancreas
Causes
Gallstones, or
Alcohol

Diagnosis
Serum amylase
elevation, USS
complications
pseudocyst,
phlegmon
abcess
Ruptured AAA
• AAA result of degeneration in media of arterial wall,
resulting in slow and continuous dilatation of vessel
lumen
• AAA caused by mycotic aneurysms of
haematogenous origin in 5%.
• AAA fusiform or saccular
• Male >60 yrs
• Risk of rupture at >6cm
• >80% with rupture present without previous diagnosis
of AAA
• CT scan best modality. USS scan be useful
Gynecological acute
abdomen

• Non – specific Abdominal Pain – 48%
• Appendicites – 22%
• Pelvic Inflamatory Disease (PID)-14%
• Urinary Tract Infection (UTI) – 12%
• Ovarian Cyst – 4%
• Ectopic Pregnancy – 1%
PUJ Obstruction
• Causes: idiopathic, RPF, secondary to trauma or
infection
Idiopathic PUJ obstruction
• PUJ obstruction more common in men
• affects left kidney more often than right
• 10% bilateral
• aetiology unknown but factors may be
- aberrant lower pole vessels
- persistent foetal urothelial fold
• Definitive treatment is pyeloplasty
Special Circumstances
• Pregnancy
- appendicitis, cholecystitis, pyelonephritis
- adnexal problems (ovarian torsion, ovarian cyst
rupture)
• Very young
- appendicitis and abdominal trauma secondary to
abuse
- PID, Meckel’s diverticulum, cystitis, enteritis, IBD
Special Circumstances
• Very old
- symptoms may be subtle
- compulsive evaluation
• Immunocompromised
- chemotherapy, organ transplants,
immunosuppression for autoimmune disease, AIDS
- symptoms subtle
- unique to immunocompromised host (neutropenic
enterocolitis, GVH, CMV, KS)
When to Operate ?
• Peritonitis
• Excluding primary peritonitis
• Abdominal pain/tenderness + sepsis
• Acute intestinal ischemia
• Pneumoperitoneum
• Make sure pancreatitis is excluded
What if it’s not clear?
• Challenging patients
– Neurologically compromised
– Intoxicated
– Steroids
– Inmmunosupressed
• If signs and symptoms are equivocal
– Serial exams (same person)
– Imaging
– Serial labs (check for WBC increases)
– Keep off antibiotics
– “Tincture of time”
When NOT to Operate ?
• Cholangitis
• Appendiceal abscess
• Acute diverticulitis + abscess
• Acute pancreatitis or hepatitis
• Ruptured ovarian cysts
• Long standing perforated ulcers?
Acute Abdomen-Summary
• History and physical more important than
tests
• Making the decision to operate is much more
important than making the diagnosis
• Treatment is often (BUT NOT ALWAYS)
surgical
• “Very old, very young, very odd…be very
careful!”
de Domball
Questions ?

The Doctor by Sir Luke Fildes