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 gallblader Large bowell

spleen stomach

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 hernia • Low mechanical small bowel obstruction • Cholecystitis • Pancreatitis • Meckel’s Diverticulitis • Peptic ulcer • Gastritis • Mesenteric lymphadenitis • Terminal ileitis (Crohn’s)

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 intraluminal 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 bacterial overgrowth mucous secret distention Increased intraluminal pressure • lymphatic obstruction • venous obstruction • • • • • • inflammation edema ischemia necrosis perforation abscess or localized peritonitis • diffuse peritonitis

History and Physical Exam
Table 6 --Clinical Features of Appendicitis
Symptoms Duration of symptoms (hrs, median) Abdominal pain (% of cases) Nausea or vomiting (% of cases) Anorexia (% of cases) Fever by history (% of cases) Dysuria or frequency (% of cases) Physical Findings Right lower quadrant tenderness (% of cases) Rebound tenderness (% of cases) Rectal tenderness (% of cases)

22.0 hrs 100.0 67.5 61.0 17.9 10.6 95.9 69.5 41.5

Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann Surg 1984;200:567.

Distinguishing Appendiceal Perforation
Appendicitis With Perforation N=70 Duration of symptoms (hrs, median) Fever as presenting complaint (% of cases) Nausea or vomiting (% of cases) Anorexia (% of cases) Urinary symptoms (% of cases) Rebound tenderness (% of cases) Rectal tenderness (% of cases) Impression of a mass (% of cases) Appendicitis w/o Perforation N=176

48.5 hrs 34.3 60.0 52.9 10.0 64.3 41.4 21.4

18.0 hrs 11.4 70.5 64.2 10.8 71.6 41.5 6.2

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

• Free air under diaphragm – rt.

Perforated peptic ulcer

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 Xray 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.
Risk factors-cardioemboli, hypotension, CHF, MI, Digoxin, diuretics, hypercoag states

Acute Colonic
Risk Factors- Vasculitis(SLE, PN), Sickle cell dis, hypercoag, Dig, Gold, 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, crampy mild LLQ pain with urge to defecate and passage of BRB within 24hrs. Exam reveals mild tenderness most common over sigmoid or rectum. X-ray- normal to thumbprinting of colon Dx-colonoscopy for mucosal bx; angio if Rt colon only involved Rx- supportive;infarction/toxi megacolon rare

Presentation- sudden severe abd pain in pt with risk factors. Exam is nonspecific early then right sided abd tenderness and maroon stool, and ultimatley peritoneal signs with infarction X-ray- negative early then thumbprinting of SI and Rt Colon Dx- Angiography required Rx- papaverine infusion vs surgery Course-mortality 10% if Rx prior

Volvulus
• 80% sigmoid • Classic presentation in elderly with chronic constipation that presents with 12 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 Causes Gallstones, or Alcohol Diagnosis Serum amylase elevation, USS complications pseudocyst, phlegmon abcess

Pancreas

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 Serial exams (same person) Imaging Serial labs (check for WBC increases) Keep off antibiotics “Tincture of time”

• If signs and symptoms are equivocal

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

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