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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 1

1 ACUTE ABDOMINAL PAIN

David I. Soybel, M.D., F.A.C.S., Romano Delcore, M.D., F.A.C.S.

The term acute abdominal pain generally refers to previously undi- agnosed pain that arises suddenly and is of less than 7 days’ (usual- ly less than 48 hours’) duration. 1 It may be caused by a great variety of intraperitoneal disorders, many of which call for surgical treat-

ment, as well as by a range of extraperitoneal disorders, 2 which typ- ically do not call for surgical treatment [see Clinical Evaluation,Ten- tative Differential Diagnosis, below]. Abdominal pain that persists for 6 hours or longer is usually caused by disorders of surgical sig- nificance. 3 The primary goals in the management of patients with acute abdominal pain are (1) to establish a differential diagnosis and a plan for confirming the diagnosis through appropriate imag- ing studies, (2) to determine whether operative intervention is nec- essary, and (3) to prepare the patient for operation in a manner that minimizes perioperative morbidity and mortality.

In many cases, these goals are easily accomplished. On occasion,

however, the evaluation of patients with acute abdominal pain can be one of the most difficult challenges in clinical surgery. It is essen- tial to keep in mind that most (at least two thirds) of the patients who present with acute abdominal pain have disorders for which surgical intervention is not required. 2,4,5 In addition, most clinicians depend on recognition of specific patterns and sequences of symp- toms and signs to determine the need for further testing and to make decisions regarding the timing of operation; however, at least one third of patients with acute abdominal pain exhibit atypical fea- tures that render pattern recognition unreliable. 2,5 Finally, it is not clear that individual clinicians always or even usually agree on pre- senting symptoms and physical signs. In one study of abdominal pain in children, agreement between individual observers was reached 50% of the time for the physical sign of rebound tender- ness; however, for five other signs (abdominal distention, abdominal tenderness to percussion, abdominal tenderness to palpation, ab- dominal guarding, and bowel sounds), interobserver agreement was not reached in more than one third of patients.These findings high- light the difficulties inherent in evaluation and management of acute abdominal pain. In addition, they emphasize the importance of integrating care among different providers to minimize loss of in- formation and maximize continuity of care.

loss of in- formation and maximize continuity of care. Clinical Evaluation HISTORY A careful and methodical

Clinical Evaluation

HISTORY

A careful and methodical

clinical history should be obtained. Key features of the history include the di-

mensions of pain (i.e., mode of onset, duration, frequency, charac- ter, location, chronology, radiation, and intensity), as well as the presence or absence of any aggravating or alleviating factors and as- sociated symptoms. Often, such a history is more valuable than any single laboratory or x-ray finding and determines the course of sub- sequent evaluation and management. Unfortunately, when the ability of clinicians to take an organized and accurate history has been studied, the results have been disap-

pointing. 6 For this reason, the use of standardized history and phys- ical forms, with or without the aid of diagnostic computer pro- grams, has been recommended. 7-10 A large-scale study that includ- ed 16,737 patients with acute abdominal pain demonstrated that integration of computer-aided diagnosis into management yielded a 20% improvement in diagnostic accuracy. 7 The study also docu- mented statistically significant reductions in inappropriate admis- sions, negative laparotomies, serious management errors (e.g., fail- ure to operate on patients who require surgery), and length of hospital stay, as well as statistically significant increases in the num- ber of patients who were immediately discharged home without ad- verse effects and the promptness with which those requiring surgery underwent operation.Although many factors may have contributed to the observed benefits of computer-aided decision-making, it is clear that the use of structured and standardized means of collect- ing clinical and laboratory data was crucial. An example of such a structured data sheet is the pain chart developed by the World Or- ganization of Gastroenterology (OMGE) [see Figure 1]. Because this pain chart is not exhaustive and does not cover all potential sit- uations, individual surgeons may want to add to it; however, they would be well advised not to omit any of the symptoms and signs on the OMGE data sheet from their routine examination of pa- tients with acute abdominal pain. 11 The patient’s own words often provide important clues to the correct diagnosis.The examiner should refrain from suggesting spe- cific symptoms, except as a last resort. Any questions that must be asked should be open-ended—for example, “What happens when you eat?” rather than “Does eating make the pain worse?” Leading questions should be avoided. When a leading question must be asked, it should be posed first as a negative question (i.e., one that calls for an answer in the negative) because a negative answer to a question is more likely to be honest and accurate. For example, if peritoneal inflammation is suspected, the question asked should be “Does coughing make the pain better?” rather than “Does cough- ing make the pain worse?” The mode of onset of abdominal pain may help the examiner de- termine the severity of the underlying disease. Pain that has a sud- den onset suggests an intra-abdominal catastrophe, such as a rup- tured abdominal aortic aneurysm (AAA), a perforated viscus, or a ruptured ectopic pregnancy; a near loss of consciousness or stamina associated with sudden-onset pain should heighten the level of con- cern for such a catastrophe. Rapidly progressive pain that becomes intensely focused in a well-defined area within a period of a few minutes to an hour or two suggests a condition such as acute chole- cystitis or pancreatitis. Pain that has a gradual onset over several hours, usually beginning as slight or vague discomfort and slowly progressing to steady and more localized pain, suggests a subacute process and is characteristic of processes that lead to peritoneal in- flammation. Numerous disorders may be associated with this mode of onset, including acute appendicitis, diverticulitis, pelvic inflam- matory disease (PID), and intestinal obstruction. Pain can be either intermittent or continuous. Intermittent or cramping pain (colic) is pain that occurs for a short period (a few minutes), followed by longer periods (a few minutes to one-half

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 2

Assessment of Acute Abdominal Pain

Generate working diagnosis

Proceed with subsequent management on the basis of the working diagnosis. Reevaluate patient repeatedly. If patient does not respond to treatment as expected, reassess working diagnosis and return to differential diagnosis.

Patient presents with acute abdominal pain

Obtain clinical history

Assess mode of onset, duration, frequency, character, location, chronology, radiation, and intensity of pain. Look for aggravating or alleviating factors and associated symptoms. Use structured data sheets if possible.

Perform basic investigative studies

Laboratory: complete blood count, hematocrit, electrolytes, creatinine, blood urea nitrogen, glucose, liver function tests, amylase, lipase, urinalysis, pregnancy test, ECG (if patient is elderly or has atherosclerosis). Imaging: Perform US or CT as indicated by results of examination and basic laboratory studies.

Patient has acute surgical abdomen

Operate immediately. Conditions necessitating immediate laparotomy include ruptured abdominal aortic or visceral aneurysm, ruptured ectopic pregnancy, spontaneous hepatic or splenic rupture, major blunt or penetrating abdominal trauma, and hemoperitoneum from various causes. Severe hemodynamic instability is the essential indication.

Patient has subacute surgical abdomen

Treat surgically when diagnosis is confirmed.

Patient requires urgent laparotomy or laparoscopy

Conditions necessitating urgent laparotomy include perforated hollow viscus, appendicitis, Meckel diverticulitis, strangulated hernia, mesenteric ischemia, and ectopic pregnancy (unruptured). Laparoscopy is recommended for acute appendicitis and perforated ulcers (provided that surgeon has sufficient experience and competence with the technique).

Patient should be hospitalized and observed

Observe patient carefully, and reevaluate condition periodically. Consider additional investigative studies (e.g., CT, US, diagnostic peritoneal lavage, radionuclide imaging, angiography, MRI, and GI endoscopy). Diagnostic laparoscopy is recommended if pain persists after a period of observation.

Patient requires early laparotomy or laparoscopy

Early laparotomy or laparoscopy is reserved for patients whose conditions are unlikely to become life
Early laparotomy or laparoscopy is
reserved for patients whose conditions
are unlikely to become life threatening
if operation is delayed for 24–48
hr (e.g., those with uncomplicated
intestinal obstruction, uncomplicated
acute cholecystitis, uncomplicated
acute diverticulitis, or nonstrangulated
incarcerated hernia).

Patient is candidate for elective laparotomy or laparoscopy

Elective laparotomy or laparoscopy is reserved for patients who are highly likely to respond to conservative medical management or whose conditions are highly unlikely to become life threatening during prolonged evaluation (e.g., those with IBD, peptic ulcer disease, pancreatitis, or endometriosis).

Diagnosis is uncertain, or patient has suspected nonsurgical abdomen

Reevaluate patient as appropriate (see facing page).

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 3

Generate tentative differential diagnosis

Remember that the majority of patients will turn out to have nonsurgical diagnoses. Take into account effects of age and gender on diagnostic possibilities.

Perform physical examination

Evaluate general appearance and ability to answer questions; estimate degree of obvious pain; note position in bed; identify area of maximal pain; look for extra-abdominal causes of pain and signs of systemic illness. Perform systematic abdominal examination: (1) inspection, (2) auscultation, (3) percussion, (4) palpation. Perform rectal, genital, and pelvic examinations.

Patient has abdominal pain of uncertain origin

Observe patient to determine whether operation is indicated.

Patient should be hospitalized and observed

Provide narcotic analgesia as appropriate. Observe patient carefully, and reevaluate condition periodically. Consider additional investigative studies. CT and US may be especially useful.

Patient has suspected surgical abdomen

Reevaluate patient as appropriate (see facing page).

Patient can be evaluated in outpatient setting

Diagnosis is uncertain, or patient has suspected nonsurgical abdomen

Reevaluate patient as appropriate (see above, right, and facing page).

Patient has nonsurgical condition or chronic relapsing condition that does not necessitate operative intervention

Nonsurgical conditions causing acute abdominal pain include both extraperitoneal [see Table 2] and intraperitoneal disorders.

Patient should be hospitalized and observed

Provide narcotic analgesia as appropriate. Observe patient carefully, and reevaluate condition periodically. Consider additional investigative studies.

Diagnosis is uncertain or patient has suspected surgical abdomen

Reevaluate patient as appropriate (see above, left, and facing page).

Diagnosis is

nonsurgical

Refer patient for medical management.

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 4

ABDOMINAL PAIN CHART NAME REG. NUMBER MALE FEMALE AGE FORM FILLED BY MODE OF ARRIVAL
ABDOMINAL PAIN CHART
NAME
REG. NUMBER
MALE
FEMALE
AGE
FORM FILLED BY
MODE OF ARRIVAL
DATE
TIME
Site of Pain
Aggravating Factors
movement
At Onset
coughing
respiration
Progression of Pain
better
same
worse
food
Duration
At Present
other
Type
none
intermittent
Relieving Factors
steady
lying still
colicky
vomiting
Radiation
Severity
antacids
moderate
food
severe
other
none
Nausea
Bowels
Previous Similar Pain
yes
no
normal
yes
no
constipation
Vomiting
Previous Abdominal Surgery
diarrhea
yes
no
yes
no
blood
Anorexia
Drugs for Abdominal Pain
mucus
yes
no
yes
no
Micturition
Indigestion
Female-LMP
normal
yes
no
pregnant
frequency
vaginal discharge
dysuria
Jaundice
dizzy/faint
dark
yes
no
hematuria
Temp.
Pulse
Location of Tenderness
Initial Diagnosis & Plan
BP
Mood
Rebound
normal
yes
no
upset
Guarding
anxious
yes
no
Results
amylase
blood count (WBC)
Color
Rigidity
normal
yes
no
urine
x-ray
pale
Mass
flushed
yes
no
jaundiced
cyanotic
Murphy’s Sign Present
other
yes
no
Intestinal Movement
normal
Bowel Sounds
poor/nil
normal
Diagnosis & Plan after Investigation
peristalsis
absent
increased
Scars
yes
no
Rectal-Vaginal Tenderness
left
Distention
(time
)
yes
no
right
general
mass
none
Discharge Diagnosis
History and examination of other systems on separate case notes.
Figure 1
Shown on facing page is a data sheet modified from the abdominal pain chart developed by the
OMGE. 10
PAINHISTORYEXAMINATION

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 5

hour) of complete remission during which there is no pain at all. In- termittent pain is characteristic of obstruction of a hollow viscus and results from vigorous peristalsis in the wall of the viscus proxi- mal to the site of obstruction.This pain is perceived as deep in the abdomen and is poorly localized.The patient is restless, may writhe about incessantly in an effort to find a comfortable position, and of- ten presses on the abdominal wall in an attempt to alleviate the pain.Whereas the intermittent pain associated with intestinal ob- struction (typically described as gripping and mounting) is usually severe but bearable, the pain associated with obstruction of small conduits (e.g., the biliary tract, the ureters, and the uterine tubes) often becomes unbearable. Obstruction of the gallbladder or the bile ducts gives rise to a type of pain often referred to as biliary col- ic; however, this term is a misnomer, in that biliary pain is usually constant because of the lack of a strong muscular coat in the biliary tree and the absence of regular peristalsis. Continuous or constant pain is pain that is present for hours or days without any period of complete relief; it is more common than intermittent pain. Continuous pain is usually indicative of a process that will lead, or has already led, to peritoneal inflammation or is- chemia. It may be of steady intensity throughout, or it may be asso- ciated with intermittent pain. For example, the typical colicky pain associated with simple intestinal obstruction changes when strangu- lation occurs, becoming continuous pain that persists between episodes or waves of cramping pain. Certain types of pain are generally held to be typical of certain pathologic states. For example, the pain of a perforated ulcer is often described as burning, that of a dissecting aneurysm as tearing, and that of bowel obstruction as gripping. One may imagine that the first type of pain is explained by the efflux of acid, the second by the sud- den expansion of the retroperitoneum, and the third by the churning of hyperperistalsis. Colorful as these images may be, in most cases, the pain begins in a nondescript way. It is only by carefully following the patient’s description of the evolution and time course of the pain that such images may be formed with confidence. For several reasons—atypical pain patterns, dual innervation by visceral and somatic afferents, normal variations in organ position, and widely diverse underlying pathologic states—the location of ab- dominal pain is only a rough guide to diagnosis. It is nevertheless true that in most disorders, the pain tends to occur in characteristic locations, such as the right upper quadrant (cholecystitis), the right lower quadrant (appendicitis), the epigastrium (pancreatitis), or the left lower quadrant (sigmoid diverticulitis) [see Figure 2]. It is impor- tant to determine the location of the pain at onset because this may differ from the location at the time of presentation (so-called shifting pain). In fact, the chronological sequence of events in the patient’s history is often more important for diagnosis than the location of the pain alone. For example, the classic pain of appendicitis begins in the periumbilical region and settles in the right lower quadrant.A similar shift in location can occur when escaping gastroduodenal contents from a perforated ulcer pool in the right lower quadrant. It is also important to take into account radiation or referral of the pain, which tends to occur in characteristic patterns [see Figure 3]. For example, biliary pain is referred to the right subscapular area, and the boring pain of pancreatitis typically radiates straight through to the back. Obstruction of the small intestine and the proximal colon is referred to the umbilicus, and obstruction distal to the splenic flexure is often referred to the suprapubic area. Spasm in the ureter often radiates to the suprapubic area and into the groin.The more severe the pain is, the more likely it is to be associ- ated with referral to other areas. The intensity or severity of the pain is related to the magnitude of the underlying insult. It is important to distinguish between the in-

tensity of the pain and the patient’s reaction to it because there ap- pear to be significant individual differences with respect to tolerance of and reaction to pain. Pain that is intense enough to awaken the patient from sleep usually indicates a significant underlying organic cause. Past episodes of pain and factors that aggravate or relieve the pain often provide useful diagnostic clues. For example, pain caused by peritonitis tends to be exacerbated by motion, deep breathing, coughing, or sneezing, and patients with peritonitis tend to lie qui- etly in bed and avoid any movement.The typical pain of acute pan- creatitis is exacerbated by lying down and relieved by sitting up. Pain that is relieved by eating or taking antacids suggests duodenal ulcer disease, whereas diffuse abdominal pain that appears 30 min- utes to 1 hour after meals suggests intestinal angina. Associated gastrointestinal symptoms (e.g., nausea, vomiting, anorexia, diarrhea, and constipation) often accompany abdominal pain; however, these symptoms are nonspecific and therefore may not be of great value in the differential diagnosis.Vomiting in partic- ular is common: when sufficiently stimulated by pain impulses trav- eling via secondary visceral afferent fibers, the medullary vomiting centers activate efferent fibers and cause reflex vomiting. Once again, the chronology of events is important, in that pain often precedes vomiting in patients with conditions necessitating operation, where- as the opposite is usually the case in patients with medical (i.e., non- surgical) conditions. 5,12 This is particularly true for adult patients with acute appendicitis, in whom pain almost always precedes vom- iting by several hours. In children, vomiting is commonly observed closer to the onset of the pain, though it is rarely the initial symptom. Similarly, constipation may result from a reflex paralytic ileus when sufficiently stimulated visceral afferent fibers activate effer- ent sympathetic fibers (splanchnic nerves) to reduce intestinal peristalsis. Diarrhea is characteristic of gastroenteritis but may also accompany incomplete intestinal or colonic obstruction. More significant is a history of obstipation, because if it can be definitely established that a patient with acute abdominal pain has not passed gas or stool for 24 to 48 hours, it is certain that some degree of intestinal obstruction is present. Other associated symp- toms that should be noted include jaundice, melena, hema- tochezia, hematemesis, and hematuria.These symptoms are much more specific than the ones just discussed and can be extremely valuable in the differential diagnosis. Most conditions that cause acute abdominal pain of surgical significance are associated with some degree of fever if they are allowed to continue long enough. Fever suggests an inflammatory process; however, it is usually low grade and often absent altogether, particularly in elderly and im- munocompromised patients.The combination of a high fever with chills and rigors indicates bacteremia, and concomitant changes in mental status (e.g., agitation, disorientation, and lethargy) sug- gest impending septic shock. A history of trauma (even if the patient considers the traumatic event trivial) should be actively sought in all cases of unexplained acute abdominal pain; such a history may not be readily volun- teered (as is often the case with trauma resulting from domestic vio- lence).The history may be particularly relevant in a patient taking anticoagulants and presenting with acute onset of abdominal pain accompanied by tenderness but no clear signs of inflammation. Hematoma within the rectus muscle sheath can easily be mistaken for appendicitis or other lower abdominal illnesses; hematoma else- where can produce symptoms of obstruction or acute bleeding into the peritoneum and the retroperitoneum. In female patients, it is es- sential to obtain a detailed gynecologic history that includes the timing of symptoms within the menstrual cycle, the date of the last menses, previous and current use of contraception, any abnormal vaginal bleeding or discharge, an obstetric history, and any risk fac-

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 6

a

b

Principles and Practice 1 Acute Abdominal Pain — 6 a b EPIGASTRIC REGION Peptic Ulcer Gastritis
EPIGASTRIC REGION Peptic Ulcer Gastritis Pancreatitis Duodenitis Gastroenteritis Early Appendicitis Mesenteric
EPIGASTRIC REGION
Peptic Ulcer
Gastritis
Pancreatitis
Duodenitis
Gastroenteritis
Early Appendicitis
Mesenteric Adenitis
Mesenteric Thrombosis
Intestinal Obstruction
Inflammatory Bowel
Disease
DIFFUSE
Peritonitis
Early Appendicitis
Pancreatitis
Leukemia
Sickle Cell Crisis
Gastroenteritis
Mesenteric Adenitis
Mesenteric Thrombosis
Intestinal Obstruction
Inflammatory Bowel
Disease
Aneurysm
Metabolic Causes
Toxic Causes
c
LEFT UPPER QUADRANT
Gastritis
Pancreatitis
Splenic Enlargement
Splenic Rupture
Splenic Infarction
Splenic Aneurysm
Pyelonephritis
Nephrolithiasis
Herpes Zoster
Myocardial Ischemia
Pneumonia
Empyema
Diverticulitis
Intestinal Obstruction
Inflammatory Bowel Disease

RIGHT UPPER QUADRANT Cholecystitis Choledocholithiasis Hepatitis Hepatic Abscess Hepatomegaly from Congestive Heart Failure Peptic Ulcer Pancreatitis Retrocecal Appendicitis Pyelonephritis Nephrolithiasis Herpes Zoster Myocardial Ischemia Pericarditis Pneumonia Empyema Gastritis Duodenitis Intestinal Obstruction Inflammatory Bowel Disease

RIGHT LOWER QUADRANT Appendicitis Intestinal Obstruction Inflammatory Bowel Disease Mesenteric Adenitis Diverticulitis Cholecystitis Perforated Ulcer Leaking Aneurysm Abdominal Wall Hematoma Ectopic Pregnancy Ovarian Cyst/Torsion Salpingitis Mittelschmerz Endometriosis Ureteral Calculi Pyelonephritis Nephrolithiasis Seminal Vesiculitis Psoas Abscess Hernia

Nephrolithiasis Seminal Vesiculitis Psoas Abscess Hernia LEFT LOWER QUADRANT Diverticulitis Intestinal Obstruction

LEFT LOWER QUADRANT Diverticulitis Intestinal Obstruction Inflammatory Bowel Disease Appendicitis Leaking Aneurysm Abdominal Wall Hematoma Ectopic Pregnancy Mittelschmerz Ovarian Cyst/Torsion Salpingitis Endometriosis Ureteral Calculi Pyelonephritis Nephrolithiasis Seminal Vesiculitis Psoas Abscess Hernia

UMBILICAL REGION Early Appendicitis Gastroenteritis Pancreatitis Hernia Mesenteric Adenitis Mesenteric Thrombosis Intestinal Obstruction Inflammatory Bowel Disease Aneurysm

HYPOGASTRIC REGION Cystitis Diverticulitis Appendicitis Prostatism Salpingitis Hernia Ovarian Cyst/Torsion Endometriosis Ectopic Pregnancy Nephrolithiasis Intestinal Obstruction Inflammatory Bowel Disease Abdominal Wall Hematoma

Figure 2

in specific locations. (a) Diffuse pain suggests a certain set of diagnostic possibilities. (b) Differing groups of disorders give rise to abdominal pain in the epigastric, umbilical, and hypogastric regions. (c) Disorders that give rise to acute abdominal pain may be grouped according to the quadrant of the abdomen in which pain tends to occur.

In most disorders that give rise to acute abdominal pain, the pain tends to occur

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 7

Esophagus Perforated Duodenal Ulcer (Diaphragmatic Irritation) Stomach Liver and Biliary Colic Gallbladder Pylorus
Esophagus
Perforated Duodenal Ulcer
(Diaphragmatic Irritation)
Stomach
Liver and
Biliary Colic
Gallbladder
Pylorus
Colon
Acute Pancreatitis and
Renal Colic
Left and Right
Kidneys
Uterine and Rectal Pain
Ureter
Figure 3
Pain of abdominal origin tends to be referred in characteristic patterns. 80 The more severe the pain is, the

more likely it is to be referred. Shown are anterior (left) and posterior (right) areas of referred pain.

tors for ectopic pregnancy (e.g., PID, use of an intrauterine device, or previous ectopic or tubal surgery). A complete history of previous medical conditions must be ob- tained because associated diseases of the cardiac, pulmonary, and renal systems may give rise to acute abdominal symptoms and may also significantly affect the morbidity and mortality associated with surgical intervention.Weight changes, past illnesses, recent travel, environmental exposure to toxins or infectious agents, and medica- tions used should also be investigated.A history of previous abdom- inal operations should be obtained but should not be relied on too heavily in the absence of operative reports.A careful family history is important for detection of hereditary disorders that may cause acute abdominal pain. A detailed social history should also be ob- tained that includes any history of tobacco, alcohol, or illicit drug use, as well as a sexual history.

TENTATIVE DIFFERENTIAL DIAGNOSIS

Once the history has been obtained, the examin- er should generate a tenta- tive differential diagnosis and carry out the physical

examination in search of specific signs or findings that either rule out or confirm the diag- nostic possibilities. Given the diversity of conditions that can cause acute abdominal pain [see Tables 1 and 2], there is no substi- tute for general awareness of the most common causes of acute abdominal pain and the influence of age, gender, and geography on the likelihood of any of these potential causes. Although acute abdominal pain is the most common surgical emergency and most non–trauma-related surgical admissions (and 1% of all hos- pital admissions) are accounted for by patients complaining of abdominal pain, little information is available regarding the clini- cal spectrum of disease in these patients. 13 Nevertheless, detailed epidemiologic information can be an invaluable asset in the diag- nosis and treatment of acute abdominal pain. Now that patients from different parts of the world are increasingly being seen in

different parts of the world are increasingly being seen in North American emergency rooms, it is

North American emergency rooms, it is important to consider endemic diseases, including tuberculosis, 14,15 parasitic diseases, 16- 18 bezoars from unusual dietary habits, 19,20 and unusual malig- nancies. 21,22 The value of detailed epidemiologic knowledge notwithstanding, it is worthwhile to keep in mind the truism that common things are common. Regarding which things are common, the most extensive information currently available comes from the ongoing survey be- gun in 1977 by the Research Committee of the OMGE. As of the last progress report on this survey, which was published in 1988, 23 more than 200 physicians at 26 centers in 17 countries had accu- mulated data on 10,320 patients with acute abdominal pain [see Table 3].The most common diagnosis in these patients was nonspe- cific abdominal pain (NSAP)—that is, the retrospective diagnosis of exclusion in which no cause for the pain can be identified. 24,25 Non- specific abdominal pain accounted for 34% of all patients seen; the four most common diagnoses accounted for more than 75%.The most common surgical diagnosis in the OMGE survey was acute appendicitis, followed by acute cholecystitis, small bowel obstruc- tion, and gynecologic disorders. Relatively few patients had perfo- rated peptic ulcer, a finding that confirms the current downward trend in the incidence of this condition. Cancer was found to be a significant cause of acute abdominal pain.There was little variation in the geographic distribution of surgical causes of acute abdominal pain (i.e., conditions necessitating operation) among developed countries. In patients who required operation, the most common causes were acute appendicitis (42.6%), acute cholecystitis (14.7%), small bowel obstruction (6.2%), perforated peptic ulcer (3.7%), and acute pancreatitis (4.5%). 23 The OMGE survey’s finding that NSAP was the most common diagnosis in patients with acute ab- dominal pain has been confirmed by several srudies 12,13,25 ; the find- ing that acute appendicitis, cholecystitis, and intestinal obstruction were the three most common diagnoses in patients with acute ab- dominal pain who require operation has also been amply confirmed [see Table 3]. 1,12,13 The data described so far provide a comprehensive picture of the most likely diagnoses for patients with acute abdominal pain in many centers around the world; however, this picture does not take

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 8

Inflammatory

Table 1

Peritoneal Chemical and nonbacterial peritonitis Perforated peptic ulcer/biliary tree, pancreatitis, ruptured ovarian cyst, mittelschmerz Bacterial peritonitis Primary peritonitis Pneumococcal, streptococcal, tuberculous Spontaneous bacterial peritonitis Perforated hollow viscus Esophagus, stomach, duodenum, small intestine, bile duct, gallbladder, colon, urinary bladder Hollow visceral Appendicitis Cholecystitis Peptic ulcer Gastroenteritis Gastritis Duodenitis Inflammatory bowel disease Meckel diverticulitis Colitis (bacterial, amebic) Diverticulitis Solid visceral Pancreatitis Hepatitis

Intraperitoneal Causes of Acute Abdominal Pain 81

Pancreatic abscess Hepatic abscess Splenic abscess Mesenteric Lymphadenitis (bacterial, viral) Epiploic appendagitis Pelvic Pelvic inflammatory disease (salpingitis) Tubo-ovarian abscess Endometritis

Mechanical (obstruction, acute distention)

Hollow visceral Intestinal obstruction Adhesions, hernias, neoplasms, volvulus Intussusception, gallstone ileus, foreign bodies Bezoars, parasites Biliary obstruction Calculi, neoplasms, choledochal cyst, hemobilia Solid visceral Acute splenomegaly Acute hepatomegaly (congestive heart failure, Budd-Chiari syndrome) Mesenteric Omental torsion Pelvic Ovarian cyst

Torsion or degeneration of fibroid Ectopic pregnancy

Hemoperitoneum

Ruptured hepatic neoplasm Spontaneous splenic rupture Ruptured mesentery Ruptured uterus Ruptured graafian follicle Ruptured ectopic pregnancy Ruptured aortic or visceral aneurysm

Ischemic

Mesenteric thrombosis Hepatic infarction (toxemia, purpura) Splenic infarction Omental ischemia Strangulated hernia

Neoplastic

Primary or metastatic intraperitoneal neoplasms

Traumatic

Blunt trauma

Penetrating trauma

Iatrogenic trauma

Domestic violence

Miscellaneous

Endometriosis

into account the effect of age on the relative likelihood of the vari- ous potential diagnoses. It is well known that the disease spectrum of acute abdominal pain is different in different age groups, espe- cially in the very old 4,26,27 and the very young. 28-30 In the OMGE survey, well over 90% of cases of acute abdominal pain in children were diagnosed as acute appendicitis (32%) or NSAP (62%). 28 Similar age-related differences in the spectrum of disease have been confirmed by other studies, 16 as have various gender-related differences. This variation in the disease spectrum is readily apparent when

the 10,320 patients from the OMGE survey are segregated by age [see Table 4]. In patients 50 years of age or older, 27 cholecystitis was more common than either NSAP or acute appendicitis; small bowel obstruction, diverticular disease, and pancreatitis were all approximately five times more common than in patients younger than 50 years. Hernias were also a much more common problem in older patients. In the entire group of patients, only one of every

10 instances of intestinal obstruction was attributable to a hernia,

whereas in patients 50 years of age or older, one of every three in- stances was caused by an undiagnosed hernia. Cancer was 40 times more likely to be the cause of acute abdominal pain in pa- tients 50 years of age or older; vascular diseases (including my- ocardial infarction, mesenteric ischemia, and ruptured AAA) were

25 times more common in patients 50 years of age or older and

100 times more common in patients older than 70 years.What is

more, outcome was clearly related to age: mortality was signifi- cantly higher in patients older than 70 years (5%) than in those younger than 50 years (< 1%). Whereas the peak incidence of acute abdominal pain occurred in patients in their teens and 20s, 28 the great majority of deaths occurred in patients older than

70 years. 27

PHYSICAL EXAMINATION

in patients older than 70 years. 27 PHYSICAL EXAMINATION In the physical examina- tion of a

In the physical examina- tion of a patient, as in the taking of the history, there is no substitute for organiza- tion and patience; the amount of information that

can be obtained is directly proportional to the gentleness and thoroughness of the examiner. The physical examination begins with a brief but thorough evalua- tion of the patient’s general appearance and ability to answer ques- tions.The degree of obvious pain should be estimated.The patient’s position in bed should be noted.A patient who lies motionless with flexed hips and knees is more likely to have generalized peritonitis.A restless patient who writhes about in bed is more likely to have col- icky pain. The area of maximal pain should be identified before the physi- cal examination is begun.The examiner can easily do this by simply asking the patient to cough and then to point with two fingers to the area where pain seems to be focused.This allows the examiner to avoid the area in the early stages of the examination and to confirm it at a later stage without causing the patient unnecessary discom- fort in the meantime. The physical examination should be directed, in the sense that it should address critical findings that would confirm or exclude the likeliest disorders in the differential diagnosis. In this context, how- ever, it should be complete. Some processes that can cause abdom- inal pain occur within the chest (e.g., pneumonia, ischemic heart disease or arrhythmia, esophageal muscular disorders); thus, aus- cultation of the lungs and the heart is integral to the examination. Pelvic examination should be performed in women, and examina-

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 9

tion of the rectum and the groin should be performed in all patients. It should not be assumed that advanced imaging technology (e.g., CT, MRI, or ultrasonography [US]) will provide the diagnosis most quickly or with the highest level of confidence.The sensitivity and specificity (not to mention the cost-effectiveness) of any laboratory or imaging study are grounded in the intelligent gathering and cate- gorization of signs and symptoms. 31,32 Before attention is directed to the patient’s abdomen, signs of systemic illness should be sought. Systemic signs of shock (e.g., di- aphoresis, pallor, hypothermia, tachypnea, tachycardia with or- thostasis, and frank hypotension) usually accompany a rapidly pro- gressive or advanced intra-abdominal condition and, in the absence of extra-abdominal causes, are indications for immediate laparoto- my.The absence of any alteration in vital signs, however, does not necessarily exclude a serious intra-abdominal process. Examination of the abdomen begins with the patient resting in a comfortable supine position.A right-handed examiner should stand on the patient’s right side, and the patient’s abdomen should be lev- el with the elbow at rest. In some cases, to make sure that the exam- ination is unhurried and the patient’s anxiety is allayed, the examin- er may find it useful to sit at the bedside.The examination should include inspection, auscultation, percussion, and palpation of all ar- eas of the abdomen, the flanks, and the groin (including all hernia orifices) in addition to rectal and genital examinations (and, in fe- male patients, a full gynecologic examination). A systematic ap-

proach is crucial: an examiner who methodically follows a set pat- tern of abdominal examination every time will be rewarded more frequently than one who improvises haphazardly with each patient. The first step in the abdominal examination is careful inspection of the anterior and posterior abdominal walls, the flanks, the per- ineum, and the genitalia for previous surgical scars (possible adhe- sions), hernias (incarceration or strangulation), distention (intestinal obstruction), obvious masses (distended gallbladder, abscesses, or tumors), ecchymosis or abrasions (trauma), striae (pregnancy or as- cites), an everted umbilicus (increased intra-abdominal pressure), visible pulsations (aneurysm), visible peristalsis (obstruction), limi- tation of movement of the abdominal wall with ventilatory move- ments (peritonitis), or engorged veins (portal hypertension). The next recommended step in the abdominal examination is auscultation. Although it is important to note the presence (or ab- sence) of bowel sounds and their quality, auscultation is probably the least rewarding aspect of the physical examination. Severe intra- abdominal conditions, even intra-abdominal catastrophes, may oc- cur in patients with normal bowel sounds, and patients with silent abdomens may have no significant intra-abdominal pathology at all. In general, however, the absence of bowel sounds indicates a para- lytic ileus; hyperactive or hypoactive bowel sounds often are varia- tions of normal activity; and high-pitched bowel sounds with splashes, tinkles (echoing as in a large cavern), or rushes (pro- longed, loud gurgles) indicate mechanical bowel obstruction.

Table 2 Extraperitoneal Causes of Acute Abdominal Pain Genitourinary Endocrine Hematologic Pyelonephritis
Table 2
Extraperitoneal Causes of Acute Abdominal Pain
Genitourinary
Endocrine
Hematologic
Pyelonephritis
Perinephric abscess
Renal infarct
Nephrolithiasis
Ureteral obstruction (lithiasis, tumor)
Acute cystitis
Prostatitis
Seminal vesiculitis
Epididymitis
Orchitis
Testicular torsion
Dysmenorrhea
Threatened abortion
Diabetic ketoacidosis
Hyperparathyroidism (hypercalcemia)
Acute adrenal insufficiency (Addisonian
crisis)
Hyperthyroidism or hypothyroidism
Sickle cell crisis
Acute leukemia
Acute hemolytic states
Coagulopathies
Pernicious anemia
Other dyscrasias
Musculoskeletal
Rectus sheath hematoma
Arthritis/diskitis of thoracolumbar spine
Vascular
Vasculitis
Periarteritis
Neurogenic
Pulmonary
Pneumonia
Empyema
Pulmonary embolus
Herpes zoster
Tabes dorsalis
Nerve root compression
Spinal cord tumors
Osteomyelitis of the spine
Abdominal epilepsy
Abdominal migraine
Multiple sclerosis
Toxins
Bacterial toxins (tetanus, staphylococcus)
Insect venom (black widow spider)
Animal venom
Heavy metals (lead, arsenic, mercury)
Poisonous mushrooms
Drugs
Withdrawal from narcotics
Pulmonary infarction
Pneumothorax
Inflammatory
Retroperitoneal
Cardiac
Myocardial ischemia
Myocardial infarction
Acute rheumatic fever
Acute pericarditis
Schönlein-Henoch purpura
Systemic lupus erythematosus
Polyarteritis nodosa
Dermatomyositis
Scleroderma
Retroperitoneal hemorrhage (spontaneous
adrenal hemorrhage)
Psoas abscess
Psychogenic
Hypochondriasis
Somatization disorders
Infectious
Metabolic
Factitious
Acute intermittent porphyria
Familial Mediterranean fever
Hypolipoproteinemia
Hemochromatosis
Hereditary angioneurotic edema
Bacterial
Parasitic (malaria)
Viral (measles, mumps, infectious
mononucleosis)
Rickettsial (Rocky Mountain spotted
fever)
Munchausen syndrome
Malingering

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 10

Table 3

Frequency of Specific Diagnoses in Patients with Acute Abdominal Pain

   

Frequency in Individual Studies (% of Patients)

 

Diagnosis

OMGE 23 (N = 10,320)

Wilson 82 (N = 1,196)

Irvin 13 (N = 1,190)

Brewer 12 (N = 1,000)

de Dombal 1

Hawthorn 83

(N

= 552)

(N = 496)

Nonspecific abdominal pain

34.0

45.6

34.9

41.3

 

50.5

36.0

Acute appendicitis

28.1

15.6

16.8

4.3

 

26.3

14.9

Acute cholecystitis

9.7

5.8

5.1

2.5

 

7.6

5.9

Small bowel obstruction

4.1

2.6

14.8

2.5

 

3.6

8.6

Acute gynecologic disease

4.0

4.0

1.1

8.5

 

Acute pancreatitis

2.9

1.3

2.4

 

2.9

2.1

Urologic disorders

2.9

4.7

5.9

11.4

 

12.8

Perforated peptic ulcer

2.5

2.3

2.5

2.0

 

3.1

Cancer

1.5

3.0

 

Diverticular disease

1.5

1.1

3.9

 

2.0

3.0

Dyspepsia

1.4

7.6

1.4

1.4

 

Gastroenteritis

0.3

6.9

 

5.1

Inflammatory bowel disease

0.8

 

2.1

Mesenteric adenitis

3.6

 

1.5

Gastritis

2.1

1.4

 

Constipation

2.4

2.3

 

Amebic hepatic abscess

1.2

1.9

 

Miscellaneous

6.3

1.3

5.2

15.5

 

4.0

8.0

The third step is percussion to search for any areas of dullness, flu-

id collections, sections of gas-filled bowel, or pockets of free air under the abdominal wall.Tympany may be present in patients with bowel obstruction or hollow viscus perforation. Percussion can be useful as

a way of estimating organ size and of determining the presence of as-

cites (signaled by a fluid wave or shifting dullness). Gentle percussion over the four quadrants of the abdomen can also be used to elicit a sign of peritoneal irritation, and patients tolerate this maneuver rea- sonably well. Pain associated with mild levels of percussion is a good indicator of peritonitis if the maneuver is performed in the same way each time. In general, however, maneuvers associated with palpation are best for determining whether peritonitis is present. The last step, palpation, is the most informative aspect of the physical examination. Palpation of the abdomen must be done very gently to avoid causing additional pain early in the examination. It should begin as far as possible from the area of maximal pain and then should gradually advance toward this area, which should be the last to be palpated.The examiner should place the entire hand on the patient’s abdomen with the fingers together and extended, ap- plying pressure with the pulps (not the tips) of the fingers by flexing the wrists and the metacarpophalangeal joints. It is essential to de- termine whether true involuntary muscle guarding (muscle spasm)

is present.This determination is made by means of gentle palpation

over the abdominal wall while the patient takes a long, deep breath. If guarding is voluntary, the underlying muscle immediately relaxes under the gentle pressure of the palpating hand. If, however, the pa- tient has true involuntary guarding, the muscle remains in spasm

(i.e., taut and rigid) throughout the respiratory cycle (so-called boardlike abdomen).True involuntary guarding is indicative of lo- calized or generalized peritonitis. It must be remembered that mus-

Table 4

Frequency of Specific Diagnoses in

Younger and Older Patients with Acute Abdominal

Pain in the OMGE Study 23,27

 

Frequency (% of Patients)

Diagnosis

Age < 50 Yr

Age 50 Yr

(N

= 6,317)

(N = 2,406)

Nonspecific abdominal pain

 

39.5

15.7

Appendicitis

 

32.0

15.2

Cholecystitis

 

6.3

20.9

Obstruction

 

2.5

12.3

Pancreatitis

 

1.6

7.3

Diverticular disease

 

< 0.1

5.5

Cancer

 

< 0.1

4.1

Hernia

 

< 0.1

3.1

Vascular disease

 

< 0.1

2.3

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ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 11

Table 5

Common Abdominal Signs and Findings Noted on Physical Examination 6

Sign or Finding

Description

Associated Clinical Condition(s)

Aaron sign

Referred pain or feeling of distress in epigastrium or precordial re- gion on continued firm pressure over the McBurney point

Acute appendicitis

Ballance sign

Presence of dull percussion note in both flanks, constant on left side but shifting with change of position on right side

Ruptured spleen

Bassler sign

Sharp pain elicited by pinching appendix between thumb of examin- er and iliacus muscle

Chronic appendicitis

Beevor sign

Upward movement of umbilicus

Paralysis of lower portions of rectus abdominis muscles

Blumberg sign

Transient abdominal wall rebound tenderness

Peritoneal inflammation

Carnett sign

Disappearance of abdominal tenderness when anterior abdominal muscles are contracted

Abdominal pain of intra-abdominal origin

Chandelier sign

Intense lower abdominal and pelvic pain on manipulation of cervix

Pelvic inflammatory disease

Charcot sign

Intermittent right upper quadrant abdominal pain, jaundice, and fever

Choledocholithiasis

Chaussier sign

Severe epigastric pain in gravid female

Prodrome of eclampsia

Claybrook sign

Transmission of breath and heart sounds through abdominal wall

Ruptured abdominal viscus

Courvoisier sign

Palpable, nontender gallbladder in presence of clinical jaundice

Periampullary neoplasm

Cruveilhier sign

Varicose veins radiating from umbilicus (caput medusae)

Portal hypertension

Cullen sign

Periumbilical darkening of skin from blood

Hemoperitoneum (especially in ruptured ectopic pregnancy)

Cutaneous

Increased abdominal wall sensation to light touch

Parietal peritoneal inflammation secondary to inflammatory intra-abdominal pathology

hyperesthesia

Dance sign

Slight retraction in area of right iliac fossa

Intussusception

Danforth sign

Shoulder pain on inspiration

Hemoperitoneum (especially in ruptured ectopic pregnancy)

Direct abdominal wall tenderness

Localized inflammation of abdominal wall, peritoneum, or an intra-abdominal viscus

Fothergill sign

Abdominal wall mass that does not cross midline and remains palpa- ble when rectus muscle is tense

Rectus muscle hematoma

cle rigidity is relative: for example, muscle guarding may be less pro- nounced or absent in debilitated and elderly patients who have poor abdominal musculature. In addition, the evaluation of muscle guarding is dependent on the patient’s cooperation. Palpation is also useful for determining the extent and severity of the patient’s tenderness. Diffuse tenderness indicates generalized peritoneal inflammation. Mild diffuse tenderness without guarding usually indicates gastroenteritis or some other inflammatory intesti- nal process without peritoneal inflammation. Localized tenderness suggests an early stage of disease with limited peritoneal inflamma- tion. Rebound tenderness is elicited by applying gentle but deep pressure to the region of interest and then letting go abruptly.As a means of distraction, the examiner may use the stethoscope to ap- ply the pressure.The main difficulties associated with palpation are that the deep pressure may increase anxiety and that the surprise of the sudden withdrawal may elicit pain where peritoneal irritation is not the cause. Careful palpation can elicit several specific signs [see Table 5], such as the Rovsing sign (pain in the right lower quadrant when the left lower quadrant is palpated deeply), which is associated with acute appendicitis, and the Murphy sign (arrest of inspiration when the right upper quadrant is deeply palpated), which is associated with acute cholecystitis.These signs are indicative of localized peri- toneal inflammation. Similarly, specific maneuvers can elicit signs of localized peritoneal irritation.The psoas sign is elicited by placing

(continued)

the patient in the left lateral decubitus position and extending the right leg. In settings where appendicitis is suspected, pain on exten- sion of the right leg indicates that the psoas is irritated and thus that the inflamed appendix is in a retrocecal position.The obturator sign is elicited by raising the flexed right leg and rotating the thigh inter- nally. In settings where appendicitis is suspected, pain on rotation of the right thigh indicates that the obturator is irritated and thus that the inflamed appendix is in a pelvic position. The Kehr sign is elicited when the patient is placed in the Trendelenburg position. Pain in the shoulder indicates irritation of the diaphragm by a nox- ious fluid (e.g., gastric contents from a perforated ulcer, pus from a ruptured appendix, or free blood from a fallopian tube pregnancy). Another useful maneuver is the Carnett test, in which the patient elevates his or her head off the bed, thus tensing the abdominal muscles. When the pain is caused by abdominal wall conditions (e.g., rectal sheath hematoma), tenderness to palpation persists, but when the pain is caused by intraperitoneal conditions, tenderness to palpation decreases or disappears (the Carnett sign). Rectal, genital, and (in women) pelvic examinations are essential to the evaluation of all patients with acute abdominal pain.The rec- tal examination should include evaluation of sphincter tone, tender- ness (localized versus diffuse), and prostate size and tenderness, as well as a search for the presence of hemorrhoids, masses, fecal im- paction, foreign bodies, and gross or occult blood.The genital ex- amination should search for adenopathy, masses, discoloration,

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 12

Table 5(continued)

Sign or Finding

Description

Associated Clinical Condition(s)

Grey Turner sign

Local areas of discoloration around umbilicus and flanks

Acute hemorrhagic pancreatitis

Iliopsoas sign

Elevation and extension of leg against pressure of examiner’s hand causes pain

Appendicitis (retrocecal) or an inflammatory mass in contact with psoas

Kehr sign

Left shoulder pain when patient is supine or in the Trendelenburg po- sition (pain may occur spontaneously or after application of pres- sure to left subcostal region)

Hemoperitoneum (especially ruptured spleen)

Kustner sign

Palpable mass anterior to uterus

Dermoid cyst of ovary

Mannkopf sign

Acceleration of pulse when a painful point is pressed on by examiner

Absent in factitious abdominal pain

McClintock sign

Heart rate > 100 beats/min 1 hr post partum

Postpartum hemorrhage

Murphy sign

Palpation of right upper abdominal quadrant during deep inspiration results in right upper quadrant abdominal pain

Acute cholecystitis

Obturator sign

Flexion of right thigh at right angles to trunk and external rotation of same leg in supine position result in hypogastric pain

Appendicitis (pelvic appendix); pelvic abscess; an inflammato- ry mass in contact with muscle

Puddle sign

Alteration in intensity of transmitted sound in intra-abdominal cavity secondary to percussion when patient is positioned on all fours and stethoscope is gradually moved toward flank opposite percussion

Free peritoneal fluid

Ransohoff sign

Yellow pigmentation in umbilical region

Ruptured common bile duct

Rovsing sign

Pain referred to the McBurney point on application of pressure to de- scending colon

Acute appendicitis

Subcutaneous

   

crepitance

Palpable crepitus in abdominal wall

Subcutaneous emphysema or gas gangrene

Summer sign

Increased abdominal muscle tone on exceedingly gentle palpation of right or left iliac fossa

Early appendicitis; nephrolithiasis; ureterolithiasis; ovarian torsion

Ten Horn sign

Pain caused by gentle traction on right spermatic cord

Acute appendicitis

Toma sign

Right-sided tympany and left-sided dullness in supine position as a result of peritoneal inflammation and subsequent mesenteric con- traction of intestine to right side of abdominal cavity

Inflammatory ascites

edema, and crepitus. The pelvic examination in women should check for vaginal discharge or bleeding, cervical discharge or bleed- ing, cervical mobility and tenderness, uterine tenderness, uterine size, and adnexal tenderness or masses. Although a carefully per- formed pelvic examination can be invaluable in differentiating non- surgical conditions (e.g., pelvic inflammatory disease and tubo- ovarian abscess) from conditions necessitating prompt operation (e.g., acute appendicitis), the possibility that a surgical condition is present should not be prematurely dismissed solely on the basis of a finding of tenderness on pelvic or rectal examination.

Investigative Studies

Laboratory tests and imaging studies rarely, if ever, establish a definitive diagnosis by themselves; however, if used in the cor- rect clinical setting, they can

confirm or exclude specific diagnoses suggested by the history and the physical examination.

suggested by the history and the physical examination. LABORATORY TESTS In all patients except those in

LABORATORY TESTS

In all patients except those in extremis, a complete blood count, blood chemistries, and a urinalysis are routinely obtained before a decision to operate.The hematocrit is important in that it allows the surgeon to detect significant changes in plasma volume (e.g., dehy- dration caused by vomiting, diarrhea, or fluid loss into the peri-

toneum or the intestinal lumen), preexisting anemia, or bleeding. An elevated white blood cell (WBC) count is indicative of an in- flammatory process and is a particularly helpful finding if associated with a marked left shift; however, the presence or absence of leuko- cytosis should never be the single deciding factor as to whether the patient should undergo an operation. A low WBC count may be a feature of viral infections, gastroenteritis, or NSAP. Other tests, such as C-reactive protein assay, may be useful for increasing confidence in the diagnosis of an acute inflammatory condition.An important consideration in the use of any such test is that derangements devel- op over time, becoming more likely as the illness progresses; thus, serial examinations might be more useful than a single test result obtained at an arbitrary point. Indeed, for the diagnosis of acute ap- pendicitis, serial observations of the leukocyte count and the C-re- active protein level have been shown to possess greater predictive value than single observations. 33 Serum electrolyte, blood urea nitrogen (BUN), and creatinine concentrations are useful in determining the nature and extent of fluid losses. Blood glucose and other blood chemistries may also be helpful. Liver function tests (serum bilirubin, alkaline phosphatase, and transaminase levels) are mandatory when abdominal pain is suspected of being hepatobiliary in origin. Similarly, amylase and li- pase determinations are mandatory when pancreatitis is suspected, though it must be remembered that amylase levels may be low or normal in patients with pancreatitis and may be markedly elevated in patients with other conditions (e.g., intestinal obstruction, mesenteric thrombosis, and perforated ulcer). Urinalysis may reveal red blood cells (RBCs) (suggestive of renal

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 13

or ureteral calculi),WBCs (suggestive of urinary tract infection or inflammatory processes adjacent to the ureters, such as retrocecal appendicitis), increased specific gravity (suggestive of dehydration), glucose, ketones (suggestive of diabetes), or bilirubin (suggestive of hepatitis).A pregnancy test should be considered in any woman of childbearing age who is experiencing acute abdominal pain. Electrocardiography is mandatory in elderly patients and in pa- tients with a history of cardiomyopathy, dysrhythmia, or ischemic heart disease. Abdominal pain may be a manifestation of myocar- dial disease, and the physiologic stress of acute abdominal pain can increase myocardial oxygen demands and induce ischemia in pa- tients with coronary artery disease.

IMAGING

Until relatively recently, initial radiologic evaluation of the patient with acute abdominal pain included plain films of the abdomen in the supine and standing positions and chest radiographs. 34 Current- ly, CT scanning (when available) is generally considered more likely to be helpful in most situations. 35,36 Still, there remain some situa- tions in which plain films may be a more useful and safe form of in- vestigation—as, for example, when a strangulating obstruction is thought to be the most likely diagnosis and plain films are used for rapid confirmation. If the diagnosis of strangulating obstruction is in doubt, however, CT scanning—particularly with the newer genera- tions of scanning instruments—is useful for making a definitive di- agnosis and for identifying clinically unsuspected strangulation. 37-39 When performed in the correct clinical setting, imaging studies may confirm diagnoses such as pneumonia (signaled by pulmonary infiltrates); intestinal obstruction (air-fluid levels and dilated loops of bowel); intestinal perforation (pneumoperitoneum); biliary, renal, or ureteral calculi (abnormal calcifications); appendicitis (fecalith); in- carcerated hernia (bowel protruding beyond the confines of the peri- toneal cavity); mesenteric infarction (air in the portal vein); chronic pancreatitis (pancreatic calcifications); acute pancreatitis (the so- called colon cutoff sign);visceral aneurysms (calcified rim);retroperi- toneal hematoma or abscess (obliteration of the psoas shadow); and ischemic colitis (so-called thumbprinting on the colonic wall). Although in most settings, CT is the preferred modality for pri- mary evaluation of acute abdominal pain, there are certain settings in which US should be considered.When gallstones are considered a likely diagnosis, US is more apt to be diagnostic than CT is, given that about 85% of gallstones are not detectable by x-rays. In disor- ders of the female genitourinary tract, US is also quite sensitive and specific for diagnoses such as ovarian cyst, fallopian tube pregnan- cy, and intrauterine pregnancy. Although there are reassuring re- ports that the risks of radiation from CT scanning can be managed in children and pregnant women with abdominal pain, 40,41 there re- main theoretical concerns regarding the teratogenicity of the radia- tion dose. 42 Accordingly, it would seems prudent to consider US the preferred initial imaging test for such patients. In these circum- stances, CT is employed only if the diagnosis remains unresolved and if the potential delay in diagnosis (from not obtaining a CT scan) is likely to cause harm.

Working or Presumed Diagnosis

The tentative differential diagnosis developed on the basis of the clinical history is refined on the basis of the physical examination and the investigative studies per-

the physical examination and the investigative studies per- formed, and a working or presumed diagnosis is

formed, and a working or presumed diagnosis is generated. Once a working diagnosis has been established, subsequent management depends on the accepted treatment for the particular condition be- lieved to be present. In general, the course of management follows four basic pathways [see Management: Surgical versus Nonsurgical Treatment, below], depending on whether the patient (1) has an acute surgical condition that necessitates immediate laparotomy, (2) is believed to have an underlying surgical condition that does not necessitate immediate laparotomy but does call for urgent or early operation, (3) has an uncertain diagnosis that does not neces- sitate immediate or urgent laparotomy and that may prove to be nonsurgical, or (4) is believed to have an underlying nonsurgical condition. It must be emphasized that the patient must be constantly reeval- uated (preferably by the same examiner) even after the working di- agnosis has been established. If the patient does not respond to treat- ment as expected, the working diagnosis must be reconsidered, and the possibility that another condition exists must be immediately en- tertained and investigated by returning to the differential diagnosis.

Management: Surgical versus Nonsurgical Treatment

ACUTE SURGICAL AB- DOMEN

A thorough but expedi- tious approach to patients with acute abdominal pain is essential because in some patients, action must be

taken immediately and there is not enough time for an exhaustive evaluation. As outlined (see above), such an approach should include a brief initial assess- ment, a complete clinical history, a thorough physical examination, and targeted laboratory and imaging studies.These steps can usual- ly be completed in less than 1 hour and should be insisted on in the evaluation of most patients. In most cases, it is wise to resist the temptation to rush to the operating room with an incompletely eval- uated, unprepared, and unstable patient. Sometimes, the anxiety of the patient or the impatience of the health care providers requesting the surgeon’s consultation creates an unwarranted feeling of ur- gency. Often, however, the anxiety or impatience is on the part of the surgeon and, if indulged, may be a cause of subsequent regret. There are very few abdominal crises that mandate immediate operation, and even with these conditions, it is still necessary to spend a few minutes on assessing the seriousness of the problem and establishing a probable diagnosis.Among the most common of the abdominal catastrophes that necessitate immediate operation are ruptured AAAs or visceral aneurysms, ruptured ectopic preg- nancies, and spontaneous hepatic or splenic ruptures.The relative rarity of such conditions notwithstanding, it must always be re- membered that patients with acute abdominal pain may have a pro- gressive underlying intra-abdominal disorder causing the acute pain and that unnecessary delays in diagnosis and treatment can ad- versely affect outcome, often with catastrophic consequences.

affect outcome, often with catastrophic consequences. SUBACUTE SURGICAL AB- DOMEN When immediate opera- tion is

SUBACUTE SURGICAL AB- DOMEN

When immediate opera- tion is not called for, the physician must decide whether urgent laparotomy or nonurgent but early op-

immediate opera- tion is not called for, the physician must decide whether urgent laparotomy or nonurgent

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1 Acute Abdominal Pain — 14

eration is necessary. Urgent laparotomy implies operation within 4 hours of the patient’s arrival; thus, there is usually sufficient time for adequate resuscitation, with proper rehydration and restoration of vital organ function, before the procedure. Indications for urgent la- parotomy may be encountered during the physical examination, may be revealed by the basic laboratory and radiologic studies, or may not become apparent until other investigative studies are per- formed. Involuntary guarding or rigidity during the physical exami- nation, particularly if spreading, is a strong indication for urgent la- parotomy. Other indications include increasing severe localized tenderness, progressive tense distention, physical signs of sepsis (e.g., high fever, tachycardia, hypotension, and mental-status changes), and physical signs of ischemia (e.g., fever and tachycar- dia). Basic laboratory and radiologic indications for urgent laparo- tomy include pneumoperitoneum, massive or progressive intestinal distention, signs of sepsis (e.g., marked or rising leukocytosis, in- creasing glucose intolerance, and acidosis), and signs of continued hemorrhage (e.g., a falling hematocrit). Additional findings that constitute indications for urgent laparotomy include free extravasa- tion of radiologic contrast material, mesenteric occlusion on an- giography, endoscopically uncontrollable bleeding, and positive re- sults from peritoneal lavage (i.e., the presence of blood, pus, bile, urine, or GI contents). Acute appendicitis, perforated hollow vis- cera, and strangulated hernias are examples of common conditions that necessitate urgent laparotomy. If early operation is contemplated, it may still be prudent to ob- tain additional studies to obtain information related to the site of the lesion or to associated anatomic pitfalls. In deciding whether to order such studies, it is important to consider not only whether the additional information obtained will increase confidence in the di- agnosis but also whether the extra time, expense, and discomfort in- volved will be justified by the quality and usefulness of the informa- tion. 43 During a short, defined period of resuscitation, it may be possible to employ CT scanning to identify the location of the in- flamed appendix in difficult (i.e., retrocecal or pelvic) locations. Knowing the location of the appendix and its morphology can be helpful in directing the incision in an open operation or determining the most expeditious exposure in a laparoscopic procedure. CT scanning may also be used to identify an atypical site of a visceral perforation (e.g., the proximal stomach, the distal or posterior wall of the duodenum, or the transverse colon), thereby guiding place- ment of the incision and obviating needless dissection of tissue planes. In the setting of distal bowel obstruction, an expeditious Gastrografin (Bracco Diagnostics, Princeton, New Jersey) enema or CT scan may alert the surgeon to the possibility of an otherwise un- detectable malignancy (e.g., cecal carcinoma causing distal bowel obstruction). In cases where ischemic bowel is suspected, the site of vascular blockage can be localized by using a CT-angiogram imag- ing protocol. In each of these examples, the information gained may permit the surgeon to plan the operation, to optimize time spent under anesthesia, and to minimize postoperative discomfort after laparotomy. The use of preoperative imaging has become increasingly impor- tant as an operative planning tool, particularly when laparoscopic approaches are contemplated for management of acute abdominal emergencies. In the 1990s and the first few years of the 21st centu- ry, a number of trials were performed to determine whether la- paroscopy or open operation should be the approach of choice when the primary clinical diagnosis is acute appendicitis.This topic has been reviewed extensively in the literature 44-46 and in a 2004 up- date of a Cochrane meta-analysis. 47 In some environments, the an- swer to this question remains unclear. 48,49 In many settings, howev- er, the current consensus is that uncomplicated appendicitis can be

treated laparoscopically, with a clear expectation of less postopera- tive pain, a shorter hospital stay, and an earlier return to work and regular activities.These advantages, though significant, do not indi- cate that a laparoscopic approach is to be preferred in all or most clinical settings or that it is necessarily more cost-effective than an open approach. 47 Laparoscopic appendectomy requires a high level of organization with respect to operating room resources, and this level of organization may be difficult to achieve in institutions where the procedure is not performed regularly (particularly in the middle of the night). In addition, it is not clear whether patients with ap- pendicitis that is complicated by a well-established abscess or bowel obstruction benefit from laparoscopic approaches. Anatomic considerations also enter into the decision whether to perform the procedure laparoscopically. For instance, it can be very difficult to separate a perforated retrocecal appendix from adherent colon in a safe manner. In many cases, it is prudent not to persist in attempting to extract the appendix without a standard open inci- sion, excellent exposure, and controlled technique.The importance of anatomic considerations underscores the usefulness of preopera- tive CT in identifying pathologic anatomy, associated abnormalities, and potential pitfalls for either open or laparoscopic approaches. The advantages of laparoscopy in the management of other ab- dominal emergencies are less clear-cut. It is important that the sur- geon determine not only whether the particular clinical scenario is amenable to a laparoscopic approach but also whether the experi- ence of the entire team and that of the institution as a whole are suf- ficient for what may be an advanced procedure performed in an acute situation.With this caveat in mind, various investigators have demonstrated that laparoscopy can be employed safely and with good clinical results in selected patients with perforated peptic ul- cers. 50-54 Two prospective, randomized, controlled trials comparing open repair of perforated peptic ulcers with laparoscopic repair found that the latter was safe and reliable and was associated with shorter operating times, less postoperative pain, fewer chest compli- cations, shorter postoperative hospital stays, and earlier return to normal daily activities than the former. 52,54

ACUTE ABDOMINAL PAIN REQUIRING OBSERVATION

It is widely recognized that of all patients admitted for acute abdominal pain, only a minority require im- mediate or urgent opera-

tion. 2,12 It is therefore both cost-effective and prudent to adopt a system of evaluation that al- lows for thought and investigation before definitive treatment in all patients with acute abdominal pain except those identified early on as needing immediate or urgent laparotomy. The traditional wis- dom has been that spending time on observation opens the door for complications (e.g., perforating appendicitis, intestinal perforation associated with bowel obstruction, or strangulation of an incarcerat- ed hernia). However, clinical trials evaluating active in-hospital ob- servation of patients with acute abdominal pain of uncertain origin have demonstrated that such observation is safe, is not accompa- nied by an increased incidence of complications, and results in few- er negative laparotomies. 55 Many institutions now employ CT scan- ning liberally in patients with uncertain diagnoses; this practice should greatly minimize the incidence of diagnostic failures or delays in patients with acute conditions necessitating surgical intervention. 32 The initial resuscitation and assessment are followed by appropri- ate imaging studies and serial observation. Specific monitoring mea-

and assessment are followed by appropri- ate imaging studies and serial observation. Specific monitoring mea-

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5 GASTROINTESTINAL TRACT AND ABDOMEN

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1 Acute Abdominal Pain — 15

sures are chosen (e.g., examination of the abdomen, measurement of urine output, a WBC count, and repeat CT scans), and end points of therapy should be identified.Active observation allows the surgeon to identify most of the patients whose acute abdominal pain is caused by NSAP or by various specific nonsurgical conditions. It must be emphasized that active observation involves more than sim-

ply admitting the patient to the hospital and passively watching for obvious problems: it implies an active process of thoughtful, dis- criminating, and meticulous reevaluation (preferably by the same examiner) at intervals ranging from minutes to a few hours, com- plemented by appropriately timed additional investigative studies.

A major point of contention in the management of patients with

acute abdominal pain is the use of narcotic analgesics during the observation period.The main argument for withholding pain med- ication is that it may obscure the evolution of specific findings that would lead to the decision to operate.The main argument for giv- ing narcotic analgesics is that in a controlled setting where patients are being observed by experienced clinicians, outcomes are not

compromised and patients are more comfortable. 56 It has also been suggested that providing early pain relief may allow the more criti- cal clinical signs to be more clearly identified 57 and that severe pain persisting despite adequate doses of narcotics suggests a serious condition for which operative intervention is likely to be necessary.

In my view, the decision whether to provide or withhold narcotic

analgesia must be individualized. 58 The current consensus is that for most patients undergoing evaluation and observation for acute abdominal pain, it is safe to provide medication in doses that would “take the edge off” the pain without rendering the patient unable to cooperate during the observation period. It may be especially desir- able to provide medication in a manner that allows the patient to be comfortable while lying in the CT scanner. In these cases, the goal of pain relief is to make it easier to obtain accurate information that will facilitate and expedite the diagnosis and the development of a treatment plan. Given the high diagnostic yield and accuracy of the new generation of CT scanners, it is generally safe to provide pain medication while obtaining the diagnosis. On occasion, however, reflex administration of pain medication solely with the aim of relieving pain may be undesirable or even harmful. For example, in situations where advanced imaging is un- available, physical examination may be so crucial to decision mak- ing that any risk of obscuring important physical findings is deemed unacceptable, and therefore, pain medication should be withheld.

In addition, narcotic analgesia should be used cautiously in patients with acute intestinal obstruction when strangulation is a concern. 59 These patients present with abdominal pain that is out of propor- tion to the physical findings, a syndrome whose differential diagno- sis includes acute intestinal ischemia, pancreatitis, ruptured aortic aneurysm, ureteral colic, and various medical causes (e.g., sickle cell crisis and porphyria).A period of resuscitation and evaluation, in conjunction with advanced imaging studies (e.g., CT) may then yield a tentative diagnosis of intestinal obstruction caused by adhe- sions (e.g., if the patient has a history of abdominal surgery and no evidence of herniation or obturation) without evidence of bowel is- chemia. In this setting, the decision whether to admit the patient for observation rather than immediate operation depends on the extent to which the surgeon is confident that the obstruction is not a “closed loop.” 59 However, within a relatively short period (perhaps 4 to 24 hours), the surgeon must determine whether any indica- tions for operation will arise, and the main parameters for observa- tion include the WBC count, the urine output, and the develop- ment of peritoneal findings. In such cases, it may well be prudent to withhold pain medication until there is a high level of confidence that the timing of surgery will not be delayed.

A final point is that over the course of a 24- to 48-hour observa- tion period, the patient’s condition may neither deteriorate nor im- prove, and supplemental investigation may be considered. Diagnos- tic laparoscopy has been recommended in cases where surgical disease is suspected but its probability is not high enough to war- rant open laparotomy. 60,61 It is particularly valuable in young women of childbearing age, in whom gynecologic disorders fre- quently mimic acute appendicitis. 62-64 A 1998 report showed that diagnostic laparoscopy had the same diagnostic yield as open la- parotomy in 55 patients with acute abdomen; 34 (62%) of these patients were safely managed with laparoscopy alone, with no in- crease in morbidity and with a shorter average hospital stay. 63 Diag- nostic laparoscopy has also been shown to be useful for assessing acute abdominal pain in acutely ill patients in the intensive care unit. 60,65 In patients with AIDS, 66,67 there are a number of unusual diag- noses that may be related to or coincident with an episode of ab- dominal pain.The differential diagnosis includes lymphoma, Ka- posi sarcoma, tuberculosis and variants thereof, and opportunistic bacterial, fungal, and viral (especially cytomegaloviral) infections. Laparoscopy has been used for the purposes of diagnosis, biopsy, and treatment in patients with an established AIDS diagnosis who manifest acute abdominal pain syndrome. 66,67 The complication rate and mortality associated with surgery are related to the under- lying illness, and outcomes have improved steadily over the years. 68 It is important to note that patients who are infected with HIV but have no clinical manifestations of AIDS are evaluated and managed in the same fashion as patients without HIV infection when they present with acute abdominal pain.The differential diagnosis and the outcomes are essentially no different, unless there are reasons to think that the new onset of pain in an HIV-infected patient is a manifestation of AIDS. 58,68

Subacute or Chronic Relapsing Abdominal Pain: Role of Outpa- tient Evaluation and Management

For every patient who requires hospitalization for acute abdomi- nal pain, there are at least two or three others who have self-limiting conditions for which neither operation nor hospitalization is neces- sary. Much or all of the evaluation of such patients, as well as any treatment that may be needed, can now be completed in the outpa- tient department.To treat acute abdominal pain cost-effectively and efficiently, the surgeon must be able not only to identify patients who need immediate or urgent laparotomy or laparoscopy but also to reliably identify those whose condition does not present a serious risk and who therefore can be managed without hospitalization. The reliability and intelligence of the patient, the proximity and availability of medical facilities, and the availability of responsible adults to observe and assist the patient at home are factors that should be carefully considered before the decision is made to evalu- ate or treat individuals with acute abdominal pain as outpatients.

SUSPECTED NONSURGICAL ABDOMEN

There are numerous dis- orders that cause acute ab- dominal pain but do not call for surgical intervention. These nonsurgical condi-

tions are often extremely difficult to differentiate from surgical conditions that present with al- most indistinguishable characteristics. 2 For example, the acute ab- dominal pain of lead poisoning or acute porphyria is difficult to dif- ferentiate from the intermittent pain of intestinal obstruction, in that

or acute porphyria is difficult to dif- ferentiate from the intermittent pain of intestinal obstruction, in

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5 GASTROINTESTINAL TRACT AND ABDOMEN

ACS Surgery: Principles and Practice

1 Acute Abdominal Pain — 16

marked hyperperistalsis is the hallmark of both.As another example, the pain of acute hypolipoproteinemia may be accompanied by pan- creatitis, which, if not recognized, can lead to unnecessary laparoto- my. Similarly, acute and prostrating abdominal pain accompanied by rigidity of the abdominal wall and a low hematocrit may lead to un- necessary urgent laparotomy in patients with sickle cell anemia crises.To further complicate the clinical picture, cholelithiasis is also often found in patients with sickle cell anemia. In addition to numerous extraperitoneal disorders [see Table 2], nonsurgical causes of acute abdominal pain include a wide variety of intraperitoneal disorders, such as acute gastroenteritis (from en- teric bacterial, viral, parasitic, or fungal infection), acute gastritis, acute duodenitis, hepatitis, mesenteric adenitis, salpingitis, Fitz- Hugh–Curtis syndrome, mittelschmerz, ovarian cyst, endometritis, endometriosis, threatened abortion, spontaneous bacterial peritoni- tis, and tuberculous peritonitis.As noted (see above), acute abdom- inal pain in immunosuppressed patients or patients with AIDS is now encountered with increasing frequency and can be caused by a number of unusual conditions (e.g., cytomegalovirus enterocolitis, opportunistic infections, lymphoma, and Kaposi sarcoma), as well as by the more usual ones. Although such disorders typically are not treated by operative means, operation is sometimes required when the diagnosis is un- certain or when a surgical illness cannot be excluded with confi- dence. In such cases, laparoscopy can be very helpful, permitting relatively complete and systematic exploration without involving the potential morbidity or the longer postoperative recovery and reha- bilitation period associated with open exploration. 69-72 From the surgeon’s point of view, an optimal outcome for laparoscopic explo- ration in these settings is one in which a diagnosis is established by means of visualization, with or without biopsy, and in which symp- toms improve as a consequence of a therapy directed by the laparo- scopic findings. Overall, candidate lesions—including appendiceal pathology (e.g., chronic appendicitis or carcinoid tumor), adhe- sions, hernias, endometriosis, mesenteric lymphadenopathy—are identified in about 50% of cases, with pelvic adhesions the most common finding. From the patient’s point of view, however, estab- lishing a precise diagnosis may not be particularly critical, and symptomatic improvement, by itself, may suffice to render the out- come successful. Indeed, a number of reports have emphasized that laparoscopy often leads to improvement in symptoms even if no le- sion is identified or treated. 69,70 This point may be illustrated by considering pelvic adhesions. Given the frequency with which laparoscopic exploration identi-

References

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Acknowledgments

Figures 2 and 3 Tom Moore. Portions of this chapter are based on a previous itera- tion written for ACS Surgery by Romano Delcore, M.D., F.A.C.S., and Laurence Y. Cheung, M.D., F.A.C.S.The author wishes to thank Drs. Delcore and Cheung.