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The Acute Abdomen in the Adult

American College of Surgeons


Prepared by the Advisory Council for Surgery and Gayle Minard, MD, FACS

Overview

Definition Pathophysiology Symptoms Signs Work-up Specific Diseases


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Definition of Acute Abdomen

Sudden onset Severe pain Requires urgent


decision/diagnosis Treatment often surgical
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Acute Abdomen
10% of ER visits or admitted patients 40% discharged from ER with pain of

unknown etiology 60% discharged from ER have wrong diagnosis The older the patient, the less accurate the diagnosis

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Referred pain Somatic pain

Pathophysiology of Abdominal Pain


Pain sensed at a considerable
distance from source

Segmental spinal nerves Visceral pain Sympathetic, parasympathetic, or


somatic pathways
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History

Description of pain Associated symptoms Gynecologic/GU history Past medical history Family, social history
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Description of Pain
The abdominal pain checklist

Onset and duration Character and severity Location and radiation What makes it better What makes it worse Progression of pain Associated symptoms
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Associated Symptoms

Nausea, vomiting Fever, chills Anorexia, weight loss Food intolerance Pulmonary symptoms Change in bowel habits GU complaints
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Gynecologic / GU History

Last menses Contraception Sexual history Obstetric history Vaginal discharge, bleeding Previous STDs Urinary symptoms
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Past Medical History

Cardiac or pulmonary disorders GI, vascular diseases Diabetes, HIV Medications Recent invasive procedures Trauma Recent URI or strep throat
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Family & Social History

Inflammatory bowel disease Connective tissue disorders Bleeding diatheses Cancer Recent travel Environmental hazards Drugs, alcohol
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Physical Examination

General appearance Chest Abdomen Rectal Pelvic GU


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General Examination

Distress Acutely or chronically ill Body position Color Vital signs


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Chest Examination

Cardiac arrhythmias Murmurs Mechanical heart valves Signs of pneumonia


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Abdominal Exam - LOOK

Distention Breathing pattern,


patient movement Discoloration

Scars, hernia

Cullens sign Grey Turners sign


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Abdominal Exam - LISTEN

Percussion Auscultation

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Abdominal Exam - FEEL

Area of maximal tenderness CVA or flank tenderness Masses Hernia Peritoneal signs
involuntary guarding pain on motion
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Abdominal Exam
Special Signs

Rovsings sign Murphys sign Psoas sign Obturator sign


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Method of eliciting psoas sign


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Method of performing obturator test


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Pelvic / Rectal / GU Exam

Tenderness Masses Hernias Discharge, bleeding Blood - occult or gross


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Work-up of Acute Abdomen Basic

Urinalysis Amylase, lipase Pregnancy test Liver tests EKG Chest x-ray, abdominal films CBC
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Work-up of Acute Abdomen Complex

Ultrasound (US) Computed tomography (CT) Angiography

Barium enema or endoscopy


never with peritonitis Laparoscopy, especially in young women
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Common Causes of Acute Abdomen

Appendicitis Diverticulitis Cholecystitis Pancreatitis Bowel obstruction Perforated bowel Perforated ulcer

IBD Ectopic pregnancy PID / TOA Gastroenteritis Mesenteric

ischemia Nephrolithiasis
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Appendicitis
History:

periumbilical cramping pain migrating to RLQ; anorexia Exam: tenderness in RLQ and on rectal or pelvic + Rovsings sign, Psoas sign, obturator sign US useful in young women CT in doubtful cases Laparoscopy in young women and doubtful cases
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Small Bowel Obstruction

History of previous abdominal


operation or hernia Triad of diagnostic symptoms

cramping abdominal pain vomiting obstipation

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Small Bowel Obstruction


Quartet of physical findings Distention Early: little or no tenderness Late: tenderness and guarding Borborygmi Radiographic findings Air-fluid levels with J loops Absence of air in colon
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Perforated Peptic Ulcer

History:

PUD, NSAIDS, steroids, critical illness Exam: generalized peritonitis Free air seen on plain radiographs or CT
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Diverticulitis

History:

constipation, LLQ pain, fever, diarrhea Exam: LLQ tenderness, mass Laboratory tests Pyuria, WBC elevated CT - up to 93% sensitivity
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Pancreatitis

History:

gallstones, alcohol, epigastric pain radiating to the back Exam: generalized upper abdominal tenderness, most marked in epigastrium Increased amylase and lipase values US - detects gallstones CT - 70-100% accuracy
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Cholecystitis

History:
Exam:

cramping epigastric and RUQ pain, fatty food intolerance, + family history
RUQ tenderness, + Murphys sign, jaundice+ US - thickened GB wall, pericholecystic fluid
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Ureterolithiasis

History: Exam:

flank pain, hematuria, radiation to groin, previous attacks


restless; no abdominal tenderness, flank tenderness

Urinalysis: RBCs, crystals CT, IVP and US useful


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Inflammatory Bowel Disease

History:

intermittent cramping abdominal pain, diarrhea, low grade fever, weight loss Exam: localized abdominal tenderness, + stool for blood CT and Barium studies usually diagnostic
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Ectopic Pregnancy

History:

menstrual irregularities, + sexual history, symptoms of early pregnancy Exam: adnexal mass on pelvic; may have hypotension and tachycardia Pregnancy test + US and laparoscopy diagnostic
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PID / TOA

History:

premenopausal woman, midcycle, previous STD, vaginal discharge, dysuria, Kehrs sign Exam: cervical motion tenderness, adnexal mass Pyuria US useful to diagnose
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Gastroenteritis

History:

diarrhea, vomiting, crampy pain Exam: no localizing peritoneal signs Normal WBC
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Mesenteric Ischemia / Infarction

History:

Angiography indicated - urgent!

intestinal angina, arrhythmias, low flow, hypercoagulable state Exam: pain out of proportion to findings WBC and amylase elevated Acidosis, stool + for blood Thumb printing on plain film

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Other Causes of Acute Abdomen

Volvulus Cholangitis Pneumonia Acute M I Ovarian torsion / cyst Hepatitis Sickle cell disease

Diabetic

ketoacidosis Uremia Porphyria Intussusception Lupus HIV intestinal disease

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Pitfalls

Old age Spinal cord injury HIV Steroids


Very young? Very old? Very odd? Be very careful. F.T. de Dombal, MA, MD
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Summary

History and physical examination


much more important than laboratory tests Making the management decision is more important than making the diagnosis Treatment is often surgical
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