Acute abdominal pain
Abdominal pain is a very common presenting complaint, one of the top five causes of emergency department visits. The differential diagnosis is very broad and therefore, a detailed history and careful physical examination is often needed. Laboratory and imaging tests needed, depend on the causes suspected on the basis of the history and physical examination (apart from some basic tests ordered in every case, see below).
Pathophysiology of abdominal pain
Abdominal pain is divided into three categories: visceral (autonomic), parietal (somatic), and referred pain.
Visceral pain originates from the abdominal viscera, which are innervated by autonomic nerve fibers. It is usually caused by distention or a forceful muscular contraction of the walls of hollow organs (e.g the stomach, the intestine, the biliary tract, or the ureter) or the distention of the capsule of a solid organ (e.g the liver) and less commonly by early ischemia or early inflammation. Visceral pain is typically a vague, dull pain, of variable intensity (it can be mild or severe) poorly localized (it cannot be localized precisely to a small area) and it is usually felt at an area corresponding to the embryonic origin of the affected viscera. For this reason, structures causing upper abdominal pain mainly felt on the epigastrium include the stomach, duodenum, liver, biliary tract and pancreas. Periumbilical pain originates from midgut structures, such as the small bowel, proximal colon (the cecum), and appendix, whereas lower abdominal pain (in the hypogastric or suprapubic area) originates from the distal colon and the intraperitoneal portions of the genitourinary tract. Intraperitoneal visceral pain is usually felt in the midline, independent of its right- or left-sided anatomic origin, because intraperitoneal organs are bilaterally innervated and nervous stimuli are sent to both sides of the spinal cord. For this reason, in the early phase of appendicitis, the pain resulting from the obstruction of the lumen of the appendix is a visceral pain felt at the midline in the periumbilical area. Later, when inflammation of the appendix results in the irritation of the overlying peritoneum the location of the pain changes, because parietal pain develops, which is felt at the right lower abdominal quadrant.Parietal or somatic pain originates from an inflammation of the parietal peritoneum, which is innervated by somatic nerves. The inflammation of the parietal peritoneum results from peritoneal irritation from infectious or chemical processes. Somatic pain is sharp and well localized to the area overlying the site of the affected organ.
Referred pain, is a term for pain perceived at a location distant from its source, i.e. distant to the diseased organ, and results from the convergence of nerve fibers at the spinal cord. Examples of referred pain are scapular pain resulting from biliary colic, shoulder pain due to an infection irritating the diaphragm and groin pain in case of a renal colic. Although referred pain is felt at a location distal to the diseased organ, in contrast to visceral pain, the location of a referred pain is usually ipsilateral to the involved organ, whereas it is felt in the midline only when the pathologic process is also located in the midline.
Referred pain and visceral pain produce only symptoms and no signs, in contrast to parietal (somatic) pain which produces also signs (such as sharply localized tenderness, rigidity and rebound tenderness).
The four broad etiologies of acute abdominal pain and how to differentiate between them (SOS !)
1 Perforation of a hollow viscus
(e.g. a perforated peptic ulcer)
This characteristically causes a sudden onset generalized continuous abdominal pain with diffuse and impressive findings in the physical examination of the abdomen, due to peritonitis (abdominal tenderness, guarding and rigidity of the abdominal walls, diminished bowel sounds as a later finding). The patient tends to stay motionless (because the pain increases with motion).
2 Obstruction of a hollow viscus
(e.g. biliary colic, renal colic, intestinal obstruction).
This causes pain of sudden onset, but it is usually not generalized (with the exception of intestinal obstruction which may cause a diffuse pain). The location and radiation of pain depend on the affected organ. The pain is often not steady but intermittent. The patient is restless, changing position while trying to find a more comfortable position (which he cannot find). Physical examination usually does not reveal impressive signs.
3. An inflammatory process
("-itis" means inflammation of an organ, e.g. appendicitis, cholecystitis, diverticulitis, pancreatitis, etc)
The onset of the pain is usually gradual, taking hours to reach its maximum intensity. After reaching its maximum intensity it is a constant pain and its location depends on the organ affected (the site of inflammation). Usually, there is tenderness over the site of inflammation and thus local physical findings are present. Usually, fever is present and lab-tests show in most cases elevated leucocytes and c-reactive protein (CRP).
4. Bowel ischemia
The pain is severe but usually, there is relatively mild tenderness and the physical findings are not impressive. So, the pain is out of proportion to the findings of physical examination. Often (but not always) there is blood in the stool. (Thus, the combination of acute abdominal pain and blood in the stool should raise a suspicion for this diagnosis, especially in an elderly individual). A cardiovascular condition that predisposes to thromboembolism, such as atrial fibrillation, is often present.
5 Vascular-hemorrhagic causes
Hemorrhagic causes are a ruptured abdominal aortic aneurysm and a ruptured ectopic pregnancy. These conditions result in severe hemorrhage, thus apart from acute abdominal pain they also display manifestations of circulatory shock (e.g. pallor, perspiration, tachycardia with a weak or thready pulse, cold extremities, hypotension, irritability, dizziness or confusion). Back pain with shock suggests rupture of an abdominal aortic aneurysm. In such cases, a pulsatile abdominal mass may also be present.
The history in patients with abdominal pain
At the onset of history taking, also check the patient's vital signs (blood pressure, heart rate, temperature), because they can provide an indication of a serious underlying cause (see below).
Useful information that must be sought is:
The onset of pain
In general, pain of abrupt onset is more suspicious for a serious surgical condition, although there are also some serious conditions that cause pain of gradual onset (such as appendicitis, cholecystitis, diverticulitis and bowel obstruction). Pain of abrupt onset happens in cases of rupture of an abdominal aortic aneurysm, perforation of a peptic ulcer, rupture of an ectopic pregnancy and acute mesenteric ischemia). Note: Pain that has awakened the patient from sleep should be considered as suspicious of a potentially serious cause, until proven otherwise.
The duration of pain and if it is persistent or intermittent.
Intermittent pain usually occurs in intestinal obstruction (intestinal colic) and renal colic. Biliary colic usually occurs as a persistent pain, but with fluctuations in intensity. Inflammatory causes of abdominal pain, such as appendicitis cholecystitis, diverticulitis, pancreatitis, also cause a persistent pain.
The location of pain, and also if there was a change in location or if there is also referred pain at another site.
Conditions causing diffuse or periumbilical abdominal pain include gastroenteritis, inflammatory bowel disease, irritable bowel, the early phase of appendicitis (later the pain becomes located at the right lower abdominal quadrant), peritonitis, intestinal obstruction, mesenteric arterial thrombosis, dissection progressing to the abdominal aorta, rupture of an abdominal aortic aneurysm, and some manifestations of systemic disorders, such as diabetic ketoacidosis and sickle cell crisis.
Epigastric pain is caused by disorders of the stomach, duodenum (e.g. peptic ulcer, gastritis), pancreas (pancreatitis), liver (acute hepatitis, hepatic abscess), and biliary tract (biliary colic, cholecystitis), and occasionally some cardiac disorders (some cases of acute myocardial infarction, or pericarditis).
Right upper quadrant pain can be caused by biliary disease (cholelithiasis, cholecystitis, cholangitis), hepatic disease (acute hepatitis, abscess), disease of the colon (colitis), of the right kidney (renal colic due to nephrolithiasis, pyelonephritis), disease of the right lower lung (pneumonia at the right lung base, pulmonary embolism).
Left upper quadrant pain can be felt with gastritis, acute pancreatitis (although acute pancreatitis usually causes midline epigastric pain), disease of the spleen (infarct, rupture or enlargement), disease of the left kidney (renal colic, pyelonephritis), disease of the left lower lung (pneumonia of the left lower lobe, pulmonary embolism).
Right lower quadrant pain:
appendicitis, mesenteric adenitis, Meckel's diverticulitis, cecal diverticulitis, regional enteritis, right renal colic, ruptured ectopic pregnancy, twisted ovarian cyst, endometriosis, strangulated groin hernia.
Left lower quadrant pain
Sigmoid diverticulitis, regional enteritis, renal colic (calculus in the left ureter), ruptured ectopic pregnancy, twisted ovarian cyst, endometriosis, strangulated groin hernia.
Hypogastric (lower abdominal) pain
cystitis, intra-abdominal abscess, strangulated hernia, testicular torsion, torsion of an ovarian cyst, pelvic inflammatory disease, endometriosis.
The radiation of pain also provides diagnostic indications.
In acute pancreatitis, the radiation of pain is straight from the epigastrium to the middle of the back.Generally, radiation of pain to the back is seen primarily in association with pancreatitis, perforated duodenal ulcers, abdominal aneurysms, and acute aortic dissection.
Biliary pain may radiate from the right upper abdominal quadrant to the lower right scapula.
Radiation of pain to the left shoulder is an indication of splenic pathology or diaphragmatic irritation (e.g. from a subphrenic abscess)
Conditions causing diffuse or periumbilical abdominal pain include gastroenteritis, inflammatory bowel disease, irritable bowel, the early phase of appendicitis (later the pain becomes located at the right lower abdominal quadrant), peritonitis, intestinal obstruction, mesenteric arterial thrombosis, dissection progressing to the abdominal aorta, rupture of an abdominal aortic aneurysm, and some manifestations of systemic disorders, such as diabetic ketoacidosis and sickle cell crisis.
Epigastric pain is caused by disorders of the stomach, duodenum (e.g. peptic ulcer, gastritis), pancreas (pancreatitis), liver (acute hepatitis, hepatic abscess), and biliary tract (biliary colic, cholecystitis), and occasionally some cardiac disorders (some cases of acute myocardial infarction, or pericarditis).
Right upper quadrant pain can be caused by biliary disease (cholelithiasis, cholecystitis, cholangitis), hepatic disease (acute hepatitis, abscess), disease of the colon (colitis), of the right kidney (renal colic due to nephrolithiasis, pyelonephritis), disease of the right lower lung (pneumonia at the right lung base, pulmonary embolism).
Left upper quadrant pain can be felt with gastritis, acute pancreatitis (although acute pancreatitis usually causes midline epigastric pain), disease of the spleen (infarct, rupture or enlargement), disease of the left kidney (renal colic, pyelonephritis), disease of the left lower lung (pneumonia of the left lower lobe, pulmonary embolism).
Right lower quadrant pain:
appendicitis, mesenteric adenitis, Meckel's diverticulitis, cecal diverticulitis, regional enteritis, right renal colic, ruptured ectopic pregnancy, twisted ovarian cyst, endometriosis, strangulated groin hernia.
Left lower quadrant pain
Sigmoid diverticulitis, regional enteritis, renal colic (calculus in the left ureter), ruptured ectopic pregnancy, twisted ovarian cyst, endometriosis, strangulated groin hernia.
Hypogastric (lower abdominal) pain
cystitis, intra-abdominal abscess, strangulated hernia, testicular torsion, torsion of an ovarian cyst, pelvic inflammatory disease, endometriosis.
The radiation of pain also provides diagnostic indications.
In acute pancreatitis, the radiation of pain is straight from the epigastrium to the middle of the back.Generally, radiation of pain to the back is seen primarily in association with pancreatitis, perforated duodenal ulcers, abdominal aneurysms, and acute aortic dissection.
Biliary pain may radiate from the right upper abdominal quadrant to the lower right scapula.
Radiation of pain to the left shoulder is an indication of splenic pathology or diaphragmatic irritation (e.g. from a subphrenic abscess)
The quality of pain (how it is felt by the patient-sharp, dull, aching, burning, tearing etc)
The intensity (severity) of the pain.
The intensity (severity) of the pain.
and if there are any conditions that relieve or exacerbate the pain
The pain of peritonitis is made worse by movements and coughing, thus the patient tends to avoid movement. It is a severe pain. On the contrary, the pain of renal or intestinal colic is not exacerbated by movements and the patient tends to be restless and active, changing position. In acute pancreatitis, some relief of the pain is usually provided by sitting upright and leaning forward.
Other associated symptoms
Nausea and vomiting are often present in patients with acute abdominal pain of many etiologies, thus they are non-specific symptoms. Nausea and vomiting may result from irritation of intrabdominal organs or peritoneum, or from conditions with obstruction and spasm of muscular organs such as intestinal obstruction, biliary colic, renal colic. Typically in surgical causes of acute abdominal pain, the pain precedes vomiting.
Fever, sweats, and chills are suggestive of an infectious process.
Anorexia (lack of appetite for food) is also common in patients with gastrointestinal causes of abdominal pain, but it may be also present in patients with abdominal pain of other etiologies.
Diarrhea is often a symptom of gastroenteritis or enterocolitis but it may also be present in appendicitis (in 15% of cases).
Bloody diarrhea can occur in inflammatory bowel disease or infective enterocolitis.
Failure to pass flatus and feces should raise the suspicion of intestinal obstruction.
Nausea and vomiting are often present in patients with acute abdominal pain of many etiologies, thus they are non-specific symptoms. Nausea and vomiting may result from irritation of intrabdominal organs or peritoneum, or from conditions with obstruction and spasm of muscular organs such as intestinal obstruction, biliary colic, renal colic. Typically in surgical causes of acute abdominal pain, the pain precedes vomiting.
Fever, sweats, and chills are suggestive of an infectious process.
Anorexia (lack of appetite for food) is also common in patients with gastrointestinal causes of abdominal pain, but it may be also present in patients with abdominal pain of other etiologies.
Diarrhea is often a symptom of gastroenteritis or enterocolitis but it may also be present in appendicitis (in 15% of cases).
Bloody diarrhea can occur in inflammatory bowel disease or infective enterocolitis.
Failure to pass flatus and feces should raise the suspicion of intestinal obstruction.
The patient's previous history (any previous or chronic diseases, alcohol consumption, smoking, medications that the patient currently uses, previous surgeries). Note that increased consumption of alcohol predisposes to pancreatitis and smoking predisposes to peptic ulcers and coronary artery disease (myocardial infarction). Cholelithiasis also predisposes to pancreatitis. There are some drugs that can cause gastrointestinal problems (e.g non-steroidal anti-inflammatory drugs-NSAIDS and glucocorticoids can cause ulcers or gastritis).
Menstrual history: In women before menopause, a missed period in conjunction with acute abdominal pain can raise the suspicion of a ruptured ectopic pregnancy.
Physical examination of the patient with abdominal pain
Usually, physical examination starts with a quick general inspection of the patient and the vital signs (blood pressure, heart rate, temperature). The patient's general appearance may provide some clues: A comfortable-appearing patient rarely has an acute and serious underlying cause, while a patient who is pale, diaphoretic, or in obvious pain and distress, will raise suspicion of a more serious and acute condition. (There are exceptions to this rule, but it remains a useful initial clue).Jaundice (a yellowish pigmentation of the white of the eyes or the skin due to high levels of bilirubin) may be present in hepatitis, biliary colic, cholangitis or pancreatitis.
Significant tachycardia and hypotension are indications suggesting hypovolemia (reduced blood volume) or sepsis (severe infection).
The heart and lungs should be auscultated because pericarditis or a lower lobe pneumonia can manifest with upper abdominal pain.
Inspection of the abdomen:
The abdomen should be inspected for distention (this can be found in ascites or intestinal obstruction), scars (from previous surgery), hernias (also inspect the groins), ecchymoses (this may be present with pancreatitis), and visible hyperperistalsis.
Ascites is an abnormal collection of fluid in the abdominal cavity, commonly caused by liver cirrhosis, congestive heart failure, constrictive pericarditis or a malignancy. Ascites can be complicated by spontaneous bacterial peritonitis.
Scars from previous surgery may suggest adhesions causing intestinal obstruction in a patient with severe generalized colicky abdominal pain, high pitched bowel sounds and vomiting.
Auscultation of the abdomen (listening for bowel sounds) is the next step after inspection. Bowel sounds can be absent in peritonitis, increased in gastroenteritis due to increased bowel movement (hyperperistalsis). Short, high-pitched rushes of bowel sounds are suggestive of bowel obstruction (a later finding in bowel obstruction is the absence of bowel sounds).
Hypoactive or absent bowel sounds, apart from being a late finding in intestinal obstruction, often indicate an ileus (paralysis of the intestine) due to an intra-abdominal infection, electrolyte imbalance or the effect of an anticholinergic medication.
Palpation of the abdomen: Ask where the pain is located and examine the most painful part last. Palpate the entire abdomen while watching the patient’s face for signs of discomfort. In this way, you can locate regions of tenderness. In general, tenderness may be caused by inflammation of the peritoneum or a viscus or distention of the capsule of a solid organ (but tenderness may also arise from inflammation or trauma of the abdominal wall).
Rigidity of the abdominal muscles (guarding) may be voluntary (in anxious patients and often it can be abolished by distracting the patient with conversation) or involuntary. Voluntary rigidity can also occur if the hands of the examiner are cold. Involuntary guarding is a sign of irritation of the peritoneum of the affected area. It is due to reflex muscle spasm caused by the peritoneal irritation.
Rebound tenderness (Blumberg's sign): Press your fingertips gently into the abdomen and then suddenly withdraw them. If the pain is worsened immediately after withdrawal, there is rebound tenderness. The pain may occur at the site of pressure or remote from it. Rebound tenderness is a useful and reliable sign of peritoneal inflammation. Another test for peritoneal inflammation is to move the patient's pelvis with your hands vigorously from side to side. This will cause pain at the site of peritoneal irritation.
In female patients with lower abdominal pain, a pelvic examination is also necessary.
Laboratory and imaging tests in patients with acute abdominal pain
Standard tests (complete blood count-CBC, chemistries, urinalysis) are done in every patient with acute abdominal pain but the results although helpful in some cases, have a low specificity. Elevated white blood cells with a high neutrophil count are often found in inflammatory disorders such as cholecystitis, appendicitis, peritonitis.In the urinalysis, hematuria can be an indication of nephrolithiasis and pyuria an indication of a urinary tract infection (cystitis or pyelonephritis), although pyuria is occasionally also present in appendicitis.
A marked elevation in serum amylase indicates acute pancreatitis, but serum lipase is more specific for this diagnosis.
A bedside urine pregnancy test is mandatory for all women of childbearing age because a negative result can effectively exclude ruptured ectopic pregnancy.An ECG is performed in every case. (Note that one of the conditions that can mimic acute abdomen is inferior wall myocardial infarction). Atrial fibrillation in the appropriate clinical picture can raise suspicion of mesenteric ischemia (since atrial fibrillation, especially without appropriate anticoagulant treatment, can lead to arterial embolic complications).
A chest X-ray can demonstrate a lower lobe pneumonia (which may mimic acute abdomen), or free air under the diaphragm (an indication of a perforated ulcer)
An abdominal X-ray can be helpful in cases of intestinal obstruction, where it shows dilated bowel loops and air-fluid levels.
Ultrasound can demonstrate biliary tract disease, renal stones, fluid accumulation in the peritoneal cavity (e.g. in peritonitis, perforation of a hollow viscus, or ascites due to liver cirrhosis), an abdominal aortic aneurysm or an ectopic pregnancy (transvaginal probe) or appendicitis in children. Although ultrasound can detect an abdominal aortic aneurysm, it often cannot reliably identify rupture of an aneurysm.
An advanced imaging modality, which is very efficient when there are diagnostic difficulties, is abdominal computerized tomography (CT) with oral and intravenous contrast. This test is diagnostic in about 95% of patients with severe abdominal pain. However, imaging must not delay surgery in patients with definitive symptoms and signs of an acute surgical condition.
A patient 62 years old with severe, diffuse abdominal pain of sudden onset. Physical examination showed diffuse abdominal tenderness and guarding
What is the diagnosis?
This upright chest X-ray shows free air under both hemidiaphragms. This is a sign suggesting a perforation of the gastrointestinal tract (e.g a perforated peptic ulcer).
(Also note a dilated ascending aorta, which is an incidental finding).
An emergency laparotomy was performed, which revealed a perforated duodenal ulcer.
Case courtesy of Dr Kewal Arunkumar Mistry, Radiopaedia.org
<a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/35318">rID: 35318</a>
https://radiopaedia.org/cases/subdiaphragmatic-free-gas-2
A 45- years- old, obese woman, with epigastric pain radiating to the right scapula, fever, nausea, and tenderness on palpation of the right upper abdominal quadrant (especially on the right subcostal area). Blood tests have shown an elevated neutrophil count, mildly elevated AST and moderately elevated γGT and ALP. What are the findings in the ultrasound and what is the diagnosis?
This upper abdominal ultrasound shows gallstones and thickening of the wall of the gallbladder. The clinical, laboratory and ultrasonic findings are diagnostic of acute cholecystitis
( I recommend this VIDEO : How to: Gallblader Ultrasound Part 3 - Acute Cholecystitis Case Study by Dr Phillip Perera (You Tube channel: Sonosite , LINK https://www.youtube.com/watch?v=SMCwcNm9WOw )
Treatment of acute abdomen, general principles and notes about some of the common causes:
Initial management: NPO (nothing per os-nothing by mouth)Placement of an intravenous (IV) line and infusion of IV fluids.
There is no evidence to support avoiding analgesics in patients with acute abdominal pain. (There are concerns that they might interfere with the accuracy of subsequent abdominal examinations, but evidence does not support these concerns). In the acute setting, analgesia usually is accomplished with IV opioids in small to moderate doses. In some cases, IV antiemetics are also administered (promethazine, prochlorperazine, or droperidol).
If there are signs of peritonitis (i.e. guarding and rebound tenderness with rigidity), IV fluids, and IV antibiotics are administered. Generally, if an intra-abdominal infection is suspected, parenteral administration of broad-spectrum antibiotics should begin promptly.
Gastric emptying by nasogastric tube is indicated for
suspected bowel obstruction and also usually in acute pancreatitis and in patients with paralysis of the intestine (ileus).
The need for surgical intervention depends on the specific diagnosis, the severity of the patient's clinical condition and the presence or absence of peritonitis.
Acute appendicitis:
Gastric emptying by nasogastric tube is indicated for
suspected bowel obstruction and also usually in acute pancreatitis and in patients with paralysis of the intestine (ileus).
The need for surgical intervention depends on the specific diagnosis, the severity of the patient's clinical condition and the presence or absence of peritonitis.
Acute appendicitis:
Obstruction of the lumen of the appendix, most commonly from a fecalith, causes increased intraluminal pressure and reduced venous and lymphatic drainage with superimposed infection of the appendiceal wall.
Typically there is a diffuse periumbilical abdominal pain (visceral pain), which later migrates to the right lower abdominal quadrant (parietal pain) with tenderness in palpation. Often there is anorexia, nausea and vomiting. Fever can be present, but in many cases there is no fever. There are some signs, that can assist the diagnosis, such as:
McBurney's sign or McBurney's point, which is the usual point of maximal tenderness in acute appendicitis: One third the distance between the anterosuperior iliac spine and the umbilicus. This tenderness on palpation is the result of local inflammation of the parietal peritoneum.
Rovsing's sign, which is pain in the right lower quadrant on palpation of the left lower quadrant,
In some cases of appendicitis there is a positive psoas sign (when a retrocecal inflamed appendix irritates the psoas muscle). This sign is the occurence of right lower quadrant pain when:
The patient lies on his left side and his hip is passively extended bacwards, or when
The patient lies in the supine position and tries to extend his lower extremity, against mild resistance from the examiner, who exerts downward pressure on the thigh. ( Watch a video from the you tube channel
MDforAll LINK: Psoas sign)
In some cases of appendicitis there is a positive psoas sign (when a retrocecal inflamed appendix irritates the psoas muscle). This sign is the occurence of right lower quadrant pain when:
The patient lies on his left side and his hip is passively extended bacwards, or when
The patient lies in the supine position and tries to extend his lower extremity, against mild resistance from the examiner, who exerts downward pressure on the thigh. ( Watch a video from the you tube channel
MDforAll LINK: Psoas sign)
Treatment of acute appendicitis is with surgery (appendicectomy = excision of the appendix), since there is a risk of perforation of the appendix, which causes peritonitis.
Acute cholecystitis:
Prolonged obstruction of the cystic duct (the tube through which the gallbladder empties) causes dilation, inflammation and infection of the gallbladder.
Acute cholecystitis manifests with right upper quadrant pain (which is usually more severe and longer lasting than the pain of biliary colic). There is also nausea, vomiting and fever. Physical examination shows tenderness on the right upper quadrant, possibly with guarding and a positive Murphy sign (interruption of inspiration during deep palpation of the right upper quadrant).
Initially acute cholecystitis is treated non-operatively with IV antibiotics. Because there is a high risk of recurrent attacks, cholecystectomy should follow (excision of the gallbladder), which is the definite therapy.
Acute diverticulitis:
Diverticula are sac-like projections of the lumen.
The majority if diverticula occur in the left colon (usually the sigmoid). Diverticulitis happens when there is diverticular obstruction with stool followed by subsequent inflammation. Diverticulitis is more common in elderly patients and presents with focal abdominal pain and tenerness (usually on the left lwer abdominal quadrant). Fever, nausea and vomiting may be
present. Complicated diverticulitis involves inflammation extending beyond pericolonic fat and manifests with more severe tenderness with or without evidence of local peritonitis.
Conservative therapy is the usual choice with IV fluids, antibiotics, and analgesia, but if perforation has occurred, then surgical resection is indicated.
Small bowel obstruction:
It is a mechanical obstuction (partial or complete) of the small bowel lumen preventing passage of intestinal contents. Main causes are:
Adhesions (the most common cause in adults)
Neoplasms ( e.g. lymphoma, adenocarcinoma)
A strangulated hernia (the third most common cause)
Crohn disease
Volvulus (rotation or twisting of a bowel segment)
Intussusception (most common in children < 2 y- this is a condition in which a bowel segment invaginates into the next more distal segment)
The manifestations of a mechanical small bowel obstruction include intermittent crampy abdominal pain which is usually diffuse (poorly localized) and vomiting. Bilious emesis (vomit which contains bile) usually occurs in obstruction of the proximal small bowel (but distal to the pylorus). Note that passage of flatus and stool may continue for as long as 24 hours aftr complete small bowel obstruction. Abdominal distention is present (which is more pronounced with distal obstructions) In early obstruction bowel sounds are increased and high pitched, but in late obstruction they are diminished. In case of a small bowel obstruction, place a nasogastric tube (Levin). Management depends on the etiology. In case of a strangulated hernia, urgent surgery is indicated. In intestinal obstruction caused by adhesions from previous surgery, only patients who do not improve within 48 hours with IV fluids, fasting and nasogastric aspiration, or who develop signs of intestinal strangulation (abdominal pain becoming constant instead of colicky, peritonitis, fever, leucocytosis) require surgical intervention.
Large bowel obstruction:
The most common causes of large bowel mechanical obstruction are colorectal cancer (the most common cause), followed by diverticulitis and volvulus (a twisted intestinal segment).
Acute colonic pseudo-obstruction (Ogilvie syndrome)
is seen in elderly patients with a severe illness or multiple comorbidities.There is dilatation of the cecum and right colon in the absence of a mechanical obstruction. It may be caused by infection, electrolyte abnormalities or medications.
Pseudoobstruction is treated nonoperatively (bowel rest, rectal tube, hydration, correction of electrolyte disturbances, avoidance of medications that slow motility of the colon, neostigmine)
Mechanical obstruction requires surgical treatment. Differentiation between the two is by a watersoluble contrast enema.
A rare complication of bowel obstruction is bowel perforation which causes peritonitis.
Perforated viscus:
Gastric and duodenal perforations are usually due to erosion of an ulcer
Small bowel perforation can be due to a strangulated hernia, ischemia, inflammatory bowel disease, abdominal penetrating or blunt trauma, a tumor (benign or malignant), or an infection (tuberculosis, typhoid fever)
Large bowel perforation is a rare, but severe, condition and can be due to colorectal cancer, diverticulitis, ulcerative colitis or a foreign body.
Perforation of a viscus causes severe abdominal pain which quickly becomes generalized. On examination there are signs of peritonitis: bowel sounds are reduced or absent with diffuse abdominal tenderness and often rigidity of the abdominal wall. The patient usually prefers to remain immobile. Abdominal or chest radiographs may show free air in the peritoneal cavity. In some cases with diagnostic uncertainty, CT may be required.
Perforation is a surgical emergency.
Surgical closure of the perforation is performed.
NPO, adequate and aggressive administration of intravenous fluids, IV antibiotics, and analgesia is required before surgery.
Acute pancreatitis:
This is an acute inflammation of the pancreas resulting from inappropriate intrapancreatic activation of pancreatic proteolytic enzymes. Frequent causes are alcohol abuse and cholelithiasis Other causes include hyperlipidemia (severe elevation of triglyceride levels), hyperparathyroidism/hypercalcemia and trauma. Initial therapy is with nasogastric suction, intravenous fluids (started immediately) and opioid analgesics, (e.g. fentanyl or hydromorphone). Antibiotics are not administered. After the acute phase resolves, therapy entails oral analgesics, effective hydration, and a diet high in carbohydrates and lower in long-chain triglycerides. Protein does not need to be restricted.
Note that in some patients, pancreatitis develops a severe complicated course. Admission to an intensive care unit (ICU) is indicated for patients with hemodynamic instability, evidence of hemorrhagic pancreatitis, or evidence of organ failure (e.g. creatinine >2 mg/dL).
Bibliography and links
Prolonged obstruction of the cystic duct (the tube through which the gallbladder empties) causes dilation, inflammation and infection of the gallbladder.
Acute cholecystitis manifests with right upper quadrant pain (which is usually more severe and longer lasting than the pain of biliary colic). There is also nausea, vomiting and fever. Physical examination shows tenderness on the right upper quadrant, possibly with guarding and a positive Murphy sign (interruption of inspiration during deep palpation of the right upper quadrant).
Initially acute cholecystitis is treated non-operatively with IV antibiotics. Because there is a high risk of recurrent attacks, cholecystectomy should follow (excision of the gallbladder), which is the definite therapy.
Acute diverticulitis:
Diverticula are sac-like projections of the lumen.
The majority if diverticula occur in the left colon (usually the sigmoid). Diverticulitis happens when there is diverticular obstruction with stool followed by subsequent inflammation. Diverticulitis is more common in elderly patients and presents with focal abdominal pain and tenerness (usually on the left lwer abdominal quadrant). Fever, nausea and vomiting may be
present. Complicated diverticulitis involves inflammation extending beyond pericolonic fat and manifests with more severe tenderness with or without evidence of local peritonitis.
Conservative therapy is the usual choice with IV fluids, antibiotics, and analgesia, but if perforation has occurred, then surgical resection is indicated.
Small bowel obstruction:
It is a mechanical obstuction (partial or complete) of the small bowel lumen preventing passage of intestinal contents. Main causes are:
Adhesions (the most common cause in adults)
Neoplasms ( e.g. lymphoma, adenocarcinoma)
A strangulated hernia (the third most common cause)
Crohn disease
Volvulus (rotation or twisting of a bowel segment)
Intussusception (most common in children < 2 y- this is a condition in which a bowel segment invaginates into the next more distal segment)
The manifestations of a mechanical small bowel obstruction include intermittent crampy abdominal pain which is usually diffuse (poorly localized) and vomiting. Bilious emesis (vomit which contains bile) usually occurs in obstruction of the proximal small bowel (but distal to the pylorus). Note that passage of flatus and stool may continue for as long as 24 hours aftr complete small bowel obstruction. Abdominal distention is present (which is more pronounced with distal obstructions) In early obstruction bowel sounds are increased and high pitched, but in late obstruction they are diminished. In case of a small bowel obstruction, place a nasogastric tube (Levin). Management depends on the etiology. In case of a strangulated hernia, urgent surgery is indicated. In intestinal obstruction caused by adhesions from previous surgery, only patients who do not improve within 48 hours with IV fluids, fasting and nasogastric aspiration, or who develop signs of intestinal strangulation (abdominal pain becoming constant instead of colicky, peritonitis, fever, leucocytosis) require surgical intervention.
Large bowel obstruction:
The most common causes of large bowel mechanical obstruction are colorectal cancer (the most common cause), followed by diverticulitis and volvulus (a twisted intestinal segment).
Acute colonic pseudo-obstruction (Ogilvie syndrome)
is seen in elderly patients with a severe illness or multiple comorbidities.There is dilatation of the cecum and right colon in the absence of a mechanical obstruction. It may be caused by infection, electrolyte abnormalities or medications.
Pseudoobstruction is treated nonoperatively (bowel rest, rectal tube, hydration, correction of electrolyte disturbances, avoidance of medications that slow motility of the colon, neostigmine)
Mechanical obstruction requires surgical treatment. Differentiation between the two is by a watersoluble contrast enema.
A rare complication of bowel obstruction is bowel perforation which causes peritonitis.
Perforated viscus:
Gastric and duodenal perforations are usually due to erosion of an ulcer
Small bowel perforation can be due to a strangulated hernia, ischemia, inflammatory bowel disease, abdominal penetrating or blunt trauma, a tumor (benign or malignant), or an infection (tuberculosis, typhoid fever)
Large bowel perforation is a rare, but severe, condition and can be due to colorectal cancer, diverticulitis, ulcerative colitis or a foreign body.
Perforation of a viscus causes severe abdominal pain which quickly becomes generalized. On examination there are signs of peritonitis: bowel sounds are reduced or absent with diffuse abdominal tenderness and often rigidity of the abdominal wall. The patient usually prefers to remain immobile. Abdominal or chest radiographs may show free air in the peritoneal cavity. In some cases with diagnostic uncertainty, CT may be required.
Perforation is a surgical emergency.
Surgical closure of the perforation is performed.
NPO, adequate and aggressive administration of intravenous fluids, IV antibiotics, and analgesia is required before surgery.
Acute pancreatitis:
This is an acute inflammation of the pancreas resulting from inappropriate intrapancreatic activation of pancreatic proteolytic enzymes. Frequent causes are alcohol abuse and cholelithiasis Other causes include hyperlipidemia (severe elevation of triglyceride levels), hyperparathyroidism/hypercalcemia and trauma. Initial therapy is with nasogastric suction, intravenous fluids (started immediately) and opioid analgesics, (e.g. fentanyl or hydromorphone). Antibiotics are not administered. After the acute phase resolves, therapy entails oral analgesics, effective hydration, and a diet high in carbohydrates and lower in long-chain triglycerides. Protein does not need to be restricted.
Note that in some patients, pancreatitis develops a severe complicated course. Admission to an intensive care unit (ICU) is indicated for patients with hemodynamic instability, evidence of hemorrhagic pancreatitis, or evidence of organ failure (e.g. creatinine >2 mg/dL).
Cartwright SL1, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 ;77:971-978. LINK https://www.aafp.org/afp/2008/0401/p971.html
Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine. 2012;5:789-797. doi:10.2147/IJGM.S25936.
LINK https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468117/McNamara R, Dean AJ.Approach to acute abdominal pain. Emerg Med Clin North Am. 2011; 29:159-173
Mayumi T, et al. The Practice Guidelines for Primary Care of Acute Abdomen 2015. Journal of General and Family Medicine 2016;17:5–52. LINK http://onlinelibrary.wiley.com/doi/10.14442/jgfm.17.1_5/pdf
The acute abdomen -Surg Wiki
The acute abdomen- Teachmesurgery.com
Assessment and management of the acute abdomen-oscestop.com
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