ACUTE ABDOMEN

Introduction

Acute abdomen is the most common cause of admission in emergency. Acute abdomen
continues to be one of the most challenging diagnostic dilemmas for MOs. The modern
physician should be humbled by the fact that, despite diagnostic and therapeutic advances,
the misdiagnosis rate of the most common surgical emergency, acute appendicitis, has
changed little over time. Although a common presentation, abdominal pain must be
approached in a serious manner, as it is often a symptom of serious disease and misdiagnosis
may occur. Various factors can obscure the presentation, delaying or preventing the correct
diagnosis, with subsequent adverse outcomes.

History

MO should try to obtain a complete history as this is generally the cornerstone of an accurate
diagnosis. The history should include a complete description of the patient’s pain and
associated symptoms. Medical, surgical, and social history should also be sought.

Assessment of pain
The PQRST mnemonic for a complete pain history is as follows:
P3 – Position, palliating, and provoking factors
Q – Quality
R3 – Region, radiation, referral
S – Severity
T3 – Temporal factors (time and mode of onset, progression, previous episodes)

Location
Embryology determines where a patient will “feel” visceral pain, generally in the midline.
Visceral nociceptors can be stimulated by distention, vigorous contraction, and ischemia.
Pain from foregut structures (stomach, pancreas, liver, biliary system, and proximal
duodenum) will be localized to the epigastric region. Pain associated with midgut structures
(rest of the small bowel and proximal one-third of colon including appendix) is perceived in
periumbilical region. Hindgut structures such as bladder, distal two-thirds of colon, and
pelvic genitourinary organs usually cause pain in the suprapubic region. Pain is usually
reported in the back for retroperitoneal structures such as the aorta and kidneys.

Character
Clinicians should seek to distinguish between the dull, poorly localized pain generated by
viscerally innervated organs, compared with the “sharp”, more localized somatic pain caused
by irritation of the parietal peritoneum or other somatically innervated structures.

Onset
Severe acute-onset pain should prompt immediate concern about a potential intra-abdominal
catastrophe such as a ruptured abdominal aortic aneurysm (AAA) or aortic dissection. Other
considerations include a perforated ulcer, volvulus, mesenteric ischemia, and torsion. A
gradual onset is seen in case of an infectious or inflammatory process. Pain that awakens the
patient from sleep should be considered serious until proven otherwise.
Intensity
Pain that is severe should heighten the concern for a serious underlying cause; however,
descriptions of milder pain cannot exclude serious illness, especially in older patients who
may under-report symptoms.

Patterns of radiation and referral of pain

Neural pathways give rise to referred pain and radiation. Kehr’s sign is where diaphragmatic
irritation, usually from free intraperitoneal fluid, causes shoulder pain. Another example is
ipsilateral scapular pain caused by biliary disease. Radiation may also reflect progression of
disease such as with continued aortic dissection, or ongoing passage of a ureteral stone. It is
important to remember that deep musculoskeletal structures are innervated by visceral
sensory fibers with similar qualities to those arising from intra-abdominal organs. Thus, in
cases where a patient’s perceived location of symptoms appears to be completely unrevealing
on physical exam, a careful assessment of musculoskeletal structures should be made.

Duration and progression

Persistent worsening pain is worrisome, while reducing of pain is usually favorable. Serious
causes of abdominal pain generally present early in their course; however, delays in
presentation can occur, especially in the elderly. Certain patterns of progression can be
diagnostic, such as the migration of pain in appendicitis where the initial distention of the
appendix causes a periumbilical visceral pain that shifts to the right lower quadrant once the
inflammatory process is detected by the somatic sensors of the parietal peritoneum. Although
labeled “colic,” gallbladder pain is generally not paroxysmal, and lasts for an average of 5–16
hours duration. Small bowel obstruction progresses from an intermittent (“colicky”) pain to
more constant pain when distention occurs. One would expect somatic pain (arising from
transmural ischemia or perforation contiguous to the parietal peritoneum) late in the course of
a bowel obstruction.

Provocative and palliating factors

The MO needs to ask what makes the pain worse and what improves the pain. If jarring
motions such as coughing or walking exacerbate the pain, it is suggestive of peritoneal
irritation. With upper abdominal pain one should specifically ask whether it is pleuritic as this
may signify chest disease. PUD may be exacerbated (gastric) or relieved (duodenal) by
eating. Mesenteric ischemia may be precipitated by eating, as can the pain of intermittently
symptomatic gallstones, often associated with fatty meals. The patient should be questioned
about any self-treatments, particularly analgesics and antacids, and the response to these
measures.

Previous episodes
Recurrent episodes generally point to a medical cause, with the exceptions of mesenteric
ischemia (intestinal angina), gallstones, or partial bowel obstruction.

Assessment of the associated symptoms

Gastrointestinal and urinary symptoms are important, also ask about fever and
cardiopulmonary symptoms.

Anorexia
With appendicitis, most physicians expect the patient to have anorexia. However, the report
of this symptom decreases in elderly patients with appendicitis.
Vomiting
Pain generally precedes vomiting in surgical conditions, with the important exception of
esophageal rupture from forceful emesis. It is usually present in small bowel obstruction,
unless the obstruction is partial. Many other serious entities including large bowel obstruction
frequently present without vomiting. The nature of the vomiting may be diagnostically
helpful. With small bowel obstruction, one anticipates a progression from gastric contents to
bilious to feculent emesis with the progression of illness. Frequent nonproductive retching
can point to gastric volvulus, while repetitive nonbilious vomiting may indicate gastric outlet
obstruction. Bilious vomiting in an infant is almost always a serious illness such as intestinal
malrotation. Blood or coffee ground emesis are usually caused by gastric diseases or
complications of liver disease. Massive hematemesis in a patient with a prior abdominal
aortic aneurysm repair may be due to aorto-enteric fistula. The vomiting from benign causes
such as viral or food-borne illness is self-limited.

Bowel symptoms
While diarrhea is frequent in more benign abdominal conditions, its presence alone should
never rule out serious disease. For example, diarrhea is commonly reported with mesenteric
ischemia and appendicitis. Diarrhea also occurs in early small bowel obstruction as the
reflexively hyperactive bowel distal to the obstruction clears itself, and with partial
obstruction, diarrhea may be ongoing. Absence of flatus is a more reliable sign than
constipation in bowel obstruction, since the bowel clears gas more rapidly than fluid. Bloody
stool in the presence of significant abdominal pain should raise the suspicion for mucosal
compromise from ischemia. Melena suggests an upper source of bleeding, while frank blood
can indicate a lower source or a massive upper bleed with rapid transit time. The urge to
defecate in a patient with acute abdominal pain has been described as a harbinger of serious
disease including ruptured aneurysm in older patient or ruptured ectopic pregnancy in young.

Other symptoms
Many genitourinary tract diseases can present with abdominal pain. Conversely, any
inflammatory process contiguous to the genitourinary tract (including appendicitis,
cholecystitis, pancreatitis, or any inflammatory process involving bowel) may result in both
pyuria and dysuria. This can lead to misdiagnosis of both gastrointestinal and genitourinary
conditions. In men, testicular torsion may present as abdominal pain, nausea, and vomiting.
In women, the enlarging uterus of pregnancy can itself cause discomfort and displace
abdominal organs in such a way as to further complicate the diagnosis of many abdominal
conditions, especially appendicitis. For these reasons, a menstrual (where applicable), sexual,
and genitourinary history should be obtained in most patients with abdominal pain. The
report of normal, regular menses should not preclude consideration of current pregnancy.
Cardiopulmonary symptoms such as cough and dyspnea can point to a nonabdominal cause
of abdominal pain. Syncope may indicate disease originating in the chest (pulmonary
embolism, dissection) or abdomen (acute aortic aneurysm, ectopic pregnancy).

Past medical and surgical history, current medications

A history of prior abdominal surgery can rule out a condition or raise the suspicion for a
complication such as obstruction from adhesions. Many medical conditions cause acute
abdominal pain, including DKA, hypercalcemia, Addison’s disease, and sickle cell crisis. The
patient’s current medications should be reviewed with attention to those affecting the
integrity of the gastric mucosa (steroids and NSAIDs), immunosuppressive agents (impair
host defenses), and any that can impair nociception (narcotics may also cause pain due to
constipation).
Social history
The patient’s use of drugs and alcohol may have important diagnostic implications. Cocaine
use may cause intestinal as well as cardiac ischemia. Gastrointestinal complications of
alcohol abuse are extensive and well known. Domestic violence may reveal a traumatic
source of pain.

Physical examination

The general appearance of the patient is noted first. An “ill appearing” patient with
abdominal pain is always of great concern. On the other hand, especially in elderly, one must
not be misled by a well appearing patient. The clinician should note the patient’s position,
spontaneous movements, respiratory pattern, and facial expression.

Vital signs
Vital sign abnormalities should alert one to a serious cause of the abdominal pain. While
fever certainly points to an infectious cause or complication, it is frequently absent with
infectious causes of abdominal pain, eg., appendicitis and acute cholecystitis. Tachypnea may
be a nonspecific finding, but it should prompt consideration of chest disease or metabolic
acidosis from entities such as ischemic bowel or diabetic ketoacidosis.

The abdominal examination

The DMO should know the key elements of the abdominal examination while understanding
their limitations.

Inspection, auscultation, and percussion

Detection of surgical scars, skin changes including signs of herpes zoster, liver disease (caput
medusa), and hemorrhage (Grey Turner’s sign of flank ecchymoses with a retroperitoneal
source, Cullen’s sign of a bluish umbilicus with intraperitoneal bleeding). With distention,
percussion will allow the differentiation between large bowel obstruction (drum-like
tympany) and advanced ascites (shifting dullness). Auscultation is of very limited diagnostic
utility. Bruits have been described with aortic, renal, or mesenteric stenosis, but are rarely
appreciated in a busy ED.

Palpation
The ED abdominal exam is directed primarily to the localization of tenderness, the
identification of peritonitis, and the detection of certain enlargements such as the abdominal
aorta. To improve the palpation phase of the examination, progress from nonpainful areas to
the location of pain. It may be useful to palpate the abdomen of anxious or less cooperative
children with the stethoscope to define areas of tenderness.
Localized tenderness is generally a reliable guide to the underlying cause of the pain. More
generalized tenderness presents a greater diagnostic challenge. Unless the patient has had an
appendectomy, given its frequency as a serious cause of abdominal pain, continue
consideration of appendicitis in any patient with right lower quadrant tenderness. If tolerated
by the patient, palpation or percussion may include assessment of the liver and spleen size
and a search for pulsatile or other masses and an assessment of the quality of femoral pulses.
A tender pulsatile and expansile mass is the key distinguishing feature of an acute abdominal
aortic aneurysm. The femoral pulses may be unequal with aortic dissection. Inspection and
palpation of the patient while they are standing may reveal the presence of hernias undetected
in the supine position.
Tests for peritoneal irritation
Determining the presence or absence of peritonitis is a primary objective of the abdominal
examination; unfortunately, the methods for detecting it are often inaccurate. Traditional
rebound testing is performed by gentle depression of the abdominal wall for approximately
15–30 seconds with sudden release. There are indirect tests such as the “cough test”.
Guarding is increased abdominal wall muscular tone and is of significance as an involuntary
reflex as it reflects a physiological attempt to minimize movement of the intraperitoneal
structures. “voluntary guarding” is frequently seen in normal patients with apprehension
about the abdominal exam. Rigidity is the extreme example of true guarding. To identify true
guarding, the examiner gently assesses muscle tone through the respiratory cycle, preferably
with the knees and hips flexed to further relax the abdomen. With “voluntary guarding,” the
tone will decrease with inspiration, while with true guarding, continued abdominal wall
tension will be seen throughout the respiratory cycle. Guarding and rigidity may be lacking in
the elderly because of laxity of abdominal wall musculature.

Special abdominal examination techniques

There are a number of examination techniques that may be useful to the emergency physician
in helping to establish a diagnosis.
Cough test
This test seeks evidence of peritoneal irritation by having the patient cough. A positive test is
a cough causing a sharp, localized pain. Signs of pain seen on coughing can be flinching,
grimacing, or moving of hands to the abdomen.
Closed eyes sign
Based on the assumption that the patient with an acute abdominal condition will carefully
watch the examiner’s hands to avoid unnecessary pain, this test is considered an indicator of
nonorganic cause of abdominal pain. The test is considered positive if the patient keeps their
eyes closed when abdominal tenderness is elicited.
Murphy’s sign
Inspiratory arrest while deeply palpating the right upper quadrant is the most reliable clinical
indicator of cholecystitis.
The psoas sign
By having the supine patient lift the thigh against hand resistance, or with the patient laying
on their contralateral side and the hip joint passively extended, increased pain suggests
irritation of the psoas muscle by an inflammatory process contiguous to the muscle. When
positive on the right, this is a classic sign of appendicitis. Other inflammatory conditions
involving the retroperitoneum, including pyelonephritis, pancreatitis, and psoas abscess, will
also elicit this sign.
The obturator sign
The obturator sign is elicited with the patient supine and the examiner supporting the
patient’s lower extremity with the hip and knee both flexed to 90 degrees. The sign is positive
if passive internal and external rotation of the hip causes reproduction of pain, and suggests
the presence of an inflammatory process adjacent to the muscle deep in lateral walls of the
pelvis. Potential diagnoses include a pelvic appendicitis, sigmoid diverticulitis, pelvic
inflammatory disease, or ectopic pregnancy.
The Rovsing sign
It is a form of indirect rebound testing in which the examiner applies pressure in the left
lower quadrant, remote from the usual area of appendiceal pain and tenderness. The test is
positive if the patient reports rebound pain in the right lower quadrant when the examiner
releases pressure.
Other examination elements
In addition to skin inspection, the back should be assessed for tenderness at the costovertebral
angle, spinous processes, and paraspinal regions. Because any chest disease can present with
abdominal pain, particular attention should be paid to the cardiopulmonary examination. The
groin, including the femoral triangle, is assessed for hernias. The male patient must be
inspected for testicular pathology including torsion and infection. In females with lower
abdominal pain a pelvic examination is almost always necessary. The pelvic examination
presents an opportunity to assess the pelvic peritoneum directly for signs of inflammation.

Analgesia and the abdominal examination

The emergency physician should not hesitate to administer adequate analgesic medication to
the patient with acute abdominal pain. It does not obscure the diagnosis or interfere with the
treatment of the patient.

Approach to the unstable patient

The usual sequence of resuscitation is applied to the unstable abdominal pain patient with
airway control achieved as necessary. Hypotension requires the parallel process of treatment
and an early assessment for life threatening conditions requiring emergent surgical
intervention. Hypotension from blood and fluid loss from the GIT is usually apparent from
the history. If this evidence is lacking in the patient, there needs to be early consideration of
third spacing, which can cause enormous fluid shifts into the bowel lumen or peritoneal
space. Bedside ultrasonography is an extremely useful diagnostic adjunct in such patients. In
the older patient, hypotension should prompt an immediate search for an abdominal aortic
aneurysm, immediately followed by sonography of the inferior vena cava for intravascular
volume status, and sonography of the thorax to exclude massive effusions or pulmonary
embolus. Bedside echocardiography will also identify severe global myocardial depression as
a cardiogenic cause of shock. In the younger patient, a large amount of free fluid detected by
ultrasound in an unstable patient is most commonly due to rupture of an ectopic pregnancy,
spleen, or hemorrhagic ovarian cyst. An immediate UPT will be the first step in
distinguishing these.

The proper place for the unstable patient with an acute abdominal aortic aneurysm is the
operation theatre. Attempts to obtain CT imaging, may cause fatal delays in definitive
treatment. With a high clinical index of suspicion (if possible, supported by emergency
bedside ultrasonography), most patients sent directly to surgery will be found to have an
acute AAA, and nearly all others will have a diagnosis that still needs operative intervention.

Diagnostic studies

Appropriate diagnostic testing is advised: however, it must be emphasized that there are
significant limitations of imaging and laboratory studies in the evaluation of acute abdominal
pain and all diagnostic tests have a false-negative rate. If the history and physical
examination leads to a high pre-test probability of a disease, a negative test cannot exclude
the diagnosis. For example, the total leukocyte count can be normal in the face of serious
infection such as appendicitis or cholecystitis. CT remains an imperfect test for conditions
such as appendicitis and may add little to the clinical assessment.
Plain abdominal radiographs are of limited utility in the evaluation of acute abdominal pain.
Although they may be helpful (free intraperitoneal air, calcified aortic aneurysm, air fluid
levels in obstruction) other diagnostic studies almost always perform better as initial testing.

The oft repeated axiom of “treat the patient, not the test” applies in the patient with acute
abdominal pain. Whenever the diagnosis is in question, serial examination as an inpatient in
an observation unit or in the ED is a sound strategy. When a patient is discharged home after
an evaluation for abdominal pain, it should be with instructions to return if the pain worsens,
new vomiting or fever occurs, or if the pain persists beyond 8–12 hours. Such instructions are
targeted at ensuring the return of a patient who has progressed from an early appendicitis or
small bowel obstruction, the two most common surgical entities erroneously discharged from
an A&E.