Acute Abdominal Pain

Dr. Muhammad Naeem

Associate Professor, Dept. of Surgery
MTI, KMC, KTH
Case #1
 24 yr healthy M with one day hx of abdominal pain. Pain
was generalized at first, now worse in right lower abd &
radiates to his right groin. He has vomited twice today.
Denies any diarrhea, fevers, dysuria or other complaints.
No appetite today. ROS otherwise negative.
 PMHx: negative
 PSurgHx: negative
 Meds: none
 NKDA
 Social hx: no alcohol, tobacco or drug use
 Family hx: non-contributory
Abdominal pain
 Abdominal pain can be short-lived (acute) or
occur over weeks, months or years (chronic)
 How do you approach the complaint of
abdominal pain in general?
 Let’s review in this lecture:
 Types of pain
 History and physical examination
 Differential diagnosis
 Labs and imaging
 cases
 Clinical pearls
“Questions to ask regarding pain”

Location
Quality
Severity
Onset
Duration
Modifying factors
Change over time
What kind of pain is it?
 Visceral
 Involves hollow or solid organs; midline pain due to bilateral innervation
 Steady ache or vague discomfort to excruciating or colicky pain
 Poorly localized
 Epigastric region: stomach, duodenum, biliary tract
 Periumbilical: small bowel, appendix, cecum
 Suprapubic: colon, sigmoid, GU tract
 Parietal
 Involves parietal peritoneum
 Localized pain
 Causes tenderness and guarding which progress to rigidity and rebound as
peritonitis develops
 Referred
 Produces symptoms not signs
 Based on developmental embryology
 Ureteral obstruction → testicular pain
 Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain
 Gynecologic pathology → back or proximal lower extremity
 Biliary disease → right infrascapular pain
 MI → epigastric, neck, jaw or upper extremity pain
The detailed past history
 GI
 Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD
 GU
 Past surgeries, h/o kidney stones, pyelonephritis, UTI
 Gyn
 Last menses, sexual activity, contraception, h/o PID or STDs, h/o
ovarian cysts, past gynecological surgeries, pregnancies
 Vascular
 h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA
 Other medical history
 DM, organ transplant, HIV/AIDS, cancer
 Social
 Tobacco, drugs – Especially cocaine, alcohol
 Medications
 NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin
Relevant review of systems
 GI symptoms
Nausea, vomiting, hematemesis, anorexia, diarrhea,
constipation, bloody stools, melena stools
 GU symptoms
Dysuria, frequency, urgency, hematuria, incontinence
 Gyn symptoms
Vaginal discharge, vaginal bleeding
 General
Fever, lightheadedness
Physical Examination
 General
 Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying
still or moving around in the bed
 Vital Signs
 Orthostatic VS when volume depletion is suspected
 Cardiac
 Arrhythmias
 Lungs
 Pneumonia
 Abdomen
 Look for distention, scars, masses
 Auscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise
not very helpful
 Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity
 Percuss for tympany
 Look for hernias!
 rectal exam
 Back
 CVA tenderness
 Pelvic exam
 CMT
 Vaginal discharge – Culture
 Adenexal mass or fullness
Abdominal Findings
 Tenderness
 Guarding
 Voluntary
 Contraction of abdominal musculature in anticipation of palpation
 Diminish by having patient flex knees
 Involuntary
 Reflex spasm of abdominal muscles
 aka: rigidity
 Suggests peritoneal irritation
 Rebound
 Present in 1 of 4 patients without peritonitis
 Pain referred to the point of maximum tenderness when palpating an
adjacent quadrant is suggestive of peritonitis
 Rovsing’s sign in appendicitis
 Rectal exam
 Little evidence that tenderness adds any useful information beyond
abdominal examination
 Gross blood or melena indicates a GIB
 Differential Diagnosis
 Gastritis, ileitis, colitis, esophagitis  Hemilith infestation
 Ulcers: gastric, peptic, esophageal  Porphyrias
 Biliary disease: cholelithiasis, cholecystitis  ACS
 Hepatitis, pancreatitis, Cholangitis  Pneumonia
 Splenic infarct, Splenic rupture  Abdominal wall syndromes: muscle strain,
 Pancreatic psuedocyst hematomas, trauma,
 Hollow viscous perforation  Neuropathic causes: radicular pain
 Bowel obstruction, volvulus  Non-specific abdominal pain
 Diverticulitis  Group A beta-hemolytic streptococcal pharyngitis
 Appendicitis  Rocky Mountain Spotted Fever
 Ovarian cyst  Toxic Shock Syndrome
 Ovarian torsion  Black widow envenomation
 Hernias: incarcerated, strangulated  Drugs: cocaine induced-ischemia, erythromycin,
 Kidney stones tetracyclines, NSAIDs
 Pyelonephritis  Mercury salts
 Hydronephrosis  Acute inorganic lead poisoning
 Inflammatory bowel disease: crohns, UC  Electrical injury
 Gastroenteritis, enterocolitis  Opioid withdrawal
 pseudomembranous colitis, ischemia colitis  Mushroom toxicity
 Tumors: carcinomas, lipomas  AGA: DKA, AKA
 Meckels diverticulum  Adrenal crisis
 Testicular torsion  Thyroid storm
 Epididymitis, prostatitis, orchitis, cystitis  Hypo- and hypercalcemia
 Constipation  Sickle cell crisis
 Abdominal aortic aneurysm, ruptures aneurysm  Vasculitis
 Aortic dissection  Irritable bowel syndrome
 Mesenteric ischemia  Ectopic pregnancy
 Organomegaly  PID
 Urinary retention
 Ileus, Ogilvie syndrome
Most Common Causes
 Non-specific abd pain 34%
 Appendicitis 28%
 Biliary tract dz 10%
 SBO 4%
 Gyn disease 4%
 Pancreatitis 3%
 Renal colic 3%
 Perforated ulcer 3%
 Cancer 2%
 Diverticular dz 2%
 Inferior Wall MI 2%
 Lower Lobe pneumonia 2%
 Other
Investigations
 Radiological  Biochemical
 Abdominal series
 CBC: “What’s the white count?”
 3 views: upright chest, flat view of
abdomen, upright view of abdomen  RFTS
 Limited utility: restrict use to  Liver function tests,
patients with suspected obstruction
or free air Lipase,amylase
 Ultrasound  Coagulation studies
 Good for diagnosing AAA but not  Urinalysis, urine culture
ruptured AAA
 Good for pelvic pathology  GC/Chlamydia swabs
 CT abdomen/pelvis  Lactate
 Noncontrast for free air, renal colic,  Electrolyes for obstruction
ruptured AAA, (bowel obstruction)
 Contrast study for abscess,
infection, inflammation, unknown  ECG should be done in elderly to
cause rule out MI
 MRI
 Most often used when unable to
obtain CT due to contrast issue
Back to Case #1….24 yo with RLQ pain

 Physical exam:
 T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100%
room air
 Uncomfortable appearing, slightly pale
 Abdomen: soft, non-distended, tender to
palpation in RLQ with mild guarding; hypoactive
bowel sounds
 Genital exam: normal

 What is your differential diagnosis and what

do you do next?
Appendicitis
 Classic presentation  Findings
 Periumbilical pain  Depends on duration of symptoms
 Anorexia, nausea, vomiting  Rebound, voluntary guarding,
 Pain localizes to RLQ rigidity, tenderness on rectal exam
 Occurs only in ½ to 2/3 of patients  Psoas sign
 26% of appendices are retrocecal  Obturator sign
and cause pain in the flank; 4%  Fever (a late finding)
are in the RUQ  Urinalysis abnormal in 19-40%
 A pelvic appendix can cause  CBC is not sensitive or specific
suprapubic pain, dysuria  Abdominal xrays
 Males may have pain in the  Appendiceal fecalith or gas,
testicles localized ileus, blurred right psoas
muscle, free air
 CT scan
 Pericecal inflammation, abscess,
periappendiceal phlegmon, fluid
collection, localized fat stranding
Appendicitis: Psoas Sign
Appendicitis: Psoas Sign
Appendicitis: Obturator Sign

Passively flex
right hip and knee
then internally
rotate the hip
 Appendicitis: CT findings

Cecum

Abscess, fat
stranding
Appendicitis
 Diagnosis  Treatment
 WBC  NPO
 Clinical appendicitis – call  IVFs
your surgeon  Preoperative antibiotics –
 Maybe appendicitis - CT decrease the incidence of
scan postoperative wound
 Not likely appendicitis – infections
observe for 6-12 hours or  Cover anaerobes, gram-
re-examination in 12 negative and enterococci
hours  Zosyn 3.375 grams IV or
Unasyn 3 grams IV
 Analgesia
Case #2

46 yo M with hx of alcohol abuse with 3

days of severe upper abd pain, vomiting,
subjective fevers.
Med Hx: negative
Surg Hx: negative
Meds: none; Allergies: NKDA
Social hx: homeless, heavy alcohol use,
smokes 2ppd, no drug use
Case #2 Exam
Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat:
95% room air
 General: ill-appearing, appears in pain
 CV: tachycardic, normal heart sounds, pulses normal
 Lungs: clear
 Abdomen: mildly distended, moderately TTP epigastric,
+voluntary guarding
 Rectal: heme neg stool

 What is your differential diagnosis & what next?

Pancreatitis
 Risk Factors  Physical Findings
 Alcohol  Low-grade fevers
 Gallstones  Tachycardia, hypotension
 Drugs  Respiratory symptoms
 Amiodarone, antivirals,  Atelectasis
diuretics, NSAIDs,  Pleural effusion
antibiotics, more…..
 Peritonitis – a late finding
 Severe hyperlipidemia
 Ileus
 Idiopathic
 Cullen sign*
 Clinical Features  Bluish discoloration around
 Epigastric pain the umbilicus
 Constant, boring pain  Grey Turner sign*
 Radiates to back  Bluish discoloration of the
 Severe flanks
 N/V
 bloating *Signs of hemorrhagic pancreatitis
Pancreatitis
 Treatment
 Diagnosis  NPO
 Lipase  IV fluid resuscitation
 Elevated more than 2  Maintain urine output of
times normal 100 mL/hr
 Sensitivity and specificity  NGT if severe, persistent
>90% nausea
 Amylase  No antibiotics unless severe
 Nonspecific disease
 Don’t bother…  E coli, Klebsiella,
enterococci,
 RUQ US if etiology unknown staphylococci,
 CT scan pseudomonas
 Insensitive in early or mild  Imipenem or cipro with
disease metronidazole
 NOT necessary to  Mild disease, tolerating oral
diagnose pancreatitis fluids
 Useful to evaluate for  Discharge on liquid diet
complications  Follow up in 24-48 hours
 All others, admit
Case #3
 72 yo M with hx of CAD on aspirin and Plavix
with several days of dull upper abd pain and
now with worsening pain “in entire abdomen”
today. Some relief with food until today, now
worse after eating lunch.
 Med Hx: CAD, HTN, CHF
 Surg Hx: appendectomy
 Meds: Aspirin, Plavix, Metoprolol, Lasix
 Social hx: smokes 1ppd, denies alcohol or drug
use, lives alone
Case #3 Exam
 T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96%
room air
 General: elderly, thin male, ill-appearing
 CV: normal
 Lungs: clear
 Abd: mildly distended and diffusely tender to
palpation, +rebound and guarding
 Rectal: blood-streaked heme + brown stool

 What is your differential diagnosis & what

next?
Peptic Ulcer Disease
 Risk Factors  Physical Findings
 H. pylori  Epigastric tenderness
 NSAIDs
 Severe, generalized pain
 Smoking
may indicate perforation
 Hereditary
with peritonitis
 Clinical Features
 Occult or gross blood per
 Burning epigastric pain
rectum or NGT if bleeding
 Sharp, dull, achy, or “empty” or
“hungry” feeling
 Relieved by milk, food, or antacids
 Awakens the patient at night
 Nausea, retrosternal pain and
belching are NOT related to PUD
 Atypical presentations in the
elderly
Peptic Ulcer Disease
 Diagnosis  Treatment
 Rectal exam for occult blood  Empiric treatment
 CBC  Avoid tobacco, NSAIDs,
 Anemia from chronic blood aspirin
loss  PPI or H2 blocker
 LFTs  Immediate referral to GI if:
 Evaluate for GB, liver and
 >45 years
pancreatic disease
 Weight loss
 Definitive diagnosis is by EGD
or upper GI barium study  Long h/o symptoms
 Anemia
 Persistent anorexia or
vomiting
 Early satiety
 GIB
Here is your patient’s x-ray….
Perforated Peptic Ulcer

Abrupt onset of severe epigastric pain

followed by peritonitis
IV, oxygen, monitor
CBC, T&C, Lipase
Acute abdominal x-ray series
Lack of free air does NOT rule out perforation
Broad-spectrum antibiotics
Surgical consultation
Case #4
 35 yo healthy F to ED c/o nausea and vomiting
since yesterday along with generalized
abdominal pain. No fevers/chills, +anorexia. Last
stool 2 days ago.
 Med Hx: negative
 Surg Hx: s/p hysterectomy (for fibroids)
 Meds: none, Allergies: NKDA
 Social Hx: denies alcohol, tobacco or drug use
 Family Hx: non-contributory
Case #4 Exam
 T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat:
97% room air
 General: mildly obese female, vomiting
 CV: normal
 Lungs: clear
 Abd: moderately distended, mild TTP diffusely,
hypoactive bowel sounds, no rebound or
guarding

 What is your differential and what next?

Upright abd x-ray
Bowel Obstruction
 Mechanical or nonmechanical  Physical Findings
causes
 #1 - Adhesions from previous
 Distention
surgery  Tympany
 #2 - Groin hernia incarceration  Absent, high pitched or
 Clinical Features tinkling bowel sound or
 Crampy, intermittent pain “rushes”
 Periumbilical or diffuse  Abdominal tenderness:
 Inability to have BM or flatus diffuse, localized, or
 N/V minimal
 Abdominal bloating
 Sensation of fullness, anorexia
Bowel Obstruction
 Diagnosis  Treatment
 CBC and electrolytes  Fluid resuscitation
 electrolyte abnormalities  NGT
 WBC >20,000 suggests bowel  Analgesia
necrosis, abscess or  Surgical consult
peritonitis  Hospital observation for ileus
 Abdominal x-ray series  OR for complete obstruction
 Flat, upright, and chest x-ray  Peri-operative antibiotics
 Air-fluid levels, dilated loops of • Zosyn or unasyn
bowel
 Lack of gas in distal bowel and
rectum
 CT scan
 Identify cause of obstruction
 Delineate partial from
complete obstruction
Case #5
48 yo obese F with one day hx of upper
abd pain after eating, does not radiate, is
intermittent cramping pain, +N/V, no
diarrhea, subjective fevers. No prior similar
symptoms.
Med hx: denies
Surg hx: denies
No meds or allergies
Social hx: no alcohol, tobacco or drug use
Case #5 Exam
 T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat:
100% room air
 General: moderately obese, no acute distress
 CV: normal
 Lungs: clear
 Abd: moderately TTP RUQ, +Murphy’s sign,
non-distended, normal bowel sounds

 What is your differential and what next?

Cholecystitis
 Clinical Features  Physical Findings
RUQ or epigastric pain Epigastric or RUQ pain
Radiation to the back or Murphy’s sign
shoulders Patient appears ill
Dull and achy → sharp Peritoneal signs
and localized suggest perforation
Pain lasting longer than
6 hours
N/V/anorexia
Fever, chills
Cholecystitis
 Diagnosis  Treatment
 CBC, LFTs, Lipase  Surgical consult
 Elevated alkaline  IV fluids
phosphatase  Correct electrolyte
 Elevated lipase suggests abnormalities
gallstone pancreatitis  Analgesia
 RUQ US  Antibiotics
 Thicken gallbladder wall
 Ceftriaxone 1 gram IV
 Pericholecystic fluid
 If septic, broaden coverage
 Gallstones or sludge to zosyn, unasyn,
 Sonographic murphy sign imipenem or add anaerobic
 HIDA scan coverage to ceftriaxone
 more sensitive & specific  NGT if intractable vomiting
than US

 H&P and laboratory findings

have a poor predictive value –
if you suspect it, get the US
Case #6
 34 yo healthy M with 4 hour hx of sudden onset
left flank pain, +nausea/vomiting; no prior hx of
similar symptoms; no fevers/chills. +difficulty
urinating, no hematuria. Feels like has to urinate
but cannot.
 PMHx: neg
 Surg Hx: neg
 Meds: none, Allergies: NKDA
 Social hx: occasional alcohol, denies tobacco or
drug use
 Family hx: non-contributory
Case #6 Exam
 T: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99% room
air
 General: writhing around on stretcher in pain,
+diaphoretic
 CV: tachycardic, heart sounds normal
 Lungs: clear
 Abd: soft; non-tender
 Back: mild left CVA tenderness
 Genital exam: normal
 Neuro exam: normal

 What is your differential diagnosis and what next?

Renal Colic
 Clinical Features  Physical Findings
Acute onset of severe, non tender or mild
dull, achy visceral pain tenderness to palpation
Flank pain Anxious, pacing,
Radiates to abdomen or writhing in bed – unable
groin including testicles to sit still
N/V and sometimes
diaphoresis
Fever is unusual
Waxing and waning
symptoms
Renal Colic
 Diagnosis  Treatment
 Urinalysis  IV fluid boluses
 RBCs  Analgesia
 WBCs suggest infection or  Narcotics
other etiology for pain (ie  NSAIDS
appendicitis) • If no renal insufficiency
 CBC  Strain all urine
 If infection suspected  Follow up with urology in 1-2
 BUN/Creatinine weeks
 In older patients
 If patient has single kidney
 If severe obstruction is  If stone > 5mm, consider
suspected admission and urology consult
 CT scan  If toxic appearing or infection
 In older patients or patients found
with comorbidities (DM,  IV antibiotics
SCD)
 Not necessary in young  Urologic consult
patients or patients with h/o
stones that pass
spontaneously
Mesenteric Ischemia
 Consider this diagnosis in all elderly patients with risk factors
 Atrial fibrillation, recent MI
 Atherosclerosis, CHF, digoxin therapy
 Hypercoagulability, prior DVT, liver disease
 Severe pain, often refractory to analgesics
 Relatively normal abdominal exam
 Embolic source: sudden onset (more gradual if thrombosis)
 Nausea, vomiting and anorexia are common
 50% will have diarrhea
 Eventually stools will be guiaic-positive
 Metabolic acidosis and extreme leukocytosis when advanced
disease is present (bowel necrosis)
 Diagnosis requires mesenteric angiography or CT angiography
Abdominal Pain Clinical Pearls
 Significant abdominal tenderness should never be attributed to
gastroenteritis
 Incidence of gastroenteritis in the elderly is very low
 Always perform genital examinations when lower abdominal pain is present
– in males and females, in young and old
 In older patients with renal colic symptoms, exclude AAA
 Severe pain should be taken as an indicator of serious disease
 Pain awakening the patient from sleep should always be considered
signficant
 Sudden, severe pain suggests serious disease
 Pain almost always precedes vomiting in surgical causes; converse is true
for most gastroenteritis and NSAP
 Acute cholecystitis is the most common surgical emergency in the elderly
 A lack of free air on a chest xray does NOT rule out perforation
 Signs and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia
have significant overlap
 If the pain of biliary colic lasts more than 6 hours, suspect early cholecystitis
PRACTICE, PRACTICE and PRACTICE!

THANK YOU!