Examining The Acute Abdomen

in the Adult

Guy R. Nicastri, MD, FACSAssociate Professor of Surgery and Family

MedicineWarren Alpert Medical School of Brown

University

Overview Definition Pathophysiology Review Abdominal Exam Organize a “work-up” Specific diseases

Definition of Acute Abdomen

Sudden onset, usually <24 hours Severe pain Requires urgent

decision/diagnosis Treatment often surgical

Abdominal Pain 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

Pathophysiology of Abdominal Pain

Somatic pain Nociceptors in skin, ligaments, deep

tissues, muscles, bones, or joints (body wall)

Well localized Visceral pain

Nociceptors in internal organs Poorly localized

Referred pain Pain sensed at a considerable distance

from source

What’s Needed?

What’s NOT?

A Good History is Essential!!

When Where How Associated symptoms Recurring Previous surgery Other medical conditions

History Description of pain Associated symptoms Gynecologic/GU history Past medical history Family, social history

Description of PainThe abdominal pain checklist

bOnset and durationbCharacter and severitybLocation and radiationbWhat makes it better bWhat makes it worsebProgression of painbAssociated symptoms

Associated Symptoms Nausea, vomiting Fever, chills Anorexia, weight loss Food intolerance Pulmonary symptoms Change in bowel habits GU complaints

Gynecologic / GU History Last menses Contraception Sexual history Obstetric history Vaginal discharge, bleeding Previous STDs Urinary symptoms

Past Medical History Cardiac or pulmonary disorders GI, vascular diseases Diabetes, HIV Medications Recent invasive procedures Trauma Recent URI or strep throat

Family & Social History Inflammatory bowel disease Connective tissue disorders Bleeding diatheses Cancer Recent travel Environmental hazards Drugs, alcohol

Physical Examination General appearance Chest Abdomen Rectal Pelvic GU

General Examination Distress Acutely or chronically ill Body position Color Vital signs Keep an “open” mind

General Impression Matters

Chest Examination Matters

Cardiac arrhythmias Murmurs Mechanical heart valves Signs of pneumonia

RLL pneumonia

Abdominal Exam - LOOK Distention Breathing pattern, patient

movement Discoloration

Cullen’s sign Grey Turner’s sign

Scars, hernia

Abdominal Exam - LISTEN

Auscultation: Bowel sounds: full 2 minutes. Not necessary to listen in multiple areas! Borborygmi = loud, prolonged high-pitched BS often heard in PSBO

Bruits: rumbling sounds heard over vascular structures

Auscultation Abdominal Vascular

Percussion Identifies ascitic fluid Measures liver size (sometimes

spleen) Solid or fluid-filled masses “Air” in stomach and bowel

Abdominal Exam - FEEL Area of maximal tenderness CVA or flank tenderness Masses Hernia Peritoneal signs

pain on motion, i.e., REBOUND

involuntary guarding

Can often palpate the Aorta!

Peritoneal Signs

Very worrisome finding “rebound” tenderness local vs

diffuse Often will mean surgery …but not always Pancreatitis, localized diverticulitis,

Rebound

Demonstrates peritoneal irritation (somatic)

Press down, abruptly release Pain with release Usually worrisome finding

NOPE

Rectal is part of the Abdominal Exam!

Digital Rectal Exam Only rarely should be omitted,

integral part of abdominal exam Valuable information: Perianal lesions, fistulas, abscesses,

hemorrhoids Anal canal masses, fissures,

tenderness, induration, sphincter tone

Presence of stool, occult/frank blood Males, evaluate prostate

Pelvic Exam Extremely important Have a female chaperone present Assess external anatomy Speculum and bimanual exam Can perform swabbing if indicated Note position of uterus, cervical

motion tenderness, adnexal masses or tenderness

Ancillary Tests: Basic CBC Amylase, lipase Urine Analysis Pregnancy test Liver tests (AST, ALT, Alk Phos, T

Bili) EKG Chest x-ray, abdominal films

Free Air

Ancillary Tests: Complex

Ultrasound (US) Computed tomography (CT) Angiography (rare) Nuclear Medicine (HIDA) Laparoscopy, especially in young

women Barium enema or endoscopy never

with peritonitis

Common Causes of Acute Abdomen

Appendicitis Cholecystitis Perforated

bowel Perforated ulcer Ectopic

pregnancy PID / TOA Mesenteric

ischemia

IBD Gastroenteritis Nephrolithiasis Pancreatitis Diverticulitis Bowel

obstruction

Putting it all together… See the patient: Get a general

impression Take a detailed history: likely will

steer you in the ‘right” direction Exam: should further define your

differential Ancillary testing: even more data Diagnosis Treatment

Appendicitis

Most common cause of abd pain requiring surgery

300,000 appendectomies annually in U.S.

History: usually less then 48 hours Remains a clinical diagnosis Dangerous in the very young and

very old

Appendicitis History: periumbilical cramping pain

migrating to RLQ; anorexia, nausea,+/- vomiting

Exam: tenderness in RLQ and on rectal/pelvic exam

Often note “low-grade” fevers (<102) Slight leukocytosis (WBC in “teens”) US helpful in infants and females CT in many cases confirms clinical

diagnosis Laparoscopy a reasonable option in

equivacal cases

Abdominal Exam

McBurney’s point tenderness Rovsing’s sign Psoas sign Obturator sign

McBurney’s Point

Charles McBurney, (1845–1913)

Rovsing’s Sign

“Referred” rebound tenderness Press deeply in LLQ and release

quickly Causes pain in RLQ

Niels Thorkild Rosving (1862-1927)

Niels Thorkild Rosving (1862-1927)

Psoas Sign Psoas muscle is located in lower

retroperitoneum location In cases of “retrocecal” appendicitis, full

extension of hip stretches muscle and causes pain when retrocecal appendicitis is present

Obturator Sign

Flex knee and hip to ninety degrees Rotate hip by moving ankle away

from the body while allowing the knee to move only inward

Inflamed appendix in contact with the obturator internus muscle ‘stretches” with this maneuver causing pain

Obturator Sign

Cholecystitis vs Biliary Colic History: severe epigastric/RUQ

pain, typically 2-4 hours after eating Exam: RUQ tenderness, + Murphy’s

sign Elevated WBC vs normal Elevated LFT’s vs normal US: thickened GB wall,

pericholecystic fluid, gallstones vs gallstones only

Murphy’s Sign Pt supine Ask pt to exhale Gentle deep palpation under R subcostal margin,

midclavicular line Ask pt to slowly inhale Inhalation causes diaphragm to push liver and

GB down towards palpating hand Inflamed GB causes pain causing pt to abruptly

stop with breath. This is a POSITIVE Murphy’s sign

Can be done with Ultrasound as well

John Benjamin Murphy (1857-1916)

inflamed

Small Bowel Obstruction History of previous abdominal

operation most common cause. Adhesions etiology in these cases.

Hernia: Abdominal wall vs internal Triad of diagnostic symptoms

cramping abdominal pain vomiting obstipation

Bowel Obstruction Determining ‘partial” from complete

very important Peritoneal signs, high WBC (usually

>20,000), fevers, “toxic” appearance all worrisome

75% of PSBO pts with adhesions from prior surgery as etiology will resolve without need for surgery

Small Bowel Obstructioni Radiographic findings

Air-fluid levels with “J” loops Absence of air in colon

i Quartet of physical findings Distention Early: little or no tenderness Late: tenderness and guarding Borborygmi

SBO: Upright and “flat-plate” x-rays

CT SBO

Perforated Peptic Ulcer

History: PUD, NSAIDS, steroids, critical illness

Exam: Severe tenderness, generalized rebound

Tympanic on percussion Free air seen on plain radiographs

or CT Mostly treated surgically

Diverticulitis History: constipation, LLQ pain,

fever, diarrhea Exam: LLQ tenderness, local

rebound not uncommon, mass sometimes palpable

Laboratory testsPyuria, WBC elevatedCT - up to 93% sensitivity

Pancreatitis History: gallstones, alcohol,

medications Severe epigastric pain radiating to

the back, +/- nausea, vomiting Exam: generalized upper abdominal

tenderness, most marked in epigastrium, +/- rebound

Increased amylase and lipase values common

Elevated WBC and fever common

CT PancreasNormal Acute pancreatitis

Ureterolithiasis History: flank pain, hematuria,

radiation to groin, previous attacks Exam: restless; no abdominal

tenderness, flank tenderness Urinalysis: RBCs, crystals CT, IVP and US useful

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 helpful Endoscopy

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

PID / TOA History: premenopausal woman,

midcycle, previous STD, vaginal discharge, dysuria, Kehr’s sign

Exam: cervical motion tenderness, adnexal mass

Pyuria US useful to diagnose

Gastroenteritis

History: diarrhea, vomiting, crampy pain

Exam: no localizing peritoneal signs Normal WBC common

Mesenteric Ischemia / Infarction

History: 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 CT replacing angiography High Index Of Suspicion a Must!

Thumb Printing

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

Pitfalls Old age, infants Spinal cord injury HIV Steroids

“Very young? Very old? Very odd? Be very careful.”

F.T. de Dombal, MA, MD

Summary

Abrupt onset of severe abdominal pain is of unclear etiology in many cases is a medical emergency, requiring urgent and specific diagnosis.

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