Acute abdominal pain       

TEERACHAI UKRITMANOROAT
General Surgical Department

Definition : abdominal pain

arises suddenly, less than seven days (usually less
than 48 hours)

Caused by - Intraperitoneal disorder
- Extraperitoneal disorder

Primary goal in management of acute
abdominal pain : To determine whether
Operative intervention is necessary ?

Intraperitoneal Cause of Acute Abdominal Pain

Inflammatory
Peritoneal
Chemical and nonbacterial peritonitis
Perforated peptic ulcer/biliary tree, pancreatitis,
ruptured ovarian cyst, mittelschmerz
Bacterial peritonitis
Primary peritonitis
Pneumococcal, streptococcal, tuberculous
Spontaneous bacterial peritonitis
Perforated hollow viscus
Esophagus, stomach, duodenum,
small intestine, bile duct, gallbladder,
urinary bladder
    

Extraperitoneal Cause of Acute Abdominal Pain

Genitourinary,Pyelonephritis,Perinephric abscess,Renal infarct,Nephrolithiasis,,Seminal vesiculitis,Epididymitis,Orchitis,Testicular torsion,Dysmenorrhea
Threatened abortion,Ureteral obstruction (lithiasis, tumor),acute cystitis,Prostatitis

Pulmonary
Pneumonia,Empyema,Pulmonary embolus
Pulmonary infarction,Pneumothorax

Cardiac
Myocardial ischemia,Myocardial infarction,Acute rheumatic fever
Acute pericarditis

Metabolic
Acute intermittent porphyria,familial mediterranean fever
Hypolipoproteinemia,Hemochromatosis
Hereditary angioneurotic,edema

Endocrine
Diabetic ketoacidosis,Hyperparathyroidism
(hypercalcemia),Acute adrenal insufficiency
(Addisonian crisis),Hyperthyroidism orhypothyroidism

Musculoskeletal
Rectus sheath hematoma,Arthritis/diskitis of
thoracolumbar spine

Neurogenic
Herpes zoster,Tabes dorsalis,Nerve root compression
Spinal cord tumors,osteomyelitis of the spine
Abdominal epilepsy,Abdominal migraine,Multiple sclerosis

Inflammatory
Schonlein-Henoch purpura
Systemic lupus erythematosus

Infectious
Bacterial
Parasitic (malaria)
Viral (measles, mumps,
infectious mononucleosis)
Rickettsial (Rocky Mountain
spotted fever)

Hematologic
Sickle cell crisis,Acute leukemia,Acute hemolytic states
Coagulopathies,Pernicious anemia,other dyscrasias

Vascular
Vasculitis,Periarteritis

Toxins
Bacterial toxins (tetanus,staphylococcus),Insect venom (black widow spider)
Animal venom,Heavy metals (lead, arsenic, mercury)
Poisonous mushrooms,Drugs,Withdrawal from narcotics

Retroperitonel
Retroperitoneal hemorrhage(spontaneous adrenal hemorrhage)
Psoas abscess

Psychogenic
Hypochondriasis,Somatization disorders

Factitious
Munchausen syndrome
Malingering

Clinical History

Mode of onset : sudden, rapidly progress, gradual onset
Duration
Frequency
Character : intermittent (colic) , continuos (constant),
Burning, tearing
Location : at onset, shifting pain
Radiation (Referal pain)
Intensity of pain (severity)
Aggravating or alleviating factor : motion, deep breathing,
coughing, lyingdown

Associated G.I. symptom : nausea, vomiting, anorexia,
diarrhea, constipation, obstipation, jaundice, melena,
hematochesia, hematemesis
HX of trauma
Gynecologic HX
Previous medical condition : cardiac, pulmonary,
renal system
Previous abdominal operations

Physical Examination
General appearance : degree of obvious pain, patient’s
position in bed (eg : motionless with flexed hips and knees)
Extra abdominal causes of pain
Signs of systemic illness
Abdominal exam :
Comfortable supine position
Inspection, auscultation, percussion, palpation
Include abdomen, flanks, groin, rectal exam,
genital exam, gynecologic exam (female)

Inspection
Anterior and posterior abdominal walls, flanks,
perineum, genitalia
For :
previous surgical scars (adhesion)
hernias
distention (intestinal obstruction)
obvious mass (gall bladder, abscesses, tumors)
visible peristalsis (obstruction)
visible pulsation (aneurysm)
limitation of movement (peritonitis)
dilated superficial vein (portal HT)

auscultation:Bowel sound : absence (paralytic ileus), high-pitched with splashes, tinkles or rushes
(mechanical bowel obstruction)

Percussion:Search for Dullness, fluid collection,
gas-filled bowel, pockets of free air
Tympany (may be in bowel obstruction)
Presence of as cites (fluid thrill, shifting dullness)
Peritoneal irritation (Rebound tenderness)
Percussion test, cough tenderness

Palpation:Begin as far as possible from the area of maximal pain
Place entire hand e applying pressure e the pulps of
the finger by flexing the wrists and MCP joints
True involuntary guarding, rigidity
Tenderness
Rovsing’s sign
Murphy’s sign
Psoas sign, Obturator sign
Kehr’s sign
Carnett’s sign

Laboratory Studies

Complete blood count, blood chemistry
Urinalysis
LFT.
Serum amylase and lipase
Pregnancy test
Electrocardiogram in eldery patient and
HX of atherosclerotic heart disease

Radiologic Studies

Plain films abdomen supine, upright
(or lateral decubitus)
Chest x-ray

Differential Diagnosis

Acute abdominal pain ~ 5 - 10% of all patient
in ER
Most common diag = non specific abdominal
pain (34%)
The most common surg diagnosis
acute appendicitis
acute cholecystitis
peptic ulcer perforation
Different in age group