Christian Sonnier M.D.LSU Family Medicine Alexandria PGY-2

6/16/15

This is supplemental information and is not intended to replace the information presented on the AFMB review lecture. In the event of any discrepancy between the information here and the AFMB review, you should err on the side of the AFMB review.

goals/learning pointsDefinition of acute abdomen

Differential Diagonosis

Clinical manifestation and diagnosis

Treatment

Atypical abdominal pain

DEFINITIONThe term acute abdomen refers to a

sudden, severe abdominal pain that is less than 24 hours in duration.

Abdominal pain can be Visceral Somatic Referred/neurological

CLINICAL ASSESSMENT: Characterizing the pain is the key

Visceral pain Stretching of

peritoneum or organ capsules by distension or edema

Diffuse Poorly localized May be perceived at

remote locations related to organ’s sensory innervation

Somatic pain Inflammation of parietal

peritoneum or diaphragm Sharp Well-localized Referred pain Perceived at distance

from diseased organ Pneumonia Acute MI Male GU problems Right shoulder pain can

be gall bladder or pancrease

CLINICAL ASSESSMENTLocation

Upper abdomen → PUD, cholecystitis, pancreatitisLower abdomen → Diverticulitis, ovary cyst, TOAMid abdomen → early appendicitis, SBO

Migratory pattern Epigastric → Peri-umbil → RLQ = Acute appendicitis Localized pain → Diffuse = Diffuse peritonitis

“Referred pain”Biliary disease → R shoulder or backSub-left diaphragm abscess → L shoulderAbove diaphragm(lungs) → Neck/shoulder

Acute onset & unrelenting pain = bad/consider sugical emergency Other red flags: rebound, rigidity, hemodynamic instability

Pain which resolves usually. not surgical

Clinical Assessment : Other History

GI symptomsNausea, emesis ( bilious

or bloody)Constipation,

obstipation (last BM or flatus)

Diarrhea (? bloody)Both Nausea/Diarrhea

present usu. medicalChange in sx w eating?

NSAID use (perf DU)Jaundice, acholic

stools, dark urine

Drinking history (pancreas)

Prior surgeries (adhesions → SBO, ?still have gallbladder & appendix)

History of herniasUrine output

(dehydrated)Constituational Sx

Fevers/chillsSexual history

Clinical DiagnosisLocation of pain by

organ*RUQ

GallbladderEpigastrum

StomachPancreas

Mid abdomenSmall intestine

Lower abdomenColon, GYN pathology

Clinical Diagnosis

Think Broad categories for DDxInflammationObstructionIschemiaTraumainfectionPerforation (any of above can end here)

Offended organ becomes distendedLymphatic/venous obstrux due to ↑pressureArterial pressure exceeded → ischemiaProlonged ischemia → perforation

Inflammation versus ObstructionOrgan Lesion

Stomach Gastric Ulcer

Duodenal Ulcer

Biliary Tract

Acute chol’y +/-choledocholithiasis

Pancreas Acute, recurrent, or chronic pancreatitis

Small Intestine

Crohn’s disease

Meckel’s diverticulum

Large Intestine

Appendicitis

Diverticulitis

Location Lesion

Small Bowel Obstruction

Adhesions

Bulges

Cancer

Crohn’s disease

Gallstone ileus

Intussusception

Volvulus

Large Bowel

Obstruction

Malignancy

Volvulus: cecal or sigmoid

Diverticulitis

Ischemia / PerforationAcute mesenteric ischemia

Usually acute occlusion of the SMA from thrombus or embolism

“cramping/tight/pressure feeling of abdomen”Think the acs of the bowels

Chronic mesenteric ischemiaTypically smoker, vasculopath with severe

atherosclerotic vessel diseaseIschemic colitisAny inflammation, obstructive, or ischemic

process can progress to perforationRuptured abdominal aortic aneurysm

Profound hemodynamic instability

GYN EtiologiesOrgan Lesion

Ovary Ruptured graafian follicle

Torsion of ovary

Tubo-ovarian abscess (TOA)

Fallopian tube Ectopic pregnancy

Acute salpingitis

Pyosalpinx

Uterus Uterine rupture

Endometritis

Labs & ImagingTest Reason

CBC w diff Left shift can be very telling

CMP N/V, lytes, acidosis, dehydration

Amylase Pancreatitis, perf DU, bowel ischemia

LFT Jaundice,hepatitis

UA GU- UTI, stone, hematuria

Beta-hCG Ectopic

Test ReasonKUBFlat & Upright

SBO/LBO, free air, stones

Ultrasound Cholecystitis, jaundice,

GYN pathology

CT scan-Diagnostic

accuracy

Anatomic dx,

Case not straightforward

CT scan

What is the diagnosis? Acute appendicitis

Non-Surgical Causes by Systems

System Disease System DiseaseCardiac Myocardial infarction

Acute pericarditisEndocrine Diab ketoacidosis

Addisonian crisis

Pulmonary Pneumonia

Pulmonary infarction

PE

Metabolic Acute porphyria

Mediterranean fever

Hyperlipidemia

GI Acute pancreatitis

Gastroenteritis

Acute hepatitis

Musculo- skeletal

Rectus muscle hematoma

GU Pyelonephritis CNS

PNS

Tabes dorsalis (syph)

Nerve root compression

Vascular Aortic dissection Heme Sickle cell crisis

Special Circumstances[Atypical presentations]

Situations making diagnosis difficultStroke or spinal cord injuryInfluence of drugs or alcohol

Severity of disease can be masked by:SteroidsImmunosuppression (i.e. AIDS)Threshold to operate must be even lower

MANAGEMENTO2 by ncmaskcpap/bipapmechanical

ventilationIV LR or NSEmperic antibiotic treatment as appropriateManagement of sepsis as neededDetermine if need for surgical consult as well

as need for ICU care

MANAGEMENT [contd.]Monitor EKG

CONSIDER POSSIBLE MI WITH PAIN REFERRED TO ABDOMEN IN PTs >30 YEARS OLD

Keep pt NPOAnalgesia – controversial, Demerol has some limited

evidence of being superior however goal is to relieve pain so may require opiods

PASG* J Trauma. 1993 May;34(5)

This stands for Pneumatic Abdominal Anti-Shock Garment. An inflated abdominal wrapping designed to place pressure on

the abdomen in the setting of intra-abdominal hemorrhage. Fallen out of use but you may still see it

Decision to operatePeritonitis

Tenderness w/ rebound, involuntary guardingSevere / unrelenting pain“Unstable” (hemodynamically, or septic)

Tachycardic, hypotensive, white countIntestinal ischemia, including strangulationPneumoperitoneumComplete or “high grade” obstruction

Take Home PointsCareful history (pain, other GI symptoms)Remember DDx in broad categoriesNarrow DDx based on hx, exam, labs, imagingAlways perform ABC, Resuscitate before DxIf patient’s sick or “toxic”, get to OR (surgical

emergency) Ideally, resuscitate patients before going to the OR

Don’t forget GYN/medical causes, special situationsFor acute abdomen, think of these commonly (below)

Perf DU Appendicitis +/- perforation

Diverticulitis +/- perforation

Bowel obstruction

Cholecystitis Ischemic or perf bowel

Ruptured aneurysm

Acute pancreatitis

Pt is a 55 year old male with history of 30 pack year smoking, prior MI with stents, and long term heavy alcohol abuse. Presents to the ED following MVC one hour ago. The patient has stable vital signs and is complaining of intense abdominal pain diffusely . Labs show wbc of 25 with left shift. CMP is wnl with a metabolic acidosis. EKG, CT abdomen/pelvis and cxr as well as other labs are pending. What should be included on differential dx?

A) acute MIB) GastroenteritisC) PancreatitisD) Bowel perforationE) Aortic AneurysmF) Ischemic coltis

Answer:

All of the above.

Rational: -Acute MI: patient has prior MI and has significant CAD history-Gastroenteritis: should always been on the differential of abdominal pain as it is one of the most common reasons for abdominal pain-Pancreatitis: patient has significant alcohol abuse history-Bowel perforation: any acute abdominal process can lead to perforation if inflammation or trauma is bad enough. Trauma from mvc-Aortic Aneurysm: patient has significant cad history-ischemic Colitis: significant CAD history

Take home point: acute severe abdominal pain under the right circumstances has a very broad ddx

Suppose the same patient has the following:

Sudden acute hemodynamic instability and on exam patient has intense abdominal pain with light palpation and shaking of bed or legs as well as percussion of the abdomen. During exam and interview the patient suddenly develops hypotension and respiratory distress and a decrease in GCS from 15 to 6 as he becomes somulent. The patient has not made it to the CT scanner yet.

What is the best next course of action?

A)Stabilize patient with intubation as needed and cvc with rapid fluid infusionB)Obtain stat surgical consultC)Apply PASG D)Perform diagnostic peritoneal lavage and FAST ScanE)Admit to SICU F)Wait for ct scan of abdomen and pelvis before further action

Answer:

All of the above with exception of waiting for ct scan are valid option. The patient is becoming rapidly unstable and needs stabilization and stat surgical consult. The differential diagnosis is still very broad as he may have aortic dissection, perforation or intra-abdominal hemorrhage.

Fast Scan if available can remove need for diagnostic perotoneal lavage and per ATLS is replacing this as the prefered diagnostic modality however it is still an option if ultrasound is not available however it would be best to run this by the surgical consult first.

PASG: Pneumatic Abdominal Anti-Shock Garment is a pressurized air wrapping which is used to apply pressure to intra-abdominal space to stabilize hemmorrage

27 yo female G2P2 with history of PUD, c-section x2, and smoking history presents to ED with sudden onset abdominal pain described as sharp and 10/10 with n/v for the past 1 day. The patient reports her entire abdomen is sore with pain worse in the RLQ. She is sexually active with a new partner. She reports vague history of attending outdoor picnic and eating room temperature potato salad yesterday, she also reports the pain was worse in the middle of her abdomen and the most intense pain is now over the RLQ. Vitals are wnl as is cbc and cmp. The patient has further imaging studies pending and you are called by the ED to evaluate the patient.

What should be included on the DDxA)AppendicitisB)Food poisoningC)PID D)Ectopic pregnancyE)Perforated gastric ulcer

Follow up question: what else would you like to order?

Answer: all of the above and more

As stated previously the ddx for acute abdominal pain is very broad an this patient has several things in her history which cloud the picture

Appendicitis: the history of sudden onset with pain over umbilicus then moving to the RLQ is suspicious however in females of reproductive age ectopic pregnancy should always be considered. Also remember even in early appendicitis cbc can be normal

PID: new sexual partner increases risk of this

Food poisoning: while this should be lower on the list the hx of recent picnic and exposed food should be kept in mind

Gastric ulcer: patient has history of PUD in the past, no mention of what treatment she received therefore it is conceivable she could have another

Other things to consider ordering:

1)Pregnancy test2)Ultrasound of abdomen such as fast scan3)Ua to look for uti4)Perform pelvic exam with culture5)Blood cultures or urine cultures6)Egd (history of PUD)7)Fobt8)Stool studies

Questions?

Sources

UptodateAAFP notebookHarrisons textbook of medicineCecils textbook of medicineNIH archives