examining the acute abdomen
TRANSCRIPT
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