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Acute

Abdominal Pain
dr. Nurcahya Setyawan, SpB-KBD, FinaCS, FICS
Sub. Bagian Bedah Digestif
FK-UGM/RSUP dr. Sardjito, Yogyakarta

Definisi :

Sudden severe abdominal pain


(maximum VAS).

One of the most common presenting


complaints in the emergency department
(5-10% of all ED visits).

Terminology:

Pain ?

Sign or symptom ?

Signs

SIGNS are objective and reproducible


findings
D
D
D
D
D
D
D

Tenderness
Rigidity
Masses
Altered bowel sounds
Evidence of malnutrition
Bleeding
Jaundice

Symptoms

D
D

SYMPTOMS reflect a subjective


change from normal function
Pain
Appetite: anorexia, nausea, vomiting,
dysphagia, weight loss
Bowel habits: bloating, diarrhea,
constipation, flatulence

Physiology of Abdominal Pain


Visceral pain.
Somatic pain.
Referred pain.

Visceral Pain
D

Stimuli

Distention

of the gut or other


hollow abdominal organ
Traction on the bowel
mesentery
Inflammation
Ischemia
foregu
D

Sensation

Corresponds

to the
embryologic origin of the
diseased organ (foregut,
midgut, hindgut)

t
midgut
hindgut

Somatic Pain
D

Stimuli

Sensation

Irritation of the
peritoneum
Sharp, localized pain
Easily described

Cardinal signs

Pain
Guarding
Rebound
Absent bowel sounds
Example: McBurneys point in late appendicitis

Referred Pain
Diaphragmatic irritation
Gastric pain
Liver and biliary pain
Colonic pain

Biliary colic
Pancreatic and renal pain
Uterine and rectal pain

Ureteral or kidney pain

Common causes of acute abdominal pain:


conditions in italic type often require surgery.
Gastrointestinal tract disorders

Nonspecific abdominal pain


Appendicitis
Small and large bowel obstruction
Incarcerated hernia
Perforated peptic ulcer
Bowel perforation
Meckel's diverticulitis

Boerhaave's syndrome

Diverticulitis

Inflammatory bowel disorders

Mallory-Weiss syndrome

Gastroenteritis

Acute gastritis

Mesenteric adenitis

Liver, spleen, and biliary tract disorders


Acute cholecystitis Acute
cholangitis Hepatic abscess
Ruptured hepatic tumor
Spontaneous rupture of the spleen
Splenic infarct Biliary colic Acute
hepatits

Pancreatic disorders
Acute pancreatitis

Urinary tract disorders


Ureteral or renal colic Acute
pyelonephritis Acute cystitis
Renal infarct
Gynecologic disorders
Ruptured ectopic pregnancy
Twisted ovarian tumor
Ruptured ovarian follicle cyst
Acute salpingitis
Dysmenorrhea
Endometriosis

Vascular disorders
Ruptured aortic and visceral aneurysms
Acute ischemic colitis
Mesenteric thrombosis
Peritoneal disorders
lntra-abdominal abscesses
Primary peritonitis
Tuberculous peritonitis
Retro-peritoneal disorders
Retro-peritoneal hemorrhage

Extra-Abdominal Causes
of the Acute Abdomen

D
D
D
D
D

Supra-diaphragmatic

Myocardial infarction
Pericarditis
Left lower lobe pneumonia
Pneumothorax
Pulmonary infarction

Drugs
Metabolic
Nervous System
D
D
D

Hematologic
D
D

Sickle cell disease


Acute leukemia

Herpes Zoster
Tabes dorsalis
Nerve root compression

Endocrine
D
D

Diabetic ketoacidosis
Addisonian crisis

How to approach the patient


with acute abdominal pain ?

Detailed history and


Careful physical examination alone.

the correct diagnosis can be established


(in most cases)

Laboratory tests or
other investigation are

usually needed
for diagnostic confirmation.

How to approach the patient


with acute abdominal pain ?

Question key
Physical examination key point
Laboratory investigation
Radiology investigation
Other investigation
Planning

Question key point :


What are the patients vital signs?
where is the location of pain?
Does the pain radiate?
What is the quality of pain ?
When did the pain begins?
What relieves the pain or makes it worse?
Are there any associated symptoms?
For women, what is the patients menstrual history?
What is the patients past history?

Physical examination key points :

Vital sign & general exam


Lung
Heart
Abdomen
Rectum
Female genitalia

Laboratory investigations points :

Hemology
Electrolit & Serum creatinin
LFT
Amylase lipase
Pregnancy test
Urine analysis
Cervical culture

Radiology investigations :

Erect and supine abdominal films


Chest X-ray
USG
CT Scan
Barium study
IVP

Other investigations :

ECG
Paracentesis
Endoscopy
Arteriography

Planning:

Observation
Surgery / indication ?

The Questions key points :


1. What are the patient vital signs?
Tachycardia and hypotension suggest circulatory or
septic shock from perforation, hemorrhage or fluid loss
into the intestinal lumen or peritoneal cavity.
Fever occurs in inflammatory conditions such as
cholecystitis and appendicitis.
Fever may not be present in: elderly patients, patients on
corticosteroids and patients who are immunocompromised.

2. where is the location of pain?

Visceral pain is dull pain located


in the midline and poorly localized.

Unilateral pain: is caused by organs


unilateral innervation such the kidney,
ureter, or ovary
Mid epigastric pain: is caused by diseases in
the stomach, duodenum, pancreas, liver and
biliary tract.

Periumbilical pain: is caused by


diseases in the small intestine, appendix, upper
ureters, testes and ovaries.
Lower abdominal pain is caused by
diseases in the colon, bladder, lower
ureters and uterus.
Parietal peritoneum inflammation results
in more severe pain well localized to the area of
inflammation.

The Quadrants

Differential Diagnosis: RUQ Pain


CONDITION

CLUES

Biliary colic, acute


cholecystitis

Recurrent attacks, tender over gall bladder


area

Acute hepatitis

Alcohol history, jaundice, medications

Right pyelonephritis

Dysuria, fever, costovertebral angle


tenderness

Congestive heart failure

Edema, dyspnea, elevated JVP

Retrocecal appendicitis

Shift of pain, tenderness

Right lower lobe


pneumonia

Fever, tachypnea, bronchial breathing

Differential Diagnosis:
LUQ and Epigastric Pain
CONDITION

CLUES

Splenic rupture

History of trauma or splenic disease

Fractured ribs

History of trauma, gross deformity, extreme


tenderness on palpation

Pancreatitis

History of alcohol consumption, history of


similar event, elevated labs

Gastritis / Peptic ulcer


disease

Recurrent, relationship to meals, relationship


to posture

Pneumonia

Fever, XR findings, bronchial breathing

Differential Diagnosis: RLQ Pain


CONDITION

CLUES

Acute appendicitis

Shift of pain, anorexia, localized tenderness

Mesenteric adenitis

Fever, inconstant signs

Right renal colic

Colicky pain, hematuria

Torsed right testis

Tender swollen testis, usually young age

Crohns disease

Recurrent, several days history

Gynecologic causes

see next

Gynecologic Causes of RLQ Pain

CONDITION

CLUES

Ruptured follicle

Fever, cervical excitation, discharge

Torsion of ovary

Midcycle, sudden onset

Ruptured ectopic
pregnancy

Severe pain, vomiting

Pelvic inflammatory
disease

Sudden onset, amenorrhea, shock

Differential Diagnosis: LLQ Pain


CONDITION

CLUES

Diverticular disease

Elderly patient, recurrent

Acute urinary retention

Palpable bladder, difficulty passing urine

Urinary tract infection

Dysuria, frequency

Inflammatory bowel disease

Recurrent attacks, diarrhea (+/- mucus, blood)

Large bowel obstruction

Colicky pain, obstipation

Left renal colic

Colicky pain, hematuria

Torsion of testis

Tender, swollen testis, young age


Gynecologic causes as for RLQ pain

Differential Diagnosis: Periumbilical Pain


CONDITION

CLUES

Gastroenteritis

Vomiting and diarrhea

Constipation

Colicky pain, hard stool

Inflammatory bowel
disease
Early appendicitis

Recurrent diarrhea, +/- mucus and


blood
Nausea, short history

Small bowel
obstruction
Ischemic bowel

Colicky pain, vomiting, no flatus


Severe pain, tenderness less marked,
rectal bleeding

3. Does the pain radiate?


Biliary pain can radiate from the right upper
quadrant to the right inferior scapula.
Pancreatic and abdominal aneurysmal pain
may radiate to the back.
Ureteral colic classically is referred to the groin
and thigh.

Diaphragmatic irritation due to subphrenic


collections of pus or blood often radiates
to the supraclavicular area.
Pain that becomes rapidly generalized means
perforation and leakage of fluid into the
peritoneal cavity.

Referred Pain

4. When did the pain begins?


Sudden onset suggests:

perforated ulcer
mesentric occlusion
ruptured aneurysm.
ruptured ectopic pregnancy

More gradual onset (>1hour) suggests an inflammatory cond.


appendicitis, cholecystitis diverticulitis, bowel obstruction.

5. what is the quality of pain?


Intestinal colic is cramping abdominal pain
interposed with pain-free intervals.
Biliary colic is not a true colicky but it is
usually sustained persistent pain.
The terms sharp, burning, dull and tearing
seldom assist in diagnosis.

6. What relieves the pain or makes it worse?


Pain with deep inspiration is assosiated with
diaphragmatic irritation is assosiated with
pleuricy upper abdominal inflammation.

Coughing increases the


due to peritonitis.

abdominal pain

Patients with peritonitis take some relief of


pain by avoiding all motions whereas patients
with intestinal or ureteral colic are usually
restless and active.

7. Are there any associated symptoms?

Vomiting :

intestinal obstruction.
visceral reflex due to the pain

In acute surgical conditions, the vomiting


follows the onset of pain.

Haematemesis : gastritis or
peptic ulcer disease

Diarrhea :

Absolute constipation : Mechanical


intestinal obstruction.

Haematuria : Urinary tract disease.

Coughing and sputum : lower lobe pneumonia.

Gastro enteritis
Ischemic colitis
Inflammatory bowel disease.

8. For women, what is the patients


menstrual history?

Missed period :

Foul vaginal discharge : pelvic


inflammatory disease.

disturbed ectopic
pregnancy .

9. What is the patients past medical


history?

Peptic ulcer disease, gall stones, diverticulosis,


alcohol abuse, abdominal operations suggesting
adhesions.

Abdominal aortic aneurysm or cardiac disease may


suggest embolization.

Physical examination key points :

Vital sign & general exam


Lung
Heart
Abdomen
Rectum
Female genitalia

Physical examination key points :


1 Vital signs & general exam:

Tachycardia

Hypotension

Fever

Posture

Jaundice

2. Lungs:

Evidence of consolidation.
Friction rub.
Effusion.

3. Heart:

Arrhythmias.
Valvular lesion.
Heart failure.

4. Abdomen:
a. Inspection:
: obstruction, ileus, ascites.

Distension

Ecchymoses : haemorrhgic pancreatitis.

Surgical scars : adhesions.

b. Palpation:
Tenderness & rigidity
Organomegaly.

c. Percussion:
:

Tympany

Shifting dullness :

distended bowel loops.


suggests ascites with
peritonitis

d. Auscultation : bowel sounds

Absent

: ileus.

Hyper peristaltic

: gastroenteritis.

High pitched rushes : small bowel


obstruction.

e. Other sign:

Psoas sign.
Obturator sign
Rovsings sign

Acute
appendicitis

5. Rectum

Mass

Lateral tenderness.

If stool is present, evaluate for occult


blood.

6. Female genitalia

Pain with cervical motion


Cervical discharge

Adnexal masses :

Pelvic inflammatory
diseases

ectopic pregnancy
ovarian abscess cyst
neoplasm

Laboratory investigations points :

Value :

In cases in which the etiology is unclear.

Preoperative assessment.

Laboratory investigations points :

Hemology
Electrolit & Serum creatinin
LFT
Amylase lipase
Pregnancy test
Urine analysis
Cervical culture

1. Hemology :

Hematocit suggests hemoconcentration from volume


loss as in cases of pancreatitis.
Hematocit suggests intra abdominal or acute
G.I hemorrhage.

WBCS suggests an inflammatory process as acute


appendicitis and cholecystitis.

2. Electrolytes and S. creatinine

Bowel obstruction :

Volume depletion and G.I bleeding :


s.creatinine.

hypokalemia,
azotemia and
alkalosis

3. liver function tests


Including bilirubin, transaminases and
kaline phosphatase.
The results are elevated in cases of
acute hepatitis, cholecystitis, and
other biliary tract diseases.

4- Amylase / lipase :
Elevated in cases of acute pancreatitis.
In up to 30% of patients with acute pancreatitis,
amylase may be normal.
S. amylase is also elevated in cases of

Perforated peptic ulcer.

Strangulated small bowel.

Ruptured ectopic pregnancy

S.Lipase will help differentiate pancreatitis from


other causes of hyperamylasemia.

5 Pregnancy test
6. Urine analysis for haematuria and/or
pyuria.
7. Cervical culture PID.

Radiology investigations :

Erect and supine abdominal films


Chest X-ray
USG
CT Scan
Barium study
IVP

Radiology investigation :
1 Erect and supine abdominal films: looking for :

Air-fluid levels

Evidence of bowel dilation.

Pancreatic, biliary or renal calcifications.


Loss of psoas margin suggesting retro peritoneal
bleeding.

Aortic calcification.

Presence or absence of air in the biliary tract.

2. Chest x ray : looking for

Lower lobe pneumonia


Pleural effusion.
Elevation of a hemidiaphragm.
Free air under the diaphragm.

3. Ultra sound : looking for

Gall stones or biliary tract dilatation.

Ectopic pregnancy.

Free fluid in the peritoneal cavity.

CT: very sensitive in many


possible diagnoses.

Barium studies.

I.V.P

Other investigations :

ECG
Paracentesis
Endoscopy
Arteriography

Other investigation
ECG: in patients with acute upper abdominal pain
to rule out acute myocardial infarction or
pericarditis.
paracentesis.
Endoscopic studies: upper or lower G.I endoscopy
or ERCP.
Arteriography in cases of suspected acute
mesenteric artery ischemia.

Management / plan :

The initial goal is :


to determine whether surgical treatment is
needed or not.

Indication for urgent operation

Indication for urgent operation

Physical findings

Involuntary
spreading.

guarding

or rigidity,

especially

Increasing or severe localized tenderness.

Tense or progressive distension.

Tender abdominal or
or hypotension.

Rectal bleeding with shock or acidosis.

if

rectal mass with high fever

Radiologic findings

Endoscopic findings

Pneumoperitoneum
Gross or progressive bowel distension
Free extravasation of contrast material
Space-occupying lesion on
CT scan with fever
Mesenteric occlusion on angiography

Perforated or uncontrollably bleeding lesion

Paracentesis findings

Blood, bile, pus, bowel contents, or urine

Management / plan :

observation: include

Serial clinical examinations by the same clinician.


I.V fluids in cases of septic shock or fluid loss
Use of antibiotics an analgesics
Gastric decompression : in cases of mechanical
intestinal obstruction.

Referral (when ?)

Surgical / non surgical consultation

Algorithm.

Algorithm.

Abdominal Pain Referral


When to Refer to :

Surgeon Acute abdomen on physical examination Hemodyn


instability
Free intraperitoneal air on radiographs Suspected b
obstruction
Suspected acute mesenteric ischemia Suspected a
appendicitis
Suspected acute cholecystitis or biliary colic

file:///C:/Users/nurcahya/Downloads/Abdominal%20Pain%20Referral.html

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Abdominal Pain Referral

When to Refer
to :
Urologist

Gynecologist

Nephrolithiasis with fever or complete ureteral


obstruction
Nephrolithiasis with solitary kidney or failure to pass
stone within 6 weeks Nephrolithiasis with stone > 7 mm
diameter
Suspected adnexal torsion
Lower abdominal pain and positive pregnancy test
Suspected pelvic inflammatory disease
Suspected endometriosis

file:///C:/Users/nurcahya/Downloads/Abdominal%20Pain%20Referral.html

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Abdominal Pain Referral


When to Refer to :
Gastroenterologist

Unable to make a definitive diagnosis


Need for endoscopic procedure for diagnosis
Irritable bowel syndrome refractory to standard therapy
Suspected ischemic bowel (chronic)
Suspected diverticulitis
Suspected ulcerative colitis or Crohn's disease
Suspected pancreatitis
Suspected pancreatic carcinoma

file:///C:/Users/nurcahya/Downloads/Abdominal%20Pain%20Referral.html

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Undiagnosed (non specific)


acute abdominal pain (NSAP)
In a large proportion of patients with acute abdomen
a specific diagnosis can not be reached.
The incidence of these patients varies considerably
in different studies (varying from 15-42%).
The psychological results demonstrated that
the NSAP group had the same level of anxiety and
depression as the control group and also had no evidence
of increased preceding life events.

The majority of these patients will be recovered.


However, some patients will worsen and require
subsequent hospitalization & surgery.

The emergency physician should avoid labeling


non specific abdominal pain as gastritis or
gastroenteritis or other similar terms.

Scheduled out-patient follow up & reassesment is


necessary.

Patients should not


or that they are not
be reassured and
available today, it
cause of their pain.

be told that nothing is wrong


having pain. But, they should
advised that by means
is not possible to identify the

Patients may be better managed by referral


to a pain clinic as the pain has an impact on the
quality of life.