ACUTE ABDOMINAL PAIN Condition Pathophysiology Risk Factors Key History findings Examination findings Bedside tests/ useful tips Investigations Treatment Complications Generalised peritonitis Serious condition resulting from either: Infection – e.g. perforated appendix/ diverticula Chemical irritation from leaking bowel contents e.g. perforated ulcer Acute inflammation with production of inflammatory exudate Ulcer = Disruption to mucosal lining of stomach Perforation leaks acidic gastric contents into the peritoneum, causing generalised peritonitis - Peptic/duodenal ulcer - Undiagnosed/ delayed treatment for appendicitis - Diverticulitis - Gall stone disease - Crohn’s /UC - Local peritonitis - Generalised severe abdominal pain - Worse on movement - Nausea - Vomiting - Anorexia - Generalized tenderness Rebound tenderness Guarding Distended abdomen Board-like rigidity Absent bowel sounds Look for hypovolaemic shock: - Hypotension - Weak thready pulse - Tachypnoea - Low urine output - Clammy cold peripheries - Hypothermia - Confusion - Weakness - Thirst  Erect CXR – look for pneumoperitoneum  Serum amylase (rule out pancreatitis)  CT/ultrasound for diagnosis  Resuscitation (IV fluids, NG tube and ABX)  Then surgery: peritoneal lavage, and specific treatment of underlying condition - Superadded infection due to E. coli or bacteroides - Any delay can lead to toxaemia, septiceamia and multi-organ failure - Local abscess formation (swinging fever, high WCC and continuing pain) - Alcohol NSAIDS H Pylori. Steroids Smoking Blood group O - Longstanding meal related dyspepsia - Sudden onset severe acute epigastric pain - Vomiting - Collapse and shock - Temporary relief in symptoms, before general pain and distension from peritonitis develops. - Tenderness in LUQ or epigastrium - Guarding, rebound tenderness - Board-like rigidity - Abdominal distension - Absent bowel sounds. - Anaemia if large blood loss - Shallow breathing with minimal abdominal wall movement Alarm symptoms: Anaemia Loss of weight Anorexia Recent onset progressive symptoms Malaena or heamatemesis Swallowing difficulty  Erect CXR (pneumoperitoneu m  FBC (CRP, U&E, LFT, Hb)  H. Pylori breath test  OGD with biopsy after peritonitis settles - Likely to recur, so manage risk factors aggressively Inflammation of the pancreas on background of normal healthy pancreas Proteolytic Autodigestion due to raised intracellular levels causes pancreatic necrosis Or: Stone occlusion of ampulla causing pancreatic ductal hypertension, increasing free cytosolic ionized calcium, initiating auto-digestion and necrosis. I GET SMASHED: - Idiopathic - Gall stones - Ethanol - Trauma - Steroids - Mumps - Autoimmune disease - Scorpion venom - Hypercalcaemia hyperlipidaemia hypothermia - ERCP & Emboli - Drugs - Severe epigastric pain that radiates to the back - Pain slightly relieved when sitting forward - Nausea, vomiting, anorexia - Tachycardia, fever &jaundice are possible - Diarrhoea (steatorrhoea) - Peripheral oedema/ ascites - Hypovolaemia/shock - Examination shows little at first until peritonitis develops - Tender upper abdomen - Fever - Ascites + huge peripheral oedema - Bruising at flanks (GreyTurner’s signs) - Cullen’s sign: periumbilical or loin bruise due to bleeding into falciform ligament = severe necrotizing pancreatitis. - Guarding reduced or absent bowel sounds - May be tachycardic, hypotensive or oliguric  Elevation of CRP>200mg/L in first day predicts severe attack.  Ranson and Glasgow scoring system have 80% sensitivity for predicting severe attack when done 48hrs after initial presentation  BMI>25 causes worse outcome as adipose tissue is substrate for activated proteolytic activity and inflammation  FBC (amylase, lipase + CRP, WCC, LFT etc…)  Urinary amylase  Ultrasound pancreas  Erect CXR to exclude perforated ulcer  CT abdo enhanced to look at pancreatic necrosis extent.  Abdominal X-Ray – look for paralytic ileus  MRCP to assess damage  Surgery to repair perforation, and wash out peritoneum  PPI (Omeprazole) or H2 receptor antagonist (ranitidine)  Stop NSAID use  Lifestyle – ↓ alcohol, stop smoking  Triple therapy if H pylori +ve: (PPI, amoxicillin/ metronidazole & clarithromycin)  ITU if severe case predicted – test after 24hrs & 48hrs.  IV fluids & electrolyte balance  NG tube and suction to prevent abdo distension and aspiration  Oxygen (monitor ABG)  Catheterization to monitor fluid balance  Furosemide  Analgesia  Pancreatic enzymes (Creon, pancrex)  Anti-coagulate for DVT prophylaxis  Surgery if required Results after stone impaction at the neck of the gallbladder Increase in glandular secretions, Progressive distension and - Hypercalcaemia - Hypercholesterol aemia - Fatty diet - Known history of biliary colic - Initial biliary ‘colic’ - Progression with severe RUQ pain (parietal peritonitis) - Fever, - Nausea and Vomiting - Anorexia - Referred pain to the - Local Peritonism (Tenderness and guarding in RUQ) - Pyrexia - Murphy’s sign (+)  NBM  Opiate Analgesia &IV fluids  Cefuroxime (IV ABX)  Cholecystectomy after a few days when symptoms settle  Urgent surgery if symptom’s don’t settle e.g. - Chronic cholecystitis: abdo distension, discomfort, nausea, flatulence, fat intolerance= elective cholecystectomy - Empyaema - Abscess formation - Acute gangrenous Perforated Peptic/ duodenal ulcer Acute Pancreatitis Cholecystitis Alcohol and gall stones are the 2 most common  Bloods: WCC, CRP.  ↑bilirubin and alk phos indicates CBD obstruction  Ultrasound: thick wall, stones in gall bladder neck or - Diabetes - Renal failure from volume depletion - 25% cases are severe, leading to haemolytic instability, multiple organ failure and mortality of 4050%: need to predict severe cases early. Appendicitis compromised vascular supply. Bile retention causes inflammatory response Resulting infection Acute inflammation of the appendix after obstruction with a feacolith shoulder-tip - Idiopathic Bowel Obstruction Mechanical obstruction of the bowel Non-functioning e.g. after abdominal surgery or peritonitis - Hernia - Previous abdo surgery (adhesions) - Crohn’s - Intussusception - Volvulus - Tumour - Gall stones - Diverticulitis - Constipation Acute diverticulitis High intraluminal pressures cause pouches of mocosa to extrude through weakened muscle wall near blood vessels, forming diverticulae Feacal obstruction of neck of diverticula causing stagnation, bacterial accumulation and inflammation. - Low fibre diet - Age >50 - Constipation GI conditions causing chronic abdo pain: 1. IBS 2. Crohn’s disease fever↑, pain↑, empyaema or gangrene develops cholecystitis  perforation - Risks of cholecystectomy: biliary leak/ injury to bile duct, biliary sepsis, 2o biliary liver injury.  FBC (↑CRP,↑WCC)  Ultrasound – enlarged appendix, inflamed, fluid surrounded.  CT appendix – fluid filled, distended, periappendiceal fat stranding  Laparoscopic appendicectomy  Or if appendix mass present treat conservatively:  IV fluids and ABX (mass will disappear over a few weeks, pain within a few days, then elective appendectomy to prevent recurrence. - Perforation and generalised peritonitis - Acute gangrenous appendicitis - Abscess formation  ‘Drip & Suck’: NG tube (decompression), IV fluids (isotonic saline and potassium) and analgesia  Catheterization  Flexible sigmoidoscopy to un-kink volvulus  If deterioration (↑temp, ↑HR, more pain and rising WCC) you need urgent CT and possible laparotomy  Can have colorectal stent for carcinoma causes  IV Antibiotics  Analgesia  Fluids  Osmotic Laxatives  Drain an abscess  Surgery if complicated and persistent - Paralytic ileus = painless, no bowel sounds - If pain becomes constant/ persistent with abdo tenderness this suggests intestinal ischaemia from e.g. strangulated hernia, requiring urgent surgery. - Strangulated bowel can become gangrenous and needs resecting before peritonitis/ perforation occurs. - Perforation leadiung to paracolic abscess, pelvic abscess or peritonitis (generalized) - Fistula formation to bladder (colovesical) or vagina causing dysuria or discharge - Intestinal obstruction - Haemorrhage if invading local artery - Mucosal inflammation that looks like colitis on endoscopy cystic duct, tenderness, fluid surrounding it  CT abdomen  ERCP/MRCP - Sudden onset colicky umbilical pain (inflamed midgut viscus) - Migration to persistent pain and tenderness in RIF (localized peritoneal inflammation) - Nausea - Vomiting - Anorexia - Occasional diarrhoea - Vomiting (prolonged) - Colicky pain central abdo - Absolute Constipation (no passage of wind) - Nausea and vomiting - Distension above block - Fever - Tenderness in RIF - Guarding in RIF (localized peritonitis) - Possible palpable mass - Signs of sepsis - Rovsing’s +ve - Psoas/obturator test +ve - Pelvic peritonitis on rectal examination Simple bedside tests: - Rovsing’s sign - Kocher’s sign - Blumberg’s sign - Psoas sign - Obturator sign - Dunphey’s sign - Sitkovsky’s sign - Distension - Tinkling/absent bowel sounds depending on cause - Surgical scars, hernias past or present - Mass present - Visible peristalsis - Marked tenderness = strangulation – act quickly! - Check for hernia - Small bowel obstruction produces less distension, earlier vomiting, and pain higher in the abdomen that large bowel obstruction.  Abdominal X-ray: Small bowel =central gas shadows & valvulae conniventes Large bowel= peripheral gas shadows & haustra  CT to localize the obstruction  Bloods: amylase, FBC, U&E - Severe pain in Left iliac fossa - Fever - Constipation - Longstanding Hx of constipation not fully relieved by laxatives - Look for local peritonitiss - Hip flexion test - Cough test - Blumberg’s test  Bloods: ↑ESR ↑CRP  Polymorphonuclear leukocytosis present  Spiral CT abdo: streakiy increased density extending into pericolic fat, and thickening of pelvic fascia planes  Ultrasound – colonic wall thickening, diverticular and pericolic collections Febrile Tachycardia Tenderness LIF Guarding Rigidity on L side Palpable tender mass Non-GI causes of acute abdo pain: 1. Ruptured AAA, mesenteric infarction 2. Pyelonephritis, renal/ureteric caliculi 3. Ectopic pregnancy, pelvic inflammatory disease, testicular/ovarian torsion. 4. Myocardial Infarction (atypical) 5. Pleurisy, Pneumonia 6. Diabetic Ketoacidosis 7. Acute vertebral collapse, spinal cord compression - Alvorado scoring system Other GI presenting complaints to learn about: 1. Change in bowel habit 2. GI bleed 3. Vomiting & haematemesis 4. Jaundice References: 1. Davey, P. 2006. Medicine at a Glance. Blackwell Publishing 2. Grace, P. A. & B. N. R. 2009. Surgery at a Glance. Blackwell publishing 3. Kumar, P. & M. Clark. 2009. Clinical Medicine. Saunders, Elsevier 4. Longmore, M., I. B. Wilkinson, E. H. Davidson, A. Foulkes & A. R. Mafi. 2010. Oxford Handbook of Clinical Medicine. Oxford University Press 5. Macleod, J. 2009. Macleod's Clinical Examination. Churchill Livingstone, Elsevier Hermione Leach