Acute Pain Abdomen in Surgical Practice

7/31/2019 Acute Pain Abdomen in Surgical Practice

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Dr. Mintu Borgohain, MS


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Acute abdomen means the presentation of abdominal

pain that may occur suddenly or gradually over a period

of several hours and presents as symptom complexwhich suggest a disease that possibly threatens life and

demands an immediate or urgent diagnosis for early

treatment .

It is one of the commonest causes of surgical

emergency

More than 1000 causes

20-40% admission rates

50-65% inaccurate initial diagnosis


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Common causes of acute abdomen :

Acute appendicitis (28%)

Acute cholecystitis (10%)

Small Bowel Obstruction (4%)

Perforated PU (3%)

Pancreatitis (3%)

Diverticular disease (2%)

Non specific causesOthers (13%) : intussuception, volvulus


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Common causes of pain abdomen in women

Pelvic Inflammatory Disease or PID

Ectopic pregnancy

Abortion and other pregnancy events

FibroidsEndometriosis

Endometritis

Ruptured ovarian cyst

Twisted ovarian cyst

Ovarian cancer

Mittleschmerz

Urinary Tract Infection


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Causes in different age group


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Etiology of Abdominal Pain

Three main categories of abdominal pain:

GI (Appendicitis, Diverticulitis, etc, etc, etc)

GU (Renal Colic, etc, etc, etc)

Gyn (Acute PID, Pregnancy, etc)

Vascular systems (AAA, Mesenteric Ischemia, etc)

Cardiopulmonary (AMI, etc)

Abdominal wall (Hernia, Zoster etc)

Toxic-metabolic (DKA, lead poisoning etc)

Neurogenic pain (Zoster, etc)Psychic (Anxiety, Depression, etc)


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Patho physiology

Three types of pain exist:

1. Visceral

2. Parietal

3. Referred


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1. Visceral painDue to stretching of fibers innervating the walls of hollow or solid organs.

It occurs early and poorly localized

Distention, inflammation or ischaemia in hollow viscous & solid organs

Localisation depends on the embryologic origin of the organ:Forgut to epigastrium

Midgut to umbilicusHindgut to the hypogastric region

2.Parietal pain

Caused by irritation of parietal peritoneum fibers.

It occurs late and better localized.

It is localised to the dermatome above the site of the stimulus.


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3. Referred painPain is felt at a site away from the pathological organ.

Pain is usually ipsilateral to the involved organ and is felt midline ifpathology is midline.

Gastric/duodenal

pain T5-8

Liver and biliary pain

Colonic painT11,12L1.2

Ureteric/ renal pain L1,2

Diaphragmatic irritation C5

Biliary pain T7-9

Pancreatic / renal pain

Uterine / rectal pain S2,3


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Causes of pain according to quadrants :

oPerforation

oAcute pancreatitis

oBilateral pleurisy

oEarly appendicitisoSmall Bowel Obstruction

oAcute gastritis

oAcute pancreatitis

oRuptured Abdominal Aorta

Aneurysm

oMesenteric thrombosis


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Epigastric pain

DU / GUOesophagitis

Acute pancreatitisAAA

RUQ pain

Gallbladder diseaseDU

Acute pancreatitisPneumoniaSubphrenic abscess

cont


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Left Upper Quad pain

Peptic UlcerPneumonia

Acute pancreatitisSpontaneous splenic rupture

Acute perinephritisSubphrenic abscess

Suprapubic pain

Acute urinary retentionUTIsCystitisPIDEctopic pregnancyDiverticulitis

cont


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Right Iliac Fossa pain

Acute appendicitis

Mesenteric adenitis (young)Perforated DUDiverticulitisPIDSalpingitisUreteric colicMeckels diverticulumEctopic pregnancyCrohns diseaseBiliary colic (low-lying gall bladder)

cont


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Left Iliac Fossa pain

DiverticulitisConstipationIBSPIDRectal CaUreteric CalculiEctopic pregnancy

cont


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colicy pain of acute intestinal obstruction

may change into constant burning type indicates strangulation

Deep inspiration in diaphragmatic irritation

Fatty food in cholecystitis

Spicy fried food, alcohol in peptic ulcer disease

Intake of food in duodenal ulcer

Gastric ulcer pain decrease after vomiting

Peritonitis pain marginally reduced on lying still

Fever/ vomiting/ jaundice/constipation/ passage of blood & putrid stool (in

mesenteric thrombosis) / burning micturition

Vomitus any be projectile : high intestinal obstruction, toxic enteritis

Non projectile : peptic ulcer perforation ,general peritonitis

Contd.


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Anxious look, bright eyes, pinched face and cold sweat k/a interminal stage of peritonitis

In colic- tossing and turning in bed

In pancreatitis- knee chest position

CBD obstruction

Peritonitis, Small Bowel obstruction


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Scaphoid or flat in peptic ulcer

Distended in ascitis or intestinal obstruction

Visible peristalsisladder pattern in small bowel obstruction

Discoloration of skin in left flank(Grey Turner sign) or bluish hue aroundumbilicus (Cullen sign) occasionally seen in acute hemorrhagic pancreatitis


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Check for Hernia sites

Tenderness

Rebound tenderness

Guarding- involuntary spasm of muscles duringpalpation

Rigidity- when abdominal muscles are tense &board-like. Indicates peritonitis.

Distensioncentral distension in acute intestinalobstruction

Lumpappendicular lump/ in cases of intussceptionsausage shaped lump in epigastric or left lumbar region


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Guarding

Rebound tenderness with (a) hand down (b)hand up

ab

Muscle guarding suggest irritation of parietal peritoneumRebound tenderness(Blumbergs sign)


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Copes Psoas test in retrocaecalappendicits

Obturator test in pelvic appendix


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Some Important Signs in Patients with Abdominal Pain

Sign Finding Association

Cullen's signBluish periumbilical discoloration Retroperitoneal haemorrhage

Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture

McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side Appendicitis

Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant

Acute cholecystitis

Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis

Obturator's sign Internal rotation of flexed right hip causingabdominal pain

Appendicitis

Grey-Turner'ssign

Discoloration of the flank Retroperitoneal haemorrhage

Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table

Pelvic inflammatory disease

Rovsing's sign Right lower quadrant pain with palpation ofthe left lower quadrant

Appendicitis


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Percussion :Light percussion elicits tendernessShifting dullness presence of free fluid in some conditions like peptic ulcerperforation, ruptured ectopic pregnancy.

Obliteration of liver dullness - in hollow viscus perforation

Auscultation :Silent abdomen in peritonitisBorborygmi in acute intestinal obstruction

Rectal examination :very important

Gynaecological examination essential in female patients


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Investigations

CBC

LFT, Amylase/LipaseCreatinine, BUN, electrolytes

Urine R/E & culture

Pregnancy test

Cardiac enzymes if appropriate

Electrocardiogram

Erect/ Supine

Plain abdominal radiographs or abdominal series has several limitations and is

subject to reader interpretation.

CT scan in conjunction with ultrasound is superior in identifying any abnormality

seen on plain film.

IVU (renal/ureteric colic)


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Has good specificity and sensitivity in

picking up stones and common duct

obstructions.

Less invasive / less complications than

ERCP(ERCP can induce GI perforation, pancreatitis,

biliary duct injury)


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Gas under diaphragm

Appendicitis in USG


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GB stone on USG

CBD stone USG


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Multiple air fluid level in bowel obstruction

CT acute pancreatitis


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Ruptured ectopic Right side


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1. ABC

2. Start large bore IV with either saline or lactated Ringers solution IV

pain medication

3. Nasogastric tube if vomiting or concerned about obstruction

4. Foley catheter to follow hydration status and to obtain urinalysis

5. Antibiotic administration if suspicious of inflammation or perforation6

.


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ConclusionAcute abdomen is one of the commonest causes of surgicalemergency. It goes without saying that it is very important thatan early diagnosis is made. Any delay will worsen the condition

of the patient and may even lead to fatal outcome.Although etiologies are many, a careful and through clinicalevaluation with the help of different investigative procedurescan help us towards a diagnosis

Immediate resuscitation is most important.

Pain management is crucial


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And Happy New Year

Acute Pain Abdomen in Surgical Practice

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