A P CUTE

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