This document discusses the evaluation and differentiation of acute abdominal pain as either surgical or nonsurgical in nature. It provides details on: 1. Characteristics that suggest a surgical condition include sudden onset of severe, continuous pain not relieved by changing position that began during rest and localized pain that shifts locations. 2. Nonsurgical conditions typically present with gradual onset of intermittent pain that is relieved by changing position and preceded by nausea. 3. The physical exam involves inspection, auscultation, palpation and focuses on vital signs, pain localization, and rebound tenderness to differentiate surgical from nonsurgical disorders.

1. Acute abdomen
first aid
高醫外傷科
林杏麟

2. 外科? 內科?
• The critical distinction, then, is not
between acute and nonacute pain, but
between surgical and nonsurgical
conditions.

3. 外科
• serious condition : arises suddenly and is
continuous, progressively worse, and long
lasting, begins during inactivity; and is not
near the umbilicus

4. Gastrointestinal Tract
• Appendicitis, acute*
Meckel's diverticulitis*
Perforated bowel*
Perforated peptic ulcer*
Small and large bowel obstruction*
Strangulated hernia*
Diverticulitis
Gastritis
Gastroenteritis
Inflammatory bowel disease
Mesenteric lymphadenitis

5. Liver, Spleen, and Biliary Tract
• Cholangitis, acute*
Cholecystitis, acute*
Hepatic abscess*
Ruptured hepatic tumor*
Ruptured spleen*
Biliary colic
Hepatitis, acute
Splenic infarct

6. Peritoneum
• Intra-abdominal abscess*
Primary peritonitis
Tuberculous peritonitis

7. Pancreas
• Pancreatitis, acute

8. Urinary Tract
• Cystitis, acute
Pyelonephritis, acute
Renal infarct
Ureteral or renal colic

9. Female Reproductive System
• Ruptured ectopic pregnancy*
Ruptured ovarian follicular cyst*
Twisted ovarian tumor*
Dysmenorrhea
Endometriosis
Salpingitis, acute

10. Vascular System
• Ischemic colitis, acute*
Mesenteric thrombosis*
Ruptured arterial aneurysm

11. Retroperitoneum
• Retroperitoneal hemorrhage

12. Miscellaneous
• Precompetition anxiety
Trauma

13. Appendicitis, acute
• Constant pain, progressively more severe;
begins in periumbilical region, moves to
right lower quadrant; nausea, vomiting,
and anorexia follow pain; low-grade fever;
patient appears ill

14. Cholecystitis, acute
• Constant pain in right upper quadrant,
onset often postprandial; nausea and
vomiting; tenderness in right upper
quadrant and right shoulder; splinting on
right side

15. Perforated peptic ulcer
• Sudden onset of pain in midepigastrium
that spreads and is aggravated by
movement; patient appears acutely ill and
is reluctant to move; rigid abdomen;
grunting respiration; bowel sounds absent

16. Ectopic pregnancy
• Pain sudden, severe, and persistent,
generally following a missed or abnormal
period, typically epigastric; often
associated with hypotension and
tachycardia

17. Ovarian cyst
• Pain constant with sharp, sudden onset;
usually in ipsilateral hypogastrium; may
have nausea and vomiting following the
pain

18. Pelvic inflammatory disease
• Pain at end of or shortly after normal
menstrual period; bilateral lower quadrant
pain aggravated by cervical manipulation;
anorexia, nausea, and vomiting rare;
possible cervical discharge; fever

19. Urinary calculus
• Pain location changes with movement of
stone, may radiate to testicle, groin of
involved side; pain very severe; patient
cannot get comfortable

20. History and PE

21. Mode of onset, progression,
character, and severity of pain
• surgical etiology: sudden in onset, severe
or explosive, progressive, continuous, and
lasts more than 6 hours generally.
• nonsurgical diagnosis: gradual in onset,
mild to moderate in intensity, intermittent,
recurrent, or resolves partially or
completely in less than 6 hours.

22. Colic pain
• Pain arising in a hollow, tubular structure,
such as the ureter, intestine, biliary
radicles, or fallopian tubes, may be
continuous or intermittent

23. Activity during which pain was
first noted
• Surgical etiology: awakens the patient or
begins during relative inactivity
• Nonsurgical diagnosis: during or closely
following strenuous activity--or after
eating

24. Initial location of pain
• the farther from the umbilicus the pain localizes, the
greater the chance that a surgical condition exists.
• Epigastrium: foregut derivatives (stomach, duodenum,
biliary tract, and pancreas) or the spleen presents.
• periumbilical area: midgut derivatives (jejunum, ileum,
proximal third of the colon, and appendix).
• Hypogastrium: embryonic hindgut (distal two-thirds of
the colon), internal reproductive organs (ovaries,
fallopian tubes, uterus, seminal vesicles, and prostate),
and the urinary bladder.

25. Shifting pain
• When the original inflammation extends to
the parietal peritoneum.
• Appendicitis initially causes pain in the
periumbilical area. Then, after 4 to 6
hours, the inflammation extends to the
regional peritoneal surface and is
perceived in the right lower quadrant.

26. Associated symptoms
• In surgical conditions, pain may be
followed by nausea, vomiting, and
anorexia.
• In nonsurgical conditions nausea, vomiting,
and anorexia typically precede pain.
• Clinical experience: vomiting in the obese
patient is an ominous symptom and
suggests serious abnormalities.

27. • Fever is a common finding in patients who
have abdominal pain.
• However, fever and chills is rarely seen in
surgical processes. This combination
suggests infection in the urinary tract,
respiratory system, etc.

28. • Obstipation--nonpassage of both stool and
gas--however, always suggests a surgical
problem.
• Diarrhea, especially with cramps, indicates
gastroenteritis and other nonsurgical
conditions like inflammatory bowel disease.

29. What aggravates the pain
• Always ask first about which activities aggravate the pain.
(One can generally assume that the opposite will ease
the pain.)
• If the patient hears questions about what eases the pain,
he or she may perceive it as minimizing the problem and
become defensive.
• Coughing, sneezing, rapid movements, and walking,
especially down stairs, can cause peritoneal irritation.
Musculoskeletal pain is often relieved by changing
position. A bowel movement often eases the pain of
gastroenteritis, but the pain may promptly recur.

30. • Men who do experience abdominal pain
have a higher incidence of surgical disease.

31. Medications and supplements
• Aspirin and other nonsteroidal anti-
inflammatory drugs, erythromycin,
potassium, and salt tablets commonly
cause gastric irritation and abdominal pain.

32. nonsurgical diagnosis
• Previous episodes, family history of
similar problems, peers with the
same symptoms, food intolerance,
allergies, sudden changes in training
or diet, and travel to regions with
endemic disease.

33. Physical Exam Pointers
• vital signs, inspection, auscultation, light
touch, palpation, percussion, and
rectovaginal exam

34. keys to the physical exam
• tell the patient
• Auscultation should precede other modalities
• farthest from the site of maximal pain
• ask the patient questions and have him or her
answer during palpation
• rebound tenderness
• Any pain elicited in the obese patient is
significant