Emergency medicine

1. ACUTE ABDOMINAL PAIN
Dr. Abed Hashash
By: Lana Hilo

2. I. Defining Features
• The goal of the emergency physician is to first
rule out immediate life-threatening conditions
• In the hypotensive elderly patient, a ruptured
AAA is present until proven otherwise

3. • After immediate life-threatening conditions are
excluded, other conditions such as appendicitis,
cholecystitis, ruptured viscus, mesenteric
ischemia, and cholangitis should be considered

4. • Despite thorough evaluation, 30% of patients
are discharged from the ED with a diagnosis of
“abdominal pain of unclear etiology”

6. II. Pathophysiology
• Abdominal pain is classified as:
 Visceral
Parietal
Referred in origin
• Pain may begin as visceral and become parietal

7. III. Risk Factors
• Elderly
• Pregnancy
• Immunocompromised (eg, HIV/aids,diabetes
mellitus)
• Prior abdominal surgery

8. IV. Clinical Presentation
• History
• PE

9. History
• Duration
• Pain pattern
• Location
• Radiation
• Exacerbating and alleviating factors
• Associated symptoms
• past medical/surgical history, medications,
allergies, and social history

10. Duration
• Pain that began within the preceding week is
more likely to be of serious consequence than
pain of chronic duration
• Sudden onset of pain that awakens a patient
from sleep is especially concerning and suggests a
ruptured viscus or vascular event

11. Pain pattern
• Patients with visceral pain are usually seen to be
“writhing” in pain and cannot find a comfortable
position
• Patients with parietal pain from peritoneal
irritation will report constant pain that is worse
with the slightest movement

12. Location
• Pain located in a particular portion of the
abdomen frequently suggests the underlying
organs that are affected
• A classic example is appendicitis

13. Radiation
• Pain that radiates to the back suggests
pancreatitis, cholecystitis,or aortic aneurysm
• Pain radiating to the shoulder reflects irritation of
the diaphragm and suggests intraperitoneal
infection or blood, hepatitis, or cholecystitis
• Pain that radiates to the groin may indicate an
aortic aneurysm or nephrolithiasis

14. Associated symptoms
• Fever
• Nausea
• Vomiting
• Weight loss
• Diarrhea
• Urinary frequency
• Dysuria
• Blood in the stool
• Loss of appetite

15. Exacerbating and alleviating factors
• Changes in the intensity of abdominal pain with
eating suggest PUD or biliary colic
• One third of patients with biliary colic do not
have onset of pain related to meals

16. Physical Examination
• Vital signs
• Abdominal examination
• GU examination

17. Vital signs
• Should be noted
• Any abnormal value rechecked

18. • The presence of fever should raise suspicion of
serious pathology
• Although it may be present in benign disease
processes such as gastroenteritis
Fever

19. Hypotension and tachycardia
• Suggest sepsis or ruptured AAA
• Should be addressed immediately before
proceeding to perform a thorough history and
physical examination

20. Abdominal examination
• Inspection
• Auscultation
• Percussion

21. Inspection
• Distention
• Wounds
• Visible mass
• Pulsation

22. Auscultation
• Hyperactive sounds are present in bowel
obstruction

23. percussion
• Palpation of the non-tender quadrant is
initiated first, followed by the tender
quadrants
• Significant percussion tenderness is present in
patients with peritonitis

24. GU examination
• Should be performed in both men and women
• May identify an obvious source of pain, including
hernias, PID, testicular torsion,or epididymitis
• A rectal examination will detect masses and
allow for Hemoccult testing

25. V. Differential Diagnosis

26. V. Differential Diagnosis
• A. Epigastric pain
 Pancreatitis
 Biliary colic
 Cholecystis
 Choledocholithiasis
 PUD
 Gastritis
 Hepatitis

27. • B. Periumbilical pain
Appendicitis (early)
Enteritis
 Inflammatory bowel disease

28. • C. Suprapubic pain
Appendicitis (late and usually RLQ)
Diverticulitis (usually LLQ)
UTI
PID (bilateral)
Ectopic pregnancy
Testicular torsion

29. • D. Other
• Ruptured AAA (site of pain depends on direction
of rupture: back in 50% of cases, LLQ, epigastric)
• Bowel obstruction (diffuse)
• Mesenteric ischemia (diffuse)
• Nephrolithiasis (flank and lower quadrant)

30. VI. Diagnostic Findings
A. Laboratory Studies
 Wbc count
 Electrolytes and glucose
 Bun/crea
 UA
 Urine pregnancy test
 Lipase
 LFT
B. Imaging Studies
 Obstructive series
 Upright CXR
 Abdomen and pelvis CT
scan
 US

31. Laboratory Studies

32. 1. WBC count
• A normal value does not rule out serious
underlying pathology
• An elevated WBC count can be consistent with
benign conditions such as gastroenteritis

33. 2. Electrolytes and glucose
• Patients with hypercalcemia may present with
abdominal pain.
• A patient with DKA may present with nonspecific
abdominal pain

34. 3. BUN and creatinine
• A patient with uremia may present with
abdominal pain. In addition,
• Renal function tests may be useful in dehydrated
patients and are also necessary before IV contrast
is given for CT scan

35. 4. Urinalysis
• To determine the presence of ketones in DKA
• Provides evidence of a UTI (eg, cystitis or
pyelonephritis)
• Inflammatory processes near the ureter may
produce pyuria in the absence of a UTI
• The absence of urobilinogen on the urinalysis
suggests a complete common bile duct
obstruction

36. 5. Urine pregnancy test
• Should be ordered in all females of childbearing
age

37. 6. Lipase
• A value 2 times normal is 94% sensitive and 95%
specific for pancreatitis

38. 7. Liver function tests
• are useful in patients with common bile duct
stones and hepatitis

39. Imaging Studies

40. 1. Obstructive series
• Will detect bowel obstruction
• These radiographs are not Routinely indicated
unless there is clinical suspicion of obstruction

41. 2. Upright CXR
• Is useful to determine whether free air is present
under the diaphragm
• The sensitivity of this test in patients with
perforated peptic ulcer is 60% and may be
improved when the patient is upright for 5–10
minutes before the radiograph is taken

43. 3. Abdomen and pelvis CT scan
• Is sensitive and specific for the diagnoses of
appendicitis, bowel obstruction, pancreatitis,
diverticulitis, nephrolithiasis,aortic aneurysm
• Identify dilation of the common bile duct
(stones) and can diagnose cholecystitis.
• If bowel perforation is suspected gastrografin oral
contrast should be substituted for barium
• Barium is an irritant to the peritoneal cavity

44. 4. Ultrasound
• Is used to diagnose cholecystitis and ectopic
pregnancy
• Detect common bile duct dilation, aortic
aneurysm, pancreatitis, and hydronephrosis

45. VII. Treatment
• A. Treatment depends on the underlying etiology
• B. IV fluids are indicated if the patient has
abnormal vital signs or history of fluid losses
• C. Pain control depends on the suspected
underlying disease process
• D. Antibiotics are indicated in patients with
appendicitis, cholecystitis, sepsis, diverticulitis,
PID, and perforated PUD

46. • E. Consultation with a surgeon or gynecologist
is recommended when surgery is indicated or
the diagnosis is unclear and there is concern
for serious pathology

47. VIII. Disposition
• A. Admission
 Necessary in patients with a work-up that
supports the diagnosis of serious underlying
abdominal pathology
 In patients with intractable pain or vomiting
regardless of the etiology of pain

48. • B. Discharge
Acceptable in patients with resolution of
symptoms without suspicion of serious
underlying pathology
Follow-up with a primary physician should be
ensured, and the patient should be instructed
to return if there is progression of symptoms

50. SUMMARY POINTS
• History and physical examination will help rule
out serious pathology
• Obtain a urine pregnancy test in any female of
childbearing age with abdominal pain to exclude
ectopic Pregnancy

51. CASE PRESENTATION

52. Case 1
• A 16-year-old boy presents with abdominal
pain
1. What additional questions should you ask the
patient?
2. On examination, what findings might you
elicit?
3. What are the keys to management of this
patient?

53. • Pain began 12 hours ago
• Initially, he felt pain in his periumbilical area
• He now states that it has moved to the RLQ
• Anorexia
• He has vomited once

54. • Tenderness
• Guarding
• Rigidity
• Rovsing’s sign
• Psoas sign
• Obturator sign

56. Diagnostic Findings
• CBC
 Approximately 70–90% of patients will have an elevated WBC count
• UA
 may suggest the diagnosis of pyelonephritis
 Inflammation of the appendix in proximity to the ureter or bladder
will result in WBCs in the urine
• CT
 imaging modality of choice
• US
 in pregnant patients

57. • Keep the patient NPO for possible surgery
• Administer analgesics as needed
• Provide prompt surgical consultation
• CT scan may be indicated if the examination
findings are equivocal

59. SUMMARY POINTS
 Appendicitis is a common condition and is present in
25% of patients < age 60 who present to the ED with
acute abdominal pain
 Absence of leukocytosis or the presence of diarrhea
does not rule out the diagnosis of appendicitis
 Rapid diagnosis and early surgical intervention help
to avoid the complications associated with rupture
 If perforation is likely, IV antibiotics should be
administered

60. Case 2
• A 40-year-old woman presents to the ED with
epigastric pain
1. What additional questions should you ask the
patient?
2. What findings should be elicited on physical
examination?
3. What are the keys to management of this
patient?

61. • 12 hours duration.
• She has had several bouts of vomiting
• she has had 1 previous episode of similar
symptoms in the past
• Is the pain related to eating?
• Referred pain?
• Has she had any fevers?
• Past medical/surgical history?

62. • Tenderness in the RUQ?
• Murphy’s sign?

64. Diagnostic Findings
• CBC
 Leukocytosis is present in 63% of patients with acute cholecystitis
• Chemistry
 Electrolytes should be checked, especially in the presence of significant
vomiting
• Liver function tests. Alkaline phosphatase, liver
enzymes, lipase, and bilirubin
 rule out common bile duct obstruction and hepatitis
• Urinalysis
 to exclude pyelonephritis
• Ultrasound

65. Management
• A. IV fluids and antiemetics in patients with
significant vomiting
• B. Analgesics
• C. Antibiotics
• D. Surgery consultation
• Definitive treatment includes laparoscopic
cholecystectomy

67. SUMMARY POINTS
 Biliary colic frequently presents with epigastric
pain and is not associated with fever or
leukocytosis
Antibiotics should be administered early in ill-
appearing patients who are suspected of having
acute cholecystitis

68. Case 3
• An 80-year-old man presents to the ED with
acute onset of abdominal pain and vomiting.
He is seen unable to find a comfortable
position. Examination reveals a distended,
diffusely tender abdomen without signs of
peritonitis

69. Diagnostic Findings
• Electrolyte abnormalities due to vomiting and
third spacing of fluids
• BUN or creatinine may be elevated due to
dehydration
• CBC: Leukocytosis may be present and suggests
infection
• Obstruvtive series
• CT

70. Imaging in IO
• Obstructive series
Upright CXR
Supine abdominal radiograph
Upright abdominal radiograph
• In patients unable to stand, a lateral decubitus is
obtained

72. 1. What findings support the diagnosis of
intestinal obstruction on plain radiographs?
 Multiple air-fluid levels
 Absence of air in the rectum
Dilated loops of bowel

73. • 2. What is the appropriate ED treatment of
patients with intestinal obstruction?
 IV fluids
NG tube placement
Anti-emetics
Narcotic pain medication
Antibiotics if there is fever, peritonitis, or signs of
sepsis

75. SUMMARY POINTS
• Intestinal obstruction presents with acute
abdominal pain, abdominal distension, and
vomiting
• An upright abdominal film is diagnostic in most
cases, but if negative and clinical suspicion
remains, a CT scan should be obtained
• Intestinal obstruction is treated with IV fluids, NG
suctioning, anti-emetics, narcotic pain
medications,and antibiotics in select cases

76. Case 4
• A 14-year-old boy presents to the ED complaining
of abdominal pain. The pain awoke him from
sleep 2 hours prior to his arrival at the ED. His
mother notes that he has had several episodes of
vomiting but no diarrhea. During your physical
examination, you ask the mother to step outside
the room.
• While you are examining the patient’s abdomen,
he tells you with some embarrassment that the
pain is actually in his scrotum

77. • 1. What other historical facts do you want to
know?
 Trauma?
Previous torsion?
Duration of pain?

78. • 2. What will you look for on physical
examination?
Scrotal tenderness and swelling
Scrotal trauma
Abnormally elevated or horizontal lie of the
testicle
Lack of a cremasteric reflex
Minimal abdominal findings

80. • Color Doppler ultrasound is the preferred
diagnostic study and has a sensitivity of 85–100%
and a specificity of 100%
Diagnostic Findings

82. SUMMARY POINTS
• Consider the diagnosis of testicular torsion in any
male with abdominal pain
• Perform a GU examination on males complaining of
abdominal pain, even if they have no GU complaints
• When considering testicular torsion as a diagnosis,
never allow an imaging study or laboratory test to
delay an emergent urological consultation

83. • The amount of testicular damage is related to
the degree and duration of venous and
arterial obstruction
• If pain has been present for < 6 hours, the
testicular salvage rate is 80–100%

84. Case 5
• A 60-year-old man is brought to the ED by
paramedics and is complaining of right flank
pain that occurred suddenly at 5 AM,
awakening him from sleep. He has a history of
hypertension
• He is hypertensive, tachycardic, diaphoretic,
and is vomiting

85. 1. What other historical facts do you want to
know?
Hematuria?
History of kidney stones?
Fevers?

86. 2. What will you look for on physical
examination?
Pulsatile mass in abdomen
 Symmetric femoral pulses
 Abdominal pain or guarding

89. Diagnostic studies
• Ultrasound has a sensitivity approaching 100%
for the presence of an AAA

90. SUMMARY POINTS
• In 30% of patients with ruptured AAA, the
diagnosis is missed or delayed. The most
common misdiagnosis is renal colic
• When ruptured AAA is suspected, the evaluation
should proceed rapidly with a goal to get the
patient to the operating room as quickly as
possible.

91. • CT scan of the abdomen and pelvis is the test of
choice for diagnosing nephrolithiasis
• Urological consultation is mandatory in patients
with coexisting infection or renal insufficiency