Dr. Guy Nicastri, Associate Professor of Surgery and Family Medicine at the Warren Alpert School of Medicine at Brown University takes us through some of the pearls of the Acute Abdomen Examination in the Adult

1. Examining The Acute
Abdomen
in the Adult
Guy R. Nicastri, MD, FACS
Associate Professor of Surgery and Family Medicine
Warren Alpert Medical School of Brown University

2. Overview
 Definition
 Pathophysiology
 Review Abdominal Exam
 Organize a “work-up”
 Specific diseases

3. Definition of
Acute Abdomen
 Sudden onset, usually <24 hours
 Severe pain
 Requires urgent decision/diagnosis
 Treatment often surgical

4. Abdominal Pain
 10% of ER visits or admitted patients
 40% discharged from ER with “pain of
unknown etiology”
 60% discharged from ER have wrong
diagnosis
 The older the patient, the less accurate the
diagnosis

5. Pathophysiology of Abdominal Pain
 Somatic pain
 Nociceptors in skin, ligaments, deep tissues, muscles,
bones, or joints (body wall)
 Well localized
 Visceral pain
 Nociceptors in internal organs
 Poorly localized
 Referred pain
 Pain sensed at a considerable distance from source

6. What’s Needed?

7. What’s NOT?

8. A Good History is Essential!!
 When
 Where
 How
 Associated symptoms
 Recurring
 Previous surgery
 Other medical conditions

9. History
 Description of pain
 Associated symptoms
 Gynecologic/GU history
 Past medical history
 Family, social history

10. Description of Pain
The abdominal pain checklist
Onset and duration
Character and severity
Location and radiation
What makes it better
What makes it worse
Progression of pain
Associated symptoms

11. Associated Symptoms
 Nausea, vomiting
 Fever, chills
 Anorexia, weight loss
 Food intolerance
 Pulmonary symptoms
 Change in bowel habits
 GU complaints

12. Gynecologic / GU History
 Last menses
 Contraception
 Sexual history
 Obstetric history
 Vaginal discharge, bleeding
 Previous STDs
 Urinary symptoms

13. Past Medical History
 Cardiac or pulmonary disorders
 GI, vascular diseases
 Diabetes, HIV
 Medications
 Recent invasive procedures
 Trauma
 Recent URI or strep throat

14. Family & Social History
 Inflammatory bowel disease
 Connective tissue disorders
 Bleeding diatheses
 Cancer
 Recent travel
 Environmental hazards
 Drugs, alcohol

15. Physical Examination
 General appearance
 Chest
 Abdomen
 Rectal
 Pelvic
 GU

16. General Examination
 Distress
 Acutely or chronically ill
 Body position
 Color
 Vital signs
 Keep an “open” mind

17. General Impression Matters

18. Chest Examination Matters
 Cardiac arrhythmias
 Murmurs
 Mechanical heart valves
 Signs of pneumonia
 RLL pneumonia

19. Abdominal Exam - LOOK
 Distention
 Breathing pattern, patient movement
 Discoloration
 Cullen’s sign
 Grey Turner’s sign
 Scars, hernia

21. Abdominal Exam - LISTEN
 Auscultation: Bowel sounds: full 2 minutes. Not
necessary to listen in multiple areas! Borborygmi =
loud, prolonged high-pitched BS often heard in
PSBO
 Bruits: rumbling sounds heard over vascular
structures

22. Auscultation Abdominal Vascular

23. Percussion
 Identifies ascitic fluid
 Measures liver size (sometimes spleen)
 Solid or fluid-filled masses
 “Air” in stomach and bowel

25. Abdominal Exam - FEEL
 Area of maximal tenderness
 CVA or flank tenderness
 Masses
 Hernia
 Peritoneal signs
pain on motion, i.e., REBOUND
involuntary guarding

26. Can often palpate the Aorta!

27. Peritoneal Signs
 Very worrisome finding
 “rebound” tenderness local vs diffuse
 Often will mean surgery
 …but not always
 Pancreatitis, localized diverticulitis,

28. Rebound
 Demonstrates peritoneal irritation (somatic)
 Press down, abruptly release
 Pain with release
 Usually worrisome finding
NOPE

29. Rectal is part of the Abdominal
Exam!

30. Digital Rectal Exam
 Only rarely should be omitted, integral part of
abdominal exam
 Valuable information:
 Perianal lesions, fistulas, abscesses, hemorrhoids
 Anal canal masses, fissures, tenderness,
induration, sphincter tone
 Presence of stool, occult/frank blood
 Males, evaluate prostate

31. Pelvic Exam
 Extremely important
 Have a female chaperone present
 Assess external anatomy
 Speculum and bimanual exam
 Can perform swabbing if indicated
 Note position of uterus, cervical motion
tenderness, adnexal masses or tenderness

32. Ancillary Tests: Basic
 CBC
 Amylase, lipase
 Urine Analysis
 Pregnancy test
 Liver tests (AST, ALT, Alk Phos, T Bili)
 EKG
 Chest x-ray, abdominal films

34.  Free Air

35. Ancillary Tests: Complex
 Ultrasound (US)
 Computed tomography (CT)
 Angiography (rare)
 Nuclear Medicine (HIDA)
 Laparoscopy, especially in young women
 Barium enema or endoscopy never with
peritonitis

36. Common Causes
of Acute Abdomen
 Appendicitis
 Cholecystitis
 Perforated bowel
 Perforated ulcer
 Ectopic pregnancy
 PID / TOA
 Mesenteric ischemia
 IBD
 Gastroenteritis
 Nephrolithiasis
 Pancreatitis
 Diverticulitis
 Bowel obstruction

37. Putting it all together…
 See the patient: Get a general impression
 Take a detailed history: likely will steer you in
the ‘right” direction
 Exam: should further define your differential
 Ancillary testing: even more data
 Diagnosis
 Treatment

38. Appendicitis
 Most common cause of abd pain requiring
surgery
 300,000 appendectomies annually in U.S.
 History: usually less then 48 hours
 Remains a clinical diagnosis
 Dangerous in the very young and very old

39. Appendicitis
 History: periumbilical cramping pain migrating to
RLQ; anorexia, nausea,+/- vomiting
 Exam: tenderness in RLQ and on rectal/pelvic exam
 Often note “low-grade” fevers (<102)
 Slight leukocytosis (WBC in “teens”)
 US helpful in infants and females
 CT in many cases confirms clinical diagnosis
 Laparoscopy a reasonable option in equivacal cases

40. Abdominal Exam
 McBurney’s point tenderness
 Rovsing’s sign
 Psoas sign
 Obturator sign

41. McBurney’s Point
 Charles McBurney, (1845–1913)

42. Rovsing’s Sign
 “Referred” rebound tenderness
 Press deeply in LLQ and release quickly
 Causes pain in RLQ
Niels Thorkild Rosving (1862-1927)

43. Psoas Sign
 Psoas muscle is located in lower retroperitoneum
location
 In cases of “retrocecal” appendicitis, full extension of
hip stretches muscle and causes pain when retrocecal
appendicitis is present

44. Obturator Sign
 Flex knee and hip to ninety degrees
 Rotate hip by moving ankle away from the
body while allowing the knee to move only
inward
 Inflamed appendix in contact with the obturator
internus muscle ‘stretches” with this maneuver
causing pain

45. Obturator Sign

46. Cholecystitis vs Biliary Colic
 History: severe epigastric/RUQ pain, typically
2-4 hours after eating
 Exam: RUQ tenderness, + Murphy’s sign
 Elevated WBC vs normal
 Elevated LFT’s vs normal
 US: thickened GB wall, pericholecystic fluid,
gallstones vs gallstones only

47. Murphy’s Sign
 Pt supine
 Ask pt to exhale
 Gentle deep palpation under R subcostal margin, midclavicular
line
 Ask pt to slowly inhale
 Inhalation causes diaphragm to push liver and GB down towards
palpating hand
 Inflamed GB causes pain causing pt to abruptly stop with breath.
This is a POSITIVE Murphy’s sign
 Can be done with Ultrasound as well

48. John Benjamin Murphy (1857-1916)

49. inflamed

50. Small Bowel Obstruction
 History of previous abdominal operation most
common cause. Adhesions etiology in these
cases.
 Hernia: Abdominal wall vs internal
 Triad of diagnostic symptoms
 cramping abdominal pain
 vomiting
 obstipation

51. Bowel Obstruction
 Determining ‘partial” from complete very
important
 Peritoneal signs, high WBC (usually >20,000),
fevers, “toxic” appearance all worrisome
 75% of PSBO pts with adhesions from prior
surgery as etiology will resolve without need for
surgery

52. Small Bowel Obstruction
 Radiographic findings
 Air-fluid levels with “J” loops
 Absence of air in colon
 Quartet of physical findings
 Distention
 Early: little or no tenderness
 Late: tenderness and guarding
 Borborygmi

53. SBO: Upright and “flat-plate” x-rays

54. CT SBO

56. Perforated Peptic Ulcer
 History: PUD, NSAIDS, steroids, critical illness
 Exam: Severe tenderness, generalized rebound
 Tympanic on percussion
 Free air seen on plain radiographs or CT
 Mostly treated surgically

58. Diverticulitis
 History: constipation, LLQ pain, fever, diarrhea
 Exam: LLQ tenderness, local rebound not
uncommon, mass sometimes palpable
 Laboratory tests
Pyuria, WBC elevated
CT - up to 93% sensitivity

59. Pancreatitis
 History: gallstones, alcohol, medications
 Severe epigastric pain radiating to the back, +/-
nausea, vomiting
 Exam: generalized upper abdominal tenderness,
most marked in epigastrium, +/- rebound
 Increased amylase and lipase values common
 Elevated WBC and fever common

60. CT Pancreas
Normal Acute pancreatitis

61. Ureterolithiasis
 History: flank pain, hematuria, radiation to
groin, previous attacks
 Exam: restless; no abdominal tenderness, flank
tenderness
 Urinalysis: RBCs, crystals
 CT, IVP and US useful

62. Inflammatory Bowel Disease
 History: intermittent cramping abdominal pain,
diarrhea, low grade fever, weight loss
 Exam: localized abdominal tenderness, + stool
for blood
 CT and Barium studies helpful
 Endoscopy

63. Ectopic Pregnancy
 History: menstrual irregularities, + sexual
history, symptoms of early pregnancy
 Exam: adnexal mass on pelvic; may have
hypotension and tachycardia
 Pregnancy test +
 US and laparoscopy diagnostic

64. PID / TOA
 History: premenopausal woman, midcycle,
previous STD, vaginal discharge, dysuria, Kehr’s
sign
 Exam: cervical motion tenderness, adnexal
mass
 Pyuria
 US useful to diagnose

65. Gastroenteritis
 History: diarrhea, vomiting, crampy pain
 Exam: no localizing peritoneal signs
 Normal WBC common

66. Mesenteric Ischemia / Infarction
 History: intestinal angina, arrhythmias, low
flow, hypercoagulable state
 Exam: pain out of proportion to findings!!!
 WBC and amylase elevated
 Acidosis, stool + for blood
 “Thumb printing” on plain film
 CT replacing angiography
 High Index Of Suspicion a Must!

67. Thumb Printing

68. Other Causes of Acute Abdomen
 Volvulus
 Cholangitis
 Pneumonia
 Acute M I
 Ovarian torsion / cyst
 Hepatitis
 Sickle cell disease
 Diabetic ketoacidosis
 Uremia
 Porphyria
 Intussusception
 Lupus
 HIV intestinal disease

69. Pitfalls
 Old age, infants
 Spinal cord injury
 HIV
 Steroids
“Very young? Very old? Very odd?
Be very careful.”
F.T. de Dombal, MA, MD

70. Summary
 Abrupt onset of severe abdominal pain is
of unclear etiology in many cases is a
medical emergency, requiring urgent and
specific diagnosis.

71. Summary
 History and physical examination much more
important than laboratory tests
 Making the management decision is more
important than making the diagnosis
 Treatment is often surgical