Symptoms and Signs in Acute Abdominal Pain

Symptoms and Signs in Acute
Abdominal Pain
Aims & Objectives
• Describe types of pain
• Evaluate features of abdominal pain
• Outline a plan for investigation
• List some special circumstances
• Explore differentials
• Debunk a few myths
• Highlight pitfalls
Pain
• Type
• Site
• Duration
• Aggravating / Relieving factors
• Character
• Radiation
• Associated Phenomena
Types of Pain
• Visceral pain:
– dull, poorly localized pain in midline epigastrium,
periumbilical region or lower midabdomen
– crampy, burning and gnawing
• Referred Pain:
– pain felt in areas remote to the disease organ (subphrenic
abscess felt as shoulder pain)
Chronology
• Sudden onset, well localized = intra-abdominal catastrophe
– perforated viscus,
– mesentaric infarction
– ruptured aneurysm
• Progression
– appendicitis increases,
– gastroenteritis decreases,
– colic crescendo/decrescendo
• Duration hours to days more severe than pain lasting weeks
Site
• May not be specific
• Pain of diaphragmatic irritation may
present as shoulder pain
• Changes in location may be marker of
progression
• Appendicitis - McBurney’s point
• Perforated ulcer - vague pain to
peritonitis
Aggravating and Relieving factors
• Peritonitis  lie motionless

• Renal colic  writhe, unable to find comfortable position
• Fatty foods  biliary colic
• Pain improves with eating  DU
• Worse with eating  GU, mesenteric ischemia
Intensity and character
• Perception of intensity is dependent on point of
reference of patient
• Not very useful
• Treat
• ‘Patient is always right’
Obtaining a history
• PMH
– bowel obstruction, renal colic, PID tend to recur
• ROS
– fever, chills  infectious
– nausea, vomiting with no flatus  bowel obstruction
– dysuria, pregnancy, menstrual history
Physical Examination
• Still patient  peritonitis
• Writhing patient  colic, bowel obstruction
• Look for medical causes
- lower lobe pneumonia
- myocardial Infarction
• Remember the old and the young may present very
atypically
– elderly, diabetics, immunocompromised may present with
minimal symptoms
• Severe tenderness with rigidity  peritonitis 
surgical colleagues
• Mild tenderness  gastroenteritis
• Palpate from areas of least pain to areas with most pain
• Peritonitis (shake bed, deep breath)
• Pelvic, Genital and Rectal exam on every patient with
severe abdominal pain
Investigations
Investigations
• FBC
• U&E
• Pregnancy test in all women of reproductive age
with abdominal pain
• LFTs, amylase on patients with upper abdominal
pain
Diagnostic Imaging
• Plain Film
– Consider erect chest x-ray
– Consider abdomen (will it really make a difference? )
• Ultrasound for patients with biliary or pelvic symptoms
• CT Abdomen and Pelvis
– evaluates vasculature, inflammation and solid organs
The differential..
• Acute Cholecystitis
– cystic duct obstructed, RUQ pain  R scapula
– Murphy’s sign,
– LFTS, amylase
• Acute Appendicitis
– anorexia, N/V and vague periumbilical pain
– 6-8 hrs pain migrates to RLQ, fever
– Progresses to localized peritoneal irritation
The differential (cntd)
• Pancreatitis
• Inflammatory bowel disease
• Acute Diverticulitis
– most commonly in sigmoid colon
– symptoms related to inflammation or obstruction
– Consider CT useful early to r/o abscess
• Bowel Obstruction
– 70% of cases in adults are post-op
– adhesions, incarcerated hernias
– bilious vomiting, feculent vomiting  distal
obstruction
– X-rays  dilated bowel with fluid levels
• Perforated DU
– usually in the anterior duodenal bulb
– usually sudden acute pain with peritonitis
– Chest x-ray may show free air under diaphragm
• Acute mesenteric ischemia
– intestinal angina (pain with eating)
– “vasculopath” (cad, pvd, abdo bruits etc)
– acute onset of periumbilical abdominal pain out of proportion
to physical findings
– Consider if atrial fibrillation
– acidosis may herald intestinal infarction
– surgery if acute vascular occlusion noted
• AAA
– acute onset of tearing abdominal pain
– tender abdominal mass in 90%
– triad of hypotension, pulsatile mass and abdominal pain
noted in 75%
– Alert surgeons/anaesthetist/theater
• Others:
– endometriosis, salpingitis, tubo-ovarian absess, ovarian
cysts or torsion, ectopic pregnancy
Special Circumstances
• Pregnancy
– appendicitis, cholecystitis, pyelonephritis,
– adnexal problems (ovarian torsion, ovarian cyst rupture)
– appendicitis 7/1000 pregnancies
– 3% fetal loss with surgery, but 20% with perforated
appendix
• Very Young
– appendicitis and abdominal trauma secondary to NAI
– PID, Meckel’s diverticulum, cystitis, enteritis, IBD
• Very Old
– symptoms may be subtle
– compulsive evaluation
• Immuno-compromised
– chemotherapy, organ transplants, immunosupression for
autoimmune disease, AIDS
– symptoms are subtle
– unique to immunocompromised host (neutropenic enterocolitis,
GVH, CMV infections, KS, lymphoma/leukemia obstruction)
Chronic Abdominal Pain
• 15% of population complain of recurrent chronic
abdominal pain
– Abdominal pain lasting > 6 months
– IBS
– Women 70% of all IBS patients
– obtain history of abuse (physical/sexual)
– exhaustive work-up usually negative
Any Questions
?
Summary
• Obtain detailed history
• Careful examination and re-examination
• Consider patient co-morbidity
• Prompt, appropriate investigations
• Ask for help if confused!!
Upper G.I. Haemorrhage
Causes
• Oesophageal Mallory Weiss Tumour
Oesophagitis Varices
• Peptic Ulcer Disease
• NSAIDs
• Aorto-eneteric fistula
Clinical Presentation
• Melaena
• Haematemesis
• Hypovolaemia
• Anaemia
• History of recent abdo pain
• History of NSAIDs
Primary Assessment
A
B
C
Primary Assessment
• Protect airway against aspiration
• Pulse
• Blood pressure
• Respiratory Rate
• Look for indicators of cause
Resuscitation
• Oxygen
• Cardiac Monitor
• Widebore Cannulation
• Restore intravascular volume
Warmed saline
Blood
• Insert CVP
• Insert urinary catheter
Resuscitation
• Consider FFP
• Consider platelets
• Endoscopy
• Early surgical referral
• +/- Surgery
Secondary Assessment
• Good History
• Drug History
• Jaundice
• Other medical problems
• PR
Secondary Assessment
• FBC
• Gp and X-match
• Coag Screen
• U&E
• LFTs
• CXR
• ECG
Definitive Care
• Early endoscopy
• +/- surgery
Severe continuous bleeding
60 years with > 4 units transfusion
< 60 years with > 8 units transfusion
Adverse prognostic factors
• Age > 60
• Signs of hypovolaemia
• Hb <10gm
• Severe co-existent disease
• Continued bleeding or re-bleeding
• Varices
Any Questions
?
Summary
• Is the airway at risk ?
• Is oxygenation adequate ?
• Are there signs of circulatory failure ?
• Early attention to electrolytes
• Attention to fluid balance
• Early referral

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Symptoms and Signs in Acute

• Peritonitis  lie motionless

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