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
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Examining the Acute Abdomen
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
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
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
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
27. Peritoneal Signs
Very worrisome finding
“rebound” tenderness local vs diffuse
Often will mean surgery
…but not always
Pancreatitis, localized diverticulitis,
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
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
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
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
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
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
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
57.
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
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
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!
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