Differentials of acute abdominal pain in Emergency Room (ER) cases. Source: Tintinalli

1. ACUTE
ABDOMINAL PAIN
PGI Karen Cas

2. Acute abdominal pain
O Pain of less than 1
week’s duration

3. 3 categories
O VISCERAL PAIN
O PARIETAL PAIN
O REFERRED PAIN

4. Visceral Pain
O Usually caused by stretching of fibers
innervating the walls or capsules of hollow
or solid organs, respectively.

5. Parietal Pain
O Caused by irritation of fibers that innervate
the parietal peritoneum, usually the
portion covering the anterior abdominal
wall.
O Can be localized to the dermatome
superficial to the site of the painful
stimulus

6. Referred pain
O Felt at a location distant from the diseased
organ
O Usually ipsilateral to the involved organ

7. Abdominal Topography:
“Four-quadrant approach”

8. Pain Attributes
O P – precipitating (aggravating) / palliating
(alleviating) factors
O Q – quality
O R – radiation
O S – severity
O T – timing / duration / onset

9. Physical Exam
O INSPECTION – distention, scars, masses
O AUSCULTATION – normal / increased
bowel sounds, hyperactive / obstructive
bowel sounds
O PALPATION – tenderness, voluntary
guarding
O PELVIC EXAM – women of reproductive
age
O RECTAL EXAM – stool color, +/- blood,
tenderness

10. CLASSIFICATION
O INTRA-ABDOMINAL
O Gastrointestinal
O Genitourinary
O Gynecologic
O Vascular
O EXTRA-ABDOMINAL
O Cardiopulmonary
O Abdominal wall
O Toxic
O Metabolic
O Neurogenic
O NON-SPECIFIC
ABDOMINAL PAIN

11. Treatment
O HYPOTENSION
O Isotonic crystalloid
O Vasoconstrictors (dopamine,
norepinephrine)
O Pump failure : Dobutamine
O ANALGESIC
O Opioids, NSAIDs
O ANTI-EMETIC
O Metoclopramide
O ANTIBIOTICS

12. Disposition
O Indication for admission:
O Appear ill
O Elderly or immunocompromised
O With unclear diagnosis
O With reasonably unexcluded potential causes of
abdominal pain
O Intractable pain or vomiting
O Acute or chronically altered mental status
O Inability to follow discharge or follow-up
instructions
O Lacking social supports
O Alcohol or other drug use

13. THANK YOU!

14. Gastrointestinal
O APPENDICITIS
O BILIARY TRACT DISEASE
O SMALL BOWEL OBSTRUCTION
O ACUTE PANCREATITIS
O DIVERTICULITIS

15. Appendicitis
O Clinical features
with predictive
value
O RLQ pain
O Pain migration
from the
periumbilical
area to RLQ
O Rigidity
O Pain before
vomiting
O Positive psoas
sign

16. Appendicitis
O CT scan – generally preferred
O ULTRASOUND
O Color flow Doppler

17. Biliary Tract Disease
O Most ommon
diagnosis in ED
patients ≥50 years
old
O Steady post-
prandial upper
abdominal pain that
radiates to the
upper back

18. Biliary Tract Disease
O ULTRASOUND is better in the
identification of Cholecystitis than in the
detection of Common duct obstruction
O Cholescintigraphy (radionuclide
scanning)
O MR Cholangiography

19. Small Bowel Obstruction
O Central issues:
O Diagnosis of the
primary disorder, and
O Early detection of
secondary
strangulation or
ischemia
O Historical features
1. Previous
abdominal
surgery
2. Intermittent/colick
y pain
O PE findings
1. Abdominal
distention
2. Abnormal BS

20. Small Bowel Obstruction
O Ischemic bowel sec to
strangulation
O Extremely difficult to
detect clinically or
with plain
radiography
O CT
O Useful in altering the
likelihood of
ischemia

21. Acute Pancreatitis
O 80% caused by alcohol
or gallstones
O Steady and severe pain
that extends well
beyond the upper
abdomen to cause
generalized tenderness
O Resides deep in the
belly and extends into
the retroperitoneum

22. Acute Pancreatitis
O Serum lipase – begun to replace amylase
as the preferred ED screening test for
suspected acute pancreatitis
O Accuracy of serum lipase in the diagnosis
of acute pancreatitis is inversely related to
the time elapsed between symptom onset
and presentation

23. Acute Pancreatitis
O Double contrast
helical CT
O MR
cholangiopancreato
graphy (MRCP)
O ALT >150 U/L
(including
alcoholics)
O Increased risk of
biliary pancreatitis

24. Diverticulitis
O Pain confined to LLQ (<1/4 of cases)
O Pain in lower half of abdomen (1/3 of
cases)
O Generalized tenderness
O Elderly

25. Diverticulitis
O CT with colonic
contrast
O Sonography

26. Genitourinary
O RENAL COLIC
O ACUTE URINARY RETENTION

27. Renal Colic
O Pain: unilateral
flank, abrupt
onset, colicky, radiates
to groin/testicle/labia
O Non-contrast helical CT
O Doppler UTZ +
elevation of “renal
resistive index” in one
kidney relative to the
other may identify stone
in ipsilateral ureter

28. Renal Colic
O Older patients: exclusion of an abdominal
aortic aneurysm (AAA)
O (+) Anterior abd tenderness – impacted
stone at the ureterovesical junction

29. Acute Urinary Retention
O ACUTE URETHRAL OBSTRUCTION
O Another most common GU cause of abd
pain
O Distended bladder
O Insertion of urethral catheter – dx & tx

30. Gynecologic
O ACUTE PID
O ECTOPIC PREGNANCY

31. Acute Pelvic Inflammatory
Disease
O Abnormal vaginal discharge
O Only PE finding assoc with laparoscopic
PID
O Transvaginal sonography
O Positive: thickened tubal wall
O Transvaginal power doppler
O Positive: hyperemia + tubal inflammation

32. Ectopic Pregnancy
O Pain may be absent at earlier stage with a
sentinel complaint of only vaginal bleeding
O ANY WOMAN OF CHILDBEARING AGE
WHO PRESENTS TO ED W/ ABD PAIN
OR ABNORMAL VAGINAL BLEEDING
SHOULD RECEIVE A QUALITATIVE
PREGNANCY TEST AS A SCREENING
MEASURE.

33. Ectopic Pregnancy
O Transvaginal sonography
O Culdocentesis – compares poorly to TVS

34. Vascular
O ABDOMINAL AORTIC ANEURYSM
O MESENTERIC ISCHEMIA
O ISCHEMIC COLITIS

35. Abdominal Aortic Aneurysm
O Tend to enlarge, become aneurysmal over
years
O Triad:
HYPOTENTION, ABDOMINAL/BACK
PAIN, PULSATILE ABDOMINAL MASS
O Absence of abd pain – compatible with a
contained leak extending to
retroperitoneum

36. AAA
O Aortic sonogram
O Non-contrast helical
CT
O Helical unenhanced
abdominopelvic CT

37. Mesenteric Ischemia
O Arterial disease
O Occlusive (thrombotic/embolic)
O Non-occlusive (NOMI)

38. Mesenteric Ischemia
O Distinctions made among 4 major forms
1. Embolic is abrupt; MVT is most indolent
2. NOMI accompanied by low-flow
state, typically due to cardiac disease
3. MVT may be more amenable to non-
invasive diagnosis with CT; in younger
px; lower mortality; tx w/ immediate
anticoag
4. Arteriography w/ papaverine infusion –
impt in px w/ splanchnic vasoconstriction

39. Ischemic colitis
O A disease of older patients
O Diffuse or lower abdominal visceral pain
O Accompanied by diarrhea, often mixed
with blood
O Rectal sparring
O Segmental portions of the mucosa and
submucosa slough

40. Ischemic colitis
O Colonoscopy
O Color doppler sonography

41. Cardiopulmonary
O Pain of the upper half of the abdomen
(with or without tenderness)
O Chest film
O Epigastric pain + age grp CAD is
prevalent
O Cardiac history
O ECG

42. Abdominal wall
O Pain originating from the abdominal wall
may be confused with visceral pain
because superficial innervation from the
lower thoracic roots enter the spinal cord
via the same dorsal horn as the deeper
visceral afferents
O Carnett’s sign / sit-up test
O (+) abdominal wall syndrome

43. Hernias
O Defect through which intraabdominal
contents protrude, often
intermittently, during transient increases in
intraabdominal pressure
O Uncomplicated
O Asymptomatic or at worst, aching &
uncomfortable
O Significant pain: incarcerated or
strangulated

44. Hernias
O Inguinal – most common
O Femoral hernias – women
O Sonography of the abdominal wall

45. Toxic
O Infectious agents
irritate GI tract –
crampy
O Concomitant vomiting
or diarrhea
O Poisoning
O Overdose
O Opioid withdrawal
O Peritoneal tenderness
O Infarction
O Penetration
O Perforation

46. Metabolic
O Anion-gap metabolic acidoses (DKA,
AKA)
O Gastric distention
O Paralytic ileus
O If acidosis is resistant to standard
treatment, or pain persists after
normalization of pH, intraabdominal
disease should be suspected

47. Metabolic
O ENDOCRINOPATHIES
O Adrenal crisis
O Thyroid storm
O Hypo- and hypercalcemia
O Shock
O Diffusely peritoneal

48. Neurogenic
O Dysesthetic sensation
O “hover” sign
O Radicular problems
O Zosteriform radiculopathy
O Dysesthesia outlining a dermatome on either
side of the involved root
O Lancinating, ticlike bouts of shooting pain or
continuous burning
O Vesicles

49. NSAP
O Diagnosis of exclusion
O Nausea – most common symptom after
abdominal pain
O Mid-epigastric and lower half of the
abdomen
O Lab test usually normal / mild leukocytosis