Acute Abdominal Pain Diagnosis

Acute Abdomen
Hamed Rashad
Professor of surgery Banha University - Egypt

The acute abdomen refers to the
clinical situation in which an acute
change in the condition of the
intraabdominal organs, demands
immediate and accurate diagnosis.

“The term “acute abdomen” should never be
equated with the invariable need for
operation.”
Zachary Cope, MD, 1927

The Acute Abdomen
• Most patients are found to have self
limited conditions
• A subset of patients harbor serious
intra abdominal disease that requires
urgent surgical or medical intervention

The severity of the pain does not always
correlate with the gravity of situation,
nor all patients with the so called
"acute abdomen"
require surgical intervention.

Careful History and Complete Physical
Examination supplemented with simple
Laboratory Tests can clench diagnosis in
most case.
Sometimes newer techniques of
Abdominal Imaging are needed

N.B.: An excessive reliance on tests
can lead to unnecessary delay and
must be avoided.

A- Visceral.
B- Somatic.
C- Referred
Physiologic bases
of Abdominal Pain

Mechanisms of pain transmission
VisceralVisceral
SomaticSomatic
ReferredReferred

a-Visceral pain:
- Visceral peritoneum is supplied by
autonomic nerves (symp. And parasymp.
- Vaguely localized.
- Starts then radiates to a somatic sites.

• Visceral pain
– Stretching of peritoneum or organ
capsules by distension or edema
– Diffuse
– Poorly localized
– May be perceived at remote locations
related to organ’s sensory innervation

-Visceral pain:
- Hollow organs are insensitive except to:
* Distension.
* Stretching.
* Spasm.
* Ischemia.
* Inflammation.

b-Somatic pain:
Will localized (parietal peritoneum is
sensitive).
- Sharp severe and persistent.
- Stitching
- Due to irritation of the parietal peritoneum.
 Pain direct over the organ.

• C- Referred pain
– Perceived at distance from diseased organ
– Pneumonia
– Acute MI
– Male GU problems

Anatomic consideration
of abdominal pain
-Individual abdominal organs and visceral
peritoneum are innervated by autonomic
nervous system (symp. And parasymp.)

Anatomic consideration
of abdominal pain
-The parietal peritoneum which invests the
abdominal walls and the diaphragmatic and
pelvic surfaces is innervated by the spinal
nerves from
D : 5 to D: 11 segments.

- Phrenic nerve
innervates the diaphragm and its peritoneal
and pleural surfaces is supplied from
C4 segment that also supplies the shoulder.

• Pain of foregut origin starts in the
epigastrium (G & D ulcers,
cholecystitis, biliary pain, pancreatitis).
• sympathetic supply D6, 7, 8, 9

*Pain of midgut origin radiates around the
umbilicus: appendicits, Mickle's
diverticulitis, ileum, caecum &
ascending colon.
* sympathetic supply D10.

• Pain of hindgut origin starts in the
hypogastrium (suprapubic) volvulus of
sigmoid, diverticulitis…
• sympathetic supply D11 and 12.

Sites of Visceral PainSites of Visceral Pain

How we feel pain
SMG
C
G
Symp.
trunk
• Visceral afferent from GI tract via
sympathetics to cord
– appendix, left colon, rectum and
pelvic organs via
parasympathetic
• Afferent cell bodies lie in DRG of
corresponding spinal cord segment
– dorsal horn cells also receive
sensory input from afferents
supplying skin/subcut and
muscle
• accounts for referred pain
DRG
Spinal
sensory
afferents
Splanchnic

• Pain of renal or ureteric origin starts in the
loin and refers to the scrotum or labia and
thigh.
Along the 1st lumbar N (genitofemoral)
* Pain of the base of the bladder and prostate
radiates to perineum and tip of penis (sacral
plexus).
* Pain of uterine or tubal origin radiates to
sacrum (sacral plexus).

*Posterior parietal peritoneum and pelvic
peritoneum are insensitive
So: retroperitoneal organs give only:
- Deep seated pain.
- Little tenderness and rigidity.
*Diaphragmatic peritoneum and pleura are
sensitive (phrenic nerve C4)
shoulder and scapula, rupture spleen,
cholecystitis, intraperitoneal haemorrhage,
basal pleurisy……

Clinical Manifestations
of Acute Abdomen
In the majority of cases a thorough
history and physical examination will
reveal the cause of abdominal pain or at
least sufficiently narrow down the
possibilities to allow initial treatment
decision to be made.

Clinical Diagnosis
• Location of pain by
organ
• RUQ
– Gallbladder
• Epigastrum
– Stomach
– Pancreas
• Mid abdomen
– Small intestine
• Lower abdomen
– Colon, GYN pathology

The Acute Abdomen
• Early evaluation is important, as once the
initial evaluation is done analgesia may be
given
• Antibiotics should not be given until a
working diagnosis is made
• Serial examinations by the same physician
during the patient’s work up determines
disease progression or resolution

Peritoneal Signs
• Palpation and Percussion – BE GENTLE
• Rebound – please do not perform this test
– Causes unexpected and unnecessary pain
– Does not add information to an
examination after percussion
• Rigidity
– not present in pelvic inflammation or
obstruction, unreliable

Onset
• Sudden, gradual or prolonged
• ? Prodromal symptoms
• Minutes – perforated ulcer or diverticulum,
ruptured AAA, testicular or ovarian torsion,
ectopic pregnancy, pancreatitis, mesenteric
infarct
• Hours – biliary disease, appendicitis,
diverticulitis, SBO
• Days – inflammatory bowel disease,
malignant obstruction

Symptoms
1- Pain
• N.B.: Abdominal pain that
persists more than 6 hours
search for a surgical cause.

2-Vomiting:
*Relation to pain is important.
- In appendicitis it occurs 3-4
hours after pain.
- In gastroenteritis the reverse
is true.
* Common in obstruction  momentary
relieve of pain.

Vomiting
• Vomiting is early, sudden and violent in
ureteric colic
• Early and copious in upper intestinal
obstruction
• No vomiting until late in large bowel
obstruction
• Frequent scanty in A/c pancreatitis
• Vomiting precedes pain in gastroenteritis

Character of Vomitus
• In gastritis vomitus contains food particle
and some bile
• In CHPS and duodenal atresia differentiated
by presence of bile in the latter
• In intestinal obstruction content varies from
gastric , bilious greenish yellow to orange
and brown indicating feculent vomitus.

3-Anorexia:
- Common in acute abdomen.
- Precede pain in acute appendicitis.

4-Bowel:
The failure to pass flatus associated with
cramping pain and vomiting strongly
supports mechanical obstruction of
the GIT.

5-Menstruation:
- Pregnancy.
- Missed period.

6-Past illness:
 Previous operation.
Hernias.
 Similar pain.
 Medications.

7-Family history:
- Mediterranean fever.
- Sickle cell anaemia.

8-Organ system review:
- Extra abdominal cause of pain.
- Systemic illness.

Examination:
* General observations:
- Appearance.
- Attitude.
- Vital sign
- Auscultation
*Chest
*Abdomen:

Examination:
* Inspection: (hernias, distension…..).
*Palpation: rigidity, tenderness……
*Percussion: tympany or dullness,
referred tenderness……
* Auscultation

Pelvis:
PR (if you do not put your finger you
might put your foot)??
Bimanual ex.
Obturator sign

Back and flanks:
Percussion (costovertebral angle
tenderness).
Iliopsoas sign.

Important points
in diagnosis of
Acute Abdomen

HistoryHistory
• Sudden onset –Sudden onset – perforated viscusperforated viscus
• CrushingCrushing – esophageal or cardiac disease– esophageal or cardiac disease
• BurningBurning – peptic ulcer disease– peptic ulcer disease
• ColickyColicky – biliary or renal disease– biliary or renal disease
• CrampingCramping – intestinal pathology– intestinal pathology
• RippingRipping – aneurismal rupture– aneurismal rupture

1-Pain:
*Main symptom.
*Detailed  clench most
conditions.

2-Onset of the disease and its course
Marsh of Events:
Most important investigation is a
"CHAIR"

*For ex. Torsions, perforatations and
internal hemorrhage have a sudden onset
within few hours there is:
- Marked shock.
-In case of perforation frank
peritonitis.

3-Relation of the pulse to the
temperature:
a-Inflammatory lesions:
-Rise of temperature and
proportionate rise of pulse.
??? Typhoid fever.

temperature:
b-Haemorrhage:
Marked rise of pulse
a subnormal temprature

temperature:
c-Abdominal colic (Renal, Biliary, Intestinal):
-Pulse rise only during colic.
-Normal pulse & temperature between colics.
-Temperature is only elevated when there is
inflammation.

3-Relation of Pulse to Temperature :
d-Intestinal obstruction:
-Pulse and temperature are normal-
-Pulse rises on dehydration.
-Temperature rises with peritonitis.

3-Relation of Pulse to Temperature
e-Perforation and torsion:
-Shock and rapid pulse from the start.
-Temp: subnormal at first  rises when
peritonitis sets in.

4-Tenderness and Rigidity:
- Irritation of parietal peritoneum.
- Directly over the responsible organ
(appendicitis).
-Retroperitoneal and pelvic lesions:
* deep tenderness but no rigidity
* PV or PR  tenderness.

4-Tenderness and Rigidity:
N.B.: Postoperative peritonitis is lacking
rigidity because of weak muscles but
tenderness and fever remain.

5-Variation in clinical picture:
-Variation in the extent and degree of the lesion.
-Individual variations  degree of symptoms.
-Variations due to secondary developments on
top of the primary condition  close
observation
= chair.

Physical Examination of the Abdomen
Inspection
Auscultation
Percussion
Palpation

Inspection
• General observation
• Look at abdominal contour, note location of
any scars, rashes or lesions

Inspection
• Patient writhing in agony - likely has
colicky abdominal pain caused by ureteral
lithiasis
• Patient lying very still - more likely to have
peritonitis
• Patient leaning forward to relieve pain -
may have pancreatitis

Inspection
• The abdominal wall is a commonly
overlooked source of abdominal pain
• Other parts of the body should also be
inspected. For example, the eyes should be
inspected for evidence of scleral icterus
which may indicate hepatobiliary disease

Auscultation
• Useful in assessing peristalsis
• Bowel sounds are widely transmitted through the
abdomen - therefore, it is not necessary to listen in
all 4 quadrants
• Auscultation should last at least 1 minute
• Bowel sounds typically highly pitched so the
diaphragm of the stethoscope should be used

Auscultation
• ? Bowel sounds-
normal/hyperactive/hypoactive
• Auscultation should precede percussion and
palpation
• ? Abdominal bruits -
– listen over aortic,iliac and
renal arteries

Auscultation
• Hypoactive bowel sounds - associated with
ileus, intestinal obstruction, peritonitis
• Intestinal obstruction can produce
hyperactive bowel sounds which are high
pitched tinkling sounds occurring at brief
intervals; very audible

Percussion
• Technique - performed by firmly pressing
the index finger of one hand on the
abdominal wall while striking the
abdominal wall with the other index finger
• Percussion note can be described as dull,
resonant, or hyperresonant

Percussion
• Dull/resonant or hyperresonant
• Tympany normally present in
supine position
• ? Unusual dullness
– ? Clue to underlying abdominal mass

Percussion
• Gastric region -
– percussion over the gastric region will
generate a hyperresonant note because
of usual presence of a gastric air bubble
• Liver -
– percussion over the liver will generate
a dull note
– A normal liver span is 6 to 12 cm in
the midclavicular line

Percussion
• Generalized percussion is a useful method
for detecting the presence of ascites or
intestinal obstruction in a distended
abdomen
• In ascites - a dull percussion note would be
generalized
• In intestinal obstruction - a hyperresonant
note would be heard

Percussion
• If ascites is suspected, then a test for
shifting dullness can be performed
• Ascites typically sinks with gravity,
percussion of the flanks generates a dull
note and percussion of the periumbilical
region generates a resonant note in the
supine patient

Percussion
• The test for shifting dullness involves
having the patient shift to a lateral decubitus
position and then performing percussion
again; the area of resonance should shift
upward

Shifting Dullness
• If dullness on percussion shifts when the patient is rolled
on the side, peritoneal fluid (ascites) may be present.

Percussion
• Splenic Enlargement
A change from tympany to dullness suggests splenic enlargement

Palpation
• Before palpating the abdomen the examiner
should ask the patient to point directly to
the area that hurts most and avoid palpating
that area until absolutely necessary
• May be difficult in patient who has
guarding (voluntary or involuntary)

Palpation
• Voluntary guarding - conscious elimination
of muscle spasms
• Involuntary guarding - reported when the
spasm response cannot be eliminated, which
usually indicates diffuse peritonits

Palpation
• Where is pain ? Begin with light palpation
• Guarding - voluntary/involuntary
• Rebound tenderness

Palpation
• Rebound tenderness is elicited by pressing on the
abdominal wall deeply with the fingers and then
suddenly releasing the pressure
• Pain on the abrupt release of steady pressure
indicates the presence of peritonitis
• Asking the patient to cough is another method of
eliciting signs of peritonitis

Rebound Tenderness
• This is a test for peritoneal irritation. Palpate deeply and
then quickly release pressure. If it hurts more when you
release, the patient has rebound tenderness

Deep Palpation
• ? Areas of deep tenderness/masses

Palpation of Aorta
• Easily palpable on most
• Pulsate with deep palpation of central
abdomen
• Enlarge aorta -
– ? Sign of aortic aneurysm

Palpation of Spleen
• Not normally palpable

Costovertebral Angle
Tenderness
• CVA tenderness is often associated with renal disease. Use
the heel of your closed fist to strike the patient firmly over
the costovertebral angles

““We diagnose what weWe diagnose what we
look for and look for whatlook for and look for what
we knowwe know””
You will diagnose whatYou will diagnose what
you think ofyou think of

Acute Abdominal Lesions
These are grouped under 8 headings:
1-Inflammations.
2-Perforations.
3-Torsions.
4-Internal hemorrhage.
5-Abdominal colics.
6-Intestinal obstruction.
7-Extra abdominal lesions giving abdominal Symptoms.
8-General medical conditions.

GYN Etiologies
Organ Lesion
Ovary Ruptured graafian follicle
Torsion of ovary
Tubo-ovarian abscess (TOA)
Fallopian tube Ectopic pregnancy
Acute salpingitis
Pyosalpinx
Uterus Uterine rupture
Endometritis

Inflammations
Acute appendicitis,
Acute cholecystitis,
Acute Salpingoophritis,
Acute Diverticutitis,
Acute Peritonitis,
Acute Pancreatitis…..

Inflammations
The mean features:
- Acute onset.
- Pain + rise of temperature and pulse
Typhoid fever ? Pancreatitis!!
- Leucocytosis.
-Tenderness and rigidity
!!pancreatitis!!

Perforations
Perforated peptic ulcer, typhoid….
Main features:
- Sudden severe, abdominal pain.
- Shock.
- Marked tenderness.
- Board like rigidity.
- Free peritoneal air.
- Marsh of symptoms and signs.

Tortions
Volvulus of sigmoid, caecum, small
intestine ……
Main features:
- Sudden severe abd. pain.
- Rapid enormous abd. distension.
- Absolute constipation.
-Plain x-ray erect bowel loop enormously
distended with fluid level.
- Shock!

Internal hemorrhage
Acute:
Organ rupture spleen, liver, mesentery in
that order……
Subacute:
Rupture ectopic pregnancy, graaffian
follicle, rarely delayed rupture
spleen……

Main features of int. Hge:
-Sudden severe abd. pain  shoulder.
-Pallor – fainting.
-Thirst – air hunger.
-Irritability.
-Tenderness and rigidity more over the
bleeding organ.
-Shifting dullness.
-Tachycardia, subnormal temperature.
-Hypotension.

Abdominal colics
(Renal, biliary and intestinal)
Main features:
- Pain is severe colicky – crampy –
comes and goes.

Physiology
• The required stimulus for pain in hollow tube is
stretch/ distension or excessive contraction against
an obstruction
• Mild degree of bowel contractions is called
flatulence and severe form, colic
• Colics occurs in paroxysms and is severe and
referred to the centre from which the nerves come
and also to the segmental distribution

Colics
• Small bowel colic pain is referred to the
epigastrium and the umbilicus
• Large bowel colic to the hypogastrium
• Renal colic from loin to groin and the
testicles
• Biliary colic to the right subscapular region

Abdominal colics
(Renal, biliary and intestinal)
- During pain the patient is:
* In agony.
* Doubled up or bent.
* Compressing the site.
* Shouting and crying.
* Pulse is high.
-Pulse and temp are normal between
the attacks.

Intestinal obstruction
Main features:
- Abdominal. colic.
- Vomiting.
- Absolute constipation.
- Abdominal. distension.
- Loud intestinal sounds 'borborygmi'.
- Multiple fluid levels.
- Ryles tube for 2 hours relieves pain = simple.
- Shock is late after dehydration.

Strangulated obstruction:
- Shock is early
- Pallor-Tachycardia
-Localized tenderness and rigidity.
-Nasogastric suction does not relieve pain.

Commonest Cause of I Obst
Stragulated Hernia

Extrabdominal lesions referring pain
to the abdomen:
-Basal pleurisy, lobar pneumonia.
- Coronary thrombosis.
- Muscular pain (abd. wall).
- Root pain.
- Tabetic or herpetic crisis.

Main features:
*Usually there is no related bowel disturbances.
*Symptoms and signs outside the abdomen.
*Meticulous history  proper diagnosis.
*Local abdominal signs are usually lacking.

Non-Surgical Causes by Systems
System Disease System Disease
Cardiac Myocardial infarction
Acute pericarditis
Endocrine Diab ketoacidosis
Addisonian crisis
Pulmonary Pneumonia
Pulmonary infarction
PE
Metabolic Acute porphyria
Mediterranean fever
Hyperlipidemia
GI Acute pancreatitis
Gastroenteritis
Acute hepatitis
Musculo-
skeletal
Rectus muscle
hematoma
GU Pyelonephritis CNS
PNS
Tabes dorsalis (syph)
Nerve root
compression
Vascular Aortic dissection Heme Sickle cell crisis

General medical condition
simulating acute abdomen:
- Uremia.
- Diabetic ketoacedosis.
- Abdominal influenza.
- Periodic peritonitis.
- Porphyria.
- Haemolytic crisis.

Uraemia:
* Ileus  distension
vomiting……
* With
- Headache.
- Coated tongue.
-Urineferous odour of the mouth.
* Uraemic may develop appendicitis and
perforated peptic ulcer……

Periodic peritonitis (familial med.
Fever):
-Recurrent attacks of acute abdominal pain not
corresponding to a special organ.
-Marked generalized tenderness, fever and
leucocytosis.
- Good response to colchicine.
- Occurs in families in Mediterranean area.

Acute porphyria:
- Central abdominal pain that may radiate to the
back.
-Pain is usually precipitated by the intake of
barbiturates, sulphonamides or alcohol.
-Absence of abd. signs.
-Muscle weakness.
-Mental symptoms.

Haemolytic crisis:
-Abdominal pain and fever.
-Signs of peritoneal irritation are absent.
-Spleen is usually enlarged.
Anaemia &
Ecteric tingue
come with attacks
of haemolysis

Investigations
• Laboratory
• Imaging

Labs & Imaging
Test Reason
CBC w diff Left shift can be
very telling
BMP N/V, lytes,
acidosis,
dehydration
Amylase Pancreatitis,
perf DU, bowel
ischemia
LFT Jaundice,hepati
tis
UA GU- UTI, stone,
hematuria
Beta-hCG Ectopic
Test Reason
KUB
Flat & Upright
SBO/LBO,
free air,
stones
Ultrasound Chol’y, jaundice
GYN pathology
CT scan
-Diagnostic
accuracy
Anatomic dx
Case not
straightforward

LABORATORY
• Laboratory tests
– insensitive, non-specific for most conditions
• some conditions require specialized tests e.g porphyria
– certain patterns may be useful
• amylase/lipase for pancreatitis
• transaminases/Alk Phos/Bili for biliary disorders
• ESR/CRP/CBC may help in inflammatory or AI conditions
– may help rule out functional disorders
– ß-HCG mandatory for childbearing women

Plain Supine and Erect film:
- Rapid & cheep.
- Free intraperitoneal air.
- Abnormal calcific densities.
- Best in mechanical small and large bowel
obstruction.

Classic Small Bowel
Obstruction supine

Classic Small Bowel
Obstruction ,Erect

Plain Supine and Erect film:
- Can detect ileus.
* Gas's in small and large bowel.
* No significant disproportion between
bowel loops.
* Air fluid levels are non changeable
event with position or with time.
- Detection of Gas's within the portal and
mesenteric venous systems.

Upper GI series:
-Water soluble contrast.
-Detecting perforations.
 free
 contained
Lower GI series:
-Large bowel obstruction.

Ultrasonography:
- Rapid evaluation of the liver, spleen
(pancreas), kidneys, ovaries, adnexa and
uterus.
- With the advent of colour Doppler the
blood vessels of the abdomen can be
studied.
- Hampered by Gas, bone and fat.

CT Scan
-Useful in patients not in urgent need for
surgery.
-Can detect organ changes even appendix
appendicoliths.
-Clench changes occurring with complicated
appendicitis.

CT Scan:
Abdominal hemorrhage.
Diagnosis and follow-up of :
-Bowel ischemia:
*Thickening.
*Gas's –intramural-venous
*Vascular occlusion.
-Acute pancreatitis.

• Early diagnostic laparoscopy may result in:
– accurate,
– prompt,
– efficient management of AAP
• Reduces the rate of unnecessary laparotomy
• Increases the diagnostic accuracy
• May be a key to solving the diagnostic dilemma of
NSAP.
10
Golash and Willson. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1320 patients. Surg Endosc. 2005 Jul;19(7):882-5
11
Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5
Laparoscopy

Management
• Monitor EKG
Keep patient npo
Analgesia controversial
Demerol is preferred narcotic analgesic
Consider possible MI with
pain referred to abdomen in
patients >30 years old

Common Causes of Acute
Abdomen
• Appendicitis
• Cholecystitis
• Pancreatitis
• Diverticulitis
• Perforated Ulcer
• IBD
• Obstruction
• Vascular Emergencies
• Gynecologic Diseases
• Urinary Tract Disease

Common Causes of Acute Abdominal Pain
by Age Groups
• Infancy
– GI
• Acute gastroenteritis
• Appendicitis
• Intussusception
• Volvulus
• Meckel's diverticula
– Other
• Colic
• Trauma
• Adolescence/childhood
– GI
– Acute gastroenteritis
– Appendicitis
– Constipation
– IBD
– Peptic ulcer disease
– Cholecystitis
– Pancreatitis
– Neoplasm

by Age Groups
Adolescence/childhood
Other
• Functional abdominal pain
• Pelvic inflammatory disease
• Pregnancy
• Pyelonephritis
• Pneumonia
• Sickle cell crisis
• Trauma
• Diabetic ketoacidosis
• Heavy metal poisoning
• Renal stone

by Age Groups
• GI
– esophagitis
– esophageal spasm
– esophageal rupture
– intestinal obstruction
• hernia, intussusception,
adhesions, volvulus
– gallstones
– ampullary stenosis
– IBD
– pancreatitis
– IBS
– non-ulcer dyspepsia
– mesenteric ischemia
– malignancy
– abscess
– chronic intractable
abdominal pain
• Cardiac
– ischemia/MI
– myocarditis/endocarditis
– CHF
AdultAdult

by Age Groups
• Thoracic
– pneumonitis
– pleurodynia
– PE/infarct
– PTX
– empyema
• Neurologic
– radiculopathy
– abdominal epilepsy
– tabes dorsalis
• Metabolic
– uremia
– DM
– porphyria
– acute adrenal insufficiency
– hyperPTH

by Age Groups
• Toxins
– hypersensitivity: insect or
venom
– lead poisoning
• Infections
– zoster
– osteomyelitis
– typhoid
• Miscellaneous
– muscle contusion,
hematoma, tumor
– narcotic withdrawal
– FMF
– psychiatric
– depression
– heat stroke
– Mittelschmerz

Abdominal wall pain
• The overlooked DDX
– rectus sheath hematoma
– rectus syndrome
– idiopathic abdominal wall pain
– abdominal endometriosis
– ilioinguinal-iliohypogastric nerve
entrapment
– diabetic thoracic polyradiculopathy
– thoracic disk herniation
– painful rib syndrome
– spinal cord tumor

CT scan
What is the diagnosis? Acute appendicitis

Appendicitis
• 1 in 15 people will develop appendicitis in
their lifetime
• It’s the most common cause of the acute
abdomen
• Peak incidence is from 10 – 30 years

Appendicitis
• History may be classic – if you’re lucky
• Vague peri-umbilical pain is the most
common symptom
• McBurney’s Point
• Hyperesthesia of the abdominal wall
• Rovsing’s, psoas and obturator signs

Appendicitis
• Inflammation of
vermiform appendix
• Usually secondary to
obstruction by fecalith
• May occur in older
persons secondary to
atherosclerosis of
appendiceal artery and
ischemic necrosis

Appendicitis
• Signs and Symptoms
– Classic: Periumbilical pain  RLQ pain/cramping
– Nausea, vomiting, anorexia
– Low-grade fever
– Pain intensifies, localizes resulting in guarding
– Patient on right side with right knee, hip flexed

Appendicitis
– McBurney’s Sign: Pain on palpation of RLQ
– Aaron’s Sign: Epigastric pain on palpation of RLQ
– Rovsing’s Sign: Pain in LLQ on palpation of RLQ
– Psoas Sign: Pain when patient:
• Extends right leg while lying on left side
• Flexes legs while supine

Appendicitis
• Rovsing’s sign can be elicited by
palpating deeply in the left iliac area and
observing for referred pain in the right iliac
fossa
• When present, the psoas and obturator signs
are also helpful in establishing a diagnosis
of appendicitis

Appendicitis
• Psoas sign - the psoas sign is pain elicited
by extending the right hip while the patient
is in the left lateral decubitus position -
• alternatively, while in the supine position,
the patient can lift the right thigh against the
examiners hand, which is placed above the
knee

Psoas Sign
• The psoas sign. Pain on passive extension of the
right thigh. Patient lies on left side. Examiner
extends patient's right thigh while applying
counter resistance to the right hip (asterisk).

Appendicitis
• Obturator sign - the obturator sign is pain
elicited by flexing the patient’s right thigh
at the hip with the knee flexed and then
internally rotating the hip
• Right sided rectal tenderness may also be
elicited on rectal exam of patients with
acute appendicitis

Obturator Sign
• The obturator sign. Pain on passive internal
rotation of the flexed thigh. Examiner moves
lower leg laterally while applying resistance to the
lateral side of the knee (asterisk) resulting in
internal rotation of the femur.

Appendicitis
– Unusual appendix position may lead to atypical
presentations
• Back pain
• LLQ pain
• “Cystitis”
– Rupture: Temporary pain relief followed by peritonitis

Appendicitis
• Retrocecal appendix occurs 64% of the time
• Ultrasound or CT Scan may be used
• CT Scan with triple contrast and 5mm cuts
through the level of the appendix is 98% sensitive
for appendicitis
• A retrocecal or pelvic appendix or abscess will
NOT cause peritoneal signs

Normal appearing appendix?
• Remove appendix
anyway?
– Especially if the pt has a
RLQ incision
– Negative predictive value
of macroscopic judgments
of the appendix are low
• Check for ovarian
pathology
• Check for mesenteric
adenitis

Meckel’s Diverticulitis
Rule of 2’s
•2% incidence
•2 types of mucosa
•2 feet from ileocecal
valve
•2-4% (now 6%) with
Meckel’s develop
symptoms
•<2 yr olds bleeding
(50%)

Appendectomy
Textbook of Sabiston, 16th ed.

Appendicitis in Pregnancy
• Appendicitis is the most common extrauterine
surgical emergency
• 1 in 6000 pregnancies
• Signs and symptoms are unreliable
• Derangements in GI physiology include decreased
gastric acid secretion, increased reflux, delayed
gastric emptying and decreased peristalsis
• CT scans in the third trimester are safe

Adler Sign
• If the point of maximal tenderness shifts
medially with repositioning on the left
lateral side, the etiology is generally
adnexal or uterine (vs appendiceal).

Ectopic Pregnancy
• Any pregnancy that
takes place outside of
uterine cavity
• Most common location
is in Fallopian tube
• Pregnancy outgrows
tube, tube wall ruptures
• Hemorrhage into pelvic
cavity occurs

Ectopic Pregnancy
• Suspect in females of child-bearing age with:
– Abdominal pain, or
– Unexplained shock
• When was last normal menstrual period?
Ectopic pregnancy does
NOT necessarily cause
missed period

Cholecystitis
• Gall bladder
inflammation,
• usually 2o
to gallstones
(90% of cases)
• Risk factors
– Five Fs: Fat, Fertile,
Febrile, Fortyish,
Females
– Heredity, diet, BCP use

Acute Cholecystitis
• Biliary colic is the most common symptom
• Pain may radiate to the right shoulder or scapula
• The pain is colicky and is associated with nausea
and vomiting
• Murphy’s sign/acute abdomen
• Ultrasound/HIDA Scans

Cholecystitis
• Acalculus cholecystitis
– Burns
– Sepsis
– Diabetes
– Multiple organ systems failure
• Chronic cholecystitis (bacterial infection)

Acute Acalculous Cholecystitis
• Rare, 3% of all biliary procedures
• Life threatening – patients have comorbidities
• Mortality approaches 60%
• Late diagnosis = bad outcome
• Ultrasound/HIDA/DISIDA with CCK stimulation
• Percutaneous drainage vs OR

Cholecystitis
– Sudden pain, often severe, cramping
– RUQ, radiating to right shoulder
– Point tenderness under right costal margin
(Murphy’s sign)
– Nausea, vomiting
– Often associated with fatty food intake
– History of similar episodes in past
– May be relieved by nitroglycerin

T2W image with fat supression
Thick walled gallbladder with
multiple hypointense stones

Thick slice SSFSE coronal
image
Dilated intra- and extrahepatic biliary
dilatationwith a hypointense stone in the
distal common bile duct

T2 w FSE axial image with fat
suppression
Hypointense stone in the distal common bile duct

Suppurative cholecystitis (GB empyema)
Sucutaneous abscess drainage

Pancreatitis: History and Physical
• History:
– Boring pain in LUQ or epigastrium
– Constant
– Radiates to midback
• PE:
– Epigastric or LUQ tenderness
– Grey-Turner or Cullen sign

Acute Pancreatitis
• Onset is acute
• Abdomen is tender, but rarely has true peritoneal
signs
• Grey Turner’s sign, Cullen’s sign and Fox’s sign
are infrequently seen
• Serum amylase and lipase are the biochemical
hallmarks
• Ranson’s criteria is used to torture surgical
housestaff – APACHE Score

Gray-Turner sign
• Flank ecchymosis
• Intraperitoneal bleeding
• Hemorrhagic pancreatitis,
ruptured abdominal aorta,
or ruptured ectopic
pregnancy

Cullen's Sign
• Periumbilical hemorrhage

Pancreatitis
– Mid-epigastric pain radiating to back
– Often worsened by food, EtOH
– Bluish flank discoloration (Grey-Turner Sign)
– Bluish periumbilical discoloration (Cullen’s
Sign)
– Fever

Pancreatitis: Diagnosis
• Lipase – most specific
• Ranson’s criteria – predicts outcome
– Acutely: >55 yo, glucose > 200, WBC >16k, SGOT
(ALT) > 250, LDH > 350
– 48 hrs: HCT decreases > 10%, BUN rises > 5, Ca < 8,
pO2 < 60, base deficit >4, fluid sequestration > 6L
• 3-4 criteria – 15% mortality

Pancreatitis
• May lead to:
– Peritonitis
– Abscess
– Pseudocyst formation
– Hemorrhage
– Necrosis
– Secondary diabetes

Acute Pancreatitis
• Chest x-rays may show segmental atelectasis,
pleural effusions and an elevated left
hemidiaphragm
• KUB may show the sentinel loop and loss of the
psoas shadow
• CT scan with double contrast will show pancreatic
edema, retroperitoneal inflammation, and areas of
pancreatic necrosis

Pancreatitis: Treatment
• NPO, IVF, pain control, antiemetics
• Antibiotics if gallstones or septic
• Surgical consult
– If gallstones, abscess, hemorrhage or
pseudocyst
• ERCP if CBD stone

Pancreatitis : CTPancreatitis : CT

Perforated Ulcer
• Perforated ulcer requires immediate operative
therapy
• Anterior gastric perforations cause peritonitis
• Posterior gastric and duodenal perforations may
not cause peritonitis, and after the acute episode of
pain, the leak may wall off, giving the impression
that the patient is improving
• Tympany over the liver at the mid-axillary line is
almost always a perforated ulcer

Perforated Ulcer
• Free air (80% of perforated ulcers)
– Go to OR
• No free air, no peritonitis
– Go to CT scan with gastrograffin
• Subhepatic fluid collection
• Fluid in the lesser sac

Perforated UlcerPerforated Ulcer
•Diagnosis: upright CXRDiagnosis: upright CXR
•Air under the diaphragmAir under the diaphragm

Diverticulitis
• Diverticula
– Pouches in colon wall
– Typically in older
persons
– Usually asymptomatic
– Related to diets with
inadequate fiber

Diverticulitis
• Diverticula trap feces, become inflamed
• Occasionally result in bright red rectal bleeding
• Rupture may cause peritonitis, sepsis

Diverticulitis
– Usually left-sided pain
– May localize to LLQ (“left-sided appendicitis”)
– Alternating constipation, diarrhea
– Bright red blood in stool

Diverticulitis
• Patients may have antecedent history of thinning
bowel movements
• Patients may know they have “pockets”
• All colonic pain is hypogastric – so bandlike pain
across the lower abdomen is common
• Differential includes perforated colon cancer
• No endoscopy or contrast enemas in the acute
phase – CT Scan

Diverticulitis
CT Scan Diagnostic criteria
• Mild: Localized wall thickening (>5 mm),
pericolic fat inflammation
• Severe: abscess, extraluminal gas/contrast
Effectiveness
• Sensitivity: 93-97%
Cho 1990, Ambrosetti 1997

Diverticulitis
• Patients with peri-diverticular pain and no
peritoneal signs may be managed as outpatients
• Patients with localized peritonitis and no abscess
may be given a trial of IV Abx
• Abscesses should be percutaneously drained trans-
abdominally
• Generalized peritonitis is rare (2-24%), but requires
laparotomy
Gordon 1999

Diverticulitis
•Diagnosis: clinical, CT

Large bowel DiverticulitisLarge bowel Diverticulitis
Acute diverticulitis
Maximal in (L) colon
Presentation LIF pain,
fever, tenderness,
leukocytosis
Middle aged or elderly

Peritonitis
• Inflammation of abdominal cavity lining
– Generalized pain, tenderness
– Abdominal rigidity
– Absent bowel sounds
– Patient resistant to movement

I. Primary peritonitis
• 1. infected ascetic fluid e.g. spontaneous
bacterial peritonitis
• 2. Infected peritoneal dialysis catheter
• 3. Miscellaneous

Primary peritonitis
• Primary peritonitis;
• It is characterized by infection in the
peritoneal cavity without an obvious source
e.g. spontaneous bacterial peritonitis in liver
cirrhosis

II. Secondary peritonitis (rupture
vicus)
• 1. intraperitoneal:
• - Biliary tree source
• - GIT source
• - Female genital
• 2. Retroperitoneal
• - Pancreas
• - UT
• 3. Localized abscess:
• lesser sac, liver, subphrenic, pelvic, spleen,
periappedicular ,Paracoilc
• Retroperitoneal,
• 4. Trauma

Ileus
• Ileus refers to an inhibition of gastrointestinal
motility. It may be Physiologic, after abdominal
surgery or pathologic also called adynamic ileus
which is defined as the functional inhibition of
propulsive bowel activity, irrespective of
pathogenic mechanism. Postoperative paralytic
ileus refers to a postoperative ileus that lasts
longer than 3 days.
•

Ileus
• Ileus of the colon with sudden massive
dilatation is called acute colonic pseudo-
obstruction or Ogilvie’s syndrome. Toxic
megacolon is colonic ileus in which
inflammation involves all colonic tissue
layers and that results in systemic toxicity.
•

Pathophysiology;
• Impairment of intestinal blood flow can
lead to an ileus with change in bowel flora
due to stasis, over growth of bacteria and
malabsorption. Fluid inside the bowel
lumen increases because of intestinal
secretion plus a failure of absorption.
Intestinal gas also contributes to the
abdominal distention.

Intra-abdominal causes of
ilues:-
• 1.Infectious disorders
• Peritonitis
• Diverticulitis
• Cholecystitis
• Appendicitis
• Tubo-ovarian abscess
• 3.Inflammatory disorders
• Pancreatitis
• Perforated viscus
• Toxic megacolon
• Intraperitoneal bleeding
• Peritonitis
• Radiation

Intraabdominal causes of ileus
• 2.Ischemic disorders
• Local arterial insufficiency
• Local venous insufficiency
• Mesenteric arteritis
• Strangulated obstruction
• 4.Retroperitoneal disorders
• Nephrolithiais
• Pyelonephritis
• Hemorrhage

Extra-abdominal causes of Ileus:
• 1.Drug – induced
• Anticholinergic medication
• Opioids
• Chemotherapy
• Ganglion blocking agents
• 3. Metabolic disturbance
• Electrolyte abnormalities
• Sepsis
• Uremia
• Diabetic ketoacidosis
• Sickle cell anemia with painful crisis
• Hypothyroidism

Extraabdominal causes of ileus
• 2.Reflex inhibition
• Myocardial infarction
• Pneumonia
• Pulmonary embolus
• Burns
• Fractures of the pelvis ribs or spine

Inflammatory Bowel Disease
• Crohn’s Disease
– Acute exacerbation in patients with
undiagnosed ileocolic Crohn’s may be confused
with appendicitis
– Laparoscopy may help determine the diagnosis
– Isolated Crohn’s colitis accounts for 25% of all
Crohn’s disease

Crohn’s Disease
Operative Indications
• Colitis refractory to
medical therapy is the
most common cause for
urgent operation
• Persistent hemorrhage and
free perforation are rare

Ulcerative Colitis
• Disease Course
Proctitis:
• 50% pan-colitis; 12% colectomy
Left-sided colitis:
• 9% pan-colitis; 23% colectomy
Pan-colitis:
• 40% colectomy
Langholz 1996

Ulcerative Colitis
Disease Severity
Mild colitis: 20%
Moderate colitis: 71%
Severe colitis: 9%
Acute disease complications
Toxic colitis or megacolon
Perforation
Hemorrhage
Langholz 1991

Toxic Colitis
Subjective appearance
Objective criteria:
• Fever
• Tachycardia
• Leukocytosis
• Hypoalbuminemia
• Colonic diameter greater than 6cm on KUB
Toxic colitis may progress to toxic megacolon

Pelvic Pouch
Functional outcome
• Frequency: 5-7 stools/day
• Nocturnal seepage: 20-30%
• Medication: 30%
• Pouch loss: 9% (10 years)
Meagher 1998

Pelvic Pouch
Quality of Life
• SF 36: Comparable to general population
• HRQOL: Comparable to patients in remission
with mild disease
• HRQOL: Comparable to general population
Fazio 1998, Martin 1998, Thirlby 1998

Pelvic Pouch
Early complications
• Small bowel obstruction: 13%
• Pelvic sepsis: 5%
• Wound infection: 3%
• Sexual dysfunction: 2%
Pemberton 1991, Fazio 1995

Pelvic Pouch
Late complications
• Small bowel obstruction: 9%
• Anastomotic leak: 2%
• Anastomotic stricture: 5%
• Pouchitis: 31%
Pemberton 1991, Fazio 1995

SBO
• Etiology
– Adhesions (>50%)
– Incarcerated hernia
– Neoplasms
– Adynamic ileus – non mechanical
• Abd trauma (post op), infection, hypokalemia,
opiates, MI, scleroderma, hypothyroidism
– Rare: intusseception, bezoar, Crohn’s ds,
abscess, radiation enteritis

LBO
• Etiology
– Tumor  left = obstruct; right = bleeding
– Diverticulitis
– Volvulus
– Fecal impaction
– Foreign body

Small Bowel Obstruction
• History
– Prior surgery
– Hernias
– Colicky abdominal pain
– Nausea and vomiting
– Abdominal distension
– Rectal exam
• No peritoneal signs

Small Bowel Obstruction
• Diagnosis
– KUB and upright abdominal films
– 3cm is upper limit of small bowel diameter
• Partial SBO
– Colonic gas
– Small bowel series if needed
• Complete bowel obstruction
– Immediate laparotomy

SBO: Treatment
• IV fluids!
• Correct electrolyte abnormalities
• NPO/NGT
• Broad spectrum abx if peritonitis
• Surgery consult

Sigmoid VolvulusSigmoid Volvulus

Sigmoid Volvulus: Imaging and
Treatment
• AAS: dilated loop of colon on left
• Barium enema: “bird’s beak”
• WBC > 20k: suggests strangulation
• CT scan
• Treatment: IVF, surgical consult, abx if
suspect perforation

Cecal volvulus
• Most common in 25-35 year olds
• No underlying chronic constipation
• History: Severe, colicky abd pain,
vomiting
• PE: Diffusely tender abdomen,
distension

Cecal Volvulus
• KUB: coffee bean – large
dilated loop colon in
midabdomen, empty
distal bowel
• Tx: surgery
– Mortality: 10-15% if
bowel viable; 30-40% if
gangrene

Large Bowel Obstruction
• Greater than 50% are malignant
– Colorectal cancer is usually the primary
– Volvulus and intussuception are other causes
– Gradual onset
– Pain is not colicky
– Vomiting is rare
• Patients with competent ileocecal valves are at
highest risk of perforation

Large Bowel Obstruction
• Diagnostic x-rays
– Obstruction vs ileus
• Rectal exam and rigid proctoscopy
– Rigid proctoscopy will detorse sigmoid volvulus
• Gastrograffin enema
• Cecal volvulus requires laparotomy

Sigmoid Volvulus
• History:
– Elderly, bedridden, psychiatric pts
– Crampy lower abd pain, vomiting, dehydration,
obstipation
– Prior h/o constipation
• PE:
– Diffuse abd tenderness
– Distension

Hernias
• Inguinal (most common) 75%
– Indirect 50% vs direct 25% men > women, high risk
incarceration in kids
• Femoral 5% - women > men
• Incisional 10%
• Umbilical – newborns, women > men
• Incarcerated – unable to reduce
• Strangulated – incarcerated with vascular
compromise

Hernias
• Clinical presentation:
– Most are asymptomatic
– Leads to SBO sxs
– Peritonitis and shock – if strangulation
• Treatment:
– Reduce if non-tender – trendelenberg, sedation,
warm compresses
– Do not reduce if possible dead bowel
– Admit via OR if strangulation

Mesenteric Ischemia
• Etiology
– 50% arterial emboli
– 20% non-occlusive dz (CHF, sepsis, shock)
– 15% arterial thrombi
– 5% venous occlusion
• Mortality rates 70-90% - delayed dx

Mesenteric Ischemia
• Pathophysiology: impaired blood supply from
SMA, IMA, celiac trunk  adynamic ileus 
mucosal infarction & 3rd
spacing  bacterial
invasion  sepsis  shock
• History: Acute, severe, colicky, poorly
localized pain, postprandial pain, N/V/D

Small IntestineSmall Intestine
Mesenteric infarct
Sudden occlusion of small
bowel arterial supply
Sudden onset of abdominal pain, shock
Peritonitis
Treatment
resuscitate/operate

Vascular Emergencies
• Acute Mesenteric Occlusion
– Embolic vs thrombotic
– Look for embolic source
– Acute onset of pain
– Pain out of proportion to exam
– High index of suspicion
– A-gram

Treatment of Acute SMA
Occlusion
• High index of suspicion
• Arteriogram
• Medical therapy
– Papavarin
– Heparin
• Surgical intervention

• Nonocclusive Mesenteric Ischemia
– Arterial constriction secondary to low cardiac
output, hypovolemia, vasoconstrictors
– Usually ICU patients
– Usually no peritonitis
– Flexible sigmoidoscopy is the first test
– Angiography may be diagnostic and therapeutic

• Abdominal Aortic Aneurysms
– Acute onset of back/flank/abdominal pain
– Palpable pulsatile mass
– Not associated with nausea or vomiting
– Rupture with hemodynamic instability - -OR
– No shock, unclear etiology – CT scan

Aortic Aneurysm
• Localized dilation due to weakening of aortic wall
• Usually older patient with history of hypertension,
atherosclerosis
• May occur in younger patients secondary to
– Trauma
– Marfan’s syndrome

Aortic Aneurysm
• Usually just above
aortic bifurcation
• May extend to one
or both iliac arteries

Aortic Aneurysm
– Unilateral lower quadrant pain; low back or leg
pain
– May be described as tearing or ripping
– Pulsatile palpable mass usually above
umbilicus
– Diminished pulses in lower extremities
– Unexplained syncope, often after BM
– Evidence of hypovolemic shock

Mesenteric Ischemia: Diagnosis
• Pain out of proportion to exam!
• Heme positive stools (>50%) – may present
as LGIB
• Peritonitis and shock – late findings
• WBC > 15k
• Metabolic acidosis (lactic acid) – high
sensitivity, not specific

Mesenteric Ischemia: Diagnosis
and Treatment
• CT scan
– Bowel wall edema/gas, +/- mesenteric thrombus,
normal CT does NOT rule out
• Plain films – late findings
– Portal venous gas or pneumatosis intestinalis
• Treatment: IVF, NGT, IV abx, surgical
and IR consult

Gynecologic Diseases
• Menstrual and sexual histories are mandatory
• Pregnancy test is mandatory
• Pelvic pain often mimics appendicitis
– Mittelschmerz
– Pelvic Inflammatory Disease
– Ruptured ectopic pregnancy
– Adnexal torsion

Urinary Tract Disease
• Renal colic
– Patients are often writhing in pain and cannot get
comfortable
• Diagnostic Tests
– UA
– KUB
– IVP
– CT

Other Causes
• Sickle Cell Anemia
– Acute onset of abdominal pain
– Diffuse pain
– Unremarkable physical exam
– May have peritoneal signs
• Acute Porphyria
– Noninflamed blisters and erosions
– Crampy abdominal pain with projectile vomiting
– Migrating pain
– Mimics peritonitis

When NOT to Operate ?
• Cholangitis
• Appendiceal abscess
• Acute diverticulitis + abscess
• Acute pancreatitis or hepatitis
• Ruptured ovarian cysts
• Long standing perforated ulcers?

Acute Abdominal Pain Diagnosis

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