1. Acute Abdominal Pain Ashley Esdaile MSIII Byron Baptist MSIII Mike Pothen MS III

3. OVERVIEW • Acute abdomen • Recent or sudden onset of abdominal pain • Either new pain, or increase in chronic pain • Pain of less than 1 week duration

4. Can be divided into 3 categories: • visceral • parietal • referred

5. Visceral pain • Visceral peritoneum • Innervated bilaterally by ANS • Described as midline, vague, deep, dull, poorly localized • Triggered by inflammation, ischemia, geometric changes (ie distension, pressure)

6. Parietal pain • Innervated unilaterally via the spinal somatic nerves (also supply abd wall) • Pain well localized, sharp, severe • Triggered by irritation of parietal peritoneum (ie chemical peritonitis from perforated peptic ulcer or bacterial peritonitis)

7. Referred pain • From deep visceral structure but superficial at presenting site • Central neural pathways common to somatic nerves and visceral organs • i.e. biliary tract pain – refer to R. inf scapular area; diaphragmatic irritation to ipsilateral shoulder

8. Pain in relation to embryologic origin • Foregut organs (stomach, duodenum and biliary tract) produce pain in the epigastric region • Midgut organs (most small bowel, appendix, cecum) produce periumbilical pain • Hindgut organs (most of colon, including sigmoid) and intraperitoneal portions of the genitourinary tract cause pain in the suprapubic or hypogastric area • Intraperitoneal visceral pain in felt in the midline because these organs have bilateral innervation

10. Classification of abdominal pain • 1. Intraabdominal • 2. Extraabdominal

11. Intrabdominal • GI • GU • GYN • Vascular

12. Extrabdominal • Cardiopulmonary • Abdominal wall • Toxic-metabolic • Neurogenic

13. HISTORY • SUDDEN ONSET OF PAIN (SECONDS) • Perforated peptic ulcer • Ruptured abdominal aortic aneurysm • Infarction (MI or acute mesenteric occlusion)

14. HISTORY • RAPIDLY ACCLERATING PAIN (WITHIN MINUTES) • COLIC SYNDROMES • Biliary colic, ureteral colic, small bowel obstruction • INFLAMMATORY PROCESSES • Appendicitis, pancreatitis, diverticulitis • ISCHEMIC PROCESSES • Mesenteric ischemia, strangulated intestinal obstruction, volvulus

15. HISTORY • GRADUAL ONSET OF PAIN (SEVERAL HOURS) • INFLAMMATORY CONDITIONS • Appendicitis, cholecystitis • OBSTRUCTIVE PROCESSES • Nonstrangulated bowel obstruction, urinary retention

16. Case 1 RUQ

18. From usmleworld qbank 2007

19. Differentials Diagnosis??

20. Differential Diagnoses • Abdominal aortic aneurysm • Acute mesenteric ischemia • Amebic hepatic abscesses • Appendicitis • Biliary colic • Biliary disease • Cholangiocarcinoma • Cholangitis • Choledocholithiasis • Cholelithiasis • GB Cancer • GB mucocele • Gastric Ulcers • Gastritis, Acute • Gastroesophageal Reflux Disease • Hepatitis, Viral • Myocardial Infarction • Nephrolithiasis • Pancreatitis, Acute • Peptic Ulcer Disease • RLL Pneumonia • Pregnancy and Urolithiasis • Pyelonephritis, Acute • Renal Disease • Renal Vein Thrombosis

21. ACUTE CHOLECYSTITIS • Inflammation of GB commonly caused by gallstone obstruction (90%) • Choice B – infection of GB present in 50-70% acute cholecystitis cases secondary to gallstone impaction in cystic duct • Patho: • Stone obstructs  eat fatty food  stimulate GB to contract  colicky pain  stasis  bacterial overgrowth  inflammation  gangrene/ perforation/ peritonitis

22. ACUTE CHOLECYSTITIS • S/Sx: • epigastric or RUQ pain • nausea and emesis 4-6 hrs after meal • Murphy’s sign • May radiate to right scapula • Labs: leukocystosis, slight elevation of liver enzymes, increased bilirubin

23. ACUTE CHOLECYSTITIS • RADIOLOGY: • UTZ – shows gallstones, gallbladder thickening, pericholecystic fluid, sonographic Murphy’s sign • TREATMENT: • Supportive: NPO, IV antibiotics, IV hydration, pain medication • Laparoscopic cholecystectomy – consider if perforation or gangrene

24. http://sites.google.com/site/drjoea/calculi-multiple-1e.jpg

25. Other RUQ differentials • Ascending Cholangitis • Infection of bile ducts secondary to ductal obstruction • Life threatening • S/Sx: • Charcot’s triad: jaundice, fever, RUQ tenderness • Reynold’s pentad: add hypotension and mental status change

26. Ascending Cholangitis • Labs • Leukocytosis, increased bilirubin, increased ALP, increased LFTs, blood cultures positive • UTZ and CT • Biliary duct dilatation from obstructing gallstones • Tx • Initially supportive: hydration and IV antibiotics • If no response: ERCP or PTC for emergency bile duct decompression

27. Biliary colic • Most common presentation of symptomatic cholelithiasis • S/Sx: constant RUQ pain to epigastric • Exception to “colicky pain” which typically waxes and wanes due to hyperpreristalsis of smooth muscle against mechanical site of obstruction • UTZ: gallstones but no GB wall thickening or pericholecystic fluid

28. http://emedicine.medscape.com/article/171256-overview

29. CHOLEDOCHOLITHIASIS • Stone in the common bile duct • s/sx: RUQ pain worse with fatty meals, juandice • UTZ: common bile duct dilatation • Labs: increase LFTs, increase bilirubin

30. Intraoperative cholangiogram showing stone in distal CBD. http://emedicine.medscape.com/article/172216-overview

31. Case 2– Epigastric region From usmleworld qbank 2007

33. explanation From usmleworld qbank 2007

34. Some Differentials for Epigastric region • Pancreatitis • Ruptured Abdominal Aortic Aneurysm • Perforated Peptic Ulcer • GERD • MI • Gastroenteritis

35. Acute Pancreatitis • MCC – alcohol and gallstones • S/Sx: severe epigastric pain radiating to patient’s back, N/V, and varying degrees of tachycardia, fever, hypotension (signs of hypovolemia due to “third spacing,” decreased bowel sounds • Hemorrhagic pancreatitis • Grey turner’s sign – ecchymotic appearing skin findings in flank; Cullen’s sign – skin findings around periumbilical area

36. Acute Pancreatitis • Labs  leukocytosis, increase serum amylase and lipase • X-ray: dilated small bowel or transverse colon adjacent to the pancreas called “sentinal loop” • CT  phlegmon, pseudocyst, necrosis, abscess • Tx: IV hydration, NPO, pain control

37. Ruptured AAA • Sudden onset of abdominal pain, radiating to flank, back or both • may present as shock (hypotension) • Exam findings possible palpable pulsatile abdominal mass • Plain Xray – may find calcification in aortic wall; CT scan gold standard (if pt hemodynamically stable) • If hypotension + known aneurysm  OR

38. PERFORATED PEPTIC ULCER • Duodenal more common than gastric • Ass. w/ chronic NSAID use • Sudden onset severe epigastric pain that progresses to peritonitis • PE remarkable for diffuse abdominal tenderness, rigidity, and peritoneal signs • Plain XR may reveal free intraperitoneal air

39. Chest radiograph. Free gas under the diaphragm caused by a perforated duodenal ulcer http://emedicine.medscape.com/article/367878-imaging&usg

40. Clinical Vignette – Case 3 • HPI: A 21 year old African American female presents to the ER with the sudden onset of acute abdominal pain. The patient says that the pain began suddenly while she was sitting at home watching television. She localizes the source of the pain to the RLQ and describes it as sharp and continuous with no radiation to any other part of her body. She rates the severity a 10/10 and denies any aggravating or alleviating factors. She says that the pain was so severe it caused her to vomit twice and she currently feels nauseas. She says that she had noticed some crampy abdominal discomfort 2 days prior but attributed it to her getting her period soon. She denies having ever experienced this type of pain in the past.

41. PMHx: Chlamydia 2009, no chronic illness • PSHx: None • FHx: HTN (both parents), DMII (father), MI (mother) • SocHx: She is a college student and lives with a roommate. She is currently sexually active with one male partner and uses condoms occasionally. She has had five sexual partners in her life. She drinks alcohol socially and denies smoking tobacco or doing any drugs.

42. Meds: None • Allergies: NKDA

43. ROS • Gen: patient feels weak and tired. • HEENT: nml • CVA: nml • Resp: nml • GI: she has vomited twice and feels nauseas. • GU: nml • Genital: G0P0; 11/28/5 regular flow; LMP 4/29/10; uses condoms irregularly, no other form of birth control; Chlamydia ‘09, took doxycycline for 2 days • Hematologic: nml • Psych: nml

44. Physical Exam • Gen: The patient is in extreme pain • Vitals: BP 90/63 R 20 P 54 T 97.8 SaO2 98% • CVA: S1S2 present, no murmurs heard, bradycardia. • Resp: Lungs clear, no wheezing/crackles/rales. • Abd: soft and tender in RLQ, guarding present. • GU: right adnexal mass palpated, cervical motion tenderness present. Vaginal bleeding present.

45. Differentials

46. Differentials • Ectopic pregnancy • Appendicitis • Ovarian torsion • Salpingitis/tubo-ovarian abscess • Endometriosis • Yersinia enterocolitis

47. Appendicitis • RLQ pain or tenderness at first diffuse then migrates to McBurney’s point • Fever • Diarrhea • PE: rectal exam to check for retroperitoneal appendicitis • Labs: high leukocyte count, fecalith present on abd CT or x ray

48. Ovarian torsion • Acute, sharp unilateral abd pain that may be intermittent • Pain is related to change in position • Nausea • Fever • Tender adnexal mass • Confirm via ultrasound and laparoscopy

49. Salpingitis/tubo-ovarian abscess • Constant to crampy or sharp to dull, lower abd pain • Purulent vaginal discharge • Cervical motion tenderness • Adnexal mass • Wet mount: WBCs, endocervical culture positive for N. gonorrhoeae or Chlamydia • Confirm via ultrasound, CT can rule out appendicitis

50. Endometriosis • Gradual or sudden onset of lower abd pain • History of dysmenorrhea or cyclic attacks of pain in lower abd • More painful with menses • Dyspareunia, dyschezia • Mild pain: analgesics and referral to OB/GYN • Severe pain: hospitalization and possible surgery