Transcript ACUTE ABDOMINAL PAIN - Dr.Abdul.Kader WEISS

ACUTE ABDOMINAL PAIN
Abdul.Kader WEISS M.D
CHIRURGIE GENERALE ET VISCERALE /CHIRURGIE COELIOSCOPIQUE
D.E.S , A.F.S , A.F.S.A , DU / FRANCE
Reference :
Editors: Li Ern Chen , Timothy G. Buchman
Title: Washington Manual of Surgery, The 5th Edition
2008 Lippincott Williams & Wilkins
ACUTE ABDOMINAL PAIN
• DEFINITIONS
– Acute abdominal pain is the most common
general surgical problem presenting to the
emergency department.
– ACUTE ABDOMEN IS DEFINED AS A RECENT OR
SUDDEN ONSET OF ABDOMINAL PAIN.
– This can be new pain or an increase in chronic
pain.
– The differential diagnosis includes both intraand extraperitoneal processes.
– The acute abdomen does not always signify the
need for surgical intervention; however, surgical
evaluation is warranted.
KEY POINTS
• The level of abdominal pain generally relates to the origin: foregut- upper,
midgut-middle, hindgut-lower.
• Generally, colicky (visceral) pain is caused by stretching or contracting a
hollow viscus (e.g. gallbladder, ureter, ileum).
• Generally, constant localized (somatic) pain is caused by peritoneal
irritation and indicates the presence of inflammation/infection (e.g.
pancreatitis, cholecystitis, appendicitis).
• Associated back pain suggests retroperitoneal pathology (aortic aneurysm,
pancreatitis, posterior DU, pyelonephritis).
• Associated sacral or perineal pain suggests pelvic pathology (ovarian cyst,
PID, pelvic abscess).
• Generally, very severe pain indicates ischaemia or generalized
peritonitis (e.g. mesenteric infarction, perforated duodenal ulcer).
• PAIN OUT OF PROPORTION TO THE PHYSICAL SIGNS SUGGESTS
ISCHAEMIA WITHOUT PERFORATION.
• REMEMBER REFERRED CAUSES OF PAIN: PNEUMONIA (RIGHT LOWER
LOBE), MYOCARDIAL INFARCTION, LUMBAR NERVE ROOT PATHOLOGY.
ABDOMINAL TOPOGRAPHY
ABDOMINAL TOPOGRAPHY
PATHOPHYSIOLOGY
• The abdomen is analogous to a box.
• Although this chapter focuses on pathophysiology
inside the box, one must be cognizant of the fact that
pathology on the surface of the box (e.g., rectus sheath
hematoma) or even outside the box (e.g., testicular torsion) can
present as abdominal pain.
• Abdominal pain arising from intra-abdominal
pathophysiology originates in the peritoneum, which is
a membrane comprising two layers.
• These layers, the visceral and parietal peritoneum, are
developmentally distinct areas with separate nerve
supplies.
VISCERAL PAIN
• Visceral peritoneum is innervated bilaterally by
the autonomic nervous system.
• The bilateral innervation causes visceral pain to
be midline, vague, deep, dull, and poorly
localized (e.g., vague periumbilical pain of the midgut).
• Visceral pain is triggered by inflammation,
ischemia, and geometric changes such as
distention, traction, and pressure.
• Visceral pain signifies intra-abdominal disease but
not necessarily the need for surgical intervention.
PARIETAL PAIN
• Parietal peritoneum is innervated unilaterally via the spinal
somatic nerves that also supply the abdominal wall.
• Unilateral innervation causes parietal pain to localize to one
or more abdominal quadrants (e.g., inflamed appendix
producing parietal peritoneal irritation).
• Parietal pain is sharp, severe, and well localized.
• Parietal pain is triggered by irritation of the parietal
peritoneum by an inflammatory process (e.g., chemical
peritonitis from perforated peptic ulcer or bacterial peritonitis from
acute appendicitis).
• It may also be triggered by mechanical stimulation, such as
a surgical incision.
• Parietal pain is associated with physical examination
findings of local or diffuse peritonitis and frequently
signifies the need for surgical treatment.
EMBRYOLOGIC ORIGIN
• Embryologic origin of the affected organ
determines the location of visceral pain in the
abdominal midline.
1. Foregut-derived structures (stomach to the second
portion of the duodenum, liver and biliary tract,
pancreas, spleen) present with epigastric pain.
2. Midgut-derived structures (second portion of the
duodenum to the proximal two thirds of the
transverse colon) present with periumbilical pain.
3. Hindgut-derived structures (distal transverse colon
to the anal verge) present with suprapubic pain.
REFERRED PAIN
• Referred pain arises from a deep visceral
structure but is superficial at the presenting
site .
1. It results from central neural pathways that are
common to the somatic nerves and visceral
organs.
2. Examples include biliary tract pain (referred to
the right inferior scapular area) and
diaphragmatic irritation from any source, such as
subphrenic abscess (referred to the ipsilateral
shoulder).
REFERRED PAIN
Solid circles are primary or most
intense sites of pain
Solid circles are primary or most
intense sites of pain
EVALUATION
• Evaluation of the acute abdomen remains
heavily influenced by patient history and
physical exam findings.
• Ancillary imaging and lab tests can help to
complete the diagnosis and guide treatment
decisions.
EVALUATION
A. HISTORY OF PRESENT ILLNESS
B. PAST MEDICAL HISTORY, SURGICAL HISTORY,
AND ORGAN-SYSTEM REVIEW.
C. MEDICATIONS
D. PHYSICAL EXAMINATION
E. LABORATORY EVALUATION
F. RADIOLOGIC EVALUATION
A.
HISTORY OF PRESENT ILLNESS
1.
ONSET AND DURATION OF PAIN
1.
2.
Sudden onset of pain (within seconds) suggests perforation or rupture [e.g., perforated peptic ulcer ].
Rapidly accelerating pain (within minutes) may result from several sources , such as colic syndromes, [
e.g. biliary colic ] , Inflammatory processes [ e.g. acute appendicitis ] ,Ischemic processes [ e.g.
mesenteric ischemia ] .
3.
Gradual onset of pain (over several hours) increasing in intensity may be caused by one of the following:
I.
II.
2.
CHARACTER OF PAIN
1.
2.
3.
3.
Colicky pain waxes and wanes. It usually occurs secondary to hyperperistalsis of smooth muscle against
a mechanical site of obstruction (e.g., small-bowel obstruction, renal stone).
An important exception is biliary colic, in which pain tends to be constant.
Pain that is sharp, severe, persistent, and steadily increases in intensity over time suggests an
infectious or inflammatory process (e.g., appendicitis).
LOCATION OF PAIN
1.
2.
4.
5.
Inflammatory conditions, such as appendicitis and cholecystitis.
Obstructive processes, such as nonstrangulated bowel obstruction and urinary retention.
Pain caused by inflammation of specific organs may be localized [e.g., right-upper-quadrant (RUQ) pain
caused by acute cholecystitis].
Careful attention must be given to the radiation of pain. The pain of renal colic, for example, may begin
in the patient's back or flank and radiate to the ipsilateral groin, whereas the pain of a ruptured aortic
aneurysm or pancreatitis may radiate to the patient's back.
ALLEVIATING AND AGGRAVATING FACTORS
ASSOCIATED SYMPTOMS
1.
2.
3.
Nausea and vomiting frequently accompany abdominal pain and may hint at its etiology. Vomiting that
occurs after the onset of pain may suggest appendicitis, whereas vomiting before the onset of pain is
more consistent with the diagnosis of gastroenteritis or food poisoning.
Fever or chills suggests an inflammatory or an infectious process, or both.
Anorexia is present in the vast majority of patients with acute peritonitis.
CHARACTER OF PAIN
GRADUAL, PROGRESSIVE PAIN
COLICKY, CRAMPY, INTERMITTENT PAIN
SUDDEN, SEVERE PAIN
CHARACTER OF PAIN
B. PAST MEDICAL HISTORY, SURGICAL HISTORY, AND ORGAN-SYSTEM REVIEW
1.
Pathologic medical conditions may precipitate intra-abdominal pathology.
I.
II.
III.
2.
A thorough medical history and organ-system review must be carried out to
exclude various extra-abdominal causes of abdominal pain.
I.
II.
3.
Diabetic patients or patients with known coronary artery disease or peripheral vascular
disease who present with vague epigastric symptoms may have myocardial ischemia as
the cause of the abdominal symptoms.
Right-lower-lobe pneumonia may present as RUQ pain in association with cough and
fever.
A thorough menstrual history must be obtained in women.
I.
II.
III.
4.
Patients with peripheral vascular disease or coronary artery disease may have
abdominal vascular disease (e.g., AAA or mesenteric ischemia).
Patients with a history of cancer may present with bowel obstruction from recurrence.
Major medical problems are important to recognize early in the patient and may call
for urgent surgical exploration.
Pelvic inflammatory disease (PID) typically occurs early in the cycle and may be
associated with a vaginal discharge.
Ectopic pregnancy must be considered in every woman of child-bearing age with lower
abdominal pain, especially if accompanied by a history of amenorrhea.
Abdominal pain that occurs monthly suggests endometriosis.
Previous abdominal surgery in a patient with colicky abdominal pain may suggest
intestinal obstruction secondary to adhesions, incarceration of an incisional
hernia, or recurrence or malignancy.
These are generally accompanied by nausea and vomiting.
C. MEDICATIONS
– NONSTEROIDAL ANTI-INFLAMMATORY MEDICATIONS, such as aspirin or
ibuprofen, place patients at risk for the complications of peptic ulcer disease,
including bleeding, obstruction, and perforation.
– CORTICOSTEROIDS may mask classic signs of inflammation, such as fever and
peritoneal irritation, making the abdominal examination less reliable.
– ANTIBIOTICS consumed by patients may aid or hinder diagnosis.
• Patients with peritonitis may have decreased pain.
• Patients who have diarrhea and abdominal pain may have antibioticinduced pseudomembranous colitis caused by Clostridium difficile.
• Be aware of the elderly patient on immunosuppressants or antibiotics.
D. PHYSICAL EXAMINATION
1.
2.
3.
OVERALL APPEARANCE SHOULD BE ASSESSED (e.g. jaundice )
VITAL SIGNS are important indicators of a patient's overall condition ( Bp , P , T ) .
THE ABDOMINAL EXAMINATION should be carried out thoroughly and
systematically.
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
INSPECTION ( distention, surgical scars, bulging masses, and areas of erythema ).
AUSCULTATION ( high-pitched, tinkling bowel sounds of obstruction , absence of sounds due to ileus
from diffuse peritonitis ).
PERCUSSION ( tympanitic sounds of distended bowel in intestinal obstruction , fluid wave that is
characteristic of ascites ).
PALPATION of the patient's abdomen should be performed with the patient in a supine position and
with his or her knees flexed, if necessary, to relieve pain.
RECTAL EXAMINATION should be performed routinely in all patients with abdominal pain.
1.
Tenderness or a mass on the right pelvic side wall is sometimes seen in appendicitis.
2.
A mass in the rectum may indicate obstructing cancer.
3.
The presence of occult blood in the stool specimen may indicate GI bleeding from peptic ulcer
disease.
PELVIC EXAMINATION must be performed in all women of child-bearing age who present with lower
abdominal pain.
TESTICULAR AND SCROTAL EXAMINATION is essential in all males who complain of abdominal pain (
Testicular torsion , Epididymitis ) .
SPECIFIC PHYSICAL EXAMINATION findings should be sought in the appropriate clinical setting.
1.
Murphy's sign is inspiratory arrest while continuous pressure is maintained in the RUQ , seen
in acute cholecystitis .
2.
Rovsing's seen in acute appendicitis. Indicative of an inflammatory process in the right lower
quadrant (RLQ), Rovsing's sign is RLQ pain resulting from percussion in the left lower quadrant
(LLQ).
E. LABORATORY EVALUATION
1.
A complete blood count with cell count differential
A.
B.
2.
An electrolyte profile may reveal clues to the patient's overall condition.
A.
B.
3.
B.
Serum lactate is an indicator of tissue hypoxia.
Mild lactic acidosis may be seen in patients with arterial hypotension.
Urinalysis is helpful in assessing urologic causes of abdominal pain.
A.
B.
7.
Mild degrees of hyperamylasemia may be seen in several situations, such as intestinal obstruction.
Elevation of lipase usually indicates pancreatic parenchymal damage.
Lactic acid level may be obtained when considering intestinal ischemia.
A.
B.
6.
A mild elevation of transaminases (<2 times normal), alkaline phosphatase, and total bilirubin is
sometimes seen in patients with acute cholecystitis.
A moderate elevation of transaminases (>3 times normal) in the patient with acute onset of RUQ
pain is most likely due to a common bile duct (CBD) stone.
Pancreatic enzymes (amylase and lipase) should be measured if the
diagnosis of pancreatitis is considered.
A.
B.
5.
Hypokalemic, hypochloremic, metabolic alkalosis may be seen in patients with prolonged vomiting
and severe volume depletion.
Elevation of the blood urea nitrogen or creatinine is also indicative of volume depletion.
Liver enzyme levels may be obtained in the appropriate clinical setting.
A.
4.
White blood cell (WBC) count elevation may indicate the presence of an infectious source.
Hematocrit elevation may be due to volume contraction from dehydration. Conversely, a low
hematocrit may be due to occult blood loss.
Bacteriuria, pyuria, and a positive leukocyte esterase usually suggest a urinary tract infection (UTI).
Hematuria is seen in nephrolithiasis and renal and urothelial cancer.
β-Human chorionic gonadotropin must be obtained in any woman of childbearing age. A positive urine result should be quantitated by serum levels.
F. RADIOLOGIC EVALUATION :
its use should be very selective to avoid unnecessary cost and possible morbidity associated
with some modalities.
1. Plain abdominal x-rays often serve as the initial radiologic evaluation. X-rays should
be obtained in the supine and erect positions.
2. Ultrasonography (US) may provide diagnostic information in some conditions.
Ultrasound is portable, relatively inexpensive, and free of radiation exposure. US
visibility is limited in settings of obesity, bowel gas, and subcutaneous air.
I.
II.
3.
Contrast studies, although rarely indicated in the acute setting, may be helpful in
some situations.
I.
II.
4.
5.
In most instances, a water-soluble contrast agent (e.g., Hypaque) should be used to avoid possible
barium peritonitis in the event of bowel perforation.
Contrast enema is particularly useful in differentiating adynamic ileus from distal colonic
obstruction.
Computed tomographic (CT) scanning may provide a thorough evaluation of the
patient's abdomen and pelvis relatively quickly. Oral and intravenous contrast
should be administered if not specifically contraindicated by allergy, renal
insufficiency, or patient hemodynamic instability. CT scanning is the best
radiographic study in the patient with unexplained abdominal pain.
Magnetic resonance imaging (MRI)
I.
II.
III.
6.
RUQ US is particularly useful in biliary tract disease.
US can be used in the evaluation of RLQ pain.
MRI provides cross-sectional imaging while avoiding ionizing radiation.
Image acquisition takes longer than for CT scan; patients must be able to lie on their backs for a
prolonged period of time and cannot be claustrophobic.
MRI has its greatest application in pregnant women with acute abdominal and pelvic pain .
Radionuclide imaging studies have few indications in the acute setting.
DIFFERENTIAL DIAGNOSIS FOR ACUTE
ABDOMINAL PAIN
Upper abdominal
Mid and lower abdominal
Perforated peptic ulcer , Acute cholecystitis
Acute pancreatitis
Acute diverticulitis , Intestinal obstruction
Other
OB/GYN
Acute appendicitis , Mesenteric ischemia
Ruptured AAA
PID , Ectopic pregnancy , Ruptured ovarian cyst
Urological
Nephrolithiasis , Pyelonephritis/cystitis
Nonsurgical
Acute MI , Gastroenteritis , Pneumonia
THANK YOU
Abdul.Kader WEISS M.D 2010