Abdomen Pain
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ACUTE ABDOMINAL PAIN EMERGENCY CENTER FIRST AFFILIATED HOSPITAL ZHENGZHOU UNIVERSITY
Definition of pain • “An unpleasant sensory and
emotional experience associated with either actual or potential tissue damage, or described in terms of such damage” ---- International Association for the Study of Pain
Acute abdominal pain comprises about one-third of the surgical problems.Of patients presenting with abdominal pain, approximately 15% to 30% will require a surgical procedure. The most common diagnosis made in patients with acute abdominal pain is nonspecific abdominal pain for which no organic disease can be found after an extensive work-up.
Gastroenteritis is the second most common diagnosis, followed by pelvic inflammatory disease 、 urinary tract disease 、 appendicitis 、 cholecystitis, and bowel obstruction. Appendicitis is the most common surgical diagnosis. Cholecystitis, bowel obstruction 、 perforated ulcer 、 and pancreatitis are common causes of surgical abdominal pain in descending order of frequency.
Neuroanatomy of Pain Transmission
The diagnosis of abdominal pain is aided by an understanding of the anatomy and physiology of the peritoneum , the intra-abdominal viscera , and the neural pain pathways.
Classification – Visceral pain – Somatic pain – Referred pain
Visceral pain The receptors located in the visceral peritoneum surrounding hollow organs and the capsules of solid organs. Distention or ischemia of the abdominal organs stimulates these receptors. Most visceral pain is midline in nature.(Because these organs are simultaneously innervated from both sides of the spinal column .)
Visceral pain dull, crampy, and localized(Because visceral pain
poorly
fibers are bilateral and unmyelinated and enter the spinal cord at multiple levels). It is often
associated with“ visceral” symptoms such as nausea, vomiting, and diaphoresis. It usually cannot be localized to a certain organ.
Somatic pain The pain receptors located in the parietal peritoneum and the roots of the mesentery. This type of pain is more sharp, and localized.(because Pain produced by ischemia, inflammation or stretch of the parietal peritoneum is transmitted through myelinated afferent fibers to specific dorsal roots ganglia on the same side and at the same dermatomal level as the origin of the pain) .
It is responsible for the physical finding of tenderness to palpation, guarding, and rebound . The finding of somatic pain often allows anatomic localization of pain to a specific organ. Given somatic tenderness in a certain quadrant, the differential diagnosis can be narrowed down solely by anatomic localization of organ.
Referred pain The pain that is felt at a cutaneous site distant from the disease organ. For instance, visceral afferents from the diaphragm enter the spinal cord at C3C5. Pain from the diaphragm is thus referred to the cutaneous distribution of C3-C5 the lateral neck and posterior shoulder.
Because the lungs and abdomen share the T9(thoracic nerve 9) dermatome distribution, pulmonary processes such as pneumonia and pulmonary embolus can be perceived as abdominal pain. Pelvic and inguinal structures innervated by T11 and T12 can cause referred pain to the lower abdomen.
DATA GATHERING
Key Notes in Interviewing of Pain
• Sites • Character • Causes • Duration • Radiation • Accompanied symptoms • Relaxing factors
Despite all technologic advances, the history and physical examination remain the most important tools in the initial assessment of a patient who complains of abdominal pain. Although critically ill patient may be more difficult to evaluate, the data from their history and physical examination are paramount, as this information either determines a definitive diagnosis or directs further evaluation.
Pain History
Onset. Rapid onset of severe pain is more consistent with a vascular catastrophe, rupture of a viscus, ectopic pregnancy. Slower, insidious onset is more typical of an inflammatory process such as appendicitis or cholecystitis.
Pattern of Change Pain that is steadily increasing in intensity is more likely to need surgical intervention.
Character of Pain Pain that is dull, burning is more likely to be visceral than somatic. Pain that is sharp or stabbing is more likely to be peritoneal or somatic in nature. Crampy pain is classically associated with obstruction of a viscu.
Severity The patient’s quantification of pain is notoriously unreliable. In general nonspecific abdominal pain is less severe than pain from surgical causes, but there is considerable individual variation. Severe pain out of proportion to physical findings is classical for mesenteric ischemia or pancreatitis.
Location The location of abdominal pain can vary with time, especially as the pain progresses from a visceral to a somatic origin. Periumbilical pain that migrates to the right lower quadrant is classic for appendicitis. Epigastric pain that eventually localized during a period of several hours to the right upper quadrant is characteristic of cholecystitis.
Common Diseases Acute appendicitis – Pain is initially localized around the umbilicus (visceral pain) and is vague; As the inflammatory response progresses to involve the parietal peritoneum, the main site of pain shifts to the right iliac fossa (parietal or somatic pain) – Usually accompanied by fever
Acute Cholecystitis • Paroxysmal right
hypochondrium pain
• Accompanied by fever sometimes
• Paroxysmal pain in right infrascapular area
Acute Gastric Perforation • Outburst acute severe lancinating pain in umbilical region or epigastrium
Acute ileus • Vomiting • Cramping Abdominal pain
• distension • obstipation
Ureter Calculi • Paroxysmal • •
abdominal pain Referred pain to the groin area of the same side Hematuria
Rupture of the Liver or Spleen • Pain in right or left hypochondrium • Shock • Anemia
Radiation Given the pain patterns already discussed, involvement of certain organs can be implicated based on the radiating pattern of the pain.
Aggravating or Alleviating factors. What makes the pain better or worse? Parietal peritoneal pain is aggravated by movement , such as hitting bumps on the ride to the hospital or even walking. This finding is particularly supportive of the diagnosis of appendicitis, when it is part of the differential diagnosis.
Ulcer pain is usually relieved by eating, whereas biliary colic is aggravated by eating fatty foods. The pain of pancreatitis is alleviated somewhat by assuming a curled-up posture.
Prior pain history. The easiest question to ask is: Have you ever had this pain before? the majority of patients with cholecystitis have had similar pain with eating prior to presentation. Ulcers tend to be recurrent, as do pancreatitis.
Pain treatment What has the patient done to relieve the pain? What has the response been? The treatment gives some insight into the medical sophistication of the patient. The response can help measure the severity and evolution of the pain.
Associated Symptoms
Nausea and vomiting. Almost any kind of visceral abdominal pain will elicit nausea and vomiting . But , excessive vomiting should raise the suspicion of bowel obstruction . Pain that Is present before vomiting is more likely to have a surgical cause. Whereas vomiting that precedes pain is more likely to occur in patients with nonspecific abdominal pain or gastroenteritis.
Change in Bowel habits The presence of diarrhea with vomiting is almost always associated with gastroenteritis. Is the patient unable to pass gas or stool? Ileus from inflammation and blockage from mechanical obstruction are common causes of this complaint.
Past Medical History Past surgery. Prior surgery not only can eliminate many diagnosis but can increase the risk of others . For instance, abdominal surgery with secondary adhesions is the most common cause of intestinal obstruction in adults.
Medical Illness Patient with diabetes, heart disease, lung disease, liver disease, hypertension, or renal disease are not only at increased risk for certain abdominal disorders but may also require significantly different methods of stabilization, treatment, and surgical preparation
Physical Examination
General appearance The patient’s color and attitude in bed are important . Patients who are pale and diaphoretic and are lying perfectly still in bed are generally more acutely ill and are more likely to have local or diffuse peritonitis . Patients who are agitated writhing in pain are more likely to have visceral causes of abdominal pain , nonspecific abdominal pain, renal or biliary colic, or mesenteric ischemia.
Vital Signs Temperature. The patient’s temperature has been used as a general indicator of the presence or absence of infection. Blood Pressure and Pulse . These vital signs are helpful in gauging the severity of the disease process and the potential for blood or fluid loss.
Respiratory rate Pneumonia , pulmonary embolism , and myocardial infarction can raise the respiratory rate.
Extra-abdominal Examination Before examining the abdomen , the physician should listen quickly to the heart and lungs to avoid missing an extraabdominal cause of abdominal pain.
Abdominal Examination
Inspection :
Signs of distention ,symmetry , prior surgery , large masses , bruises may quickly narrow the differential diagnosis.
Auscultation Decrease bowel sounds are heard in peritonitis and other inflammatory processes that cause an adynamic ileus. Increased bowel sounds are heard in patients with nonspecific abdominal pain and gastroenteritis. Whereas highpitched sounds and rushes are classic for bowel obstruction.
Percussion Gentle percussion of all four abdominal quadrants can localize the site of pain initially. Percussion the abdomen can often provide information about the size of certain organs and the origin of abdominal distention, gaseous or solid. It is also useful for determining bladder size from urinary retention.
Palpation Most of the time and effort in the abdominal examination is spent on palpation. It is important to note the patient’s facial expressions during palpation. A grimace is usually more significant than the statement “ It hurts.” In pain of visceral origin, localization of tenderness is usually not possible . With somatic tenderness is more likely, and the following associated findings are assessed.
Muscular Signs Guarding is the reflex spasm of the abdominal wall musculature in response to palpation. Voluntary guarding is less significant than involuntary guarding. Involuntary guarding is elicited by asking the patient to take a deep breath while firm pressure is held on the tender area. If the spasm is not relieved, involuntary guarding is present. If the muscles relax, voluntary guarding is present.
Rebound Tenderness Rebound is classically the hallmark of peritoneal Irritation. It is elicited by slow, gentle, deep palpation of the tender area followed by abrupt but discreet withdrawal of the examiner’s hand. Often this procedure is not necessary because rebound can be discovered more gently by asking the patient to cough, or gentle percussing the area of tenderness.
Special Techniques Murphy’s Sign: While the physician palpates deeply in the right upper quadrant, the patient is asked to take a deep breath. Abrupt cessation of inspiration because of pain is consistent with cholecystitis, hepatitis, or other right upper quadrant abnormalities.
Fist percussion Gently percussion the costovertebral angles of the back with a fist elicits pain in patients with pyelonephritis or obstructive uropathy.
Related Examination Rectal. This examination is needed to search for occult blood, masses, and prostate tenderness.
Pelvic. All women of childbearing age with abdominal pain require a pelvic examination.
DECISION PRIORITIES AND PRELIMINARY DIFFERENTIAL DIAGNOSIS
After completing the history and physical examination , the preliminary differential diagnosis for the patient's abdominal pain is developed according to the following principles:
1. Is there a threat to life? Even though life-threatening causes of abdominal pain do not occur as frequently as common causes, they always take the highest priority. Important life -threatening intra-abdominal causes of acute abdominal pain include ruptured leaking abdominal aortic aneurysm, perforated viscus, acute pancreatitis , intestinal obstruction , and mesenteric ischemia.
2. Is the pain acute and is there a potential surgical cause for the pain? Severe pain accompanied by localized tenderness with peritoneal findings are the hallmarks of serious and possibly surgical disease. Usually the pain will have been acute in onset , and there will be accompanying abnormal vital signs or laboratory test results to support the suspicion of surgical disease.
The other causes of abdominal pain are acute appendicitis, biliary tract disease, ureteral colic, diverticulitis, peptic ulcer. All have the potential for requiring surgical intervention. .
DIAGNOSTIC ADJUNCTS
Laboratory Studies
White Blood Cell Count and Differential The white blood cell (WBC) count is a relatively useful test in evaluating acute abdominal pain . An elevated WBC count or a left-shifted differential occurs in acute appendicitis, pelvic inflammatory disease, and cholecystitis. WBC counts are often higher in patients with perforation, peritonitis, fulminant pancreatitis or sepsis
.
Amylase The serum amylase level is often considered the laboratory cornerstone in the diagnosis of pancreatitis. As many as 20% of patients with proven pancreatitis may present with normal serum amylase values. In general, the amylase concentration has remained a good test in the diagnosis of pancreatitis despite these shortcomings.
Urinalysis As a general rule, the presence of more than 10 WBC per high-power field, in a clean-catch urine sample is consistent with a diagnosis of urinary tract infection. Red cells in the urine are consistent with infection, tumor, trauma, or stone.
Tests for Pregnancy Any woman of childbearing age who presents with acute abdominal pain, especially if located in the lower abdomen, deserves a pregnancy test. The most important gynecologic emergency that causes abdominal pain is a ruptured ectopic pregnancy .
Radiologic Imaging Chest Radiograph. An upright chest radiograph can help diagnose pneumonia, and other pulmonary causes of abdominal pain. It is also the best view for detecting free intraperitoneal air from a perforated viscus.
Abdominal Radiograph An Radiographic signs that are most commonly looked for are dilated loops of small or large bowel , air fluid levels, abnormal calcifications in the urinary tract system or vascular calcifications outside of their usual anatomic location ( aortic aneurysm ) , free air under the diaphragm, and gallstones.
Ultrasound Ultrasound imaging can show multiple organ systems including the biliary tract, gallbladder. Pancreas, kidneys , aorta, and uterus. The conditions commonly detected by ultrasound include gallstones, biliary obstruction, aortic aneurysms, pancreatic pseudocysts, ureteral obstruction, and intrauterine versus ectopic pregnancies.
Electrocardiogra m Because myocardial ischemia can cause abdominal pain, most patients over 40 years old with abdominal pain deserve an ECG. Particularly if the pain is located in the upper abdomen.
PRINCIPLES OF MANAGEMENT
The main goals of the emergency physician in managing patients with acute abdominal disorders are to reverse the systemic effects of the underlying disorder and to prepare the patient for surgical intervention, if necessary, Principles of management include: volume repletion, gastric emptying, control of emesis, and pain relief.
DISPOSITION AND FOLLOW-UP
There are two possible dispositions available to an emergency physician for patients with acute abdominal pain. It is important to emphasize ,however , that each patient must be treated individually, and no recommendations for disposition are highly specific or concrete.
Immediate Surgical Consultation
Localized or diffuse peritoneal signs accompanies by historical and laboratory findings consistent with a surgical disease require an urgent surgical consultation . Acute appendicitis, intestinal obstruction ,perforated ulcer ,and acute cholecystitis are the four most common surgical causes of abdominal pain.
Male ,29 years, intestine necrosis
Emergency Department Observation
Patients who have no a potential surgical cause of disease are often observed in the emergency department .This strategy of observation often allows the clinical Situation to clarify as either the patient’s condition worsens or more information is gained to allow a decision on disposition .
FINAL POINTS AND SUMMARY
1.Abdominal pain is a common symptom of the large number of varied organs that reside within the abdominal cavity. Often the pain will remain visceral in nature and therefore will not progress to a more somatic component, which would allow the examiner to elicit specific tenderness over an inflamed organ .
2. It is the responsibility of the emergency physician to be able to recognize the 10%to 20%of patients who have a surgical cause of their pain. 3.The physician’s most important diagnostic tools are the history and physical examination. Particular emphasis is placed on palpation to elicit specific tenderness.
4. Laboratory and other ancillary diagnostic procedures are of limited value in the patient with abdominal pain .The management and disposition of the patient will depend on the clinical skill of the emergency physician
5. One of the most significant factors on the side of the physician in caring for the patient with abdominal is time and repeated examinations. 6.Patients who do not have an obvious diagnosis are observed for a period of several hours. This management strategy will allow the physician to observe any significant changes in the patient’s pain pattern and overall medical condition.
Definition of pain • “An unpleasant sensory and
emotional experience associated with either actual or potential tissue damage, or described in terms of such damage” ---- International Association for the Study of Pain
Acute abdominal pain comprises about one-third of the surgical problems.Of patients presenting with abdominal pain, approximately 15% to 30% will require a surgical procedure. The most common diagnosis made in patients with acute abdominal pain is nonspecific abdominal pain for which no organic disease can be found after an extensive work-up.
Gastroenteritis is the second most common diagnosis, followed by pelvic inflammatory disease 、 urinary tract disease 、 appendicitis 、 cholecystitis, and bowel obstruction. Appendicitis is the most common surgical diagnosis. Cholecystitis, bowel obstruction 、 perforated ulcer 、 and pancreatitis are common causes of surgical abdominal pain in descending order of frequency.
Neuroanatomy of Pain Transmission
The diagnosis of abdominal pain is aided by an understanding of the anatomy and physiology of the peritoneum , the intra-abdominal viscera , and the neural pain pathways.
Classification – Visceral pain – Somatic pain – Referred pain
Visceral pain The receptors located in the visceral peritoneum surrounding hollow organs and the capsules of solid organs. Distention or ischemia of the abdominal organs stimulates these receptors. Most visceral pain is midline in nature.(Because these organs are simultaneously innervated from both sides of the spinal column .)
Visceral pain dull, crampy, and localized(Because visceral pain
poorly
fibers are bilateral and unmyelinated and enter the spinal cord at multiple levels). It is often
associated with“ visceral” symptoms such as nausea, vomiting, and diaphoresis. It usually cannot be localized to a certain organ.
Somatic pain The pain receptors located in the parietal peritoneum and the roots of the mesentery. This type of pain is more sharp, and localized.(because Pain produced by ischemia, inflammation or stretch of the parietal peritoneum is transmitted through myelinated afferent fibers to specific dorsal roots ganglia on the same side and at the same dermatomal level as the origin of the pain) .
It is responsible for the physical finding of tenderness to palpation, guarding, and rebound . The finding of somatic pain often allows anatomic localization of pain to a specific organ. Given somatic tenderness in a certain quadrant, the differential diagnosis can be narrowed down solely by anatomic localization of organ.
Referred pain The pain that is felt at a cutaneous site distant from the disease organ. For instance, visceral afferents from the diaphragm enter the spinal cord at C3C5. Pain from the diaphragm is thus referred to the cutaneous distribution of C3-C5 the lateral neck and posterior shoulder.
Because the lungs and abdomen share the T9(thoracic nerve 9) dermatome distribution, pulmonary processes such as pneumonia and pulmonary embolus can be perceived as abdominal pain. Pelvic and inguinal structures innervated by T11 and T12 can cause referred pain to the lower abdomen.
DATA GATHERING
Key Notes in Interviewing of Pain
• Sites • Character • Causes • Duration • Radiation • Accompanied symptoms • Relaxing factors
Despite all technologic advances, the history and physical examination remain the most important tools in the initial assessment of a patient who complains of abdominal pain. Although critically ill patient may be more difficult to evaluate, the data from their history and physical examination are paramount, as this information either determines a definitive diagnosis or directs further evaluation.
Pain History
Onset. Rapid onset of severe pain is more consistent with a vascular catastrophe, rupture of a viscus, ectopic pregnancy. Slower, insidious onset is more typical of an inflammatory process such as appendicitis or cholecystitis.
Pattern of Change Pain that is steadily increasing in intensity is more likely to need surgical intervention.
Character of Pain Pain that is dull, burning is more likely to be visceral than somatic. Pain that is sharp or stabbing is more likely to be peritoneal or somatic in nature. Crampy pain is classically associated with obstruction of a viscu.
Severity The patient’s quantification of pain is notoriously unreliable. In general nonspecific abdominal pain is less severe than pain from surgical causes, but there is considerable individual variation. Severe pain out of proportion to physical findings is classical for mesenteric ischemia or pancreatitis.
Location The location of abdominal pain can vary with time, especially as the pain progresses from a visceral to a somatic origin. Periumbilical pain that migrates to the right lower quadrant is classic for appendicitis. Epigastric pain that eventually localized during a period of several hours to the right upper quadrant is characteristic of cholecystitis.
Common Diseases Acute appendicitis – Pain is initially localized around the umbilicus (visceral pain) and is vague; As the inflammatory response progresses to involve the parietal peritoneum, the main site of pain shifts to the right iliac fossa (parietal or somatic pain) – Usually accompanied by fever
Acute Cholecystitis • Paroxysmal right
hypochondrium pain
• Accompanied by fever sometimes
• Paroxysmal pain in right infrascapular area
Acute Gastric Perforation • Outburst acute severe lancinating pain in umbilical region or epigastrium
Acute ileus • Vomiting • Cramping Abdominal pain
• distension • obstipation
Ureter Calculi • Paroxysmal • •
abdominal pain Referred pain to the groin area of the same side Hematuria
Rupture of the Liver or Spleen • Pain in right or left hypochondrium • Shock • Anemia
Radiation Given the pain patterns already discussed, involvement of certain organs can be implicated based on the radiating pattern of the pain.
Aggravating or Alleviating factors. What makes the pain better or worse? Parietal peritoneal pain is aggravated by movement , such as hitting bumps on the ride to the hospital or even walking. This finding is particularly supportive of the diagnosis of appendicitis, when it is part of the differential diagnosis.
Ulcer pain is usually relieved by eating, whereas biliary colic is aggravated by eating fatty foods. The pain of pancreatitis is alleviated somewhat by assuming a curled-up posture.
Prior pain history. The easiest question to ask is: Have you ever had this pain before? the majority of patients with cholecystitis have had similar pain with eating prior to presentation. Ulcers tend to be recurrent, as do pancreatitis.
Pain treatment What has the patient done to relieve the pain? What has the response been? The treatment gives some insight into the medical sophistication of the patient. The response can help measure the severity and evolution of the pain.
Associated Symptoms
Nausea and vomiting. Almost any kind of visceral abdominal pain will elicit nausea and vomiting . But , excessive vomiting should raise the suspicion of bowel obstruction . Pain that Is present before vomiting is more likely to have a surgical cause. Whereas vomiting that precedes pain is more likely to occur in patients with nonspecific abdominal pain or gastroenteritis.
Change in Bowel habits The presence of diarrhea with vomiting is almost always associated with gastroenteritis. Is the patient unable to pass gas or stool? Ileus from inflammation and blockage from mechanical obstruction are common causes of this complaint.
Past Medical History Past surgery. Prior surgery not only can eliminate many diagnosis but can increase the risk of others . For instance, abdominal surgery with secondary adhesions is the most common cause of intestinal obstruction in adults.
Medical Illness Patient with diabetes, heart disease, lung disease, liver disease, hypertension, or renal disease are not only at increased risk for certain abdominal disorders but may also require significantly different methods of stabilization, treatment, and surgical preparation
Physical Examination
General appearance The patient’s color and attitude in bed are important . Patients who are pale and diaphoretic and are lying perfectly still in bed are generally more acutely ill and are more likely to have local or diffuse peritonitis . Patients who are agitated writhing in pain are more likely to have visceral causes of abdominal pain , nonspecific abdominal pain, renal or biliary colic, or mesenteric ischemia.
Vital Signs Temperature. The patient’s temperature has been used as a general indicator of the presence or absence of infection. Blood Pressure and Pulse . These vital signs are helpful in gauging the severity of the disease process and the potential for blood or fluid loss.
Respiratory rate Pneumonia , pulmonary embolism , and myocardial infarction can raise the respiratory rate.
Extra-abdominal Examination Before examining the abdomen , the physician should listen quickly to the heart and lungs to avoid missing an extraabdominal cause of abdominal pain.
Abdominal Examination
Inspection :
Signs of distention ,symmetry , prior surgery , large masses , bruises may quickly narrow the differential diagnosis.
Auscultation Decrease bowel sounds are heard in peritonitis and other inflammatory processes that cause an adynamic ileus. Increased bowel sounds are heard in patients with nonspecific abdominal pain and gastroenteritis. Whereas highpitched sounds and rushes are classic for bowel obstruction.
Percussion Gentle percussion of all four abdominal quadrants can localize the site of pain initially. Percussion the abdomen can often provide information about the size of certain organs and the origin of abdominal distention, gaseous or solid. It is also useful for determining bladder size from urinary retention.
Palpation Most of the time and effort in the abdominal examination is spent on palpation. It is important to note the patient’s facial expressions during palpation. A grimace is usually more significant than the statement “ It hurts.” In pain of visceral origin, localization of tenderness is usually not possible . With somatic tenderness is more likely, and the following associated findings are assessed.
Muscular Signs Guarding is the reflex spasm of the abdominal wall musculature in response to palpation. Voluntary guarding is less significant than involuntary guarding. Involuntary guarding is elicited by asking the patient to take a deep breath while firm pressure is held on the tender area. If the spasm is not relieved, involuntary guarding is present. If the muscles relax, voluntary guarding is present.
Rebound Tenderness Rebound is classically the hallmark of peritoneal Irritation. It is elicited by slow, gentle, deep palpation of the tender area followed by abrupt but discreet withdrawal of the examiner’s hand. Often this procedure is not necessary because rebound can be discovered more gently by asking the patient to cough, or gentle percussing the area of tenderness.
Special Techniques Murphy’s Sign: While the physician palpates deeply in the right upper quadrant, the patient is asked to take a deep breath. Abrupt cessation of inspiration because of pain is consistent with cholecystitis, hepatitis, or other right upper quadrant abnormalities.
Fist percussion Gently percussion the costovertebral angles of the back with a fist elicits pain in patients with pyelonephritis or obstructive uropathy.
Related Examination Rectal. This examination is needed to search for occult blood, masses, and prostate tenderness.
Pelvic. All women of childbearing age with abdominal pain require a pelvic examination.
DECISION PRIORITIES AND PRELIMINARY DIFFERENTIAL DIAGNOSIS
After completing the history and physical examination , the preliminary differential diagnosis for the patient's abdominal pain is developed according to the following principles:
1. Is there a threat to life? Even though life-threatening causes of abdominal pain do not occur as frequently as common causes, they always take the highest priority. Important life -threatening intra-abdominal causes of acute abdominal pain include ruptured leaking abdominal aortic aneurysm, perforated viscus, acute pancreatitis , intestinal obstruction , and mesenteric ischemia.
2. Is the pain acute and is there a potential surgical cause for the pain? Severe pain accompanied by localized tenderness with peritoneal findings are the hallmarks of serious and possibly surgical disease. Usually the pain will have been acute in onset , and there will be accompanying abnormal vital signs or laboratory test results to support the suspicion of surgical disease.
The other causes of abdominal pain are acute appendicitis, biliary tract disease, ureteral colic, diverticulitis, peptic ulcer. All have the potential for requiring surgical intervention. .
DIAGNOSTIC ADJUNCTS
Laboratory Studies
White Blood Cell Count and Differential The white blood cell (WBC) count is a relatively useful test in evaluating acute abdominal pain . An elevated WBC count or a left-shifted differential occurs in acute appendicitis, pelvic inflammatory disease, and cholecystitis. WBC counts are often higher in patients with perforation, peritonitis, fulminant pancreatitis or sepsis
.
Amylase The serum amylase level is often considered the laboratory cornerstone in the diagnosis of pancreatitis. As many as 20% of patients with proven pancreatitis may present with normal serum amylase values. In general, the amylase concentration has remained a good test in the diagnosis of pancreatitis despite these shortcomings.
Urinalysis As a general rule, the presence of more than 10 WBC per high-power field, in a clean-catch urine sample is consistent with a diagnosis of urinary tract infection. Red cells in the urine are consistent with infection, tumor, trauma, or stone.
Tests for Pregnancy Any woman of childbearing age who presents with acute abdominal pain, especially if located in the lower abdomen, deserves a pregnancy test. The most important gynecologic emergency that causes abdominal pain is a ruptured ectopic pregnancy .
Radiologic Imaging Chest Radiograph. An upright chest radiograph can help diagnose pneumonia, and other pulmonary causes of abdominal pain. It is also the best view for detecting free intraperitoneal air from a perforated viscus.
Abdominal Radiograph An Radiographic signs that are most commonly looked for are dilated loops of small or large bowel , air fluid levels, abnormal calcifications in the urinary tract system or vascular calcifications outside of their usual anatomic location ( aortic aneurysm ) , free air under the diaphragm, and gallstones.
Ultrasound Ultrasound imaging can show multiple organ systems including the biliary tract, gallbladder. Pancreas, kidneys , aorta, and uterus. The conditions commonly detected by ultrasound include gallstones, biliary obstruction, aortic aneurysms, pancreatic pseudocysts, ureteral obstruction, and intrauterine versus ectopic pregnancies.
Electrocardiogra m Because myocardial ischemia can cause abdominal pain, most patients over 40 years old with abdominal pain deserve an ECG. Particularly if the pain is located in the upper abdomen.
PRINCIPLES OF MANAGEMENT
The main goals of the emergency physician in managing patients with acute abdominal disorders are to reverse the systemic effects of the underlying disorder and to prepare the patient for surgical intervention, if necessary, Principles of management include: volume repletion, gastric emptying, control of emesis, and pain relief.
DISPOSITION AND FOLLOW-UP
There are two possible dispositions available to an emergency physician for patients with acute abdominal pain. It is important to emphasize ,however , that each patient must be treated individually, and no recommendations for disposition are highly specific or concrete.
Immediate Surgical Consultation
Localized or diffuse peritoneal signs accompanies by historical and laboratory findings consistent with a surgical disease require an urgent surgical consultation . Acute appendicitis, intestinal obstruction ,perforated ulcer ,and acute cholecystitis are the four most common surgical causes of abdominal pain.
Male ,29 years, intestine necrosis
Emergency Department Observation
Patients who have no a potential surgical cause of disease are often observed in the emergency department .This strategy of observation often allows the clinical Situation to clarify as either the patient’s condition worsens or more information is gained to allow a decision on disposition .
FINAL POINTS AND SUMMARY
1.Abdominal pain is a common symptom of the large number of varied organs that reside within the abdominal cavity. Often the pain will remain visceral in nature and therefore will not progress to a more somatic component, which would allow the examiner to elicit specific tenderness over an inflamed organ .
2. It is the responsibility of the emergency physician to be able to recognize the 10%to 20%of patients who have a surgical cause of their pain. 3.The physician’s most important diagnostic tools are the history and physical examination. Particular emphasis is placed on palpation to elicit specific tenderness.
4. Laboratory and other ancillary diagnostic procedures are of limited value in the patient with abdominal pain .The management and disposition of the patient will depend on the clinical skill of the emergency physician
5. One of the most significant factors on the side of the physician in caring for the patient with abdominal is time and repeated examinations. 6.Patients who do not have an obvious diagnosis are observed for a period of several hours. This management strategy will allow the physician to observe any significant changes in the patient’s pain pattern and overall medical condition.
