Evaluation of Acute Abdomen 2013A

Evaluation of Acute Abdominal Pain Dr. Napoleon B. Alcedo

Surgery – PPT, 2012B trans Surgery – Audio Recording Surgery – Medicine I Lecture on Adbominal Pain, Bates Guide to PE or Harrison’s Principle of IM

Acute Abdominal Pain  Pain with onset less than 6 hours

 responds to irritation from infectious or other inflammatory processes  can also be chemical

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 When you suspect a case of an acute onset pain with a pain scale of 7 out of 10, then it’s always a symptom of intraabdominal disease. In the elderly and sometimes in children we encounter patients who do not experience symptoms except the pain.  May present as an acute manifestation of a chronic dse like chronic cholecystitis

 Acute and Severe Pain  almost always a symptom of intra-abdominal disease  may be the only indicator for the need of a laparotomy  as in cases of acute intestinal ischemia [e.g. an elderly with a thrombus/embolus in the superior mesenteric artery; even if the px did not note history of arrhythmia and PE is normal (abdomen is soft) but presents with acute and severe pain – vascular emergency]

February 17, 2011

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 Hydrochloric Acid (HCl) type of pain – px is awakened and can tell exactly what time the pain starts by the minute (usually intensity 9-10/10) in perforated ulcer Lateralization of the discomfort is possible since only one side of the nervous system innervates a given part of the parietal peritoneum sharp and well-localized (can be pointed to by a finger) This is what you call “good morning appendicitis.” This means that when you open the appendix, it will pop out.

3. Referred Pain - perceived distant from its source  results from convergence of nerve fibers at the spinal cord  e.g. scapular pain from biliary colic, shoulder pain from diaphragmatic irritation Neuroanatomic Basis of Referred Pain:

Types of Pain 1. Visceral – your serosa is the visceral peritoneum in other words visceral peritoneum comes from the abdominal viscera/organs (as in cholecystitis, appendicitis, intestinal obstruction, etc.)

 innervated by autonomic nerve fibers  mainly due to sensation of distention and muscular contraction  vague  nauseating – because of distention and reflex ileus caused by the inflammation in the abdomen; px feels full and sometimes vomits

 poorly localized  perceived in areas corresponding to embryonic origin of affected structure  Pain in periumbilical area – involves the medial structures (jejunum, ileum, appendix, proximal colon, up to the proximal transverse colon – supplied by the superior mesenteric artery)  Lower abdomen/hindgut structures – distal transverse colon up to the anus; also includes the genitourinary tract (that’s why a renal colic is usually felt in the lower abdomen)

2. Somatic – comes from the parietal peritoneum  Felt when an inflamed abdominal structure comes in contact with the anterior abdominal wall which is innervated by somatic nerves of parietal peritoneum.

Visceral afferent fibers stimulated by irritation (A) synapse with second order neuron in the spinal cord (B) as well as somatic fibers (C) arising from the left shoulder area (Cervical roots 3 to 5 and the brain interprets the pain to be somatic in origin and localizes it to the shoulder) E.g. Kehr’s sign shoulder pain in a patient with subphrenic hematoma or splenic rupture  Reminder: Palpation should be performed LAST in a patient with abdominal pain. Go first with the history like:  type of pain  Is it sharp or constricting?  If it is constricting, it is a spastic pain in the body’s attempt to pass something through an obstruction (colicky – sudden and severe).  An example is a biliary colic (patient takes in a fatty meal → stimulates gallbladder to contract → gallbladder contracts against the biliary tree which is obstructed by stone → pain)

 The dermatomal levels come into play. The innervations of parietal peritoneum follow the dermatomal level. E.g., the dermatomal level of umbilicus is T10.

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PATIENT HISTORY Abdominal Pain Character: Type of Onset of Pain  Acute wave of sharp, constricting pain – renal or biliary colic  because the hollow viscous is attempting to get rid of the obstruction  If you have ureteral stone and your body wants to get rid of that ureteral stone and pushing it towards your bladder, the onset of the pain is severe and very acute. It’s sharp and very painful. The patient could go to neurogenic shock

 waves of dull pain with vomiting – intestinal obstruction  vomiting is NOT always present INITIALLY  it depends on the site and degree of obstruction (the more proximal the obstruction, the earlier the onset of vomiting)

 colicky pain which is on and off and then becomes steady strangulating intestinal obstruction, mesenteric ischemia  appendicitis  the appendix tries to remove the obstruction by contraction → pain  an ischemic type of pain (continuous and steady)  Phases: 1. congestive phase 2. suppurative phase [appendix loses the ability to contract because the nerves become devascularized] 3. gangrenous phase

 strangulating Intestinal obstruction  That’s why if you have a patient that you are suspecting to have an intestinal obstruction and it was confirmed by imaging studies, do not wait for the onset of steady pain. Because if you wait for the intestine to become ischemic then you will not be able to save the intestine and you have to resect that intestine in contrast to early intervention where you dissect the adhesive intestine and hopefully there will be reperfusion of the bowel and you will be able to save abdomen.  Patient initially complains of wavelike colicky pain (pain is NOT continuous; pain is felt again if the intestine tries to propel its contents against an obstruction; once the bowel relaxes, the pain disappears slowly)  metallic tinkles during an acute attack – “peristaltic rush”  if no intervention is done, then LATER it becomes a strangulated intestinal obstruction producing ischemia thus continuous pain  if the bowel perforates, “succus intericus” (intestinal juice) leaks leads generalized peritonitis (constant pain; patients lies still to ease the pain; pain aggravated by movement)

A – many causes of abdominal pains subsides spontaneously with time (acute GE) B – colicky – progresses and remits over time (intestinal, biliary and renal colic) time course varies from minutes, hours, days or weeks C – progressive (AP/diverticulitis) D – catastrophic (ruptured AAA)

Pain Location and Radiation  Upper Abdominal Pain  Foregut structures: stomach, liver, duodenum, pancreas  Peri-umbilical Pain  Midgut structures: small bowel, proximal colon, appendix  Lower Abdominal Pain  Hindgut structures: distal colon, genito-urinary tract  Right or Left Lower Quadrant Pain  abdominal or psoas abscess  abdominal wall hematomas  endometriosis, Pelvic Inflammatory Disease (PID), torsion of ovary  PID is initially is NON-surgical and managed medically, only when it becomes complicated (development of a tuboovarian abscess) that it is considered surgical

 incarcerated or strangulated hernia  inflammatory bowel disease, renal stone  Mittelschmerz  

discomfort at the time of ovulation may be due to rapid expansion of the dominant follicle, although it may also be caused by peritoneal irritation by follicular fluid released at the time of ovulation.

 ruptured ectopic pregnancy

 mesenteric ischemia  A patient experiencing colicky pain, in contrast to generalized peritonitis, would frequently change position.

 sharp constant pain worsened by movement  (generalized) peritonitis 

tenderness all over the abdomen with involuntary (true type) muscle guarding which is characterized by a rigid abdomen

 tearing pain – in dissecting aneurysm usually in the elderly  dull ache – in appendicitis, diverticulitis, pyelonephritis

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 Diffuse abdominal pain is visceral pain.  Surgical Abdomen – usually presents INITIALLY as abdominal pain; If the px presents initially with vomiting, cough/colds/fever and then later abdominal pain, then most probably it is NOT a surgical abdomen  Fever in appendicitis usually only develops during the suppurative or early gangrenous phase  A patient with acute MI can NOT be operated on  Lower lobe pneumonia can present as upper quadrant pain so you must correlate this with history (cough, DOB, etc.)

Intensity  severe pain - perforated viscus, kidney stones, peritonitis, pancreatitis, mesenteric ischemia  pain out of proportion to physical examination findings  mesenteric ischemia 

No muscle guarding, abdomen is soft, but complains of severe pain.

 in the elderly, may be caused by an arrhythmia Timing  Sudden (“like a light switching on”)  perforated ulcer  renal stone  ruptured ectopic pregnancy  torsion of ovary or testis  ruptured aneurysms

 cardiovascular disease especially with arrythmia  consider mesenteric ischemia, abdominal aortic aneurysm, referred cardiac ischemic pain presenting with severe pain in the absent of symptoms  Diabetes Mellitus - ketoacidosis  HIV  Inflammatory bowel disease Social History  tobacco abuse  consider mesenteric ischemia; vasospasm (Buerger‟s disease)  alcohol abuse  consider pancreatitis, gallstone

nicotine can cause

 skipping breakfast can also cause gallstones because the bile becomes more concentrated in the gallbladder during fasting

 medications, history of travel

PHYSICAL EXAMINATION

 the blood oozing from the ruptured aneurysms will irritate the abdominal wall thus causing sudden pain

Associated Symptoms  nausea and vomiting  usually precedes pain in non-surgical causes  severe vomiting preceeding chest pain in esophageal perforation (Boerhaave‟s)  acute appendicitis and gastroenteritis – nausea and vomiting happens after the onset of the pain

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fever anorexia diarrhea or constipation – in sigmoid diverticulitis bloody stool – in diverticulosis that became diverticulitis (inflamed diverticulosis)  dysuria – in nephrolithiasis

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Alleviating and Aggravating Factors  relieved by antacids – Peptic Ulcer Disease (PUD)  aggravated by movement – peritonitis  aggravated by fatty food intake – biliary tract disease  The classic presentation of appendicitis is initially generalized (or poorly localized periumbilical) abdominal pain, then after a few hours, pain shifts to the RLQ. And this time, it is associated with low-grade fever plus direct and rebound tenderness.

Past Medical History  history of abdominal surgery  consider post-op adhesions causing obstruction  most common cause of intestinal obstruction  cholelithiasis  surgery is done only when it becomes symptomatic  diverticulitis

A. General Appearance  acutely or chronically ill-appearing patient  malnourished patient  positioning  retroperitoneal irritation – patient flexes thighs to relax the psoas muscle  peritonitis – patient lies very still  bowel obstruction or nephrolithiasis – restless  biliary ascariasis – patient frequently (“snake-like movement”)  renal colic – restless patient

B. Back examination  ecchymosis – in hemorrhagic pancreatitis C. Cardiopulmonary examination  assess for myocardial infarction  assess for cardiac arrhythmia  arterial pulses – femoral pulse, pedal pulses D. Abdominal Examination 1. Observation  distention  generalized – sigmoid obstruction 

Distention becomes more marked in colonic than in small bowel obstruction

 asymmetry  peristalsis 

Increased peristaltic waves of intestinal obstruction

 scars from previous abdominal surgeries, trauma  hernia (signs of incarceration)  reduced chest excursion (due to guarding) 2. Auscultation  borborygmi – consider bowel obstruction  silent abdomen – consider a surgical abdomen

 can rupture, common in the elderly Faisal | James Lorenzo

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3. Palpation

IMAGING STUDIES

 do this after auscultation because it may alter the bowel sounds

 tenderness  maximal tenderness – palpate LAST 

Tenderness may originate in the abdominal wall. When the patient raises the head and shoulders, this tenderness persists, whereas tenderness from a deeper lesion (protected by the tightened muscles) decreases.

A. Directed Imaging B. Initial non-specific Radiologic Studies 1. chest x-ray detects:  to rule out perforated viscus  Identifies ~50-90% of perforated viscus  Patient on left lateral decubitus/standing position for 15mins  If the air goes up to the liver and diaphragm, it is positive for perforated viscus

 abdominal free air (pneumoperitoneum) below the diaphragm

 pulsatile masses – aneurysm  abnormal fullness – mass or abscess  muscle tone

 because a chest X-ray can visualize the dome of the diaphragm better

 to differentiate between voluntary from involuntary muscle guarding, palpate the left and right abdomen simultaneously with both hands and compare the tone  voluntary guarding – if you ask the patient to relax, then both sides would feel soft  involuntary (true) guarding – there is a difference in tone between the left and the right abdominal area

 test for presence of peritoneal irritation  

more severe than visceral tenderness Generalized peritonitis causes exquisite tenderness throughout the abdomen, together with boardlike muscular rigidity

 should be done near the end of the examination E. Genito-urinary Examination  examine for femoral hernia – located below the inguinal ligament  inguinal hernia – above the inguinal ligament  rectal exam on all patients with abdominal pain  pain on palpation  occult or frankly bloody stool  pelvic exam for females

LABORATORY AND DIAGNOSTIC STUDIES A. Urinalysis B. Complete Blood Count - leukocytosis may not always appear C. Electrocardiogram D. Pulse Oximetry E. Serum Phosphate - increased in mesenteric ischemia F. Liver Function Tests G. Blood cultures H. Amylase  Pancreatitis - (lipase preferred)  Bowel obstruction  Bowel perforation or peptic ulceration  Mesenteric Ischemia I. Lipase indications  pancreatitis  bowel obstruction  duodenal ulcer J. Arterial Blood Gas

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 congestive heart failure  pneumonia 2. KUB (kidney urinary bladder) x-ray to detect:  small bowel obstruction  incarcerated hernia – seen as loops of bowel  appendicitis – visualization of a fecalith o it is non-compressible during KUB  gallstone – calcium stones(radio-opaque)  large bowel obstruction  diverticulitis  volvulus 3. Second-line studies for unclear diagnosis  Abdominal CT scan  Abdominal ultrasound  CT Angiography – mesenteric ischemia  Endoscopy – for obstruction Shoutouts: This trans is derived from the audio recording during the lecture and trans of Medicine2012B, we didn‟t consult Schwartz because we can‟t find the specific topic on the book. As Dr. Alcedo told as at the end of the lecture, he would make his questions as practical as possible and 20-25points will be taken from this topic. “As not only the disease interested the physician, but he was strongly moved to look into the character and qualities of the patient... He deemed it essential, it would seem, to know the man, before attempting to do him good.” - NATHANIEL HAWTHORNE (18041864) “It is Nor permitted For The Sun To Catch Up To The Moon; Nor Can The Night Outstrip The Day; Each just swims along in its own orbit(according to law) (Quran 36;40)” -FAISAL “Maybe we like the pain. Maybe we're wired that way. Because without it, I don't know, maybe we just wouldn't feel real. What's that saying? Why do I keep hitting myself with a hammer? Because it feels so good when I stop.” --- Grey’s Anatomy Hi 2013A! Sorry for the late upload. I added some info from our Med lectures, Harrison‟s and Bates para mas maintindihan yung ibang part and para may kaunting review na rin for Med I. Huling ire na lang! Hehe. Kaya natin „to!   Mariel

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