ACS Surgery: 0501-Gastrointestinal Tract and Abdomen

Section 5 Gastrointestinal Tract and Abdomen

1 Acute Abdominal Pain

Associate Professor of Surgery
Harvard Medical School
Senior Staff Surgeon
Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital

Romano Delcore, M.D., F.A.C.S.

Professor of Surgery
University of Kansas Medical Center

The term acute abdominal pain generally refers to previously undiagnosed pain that arises suddenly and is of less than 7 days' (usually less than 48 hours') duration.¹ It may be caused by a great variety of intraperitoneal disorders, many of which call for surgical treatment, as well as by a range of extraperitoneal disorders,² which typically do not call for surgical treatment [see Clinical Evaluation, Tentative Differential Diagnosis, below]. Abdominal pain that persists for 6 hours or longer is usually caused by disorders of surgical significance.³ The primary goals in the management of patients with acute abdominal pain are (1) to establish a differential diagnosis and a plan for confirming the diagnosis through appropriate imaging studies, (2) to determine whether operative intervention is necessary, and (3) to prepare the patient for operation in a manner that minimizes perioperative morbidity and mortality.

In many cases, these goals are easily accomplished. On occasion, however, the evaluation of patients with acute abdominal pain can be one of the most difficult challenges in clinical surgery. It is essential to keep in mind that most (at least two thirds) of the patients who present with acute abdominal pain have disorders for which surgical intervention is not required.^2,^4,5 In addition, most clinicians depend on recognition of specific patterns and sequences of symptoms and signs to determine the need for further testing and to make decisions regarding the timing of operation; however, at least one third of patients with acute abdominal pain exhibit atypical features that render pattern recognition unreliable.^2,⁵ Finally, it is not clear that individual clinicians always or even usually agree on presenting symptoms and physical signs. In one study of abdominal pain in children, agreement between individual observers was reached 50% of the time for the physical sign of rebound tenderness; however, for five other signs (abdominal distention, abdominal tenderness to percussion, abdominal tenderness to palpation, abdominal guarding, and bowel sounds), interobserver agreement was not reached in more than one third of patients. These findings highlight the difficulties inherent in evaluation and management of acute abdominal pain. In addition, they emphasize the importance of integrating care among different providers to minimize loss of information and maximize continuity of care.

Clinical Evaluation

History

A careful and methodical clinical history should be obtained. Key features of the history include the dimensions of pain (i.e., mode of onset, duration, frequency, character, location, chronology, radiation, and intensity), as well as the presence or absence of any aggravating or alleviating factors and associated symptoms. Often, such a history is more valuable than any single laboratory or x-ray finding and determines the course of subsequent evaluation and management.

Figure 1. Data sheet modified from OMGE pain chart

Unfortunately, when the ability of clinicians to take an organized and accurate history has been studied, the results have been disappointing.⁶ For this reason, the use of standardized history and physical forms, with or without the aid of diagnostic computer programs, has been recommended.^7–10 A large-scale study that included 16,737 patients with acute abdominal pain demonstrated that integration of computer-aided diagnosis into management yielded a 20% improvement in diagnostic accuracy.⁷ The study also documented statistically significant reductions in inappropriate admissions, negative laparotomies, serious management errors (e.g., failure to operate on patients who require surgery), and length of hospital stay, as well as statistically significant increases in the number of patients who were immediately discharged home without adverse effects and the promptness with which those requiring surgery underwent operation. Although many factors may have contributed to the observed benefits of computer-aided decision-making, it is clear that the use of structured and standardized means of collecting clinical and laboratory data was crucial. An example of such a structured data sheet is the pain chart developed by the World Organization of Gastroenterology (OMGE) [see Figure 1]. Because this pain chart is not exhaustive and does not cover all potential situations, individual surgeons may want to add to it; however, they would be well advised not to omit any of the symptoms and signs on the OMGE data sheet from their routine examination of patients with acute abdominal pain.¹¹

The patient's own words often provide important clues to the correct diagnosis. The examiner should refrain from suggesting specific symptoms, except as a last resort. Any questions that must be asked should be open-ended—for example, 'What happens when you eat?' rather than 'Does eating make the pain worse?' Leading questions should be avoided. When a leading question must be asked, it should be posed first as a negative question (i.e., one that calls for an answer in the negative) because a negative answer to a question is more likely to be honest and accurate. For example, if peritoneal inflammation is suspected, the question asked should be 'Does coughing make the pain better?' rather than 'Does coughing make the pain worse?'

The mode of onset of abdominal pain may help the examiner determine the severity of the underlying disease. Pain that has a sudden onset suggests an intra-abdominal catastrophe, such as a ruptured abdominal aortic aneurysm (AAA), a perforated viscus, or a ruptured ectopic pregnancy; a near loss of consciousness or stamina associated with sudden-onset pain should heighten the level of concern for such a catastrophe. Rapidly progressive pain that becomes intensely focused in a well-defined area within a period of a few minutes to an hour or two suggests a condition such as acute cholecystitis or pancreatitis. Pain that has a gradual onset over several hours, usually beginning as slight or vague discomfort and slowly progressing to steady and more localized pain, suggests a subacute process and is characteristic of processes that lead to peritoneal inflammation. Numerous disorders may be associated with this mode of onset, including acute appendicitis, diverticulitis, pelvic inflammatory disease (PID), and intestinal obstruction.

Pain can be either intermittent or continuous. Intermittent or cramping pain (colic) is pain that occurs for a short period (a few minutes), followed by longer periods (a few minutes to one-half hour) of complete remission during which there is no pain at all. Intermittent pain is characteristic of obstruction of a hollow viscus and results from vigorous peristalsis in the wall of the viscus proximal to the site of obstruction. This pain is perceived as deep in the abdomen and is poorly localized. The patient is restless, may writhe about incessantly in an effort to find a comfortable position, and often presses on the abdominal wall in an attempt to alleviate the pain. Whereas the intermittent pain associated with intestinal obstruction (typically described as gripping and mounting) is usually severe but bearable, the pain associated with obstruction of small conduits (e.g., the biliary tract, the ureters, and the uterine tubes) often becomes unbearable. Obstruction of the gallbladder or the bile ducts gives rise to a type of pain often referred to as biliary colic; however, this term is a misnomer, in that biliary pain is usually constant because of the lack of a strong muscular coat in the biliary tree and the absence of regular peristalsis.

Continuous or constant pain is pain that is present for hours or days without any period of complete relief; it is more common than intermittent pain. Continuous pain is usually indicative of a process that will lead, or has already led, to peritoneal inflammation or ischemia. It may be of steady intensity throughout, or it may be associated with intermittent pain. For example, the typical colicky pain associated with simple intestinal obstruction changes when strangulation occurs, becoming continuous pain that persists between episodes or waves of cramping pain.

Certain types of pain are generally held to be typical of certain pathologic states. For example, the pain of a perforated ulcer is often described as burning, that of a dissecting aneurysm as tearing, and that of bowel obstruction as gripping. One may imagine that the first type of pain is explained by the efflux of acid, the second by the sudden expansion of the retroperitoneum, and the third by the churning of hyperperistalsis. Colorful as these images may be, in most cases, the pain begins in a nondescript way. It is only by carefully following the patient's description of the evolution and time course of the pain that such images may be formed with confidence.

Figure 2a. Disorders associated with diffuse abdominal pain

Figure 2b. Disorders associated with acute pain in the umbilical and hypogastric regions

Figure 2c. Disorders associated with acute pain, by quadrant

For several reasons—atypical pain patterns, dual innervation by visceral and somatic afferents, normal variations in organ position, and widely diverse underlying pathologic states—the location of abdominal pain is only a rough guide to diagnosis. It is nevertheless true that in most disorders, the pain tends to occur in characteristic locations, such as the right upper quadrant (cholecystitis), the right lower quadrant (appendicitis), the epigastrium (pancreatitis), or the left lower quadrant (sigmoid diverticulitis) [see Figures 2a, 2b and 2c]. It is important to determine the location of the pain at onset because this may differ from the location at the time of presentation (so-called shifting pain). In fact, the chronological sequence of events in the patient's history is often more important for diagnosis than the location of the pain alone. For example, the classic pain of appendicitis begins in the periumbilical region and settles in the right lower quadrant. A similar shift in location can occur when escaping gastroduodenal contents from a perforated ulcer pool in the right lower quadrant.

Figure 3. Patterns of referral of pain of abdominal origin

It is also important to take into account radiation or referral of the pain, which tends to occur in characteristic patterns [see Figure 3]. For example, biliary pain is referred to the right subscapular area, and the boring pain of pancreatitis typically radiates straight through to the back. Obstruction of the small intestine and the proximal colon is referred to the umbilicus, and obstruction distal to the splenic flexure is often referred to the suprapubic area. Spasm in the ureter often radiates to the suprapubic area and into the groin. The more severe the pain is, the more likely it is to be associated with referral to other areas.

The intensity or severity of the pain is related to the magnitude of the underlying insult. It is important to distinguish between the intensity of the pain and the patient's reaction to it because there appear to be significant individual differences with respect to tolerance of and reaction to pain. Pain that is intense enough to awaken the patient from sleep usually indicates a significant underlying organic cause. Past episodes of pain and factors that aggravate or relieve the pain often provide useful diagnostic clues. For example, pain caused by peritonitis tends to be exacerbated by motion, deep breathing, coughing, or sneezing, and patients with peritonitis tend to lie quietly in bed and avoid any movement. The typical pain of acute pancreatitis is exacerbated by lying down and relieved by sitting up. Pain that is relieved by eating or taking antacids suggests duodenal ulcer disease, whereas diffuse abdominal pain that appears 30 minutes to 1 hour after meals suggests intestinal angina.

Associated gastrointestinal symptoms (e.g., nausea, vomiting, anorexia, diarrhea, and constipation) often accompany abdominal pain; however, these symptoms are nonspecific and therefore may not be of great value in the differential diagnosis. Vomiting in particular is common: when sufficiently stimulated by pain impulses traveling via secondary visceral afferent fibers, the medullary vomiting centers activate efferent fibers and cause reflex vomiting. Once again, the chronology of events is important, in that pain often precedes vomiting in patients with conditions necessitating operation, whereas the opposite is usually the case in patients with medical (i.e., nonsurgical) conditions.^5,¹² This is particularly true for adult patients with acute appendicitis, in whom pain almost always precedes vomiting by several hours. In children, vomiting is commonly observed closer to the onset of the pain, though it is rarely the initial symptom.

Similarly, constipation may result from a reflex paralytic ileus when sufficiently stimulated visceral afferent fibers activate efferent sympathetic fibers (splanchnic nerves) to reduce intestinal peristalsis. Diarrhea is characteristic of gastroenteritis but may also accompany incomplete intestinal or colonic obstruction. More significant is a history of obstipation, because if it can be definitely established that a patient with acute abdominal pain has not passed gas or stool for 24 to 48 hours, it is certain that some degree of intestinal obstruction is present. Other associated symptoms that should be noted include jaundice, melena, hematochezia, hematemesis, and hematuria. These symptoms are much more specific than the ones just discussed and can be extremely valuable in the differential diagnosis. Most conditions that cause acute abdominal pain of surgical significance are associated with some degree of fever if they are allowed to continue long enough. Fever suggests an inflammatory process; however, it is usually low grade and often absent altogether, particularly in elderly and immunocompromised patients. The combination of a high fever with chills and rigors indicates bacteremia, and concomitant changes in mental status (e.g., agitation, disorientation, and lethargy) suggest impending septic shock.

A history of trauma (even if the patient considers the traumatic event trivial) should be actively sought in all cases of unexplained acute abdominal pain; such a history may not be readily volunteered (as is often the case with trauma resulting from domestic violence). The history may be particularly relevant in a patient taking anticoagulants and presenting with acute onset of abdominal pain accompanied by tenderness but no clear signs of inflammation. Hematoma within the rectus muscle sheath can easily be mistaken for appendicitis or other lower abdominal illnesses; hematoma elsewhere can produce symptoms of obstruction or acute bleeding into the peritoneum and the retroperitoneum. In female patients, it is essential to obtain a detailed gynecologic history that includes the timing of symptoms within the menstrual cycle, the date of the last menses, previous and current use of contraception, any abnormal vaginal bleeding or discharge, an obstetric history, and any risk factors for ectopic pregnancy (e.g., PID, use of an intrauterine device, or previous ectopic or tubal surgery).

A complete history of previous medical conditions must be obtained because associated diseases of the cardiac, pulmonary, and renal systems may give rise to acute abdominal symptoms and may also significantly affect the morbidity and mortality associated with surgical intervention. Weight changes, past illnesses, recent travel, environmental exposure to toxins or infectious agents, and medications used should also be investigated. A history of previous abdominal operations should be obtained but should not be relied on too heavily in the absence of operative reports. A careful family history is important for detection of hereditary disorders that may cause acute abdominal pain. A detailed social history should also be obtained that includes any history of tobacco, alcohol, or illicit drug use, as well as a sexual history.

Tentative Differential Diagnosis

Once the history has been obtained, the examiner should generate a tentative differential diagnosis and carry out the physical examination in search of specific signs or findings that either rule out or confirm the diagnostic possibilities. Given the diversity of conditions that can cause acute abdominal pain [see Tables 1 and 2], there is no substitute for general awareness of the most common causes of acute abdominal pain and the influence of age, gender, and geography on the likelihood of any of these potential causes. Although acute abdominal pain is the most common surgical emergency and most non-trauma-related surgical admissions (and 1% of all hospital admissions) are accounted for by patients complaining of abdominal pain, little information is available regarding the clinical spectrum of disease in these patients.¹³ Nevertheless, detailed epidemiologic information can be an invaluable asset in the diagnosis and treatment of acute abdominal pain. Now that patients from different parts of the world are increasingly being seen in North American emergency rooms, it is important to consider endemic diseases, including tuberculosis,^14,15 parasitic diseases,^16–18 bezoars from unusual dietary habits,^19,20 and unusual malignancies.^21,22

The value of detailed epidemiologic knowledge notwithstanding, it is worthwhile to keep in mind the truism that common things are common. Regarding which things are common, the most extensive information currently available comes from the ongoing survey begun in 1977 by the Research Committee of the OMGE. As of the last progress report on this survey, which was published in 1988,²³ more than 200 physicians at 26 centers in 17 countries had accumulated data on 10,320 patients with acute abdominal pain [see Table 3]. The most common diagnosis in these patients was nonspecific abdominal pain (NSAP)—that is, the retrospective diagnosis of exclusion in which no cause for the pain can be identified.^24,25 Nonspecific abdominal pain accounted for 34% of all patients seen; the four most common diagnoses accounted for more than 75%. The most common surgical diagnosis in the OMGE survey was acute appendicitis, followed by acute cholecystitis, small bowel obstruction, and gynecologic disorders. Relatively few patients had perforated peptic ulcer, a finding that confirms the current downward trend in the incidence of this condition. Cancer was found to be a significant cause of acute abdominal pain. There was little variation in the geographic distribution of surgical causes of acute abdominal pain (i.e., conditions necessitating operation) among developed countries. In patients who required operation, the most common causes were acute appendicitis (42.6%), acute cholecystitis (14.7%), small bowel obstruction (6.2%), perforated peptic ulcer (3.7%), and acute pancreatitis (4.5%).²³ The OMGE survey's finding that NSAP was the most common diagnosis in patients with acute abdominal pain has been confirmed by several srudies^12,13,²⁵; the finding that acute appendicitis, cholecystitis, and intestinal obstruction were the three most common diagnoses in patients with acute abdominal pain who require operation has also been amply confirmed [see Table 3].^1,^12,13

The data described so far provide a comprehensive picture of the most likely diagnoses for patients with acute abdominal pain in many centers around the world; however, this picture does not take into account the effect of age on the relative likelihood of the various potential diagnoses. It is well known that the disease spectrum of acute abdominal pain is different in different age groups, especially in the very old^4,^26,27 and the very young.^28–30 In the OMGE survey, well over 90% of cases of acute abdominal pain in children were diagnosed as acute appendicitis (32%) or NSAP (62%).²⁸ Similar age-related differences in the spectrum of disease have been confirmed by other studies,¹⁶ as have various gender-related differences.

This variation in the disease spectrum is readily apparent when the 10,320 patients from the OMGE survey are segregated by age [see Table 4]. In patients 50 years of age or older,²⁷ cholecystitis was more common than either NSAP or acute appendicitis; small bowel obstruction, diverticular disease, and pancreatitis were all approximately five times more common than in patients younger than 50 years. Hernias were also a much more common problem in older patients. In the entire group of patients, only one of every 10 instances of intestinal obstruction was attributable to a hernia, whereas in patients 50 years of age or older, one of every three instances was caused by an undiagnosed hernia. Cancer was 40 times more likely to be the cause of acute abdominal pain in patients 50 years of age or older; vascular diseases (including myocardial infarction, mesenteric ischemia, and ruptured AAA) were 25 times more common in patients 50 years of age or older and 100 times more common in patients older than 70 years. What is more, outcome was clearly related to age: mortality was significantly higher in patients older than 70 years (5%) than in those younger than 50 years (< 1%). Whereas the peak incidence of acute abdominal pain occurred in patients in their teens and 20s,²⁸ the great majority of deaths occurred in patients older than 70 years.²⁷

Physical Examination

In the physical examination of a patient, as in the taking of the history, there is no substitute for organization and patience; the amount of information that can be obtained is directly proportional to the gentleness and thoroughness of the examiner. The physical examination begins with a brief but thorough evaluation of the patient's general appearance and ability to answer questions. The degree of obvious pain should be estimated. The patient's position in bed should be noted. A patient who lies motionless with flexed hips and knees is more likely to have generalized peritonitis. A restless patient who writhes about in bed is more likely to have colicky pain.

The area of maximal pain should be identified before the physical examination is begun. The examiner can easily do this by simply asking the patient to cough and then to point with two fingers to the area where pain seems to be focused. This allows the examiner to avoid the area in the early stages of the examination and to confirm it at a later stage without causing the patient unnecessary discomfort in the meantime.

The physical examination should be directed, in the sense that it should address critical findings that would confirm or exclude the likeliest disorders in the differential diagnosis. In this context, however, it should be complete. Some processes that can cause abdominal pain occur within the chest (e.g., pneumonia, ischemic heart disease or arrhythmia, esophageal muscular disorders); thus, auscultation of the lungs and the heart is integral to the examination. Pelvic examination should be performed in women, and examination of the rectum and the groin should be performed in all patients. It should not be assumed that advanced imaging technology (e.g., CT, MRI, or ultrasonography [US]) will provide the diagnosis most quickly or with the highest level of confidence. The sensitivity and specificity (not to mention the cost-effectiveness) of any laboratory or imaging study are grounded in the intelligent gathering and categorization of signs and symptoms.^31,32

Before attention is directed to the patient's abdomen, signs of systemic illness should be sought. Systemic signs of shock (e.g., diaphoresis, pallor, hypothermia, tachypnea, tachycardia with orthostasis, and frank hypotension) usually accompany a rapidly progressive or advanced intra-abdominal condition and, in the absence of extra-abdominal causes, are indications for immediate laparotomy. The absence of any alteration in vital signs, however, does not necessarily exclude a serious intra-abdominal process.

Examination of the abdomen begins with the patient resting in a comfortable supine position. A right-handed examiner should stand on the patient's right side, and the patient's abdomen should be level with the elbow at rest. In some cases, to make sure that the examination is unhurried and the patient's anxiety is allayed, the examiner may find it useful to sit at the bedside. The examination should include inspection, auscultation, percussion, and palpation of all areas of the abdomen, the flanks, and the groin (including all hernia orifices) in addition to rectal and genital examinations (and, in female patients, a full gynecologic examination). A systematic approach is crucial: an examiner who methodically follows a set pattern of abdominal examination every time will be rewarded more frequently than one who improvises haphazardly with each patient.

The first step in the abdominal examination is careful inspection of the anterior and posterior abdominal walls, the flanks, the perineum, and the genitalia for previous surgical scars (possible adhesions), hernias (incarceration or strangulation), distention (intestinal obstruction), obvious masses (distended gallbladder, abscesses, or tumors), ecchymosis or abrasions (trauma), striae (pregnancy or ascites), an everted umbilicus (increased intra-abdominal pressure), visible pulsations (aneurysm), visible peristalsis (obstruction), limitation of movement of the abdominal wall with ventilatory movements (peritonitis), or engorged veins (portal hypertension).

The next recommended step in the abdominal examination is auscultation. Although it is important to note the presence (or absence) of bowel sounds and their quality, auscultation is probably the least rewarding aspect of the physical examination. Severe intra-abdominal conditions, even intra-abdominal catastrophes, may occur in patients with normal bowel sounds, and patients with silent abdomens may have no significant intra-abdominal pathology at all. In general, however, the absence of bowel sounds indicates a paralytic ileus; hyperactive or hypoactive bowel sounds often are variations of normal activity; and high-pitched bowel sounds with splashes, tinkles (echoing as in a large cavern), or rushes (prolonged, loud gurgles) indicate mechanical bowel obstruction.

The third step is percussion to search for any areas of dullness, fluid collections, sections of gas-filled bowel, or pockets of free air under the abdominal wall. Tympany may be present in patients with bowel obstruction or hollow viscus perforation. Percussion can be useful as a way of estimating organ size and of determining the presence of ascites (signaled by a fluid wave or shifting dullness). Gentle percussion over the four quadrants of the abdomen can also be used to elicit a sign of peritoneal irritation, and patients tolerate this maneuver reasonably well. Pain associated with mild levels of percussion is a good indicator of peritonitis if the maneuver is performed in the same way each time. In general, however, maneuvers associated with palpation are best for determining whether peritonitis is present.

The last step, palpation, is the most informative aspect of the physical examination. Palpation of the abdomen must be done very gently to avoid causing additional pain early in the examination. It should begin as far as possible from the area of maximal pain and then should gradually advance toward this area, which should be the last to be palpated. The examiner should place the entire hand on the patient's abdomen with the fingers together and extended, applying pressure with the pulps (not the tips) of the fingers by flexing the wrists and the metacarpophalangeal joints. It is essential to determine whether true involuntary muscle guarding (muscle spasm) is present. This determination is made by means of gentle palpation over the abdominal wall while the patient takes a long, deep breath. If guarding is voluntary, the underlying muscle immediately relaxes under the gentle pressure of the palpating hand. If, however, the patient has true involuntary guarding, the muscle remains in spasm (i.e., taut and rigid) throughout the respiratory cycle (so-called boardlike abdomen). True involuntary guarding is indicative of localized or generalized peritonitis. It must be remembered that muscle rigidity is relative: for example, muscle guarding may be less pronounced or absent in debilitated and elderly patients who have poor abdominal musculature. In addition, the evaluation of muscle guarding is dependent on the patient's cooperation.

Palpation is also useful for determining the extent and severity of the patient's tenderness. Diffuse tenderness indicates generalized peritoneal inflammation. Mild diffuse tenderness without guarding usually indicates gastroenteritis or some other inflammatory intestinal process without peritoneal inflammation. Localized tenderness suggests an early stage of disease with limited peritoneal inflammation. Rebound tenderness is elicited by applying gentle but deep pressure to the region of interest and then letting go abruptly. As a means of distraction, the examiner may use the stethoscope to apply the pressure. The main difficulties associated with palpation are that the deep pressure may increase anxiety and that the surprise of the sudden withdrawal may elicit pain where peritoneal irritation is not the cause.

Careful palpation can elicit several specific signs [see Table 5], such as the Rovsing sign (pain in the right lower quadrant when the left lower quadrant is palpated deeply), which is associated with acute appendicitis, and the Murphy sign (arrest of inspiration when the right upper quadrant is deeply palpated), which is associated with acute cholecystitis. These signs are indicative of localized peritoneal inflammation. Similarly, specific maneuvers can elicit signs of localized peritoneal irritation. The psoas sign is elicited by placing the patient in the left lateral decubitus position and extending the right leg. In settings where appendicitis is suspected, pain on extension of the right leg indicates that the psoas is irritated and thus that the inflamed appendix is in a retrocecal position. The obturator sign is elicited by raising the flexed right leg and rotating the thigh internally. In settings where appendicitis is suspected, pain on rotation of the right thigh indicates that the obturator is irritated and thus that the inflamed appendix is in a pelvic position. The Kehr sign is elicited when the patient is placed in the Trendelenburg position. Pain in the shoulder indicates irritation of the diaphragm by a noxious fluid (e.g., gastric contents from a perforated ulcer, pus from a ruptured appendix, or free blood from a fallopian tube pregnancy). Another useful maneuver is the Carnett test, in which the patient elevates his or her head off the bed, thus tensing the abdominal muscles. When the pain is caused by abdominal wall conditions (e.g., rectal sheath hematoma), tenderness to palpation persists, but when the pain is caused by intraperitoneal conditions, tenderness to palpation decreases or disappears (the Carnett sign).

Rectal, genital, and (in women) pelvic examinations are essential to the evaluation of all patients with acute abdominal pain. The rectal examination should include evaluation of sphincter tone, tenderness (localized versus diffuse), and prostate size and tenderness, as well as a search for the presence of hemorrhoids, masses, fecal impaction, foreign bodies, and gross or occult blood. The genital examination should search for adenopathy, masses, discoloration, edema, and crepitus. The pelvic examination in women should check for vaginal discharge or bleeding, cervical discharge or bleeding, cervical mobility and tenderness, uterine tenderness, uterine size, and adnexal tenderness or masses. Although a carefully performed pelvic examination can be invaluable in differentiating nonsurgical conditions (e.g., pelvic inflammatory disease and tubo-ovarian abscess) from conditions necessitating prompt operation (e.g., acute appendicitis), the possibility that a surgical condition is present should not be prematurely dismissed solely on the basis of a finding of tenderness on pelvic or rectal examination.

Investigative Studies

Laboratory tests and imaging studies rarely, if ever, establish a definitive diagnosis by themselves; however, if used in the correct clinical setting, they can confirm or exclude specific diagnoses suggested by the history and the physical examination.

Laboratory Tests

In all patients except those in extremis, a complete blood count, blood chemistries, and a urinalysis are routinely obtained before a decision to operate. The hematocrit is important in that it allows the surgeon to detect significant changes in plasma volume (e.g., dehydration caused by vomiting, diarrhea, or fluid loss into the peritoneum or the intestinal lumen), preexisting anemia, or bleeding. An elevated white blood cell (WBC) count is indicative of an inflammatory process and is a particularly helpful finding if associated with a marked left shift; however, the presence or absence of leukocytosis should never be the single deciding factor as to whether the patient should undergo an operation. A low WBC count may be a feature of viral infections, gastroenteritis, or NSAP. Other tests, such as C-reactive protein assay, may be useful for increasing confidence in the diagnosis of an acute inflammatory condition. An important consideration in the use of any such test is that derangements develop over time, becoming more likely as the illness progresses; thus, serial examinations might be more useful than a single test result obtained at an arbitrary point. Indeed, for the diagnosis of acute appendicitis, serial observations of the leukocyte count and the C-reactive protein level have been shown to possess greater predictive value than single observations.³³

Serum electrolyte, blood urea nitrogen (BUN), and creatinine concentrations are useful in determining the nature and extent of fluid losses. Blood glucose and other blood chemistries may also be helpful. Liver function tests (serum bilirubin, alkaline phosphatase, and transaminase levels) are mandatory when abdominal pain is suspected of being hepatobiliary in origin. Similarly, amylase and lipase determinations are mandatory when pancreatitis is suspected, though it must be remembered that amylase levels may be low or normal in patients with pancreatitis and may be markedly elevated in patients with other conditions (e.g., intestinal obstruction, mesenteric thrombosis, and perforated ulcer).

Urinalysis may reveal red blood cells (RBCs) (suggestive of renal or ureteral calculi), WBCs (suggestive of urinary tract infection or inflammatory processes adjacent to the ureters, such as retrocecal appendicitis), increased specific gravity (suggestive of dehydration), glucose, ketones (suggestive of diabetes), or bilirubin (suggestive of hepatitis). A pregnancy test should be considered in any woman of childbearing age who is experiencing acute abdominal pain.

Electrocardiography is mandatory in elderly patients and in patients with a history of cardiomyopathy, dysrhythmia, or ischemic heart disease. Abdominal pain may be a manifestation of myocardial disease, and the physiologic stress of acute abdominal pain can increase myocardial oxygen demands and induce ischemia in patients with coronary artery disease.

Imaging

Until relatively recently, initial radiologic evaluation of the patient with acute abdominal pain included plain films of the abdomen in the supine and standing positions and chest radiographs.³⁴ Currently, CT scanning (when available) is generally considered more likely to be helpful in most situations.^35,36 Still, there remain some situations in which plain films may be a more useful and safe form of investigation—as, for example, when a strangulating obstruction is thought to be the most likely diagnosis and plain films are used for rapid confirmation. If the diagnosis of strangulating obstruction is in doubt, however, CT scanning—particularly with the newer generations of scanning instruments—is useful for making a definitive diagnosis and for identifying clinically unsuspected strangulation.^37–39

When performed in the correct clinical setting, imaging studies may confirm diagnoses such as pneumonia (signaled by pulmonary infiltrates); intestinal obstruction (air-fluid levels and dilated loops of bowel); intestinal perforation (pneumoperitoneum); biliary, renal, or ureteral calculi (abnormal calcifications); appendicitis (fecalith); incarcerated hernia (bowel protruding beyond the confines of the peritoneal cavity); mesenteric infarction (air in the portal vein); chronic pancreatitis (pancreatic calcifications); acute pancreatitis (the so-called colon cutoff sign); visceral aneurysms (calcified rim); retroperitoneal hematoma or abscess (obliteration of the psoas shadow); and ischemic colitis (so-called thumbprinting on the colonic wall).

Although in most settings, CT is the preferred modality for primary evaluation of acute abdominal pain, there are certain settings in which US should be considered. When gallstones are considered a likely diagnosis, US is more apt to be diagnostic than CT is, given that about 85% of gallstones are not detectable by x-rays. In disorders of the female genitourinary tract, US is also quite sensitive and specific for diagnoses such as ovarian cyst, fallopian tube pregnancy, and intrauterine pregnancy. Although there are reassuring reports that the risks of radiation from CT scanning can be managed in children and pregnant women with abdominal pain,^40,41 there remain theoretical concerns regarding the teratogenicity of the radiation dose.⁴² Accordingly, it would seems prudent to consider US the preferred initial imaging test for such patients. In these circumstances, CT is employed only if the diagnosis remains unresolved and if the potential delay in diagnosis (from not obtaining a CT scan) is likely to cause harm.

Working or Presumed Diagnosis

The tentative differential diagnosis developed on the basis of the clinical history is refined on the basis of the physical examination and the investigative studies performed, and a working or presumed diagnosis is generated. Once a working diagnosis has been established, subsequent management depends on the accepted treatment for the particular condition believed to be present. In general, the course of management follows four basic pathways [see Management: Surgical versus Nonsurgical Treatment, below], depending on whether the patient (1) has an acute surgical condition that necessitates immediate laparotomy, (2) is believed to have an underlying surgical condition that does not necessitate immediate laparotomy but does call for urgent or early operation, (3) has an uncertain diagnosis that does not necessitate immediate or urgent laparotomy and that may prove to be nonsurgical, or (4) is believed to have an underlying nonsurgical condition.

It must be emphasized that the patient must be constantly reevaluated (preferably by the same examiner) even after the working diagnosis has been established. If the patient does not respond to treatment as expected, the working diagnosis must be reconsidered, and the possibility that another condition exists must be immediately entertained and investigated by returning to the differential diagnosis.

Management: Surgical versus Nonsurgical Treatment

Acute Surgical Abdomen

A thorough but expeditious approach to patients with acute abdominal pain is essential because in some patients, action must be taken immediately and there is not enough time for an exhaustive evaluation. As outlined (see above), such an approach should include a brief initial assessment, a complete clinical history, a thorough physical examination, and targeted laboratory and imaging studies. These steps can usually be completed in less than 1 hour and should be insisted on in the evaluation of most patients. In most cases, it is wise to resist the temptation to rush to the operating room with an incompletely evaluated, unprepared, and unstable patient. Sometimes, the anxiety of the patient or the impatience of the health care providers requesting the surgeon's consultation creates an unwarranted feeling of urgency. Often, however, the anxiety or impatience is on the part of the surgeon and, if indulged, may be a cause of subsequent regret.

There are very few abdominal crises that mandate immediate operation, and even with these conditions, it is still necessary to spend a few minutes on assessing the seriousness of the problem and establishing a probable diagnosis. Among the most common of the abdominal catastrophes that necessitate immediate operation are ruptured AAAs or visceral aneurysms, ruptured ectopic pregnancies, and spontaneous hepatic or splenic ruptures. The relative rarity of such conditions notwithstanding, it must always be remembered that patients with acute abdominal pain may have a progressive underlying intra-abdominal disorder causing the acute pain and that unnecessary delays in diagnosis and treatment can adversely affect outcome, often with catastrophic consequences.

Subacute Surgical Abdomen

When immediate operation is not called for, the physician must decide whether urgent laparotomy or nonurgent but early operation is necessary. Urgent laparotomy implies operation within 4 hours of the patient's arrival; thus, there is usually sufficient time for adequate resuscitation, with proper rehydration and restoration of vital organ function, before the procedure. Indications for urgent laparotomy may be encountered during the physical examination, may be revealed by the basic laboratory and radiologic studies, or may not become apparent until other investigative studies are performed. Involuntary guarding or rigidity during the physical examination, particularly if spreading, is a strong indication for urgent laparotomy. Other indications include increasing severe localized tenderness, progressive tense distention, physical signs of sepsis (e.g., high fever, tachycardia, hypotension, and mental-status changes), and physical signs of ischemia (e.g., fever and tachycardia). Basic laboratory and radiologic indications for urgent laparotomy include pneumoperitoneum, massive or progressive intestinal distention, signs of sepsis (e.g., marked or rising leukocytosis, increasing glucose intolerance, and acidosis), and signs of continued hemorrhage (e.g., a falling hematocrit). Additional findings that constitute indications for urgent laparotomy include free extravasation of radiologic contrast material, mesenteric occlusion on angiography, endoscopically uncontrollable bleeding, and positive results from peritoneal lavage (i.e., the presence of blood, pus, bile, urine, or GI contents). Acute appendicitis, perforated hollow viscera, and strangulated hernias are examples of common conditions that necessitate urgent laparotomy.

If early operation is contemplated, it may still be prudent to obtain additional studies to obtain information related to the site of the lesion or to associated anatomic pitfalls. In deciding whether to order such studies, it is important to consider not only whether the additional information obtained will increase confidence in the diagnosis but also whether the extra time, expense, and discomfort involved will be justified by the quality and usefulness of the information.⁴³ During a short, defined period of resuscitation, it may be possible to employ CT scanning to identify the location of the inflamed appendix in difficult (i.e., retrocecal or pelvic) locations. Knowing the location of the appendix and its morphology can be helpful in directing the incision in an open operation or determining the most expeditious exposure in a laparoscopic procedure. CT scanning may also be used to identify an atypical site of a visceral perforation (e.g., the proximal stomach, the distal or posterior wall of the duodenum, or the transverse colon), thereby guiding placement of the incision and obviating needless dissection of tissue planes. In the setting of distal bowel obstruction, an expeditious Gastrografin (Bracco Diagnostics, Princeton, New Jersey) enema or CT scan may alert the surgeon to the possibility of an otherwise undetectable malignancy (e.g., cecal carcinoma causing distal bowel obstruction). In cases where ischemic bowel is suspected, the site of vascular blockage can be localized by using a CT-angiogram imaging protocol. In each of these examples, the information gained may permit the surgeon to plan the operation, to optimize time spent under anesthesia, and to minimize postoperative discomfort after laparotomy.

The use of preoperative imaging has become increasingly important as an operative planning tool, particularly when laparoscopic approaches are contemplated for management of acute abdominal emergencies. In the 1990s and the first few years of the 21st century, a number of trials were performed to determine whether laparoscopy or open operation should be the approach of choice when the primary clinical diagnosis is acute appendicitis. This topic has been reviewed extensively in the literature^44–46 and in a 2004 update of a Cochrane meta-analysis.⁴⁷ In some environments, the answer to this question remains unclear.^48,49 In many settings, however, the current consensus is that uncomplicated appendicitis can be treated laparoscopically, with a clear expectation of less postoperative pain, a shorter hospital stay, and an earlier return to work and regular activities. These advantages, though significant, do not indicate that a laparoscopic approach is to be preferred in all or most clinical settings or that it is necessarily more cost-effective than an open approach.⁴⁷ Laparoscopic appendectomy requires a high level of organization with respect to operating room resources, and this level of organization may be difficult to achieve in institutions where the procedure is not performed regularly (particularly in the middle of the night). In addition, it is not clear whether patients with appendicitis that is complicated by a well-established abscess or bowel obstruction benefit from laparoscopic approaches.

Anatomic considerations also enter into the decision whether to perform the procedure laparoscopically. For instance, it can be very difficult to separate a perforated retrocecal appendix from adherent colon in a safe manner. In many cases, it is prudent not to persist in attempting to extract the appendix without a standard open incision, excellent exposure, and controlled technique. The importance of anatomic considerations underscores the usefulness of preoperative CT in identifying pathologic anatomy, associated abnormalities, and potential pitfalls for either open or laparoscopic approaches.

The advantages of laparoscopy in the management of other abdominal emergencies are less clear-cut. It is important that the surgeon determine not only whether the particular clinical scenario is amenable to a laparoscopic approach but also whether the experience of the entire team and that of the institution as a whole are sufficient for what may be an advanced procedure performed in an acute situation. With this caveat in mind, various investigators have demonstrated that laparoscopy can be employed safely and with good clinical results in selected patients with perforated peptic ulcers.^50–54 Two prospective, randomized, controlled trials comparing open repair of perforated peptic ulcers with laparoscopic repair found that the latter was safe and reliable and was associated with shorter operating times, less postoperative pain, fewer chest complications, shorter postoperative hospital stays, and earlier return to normal daily activities than the former.^52,⁵⁴

Acute Abdominal Pain Requiring Observation

It is widely recognized that of all patients admitted for acute abdominal pain, only a minority require immediate or urgent operation.^2,¹² It is therefore both cost-effective and prudent to adopt a system of evaluation that allows for thought and investigation before definitive treatment in all patients with acute abdominal pain except those identified early on as needing immediate or urgent laparotomy. The traditional wisdom has been that spending time on observation opens the door for complications (e.g., perforating appendicitis, intestinal perforation associated with bowel obstruction, or strangulation of an incarcerated hernia). However, clinical trials evaluating active in-hospital observation of patients with acute abdominal pain of uncertain origin have demonstrated that such observation is safe, is not accompanied by an increased incidence of complications, and results in fewer negative laparotomies.⁵⁵ Many institutions now employ CT scanning liberally in patients with uncertain diagnoses; this practice should greatly minimize the incidence of diagnostic failures or delays in patients with acute conditions necessitating surgical intervention.³²

The initial resuscitation and assessment are followed by appropriate imaging studies and serial observation. Specific monitoring measures are chosen (e.g., examination of the abdomen, measurement of urine output, a WBC count, and repeat CT scans), and end points of therapy should be identified. Active observation allows the surgeon to identify most of the patients whose acute abdominal pain is caused by NSAP or by various specific nonsurgical conditions. It must be emphasized that active observation involves more than simply admitting the patient to the hospital and passively watching for obvious problems: it implies an active process of thoughtful, discriminating, and meticulous reevaluation (preferably by the same examiner) at intervals ranging from minutes to a few hours, complemented by appropriately timed additional investigative studies.

A major point of contention in the management of patients with acute abdominal pain is the use of narcotic analgesics during the observation period. The main argument for withholding pain medication is that it may obscure the evolution of specific findings that would lead to the decision to operate. The main argument for giving narcotic analgesics is that in a controlled setting where patients are being observed by experienced clinicians, outcomes are not compromised and patients are more comfortable.⁵⁶ It has also been suggested that providing early pain relief may allow the more critical clinical signs to be more clearly identified⁵⁷ and that severe pain persisting despite adequate doses of narcotics suggests a serious condition for which operative intervention is likely to be necessary.

In my view, the decision whether to provide or withhold narcotic analgesia must be individualized.⁵⁸ The current consensus is that for most patients undergoing evaluation and observation for acute abdominal pain, it is safe to provide medication in doses that would 'take the edge off' the pain without rendering the patient unable to cooperate during the observation period. It may be especially desirable to provide medication in a manner that allows the patient to be comfortable while lying in the CT scanner. In these cases, the goal of pain relief is to make it easier to obtain accurate information that will facilitate and expedite the diagnosis and the development of a treatment plan. Given the high diagnostic yield and accuracy of the new generation of CT scanners, it is generally safe to provide pain medication while obtaining the diagnosis.

On occasion, however, reflex administration of pain medication solely with the aim of relieving pain may be undesirable or even harmful. For example, in situations where advanced imaging is unavailable, physical examination may be so crucial to decision making that any risk of obscuring important physical findings is deemed unacceptable, and therefore, pain medication should be withheld. In addition, narcotic analgesia should be used cautiously in patients with acute intestinal obstruction when strangulation is a concern.⁵⁹ These patients present with abdominal pain that is out of proportion to the physical findings, a syndrome whose differential diagnosis includes acute intestinal ischemia, pancreatitis, ruptured aortic aneurysm, ureteral colic, and various medical causes (e.g., sickle cell crisis and porphyria). A period of resuscitation and evaluation, in conjunction with advanced imaging studies (e.g., CT) may then yield a tentative diagnosis of intestinal obstruction caused by adhesions (e.g., if the patient has a history of abdominal surgery and no evidence of herniation or obturation) without evidence of bowel ischemia. In this setting, the decision whether to admit the patient for observation rather than immediate operation depends on the extent to which the surgeon is confident that the obstruction is not a 'closed loop.'⁵⁹ However, within a relatively short period (perhaps 4 to 24 hours), the surgeon must determine whether any indications for operation will arise, and the main parameters for observation include the WBC count, the urine output, and the development of peritoneal findings. In such cases, it may well be prudent to withhold pain medication until there is a high level of confidence that the timing of surgery will not be delayed.

A final point is that over the course of a 24- to 48-hour observation period, the patient's condition may neither deteriorate nor improve, and supplemental investigation may be considered. Diagnostic laparoscopy has been recommended in cases where surgical disease is suspected but its probability is not high enough to warrant open laparotomy.^60,61 It is particularly valuable in young women of childbearing age, in whom gynecologic disorders frequently mimic acute appendicitis.^62–64 A 1998 report showed that diagnostic laparoscopy had the same diagnostic yield as open laparotomy in 55 patients with acute abdomen; 34 (62%) of these patients were safely managed with laparoscopy alone, with no increase in morbidity and with a shorter average hospital stay.⁶³ Diagnostic laparoscopy has also been shown to be useful for assessing acute abdominal pain in acutely ill patients in the intensive care unit.^60,⁶⁵

In patients with AIDS,^66,67 there are a number of unusual diagnoses that may be related to or coincident with an episode of abdominal pain. The differential diagnosis includes lymphoma, Kaposi sarcoma, tuberculosis and variants thereof, and opportunistic bacterial, fungal, and viral (especially cytomegaloviral) infections. Laparoscopy has been used for the purposes of diagnosis, biopsy, and treatment in patients with an established AIDS diagnosis who manifest acute abdominal pain syndrome.^66,67 The complication rate and mortality associated with surgery are related to the underlying illness, and outcomes have improved steadily over the years.⁶⁸ It is important to note that patients who are infected with HIV but have no clinical manifestations of AIDS are evaluated and managed in the same fashion as patients without HIV infection when they present with acute abdominal pain. The differential diagnosis and the outcomes are essentially no different, unless there are reasons to think that the new onset of pain in an HIV-infected patient is a manifestation of AIDS.^58,⁶⁸

Subacute or Chronic Relapsing Abdominal Pain: Role of Outpatient Evaluation and Management

For every patient who requires hospitalization for acute abdominal pain, there are at least two or three others who have self-limiting conditions for which neither operation nor hospitalization is necessary. Much or all of the evaluation of such patients, as well as any treatment that may be needed, can now be completed in the outpatient department. To treat acute abdominal pain cost-effectively and efficiently, the surgeon must be able not only to identify patients who need immediate or urgent laparotomy or laparoscopy but also to reliably identify those whose condition does not present a serious risk and who therefore can be managed without hospitalization. The reliability and intelligence of the patient, the proximity and availability of medical facilities, and the availability of responsible adults to observe and assist the patient at home are factors that should be carefully considered before the decision is made to evaluate or treat individuals with acute abdominal pain as outpatients.

Suspected Nonsurgical Abdomen

There are numerous disorders that cause acute abdominal pain but do not call for surgical intervention. These nonsurgical conditions are often extremely difficult to differentiate from surgical conditions that present with almost indistinguishable characteristics.² For example, the acute abdominal pain of lead poisoning or acute porphyria is difficult to differentiate from the intermittent pain of intestinal obstruction, in that marked hyperperistalsis is the hallmark of both. As another example, the pain of acute hypolipoproteinemia may be accompanied by pancreatitis, which, if not recognized, can lead to unnecessary laparotomy. Similarly, acute and prostrating abdominal pain accompanied by rigidity of the abdominal wall and a low hematocrit may lead to unnecessary urgent laparotomy in patients with sickle cell anemia crises. To further complicate the clinical picture, cholelithiasis is also often found in patients with sickle cell anemia.

In addition to numerous extraperitoneal disorders [see Table 2], nonsurgical causes of acute abdominal pain include a wide variety of intraperitoneal disorders, such as acute gastroenteritis (from enteric bacterial, viral, parasitic, or fungal infection), acute gastritis, acute duodenitis, hepatitis, mesenteric adenitis, salpingitis, Fitz-Hugh-Curtis syndrome, mittelschmerz, ovarian cyst, endometritis, endometriosis, threatened abortion, spontaneous bacterial peritonitis, and tuberculous peritonitis. As noted (see above), acute abdominal pain in immunosuppressed patients or patients with AIDS is now encountered with increasing frequency and can be caused by a number of unusual conditions (e.g., cytomegalovirus enterocolitis, opportunistic infections, lymphoma, and Kaposi sarcoma), as well as by the more usual ones.

Although such disorders typically are not treated by operative means, operation is sometimes required when the diagnosis is uncertain or when a surgical illness cannot be excluded with confidence. In such cases, laparoscopy can be very helpful, permitting relatively complete and systematic exploration without involving the potential morbidity or the longer postoperative recovery and rehabilitation period associated with open exploration.^69–72 From the surgeon's point of view, an optimal outcome for laparoscopic exploration in these settings is one in which a diagnosis is established by means of visualization, with or without biopsy, and in which symptoms improve as a consequence of a therapy directed by the laparoscopic findings. Overall, candidate lesions—including appendiceal pathology (e.g., chronic appendicitis or carcinoid tumor), adhesions, hernias, endometriosis, mesenteric lymphadenopathy—are identified in about 50% of cases, with pelvic adhesions the most common finding. From the patient's point of view, however, establishing a precise diagnosis may not be particularly critical, and symptomatic improvement, by itself, may suffice to render the outcome successful. Indeed, a number of reports have emphasized that laparoscopy often leads to improvement in symptoms even if no lesion is identified or treated.^69,70 This point may be illustrated by considering pelvic adhesions.

Given the frequency with which laparoscopic exploration identifies pelvic adhesions, adhesiolysis might be expected to alleviate abdominal pain in many cases. However, it is unclear whether adhesiolysis is therapeutically beneficial when there is no firm evidence that the adhesions are contributing to the pain syndrome. In one prospective, randomized trial,⁷³ 100 patients with laparoscopically identified adhesions were randomly allocated to either a group that underwent adhesiolysis or one that did not. Both groups reported substantial pain relief and a significantly improved quality of life, but there were no differences in outcome between them, which suggested that the benefit of laparoscopy could not be attributed to adhesiolysis. Longer-term studies also failed to support the hypothesis that pelvic adhesions are responsible for chronic pelvic pain.⁷⁴ However, in a study conducted concurrently with the aforementioned randomized trial, 224 consecutive patients underwent laparoscopically assisted adhesiolysis, and 74% of the 224 obtained short-term relief.⁷⁵ Factors that contributed to a successful outcome were gender, age, and adhesions severe enough to have led to inadvertent enterotomy and a consequent need for open exploration. It may, therefore, be possible to identify specific subgroups that would benefit from the addition of adhesiolysis to exploratory laparoscopy.

A similar issue arises with respect to pathologic conditions of the appendix—namely, whether appendectomy should be performed when no other source of the abdominal pain can be identified. Early enthusiasm for appendectomy in patients with chronic right lower quadrant pain was sparked by observations of acute or chronic inflammation in specimens that seemed visibly normal.^76,77 In subsequent reports, however, this enthusiasm was tempered by the recognition that these pathologic findings were not very prevalent and that appendectomy did not always reduce the pain.^78,79 No randomized trial of appendectomy for chronic abdominal pain has been performed in a clearly defined patient group, as has been done for adhesiolysis.⁷³

At present, the surgeon can only use his or her best judgment as to the likelihood that a given episode of abdominal pain may originate from a set of visible adhesions or a visually normal appendix. It should be remembered that unnecessary or potentially meddlesome interventions are always best avoided; however, it should also be remembered that failure to alleviate chronic relapsing abdominal pain will lead to a program of chronic pain management, including long-term management with potentially addictive and enervating agents. Thus, if adhesiolysis or appendectomy can be performed with the expectation of low morbidity and without conversion to laparotomy, it seems reasonable to perform these procedures during laparoscopy if no other source of pain can be identified.

Acknowledgments

Figures 2 and 3 Tom Moore.

Portions of this chapter are based on a previous iteration written for ACS Surgery by Romano Delcore, M.D., F.A.C.S., and Laurence Y. Cheung, M.D., F.A.C.S. The author wishes to thank Drs. Delcore and Cheung.

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79. van den Broek WT, Bijnen AB, de Ruiter P, et al: A normal appendix found during diagnostic laparoscopy should not be removed. Br J Surg 88:251, 2001 [PMID 11167876]

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81. McFadden DW, Zinner MJ: Manifestations of gastrointestinal disease. Principles of Surgery, 6th ed. Schwartz SI, Shires GT, Spencer FC, Eds. McGraw-Hill, New York, 1994 , p 1015

82. Wilson DH, Wilson PD, Walmsley RG, et al: Diagnosis of acute abdominal pain in the accident and emergency department. Br J Surg 64:249, 1977

83. Hawthorn IE: Abdominal pain as a cause of acute admission to hospital. J R Coll Surg Edinb 37:389, 1992 [PMID 1283410]

What's New ...

Section 5 Gastrointestinal Tract and Abdomen

1 Acute Abdominal Pain

David I. Soybel, MD, FACS

Harvard Medical School

Clinical evaluation, investigative studies, presumed diagnosis, and surgical versus nonsurgical treatment are discussed.

Good Judgment Needed during Feelings of Urgency

A thorough but expeditious approach to patients with acute abdominal pain is essential because in some patients, action must be taken immediately and there is not enough time for an exhaustive evaluation. Such an approach should include a brief initial assessment, a complete clinical history, a thorough physical examination, and targeted laboratory and imaging studies. These steps can usually be completed in less than 1 hour and should be insisted on in the evaluation of most patients. In most cases, it is wise to resist the temptation to rush to the operating room with an incompletely evaluated, unprepared, and unstable patient. Sometimes, the anxiety of the patient or the impatience of the health care providers requesting the surgeon's consultation creates an unwarranted feeling of urgency. Often, however, the anxiety or impatience is on the part of the surgeon and, if indulged, may be a cause of subsequent regret.

There are very few abdominal crises that mandate immediate operation, and even with these conditions, it is still necessary to spend a few minutes on assessing the seriousness of the problem and establishing a probable diagnosis. Among the most common of the abdominal catastrophes that necessitate immediate operation are ruptured abdominal aortic aneurysms or visceral aneurysms, ruptured ectopic pregnancies, and spontaneous hepatic or splenic ruptures. The relative rarity of such conditions notwithstanding, it must always be remembered that patients with acute abdominal pain may have a progressive underlying intra-abdominal disorder causing the acute pain and that unnecessary delays in diagnosis and treatment can adversely affect outcome, often with catastrophic consequences.

Diagnosing Acute Abdominal Pain in a Shrinking World

Although acute abdominal pain is the most common surgical emergency and most non-trauma-related surgical admissions (and 1% of all hospital admissions) are accounted for by patients complaining of abdominal pain, little information is available regarding the clinical spectrum of disease in these patients. Nevertheless, detailed epidemiologic information can be an invaluable asset in the diagnosis and treatment of acute abdominal pain. Now that patients from different parts of the world are increasingly being seen in North American emergency departments, it is important to consider endemic diseases, including tuberculosis,¹ parasitic diseases,² bezoars from unusual dietary habits, and unusual malignancies.^3,4

1. Padussis J, Loffredo B, McAneny D: Minimally invasive management of obstructive gastroduodenal tuberculosis. Am Surg 71:698, 2005 [PMID 16217956]

2. Petro M, Iavu K, Minocha A: Unusual endoscopic and microscopic view of Enterobius vermicularis: a case report with a review of the literature. South Med J 98:927, 2005 [PMID 16217987]

3. Parente F, Anderloni A, Greco S, et al: Ileocecal Burkitt's lymphoma. Gastroenterology 127:368, 2004 [PMID 15236165]

4. Qiu DC, Hubbard AE, Zhong B, et al: A matched, case-control study of the association between Schistosoma japonicum and liver and colon cancers, in rural China. Ann Trop Med Parasitol 99:47, 2005 [PMID 15701255]

The Role of Plain Films in Diagnosing Acute Abdominal Pain

Until relatively recently, initial radiologic evaluation of the patient with acute abdominal pain included plain films of the abdomen in the supine and standing positions and chest radiographs. Currently, CT scanning (when available) is generally considered more likely to be helpful in most situations.¹ Still, there remain some situations in which plain films may be a more useful and safe form of investigation—as, for example, when a strangulating obstruction is thought to be the most likely diagnosis and plain films are used for rapid confirmation. If the diagnosis of strangulating obstruction is in doubt, however, CT scanning—particularly with the newer generations of scanning instruments—is useful for making a definitive diagnosis and for identifying clinically unsuspected strangulation.²

1. MacKersie AB, Lane MJ, Gerhardt RT, et al: Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series. Radiology 237:114, 2005 [PMID 16183928]

2. Mallo RD, Salem L, Lalani T, et al: Computed tomography diagnosis of ischemia and complete obstruction in small bowel obstruction: a systematic review. J Gastrointest Surg 9:690, 2005 [PMID 15862265]

Ultrasound Preferred over CT for Pregnant Patients with Abdominal Pain

Although in most settings, computed tomography is the preferred modality for primary evaluation of acute abdominal pain, there are certain settings in which ultrasonography (US) should be considered. When gallstones are considered a likely diagnosis, US is more apt to be diagnostic than CT is, given that about 85% of gallstones are not detectable by x-rays. In disorders of the female genitourinary tract, US is also quite sensitive and specific for diagnoses such as ovarian cyst, fallopian tube pregnancy, and intrauterine pregnancy. Although there are reassuring reports that the risks of radiation from CT scanning can be managed in children and pregnant women with abdominal pain,^1,2 there remain theoretical concerns regarding the teratogenicity of the radiation dose.³ Accordingly, it would seem prudent to consider US the preferred initial imaging test for such patients. In these circumstances, CT is employed only if the diagnosis remains unresolved and if the potential delay in diagnosis (from not obtaining a CT scan) is likely to cause harm.

1. Wagner LK, Huda W: When a pregnant woman with suspected appendicitis is referred for a CT scan, what should a radiologist do to minimize potential radiation risks? Pediatr Radiol 34:589, 2004 [PMID 15164139]

2. Fefferman NR, Bomsztyk E, Yim AM, et al: Appendicitis in children: low-dose CT with a phantom-based simulation technique—initial observations. Radiology 237:641, 2005 [PMID 16170015]

3. Hurwitz LM, Yoshizumi T, Reiman RE, et al: Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol 186:871, 2006 [PMID 16498123]

Acute Abdominal Pain

Question 1

A 24-year-old man presents with acute abdominal pain that is localized to the right quadrant. The pain was of gradual onset. It became localized a few hours after onset. The pain is continuous. Associated symptoms include anorexia and one episode of vomiting.

For this patient, which of the following signs would be an indication for immediate laparotomy?

Please choose the single most appropriate answer to the question

Fever

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Elevated white blood cell (WBC) count

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Rebound and guarding on physical examination

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Frank hypotension

This is correct.

Objective: To understand the significance of shock in patients with acute abdominal pain

The evaluation of patients with acute abdominal pain can be one of the most difficult challenges in clinical surgery. The physical examination of the patient should address critical findings that would confirm or exclude the likeliest disorders in the differential diagnosis. Some processes that can cause abdominal pain occur within the chest (e.g., pneumonia, ischemic heart disease or arrhythmia, esophageal muscular disorders); thus, auscultation of the lungs and the heart is integral to the examination. Pelvic examination should be performed in women, and examination of the rectum and the groin should be performed in all patients. It should not be assumed that advanced imaging technology (e.g., computed tomography, magnetic resonance imaging, or ultrasonography) will provide the diagnosis most quickly or with the highest level of confidence. The sensitivity and specificity (not to mention the cost-effectiveness) of any laboratory or imaging study are grounded in the intelligent gathering and categorization of signs and symptoms. Before attention is directed to the patient's abdomen, signs of systemic illness should be sought. Systemic signs of shock (e.g., diaphoresis, pallor, hypothermia, tachypnea, tachycardia with orthostasis, and frank hypotension) usually accompany a rapidly progressive or advanced intra-abdominal condition and, in the absence of extra-abdominal causes, are indications for immediate laparotomy. The absence of any alteration in vital signs, however, does not necessarily exclude a serious intra-abdominal process.

Question 2

A 56-year-old woman has been experiencing abdominal pain for 4 hours. The pain is in right upper quadrant and radiates into the scapular region. She has had multiple episodes of vomiting.

For this patient, which of the following signs on physical examination is associated with acute cholecystitis?

Please choose the single most appropriate answer to the question

Murphy sign

This is correct.

Objective: To understand the signs elicited during the physical examination of patients in acute abdominal pain

During physical examination, careful palpation can elicit several specific signs, such as the Rovsing sign (pain in the right lower quadrant when the left lower quadrant is palpated deeply), which is associated with acute appendicitis, and the Murphy sign (arrest of inspiration when the right upper quadrant is deeply palpated), which is associated with acute cholecystitis. These signs are indicative of localized peritoneal inflammation. The Kehr sign is elicited when the patient is placed in the Trendelenburg position. Pain in the shoulder indicates irritation of the diaphragm by a noxious fluid (e.g., gastric contents from a perforated ulcer, pus from a ruptured appendix, or free blood from a fallopian tube pregnancy). In eliciting the Carnett sign, the patient is instructed to elevate his or her head off the bed, which results in a tensing of the abdominal muscles; palpation is then performed. When the pain is caused by intraperitoneal conditions, tenderness to palpation decreases or disappears (the Carnett sign). When the pain is caused by abdominal wall conditions (e.g., rectal sheath hematoma), tenderness to palpation persists.
Rovsing sign

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Kehr sign

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Carnett sign

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Question 3

A 35-year-old man presents with acute abdominal pain of rapid onset. The patient describes the pain as being a burning sensation. The pain initially began in the upper abdomen and has now settled in the right lower quadrant. On examination, the patient is febrile. He exhibits involuntary guarding.

Which of the following is the most appropriate course of management for this patient?

Please choose the single most appropriate answer to the question

Observation

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Urgent laparotomy

This is correct.

Objective: To understand the management of acute abdominal pain

Once a working diagnosis has been established, subsequent management depends on the accepted treatment for the particular condition believed to be present. The physician must decide whether urgent laparotomy or nonurgent but early operation is necessary. Indications for urgent laparotomy may be encountered during the physical examination, may be revealed by the basic laboratory and radiologic studies, or may not become apparent until other investigative studies are performed. Involuntary guarding or rigidity during the physical examination, particularly if spreading, is a strong indication for urgent laparotomy. Other indications include increasing severe localized tenderness, progressive tense distention, physical signs of sepsis (e.g., high fever, tachycardia, hypotension, and mental-status changes), and physical signs of ischemia (e.g., fever and tachycardia). Basic laboratory and radiologic indications for urgent laparotomy include pneumoperitoneum, massive or progressive intestinal distention, signs of sepsis (e.g., marked or rising leukocytosis, increasing glucose intolerance, and acidosis), and signs of continued hemorrhage (e.g., a falling hematocrit). Additional findings that constitute indications for urgent laparotomy include free extravasation of radiologic contrast material, mesenteric occlusion on angiography, endoscopically uncontrollable bleeding, and positive results from peritoneal lavage (i.e., the presence of blood, pus, bile, urine, or GI contents). Acute appendicitis, perforated hollow viscera, and strangulated hernias are examples of common conditions that necessitate urgent laparotomy.
Nonurgent laparotomy

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Laparoscopy

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Question 4

An 18-year-old woman presents with acute right lower-quadrant pain. The patient is afebrile. The patient exhibits tenderness to palpation in the right lower quadrant, but there is no rebound or guarding. Her WBC count is slightly elevated.

Which of the following statements regarding observation of patients with acute abdominal pain is true?

Please choose the single most appropriate answer to the question

Most cases of acute abdominal pain are surgical, and observation increases the risks of complications

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Giving narcotic analgesics during observation of acute abdominal pain is contraindicated

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If symptoms do not change during the observation period, diagnostic laparoscopy is particularly valuable in young women of childbearing age, in whom gynecologic disorders frequently mimic acute appendicitis

This is correct.

Objective: To understand the observation of patients with acute abdominal pain

It is widely recognized that of all patients admitted for acute abdominal pain, only a minority require immediate or urgent operation. Clinical trials evaluating active in-hospital observation of patients with acute abdominal pain of uncertain origin have demonstrated that such observation is safe, is not accompanied by an increased incidence of complications, and results in fewer negative laparotomies. The decision whether to provide or withhold narcotic analgesia must be individualized. The current consensus is that for most patients undergoing evaluation and observation for acute abdominal pain, it is safe to provide medication in doses that would "take the edge off" the pain without rendering the patient unable to cooperate during the observation period. Over the course of a 24- to 48-hour observation period, the patient's condition may neither deteriorate nor improve, and supplemental investigation may be considered. Diagnostic laparoscopy has been recommended in cases where surgical disease is suspected but the probability of surgical disease is not high enough to warrant open laparotomy. Diagnostic laparoscopy is particularly valuable in young women of childbearing age, in whom gynecologic disorders frequently mimic acute appendicitis.
All of the above

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Acute Abdominal Pain

ACS Surgery

Chủ Nhật, 28 tháng 8, 2011

0501-Gastrointestinal Tract and Abdomen

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