Acute, Catastrophic Abdominal Pain
Intense abdominal pain of acute onset or pain associated
with syncope,hypotension,
or toxic appearance necessitates rapid yet orderly
evaluation. Consider
obstruction,perforation, or rupture of hollow viscus;
dissection or rupture of
major blood vessels (esp. aortic aneurysm); ulceration;
abdominal sepsis; ketoacidosis; and adrenal crisis.
Brief History and Physical
Examination Historic features of
importance
include age; time of onset of the pain; activity of the
pt when the pain began;
location and character of the pain; radiation to other
sites; presence of nausea,
vomiting,or anorexia; temporal changes; changes in bowel
habits; and menstrual
history. Physical exam should focus on the pt’s overall
appearance [writhing
in pain (ureteral lithiasis) vs. still
(peritonitis,perforation)], position (a pt leaning forward may have
pancreatitis or gastric perforation into the lesser sac),
presence of fever or hypothermia,
hyperventilation,cyanosis,bowel sounds,
direct or rebound abdominal tenderness,pulsating
abdominal mass, abdominal
bruits,ascites, rectal blood,rectal or pelvic tenderness,
and evidence of coagulopathy.
Useful laboratory studies include hematocrit (may be
normal with
acute hemorrhage or misleadingly high with
dehydration),WBC with differential
count,arterial blood gases, serum electrolytes, BUN,
creatinine, glucose,
lipase or amylase,and UA. Females of reproductive age
should have a pregnancy
test. Radiologic studies should include supine and
upright abdominal
films (left lateral decubitus view if upright
unobtainable) to evaluate bowel
caliber and presence of free peritoneal air,cross-table
lateral film to assess aortic
diameter; CT (when available) to detect evidence of bowel
perforation,inflammation, solid organ infarction, retroperitoneal bleeding,
abscess, or tumor. Abdominal paracentesis (or peritoneal lavage in cases of
trauma) can detect evidence of bleeding or peritonitis. Abdominal ultrasound
(when available) reveals evidence of abscess,cholecystitis, biliary or ureteral
obstruction, or hematoma and is used to determine aortic diameter.
Diagnostic Strategies The initial decision point is based
on whether the
pt is hemodynamically stable. If not,one must suspect a
vascular catastrophe
such as a leaking abdominal aortic aneurysm. Such pts
receive limited resuscitation
and move immediately to surgical exploration. If the pt
is hemodynamically
stable,the next decision point is whether the abdomen is
rigid. Rigid
abdomens are most often due to perforation or
obstruction. The diagnosis can
generally be made by a chest and plain abdominal
radiograph.
If the abdomen is not rigid,the causes may be grouped
based on whether
the pain is poorly localized or well localized. In the
presence of poorly localized
pain,one should assess whether an aortic aneurysm is
possible. If so, a CT scan
can make the diagnosis; if not,early appendicitis, early
obstruction, mesenteric
ischemia,inflammatory bowel disease, pancreatitis, and
metabolic problems are
all in the differential diagnosis.
Pain localized to the epigastrium may be of cardiac
origin,esophageal inflammation or perforation,gastritis,peptic ulcer disease,
biliary colic or cholecystitis, and pancreatitis. Pain localized to the right
upper quadrant includes
those same entities plus pyelonephritis or
nephrolithiasis,hepatic abscess, subdiaphragmatic absess,pulmonary embolus,or
pneumonia or be of musculoskeletal origin. Additional considerations with left
upper quadrant localization are infarcted or ruptured spleen,splenomegaly, and
gastric or peptic ulcer.
Right lower quadrant pain may be from appendicitis,Meckel’s
diverticulum, Crohn’s disease, diverticulitis,mesenteric adenitis,rectus sheath
hematoma, psoas abscess, ovarian abscess or torsion, ectopic
pregnancy,salpingitis,familial fever
syndromes,uterolithiasis,herpes zoster. Left lower
quadrant pain may be due
to diverticulitis,perforated neoplasm, and other entities
previously mentioned.
TREATMENT
Intravenous fluids,correction of life-threatening
acid-base disturbances, and
assessment of need for emergent surgery are the first
priority; careful followup
with frequent reexamination (when possible,by the same
examiner) is
essential. The use of narcotic analgesia is
controversial. Traditionally,narcotic
analgesics were withheld pending establishment of
diagnosis and therapeutic
plan,since masking of diagnostic signs may delay needed
intervention. However,
evidence that narcotics actually mask a diagnosis
is sparse.
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