General Surgery (Board Review Series) 1st Edition

9

Acute Abdominal Pain

Steven M. Fiser

1. Clinical Approach to Acute Abdominal Pain
2. Surgical intervention is indicated

• for most causes of severe acute abdominal pain.
• for any worsening condition.

1. Early diagnosis and treatment

• is essential in improving outcome.

1. A thorough history and physical examination

• is key in determining which patients require surgery.

1. A brief period of close observation (6–12 hours) and frequent examination

may be necessary in some situations where the etiology of pain is initially unclear.

1. History
2. Anorexia, nausea, and vomiting

• commonly occur with inflammatory processes and proximal obstructions.

1. Changes in bowel habits
2. Bloody stools or melena may indicate

• inflammation.
• infection.
• ischemia.
• diverticulosis.
• arterial-venous malformation.

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• cancer.
• ulcers.
• esophageal varices.
• other source of hemorrhage.

2. Obstipation, constipation, or diarrhea

• can occur with inflammation, obstruction, and infection.

1. Pain
2. Onset of paincan be gradual or abrupt.
3. Characteristics of pain
4. Visceral pain

• arises from the visceral peritoneum and capsule of solid organs.
• is poorly localized, deep, and dull.

1. Somatic pain

• arises from the parietal peritoneum after it becomes inflamed.
• is localized, sharp, and constant.
• gives rise to either local or diffuse peritoneal signs.

1. Colicky pain

• comes in waves.
• is caused by obstruction of a hollow lumen.

1. This type of pain is seen in

• bowel obstructions.
• nephrolithiasis.
• biliary colic.

2. Patients will often have

• intense writhing movementsin an attempt to alleviate the pain, with other periods during which they are relatively asymptomatic.

1. Referred pain

• typically arises from deep structures (Table 9-1).
• is sharp and constant.

1. Pain that awakens the patient at night or is incapacitatingis also considered significant.
2. Factors that may attenuate pain and other symptomsinclude

• antibiotics.
• narcotics.
• steroids.
• immunosuppressive agents.
• age greater than 65 years.
• diabetes.
• immunodeficiency [e.g., acquired immunodeficiency syndrome (AIDS)].

4. Location of pain

. Pain can be localized, diffuse, or shifting (e.g., appendicitis).

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1. Pain in different areasmay be associated with different etiologies (Table 9-2).

Table 9-1. Location of Referred Pain

Small bowel: epigastrium and periumbilical area Large bowel: suprapubic area Gallbladder: right shoulder/scapula Kidney/ureters: groin, genitalia, and flank Pancreas: lumbar area and left shoulder/scapula Ulcer disease: shoulders

1. Other parts of a patient's history

• may also yield clues to the diagnosis (Table 9-3).

III. Physical Examination and Laboratory Evaluation

1. Cardiovascular and pulmonary assessment
2. It is important to rule out pulmonary and cardiac causes for pain, such as pneumonia and myocardial infarction.
3. In the presence of shock, potential diagnosesinclude

• sepsis.
• pancreatitis.
• peritonitis.
• mesenteric ischemia.
• ruptured abdominal aortic aneurysm (AAA).
• aortic dissection.
• coronary thrombosis.
• ruptured ectopic pregnancy.
• aortoenteric fistula.

Table 9-2. Etiology of Localized Tenderness Based on Location

Location Etiology RUQ Acute cholecystitis, biliary colic, perforated duodenal ulcer LUQ (uncommon) Pancreatitis, perforated gastric ulcer RLQ Appendicitis, PID LLQ Diverticulitis, volvulus, PID Epigastric Pancreatitis, perforated ulcer Suprapubic PID, ruptured appendix or diverticula RUQ = right upper quadrant; LUQ = left upper quadrant; RLQ = right lower quadrant; LLQ = left lower quadrant; PID = pelvic inflammatory disease.

1. Abdominal examination
2. Narcoticsshould generally be withheld until surgical evaluation is performed.

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2. Examination of the abdomen may reveal peritoneal signs.
3. Patient remains motionlesswith the legs and knees flexed.
4. Pain may be increased by

• gentle percussion or with any movement.
• quickly releasing pressure after palpation (rebound tenderness).

1. Guarding(voluntary or involuntary)

• is caused by severe pain and peritoneal inflammation, respectively.

1. Rigidity(local or diffuse)

• is another significant finding.

Table 9-3. Components of a Complete History

Prior episodes Previous pregnancies Previous illness Menstrual history Previous surgery Social history Medications Family history Ill contacts Sexual history Recent travel Urinary habits Weight loss

1. Rectal examination

• may show fecal impaction, masses, tenderness, or blood.

1. Gynecologic examination

• may reveal masses, cervical motion tenderness, parauterine discomfort, or discharge.

1. Genitalia examination

• in males may show tenderness or masses.

1. Laboratory evaluation
2. Initial evaluationshould include

• a complete blood count with differential.
• urinalysis.
• amylase.
• beta-human chorionic gonadotropin (Β-HCG) in women of child-bearing age.

2. Assessment of electrolytes and renal functionis also important to identify potential abnormalities in metabolic and hydration status.
3. Liver function testsmay be necessary with upper abdominal pain or suspected liver or biliary disease.
4. Chest (posterior–anterior and lateral) and abdominal (upright and supine) radiographsmay frequently provide useful information in the initial evaluation.
5. Abdominal computed tomography (CT) scanningis frequently used when the diagnosis is unclear.

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1. Gastroenteritis
2. Overview
3. Gastroenteritis can be related tospecific food intake or recent respiratory infection.
4. Often other family members or close contactswill have a similar illness.
5. Etiologies include

• Escherichia coli.
• Shigellaspecies.
• Salmonellaspecies.
• Yersinia.
• Campylobacter.
• viruses.
• alcohol.
• drugs.

1. Signs and symptoms include

• dull, gnawing, epigastric discomfort, typically lasting 6–12 hours.
• marked nausea, vomiting, and diarrhea(usually occurring before the onset of pain).

1. Treatment

primarily involves adequate hydration.

1. Appendicitis (see Chapter 13)
2. Overview
3. Appendicitis most commonly occursin patients between 20–35 years of age.
4. In young children and the elderlyperforation rates are higher because there is generally a delay in the diagnosis, related to a lack of classic findings in these patients.
5. It is the most common cause of an acute abdomenin the second and third trimesters of pregnancy.
6. Signs and symptoms
7. Pain

• The onset of pain occurs 3–4 hours before nausea and vomiting, unlike with gastroenteritis, in which the converse is true. The pain worsens over time.
• Visceral, periumbilical painmay shift to somatic right lower quadrant (RLQ) pain as local peritonitis develops.

2. Loss of appetiteis common.

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3. Low-grade fever and leukocytosiswith a left shift are common.
4. High temperaturesmay be associated with perforation, but is a nonspecific finding.

• Chance of perforation 48 hours after onset of pain is 75%.
• Patients with free perforation frequently have generalized peritonitis.

5. McBurney's pointwill often be the point of maximal tenderness.

• Patients will generally have guarding, rigidity, and rebound in this area once local peritonitis develops.

6. The psoas sign

• indicates inflammation of the psoas muscle beneath the appendix.
• is elicited when the thigh is flexed against resistance.

7. The obturator sign

• indicates inflammation of the obturator muscle.
• is elicited when the thigh is flexed and internally rotated.
• is often positive with a retrocecal appendix.

8. Rovsing's sign

• occurs when the patient feels pain in the RLQ after palpation to the left lower quadrant (LLQ).

9. A retrocecal appendix

• may cause only mild tenderness and rigidity in the RLQ with less nausea and vomiting than usual.

10. A pelvic appendix

• may give rise to minimal abdominal pain but can be painful on rectal examination.

1. Radiographic studies

• are generally unnecessary in uncomplicated appendicitis because the diagnosis is generally based on clinical findings alone.

1. A CT scan or ultrasound

• is sometimes useful when the diagnosis is unclear or when complications are suspected.

1. Definitive therapy

• generally involves appendectomy.

1. Cholecystitis (see Chapter 16)
2. Overview
3. In the elderlythere is an increased incidence of bile duct obstruction and cholangitis.
4. Biliary colic, secondary to temporary cystic duct obstructionfrom passage of a gallstone, usually resolves after 4–6 hours.

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• Cholecystitis, however, will progress.
• In addition, fever and leukocytosis are characteristically absent in patients with biliary colic.

1. Major risk factors

include

• obesity.
• being female.
• age over 40 years.
• Native American descent.
• rapid weight loss.
• ileal resection.
• total parenteral nutrition (TPN).

1. Signs and symptoms
2. Signs and symptoms of cholecystitisinclude

• visceral epigastric painthat gradually progresses to somatic, right upper quadrant (RUQ) pain.
• referred painto the right shoulder and scapula.
• nausea, vomiting, and loss of appetite.Attacks frequently occur after eating, especially a fatty meal.
• tendernessand rigidity in the RUQ.
• Murphy's sign, when the patient resists inspiration after deep palpation to the RUQ, secondary to pain.

2. Patients with acute cholecystitis

• can have fever and mild jaundice.

3. Cholangitis is indicated by Charcot's triad(fever/chills, RUQ pain, and jaundice).
4. These findings plus hypotension and mental status changes (Reynolds pentad) indicate severe septic shock secondary to cholangitis.
5. Cholangitis secondary to common duct obstruction requires antibiotics and early surgical or endoscopic intervention to relieve the obstruction.
6. Laboratory evaluation
7. Leukocytosis with a left shiftis frequently present.
8. Liver function tests
9. Alkaline phosphatase

• is often elevated with obstruction and inflammation of the biliary tree.

1. Aspartate aminotransferase(AST) and alanine aminotransferase (ALT) are usually normal or slightly increased.

• If significantly elevated, primary liver pathology may be present (e.g., hepatitis).

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3. Total bilirubinhigher than 3.0 is associated with a retained common bile duct stone, which will need extraction.
4. Diagnostic studies
5. Ultrasoundcan be used to identify

• gallstones.
• gallbladder changes (e.g., wall thickening, pericholecystic fluid).
• bile duct stones.
• primary liver pathology.

2. Air in the portal systemcan indicate cholangitis or erosion of a gallstone through the gallbladder or biliary system into the gastrointestinal tract.
3. Hepatobiliary iminodiacetic acid (HIDA) scans

• can provide images of the liver and biliary tree when the diagnosis of cholecystitis is unclear.

1. Definitive treatment generally involves cholecystectomy (see Chapter 16)

VII. Intestinal Obstruction (see Chapter 13)

1. Causes of bowel obstruction
2. The most common causes of large bowel obstructionare cancer, diverticulitis and volvulus.
3. The most common causes of small bowel obstructionare adhesions from prior surgery, hernias, and cancer.
4. Crohn's disease and ulcerative colitiscan also cause obstruction in addition to fulminant colitis (toxic megacolon).
5. Signs and symptoms
6. General intestinal obstruction
7. Symptoms vary according to the

• portion of gut involved.More proximal obstructions are associated with worse symptoms.
• degree of obstruction(partial versus complete). Partial obstructions manifest less severe symptoms and may display profuse watery diarrhea but no flatus.
• presence of complications.

1. Pain

• is intermittent.
• is caused by violent peristalsis at the site of obstruction in an attempt to move intraluminal contents.

1. Vomiting

• progresses from bilious to brown intestinal contents to feculent particulate matter the more distal the obstruction.

1. Bowel ischemia associated with obstruction (strangulation) frequently presents with

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• severe, persistent pain.
• nausea.
• vomiting.
• fever.
• tachycardia.
• leukocytosis.
• Acute rigidity and peritoneal signs are generally absent unless gangrene or perforation has occurred.

1. Shock and signs of massive fluid loss

• can frequently occur with obstruction.

2. Small bowel obstruction
3. Pain

• is generally a sudden, severe, colicky type pain in the periumbilical region.

1. The patient may adopt a flexed body positionin an attempt to alleviate pain.
2. Intensity and frequency of pain paroxysmsare increased with higher obstructions.
3. Significant nausea and vomiting

• usually occurs.

1. Severity depends on the location of the obstruction.
2. More proximal obstructions result in increased severity.
3. Patients may initially have bowel movements

• but will eventually fail to pass flatus or stool.

1. Abdominal distension

• is generally more severe with more distal obstructions.

3. Large bowel obstruction
4. Patients typically pass no stool or flatus 1–2 days before seeking medical attention.

• Patient may also give a history of constipation or changed bowel habits in the preceding weeks.

1. Colicky, suprapubic pain

• is generally minimal until complications occur.

1. Nausea and vomiting

• are minimaluntil late in the course; however, anorexia is common.

1. A history of small caliber and blood-streaked stoolswith a history of worsening constipation and weight loss is suggestive of cancer.
2. Symptoms of a small bowel obstruction

• can occur with an incompetent ileocecal valve.

1. Examination will reveal significant distension and minimal tenderness.
2. Laboratory evaluation
3. White blood cell countis usually normal unless perforation or ischemia has occurred.
4. Laboratory datamay also reveal hypovolemia secondary to dehydration and intestinal “third-spacing” of fluid.

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1. Diagnostic studies
2. Abdominal series
3. Significant findingsinclude

• multiple air-fluid levels.
• distended loops of large or small bowel.
• distal decompression.

1. Closed loops

• as seen with intestinal volvulus are at high risk for rupture.

1. Cecal diameterlarger than 10–12 cm

• is a significant risk factor for rupture.

1. Toxic megacolonis massive nonmechanical colonic dilation associated with the onset of acute colitis.

• Perforation is imminent in this situation.

1. Pneumatosis intestinalis

• is air in the bowel wall.
• is associated with ischemia and dissection of air through areas of mucosal injury.

1. Air in the portal system

• usually represents infection or necrotic tissue in the large or small bowel.
• is an ominous sign.

2. Contrast studies
3. A barium or diatrizoate meglumine (Gastrografin) enema

• can be high yield in large bowel obstruction if the diagnosis is uncertain.
• Ischemic or gangrenous bowel may produce “thumbprinting”in the bowel wall.

1. Swallow studies

• are usually low yield in the initial evaluation of these patients unless gastric outlet obstruction or duodenal obstruction is suspected.

3. Endoscopy

• can be useful in the diagnosis of large bowel obstruction.
• can also be therapeutic in cases of intestinal volvulus.

1. Treatment depends on the primary cause of obstruction (see Chapters 13and 14)

VIII. Diverticulitis (see Chapter 14)

1. Overview
2. Around 90% of diverticulaare found in the sigmoid colon.
3. Complications occur in 25% of patients with diverticulitisand include

• abscess formation(most common).

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• fistula formation.
• perforation.
• obstruction.

1. Signs and symptoms
2. Patients with diverticulitis

• generally have increasing LLQ pain and constipationoccurring over several days.
• may also have pain on defecation and diarrhea.
• frequently have chills and a mild fever.
• infrequently have nausea, vomiting, and anorexia.

2. Examination reveals

• tenderness in the LLQ.
• a palpable mass, occasionally.

3. Complicated casesmay include

• high fever.
• leukocytosis.
• abdominal distension.
• peritoneal signs.

1. Diagnostic studies
2. CT scanis necessary if diagnosis is uncertain or complications are suspected.
3. Barium enema and colonoscopy are not recommended during the acute attackbecause of the potential risk of perforation.
4. Initial management

depends on the presentation (see Chapter 14), while resection of the diseased bowel is definitive therapy.

1. Volvulus
2. Overview
3. Volvolus is more common in nursing homes and psychiatric facilities.
4. Sigmoid volvulus is more common than cecal volvulus, which is very rare.
5. Risk factors include

• elderly age.
• immobility.
• adhesions.
• pregnancy.
• laxative or enema abuse.

1. Complications include

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• perforation and gangrene.

1. Signs and symptoms
2. In nonstrangulated cases

• the presentation is similar to diverticulitis.
• symptoms include pain, constipation, and abdominal distension.

2. Strangulation is associated with

• severe LLQ pain.
• rapid distension.
• obstipation.

3. Cecal volvulus

• is associated with an earlier onset of pain.
• frequently presents as a distal small bowel obstruction.

4. The white blood cell countcan be normal or elevated depending on whether or not a complication, such as ischemia or gangrene, has occurred.
5. Diagnostic studies
6. Plain abdominal radiographs

• may show a massively dilated colon.

2. A water soluble contrast enema

• may show a tapered colon (“bird's beak”).

3. Sigmoidoscopy

• can be diagnostic or therapeutic, with a 75% success rate. Fifty percent of the time, however, the volvulus will recur.

1. Ulcers
2. Risk factors include

• being male(more common in men).
• smoking.
• alcohol.
• nonsteroidal anti-inflammatory drug (NSAID) use.
• H. pyloriinfection.
• uremia.
• stress (trauma or burns).
• steroids.
• sepsis.
• chemotherapy.

1. History of antacid use

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• is also suggestive of the diagnosis.

1. Signs and symptoms include

• epigastric burning and back pain relieved with meals.
• mild nausea and vomiting with pain.
• melena or guaiac-positive stools.

1. Perforation

• is associated with a 5%–10% mortality.
• can additionally cause pancreatitis or bleeding from the gastroduodenal artery.
• Initial period

1. Patients generally complain of sudden, sharp, epigastric pain. Other significant findings include

• anxiety.
• pallor.
• vomiting.
• shallow respirations.

1. Patients may attempt to remain motionless, with the supine position providing some relief from pain.
2. Pain

• may radiate to the flanks or lower quadrants if drainage occurs in the colic gutters.
• may rarely be referred to the right shoulder with duodenal perforations and to both shoulders with stomach perforation.
• An intermediate period
• may occur 2–12 hours after onset, during which the patient feels better.

1. Acidic fluid from the perforation

• becomes diluted with leakage from the irritated intestinal wall.

1. Pain

• and nausea subside.
• will still be increased with movement.

1. The abdominal wall

• will still have “board-like” rigidity and tenderness.
• Late in the course
• (more than 12 hours), renewed nausea and vomiting along with distension, extensive peritoneal signs, and signs of shock can occur as generalized peritonitis develops.

1. Diagnostic studies
2. An upright chest radiograph(Figure 9-1) will show free air 75% of the time after rupture.
3. Free air is more common with anterior duodenal ruptures.
4. The patient needs to be upright for free air to appear under the diaphragm.

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2. An abdominal series

• may also show free air.

3. A Gastrografin swallow

• will show the presence of ulcers and leakage if perforation has occurred, although this is generally not necessary.

4. Upper endoscopy

• may also identify ulcers.

1. Treatment depends on the presentation (see Chapter 12)

Figure 9-1. Chest radiograph showing air beneath the diaphragm (arrows indicate liver edge). (Reprinted with permission from Daffner RH: Clinical Radiology: The Essentials, 2nd ed. Baltimore, Williams & Wilkins, 1999, p 267.)

1. Pancreatitis (see Chapter 17)
2. Etiologies include

• alcohol and gallstones(responsible for 90%).
• trauma.
• hyperlipidemia.

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• hypercalcemia.
• endoscopic retrograde cholangiopancreatography (ERCP).
• medications (thiazide diuretics, H-2 blockers, erythromycin, tetracycline, acetaminophen, sulfonamides, steroids, and azathioprine).
• scorpion bite (exotic islands).

1. Complications
2. General complicationsinclude

• pseudocyst formation.
• hemorrhage.
• necrosisof the pancreas (necrotizing pancreatitis).

2. Significant systemic complicationsinclude

• coagulopathy.
• hemorrhage.
• shock.
• sepsis.
• acute respiratory distress syndrome.

1. Morphine should probably be avoided

• for pain relief because it contracts the sphincter of Oddi, potentially contributing to obstruction of biliary and pancreatic drainage.

1. Signs and symptoms
2. Epigastric pain

• is usually sudden, constant, and excruciating.
• is referred to the lumbar area and left scapula/shoulder.
• Patients often have epigastric tenderness and rigidity on examination.

2. Pain

• can also originate fromthe left upper quadrant (LUQ).
• is generally exacerbated by food.
• An upright posturemay offer some relief.

3. Common signsinclude

• fever.
• anorexia.
• persistent nausea and vomiting.

4. Slight jaundice occurs

• in 50% secondary to stone obstruction or a swollen pancreas, causing impaired biliary drainage.

5. Shock

• can occur rapidly and massive volume replacement may be necessary.

6. Grey-Turner sign

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• is associated with hemorrhagic pancreatitis.
• occurs when ecchymosis is found in the flank region.

7. Cullen's sign

• is periumbilical ecchymosis caused by hemorrhage.

1. Laboratory evaluation
2. Amylase and lipasewill be elevated in most patients with the exception of some patients with chronic pancreatitis.
3. Leukocytosiswith a left shift is frequently present.
4. Hyperglycemiaand hyperlipidemia may also be present.
5. Diagnostic studies
6. CT scan
7. CT scan is necessary whenthe diagnosis has not been firmly established and significant complications are felt to have occurred.
8. Significant findings include hemorrhage, necrosis, and edema.
9. Radiographs

• An abdominal series may show a sentinel loop.
• A left-sided pleural effusion may also be present on chest radiograph.

1. Treatment

is nonsurgical in most cases (see Chapter 17).

XII. Intestinal Ischemia

1. Overview
2. This anemia characteristically occursin the elderly and patients with atherosclerosis, heart disease, arrhythmias, vasculitis, or hypercoagulable syndromes.
3. The pathogenesis involves

• embolization.
• thrombosis.
• low flow states.

1. Patients suffering from embolization often have a history of

• atrial flutter/fibrillation.
• endocarditis.
• angiography.
• recent myocardial infarction.

1. Patients with low flow states usually have a history of

• prolonged shock.
• prolonged heart bypass procedure.
• myocardial infarction.
• congestive heart failure.
• prolonged bowel wall distension.

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• strangulated hernia.
• use of digoxin (causes splanchnic vasoconstriction).

1. Signs and symptoms
2. The most common complaintsare

• midabdominal pain.
• bright red rectal bleeding.
• diarrhea.
• vomiting.

2. Patients with atherosclerotic thrombosismay have

• food fear secondary to pain after eating (intestinal angina).
• associated weight loss.

3. Venous occlusion occursmost often in hypercoagulable syndromes.
4. Pain is often out of proportion to physical examination findingsearly on.
5. The bowel wall can rapidly become gangrenous.

• At this time perforationand peritonitis will occur, followed by shock.

6. Leukocytosis

• suggests that tissue necrosis or perforation have occurred.

1. Diagnostic studies
2. CT scan can show

• bowel wall thickening.
• intramural gas.
• portal venous gas.
• vascular occlusion.

2. Early angiography

• is essential to confirm the diagnosis and plan operative intervention.

XIII. Aortic Dissection (see BRS Surgical Specialties, Chapter 2)

1. Risk factors include

• hypertension.
• Marfan's syndrome.
• atherosclerosis.
• coarctation.

1. Complications include

• cardiac tamponade.

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• aortic insufficiency.
• occlusion of aortic branches.
• tearing or occlusion of coronary arteries.
• aortic rupture.
• The majority of complications are caused by ascending aortic dissections.

1. Signs and symptoms
2. Pain

• is usually tearing-like and severe.
• usually migrates from the chest and back to the abdomen.

2. Patients may have

• unequal pulses.
• blood pressure in the upper extremities.
• associated hemiplegia or paraplegia.
• new heart murmurs.

1. Diagnostic studies
2. CT scanwill almost always show the dissection.
3. Aortogram and transesophageal echocardiographymay also be useful.
4. Management

• Because hypertension is frequently present and can lead to continued dissection and rupture, early blood pressure controlwith nitrates or Β blockers is essential.

XIV. Abdominal Aortic Aneurysm (AAA)

• Mortality with rupture is approximately 40%–50%.

1. Risk factors include

• atherosclerosis.
• hypertension.
• being male.
• smoking.
• family history.
• elderly age.

1. Signs and symptoms
2. A palpable abdominal massis common.
3. Patients may have profound hypotension or shockif rupture has occurred.

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3. Patients are usually asymptomatic;however, they may have a history of progressively increasing abdominal or back pain.
4. Diagnostic studies
5. It should be emphasized that patients should be taken directly to surgery without diagnostic studies if they have

• hypotension.
• abdominal pain.
• a pulsating abdominal mass or a history of an AAA.

2. CT scan

• gives a very accurate measurement of the size of the aneurysm.

3. Ultrasound

• can provide a rapid diagnosis in urgent situations.

1. Obstetric/Gynecologic Causes of Acute Abdominal Pain

Table 9-4. Gynecologic and Obstetrical Causes of Acute Abdominal Pain

Gynecologic Causes Pain Related to Pregnancy Pelvic inflammatory disease (PID) Ruptured uterus Endometriosis Ovarian torsion Ectopic pregnancy Splenic artery aneurysm rupture Ovarian tumor, torsion, cyst, or abscess Placental abruption Rupture of follicular or luteal cyst Ectopic pregnancy Mittelschmerz Normal intrauterine pregnancy Pelvic adhesions Miscarriage Vaginitis Endometritis Uterine fibroids Pulmonary embolism Menstrual cramps Urologic infections

1. Several gynecologic and obstetrical causes of acute abdominal pain

are listed in Table 9-4.

1. Ultrasound

is effective in diagnosing disorders of the female reproductive tract.

1. Pain accompanying menstrual period

is suspicious for threatened early abortion or tubal gestation.

1. Pelvic inflammatory disease (PID)
2. A significant risk factor

• is numerous sexual partners.

2. This disease commonly occurs

• in the first half of the menstrual cycle.

3. Complications of PIDinclude

• persistent pelvic pain.

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• infertility.
• ectopic pregnancy.

4. Patients commonly have

• hypogastric pain.
• fever.
• nausea and vomiting.
• vaginal discharge.

5. Cervical cultures

• frequently demonstrate the causative organisms.

6. Adnexal and cervical motion tenderness

• are common (chandelier sign).

1. Ectopic pregnancy
2. Risk factorsinclude

• previous tubal manipulation.
• PID.
• previous ectopic pregnancy.

2. Patients may have

• a history of a missed period.
• pain and abnormal uterine bleeding (most common complaints). Pain is usually sharp and persistent without associated vomiting.

3. Because significant hemorrhage and shock can occur

• this diagnosis should always be considered when evaluating a premenopausal female with abdominal pain.

4. Pelvic examination may show

• blood.
• an enlarged uterus.
• cervical motion tenderness.
• a blue-tinged cervix.

5. An ultrasoundmay also be useful for confirming the presence of an intrauterine pregnancy.

XVI. Urologic Causes of Acute Abdominal Pain (see BRS Surgical Specialties, Chapter 6)

1. Infection
2. Potential sources of paininclude

• pyelonephritis.
• cystitis.
• urethritis.

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2. Symptoms

• Fever and dysuria are common.
• Costovertebral tendernessis typical of pyelonephritis.

3. Urinalysis may demonstrate the presence of

• nitrates.
• leukocyte esterase.
• bacteria.
• white blood cells.
• minimal hematuria.

1. Kidney stones
2. Signs and symptomsinclude

• severe colicky-type pain due to ureteral obstruction.
• extreme restlessnesssecondary to the pain.

2. Urinalysis

• usually shows stonesor hematuria.

3. Intrascrotal causes of acute abdominal paininclude

• associated testicular tenderness and pain from trauma.
• venous thrombosis.
• epididymitis.
• seminal vesiculitis.
• Testicular torsion may be present.

XVII. Abdominal Pain in Pediatric Populations (Table 9-5)

Table 9-5. Causes of Acute Abdominal Pain in Infants and Children

Intussusception Urologic causes Pyloric stenosis Viral/bacterial enteritis Meconium ileus Appendicitis Necrotizing enterocolitis Strangulated hernia Hirschsprung's disease Trauma Malrotation Child abuse Volvulus (midgut) Poisoning Gastroesophageal reflux disease Psychosomatic illness Incarcerated hernia Mesenteric cysts Meckel's diverticulum Pancreatitis Annular pancreas Pneumonia Small bowel atresia Ruptured tumors Duodenal webs/bands Inflammatory bowel disease Gastric/intestinal duplication syndromes

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XVIII. Nonsurgical Causes of Abdominal Pain (Table 9-6)

Table 9-6. Other Causes of Acute Abdominal Pain Not Requiring Surgery

Cardiac Myocardial infarction (typically inferior), pericarditis Pulmonary Pneumonia, pulmonary embolism, pneumothorax, empyema Other thoracic Reflux disease Endocrine Adrenal insufficiency, diabetic ketoacidosis Metabolic Acute intermittent porphyria, uremia, hypercalcemia Toxic Venom from snakes and scorpions, lead poisoning, drugs, alcohol Hematologic Hemolytic crisis (sickle cell anemia), rectus sheath hematoma (warfarin use) Neurogenic Herpes zoster, spinal cord/nerve root compression from tumor or abscess, tabes dorsalis Infection Gastroenteritis, pseudomembranous colitis, hepatitis, spontaneous bacterial peritonitis, tuberculosis peritonitis, malaria, numerous bacterial/viral infections Congenital Familial Mediterranean fever Musculoskeletal Vertebral compression of abdominal wall nerves Vascular Splenic infarction

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Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

1. A 65-year-old woman with a long history of atrial fibrillation presents to the emergency department with a history of sudden onset of constant, severe abdominal pain. After the onset of the pain, she vomited once and had a large bowel movement. No flatus has passed since that time. Her vital signs are: heart rate, 124 beats/min (irregular); respiration, 18/min; blood pressure, 140/60 mm Hg; temperature, 38.0°C. Physical examination reveals a mildly distended abdomen that is mildly tender diffusely. There are no peritoneal signs. Electrocardiogram reveals the patient to be in atrial fibrillation but otherwise normal. Chest radiograph is unremarkable. Ten years ago, this patient underwent a vaginal hysterectomy. Which of the following would be most appropriate in the subsequent evaluation of this patient?

(A) Abdominal ultrasound

(B) Upper gastrointestinal endoscopy

(C) Abdominal computed tomography scan

(D) Mesenteric vessel arteriogram

(E) Upper gastrointestinal contrast study

1–D. The triad of a cardiac arrhythmia, sudden onset of severe abdominal pain, and gut emptying is classic for embolic mesenteric ischemia. This patient's pain is also out of proportion to the physical examination, another classic sign of mesenteric ischemia. In this setting, the most appropriate initial diagnostic study should be an arteriogram of the mesenteric arterial supply to characterize the extent and location of disease. Abdominal ultrasound, computed tomography scanning, and upper endoscopy are useful in other situations in which the clinical findings are more subtle or suggestive of other specific intra-abdominal diagnoses.

2. A 44-year-old, obese woman presents to the emergency department with a history of acute onset of severe epigastric pain radiating toward the back. The pain began several hours after dinner. The patient has no significant past medical history and denies any previous surgery. She takes no medications. On examination, the patient has marked epigastric tenderness with guarding and hypoactive bowel sounds. Her vital signs are: heart rate, 110 beats/min; blood pressure, 120/50 mm Hg; respiration, 28/min; temperature, 38.0°C. Amylase level is 2500 units. Which of the following is the most likely cause of this patient's pain?

(A) Gallstones

(B) Alcohol abuse

(C) Hyperparathyroidism

(D) Hyperlipidemia

(E) Peptic ulcer disease

2–A. The history, physical examination, and elevated amylase are all consistent with pancreatitis. Gallstones and alcohol account for 90% of the cases of pancreatitis in the United States. A high amylase level (over 1000) suggests gallstones over alcohol abuse. Age in the 40s, being female, and obesity are also risk factors for gallstones. Hyperparathyroidism and hyperlipidemia are rare causes of pancreatitis. A ruptured peptic ulcer could present in a similar manner but the elevated amylase suggests pancreatitis. A history of epigastric discomfort or antacid use would also suggest ulcer disease.

3. A 40-year-old man presents with significant right flank pain radiating down to his testicle. The pain is intermittent and severe in nature. Microscopic hematuria is present on urinalysis, but there are no white blood cells. Leukocyte esterase and nitrates are negative. His vital signs are: heart rate, 88 beats/min; blood pressure, 130/60 mm Hg; respiration, 20/min; temperature, 37.2°C. Which of the following is the most appropriate next step in the management of this patient?

(A) Intravenous antibiotics

(B) Immediate laparotomy

(C) Intravenous fluids and pain medication

(D) Computed tomography (CT) scan of the abdomen

(E) Immediate orchiopexy

3–C. Urinary tract calculi classically present with flank pain that is colicky in nature with radiation to the ipsilateral testicle and red blood cells and stones in the urine. Appropriate treatment of an initial episode of this disease generally involves administering intravenous fluids to assure appropriate hydration and to provide adequate pain control [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs)] during passage of the stone. Ultrasound and intravenous pyelogram (IVP) are the tests of choice in diagnosing patients with recurrent or complicated urinary tract stones. A computed tomography scan could also show stones but is not as sensitive as ultrasound or IVP. The patient's clinical presentation, in addition to the urinalysis findings of no white blood cells, nitrates, leukocyte esterase, or bacteria, makes infection possible, but less likely. Immediate orchiopexy would be appropriate if testicular torsion were suspected. This generally presents with acute abdominal pain and extreme tenderness in the affected testicle.

4. A 50-year-old woman presents to the emergency department with abdominal pain and jaundice. Her vital signs are: heart rate, 80 beats/min; blood pressure, 130/72 mm Hg; respiration, 18/min; temperature, 37.0°C. Examination reveals tenderness in the right upper quadrant (RUQ) and a positive Murphy's sign. Which of the following statements regarding this patient is true?

(A) Referred pain would likely be to the right shoulder or scapula.

(B) This disease is characterized by Charcot's triad.

(C) Jaundice is rarely present in these patients.

(D) Etiology of the pain would likely be present on abdominal film.

(E) Morphine is the most appropriate analgesic to use in this patient.

4–A. Cholecystitis is caused when a gallstone is impacted in the cystic duct. Referred pain is to the right shoulder and scapula. Jaundice may be present, despite the fact that there is no obstruction of the common bile duct. Charcot's triad is associated with ascending cholangitis, which results from bacterial infection of the biliary tree after a gallstone is impacted in the common bile duct. Only 15% of gallstones are radio-opaque, thus an abdominal film is not likely to show the etiology of the pain. Morphine should probably be avoided in patients with cholecystitis as it theoretically contracts the sphincter of Oddi, which will prevent stone passage and possibly increase the risk of complications such as pancreatitis.

5. A 23-year-old man presents to the emergency department complaining of scrotal pain. The pain began 4 days ago but has gradually worsened. The patient now feels hot and his scrotum is too tender to allow for examination. His vital signs are: heart rate, 90 beats/min; respiration, 20/min; blood pressure, 120/60 mm Hg; temperature, 38.5°C. Which of the following is the most likely diagnosis?

(A) Testicular torsion

(B) Hydrocele

(C) Epididymitis

(D) Urethritis

(E) Spermatocele

5–C. This patient most likely has acute epididymitis. The patient does not complain of penile discharge or dysuria, making urethritis less likely. Spermatocele and hydrocele are generally not associated with testicular tenderness. Testicular torsion can present with severe testicular pain and is a surgical emergency. However, torsion is generally associated with a more acute onset of pain (within minutes to hours) and is not commonly associated with fever.

6. A 50-year-old woman presents to the emergency room with ripping chest pain that is now radiating into the abdomen. The patient has unequal pulses in the upper extremities. Her vital signs are: heart rate, 125 beats/min; respiration, 20/min; temperature, 36.5°C. Which of the following statements is true?

(A) The patient will most likely be hypotensive on presentation.

(B) S-T segment elevation in the anterior leads is diagnostic.

(C) Coronary artery disease is the likely etiology of the pain.

(D) Magnetic resonance imaging of the chest is usually used to make the diagnosis.

(E) A new heart murmur can be associated with this disease.

6–E. Thoracic aortic dissection is most commonly a complication of hypertension. Patients most commonly present with hypertension and chest pain radiating to the back, although dissections involving the lower thoracic or abdominal aorta may also cause abdominal pain. S-T segment changes can occur with aortic dissections, but are not diagnostic because they may also occur with myocardial infarction. Coronary artery disease can present with similar chest pain in addition to abdominal pain, although this scenario is most likely associated with aortic dissection. A computed tomography (CT) scan of the chest or aortogram are usually used to make the diagnosis. Magnetic resonance imaging could also make the diagnosis but is generally too time consuming in this setting. New heart murmurs may occur with ascending aortic dissections, causing aortic valve incompetence.

7. A 60-year-old man presents to the emergency room with sudden abdominal pain and an expanding, pulsatile abdominal mass on examination. His vital signs are: heart rate, 130 beats/min; blood pressure, 70/20 mm Hg; respiration, 30/min; temperature, 36.0°C. Which of the following is the most appropriate next step in the management of this patient?

(A) Emergency computed tomography (CT) of the abdomen

(B) Emergency CT of the chest

(C) Emergency aortogram

(D) Emergency laparotomy

(E) Volume resuscitation and observation

7–D. The triad of acute abdominal pain, a pulsatile abdominal mass, and hypotension is classic for a ruptured abdominal aortic aneurysm (AAA). This patient should be taken to the operating room immediately. Performing a computed tomography (CT) scan or aortogram in this situation would only delay definitive operative treatment and is not indicated in this patient.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all.

Questions 8–12

1. Small bowel obstruction
2. Large bowel obstruction
3. Cholecystitis
4. Ureteral calculi
5. Pyelonephritis
6. Pancreatitis

For each clinical description, select the most likely diagnosis(es).

8. A 39-year-old man presents to the emergency room with severe vomiting and increasing abdominal pain. Abdominal radiograph shows multiple dilated loops of small bowel and air-fluid levels throughout the abdomen. The patient underwent an emergent splenectomy 1 year ago after a motor vehicle accident. (SELECT 1 DIAGNOSIS)

8–A. A small bowel obstruction characteristically presents with nausea, vomiting, abdominal pain, and eventually failure to pass stool or gas. Adhesions after surgery are the most common cause of small bowel obstruction in the United States. Abdominal films typically show multiple fluid levels. The clinical presentation in association with a history of previous abdominal surgery is more consistent with a small bowel obstruction than a large bowel obstruction.

9. A 48-year-old woman presents to the emergency room with severe epigastric pain radiating to the lumbar area. The pain is somewhat relieved with upright posture. The patient has had severe nausea and vomiting since the onset of pain. Chest and abdominal films are unremarkable. Urinalysis is normal. (SELECT 2 DIAGNOSES)

9-C, F. Gallstones and alcohol are the major causes of pancreatitis. These patients typically present with severe epigastric pain radiating to the lumbar area or left shoulder and with nausea, vomiting, and anorexia. Pain is sometimes relieved with upright posture. Amylase is generally elevated in these patients. Cholecystitis may also present with similar signs and symptoms. These patients frequently have an elevated alkaline phosphatase. Biliary ultrasound is often diagnostic.

10. A 60-year-old man presents with epigastric pain after eating. The pain seems to radiate to the right scapula. Examination reveals tenderness in the epigastric area, but no rebound or guarding are present. Amylase and lipase are normal. Chest and abdominal films are unremarkable. (SELECT 1 DIAGNOSIS)

10–C. Cholecystitis is caused by gallstones and typically presents with vague epigastric pain that eventually progresses to somatic pain in the right upper quadrant (RUQ). Alkaline phosphatase is generally elevated. Pancreatitis can present with epigastric pain; however, amylase is usually elevated.

11. A 35-year-old man presents with flank pain radiating to the ipsilateral testicle. The pain came on suddenly 2 hours ago. Urinalysis shows red blood cells. Chest and abdominal films are unremarkable. Laboratory values are unremarkable. Vital signs are normal. (SELECT 1 DIAGNOSIS)

11–D. Ureteral calculi typically present with severe pain in the flank region with radiation to the ipsilateral testicle. Urinalysis generally shows hematuria and possibly stones or crystals. Pyelonephritis could present with flank pain; however, these patients generally have a fever along with red and white blood cells in their urine. The pain from pyelonephritis is gradual in nature and is not as acute as that found with ureteral calculi.

12. A 65-year-old man presents with gradually increasing abdominal pain and obstipation over the past several weeks. The patient denies any nausea or vomiting. Vital signs are normal. Examination reveals abdominal distension and guaiac-positive stools. (SELECT 1 DIAGNOSIS)

12–B. Large bowel obstructions typically present with gradually increasing abdominal distension and eventual failure to pass gas or stool. Abdominal films commonly show dilated loops of large bowel, and possibly dilated loops of small bowel, depending on whether or not the ileocecal valve is competent. Cancer is the most common cause of large bowel obstruction. A history of guaiac-positive stools and obstipation is very suspicious for adenocarcinoma of the colon.

Questions 13–16

For each clinical scenario, select the most appropriate management plan(s).

1. Take the patient to the operating room.
2. Admit for medical treatment and observation.
3. Perform an abdominal ultrasound.
4. Perform a computed tomography (CT) scan of the chest and abdomen.
5. Perform a magnetic resonance imaging scan of the abdomen.
6. Discharge the patient with close follow-up.
7. A 65-year-old man presents to the emergency room with abdominal pain for the past 12 hours. The patient has nausea and has vomited once. The patient also has anorexia. On examination, a midline abdominal scar is noted and the pain is noted to be poorly localized. Plain films show some air–fluid levels but there is air and stool distally. The small bowel appears dilated. (SELECT 1 MANAGEMENT PLAN)

13–B. Nausea, vomiting, anorexia, and abdominal pain associated with air–fluid levels on abdominal plain film are signs of small bowel obstruction. The presence of stool and air distal to the site of obstruction is suggestive of a partial obstruction. In some patients with a partial small bowel obstruction and previous abdominal surgery, a course of inpatient management with bowel rest, volume resuscitation, and nasogastric tube decompression may be attempted. No additional diagnostic tests are necessary at this time.

14. A 45-year-old man presents with nausea and vomiting 1 hour after eating. The patient now has developed dull, epigastric discomfort, and watery diarrhea 5 hours later, although the vomiting has ceased and the patient is able to drink liquids. Abdominal films and labs are unremarkable. Past medical history is unremarkable and the patient does not take any medications. The patient tells you that his daughter has also started having diarrhea. (SELECT 1 MANAGEMENT PLAN)

14–F. Nausea and vomiting preceding abdominal pain, watery diarrhea, and epigastric discomfort following a meal is classic for gastroenteritis. Often, other family members will have similar symptoms. In this setting additional diagnostic tests are unnecessary. Computed tomography (CT) scan and ultrasound of the abdomen are likely to be poor yield in this patient. This patient does not require immediate surgery. Whether or not to discharge or admit a patient to the hospital can be a difficult decision. Because the patient is able to tolerate liquids, outpatient management with close follow-up is appropriate.

15. A 60-year-old man presents with tearing-like chest pain radiating to his back and abdomen. Electrocardiogram is normal. The patient is hypertensive and tachycardic but is otherwise alert and oriented. (SELECT 1 MANAGEMENT PLAN)

15–D. This patient may potentially have a dissection of the thoracic aorta descending into the abdomen. A computed tomography (CT) scan of the chest or an aortogram are appropriate diagnostic studies for confirming a dissection, although a transesophageal echocardiogram can also provide for excellent visualization of this portion of the aorta and may frequently be used to diagnose a suspected thoracic aortic dissection. Surgery and admission to the hospital may eventually be necessary; however, a diagnostic study is the most appropriate next step. Ultrasound could possibly detect a dissection but it is not as sensitive as the other studies noted.

16. A 54-year-old woman with a past medical history significant for ulcerative colitis presents to the emergency room with severe abdominal pain, rebound, guarding, and abdominal distention. Supine plain films show a transverse colon diameter of 13 cm. (SELECT 1 MANAGEMENT PLAN)

16–A. This patient most likely has toxic megacolon. This is a complication of ulcerative colitis and is manifested by rapid distention, usually of the transverse colon. Initial management of uncomplicated toxic megacolon includes aggressive fluid resuscitation and administration of steroids. However, when associated with signs and symptoms of peritonitis or perforation, this becomes a surgical emergency. No further diagnostic studies are necessary at this point, based on the patient's medical history and current abdominal findings.