Description

• Most common chief complaint leading to an ED visit
• Wide range of etiologies including multiple life threats
• Serious disease may be difficult to diagnose, requiring a systematic approach
• Parietal pain:
  • Irritating material causing peritoneal inflammation
  • Pain transmitted by somatic nerves
  • Exacerbated by changes in tension of the peritoneum
  • Pain is sharp, well localized with abdominal, rebound tenderness, and involuntary guarding
• Visceral pain:
  • Afferent impulses result in poorly localized pain based on the embryologic origin rather than true location of an organ:
    • Pain of foregut structures to the epigastric area
    • Pain from midgut structures to the periumbilical area
    • Pain from hindgut structures to the suprapubic region
  • Distention of a viscous or organ capsule or spasm of intestinal muscularis fibers:
    • Pain is constant and colicky
  • Inflammation:
    • Focal tenderness develops once the inflammation extends to the peritoneum
  • Ischemia from vascular emergencies:
    • Pain is severe and diffuse
• Referred pain:
  • Felt at distant location from diseased organ
  • Due to an overlapping supply by the affected neurosegment
• Abdominal wall pain:
  • Constant, aching with muscle spasm
  • Involvement of other muscle groups

Etiology

• Peritoneal irritants:
  • Gastric juice, fecal material, pus, blood, bile, pancreatic enzymes
• Visceral obstruction:
  • Small and large intestines, gallbladder, ureters and kidneys, visceral ischemia, intestinal, renal, splenic
• Visceral inflammation:
  • Appendicitis, inflammatory bowel disorders, cholecystitis, hepatitis, peptic ulcer disease, pancreatitis, pelvic inflammatory disease, pyelonephritis
• Abdominal wall pain
• Referred pain (e.g., intrathoracic disease, genitourinary)

Signs and Symptoms

• Pain:
  • Nature of onset of pain
  • Time of onset and duration of pain
  • Location of pain initially and at presentation
  • Extra-abdominal radiations
  • Quality of pain (sharp, dull, crampy)
  • Aggravating or alleviating factors
  • Relation of associated finding to pain onset
  • Previous episodes
• Anorexia
• Nausea
• Vomiting (bilious, coffee-ground emesis)
• Malaise
• Fainting or syncope
• Cough, dyspnea, or respiratory symptoms
• Change in stool characteristics (e.g., melena)
• Hematuria
• Changes in bowel or urinary habits
• History of trauma or visceral obstruction
• Gynecologic and obstetric history
• Postoperative (e.g., cause ileus)
• Family history (e.g., familial aortic aneurysm)
• Alcohol use and quantity
• Medications (e.g., aspirin and NSAIDs)

• General:
  • Anorexia
  • Tachycardia
  • Tachypnea
  • Hypotension
  • Fever
  • Distal pulses and pulse amplitudes between lower and upper extremities
• Abdominal:
  • Scars
  • Distended abdomen
  • Abnormal bowel sounds:
    • High-pitched rushes with bowel obstruction
    • Absence of sound with ileus or peritonitis
  • Pulsatile abdominal mass
  • Rebound tenderness, guarding, and cough test for peritoneal irritation (e.g., appendicitis, peritonitis)
  • Rovsing sign, suggestive of appendicitis:
    • Palpation of left lower quadrant causes pain in right lower quadrant (RLQ)
  • Psoas sign suggests appendicitis (on right):
    • Pain on extension of thigh
  • Obturator sign suggests pelvic appendicitis (on the right only):
    • Pain on rotation of the flexed thigh, especially internal rotation
  • McBurney point tenderness associated with appendicitis:
    • Palpation in RLQ 2/3 distance between umbilicus and right anterior superior iliac crest causes pain
  • Murphy sign, suggestive of cholecystitis:
    • Pause in inspiration while examiner is palpating under liver
  • Carnett sign indicates abdominal wall pain:
    • Pain when a supine patient tenses the abdominal wall by lifting the head and shoulders
  • Tender or discolored hernia site
  • Rectal and pelvic examination:
    • Tenderness with pelvic peritoneal irritation
    • Cervical motion tenderness
    • Adnexal masses
    • Rectal mass or tenderness
    • Guaiac positive stool
• Genitourinary:
  • Flank pain
  • Dysuria
  • Costovertebral angle tenderness
  • Suprapubic tenderness
  • Tender adnexal mass on pelvis
  • Testicular pain:
    • May be referred from renal or appendiceal pathology
• Referred pain:
  • Kehr sign (diaphragmatic irritation due to blood or other irritants) causes shoulder pain
• Extremities:
  • Pulse deficit or unequal femoral pulses
• Skin:
  • Jaundice
  • Liver disease (caput medusa)
  • Hemorrhage:
    • Grey Turner sign of flank ecchymosis
    • Cullen sign is ecchymotic area round the umbilicus
  • Herpes zoster
  • Cellulitis
  • Rash (Henoch–Schönlein purpura)

Essential Workup

• For a woman in reproductive age group a pregnancy test is essential
• Where applicable for majority of cases, ultrasonography should be done with CT used in cases of negative or inconclusive ultrasonography

Diagnostic Tests and Interpretation

• Lab values are rarely diagnostic
• CBC
• Serum electrolytes, creatinine, and glucose
• ESR
• LFTs
• Lactic acid
• Serum lipase:
  • More sensitive and specific than amylase for pancreatitis
• Urinalysis
• Stool analysis and culture:
  • Clostridium difficile titers in patients with diarrhea taking antibiotics
• Pregnancy testing (age reproductive women)

• ECG:
  • Consider if risk factors for coronary artery disease are present
• Abdominal radiograph: Supine and upright
  • CT is superior for suspected visceral perforation and bowel obstruction
• Upright CXR:
  • Pneumoperitoneum
  • Intrathoracic disease causing referred abdominal pain
• US:
  • Biliary abnormalities
  • Hydronephrosis
  • Intraperitoneal fluid
  • Aortic aneurysm
  • Intussusception
• US (Doppler ultrasonography):
  • Volvulus and malrotation
  • Testicular and ovarian torsion
  • Hepatitis, cirrhosis, and portal vein thrombosis
• Abdominal CT:
  • Spiral CT without contrast:
    • Renal colic
    • Retroperitoneal hemorrhage
  • Appendicitis CT with IV contrast only:
    • Vascular rupture suspected in a stable patient (e.g., acute abdominal aortic aneurysm [AAA], aortic dissection)
    • Ischemic bowel
    • Pancreatitis
  • CT with IV and oral contrast:
    • History of inflammatory bowel disease
    • Thin patients (low BMI)
    • Diverticulitis
  • CT angiography:
    • Mesenteric ischemia
    • AAA
• IVP:
  • CT has replaced the use of IV urography in detection of ureteral stones
• Barium enema:
  • Intussusception
  • Treatment and confirmation of intussusception is with air contrast enema
• MRI:
  • If concerns for radiation exposure or nephrotoxicity
  • Contraindicated in patients with metallic implants

Differential Diagnosis

• AAA
• Abdominal epilepsy or abdominal migraine
• Boerhaave syndrome
• Adrenal crisis
• Early appendicitis
• Bowel obstruction
• Cholecystitis
• Constipation +/– fecal impaction
• Diabetic ketoacidosis
• Diverticulitis
• Dysmenorrhea
• Ectopic pregnancy
• Esophagitis
• Endometriosis
• Fitz-Hugh–Curtis syndrome
• Gastroenteritis
• Hepatitis
• Incarcerated hernia
• Infectious gastroenteritis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Ischemic bowel
• Meckel diverticulitis
• Neoplasm
• Ovarian torsion
• Ovarian cysts (hemorrhagic)
• Pancreatitis
• Pelvic inflammatory disease
• Peptic ulcer disease
• Peritonitis
• Renal/ureteral calculi
• Renal Infarction
• Sickle cell crisis
• Splenic infarction
• Spontaneous abortion
• Testicular torsion
• Trauma related
• Tubo-ovarian abscess
• UTI
• Volvulus
• Referred pain:
  • Myocardial infarction
  • Herpes zoster
  • Pneumonia
  • Pulmonary embolism
• Abdominal wall pain:
  • Abdominal wall hematoma or infection
  • Black widow spider bite
  • Herpes zoster

• Under 2 yr:
  • Hirschsprung disease
  • Incarcerated hernia
  • Intussusception
  • Volvulus
  • Foreign body ingestion
• 2–5 yr:
  • Appendicitis
  • Incarcerated hernia
  • Meckel diverticulitis
  • Sickle cell crisis
  • Henoch-Schönlein purpura
  • Constipation

Ed Treatment/Procedures

• Nasogastric tube decompression and bowel rest
• IV fluids and electrolyte repletion
• Antiemetics are important for comfort
• Narcotics or analgesics should not be withheld
• Send for blood type and cross-match for unstable patient
• Surgical consultation based on suspected etiology

Medication

• Fentanyl: 1–2 mcg/kg IV qh
• Morphine sulfate: 0.1 mg/kg IV q4h PRN
• Ondansetron: 4 mg IV
• Prochlorperazine: 0.13 mg/kg IV/PO/IM q6h PRN nausea; 25 mg PR q6h in adults
• Promethazine: 25–50 mg/kg IM/PO/PR

Disposition

• Surgical intervention
• Peritoneal signs
• Patient unable to keep down fluids
• Lack of pain control
• Medical cause necessitating in-house treatment (MI, DKA)
• IV antibiotics needed

Follow-Up Recommendations

• Vomiting
• Blood or dark/black material in vomit or stools
• Yellow skin or in the whites of the eyes
• No improvement or worsening of pain within 8–12 hr
• Shaking chills, or a fever >100.4°F (38°C)