ABDOMINAL PAIN
JOSEPH DEAN L. NICOLO,MD,DPBS,FPSGS
GENERAL SURGERY
Abdominal pain………… cause?
- one of the most common complaints
any physician encounters throughout
his career
- occurs in all ages
- majority of cases are no serious
threats to the patients’ lives
Abdominal Pain
Causes:
Inflammation
Stretching or
distention of an
organ
Ischemia
Spasm
Abdominal Pain
TYPES:
Hollow viscera
- crampy /paroxysmal
- often poorly localized
- related to peristalsis
- patient is writhing on exam table
Abdominal Pain
TYPES:
Peritoneal Irritation
- steady/constant
- often localized
- patient lies still with knees up
Recognition of Acute
Surgical Abdomen
- abdominal pain is the presenting
symptoms of a very serious condition
in a small subset of patients
- delayed surgical intervention carries
a high fatality rate
- early recognition of a surgical
abdomen
Recognition of Acute
Surgical Abdomen
- 70% of diagnoses can be made
based on history alone
- 90% of diagnoses can be made
based on history & physical exam
HISTORY
1. Intensity / Severity
- mild
- moderate
- severe
HISTORY
2. Progressive
- increasing pain intensity
- widening painful area
- abdominal distention
- other signs & symptoms
(vomiting, diarrhea, flatus, fever, etc.)
HISTORY
3. Persistence
- unrelieved for six hours
HISTORY
4. Non-response to medication
- not relieved by antispasmodics,
antacids, or analgesics
- strong opioids should be avoided
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
Inspection:
- asymmetry
- previous operation
- abdominal distention
- hematoma /abrasion
lesions
- inguino-scrotal mass
PHYSICAL EXAMINATION
Auscultation:
- absent
- hypoactive
- hyperactive
PHYSICAL EXAMINATION
Percussion:
- fluid wave
- tympanitic
- dull
Percussion - Liver
PHYSICAL EXAMINATION
Palpation:
- warmness
- mass
- tenderness
(direct/rebound)
Direct & Rebound Tenderness
Deep Palpation
Liver Palpation
PHYSICAL EXAMINATION
REMEMBER!!!!
Inguinal/rectal
exam on male
Pelvic/rectal
exam on female
Diagnosis of Acute Abdomen
- History
- Physical Examination
- Diagnostic tests & procedures
- Immediate Surgical Consult
“regardless of what the underlying
pathology is and abdominal organ
involved”
The Role of Diagnostic Tests
- sometimes can mislead physicians
- improper interpretation of results
- urinalysis
- cbc
- x-rays
COMMON CAUSES OF
ABDOMINAL PAIN IN
ADULTS
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
EPIGASTRIUM:
1. Duodenal Ulcer
- chronic & recurrent
disease
- high gastric acid/pepsin
secretion
- sharply localized at the
epigastric which occurs
a few hours after a meal
- occasionally the ulcer
perforates
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
EPIGASTRIUM:
2. Chronic Gastritis, Gastric
Ulcer
- role of helicobacter pylori
- gastric carcinoma
- pain on empty stomach
- occasionally perforates
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
EPIGASTRIUM:
3. Cholecystitis
- epigastric discomfort
- localized or diffuse RUQ
pain
- radiation to right scapula
- deep seated feeling of
pressure
- precipitated by heavy
meal
- perforation or cholangitis
can occur
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
EPIGASTRIUM:
4. Common bile duct calculi,
Biliary Ascariasis
- pain is more severe &
“explosive”
- jaundice & fever
- risk of ascending
cholangitis is high
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
EPIGASTRIUM:
5. Acute Pancreatitis
- more severe and
incessant
- most activities are
disrupted
- acute necrotizing
pancreatitis
- progressive intra-
abdominal sepsis
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
EPIGASTRIUM:
6. Myocardial Ischemia/Infarction
- epigastric discomfort or pain
- history of coronary heart
disease or stroke
- hypertensive, diabetic or
obese
- elderly (65 years & above)
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
LOWER QUADRANTS:
1. Acute Appendicitis
- most common cause
- occurs in any age
- epigastric discomfort-
periumbilical- RLQ
- fever, vomiting & WBC
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
LOWER QUADRANTS:
2. Ovarian Newgrowth with
Complication
- twist on its pedicle, leaks
or ruptures or bleeds
within its capsule
- pain can be persistent or
intermittent
- bimanual pelvic exam
- ultrasound
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
LOWER QUADRANTS:
3. Ureterolithiasis
- deep seated & radiates
to the flank, back &
inguinal areas
- spontaneous remission
when stone disimpacts
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
LOWER QUADRANTS:
4. Ectopic Pregnancy
- female of reproductive age
- history of missed period &
vaginal bleeding
- pallor & tachycardia
hemorrhage
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
LOWER QUADRANTS:
5. Ruptured Ovarian Follicle
(Mittelschmerz)
- moderate to severe pain
- tenderness & rigidity
- subsides in a few hours
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
LOWER QUADRANTS:
6. Pelvic Inflammatory Disease
- sexually active women
- moderate to severe abdominal pain,
occurs immediately before or after
menstrual flow
- pelvic abscess/sepsis surgery
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
LOWER QUADRANTS:
7. Endometriosis
- cyclical perimenstrual occurrence
- vague, inconsistent, infertility
- rupture hemoperitoneum surgery
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
LOWER QUADRANTS:
8. Diverticulitis
- middle age & beyond
- colonic inflammatory symptoms
- cecum & sigmoid colon
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
RIGHT UPPER QUADRANT:
1. Cholecystitis
- epigastric discomfort, RUQ pain
- persistent & progressive
- fever may be present
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
RIGHT UPPER QUADRANT:
2. Amoebic Liver Abscess
- RUQ pain, fever & tender hepatomegaly
- history of amoebiasis
- medical management
COMMON CAUSES OF
ABDOMINAL PAIN IN
CHILDREN
DIAGNOSIS
- Meticulous medical history
- onset, location & character of pain
- Usual companion/caretaker should supply
the information
- Gentle physical examination
- Laboratory examinations
COMMON CONDITIONS
ACCORDING TO AGE GROUP
INFANTS:
- intestinal obstruction from congenital
causes, intussusception, incarcerated
hernias, Meckel’s diverticulitis, Hirschsprung’s,
enterocolitis, pyelonephritis
COMMON CONDITIONS
ACCORDING TO AGE GROUP
3 – 11 YEARS:
- appendicitis, Meckel’s diverticulitis, trauma,
mesenteric adenitis
ADOLESCENTS:
- appendicitis, gastritis, Mittelschmertz,
trauma, cholecystitis
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
1. APPENDICITIS:
- direct tenderness at
McBurney’s point
- vomiting, anorexia & nausea
- DDx: pneumonia, viral
enteritis, mesenteric
adenitis, UTI, PID
- 50% perforation rates
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
2. INTUSSUSCEPTION:
- 90% ileocolic type
- healthy infant with sudden colicky
abdominal pain
- passage of currant jelly stools & palpable
sausage-shaped mass at RUQ
- doppler UTZ – target sign
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
3. INCARCERATED HERNIA:
- may cause intestinal obstruction
- if early incarceration – attempt reduction
- signs of strangulation – surgery
- evaluate testes for torsion
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
4. MALROTATION:
- a true surgical emergency
- diagnosed within the 1st few months of life
- bilious vomiting & blood in the stools
- upper GI study or barium
- abnormal location of cecum
- small intestines in the left side
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
5. INTESTINAL OBSTRUCTION:
- congenital intestinal atresia, fibrous bands
or internal hernias
- post-operative adhesions & foreign bodies
- vomiting, abdominal distention, (-) flatus
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
6. HEPATIC & BILIARY CAUSES:
- Biliary ascariasis
- violent episodes of abdominal pain with
or without jaundice
- history of passage of adult worms
- Amebic liver abscess
- hepatomegaly
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
7. INFECTIOUS CAUSES:
- Gastroenteritis
- non localized pain, vomiting & diarrhea
- hydrate & electrolyte correction
- antibiotics
- surgery is reserved for complications
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
8. OVARIAN PATHOLOGY:
- can be seen even in neonates
- movable mass in the lower abdomen
- may mimic appendicitis
- diagnosed by UTZ
The Most Common Causes of
Abdominal Pain and Acute
Surgical Abdomen
9. ABDOMINAL TRAUMA:
- due to fall or accident
- X-ray: pneumoperitoneum
- UTZ: solid organ injury/ peritoneal fluid
- Maltreatment or child abuse should be
suspected for repeated admission for
trauma.