Acute abdomen

Question 1

What is the first step in evaluating a patient with abdominal pain?

Answer 1

Assess ABCDE to determine if the patient is stable or unstable. If unstable, start acute management before any diagnostic workup.

Question 2

What is the term used to describe hyperactive bowel sounds?

Answer 2

borborygmus (pl: borborygmi).

Question 3

What is the term used to describe a bulging abdomen?

Answer 3

protuberant.

Question 4

What is the term used to describe an abdomen that is “sucked in?”

Answer 4

scaphoid.

Question 5

What are some life-threatening conditions that should be ruled out in an unstable patient with abdominal pain?

Answer 5

Acute mesenteric ischemia, perforated viscus, and ruptured abdominal aortic aneurysm.

Question 6

What are the key initial management steps for an unstable patient with abdominal pain?

Answer 6

Stabilize the airway, provide supplemental oxygen, establish IV access, and continuously monitor hemodynamics.

Question 7

What is the next step for a stable patient with abdominal pain?

Answer 7

Obtain a focused history and physical examination, characterizing the pain based on location, severity, chronicity, and associated symptoms.

Question 8

What findings on history and physical exam suggest an acute abdomen?

Answer 8

Severe distension with rigidity, diffuse tenderness, rebound, and guarding, often with a history of abdominal procedures, cancer, or aneurysm.

Question 9

What are the major considerations when a patient presents with lower or periumbilical pain?

Answer 9

Periumbilical or lower abdominal pain can stem from various organ systems, making it essential to consider the patient’s age, sex, medical history, and associated symptoms when establishing a differential diagnosis.

Potential causes of periumbilical or lower abdominal pain from the foregut include infectious gastroenteritis, gastritis, peptic ulcer disease, and pancreatitis. Causes of periumbilical or lower abdominal pain originating from the hindgut include acute appendicitis, acute diverticulitis, inflammatory bowel diseases, irritable bowel syndrome, small bowel obstruction, and acute mesenteric or colonic ischemia. A ruptured abdominal aortic aneurysm can be a life-threatening cause of lower abdominal pain and should be ruled out.

Question 10

Why is it about “location, location, location,” when it comes to evaluation of acute abdomen?

Answer 10

The location of pain can provide essential clues to the underlying etiology. Some common causes of lower abdominal pain include appendicitis, Crohn’s disease, nephrolithiasis, ovarian cyst or torsion, diverticulitis, sigmoid volvulus, urinary tract infection, pelvic inflammatory disease, endometriosis, bowel obstruction, colonic or mesenteric ischemia. The location of the pain can help narrow the differential diagnosis.

Question 11

What is the management of an acute abdomen?

Answer 11

Immediate bedside imaging (abdominal X-ray and ultrasound if imaging is actually possible), emergent surgical consultation, and possible exploratory laparotomy.

Question 12

What is the likely diagnosis for a patient with crampy, poorly localized abdominal pain, nausea, bilious vomiting, absence of flatus or bowel movements, abdominal distention, or the presence of abnormal bowel sounds that are either hypoactive or hyperactive?

Answer 12

SMALL BOWEL OBSTRUCTION

Question 13

What is the most common cause for small bowel obstruction?

Answer 13

Adhesions. The second most common cause is due to to herniations. The third most common is due to malignancy.

Question 14

A 55-year-old man presents to the emergency department with worsening periumbilical abdominal pain for the past 24 hours. He describes the pain as crampy and intermittent, occurring every 15-20 minutes. The patient also reports nausea, vomiting, an inability to pass gas, and constipation. He has a history of an appendectomy 25 years ago.
Temperature is 37°C (98.6°F), blood pressure is 128/76 mmHg, pulse is 112/min, respiratory rate 18 breaths/min, and oxygen saturation is 98% on room air. On examination, the abdomen is distended and tympanic to percussion with hyperactive bowel sounds. There is no rigidity or rebound tenderness. Which of the following is the most appropriate next step in evaluation?

Answer 14

This patient, with a history of prior abdominal surgery and presents with periumbilical abdominal pain, nausea, vomiting, inability to pass gas and stool, and physical exam findings of a tympanic abdomen with hyperactive bowel sounds, suggesting a small bowel obstruction. The diagnostic workup for abdominal pain can be guided by the clinical presentation and physical exam findings. Location of the pain can be used to aid in making a differential diagnosis and determining what further studies are needed. The most appropriate next step in evaluation, in this case, is a CT scan of the abdomen and pelvis. For patients presenting with periumbilical and lower abdominal pain history and physical examination should guide the diagnostic testing. Laboratory tests may include CBC, CMP, CRP, ESR, urinalysis, and lactate levels. Imaging studies such as plain abdominal radiography, abdominal US, CT scan of the abdomen and pelvis, MRI of the abdomen, and endoscopic evaluations may be performed.

Question 15

What are some causes of peri-umbilical abdominal pain?

Answer 15

Small bowel obstruction, infectious gastritis, or enterocolitis.

Question 16

What are the key features of small bowel obstruction?

Answer 16

Crampy peri-umbilical pain, nausea, bilious vomiting, oral intolerance, constipation or obstipation, abdominal distension, hyperactive bowel sounds, or patients with a history of abdominal surgery, IBD, or hernia.

Question 17

What imaging modality is used to confirm small bowel obstruction?

Answer 17

CT scan of the abdomen and pelvis with oral contrast, showing dilated bowel loops, transition point, distal collapsed bowel, and air-fluid levels.

Question 18

What are the classic signs and symptoms of infectious gastritis or enterocolitis?

Answer 18

Crampy peri-umbilical pain, nausea, vomiting, diarrhea, fever, recent food ingestion, sick contacts, recent travel, or antibiotic use.

Question 19

What are the key features of acute appendicitis?

Answer 19

Peri-umbilical pain migrating to the right lower quadrant, nausea, vomiting, fever, chills, anorexia, McBurney’s point tenderness, and positive Rovsing, psoas, or obturator signs.

Question 20

What are the characteristic imaging findings of appendicitis on CT scan?

Answer 20

Dilated appendix with thickened wall, peri-appendiceal fat stranding, trace amounts of fluid, possible phlegmon or appendicolith.

Question 21

What is the most common cause of left lower quadrant abdominal pain?

Answer 21

Diverticulitis.

Question 22

What are the clinical features of diverticulitis?

Answer 22

Constant left lower quadrant pain, fever, chills, bowel changes (constipation or diarrhea), localized tenderness with rebound and guarding.

Question 23

What are the characteristic CT findings of diverticulitis?

Answer 23

Diverticula with colonic wall thickening, fat stranding, extraluminal gas or fluid, possible abscess formation.

Question 24

What are the common causes of groin or abdominal wall pain?

Answer 24

Hernias, which may be reducible, incarcerated, or strangulated.

Question 25

How do you differentiate between a reducible, incarcerated, and strangulated hernia?

Answer 25

Reducible hernias protrude with coughing or valsalva. Incarcerated hernias are trapped and cannot be reduced. Strangulated hernias have compromised blood flow, leading to bowel ischemia and necrosis.

Question 26

What clinical findings raise concern for a strangulated hernia?

Answer 26

Severe pain, non-reducibility, overlying inflammatory skin changes (redness), and signs of bowel ischemia like lactic acidosis.

Question 27

What imaging is recommended if hernia diagnosis is unclear?

Answer 27

CT scan of the abdomen and pelvis to visualize the hernia and its contents.

Question 28

What alternative diagnoses should be considered if no gastrointestinal cause is found for abdominal pain?

Answer 28

UTI, kidney stones, urinary retention, pelvic inflammatory disease, ectopic pregnancy, ovarian torsion, ovarian cyst rupture, and testicular torsion.

Question 29

What is the likely diagnosis for a patient who presents with dysuria, urinary frequency, urinary urgency, suprapubic tenderness?

Answer 29

URINARY TRACT INFECTION

Question 30

What is the likely diagnosis for a patient that presents with waxing and waning flank or groin pain, hematuria, nausea,
vomiting, and restlessness?

Answer 30

NEPHROLITHIASIS

Question 31

What is the likely diagnosis when a patient presents with severe, sudden-onset abdominal or back pain, hypotension, and a pulsatile abdominal mass?

Answer 31

RUPTURED ABDOMINAL AORTIC ANEURYSM

Question 32

What is the likely diagnosis for a patient who presents with early periumbitical abdominal pain with migration to RLQ, fever, tenderness at McBurney point, Rovsing sign, psoas sign, obturator sign?

Answer 32

ACUTE APPENDICITIS

Question 33

What is the likely diagnosis for a patient who presents with crampy, diffuse abdominal pain, nausea, vomiting, diarrhea in a patient that have a history of eating raw or spoiled food?

Answer 33

INFECTIOUS GASTROENTERITIS

Question 34

What is the likely diagnosis for a patient with chronic, poorly localized abdominal pain, bloody diarrhea,
weight loss?

Answer 34

INFLAMMATORY BOWEL DISEASE (CROHN DISEASE, ULCERATIVE COLITIS)

Question 35

What is the likely diagnosis for a patient endorsing chronic, poorly localized abdominal pain and altered bowel habits that is often relieved by defecation?

Answer 35

IRRITABLE BOWEL SYNDROME

Question 36

What is the likely diagnosis for a patient with severe, poorly localized abdominal pain that is disproportionate to physical examination, with risk factors for arterial or venous thromboembolism or atherosclerosis?

Answer 36

ACUTE MESENTERIC ISCHEMIA

Question 37

What is the likely diagnosis for a patient with hypotension, bloody diarrhea, unilateral lower abdominal pain, with risk factors for atherosclerosis or thromboembolism (arterial or venous)?

Answer 37

COLONIC ISCHEMIA

Question 38

What is the likely diagnosis for a patient with heaviness or discomfort around a bulge that enlarges with standing, straining, cough or valsalva?

Answer 38

ABDOMINAL HERNIA (INGUINAL, FEMORAL, INCISIONAL, UMBILICAL)

Question 39

What is the likely diagnosis for a patient with sudden-onset lower abdominal or scrotal pain, elevated & rotated testicle, and an absent cremasteric reflex

Answer 39

TESTICULAR TORSION

Question 40

What is the likely diagnosis for a patient with sudden-onset of severe, unilateral lower abdominal pain, nausea, vomiting, and a unilateral tender adnexal mass

Answer 40

OVARIAN TORSION

Question 41

What is the likely diagnosis for a patient with a sudden-onset of severe, unilateral lower abdominal pain immediately following strenuous or sexual activity?

Answer 41

RUPTURED OVARIAN CYST

Observation and analgesics are the appropriate initial management of a patient that has been diagnosed with a ruptured ovarian cyst.

Question 42

What is the likely diagnosis for a patient with lower abdominal pain, vaginal bleeding, amenorrhea, and a positive pregnancy test?

Answer 42

ЕСТОРІС PREGNANCY

Question 43

What is the likely diagnosis for a patient with lower abdominal pain, fever, abnormal vaginal discharge, and
cervical motion tenderness?

Answer 43

PELVIC INFLAMMATORY DISEASE

Question 44

What diagnostic measure is used for most lower abdominal conditions in females?

Answer 44

Pelvic ultrasound should be ordered to confirm the diagnoses in these patients as well as to rule out more serious causes of right lower quadrant pain including ovarian torsion, pelvic inflammatory disease, and tubo-ovarian abscess.

Question 45

A 24-year-old woman presents to the emergency department with sudden-onset, sharp right lower quadrant abdominal pain that began approximately 3 hours ago, shortly after lifting weights at the gym. Her last menstrual period was 4 weeks ago. She has no dysuria, hematuria, urinary frequency, or urgency. Her vital signs are within normal limits. The patient appears comfortable. On abdominal examination, the abdomen is soft and nondistended with moderate tenderness in the right lower quadrant, without rebound or guarding. There is no costovertebral angle or suprapubic tenderness. Laboratory evaluation, including CBC, CRP, and urinalysis are within normal limits, and a urine pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation?

Answer 45

This patient presents with sudden-onset sharp RLQ abdominal pain that began shortly after exercising. In a woman of reproductive age with a negative pregnancy test (ectopic pregnancy less likely), in the absence of fever and elevated inflammatory markers (appendicitis less likely), this clinical presentation is suggestive of a ruptured ovarian cyst. A pelvic ultrasound is recommended for diagnosis and to rule out more serious causes of right lower quadrant pain like ovarian torsion. Sharp lower quadrant abdominal pain in a woman of reproductive age with a negative pregnancy test and no signs, symptoms, or laboratory results indicating appendicitis, can be caused by a ruptured ovarian cyst. A pelvic ultrasound can be used to evaluate for ovarian torsion or a ruptured ovarian cyst.