Acute Abdominal Pain

Question 1

• vague, dull

- localized to midline

Answer 1

Visceral (Soft organ) Pain

Question 2

• Stimulation of parietal peritoneum
• More intense and localized
• Worsened by movement/coughing

Answer 2

Somatoparietal Pain

Question 3

• In area remote from diseased organ
• Visceral afferents and somatic afferents converge at the same level of the spinal cord

Typical sites:

• Gallbladder (RUQ to shoulder)
• Esophagus (shoulder)
• Pancreas: straight back
• RUQ: liver, gallbladder, stomach, esophagus; lungs and heart
• LUQ: stomach, spleen

Answer 3

Referred Pain

Question 4

• Waxing and waning pain

- Commonly due to Biliary Colic

Answer 4

Colicky Pain

Question 5

• Waxing and waning RUQ pain
• due to the gallbladder contracting against a stone lodged in the cystic duct
• Typically precipitated by a fatty meal, can recur
• symptoms relieved if the stone passes

Answer 5

Biliary Colic

Question 6

• Classic heartburn
• Precipitating Factors: Fatty or greasy foods, caffeine, chocolate, alcohol, tobacco
• Diagnosis: Clinical, endoscopy, upper GI series
• Treatment: PPI

Answer 6

GERD

Question 7

• Episodic cramping pain
• Precipitated by: Hot or cold liquids, GERD
• Diagnosis: Clinical, manometry
• Treatment: PPI, nitrates, calcium channel blockers

Answer 7

Diffuse Esophageal Spasm

Question 8

• Dull gnawing pain in upper abdomen
• May change with food intake
• Perforation: sudden, sharp, severe
• Causes: H pylori, NSAIDS, Zollinger Ellison
• Diagnosis: Clinical, endoscopy, upper GI series
• Treatment: PPI, antibiotic for H pylori, endoscopy/surgery if complications

Answer 8

Peptic Ulcer Disease

Question 9

• RUQ pain – capsule distension
• Associated jaundice, fever
• Causes: Viral, drugs, ischemia
• Diagnosis: Laboratory
• Treatment: Supportive care, rarely transplant

Answer 9

Hepatitis

Question 10

• Constant and severe RUQ pain, radiation to shoulder
• Associated fever, nausea, vomiting
• Obstruction of cystic duct by gallstone
• Diagnosis: Murphy’s sign, Ultrasound, CT scan
• Treatment: Cholecystectomy or cholecystotomy

Answer 10

Acute Cholecystitis

Question 11

• Charcots Triad: Fever, RUQ pain, jaundice
• Reynolds Pentad: sepsis, mental status change
• Obstruction of common bile duct: Stone, cancer, stricture
• Diagnosis: Clinical, ultrasound, CT, endoscopy (ERCP)
• Treatment: ERCP with stone removal/stent, surgery

Answer 11

Ascending Cholangitis

Question 12

• Constant epigastric pain radiating to back
• Causes: Alcohol and gallstones
• Diagnosis: Clinical, amylase, lipase, CT scan

Answer 12

Acute Pancreatitis

Question 13

• Obstruction: complete or partial
• Spasm
• Inflammation: infection, Crohn’s disease

Answer 13

Small Intestine

Question 14

• Constant LLQ pain
• Associated fever
• Obstruction, microperforation of diverticuli
• Diagnosis: Clinical, CT scan
• Treatment: Antibiotics, drainage or surgery for abscess

Answer 14

Diverticulitis

Question 15

• Diffuse or segmental abdominal pain
• Associated diarrhea +/- blood
• Causes: Ulcerative Colitis; Ischemic; Infectious
• Diagnosis: Endoscopy, CT scan
• Treatment: Dependant on cause

Answer 15

Colitis

Question 16

• Altered mental status
• Unstable vitals: Tachycardia, Hypotension
• Peritoneal signs: acute abdominal pain, abdominal tenderness, and abdominal guarding, which are exacerbated by moving the peritoneum, e.g., coughing, flexing one’s hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness)

Answer 16

Indications for Surgical Consult

Question 17

• Classically pain beginning in umbilical area (midline) then localizing to RLQ
• McBurney’s point: 2/3 way down btw umbilicus and iliac crest
• Hamburger sign: these Pts usually not hungry at all
• May have associated nausea, vomiting, fever
• Psoas sign: lift leg straight up against resistance

Answer 17

Appendicitis

Question 18

• Sudden crampy periumbilical pain
• Associated distension, nausea, vomiting(bilious/feculent)
• Causes: adhesions, incarcerated hernia, Crohn’s, malignant
• Exam: decreased bowel sounds, tympanic
• Diagnosis: Abdominal x ray, CT scan
• Treatment: Decompression, surgery

Answer 18

Small Bowel Obstruction

Question 19

• Similar symptoms as SBO, less vomiting
• Causes: Cancer; Volvulus – sigmoid most common
• Diagnosis: Abdominal x-ray, CT
  Treatment: Surgery, colonoscopy

Answer 19

Colonic Obstruction

Question 20

• Diffuse abdominal pain out of proportion to exam
• Causes: Thromboembolism: arterial/venous; Arteriosclerosis; Hypotension, low flow states
• High pitched bowel sounds
• Diagnosis: Abdominal x-ray, CT scan , angiography
• Treatment: Mostly supportive; Intervention if massive – surgery, interventional radiology

Answer 20

Ischemia to Small Bowel or Colon

Question 21

• Evaluation difficult due to altered anatomy from enlarge uterus – atypical symptoms
• Most important factor to health of fetus is a healthy mother

Diagnosis:

• Avoid CT scans and unnecessary x –rays
• Ultrasound preferred

Treatment:
Surgery only if necessary – 2nd trimester (safest time to perform Sx)

Answer 21

Abdominal Pain in Pregnancy