Abdominal Pain

Visceral Pain

Fibers located in the walls and capsules that are “activated” by elicited by distention, inflammation, or ischemia or by sensory nerves - results in pain that is slow in onset, dull, poorly localized, and protracted (deep-seated and felt in the midline)

Parietal Pain

What type of pain is characterized by an acute onset that is sharp and better localized pain sensation that results from direct irritation of the parietal peritoneum - occurs in 1 of the 4 quadrants

Vitals, GCS (if not 15 quantify), Distress (peritonitis = still, obstructive = restless), point to MAX point, divide into 4 quadrants, Lungs, Pelvic, back, rectal (above and below)

Problem Focused Physical Exam for Abdominal pain

distended abdomen with surgical scar (adhesions, SBO), Scaphoid contracted abdomen (perf ulcer), visible peristalsis (advanced bowel obstruction), Soft doughy fullness (early paralytic ileus, mesenteric thrombosis), everted umbilicus (increased intra-abdominal pressure)

Things to look for on abdominal inspection

Peristalsis, Absence of bowel sounds (ileus), hyperactive/hypoactive (normal), high-pitched (mechanical bowel obstruction)

Things to look for on Auscultation

Tympany (bowel obstruction, hollow viscus perf, free air), Lower tones (solid organs, fluid), Tenderness on percussion (peritonitis - do a heel tap), observe for discomfort

Things to look for with percussion

Guarding voluntary vs. involuntary, Tenderness (diffuse/rebound/localized), Palpate the painful part last, try to distract (put stethoscope in the same area), Specific signs (Rovsings, murphy, psoas, obturator), Pain out of proportion in older CAD (bowel ischemia (mesenteric))

Things to look for on palpation (most informative aspect)

Grey-turner’s sign, Rhonchi, Diminished breath sounds, tactile fremitus (99), CVA tenderness

Red flags on chest exam

Adenopathy, masses, discoloration, edema, crepitus; check the rings (hernia), pelvic exam, discharge, symmetry

Red flags on GU exam

CBC, CMP, UA, serum beta HCG, Coags, lipase (pancreatitis)

Lab work up for Abdominal Pain

Elderly patients, Hx of cardiomyopathy, dysrhythmia, ischemic heart disease

Who gets an EKG?

U/S (gallstones, female GU stuff), Helical CT (most efficient), Plain chest (all cases of acute abdomen, pre-op, subdiaphragmatic air), Pain abdominal

Imaging studies for Abdominal Pain

Adequacy, bones, calcifications, deformity/density (organomegaly), extraluminal/peritoneal air, foreign bodies/fracture

ABCDEF for a plain abdominal X-ray

Air in the stomach, small bowel, rectosigmoid; psoas muscle (not great), enlarged liver (displacement of bowel), soft-tissue eval is limited

Landmarks of abdominal x-rays (KUB)

3 way abdomen - flat, upright + CXR that looks for hemo/pneumoperitoneum and identifies the need for NG tubes

KUB (kidneys, ureter, bladder) - used in trauma every once in a while

Displaced stomach, spleen projects 12th posterior rib

Signs of splenomegaly on X-ray

Stomach (rugae and the mucosal layer), Plicae circulares/valvulae conniventes (Small intestine - abnormal), Haustra (Colon - sacculated gross)

Spots for intraluminal air

ileus or obstruction

Diffuse air is a sign for

acute obstipation (nothing is moving), abdominal pain, distention, N/V

Symptoms of obstruction

Mechanical (ileus is diffuse, mild, and occurs with other intra-abdominal pathology)

Which type of obstruction has more localized and severe pain?

abdominal operations (should respond spontaneously BUT we might have to throw in an NG tube or alvimopan)

Ileus is most common after

Closed-loop obstruction

A mechanical obstruction in which a segment of a bowel obstructed proximally and distally (like an internal hernia)

adhesions from previous surgery, hernia, tumor

Most common causes of SBO

Cancer, diverticular strictures, volvulus

Most common causes of LBO

Entire bowel has air and is dilated, long air fluid level, gas in the rectum/sigmoid, no transition point on CT

Imaging findings of Ileus

multiple dilated loops (2.5 cm+) of small bowel, multiple air fluid levels

Imaging findings of a mechanical SBO

12+ cm, 6+ days dilated

Risk of Ischemia and perforation increases with the degree and duration of colon distention

Upright CXR

What is most sensitive for free intraperitoneal air?

Air under right diaphragm, rigler’s sign (air on both sides of the abdomen)

Signs of Pneumoperitoneum

Upright xrays

When it comes to air fluid levels, what do you need to order?

tubular structures (vessels), Aortic aneurysms (lateral projections), Intra-abdominal organs, Phleboliths (small rounded calcifications with a lucent center)

Calcifications to look for on KUB

Lamellar (laminar)

What type of calcification forms around a nidus inside a hollow lumen and calcifies in concentric layers?

Popcorn calcification (amorphous)

What type of calcification is formed inside of a solid organ or tumor?

Well hydrated (contrast is nephrotoxic), Metformin are at an increased (hold 24 hours before and 2 days after)

IV contrast education measures?

Barium Swallow (UGI), Barium Enema (lower GI), Cystogram, retrograde urethrogram

GI/GU contrast studies

Fever, N/V, intractable pain (not sent home if narcs are needed)

Strict return protocols if a patient is discharge

Do or DIE - blunt trauma, penetrating trauma, rupture aneurysm, aortic transection

Who needs emergent surgery?

Appendicitis, ectopic, incarcerated hernia, Anyone with guarding/rigidity, increased/severe localized tenderness, tense/progressive distention, tender abdominal/rectal mass with high fever, rectal bleeding with shock/acidosis, SIRs, pneumoperitoneum, bowel distention, free extravasation of contrast

Who needs urgent surgery (within 24 hr)