PD E2- Acute abdomen

What is an acute abdomen?

Abnormal condition characterized by sudden onset severe pain in abd cavity that requires immediate evaluation, diagnosis, and possible surgical intervention

What would a tearing pain in the chest, then abdomen and radiating to the back indicate?

Dissecting aortic aneurysm

What would pain in the umbilicus then RLQ 1-3 hours later indicate?

Appendicitis

If a patient complains of “pain all over my belly,” what might this indicate?

Rupture

Where does pain associated with pancreatitis radiate to?

Back

What can cause scrotal edema?

IVC obstruction

What can cause scrotal pain?

Kidney stone

How is pain described in a perforated gastric ulcer?

Burning

What kind of pain is associated with pyelonephritis?

Dull/aching

What kind of pain?

• hollow abd organs contract forcefully or distended or stretched (biliary tree or intestines)

• capsular distention or stretching of solid organs (liver)

• gnawing, burning, cramping

Visceral pain

What kind of pain?

• inflammation of parietal peritoneum (peritonitis)

• steady aching pain

• pt lies very still

Parietal pain

What kind of pain?

• felt more at distant sites d/t innervation at same spinal levels as disordered stuctures

• usually not as intense as area of initial pain/pathology

Referred pain

What kind of pain may radiate inferior to the scapular angle on the right?

Biliary colic

What kind of pain can radiate to the R shoulder?

Acute cholecystitis, perforated duodenal ulcer, ruptured spleen

What kind of referred pain can radiate to T8-T9 right paravertebral region?

Acute pancreatitis or renal colic

What kind of referred pain can radiate to the lumbar region?

Uterine, prosthetic (pelvic), and rectal pain

What kind of referred pain can radiate to the testicles?

Renal colic w/ ureterolithiasis or appendicitis

What can cause vomiting?

Severe irritation of the nerves of peritoneum or mesentery (ex- gastric ulcer perforation) or obstruction involuntary muscular tube (ex- biliary duct)

Periodic epigastric pain occurring 0.5-1 hour after eating is a classic symptom of _____

Gastric ulcers

Pain 2-3 hours after eating or before the next meal is characteristic of ______

Duodenal ulcer

Pain after eating can also be associated with _____

Vascular disease of the abd viscera

What quadrant?

• gallbladder, liver

RUQ

What quadrant?

• spleen, stomach, pancreas

LUQ

What quadrant?

• appendix, Ig intestines, ovaries

RLQ

What quadrant?

• Ig intestines, ovaries

LLQ

Retroperitoneal or pelvic organs?

• pancreas, kidneys, aorta, paraspinal muscles

Retroperitoneal

Retroperitoneal or pelvic organs?

• uterus, ovaries, vagina, ureter, bladder

Pelvic

What kind of pain is on and off?

Colicky/visceral → hollow tube squeezes against obstruction causing pain, relieved as squeeze relents

Disease of a solid organ or a hallow tube that is now a solid organ due to blockage (ex appendicitis, diverticulitis) would be _____

Constant

What pre-pain symptoms are seen with obstruction due to SBO or appendicitis?

Anorexia, nausea, then pain in umbilicus (appendix, small bowel), or suprapubic region (large bowel) that then moves to location of organ then becomes diffuse if bursts

What would a green hue to the abdomen indicate?

Bile duct or gallbladder rupture

What would a purple hue (ecchymosis / blood) to the flanks or around the umbilicus suggest?

Ruptured vessel in abdomen

What would cold, pulseless, blue extremities suggest?

Issue with intra-abdominal aorta

What is yellow stool associated with?

High fat content

What would yellow skin, eyes, or dark urine suggest?

Bile duct obstructed or liver is injured

What does tarry stool (melena) suggest?

Upper GI bleed

What creates a black color in stool?

Bile mixing with blood

What does red blood in the stool (hematochezia) suggest?

Lower GI bleed (colon) or brisk upper GI bleed (peptic ulcer)

What are grey, hard stools due to?

Stool without bile (ex- tumor obstructing bile duct, liver disease)

What might a fever associated with an acute abdomen suggest?

Hallow tube has burst releasing bacterial contents into abdomen OR there is a localized pocket of infection (gastroenteritis, bacterial colitis)

What can cause referred pain to the abdomen?

Porphyria

Mediterranean fever

Black widow spider bite

Addisons dz

DKA

Lead poisoning

Uremia

Narrow angle glaucoma

Calcium

Herpes zoster

What killers should be r/o in acute abdomens?

Peritonitis, GI bleed, bowel obstruction, perforation

What is inflammation of the abdominal lining?

Peritonitis

What are the 3 signs of peritonitis?

Guarding- involuntary reflex arc contraction of abd wall muscles in response to stimuli

Cross palpation tenderness- rebound tenderness, press deeply & release quickly

Completely lying still- late sign of peritonitis, exacerbated by heel tap or bumping bed

What should be done to r/o GI bleed?

Rectal exam and guaiac test for blood

What does a guaiac test not detect?

Ruptured peptic ulcers bc blood goes into peritoneum NOT the bowel

LBO or SBO?

• more distention, less vomiting

• positive occult blood

LBO

What is borborygmi?

Presence of tinkles and rushes upon auscultation of the abdomen (indicates obstruction)

What are high pitched sounds (rain chimes) that result from a strong peristaltic attempt at pushing bowel contents through SBO?

Tinkles

What are peristaltic waves overcoming the obstruction and pushing bowel contents (usually fluid) through the obstruction, heard upon auscultation?

Rushes

When does pain occur in Borborygmi?

With rushes/peristaltic waves hitting obstruction

The following presentation is associated with what condition?

• Earth: constipation d/t bowel obstruction or ileus; dull to percussion

• Wind: Free air, gas- tympanic or hyperresonant

• Water: Ascites, fluid collection

Abdominal distention

What special test?

• place finger on tender area of pt’s abdomen and have pt raise both legs off table

• negative = no increase in pain → visceral

• positive = increase in pain → abd wall pain

Carnett’s sign

What special test?

• (RLQ) pain with cough

• suggests appendicitis but not specific

Dunphy’s sign

What special test?

• pain when pt drops from toes to heels when standing

• used to assess for appendicitis

Markle sign (heel drop test)

What special test?

• hook left thumb/fingers of right hand under costal margin of pt where lateral border of rectus muscle intersect with costal margin

• have pt take deep breath

• positive = RUQ tenderness → acute cholecystitis

Murphy’s sign

What special test?

• Tenderness in RUQ of abdomen radiating to R scapula/shoulder blade

• suggests acute cholecystitis (inflammation of GB)

Boas sign

What can acute cholecystitis cause?

Irritation of phrenic nerve (innervates diaphragm) → referred pain in RUQ and shoulder

What special test?

• Raise pt’s R leg w/ knee flexed

• rotate leg internally at hip

• this stretches internal obturator muscle → inc pain

• positive = inc abd pain

Obturator sign

What special test?

• Pt turn onto L side

• extend R leg at hip

• extension at hip stretches psoas muscle causing tension → inc pain

• positive = inc pain

Psoas sign type 1

What special test?

• Pt extend leg

• place R hand on pt’s R knee

• ask pt to flex hip against resistance

Psoas sign type 2

What special test?

• press deeply into abdomen with hand

• after a moment, quickly release pressure

• positive = inc pain when hand removed quickly → peritoneal inflammation

Rebound tenderness

What special test?

• Press deeply and evenly in LLQ then withdraw

• Positive = pain in RLQ (mcburney’s point) → appendicitis

Rovsing’s sign

Where is mcburneys point?

2/3 of the way between umbilicus and ASIS

What exams should NOT be forgetten when evaluating acute abdomen?

Inguinal/rectal exam in M & pevlic/rectal exam in F

What does every case of peritonitis begin with?

Distended organ that has not yet burst (may develop sx later in dz)

RUQ pain / tenderness suggests ______

Acute cholecystitis

What is a late sign of peritonitis?

Heel tap or bumping bed

Why does obstruction (SBO, appendicitis) begin with anorexia?

Body trying ot keep any additional food from entering body