Acute Abdominal Pain Overview
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Questions and Answers

What is the abbreviation for acute abdominal pain?

AAP

What is the primary cause of visceral pain?

  • Distention
  • Inflammation
  • Ischemia
  • All of the above (correct)

Parietal pain is localized to the dermatome above the site of the stimulus.

True (A)

What is the most common cause of generalized abdominal pain?

<p>Perforation</p> Signup and view all the answers

What condition is often associated with right lower quadrant (RLQ) pain in young patients?

<p>Mesenteric adenitis</p> Signup and view all the answers

Loin pain can be caused by muscle strain.

<p>True (A)</p> Signup and view all the answers

Overlying tenderness or underlying surgical disease can impact the accuracy of diagnosing acute abdominal pain.

<p>True (A)</p> Signup and view all the answers

Atypical presentations of acute abdominal pain are uncommon, affecting only 15% of cases.

<p>False (B)</p> Signup and view all the answers

True colic is characterized by a baseline of no pain.

<p>True (A)</p> Signup and view all the answers

Stabbing pain is a characteristic feature of aortic aneurysms (AAA).

<p>True (A)</p> Signup and view all the answers

Burning or boring pain is a common symptom associated with peptic ulcer disease (PUD).

<p>True (A)</p> Signup and view all the answers

What two conditions are often associated with gnawing pain?

<p>Pancreatitis and pancreatic cancer</p> Signup and view all the answers

Previous episodes of acute abdominal pain (AP) are a significant consideration in the assessment of a patient with current AP.

<p>True (A)</p> Signup and view all the answers

Observation is an important component of the physical exam for acute abdominal pain.

<p>True (A)</p> Signup and view all the answers

What is the main purpose of checking for hernia sites during palpation of the abdomen?

<p>To identify potential hernias that may be contributing to the abdominal pain</p> Signup and view all the answers

Rebound tenderness is a reliable indicator of peritonitis, having a low false-negative rate.

<p>False (B)</p> Signup and view all the answers

Tenderness that is out of proportion to the examination is a key finding that can be suggestive of mesenteric ischemia or acute pancreatitis.

<p>True (A)</p> Signup and view all the answers

Cullen's sign is a bluish discoloration around the umbilicus and is associated with retroperitoneal hemorrhage.

<p>True (A)</p> Signup and view all the answers

Kehr's sign, severe left shoulder pain, can be a sign of splenic rupture or ectopic pregnancy rupture.

<p>True (A)</p> Signup and view all the answers

What is the specific area of tenderness associated with McBurney's sign?

<p>2/3 distance from the anterior iliac spine to the umbilicus on the right side</p> Signup and view all the answers

Murphy's sign, an abrupt interruption of inspiration on palpation of the right upper quadrant, is a sign of acute cholecystitis.

<p>True (A)</p> Signup and view all the answers

The iliopsoas sign is elicited by hyperextension of the right hip, which causes abdominal pain and is indicative of appendicitis.

<p>True (A)</p> Signup and view all the answers

The obturator's sign, characterized by internal rotation of the right hip causing abdominal pain, is another sign suggestive of appendicitis.

<p>True (A)</p> Signup and view all the answers

Grey-Turner's sign, a discoloration of the flanks, is typically caused by retroperitoneal hemorrhage.

<p>True (A)</p> Signup and view all the answers

The chandelier sign, where manipulation of the cervix causes the patient to lift their buttocks off the table, is indicative of pelvic inflammatory disease.

<p>True (A)</p> Signup and view all the answers

Rovsing's sign is a positive finding when palpation of the left lower quadrant causes pain in the right lower quadrant, suggestive of appendicitis.

<p>True (A)</p> Signup and view all the answers

The absence of bowel sounds in the abdomen can only be confirmed after listening for at least 2 minutes.

<p>True (A)</p> Signup and view all the answers

A bruit in the epigastrium can be suggestive of a potential abdominal aortic aneurysm.

<p>True (A)</p> Signup and view all the answers

Tenderness, induration, mass, and frank blood are findings that can be observed during a rectal examination.

<p>True (A)</p> Signup and view all the answers

The myth that rebound tenderness is a reliable indicator of peritonitis has been proven by clinical studies, suggesting that it is not as accurate of a sign as previously thought.

<p>True (A)</p> Signup and view all the answers

Administration of analgesics prior to surgical consultation can actually improve the accuracy of diagnosing acute abdominal pain.

<p>True (A)</p> Signup and view all the answers

When assessing a patient with acute abdominal pain, the initial management focuses primarily on stabilizing their condition, not necessarily on a firm diagnosis.

<p>True (A)</p> Signup and view all the answers

A low threshold for seeking senior help is encouraged in the management of acute abdominal pain.

<p>True (A)</p> Signup and view all the answers

A complete blood count (FBC) is a highly sensitive test that can accurately pinpoint the specific cause of acute abdominal pain.

<p>False (B)</p> Signup and view all the answers

Clotting tests can be helpful in assessing patients with acute pancreatitis, sepsis, disseminated intravascular coagulation (DIC), or liver disease.

<p>True (A)</p> Signup and view all the answers

Plain X-rays are often the first and most reliable imaging modality for diagnosing acute abdominal pain.

<p>False (B)</p> Signup and view all the answers

Laparoscopy has been proven to reduce the risk of unnecessary laparotomy and can be a valuable tool for resolving the diagnostic dilemma of non-specific abdominal pain.

<p>True (A)</p> Signup and view all the answers

While plain X-rays have limited utility in diagnosing acute abdominal pain, they are still helpful for detecting bowel obstruction or perforation.

<p>True (A)</p> Signup and view all the answers

Early diagnostic laparoscopy is favored over CT scanning because it is less invasive, has a lower risk profile, and can provide a definitive diagnosis.

<p>True (A)</p> Signup and view all the answers

Flashcards

Acute Abdominal Pain (AAP)

A sudden onset of abdominal pain that has not been previously diagnosed and lasts for less than one week.

Visceral Pain

Abdominal pain arising from stretching, inflammation, or lack of blood flow in hollow organs. Usually felt in the center of the abdomen. The location can differ based on the organ's origin.

Parietal Pain

Pain felt on the skin, but originates from underlying tissue or muscles. This is localized to a specific area related to the nerve.

Referred Pain

Pain felt somewhere other than where the source of the pain is located. It is commonly associated with internal organs.

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Colicky Pain

A type of abdominal pain that comes in waves or spasms. It is usually associated with conditions like irritable bowel syndrome (IBS) or bowel obstruction.

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Nagging & Grumbling Pain

A persistent dull, aching type of abdominal pain that is often present with conditions like biliary colic, cholecystitis, pelvic inflammatory disease (PID), and urinary tract infections (UTIs).

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Stabbing Pain

Pain that is sharp and intense, often associated with conditions like aortic aneurysm (AAA).

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Burning or Boring Pain

Pain that is burning or intense often experienced in the upper abdomen with conditions like peptic ulcer disease (PUD) or esophagitis.

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Gnawing Pain

Pain that is described as a persistent feeling of emptiness or gnawing. It is commonly associated with pancreatitis or pancreatic cancer.

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Cullen's Sign

Bluish discoloration around the belly button. Suggestive of internal bleeding that occurs in the retroperitoneal space (behind the abdomen).

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Kehr's Sign

Severe pain in the left shoulder. Suggestive of internal bleeding from a ruptured spleen or a ruptured ectopic pregnancy.

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McBurney's Sign

Tenderness when pressing on a specific point in the right lower abdomen, approximately 2/3 of the way from the anterior iliac spine (hip bone) to the belly button. Indicates appendicitis.

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Murphy's Sign

Sudden interruption of breathing when the doctor presses on the right upper quadrant of the abdomen. Often associated with acute cholecystitis.

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Iliopsoas Sign

Pain in the abdomen when the right hip is extended backward. Suggestive of appendicitis.

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Obturator Sign

Pain in the abdomen when the flexed right hip is rotated inward. It is also suggestive of appendicitis.

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Grey-Turner's Sign

Discoloration of the flank area (the side of the body between the ribs and the hip). This can indicate bleeding in the retroperitoneal space.

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Chandelier Sign

When examining a woman's cervix during pelvic examination, manipulating the cervix causes the patient to lift their buttocks off the table. This suggests pelvic inflammatory disease (PID).

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Rovsing's Sign

Pain in the right lower quadrant when pressing on the left lower quadrant. Typically indicates appendicitis.

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Scaphoid Abdomen

A condition in which the abdomen appears sunken inward due to a loss of abdominal fat or dehydration. It can be a sign of peptic ulcer disease or a major medical illness.

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Distended Abdomen

An enlarged abdomen caused by fluid buildup in the abdominal cavity (ascites), constipation, or intestinal obstruction.

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Visible Peristalsis

Visible waves of muscle contractions in the abdomen. A sign of a possible intestinal obstruction.

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Guarding

Involuntary muscle spasm in the abdomen, a reflex response to painful stimuli. This indicates inflammation of the abdominal lining (peritonitis).

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Rigidity

An extremely rigid and board-like abdomen, a strong indication of peritonitis. It signifies a serious inflammatory process in the abdominal cavity.

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Hyperactive Bowel Sounds

A rumbling sound heard during auscultation (listening) to the abdomen with a stethoscope. It can indicate bowel obstruction or hyperactive bowel activity.

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Bruit

A whooshing sound heard with a stethoscope over the abdomen. It can indicate a narrowing or blockage of blood vessels in the abdomen, usually the aorta.

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ABCDE Assessment

An initial evaluation of a patient's overall health status, focusing on airway, breathing, circulation, disability, and exposure.

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Tinkling Bowel Sounds

High-pitched, rapid bowel sounds that sound like a tinkling or bubbling sound.

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Plain X-ray

A test to help determine the presence of a bowel obstruction.

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CT Scan

A test to see the organs, blood vessels, and internal structures of the abdomen in more detail.

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Laparoscopy

A minimally invasive surgical procedure to examine the inside of the abdomen. Can be used to diagnose and treat acute abdominal pain.

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Laparotomy

A surgical procedure to make a large incision in the abdomen to see and treat the problem causing abdominal pain.

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Ascites

Fluid buildup in the abdominal cavity.

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Study Notes

Acute Abdominal Pain (AAP) Definition

  • AAP is the presentation of previously undiagnosed abdominal pain
  • Lasting for 1/52 or less
  • Prior to a clinical encounter in 1st or 2nd care

Introduction

  • Over 1000 causes of acute abdominal pain exist
  • Non-specific acute abdominal pain (SAP) accounts for 34%
  • Acute appendicitis accounts for 28%
  • Acute cholecystitis makes up 10%
  • Small bowel obstruction (SBO) accounts for 4%
  • Perforated peptic ulcer (PU) accounts for 3%
  • Pancreatitis makes up 3%
  • Diverticular disease accounts for 2%
  • Other causes account for 13%
  • Admission rates are 20-40%
  • Initial diagnosis is inaccurate in 50-65% of cases

Pathophysiology

  • Visceral pain arises from distention, inflammation, or ischemia in hollow or solid organs
  • Location of this pain is rooted in the organ's embryonic development:
    • Foregut to epigastrium
    • Midgut to umbilicus
    • Hindgut to the hypogastric region
  • Parietal pain is localized to the dermatome above the stimulating site
  • Referred pain produces symptoms (e.g., tenderness) but not signs

Generalized Acute Abdominal Pain (AP)

  • Perforation
  • Abdominal Aortic Aneurysm (AAA)
  • Acute pancreatitis
  • Diabetes Mellitus (DM)
  • Bilateral pleurisy

Central Acute Abdominal Pain (AP)

  • Early appendicitis
  • Small bowel obstruction (SBO)
  • Acute gastritis
  • Acute pancreatitis
  • Ruptured AAA
  • Mesenteric thrombosis

Epigastric Pain

  • Peptic ulcer disease (PUD)
  • Esophagitis
  • Acute pancreatitis
  • AAA

Right Upper Quadrant (RUQ) Pain

  • Gallbladder disease
  • Peptic ulcer disease (PUD)
  • Acute pancreatitis
  • Pneumonia
  • Subphrenic abscess

Left Upper Quadrant (LUQ) Pain

  • Gastrointestinal issues (GI)
  • Pneumonia
  • Acute pancreatitis
  • Spontaneous splenic rupture
  • Acute perinephritis
  • Subphrenic abscess

Suprapubic Pain

  • Acute urinary retention
  • Urinary tract infections (UTIs)
  • Cystitis
  • Pelvic inflammatory disease (PID)
  • Ectopic pregnancy
  • Diverticulitis

Right Iliac Fossa (RIF) Pain

  • Acute appendicitis
  • Mesenteric adenitis (young patients)
  • Perforated peptic ulcer disease (PUD)
  • Diverticulitis
  • Pelvic inflammatory disease (PID)
  • Salpingitis
  • Ureteric colic
  • Meckel's diverticulum
  • Ectopic pregnancy
  • Crohn's disease
  • Biliary colic (low-lying gallbladder)

Loin Pain

  • Muscle strain
  • Urinary tract infections (UTIs)
  • Renal stones
  • Pyelonephritis

Left Iliac Fossa (LIF) Pain

  • Diverticulitis
  • Constipation
  • Irritable bowel syndrome (IBS)
  • Pelvic inflammatory disease (PID)
  • Rectal cancer (Ca)
  • Ulcerative colitis (UC)
  • Ectopic pregnancy

Limitations

  • Limitations arise from the relationship between overlying tenderness and an underlying surgical pathology.
  • 35% of intra-operative diagnoses exhibit atypical presentations.

Key Points on History Taking

  • Site of pain
  • Nature and character of pain
  • Duration of pain
  • Intensity of pain
  • Precipitating and relieving factors
  • Associated symptoms

Classification by Nature of Pain

  • Colicky pain: Baseline of no pain in true colic, IBS, bowel obstruction
  • Nagging and Grumbling pain: Biliary colic, Cholecystitis, PID, UTI
  • Stabbing pain: AAA
  • Burning or boring pain: PUD, esophagitis
  • Gnawing pain: Pancreatitis, pancreatic cancer

Associated Symptoms

  • Fever
  • Genitourinary issues
  • Gynecological issues
  • Vascular issues

Past Medical History (PMH)

  • Previous episodes of AAP
  • Investigations
  • Operations
  • Chronic disease
  • Immunosuppression
  • Medications (NSAIDs)

Physical Examination

  • General Observations (OBS): Important for assessment
    • Posture: Bending forward (chronic pancreatitis), jaundice (common bile duct (CBD) obstruction), dehydration (peritonitis, small bowel obstruction)
  • Inspection:
    • Abdomen: Scaphoid or flat (peptic ulcer), distended (ascites or intestinal obstruction), visible peristalsis (thin or malnourished patient with obstruction)
  • Palpation:
    • Check for hernia sites
    • Tenderness
    • Rebound tenderness
    • Guarding (involuntary spasm of muscles during palpation)
    • Rigidity (abdominal muscles tense and board-like-indicates peritonitis)
    • Local right iliac fossa tenderness (acute appendicitis, acute salpingitis)
    • Low-grade, poorly localized tenderness (intestinal obstruction)
    • Tenderness out of proportion to examination (mesenteric ischemia, acute pancreatitis)
    • Flank tenderness (perinephric abscess, retrocecal appendicitis)
  • Specific Signs: Cullen's sign, Kehr's sign, McBurney's sign, Murphy's sign, iliopsoas sign, obturator's sign, Gray-Turner's sign, chandelier sign, Rovsing's sign
  • Auscultation:
    • Bowel sounds (BS) absent or present, high-pitched, hyperactive, or tinkling
    • Bruit in epigastrium
  • PR Examination: Tenderness, induration, mass, frank blood
  • PV Examination: Bleeding, discharge, cervical motion tenderness, adnexal masses or tenderness, uterine size or contour

Initial Management

  • Initial assessment: Very ill (resuscitation, help), stable (couple hours), reasonably well (investigations)
  • ABCDE approach for emergencies
  • Resuscitation and analgesia (opioid IV)
  • Full monitoring
  • Seeking senior help (low threshold)

Investigations

  • Blood tests: FBC, Hb, WCC, amylase (pancreatitis), U&Es, LFTs, clotting, glucose, G&S (cross-match if necessary), ABG, ECG, cardiac enzymes
  • Urinalysis: Cheap, readily available, useful with clinical scenario, microscopic urinalysis (MSU)
  • Pregnancy test
  • Radiology: Erect/supine CXR, x-ray studies, Ultrasound (?gynæ pathology), CT KUB/IVU (renal/ureteric colic)
  • Plain X-rays: Limited utility in evaluation of AAP (low diagnostic yield, misleading incidental findings, no impact on management—exception: bowel obstruction/perforation)
  • CT scanning: 1st-line imaging for AAP, modern CT quicker with thin sections
  • Laparoscopy: Early laparoscopy can improve accuracy, prompt management, and reduce unnecessary laparotomy.

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Diagnosis and Management of Acute Abdominal Pain PDF

Description

Test your knowledge on the causes, diagnosis, and pathophysiology of acute abdominal pain. This quiz covers the various types and statistics related to AAP, including common conditions like appendicitis and pancreatitis. Prepare to deepen your understanding of this critical medical topic.

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