Clinical Signs in Abdominal Examination

Acute Abdominal Pain

• Acute abdominal pain (AAP) is the presentation of previously undiagnosed abdominal pain lasting 1/52 or prior to a clinical encounter in 1° or 2° care.

Introduction

• Over 1000 causes exist for acute abdominal pain.
• Non-specific acute abdominal pain (SAP) accounts for 34% of cases.
• Acute appendicitis accounts for 28%.
• Acute cholecystitis represents 10% of cases.
• Other causes include small bowel obstruction (SBO), perforated peptic ulcer, pancreatitis, diverticular disease, and others (13%).
• Admission rates vary from 20-40%.
• Initial diagnosis is inaccurate in 50-65% of cases.

Pathophysiology

• Visceral pain arises from distension, inflammation, or ischemia in hollow or solid organs.
• Visceral pain location is related to the embryonic origin of the organ.
• Forgut organs cause pain in the epigastrium.
• Midgut organs cause pain in the umbilicus.
• Hindgut organs cause pain in the hypogastric region.
• Parietal pain is localized to the dermatome above the stimulus and can produce symptoms like tenderness, but not signs.

Generalized AP

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

Central AP

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

Epigastric Pain

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

RUQ Pain

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

LUQ Pain

• Genitourinary issues
• 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

RIF Pain

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

Loin Pain

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

LIF Pain

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

Limitations

• Overlying tenderness can mask underlying surgical disease.
• 35% of intraoperative diagnoses have atypical presentations.

Key Points on History

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

Classification by Nature

• Colicky pain: Baseline of no pain in true colic. IBS and bowel obstruction are examples.
• Nagging and grumbling pain: Biliary colic, cholecystitis, PID, and UTIs
• Stabbing pain: AAA
• Burning or boring pain: PUD and oesophagitis
• Gnawing pain: Pancreatitis or pancreatic cancer (Ca)

Associated Symptoms

• Fever
• Genitourinary issues
• Gynaecological issues
• Vascular issues

PMSH (Past Medical Surgical History)

• Previous episodes of abdominal pain (AP)
• Investigations
• Operations
• Chronic disease
• Immunosuppression
• Medications (NSAIDs)

Physical Examination

• Observations (OBS) are important
• Observations:
  • Bending forward: Chronic pancreatitis
  • Jaundice: Common bile duct (CBD) obstruction
  • Dehydration: Peritonitis or small bowel obstruction
• Inspection:
  • Scaphoid or flat in peptic ulcer disease (PUD)
  • Distended in ascites or intestinal obstruction
  • Visible peristalsis in thin/malnourished patients (with obstruction)
• Palpation:
  • Check for hernia sites
  • Tenderness
  • Rebound tenderness
  • Guarding (involuntary muscle spasm during palpation)
  • Rigidity (abdominal muscles tense and board-like): Indicates peritonitis

Local Right Iliac Fossa (RIF) Tenderness:

- Acute appendicitis
- Acute salpingitis (in females)

Low-grade, Poorly Localized Tenderness:

- Intestinal obstruction

Tenderness out of Proportion to Examination:

- Mesenteric ischemia
- Acute pancreatitis

Flank Tenderness:

- Perinephric abscess
- Retrocaecal appendicitis

Important Signs in Patients with Abdominal Pain

• Provided a list of signs and associated findings.

Physical Examination (continued)

• Auscultation:
  • Bowel sounds (BS): Absent for >2 minutes, high-pitched, hyperactive, or tinkling indicates possible bowel obstruction.
  • 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

Surgical Myths

• Rebound tenderness has a high (25%) false-negative rate for peritonitis.
• Rigidity, referred tenderness, and cough pain are not sufficient evidence for peritonitis.
• Administering analgesics before surgery does not obscure the diagnosis, instead improves accuracy.

Initial Management

• First 20 seconds: Only 3 diagnoses are possible (very ill, going to die, reasonably well).
• Very ill: Identify the situation and act accordingly if life-threatening.
• Ill: Urgent investigations and initial management.
• Reasonably well: Investigations as appropriate with diagnosis formulation.
• ABCDE approach is crucial.
• Resuscitation & analgesia (opioid IV)
• Full monitoring (including urine output)
• Low threshold for seeking senior help if needed.

Investigations

• Full blood count (FBC), hemoglobin (Hb), and white blood cell count (WCC)

• Amylase (for pancreatitis)

• Urea and electrolytes (U&Es), liver function tests (LFTs)

• Clotting profile (for acute pancreatitis, sepsis, disseminated intravascular coagulation (DIC), or liver disease)

• Blood glucose (BM)

• Group and save (G&S), cross-match if necessary

• Arterial blood gas (ABG)

• Electrocardiogram (ECG)

• Cardiac enzymes (if appropriate)

• Be mindful of WCC as a screening test; 25% of patients with elevated WCC don't have outcomes different from those with normal WCC. FBC has limited clinical utility.

• Urine analysis (URINALYSIS) - cheap & readily available, high yield when results correlate with the clinical scenario.

• MSU (mid-stream urine)

• Pregnancy test

• Radiology, Including

  • Erect and supine chest X-rays (CXR),
  • ultrasonography (USS),
  • CT KUB/IVU

• Plain X-rays have limited utility in acute abdominal pain (AAP); low yield, high misleading findings; exception: bowel obstruction or perforation

CT Scanning

• No significant advantage in diagnosing AAP with CT.
• Delay in necessary treatment.
• Routine use not justified.
• History, physical examination are crucial basis of correct diagnosis.
• CT is now a first-line for AAP.
• Multidetector CT (MDCT) is faster with thinner slices and offers higher diagnostic accuracy.

Laparoscopy

• Early diagnostic laparoscopy can offer accurate, prompt, and efficient management of acute abdominal pain (AAP).
• Reduces unnecessary laparotomy rates.
• Improves diagnostic accuracy and might resolve diagnostic dilemmas for non-specific acute abdominal pain (NSAP).