Dolor Abd Agudo ACS

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ABDOMINAL PAIN CHART

NAME REG. NUMBER

MALE FEMALE AGE FORM FILLED BY

MODE OF ARRIVAL DATE TIME

Site of PainAt Onset

At Present

Radiation

Aggravating Factorsmovementcoughingrespirationfoodothernone

Relieving Factorslying stillvomitingantacidsfoodothernone

Progression of Painbettersameworse

Duration

Typeintermittentsteadycolicky

Severitymoderatesevere

Nauseayes no

Vomitingyes no

Anorexiayes no

Indigestionyes no

Jaundiceyes no

Bowelsnormalconstipationdiarrheabloodmucus

Micturitionnormalfrequencydysuriadarkhematuria

Location of Tenderness

Reboundyes no

Guardingyes no

Rigidityyes no

Massyes no

Murphys Sign Presentyes no

Bowel Sounds

normalabsentincreased

Rectal-Vaginal Tendernessleftrightgeneralmassnone

Previous Similar Painyes no

Previous Abdominal Surgeryyes no

Drugs for Abdominal Painyes no

Female-LMPpregnantvaginal dischargedizzy/faint

Temp. Pulse

BP

Moodnormalupsetanxious

Colornormalpaleflushedjaundicedcyanotic

Intestinal Movementnormalpoor/nilperistalsis

Scarsyes no

Distentionyes no

Initial Diagnosis & Plan

Resultsamylaseblood count (WBC)urinex-ray

other

Diagnosis & Plan after Investigation

(time )

Discharge Diagnosis

History and examination of other systems on separate case notes.

P A I N

H I S T O R Y

E

X A M I N A T I O N

Figure 1 Shown is a data sheet modified from the abdominal pain chart developed by the OMGE. 13

2002 WebMD Inc. All rights reserved.II COMMON PRESENTING PROBLEMS

ACS Surgery: Principles and Practice4 ACUTE ABDOMINAL PAIN 2


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Obtain clinical history

Patient presents with acute abdominal pain

Assess mode of onset, duration, frequency, character, location,chronology, radiation, and intensity of pain.Look for aggravating or alleviating factors and associated symptoms.Use structured data sheets if possible.

Patient requires immediate laparotomy

Conditions necessitating immediate laparotomyinclude ruptured abdominal aortic or visceralaneurysm, ruptured ectopic pregnancy,spontaneous hepatic or splenic rupture, majorblunt or penetrating abdominal trauma, andhemoperitoneum from various causes.Severe hemodynamic instability is the essentialindication.

Patient requires urgent laparotomy

or laparoscopy

Conditions necessitating urgentlaparotomy include perforatedhollow viscus, appendicitis, Meckeldiverticulitis, strangulated hernia,mesenteric ischemia, and ectopicpregnancy (unruptured).Laparoscopy is recommended foracute appendicitis and perforatedulcers (provided that surgeon hassufficient experience andcompetence with the technique).

Patient should be hospitalized

and observed

Observe patient carefully, andreevaluate condition periodically.Consider additional investigativestudies (e.g., CT, ultrasonography,diagnostic peritoneal lavage,radionuclide imaging, angiography,MRI, and GI endoscopy).Diagnostic laparoscopy isrecommended if pain persists aftera period of observation.

Patient is candidate for electivelaparotomy or laparoscopy

Elective laparotomy or laparoscopyis reserved for patients who arehighly likely to respond toconservative medical managementor whose conditions are highlyunlikely to become life threateningduring prolonged evaluation (e.g.,those with IBD, peptic ulcer disease,pancreatitis, or endometriosis).

Patient requires early laparotomyor laparoscopy

Early laparotomy or laparoscopy isreserved for patients whose conditionsare unlikely to become life threateningif operation is delayed for 2448hr (e.g., those with uncomplicatedintestinal obstruction, uncomplicatedacute cholecystitis, uncomplicatedacute diverticulitis, or nonstrangulatedincarcerated hernia).

Diagnosis is uncertain,or patient has suspectednonsurgical abdomen

Reevaluate patient asappropriate(see facing page).

Patient has suspected surgical abdomen

Determine whether urgent laparotomy is necessary.

Perform basic investigative studies

Laboratory: complete blood count, hematocrit, electrolytes, creatinine,blood urea nitrogen, glucose, liver function tests, amylase, lipase,urinalysis, pregnancy test, ECG (if patient is elderly or hasatherosclerosis).

Radiologic: Plain abdominal films (upright and supine) and chest

radiographs.(Note: These studies are rarely diagnostic by themselves; their purposeis primarily confirmatory.)

Generate working diagnosis

Proceed with subsequent management on the basisof the working diagnosis.Reevaluate patient repeatedly. If patient does notrespond to treatment as expected, reassess workingdiagnosis and return to differential diagnosis.

Assessment of

Acute Abdominal Pain


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Generate tentative differential diagnosis

Remember that the majority of patients will turn out to have nonsurgicaldiagnoses.Take into account effects of age and gender on diagnostic possibilities.

Patient has suspected surgicalabdomen

Reevaluate patient as appropriate(see facing page).

Diagnosis is uncertain, or patienthas suspected nonsurgicalabdomen

Reevaluate patient as appropriate(see above, right, and facing page).

Patient should be hospitalizedand observed

Provide narcotic analgesia asappropriate.Observe patient carefully, andreevaluate condition periodically.Consider additional investigativestudies. CT and ultrasonographymay be especially useful.

Patient should be hospitalized and observed

Provide narcotic analgesia as appropriate.Observe patient carefully, and reevaluatecondition periodically.Consider additional investigative studies.

Diagnosis is uncertainor patient hassuspectedsurgical abdomen

Reevaluate patientas appropriate(see above, left, andfacing page).

Diagnosis isnonsurgical

Refer patient formedical management.

Patient can be evaluated inoutpatient setting

Diagnosis is uncertain

Determine whether patient should be hospitalized orcan be managed as an outpatient.

Patient has suspected nonsurgical abdomen

Nonsurgical conditions causing acuteabdominal pain include both extraperitoneal[see Table 2 ] and intraperitoneal disorders.

Perform physical examination

Evaluate general appearance and ability to answer questions; estimatedegree of obvious pain; note position in bed; identify area of maximalpain; look for extra-abdominal causes of pain and signs of systemic illness.Perform systematic abdominal examination: (1) inspection,(2) auscultation, (3) percussion, (4) palpation.Perform rectal, genital, and pelvic examinations.


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information for the Research Committee of the OMGE andother groups studying acute abdominal pain. 12,13 Given that thedata sheet is by no means exhaustive, individual surgeonsmay want to add to it; however, they would be well advised notto omit any of the symptoms and signs on the data sheet fromtheir routine examination of patients with acute abdominalpain. 14

When the surgeon obtains a complete clinical history with anopen mind, the patient often provides important clues to the cor-rect diagnosis. Patients should be allowed to relate the history intheir own words, and examiners should refrain from suggestingspecific symptoms, except as a last resort. Any questions that mustbe asked should be open-endedfor example, What happenswhen you eat? rather than Does eating make the pain worse?Leading questions should be avoided. When a leading questionmust be asked, it should be posed first as a negative question (i.e.,one that calls for an answer in the negative),since a negative answerto a question is more likely to be honest and accurate. For exam-ple, if peritoneal inflammation is suspected, the question askedshould be Does coughing make the pain better? rather thanDoes coughing make the pain worse?

The mode of onset of abdominal pain may help the examinerdetermine the severity of the underlying disease. Pain that has asudden onset suggests an intra-abdominal catastrophe, such as aruptured abdominal aortic aneurysm,a perforated viscus, or a rup-tured ectopic pregnancy. Rapidly progressive pain that becomesintensely centered in a well-defined area within a period of a fewminutes to an hour or two suggests a condition such as acute chole-cystitis or pancreatitis. Pain that has a gradual onset over severalhours, usually beginning as slight or vague discomfort and slowlyprogressing to steady and more localized pain, suggests a subacuteprocess and is characteristic of peritoneal inflammation.Numerousdisorders may be associated with this mode of onset, includingacute appendicitis, diverticulitis, pelvic inflammatory disease(PID), and intestinal obstruction.

Pain can be either intermittent or continuous. Intermittent orcramping pain (colic) is pain that occurs for a short period(a few minutes), followed by longer periods (a few minutes toone-half hour) of complete remission during which there isno pain at all. Intermittent pain is characteristic of obstructionof a hollow viscus and results from vigorous peristalsis in thewall of the viscus proximal to the site of obstruction. Thispain is perceived as deep in the abdomen and is poorly local-ized.The patient is restless, may writhe about incessantly in aneffort to find a comfortable position, and often presses on theabdominal wall in an attempt to alleviate the pain. Whereasthe intermittent pain associated with intestinal obstruction(typically described as gripping and mounting) is usually severebut bearable, the pain associated with obstruction of small

conduits (e.g., the biliary tract, the ureters, and the uterinetubes) often becomes unbearable. Obstruction of the gallblad-der or bile ducts gives rise to a type of pain often referredto as biliary colic; however, this term is a misnomer, in thatbiliary pain is usually constant because of the lack of a strongmuscular coat in the biliary tree and the absence of regularperistalsis.

Continuous or constant pain is pain that is present for hoursor days without any period of complete relief; it is more com-mon than intermittent pain. Continuous pain is usually indica-tive of peritoneal inflammation or ischemia. It may be of steadyintensity throughout, or it may be associated with intermittentpain. For example, the typical colicky pain associated with sim-

ple intestinal obstruction changes when strangulation occurs,becoming continuous pain that persists between episodes orwaves of cramping pain.

Certain types of pain are generally held to be typical of certainpathologic statesfor example, the general burning pain of a per-forated gastric ulcer, the tearing pain of a dissecting aneurysm,and the gripping pain of intestinal obstruction. However, the

character of the pain is not always a reliable clue to its cause.For several reasonsatypical pain patterns, dual innervation byvisceral and somatic afferents, normal variations in organ position,and widely diverse underlying pathologic statesthe location of abdominal pain is only a rough guide to diagnosis. It is neverthe-less true that in most disorders, the pain tends to occur in charac-teristic locations, such as the right upper quadrant (cholecystitis),the right lower quadrant (appendicitis), the epigastrium (pancre-atitis), or the left lower quadrant (sigmoid diverticulitis) [ see Figure2]. It is important to determine the location of the pain at onsetbecause this may differ from the location at the time of presenta-tion (so-called shifting pain). In fact, the chronological sequence of events in the patients history is often more important for diagno-sis than the location of the pain alone. For example, the classic pain

of appendicitis begins in the periumbilical region and settles in theright lower quadrant. A similar shift in location can occur whenescaping gastroduodenal contents from a perforated ulcer pool inthe right lower quadrant.

It is also important to take into account radiation or referralof the pain, which tends to occur in characteristic patterns [ see

Figure 3 ]. For example, biliary pain is referred to the right sub-scapular area, and the boring pain of pancreatitis typically radi-ates straight through to the back. The more severe the pain is,the more likely it is to be referred.

The intensity or severity of the pain is related to the magnitudeof the underlying insult. It is important to distinguish between theintensity of the pain and the patients reaction to it because thereappear to be significant individual differences with respect to toler-

ance of and reaction to pain. Pain that is intense enough to awak-en the patient from sleep usually indicates a significant underlyingorganic cause. Past episodes of pain and factors that aggravate orrelieve the pain often provide useful diagnostic clues. For example,pain caused by peritonitis tends to be exacerbated by motion, deepbreathing, coughing, or sneezing, and patients with peritonitis tendto lie quietly in bed and avoid any movement. The typical painof acute pancreatitis is exacerbated by lying down and relievedby sitting up. Pain that is relieved by eating or taking antacids sug-gests duodenal ulcer disease, whereas diffuse abdominal painthat appears 30 minutes to 1 hour after meals suggests intestinalangina.

Associated gastrointestinal symptoms, such as nausea, vomiting,anorexia, diarrhea, and constipation, often accompany abdominal

pain; however, these symptoms are nonspecific and therefore maynot be of great value in the differential diagnosis.Vomiting in par-ticular is common: when sufficiently stimulated by pain impulsestraveling via secondary visceral afferent fibers, the medullary vom-iting centers activate efferent fibers and cause reflex vomiting.Onceagain, the chronology of events is important, in that pain often pre-cedes vomiting in patients with conditions necessitating operation,whereas the opposite is usually the case in patients with medical(i.e., nonsurgical) conditions. 4,6 This is particularly true for patientswith acute appendicitis, in whom pain almost always precedesvomiting by several hours. Similarly, constipation may result froma reflex paralytic ileus when sufficiently stimulated visceral afferentfibers activate efferent sympathetic fibers (splanchnic nerves) to


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DIFFUSEPeritonitisEarly AppendicitisPancreatitisLeukemiaSickle Cell CrisisGastroenteritisMesenteric AdenitisMesenteric ThrombosisIntestinal ObstructionInflammatory Bowel

DiseaseAneurysmMetabolic CausesToxic Causes

UMBILICAL REGIONEarly AppendicitisGastroenteritisPancreatitisHerniaMesenteric AdenitisMesenteric ThrombosisIntestinal ObstructionInflammatory Bowel DiseasAneurysm

HYPOGASTRIC REGIONCystitisDiverticulitisAppendicitisProstatismSalpingitisHerniaOvarian Cyst/TorsionEndometriosisEctopic PregnancyNephrolithiasisIntestinal ObstructionInflammatory Bowel DiseasAbdominal Wall Hematoma

EPIGASTRIC REGIONPeptic Ulcer

GastritisPancreatitisDuodenitis

GastroenteritisEarly Appendicitis

Mesenteric Adenitis

Mesenteric ThrombosisIntestinal Obstruction

Inflammatory Bowel DiseaseAneurysm

LEFT UPPER QUADRANTGastritisPancreatitisSplenic EnlargementSplenic RuptureSplenic InfarctionSplenic AneurysmPyelonephritisNephrolithiasisHerpes ZosterMyocardial IschemiaPneumoniaEmpyemaDiverticulitisIntestinal ObstructionInflammatory Bowel Disease

LEFT LOWER QUADRANTDiverticulitisIntestinal ObstructionInflammatory Bowel DiseaseAppendicitisLeaking AneurysmAbdominal Wall HematomaEctopic PregnancyMittelschmerzOvarian Cyst/TorsionSalpingitisEndometriosisUreteral CalculiPyelonephritisNephrolithiasisSeminal VesiculitisPsoas AbscessHernia

RIGHT UPPER QUADRANTCholecystitis

CholedocholithiasisHepatitis

Hepatic AbscessHepatomegaly from

Congestive Heart FailurePeptic Ulcer

PancreatitisRetrocecal AppendicitisPyelonephritis

NephrolithiasisHerpes Zoster

Myocardial IschemiaPericarditisPneumonia

EmpyemaGastritis

DuodenitisIntestinal Obstruction

Inflammatory Bowel Disease

RIGHT LOWER QUADRANTAppendicitis

Intestinal ObstructionInflammatory Bowel Disease

Mesenteric AdenitisDiverticulitisCholecystitis

Perforated UlcerLeaking Aneurysm

Abdominal Wall HematomaEctopic Pregnancy

Ovarian Cyst/TorsionSalpingitis

MittelschmerzEndometriosis

Ureteral CalculiPyelonephritis

NephrolithiasisSeminal Vesiculitis

Psoas AbscessHernia

a b

c

Figure 2 In most disorders that give rise to acute abdominal pain,the pain tends to occur in specific locations.


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reduce intestinal peristalsis. Diarrhea is characteristic of gastroen-teritis but may also accompany incomplete intestinal obstruction.More significant is a history of obstipation, because if it can be def-initely established that a patient with acute abdominal pain has notpassed gas or stool for 24 to 48 hours, it is certain that some degreeof intestinal obstruction is present.Other associated symptoms thatshould be noted include jaundice, melena, hematochezia,hematemesis,and hematuria.These symptoms are much more spe-cific than the ones just discussed and can be extremely valuable in

the differential diagnosis.Most conditions that cause acute abdom-inal pain of surgical significance are associated with some degree of fever. Fever suggests an inflammatory process; however, it is usual-ly low grade and often absent altogether,particularly in elderly andimmunocompromised patients. The combination of a high feverwith chills and rigors indicates bacteremia, and concomitantchanges in mental status (e.g., agitation, disorientation, and lethar-gy) suggest impending septic shock.

A history of trauma (even if the patient considers the traumaticevent trivial) should be actively sought in all cases of unexplainedacute abdominal pain; such a history may not be readily volun teered(as is often the case with trauma resulting from domestic violence).With female patients, it is essential to obtain a detailed gynecolog-ic history that includes the timing of symptoms within the men-strual cycle, the date of the last menses, previous and current useof contraception, any abnormal vaginal bleeding or discharge, anobstetric history, and any risk factors for ectopic pregnancy (e.g.,PID,use of an intrauterine device, or previous ectopic or tubal surgery).

A complete history of previous medical conditions must beobtained because associated diseases of the cardiac, pulmonary,and renal systems may give rise to acute abdominal symptoms andmay also significantly affect the morbidity and mortality associatedwith surgical intervention. Weight changes, past illnesses, recenttravel, environmental exposure to toxins or infectious agents, andmedications used should also be investigated. A history of previousabdominal operations should be obtained but should not be reliedon too heavily in the absence of operative reports. A careful familyhistory is important for detection of hereditary disorders that may

cause acute abdominal pain. A detailed social history should alsobe obtained that includes tobacco, alcohol, or illicit drug use as wellas a sexual history.

Tentative DifferentialDiagnosis

Once the patients histo-ry has been obtained, the

examiner should generate atentative differential diag-nosis and carry out thephysical examination insearch of specific signs or findings that either rule out or confirmthe diagnostic possibilities.Given that the list of conditions that cancause acute abdominal pain is almost endless [ see Tables 1 and 2 ],there is no substitute for some general knowledge of what themost common causes of acute abdominal pain are and how age,gender, and geography may affect the likelihood that any of thesepotential causes is present.

Ambulatory patients with acute abdominal pain as a chief com-plaint constitute 2% to 3% of all patients in an office practice and5% to 10% of all patients seen in the emergency department. 4,13,15

At least two thirds of these patients have disorders that do not callfor surgical intervention. 2,4,5 Although acute abdominal pain is themost common surgical emergency and most nontrauma-relatedsurgical admissions (and 1% of all hospital admissions) areaccounted for by patients complaining of abdominal pain, littleinformation is available regarding the clinical spectrum of diseasein these patients. 16 Nevertheless, detailed epidemiologic informa-tion can be an invaluable asset in the diagnosis and treatment of acute abdominal pain.

The most extensive information available comes from the ongo-ing survey begun in 1977 by the Research Committee of theOMGE. As of the last progress report on this survey, which waspublished in 1988, 12 more than 200 physicians at 26 centers in 17countries had accumulated data on 10,320 patients with acute

Esophagus

Stomach

Pylorus

Colon

Left and RightKidneys

Liver andGallbladder

Ureter

Perforated Duodenal Ulcer(Diaphragmatic Irritation)

Biliary Colic

Acute Pancreatitis andRenal Colic

Uterine and Rectal Pain

Figure 3 Pain of abdominal origin tends to be referred in characteristic patterns. 43 The more severe the pain is, the morelikely it is to be referred. Shown are anterior (left) and posterior (right) areas of referred pain.


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abdominal pain [ see Table 3 ].The most common diagnosis in thesepatients was nonspecific abdominal pain (NSAP)that is, the ret-

rospective diagnosis of exclusion in which no cause for the pain canbe identified. 17,18 Nonspecific abdominal pain accounted for 34%of all patients seen; the four most common diagnoses accounted formore than 75%. The most common surgical diagnosis was acuteappendicitis, followed by acute cholecystitis, small bowel obstruc-tion, and gynecologic disorders. Relatively few patients had perfo-rated peptic ulcer, a finding that confirms the recent downwardtrend in the incidence of this condition. Cancer was found to be asignificant cause of acute abdominal pain.There was little variationin the geographic distribution of surgical causes of acute abdomi-nal pain (i.e., conditions necessitating operation) among developedcountries. In patients who required operation, the most commoncauses were acute appendicitis (42.6%), acute cholecystitis(14.7%), small bowel obstruction (6.2%), perforated peptic ulcer(3.7%), and acute pancreatitis (4.5%). 12

The finding that NSAP is the most common diagnosis inpatients with acute abdominal pain has been confirmed by severalother clinical studies 4,5,16,19 ; the finding that acute appendicitis,cholecystitis, and intestinal obstruction are the three most commondiagnoses in patients with acute abdominal pain who require oper-ation has also been amply confirmed 1,4,5,16,19 [see Table 3 ].

The data described so far provide a comprehensive picture of themost likely diagnoses for patients with acute abdominal pain inmany centers around the world; however, this picture does not takeinto account the effect of age on the relative likelihood of the vari-ous potential diagnoses. It is well known that the disease spectrumof acute abdominal pain is different in different age groups, espe-cially in the very old and the very young. 20 This variation is apparent

when the 10,320 patients from the OMGE study are segregated byage 21 [see Table 4 ]. In patients 50 years of age or older, cholecystitis

was more common than either NSAP or acute appendicitis, andsmall bowel obstruction, diverticular disease, and pancreatitis wereall approximately five times more common than in patientsyounger than 50 years. Hernias were also a much more commonproblem in older patients. In the entire group of patients, only oneof every 10 instances of intestinal obstruction was attributable to ahernia, whereas in patients 50 years of age or older, one of everythree instances was caused by an undiagnosed hernia. Cancer was40 times more likely to be the cause of acute abdominal pain inpatients 50 years of age or older; vascular diseases (includingmyocardial infarction, mesenteric ischemia, and ruptured abdomi-nal aortic aneurysm) were 25 times more common in patients 50years of age or older and 100 times more common in patients olderthan 70 years. What is more, outcome was clearly related to age:mortality was significantly higher in patients older than 70 years(5%) than in those younger than 50 years (less than 1%).Whereasthe peak incidence of acute abdominal pain occurred in patients intheir teens and 20s, the great majority of deaths occurred inpatients older than 70 years. 22

Further analysis of the data from the OMGE survey alsomakes it clear that the disease spectrum in children is differentfrom that in adults: well over 90% of cases of acute abdominalpain in children are diagnosed as either acute appendicitis (32%)or nonspecific abdominal pain (62%). 22 Similar age-related dif-ferences in the spectrum of disease have been confirmed byother studies, 16 as have various gender-related differences.

Knowledge of the most common causes of acute abdominal painand familiarity with the special circumstances that make particular

Table 1 Intraperitoneal Causes of Acute Abdominal Pain 44

InflammatoryPeritoneal

Chemical and nonbacterial peritonitisPerforated peptic ulcer/biliary tree,

pancreatitis, ruptured ovarian cyst,mittelschmerzBacterial peritonitis

Primary peritonitisPneumococcal, streptococcal,

tuberculousSpontaneous bacterial peritonitis

Perforated hollow viscusEsophagus, stomach, duodenum, small

intestine, bile duct, gallbladder, colon,urinary bladder

Hollow visceralAppendicitisCholecystitisPeptic ulcerGastroenteritisGastritisDuodenitisInflammatory bowel diseaseMeckel diverticulitisColitis (bacterial, amebic)Diverticulitis

Solid visceralPancreatitisHepatitis

Pancreatic abscessHepatic abscessSplenic abscess

Mesenteric

Lymphadenitis (bacterial, viral)Epiploic appendagitis

PelvicPelvic inflammatory disease (salpingitis)Tubo-ovarian abscessEndometritis

Mechanical (obstruction, acute distention)Hollow visceral

Intestinal obstructionAdhesions, hernias, neoplasms, volvulusIntussusception, gallstone ileus, foreign

bodiesBezoars, parasites

Biliary obstruction

Calculi, neoplasms, choledochal cyst,hemobiliaSolid visceral

Acute splenomegalyAcute hepatomegaly (congestive heart

failure, Budd-Chiari syndrome)Mesenteric

Omental torsionPelvic

Ovarian cyst

Torsion or degeneration of fibroidEctopic pregnancy

HemoperitoneumRuptured hepatic neoplasmSpontaneous splenic ruptureRuptured mesenteryRuptured uterusRuptured graafian follicleRuptured ectopic pregnancyRuptured aortic or visceral aneurysm

IschemicMesenteric thrombosisHepatic infarction (toxemia, purpura)Splenic infarctionOmental ischemiaStrangulated hernia

Neoplastic

Primary or metastatic intraperitonealneoplasms

TraumaticBlunt traumaPenetrating traumaIatrogenic traumaDomestic violence

MiscellaneousEndometriosis


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causes more likely than others allow the surgeon to play the odds. 14As has often been said, common things are commonor, to put itanother way, most people get what most people get.

Physical Examination

In physical examination,

as in history taking, there isno substitute for organiza-tion and patience; theamount of informationthat can be obtained is di-rectly proportional to thegentleness and thorough-ness of the examiner. Thephysical examination begins with a brief but thorough evaluationof the patients general appearance and ability to answer ques-tions. The degree of obvious pain should be estimated. Thepatients position in bed should be noted: as an example, apatient who lies motionless with flexed hips and knees is morelikely to have generalized peritonitis, whereas a restless patient

who writhes about in bed is more likely to have colicky pain,which suggests different diagnoses. The area of maximal painshould be identified before the physical examination is begun.

The examiner can easily do this by simply asking the patient tocough and then to point with one finger to the area of maximalpain. This allows the examiner to avoid the area in the earlystages of the examination and to confirm it at a later stage with-out causing the patient unnecessary discomfort in the meantime.

A complete physical examination should be performed and extra-abdominal causes of pain and signs of systemic illness should be sought

before attention is directed to the patients abdomen. Systemic signsof shock, such as diaphoresis, pallor, hypothermia, tachypnea, tachy-cardia with orthostasis, and frank hypotension,usually accompany arapidly progressive or advanced intra-abdominal condition and, inthe absence of extra-abdominal causes, are an indication for imme-diate laparotomy. The absence of any alteration in vital signs, how-ever, does not necessarily exclude a serious intra-abdominal process.

The surgeon then begins the abdominal examination.This isdone with the patient resting in a comfortable supine position.The examination should include inspection, auscultation, per-cussion, and palpation of all areas of the abdomen, the flanks,and the groin (including all hernia orifices) in addition to rectaland genital examinations (and, in female patients, a full gyneco-logic examination). A systematic approach is crucial: an examin-

er who methodically follows a set pattern of abdominal exami-nation every time will be rewarded more frequently than onewho improvises haphazardly with each patient.

GenitourinaryPyelonephritisPerinephric abscessRenal infarctNephrolithiasisUreteral obstruction (lithiasis, tumor)Acute cystitisProstatitisSeminal vesiculitisEpididymitisOrchitisTesticular torsionDysmenorrheaThreatened abortion

PulmonaryPneumoniaEmpyemaPulmonary embolusPulmonary infarctionPneumothorax

CardiacMyocardial ischemiaMyocardial infarctionAcute rheumatic feverAcute pericarditis

MetabolicAcute intermittent porphyriaFamilial Mediterranean feverHypolipoproteinemiaHemochromatosisHereditary angioneurotic edema

EndocrineDiabetic ketoacidosisHyperparathyroidism (hypercalcemia)Acute adrenal insufficiency (Addisonian

crisis)Hyperthyroidism or hypothyroidism

MusculoskeletalRectus sheath hematomaArthritis/diskitis of thoracolumbar spine

NeurogenicHerpes zosterTabes dorsalisNerve root compressionSpinal cord tumorsOsteomyelitis of the spineAbdominal epilepsyAbdominal migraineMultiple sclerosis

InflammatorySch nlein-Henoch purpuraSystemic lupus erythematosusPolyarteritis nodosaDermatomyositisScleroderma

InfectiousBacterialParasitic (malaria)Viral (measles, mumps, infectious

mononucleosis)Rickettsial (Rocky Mountain spotted

fever)

HematologicSickle cell crisisAcute leukemiaAcute hemolytic states

CoagulopathiesPernicious anemiaOther dyscrasias

VascularVasculitisPeriarteritis

ToxinsBacterial toxins (tetanus, staphylococcus)Insect venom (black widow spider)Animal venomHeavy metals (lead, arsenic, mercury)Poisonous mushroomsDrugsWithdrawal from narcotics

RetroperitonealRetroperitoneal hemorrhage (spontaneous

adrenal hemorrhage)Psoas abscess

PsychogenicHypochondriasisSomatization disorders

FactitiousMunchausen syndromeMalingering

Table 2 Extraperitoneal Causes of Acute Abdominal Pain


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The first step in the abdominal examination is careful inspec-tion of the anterior and posterior abdominal walls, the flanks,the perineum, and the genitalia for previous surgical scars (pos-sible adhesions), hernias (incarceration or strangulation), disten-tion (intestinal obstruction),obvious masses (distended gallbladder,abscesses, or tumors), ecchymosis or abrasions (trauma), striae(pregnancy or ascites), everted umbilicus (increased intra-abdom-inal pressure), visible pulsations (aneurysm), visible peristalsis(obstruction), limitation of movement of the abdominal wall withventilatory movements (peritonitis), or engorged veins (portalhypertension).

The next step in the abdominal examination is auscultation.Al-

though it is important to note the presence (or absence) of bowelsounds and their quality,auscultation is probably the least rewardingaspect of the physical examination. Severe intra-abdominal condi-tions,even intra-abdominal catastrophes, may occur in patients withnormal bowel sounds, and patients with silent abdomens may haveno significant intra-abdominal pathology at all. In general, however,the absence of bowel sounds indicates a paralytic ileus; hyperactive orhypoactive bowel sounds often are variations of normal activity;andhigh-pitched bowel sounds with splashes, tinkles (echoing as in alarge cavern), or rushes (prolonged, loud gurgles) indicate mechani-cal bowel obstruction.

The third step is percussion to search for any areas of dullness,fluid collections, sections of gas-filled bowel, or pockets of free airunder the abdominal wall. Tympany may be present in patients

with bowel obstruction or hollow viscus perforation. Percussioncan be useful as a way of estimating organ size and of determin-ing the presence of ascites (signaled by a fluid wave or shiftingdullness). It is most useful, however, as a means of demonstratingperitoneal irritation (rebound tenderness).The customary tech-nique is to dig the fingers deep into the patients abdomen andthen let go abruptly.This technique is a time-honored one, but itis painful and often misleads the examiner into assuming that anacute process is present when none exists. Gentle percussion overthe four quadrants of the abdomen is much better tolerated bythe patient; in addition, it is much more accurate in demonstrat-ing rebound tenderness.

The last step, palpation, is the most informative aspect of thephysical examination. Palpation of the abdomen must be donevery gently to avoid causing additional pain early in the exam-ination. It should begin as far as possible from the area of max-imal pain and then should gradually advance toward this area,which should be the last to be palpated. The examiner shouldplace the entire hand on the patients abdomen with the fingerstogether and extended, applying pressure with the pulps (notthe tips) of the fingers by flexing the wrists and the metacarpo-phalangeal joints. It is essential to determine whether trueinvoluntary muscle guarding (muscle spasm) is present. Thisdetermination is made by means of gentle palpation over theabdominal wall while the patient takes a long, deep breath. If guarding is voluntary, the underlying muscle immediately

Diagnosis

Frequency in Individual Studies (% of Patients)

OMGE 12(N = 10,320)

Wilson 19(N = 1,196)

Irvin16(N = 1,190)

Brewer 4(N = 1,000)

de Dombal 1(N = 552)

Hawthorn(N = 496)

Nonspecific abdominal pain

Acute appendicitis

Acute cholecystitis

Small bowel obstruction

Acute gynecologic disease

Acute pancreatitis

Urologic disorders

Perforated peptic ulcer

Cancer

Diverticular disease

Dyspepsia

Gastroenteritis

Inflammatory bowel disease

Mesenteric adenitis

Gastritis

Constipation

Amebic hepatic abscess

Miscellaneous

34.0

28.1

9.7

4.1

4.0

2.9

2.9

2.5

1.5

1.5

1.4

1.2

6.3

Table 3 Frequency of Specific Diagnoses in Patients with Acute Abdominal Pain

45.6

15.6

5.8

2.6

4.0

1.3

4.7

2.3

1.1

7.6

3.6

2.1

2.4

1.3

34.9

16.8

5.1

14.8

1.1

2.4

5.9

2.5

3.0

3.9

1.4

0.3

0.8

1.9

5.2

41.3

4.3

2.5

2.5

8.5

11.4

2.0

1.4

6.9

1.4

2.3

15.5

50.5

26.3

7.6

3.6

2.9

3.1

2.0

4.0

36.0

14.9

5.9

8.6

2.1

12.8

3.0

5.1

2.1

1.5

8.0


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relaxes under the gentle pressure of the palpating hand. If,however, the patient has true involuntary guarding, the muscleremains in spasm (i.e., taut and rigid) throughout the respira-tory cycle (so-called boardlike abdomen). True involuntaryguarding is indicative of localized or generalized peritonitis. Itmust be remembered that muscle rigidity is relative: for exam-ple, muscle guarding may be less pronounced or absent in

debilitated and elderly patients who have poor abdominal mus-culature. In addition, the evaluation of muscle guarding isdependent on the patients cooperation.

Palpation is also useful for determining the extent and severi-ty of the patients tenderness. Diffuse tenderness indicates gen-eralized peritoneal inflammation. Mild diffuse tenderness with-out guarding usually indicates gastroenteritis or some otherinflammatory intestinal process without peritoneal inflamma-tion. Localized tenderness suggests an early stage of disease withlimited peritoneal inflammation.

Careful palpation can elicit several specific signs [ see Table 5 ] such as the Rovsing sign (associated with acute appendicitis) andthe Murphy sign (acute cholecystitis)that are indicative of local-ized peritoneal inflammation. Similarly, specific maneuvers can

elicit signs of localized peritoneal irritation, such as the psoas sign(associated with retrocecal appendicitis), the obturator sign (pelvicappendicitis), and the Kehr sign (diaphragmatic irritation). Onevery important maneuver is the Carnett test, in which the patientelevates his or her head off the bed, thus tensing the abdominalmuscles.Tenderness to palpation persists when the pain is causedby abdominal wall conditions (e.g., rectal sheath hematoma) butdecreases or disappears when the pain is caused by intraperitonealconditions (the Carnett sign).

Rectal, genital, and (in women) pelvic examinations are anessential part of the evaluation in all patients with acute abdom-inal pain. The rectal examination should include evaluation of sphincter tone, tenderness (localized versus diffuse), and pros-tate size and tenderness, as well as a search for the presence of

hemorrhoids, masses, fecal impaction, foreign bodies, and grossor occult blood. The genital examination should search for

adenopathy, masses, discoloration, edema, and crepitus. Thepelvic examination in women should check for vaginal dischargeor bleeding, cervical discharge or bleeding, cervical mobility andtenderness, uterine tenderness, uterine size, and adnexal tender-ness or masses. Although a carefully performed pelvic examina-tion can be invaluable in differentiating nonsurgical conditions(e.g., PID) from conditions necessitating prompt operation (e.g.,

acute appendicitis), the possibility that a surgical condition ispresent should not be prematurely dismissed solely on the basisof a finding of tenderness on pelvic or rectal examination.

Basic InvestigativeStudies

Although laboratory andradiologic studies rarely, if ever, establish a definitivediagnosis by themselves,theyare often useful for con-firming the diagnosis sug-gested by the history and

the physical examination.

LABORATORY STUDIES

In all except extremely hemodynamically unstable patients, acomplete blood count, blood chemistries, and a urinalysis are rou-tinely obtained.The hematocrit is important in that it allows thesurgeon to detect significant changes in plasma volume (e.g.,dehydration caused by vomiting, diarrhea, or fluid loss into theperitoneum or the intestinal lumen), preexisting anemia, or bleed-ing. An elevated white blood cell count is indicative of an inflam-matory process and is a particularly helpful finding if associatedwith a marked left shift; however, the presence or absence of leuko-cytosis should never be the single deciding factor as to whether thepatient should undergo an operation. A low white blood cell count

may be a feature of viral infections, gastroenteritis, or NSAP.Serum electrolyte, blood urea nitrogen, and creatinine concen-

trations are useful in determining the nature and extent of fluidlosses.Blood glucose and other blood chemistries may also be help-ful. Liver function tests (serum bilirubin, alkaline phosphatase,andtransaminase levels) are mandatory when abdominal pain is sus-pected to be hepatobiliary in origin. Similarly, amylase and lipasedeterminations are mandatory when pancreatitis is suspected,although it must be remembered that amylase levels may be low ornormal in patients with pancreatitis and may be markedly elevatedin patients with other conditions (e.g., intestinal obstruction,mesenteric thrombosis, and perforated ulcer).

Urinalysis may reveal red blood cells (suggestive of renal or ure-teral calculi),white blood cells (urinary tract infection or inflamma-tory processes adjacent to the ureters, such as retrocecal appendici-tis), increased specific gravity (dehydration), glucose, ketones (dia-betes), or bilirubin (hepatitis). A pregnancy test should be consid-ered in any woman of childbearing age with acute abdominal pain.

An electrocardiogram is mandatory in elderly patients and in pa-tients with a history of atherosclerotic heart disease.Abdominal painmay be a manifestation of myocardial disease, and the physiologicstress of acute abdominal pain can increase myocardial oxygen de-mands and induce ischemia in patients with coronary artery disease.

RADIOLOGIC STUDIES

In most patients with acute abdominal pain, initial radiologicevaluation should include plain films of the abdomen in the

Diagnosis

Frequency (% of Patients)

Age < 50 Yr(N = 6,317)

Age 50 Yr(N = 2,406)

Nonspecific abdominal painAppendicitis

Cholecystitis

Obstruction

Pancreatitis

Diverticular disease

Cancer

Hernia

Vascular disease

39.532.0

6.3

2.5

1.6

< 0.1

< 0.1

< 0.1

< 0.1

Table 4 Frequency of Specific Diagnoses in Youngerand Older Patients with Acute Abdominal Pain in the

OMGE Study 12,21

15.715.2

20.9

12.3

7.3

5.5

4.1

3.1

2.3


12/16



supine and standing positions and chest radiographs. 23 If thepatient is unable to stand, a left lateral decubitus radiographshould be obtained. Like the basic laboratory studies (seeabove), these plain radiographs may help confirm diagnoses sug-gested by the history and the physical examination, such aspneumonia (signaled by pulmonary infiltrates); intestinalobstruction (air-fluid levels and dilated loops of bowel); intesti-nal perforation (pneumoperitoneum); biliary, renal, or ureteralcalculi (abnormal calcifications); appendicitis (fecalith); incar-cerated hernia (bowel protruding beyond the confines of theperitoneal cavity); mesenteric infarction (air in the portal vein);chronic pancreatitis (pancreatic calcifications); acute pancreatitis(the so-called colon cutoff sign); visceral aneurysms (calcifiedrim); retroperitoneal hematoma or abscess (obliteration of thepsoas shadow); and ischemic colitis (so-called thumbprinting onthe colonic wall).

A prospective study published in 1999 evaluated the utility of routine plain abdominal radiographs in the management of adultpatients with acute right lower quadrant abdominal pain. 24 Theresults seem to demonstrate that indiscriminate use of such radio-graphs in this patient subset is not helpful but that discriminatinguse in selected patients with clinically suspected small bowel obstruc-tion or urinary symptoms may be worthwhile. Admittedly, plainabdominal radiographs cost relatively little; still, refraining from

routinely obtaining them in all patients with suspected acute ap-pendicitis would help reduce the cost of medical care appreciably.

Working Diagnosis

Ideally, the tentativedifferential diagnosis listgenerated after the clinicalhistory was obtained shouldbe narrowed down to aworking diagnosis by thephysical examination andthe information providedby the basic laboratory and radiologic studies. Once this workingdiagnosis has been established, subsequent management dependson the accepted treatment for the particular condition believed tobe present. In general, the course of management follows four basicpathways (see below), depending on whether the patient (1) is inneed of immediate laparotomy, (2) is believed to have an underly-ing surgical condition, (3) has an uncertain diagnosis, or (4) isbelieved to have an underlying nonsurgical condition.

It must be emphasized that the patient must be constantlyreevaluated (preferably by the same examiner) even after theworking diagnosis has been established. If the patient does not

Sign or Finding

Aaron sign

Ballance sign

Bassler sign

Beevor sign

Blumberg sign

Carnett sign

Chandelier sign

Charcot sign

Chaussier sign

Claybrook signCourvoisier sign

Cruveilhier sign

Cullen sign

Cutaneoushyperesthesia

Dance sign

Danforth sign

Direct abdominal walltenderness

Fothergill sign

Description

Referred pain or feeling of distress in epigastrium or precordial re-gion on continued firm pressure over the McBurney point

Presence of dull percussion note in both flanks, constant on left side

but shifting with change of position on right sideSharp pain elicited by pinching appendix between thumb of examin-

er and iliacus muscle

Upward movement of umbilicus

Transient abdominal wall rebound tenderness

Disappearance of abdominal tenderness when anterior abdominalmuscles are contracted

Intense lower abdominal and pelvic pain on manipulation of cervix

Intermittent right upper quadrant abdominal pain, jaundice, andfever

Severe epigastric pain in gravid female

Transmission of breath and heart sounds through abdominal wallPalpable, nontender gallbladder in presence of clinical jaundice

Varicose veins radiating from umbilicus ( caput medusae )

Periumbilical darkening of skin from blood

Increased abdominal wall sensation to light touch

Slight retraction in area of right iliac fossa

Shoulder pain on inspiration

Abdominal wall mass that does not cross midline and remains palpa-

ble when rectus muscle is tense

Associated Clinical Condition(s)

Acute appendicitis

Ruptured spleen

Chronic appendicitis

Paralysis of lower portions of rectus abdominis muscles

Peritoneal inflammation

Abdominal pain of intra-abdominal origin

Pelvic inflammatory disease

Choledocholithiasis

Prodrome of eclampsia

Ruptured abdominal viscusPeriampullary neoplasm

Portal hypertension

Hemoperitoneum (especially in ruptured ectopic pregnancy)

Parietal peritoneal inflammation secondary to inflammatoryintra-abdominal pathology

Intussusception

Hemoperitoneum (especially in ruptured ectopic pregnancy)

Localized inflammation of abdominal wall, peritoneum, or anintra-abdominal viscus

Rectus muscle hematoma

Table 5 Common Abdominal Signs and Findings Noted on Physical Examination 7

(continued


13/16



respond to treatment as expected, the working diagnosis mustbe reassessed and the possibility that another condition existsmust be immediately entertained and investigated by returningto the differential diagnosis list.

Indications for Immediate Laparotomy

A systematic approachto patients with acute ab-dominal pain is essentialbecause in some patients,action must be taken im-mediately and there is notenough time for an ex-haustive evaluation. Asoutlined (see above), suchan approach should include a brief initial assessment, a completeclinical history, a thorough physical examination, and basic lab-oratory and radiologic studies. These steps can usually be com-pleted in less than 1 hour and should be insisted on in the eval-uation of most patients.

There are, in fact, very few abdominal crises that mandateimmediate operation, and even with these conditions, it is still nec-essary to spend a few minutes on assessing the seriousness of theproblem and establishing a probable diagnosis. Among the mostcommon of the abdominal catastrophes that necessitate immedi-

ate operation are ruptured abdominal aortic or visceral aneu-rysms, ruptured ectopic pregnancies, and spontaneous hepatic orsplenic ruptures. The relative rarity of such conditions notwith-standing, it must always be remembered that patients with acuteabdominal pain may have a progressive underlying intra-abdomi-nal disorder causing the acute pain and that unnecessary delays indiagnosis and treatment can adversely affect outcome, often withcatastrophic consequences.

When immediate operation is not called for, the physician mustdecide whether urgent or nonurgent but early operation is neces-sary, whether additional tests are required before a decision can bemade, whether the patient should be admitted to the hospital forcareful observation, or whether nonsurgical treatment is indicated[see Suspected Surgical Abdomen, Uncertain Diagnosis, and Suspected Nonsurgical Abdomen, below].

Suspected SurgicalAbdomen

INDICATIONS FOR

URGENT LAPAROTOMY

OR LAPAROSCOPY

Once a definitive diag-nosis has been made, it iseasy to decide whether a

Table 5 (continued)

Sign or Finding

Grey Turner sign

Iliopsoas sign

Kehr sign

Kustner sign

Mannkopf sign

McClintock sign

Murphy sign

Obturator sign

Puddle sign

Ransohoff sign

Rovsing sign

Subcutaneouscrepitance

Summer sign

Ten Horn sign

Toma sign

Description

Local areas of discoloration around umbilicus and flanks

Elevation and extension of leg against pressure of examiner s handcauses pain

Left shoulder pain when patient is supine or in the Trendelenburg po-sition (pain may occur spontaneously or after application of pres-sure to left subcostal region)

Palpable mass anterior to uterus

Acceleration of pulse when a painful point is pressed on by examiner

Heart rate > 100 beats/min 1 hr post partum

Palpation of right upper abdominal quadrant during deep inspirationresults in right upper quadrant abdominal pain

Flexion of right thigh at right angles to trunk and external rotation ofsame leg in supine position result in hypogastric pain

Alteration in intensity of transmitted sound in intra-abdominal cavitysecondary to percussion when patient is positioned on all fours and

stethoscope is gradually moved toward flank opposite percussion

Yellow pigmentation in umbilical region

Pain referred to the McBurney point on application of pressure to de-scending colon

Palpable crepitus in abdominal wall

Increased abdominal muscle tone on exceedingly gentle palpationof right or left iliac fossa

Pain caused by gentle traction on right spermatic cord

Right-sided tympany and left-sided dullness in supine position as aresult of peritoneal inflammation and subsequent mesenteric con-traction of intestine to right side of abdominal cavity

Associated Clinical Condition(s)

Acute hemorrhagic pancreatitis

Appendicitis (retrocecal) or an inflammatory mass in contactwith psoas

Hemoperitoneum (especially ruptured spleen)

Dermoid cyst of ovary

Absent in factitious abdominal pain

Postpartum hemorrhage

Acute cholecystitis

Appendicitis (pelvic appendix); pelvic abscess; an inflammato-ry mass in contact with muscle

Free peritoneal fluid

Ruptured common bile duct

Acute appendicitis

Subcutaneous emphysema or gas gangrene

Early appendicitis; nephrolithiasis; ureterolithiasis; ovariantorsion

Acute appendicitis

Inflammatory ascites


14/16



patient should undergo operation. On occasion, however, apatient must be operated on before a precise diagnosis isreached. In contemporary clinical practice, the misuse or abuseof available technology frequently undermines the importance of sound surgical judgment at the bedside: in particular, too manypatients with obvious surgical abdomens are subjected to time-consuming imaging studies before surgical consultation is ob-

tained. It cannot be emphasized too strongly that although diagnosticaccuracy is intellectually satisfying and undoubtedly important, the primary goal in the management of patients with acute abdominal pain is not to arrive at an exact clinicopathologic diagnosis but rather to determine which patients require immediate or urgent surgical inter-vention. Indications for immediate laparotomy (see above) areessentially limited to severe hemodynamic instability. Indicationsfor urgent laparotomy are somewhat more numerous.

Urgent laparotomy implies operation within 1 to 2 hours of thepatients arrival; thus, there is usually sufficient time for adequateresuscitation, with proper rehydration and restoration of vitalorgan function, before the procedure. Indications for urgentlaparotomy may be encountered during the physical examination,may be revealed by the basic laboratory and radiologic studies, or

may not become apparent until other investigative studies areperformed. Involuntary guarding or rigidity during the physicalexamination, particularly if spreading, is a strong indication forurgent laparotomy. Other indications include increasing severelocalized tenderness, progressive tense distention, physical signsof sepsis (e.g., high fever, tachycardia, hypotension, and mentalstatus changes), and physical signs of ischemia (e.g., fever andtachycardia). Basic laboratory and radiologic indications forurgent laparotomy include pneumoperitoneum, massive or pro-gressive intestinal distention, signs of sepsis (e.g., marked or ris-ing leukocytosis, increasing glucose intolerance, and acidosis),and signs of continued hemorrhage (e.g., a falling hematocrit).Additional findings that constitute indications for urgent lapar-otomy include free extravasation of radiologic contrast material,

mesenteric occlusion on angiography, endoscopically uncon-trollable bleeding, and positive results from peritoneal lavage (i.e.,the presence of blood, pus, bile, urine, or gastrointestinal con-tents). Acute appendicitis, perforated hollow viscera, and stran-gulated hernias are examples of common conditions that necessi-tate urgent laparotomy.

Several studies from the 1990s suggest that laparoscopy is theprocedure of choice when the primary clinical diagnosis is acuteappendicitis or perforated peptic ulcer. 25-30 In a prospective, ran-domized trial, 26 Hansen and associates reported that laparo-scopic appendectomy is as safe as open appendectomy. Althoughlaparoscopic appendectomy requires a longer operating time (63minutes versus 40 minutes), it has two advantages: the surgicalsite infection rate is lower, and patients return to normal activi-

ties earlier.Accordingly, we recommend laparoscopic appendec-tomy as a worthwhile alternative for patients with a clinical diag-nosis of acute appendicitis. It has also been shown that diagnos-tic laparoscopy through the right lower abdominal incision isvery helpful in establishing the correct diagnosis in patients whoare operated on for suspected acute appendicitis but in whomthe appendix is grossly normal. 27

Laparoscopic treatment of perforated peptic ulcerseither withan omental patch or with sutures 28-30 is becoming more popularas surgeons gain experience and competence with the technique.Compared with open approaches, laparoscopic repair results inreduced wound pain and respiratory complications as well as ear-lier return to normal activities.

HOSPITALIZATION AND

ACTIVE OBSERVATION

Numerous studies haveshown that of all patientsadmitted for acute abdom-inal pain, only a minorityrequire immediate or urgent

operation.2,4,5

It is thereforecost-effective as well as pru-dent to adopt a system of evaluation that allows for thought and investigation before defini-tive treatment in all patients with acute abdominal pain exceptthose identified early on as needing immediate or urgent laparoto-my. The traditional wisdom is that spending time on observationopens the door for complications (e.g., perforating appendicitis,intestinal perforation associated with bowel obstruction, or stran-gulation of an incarcerated hernia); however, careful clinical trialsevaluating active in-hospital observation of patients with acuteabdominal pain of uncertain origin have demonstrated that suchobservation is safe, is not accompanied by an increased incidenceof complications, and results in fewer negative laparotomies. 31

After the initial assessment has been completed, narcotic anal-gesia for pain relief should not be withheld. 32,33 In appropriateltitrated doses, analgesics neither obscure important physical findingsnor mask their subsequent development. In fact, some physical signsmay be more easily identified after adequate pain relief. 34,35 Sevpain that persists in spite of adequate doses of narcotics suggests aserious condition that is likely to call for operative intervention.

Active observation allows the surgeon to identify most of thepatients whose acute abdominal pain is caused by NSAP or vari-ous specific nonsurgical conditions. It must be emphasized thatactive observation means something more than simply admittingthe patient to the hospital: it implies an active process of thought-ful, discriminating, and meticulous reevaluation of the patient(preferably by the same examiner) at intervals ranging from min-

utes to a few hours, to be complemented by appropriately timedadditional investigative studies.

Additional investigative studies beyond the basic ones alreadymentioned should be obtained only if the results are likely to alteror improve patient management significantly. Furthermore, theinvasiveness, morbidity, and cost-effectiveness of each additionaltest must be carefully weighed. More liberal use of supplementalstudies is justified in those patients in whom the history and phys-ical findings tend to be less reliable (e.g., the very young, the elder-ly, the critically ill, or the immunocompromised).

Supplemental studies that may be considered include com-puted tomography, ultrasonography, diagnostic peritoneal la-vage, radionuclide imaging, angiography, magnetic resonanceimaging, gastrointestinal endoscopy [ see V:6 GastrointestinEndoscopy ], and diagnostic laparoscopy. Diagnostic laparoscopyhas been recommended when surgical disease is suspected butits probability is not high enough to warrant open laparoto-my. 36 It is particularly valuable in young women of childbear-ing age, in whom gynecologic disorders frequently mimic acuteappendicitis. 37 A report by Chung and coworkers showed thatdiagnostic laparoscopy had the same diagnostic yield as openlaparotomy in 55 patients with acute abdomen 38 ; 34 (62%) these patients were safely managed with laparoscopy alone,with no increase in morbidity and with a shorter average hos-pital stay. Diagnostic laparoscopy has also been shown to beuseful in the assessment of acute abdominal pain in ICUpatients 39 and patients with AIDS. 40


15/16


16/16



1. de Dombal FT: Diagnosis of Acute AbdominalPain, 2nd ed. Churchill Livingstone, London,1991

2. Purcell TB: Nonsurgical and extraperitoneal causes of abdominal pain. Emerg Med Clin North Am 7:721,1989

3. Silen W: Copes Early Diagnosis of the Acute Abdo-men, 17th ed. Oxford University Press, New York,1990

4. Brewer RJ, Golden GT, Hitch DC, et al:Abdominalpain: an analysis of 1,000 consecutive cases in a uni-versity hospital emergency room. Am J Surg 131:219,1976

5. Hawthorn IE:Abdominal pain as a cause of acute ad-mission to hospital. J R Coll Surg Edinb 37:389,1992

6. Staniland JR, Ditchburn J, de Dombal FT: Clinicalpresentation of acute abdomen: study of 600 pa-tients. Br Med J 3:393,1972

7. Hickey MS, Kiernan GJ,Weaver KE: Evaluation of abdominal pain. Emerg Med Clin North Am 7:437,1989

8. Adams ID, Chan M, Clifford PC, et al: Computeraided diagnosis of acute abdominal pain: a multicen-tre study. Br Med J 293:800,1986

9. Paterson-Brown S,Vipond MN:Modern aids to clin-ical decision-making in the acute abdomen. Br J Surg77:13, 1990

10. Wellwood J, Johannessen S, Spiegelhalter DJ: Howdoes computer-aided diagnosis improve the manage-ment of acute abdominal pain? Ann R Coll SurgEngl 74:40, 1992

11. de Dombal FT: Computers, diagnoses and patientswith acute abdominal pain.Arch Emerg Med 9:267,1992

12. de Dombal FT: The OMGE acute abdominal pain

survey.Progress Report, 1986.Scand J Gastroenterol144(suppl):35,1988

13. American College of Emergency Physicians: Clinicalpolicy for the initial approach to patients presentingwith a chief complaint of nontraumatic acute abdom-inal pain.Ann Emerg Med 23:906,1994

14. de Dombal FT: Surgical Decision Making in Prac-tice: Acute Abdominal Pain. Butterworth-Heine-mann Ltd,Oxford, 1993, p 65

15. Walters DT,Wendel HF:Abdominal pain. Prim Care13:3, 1986

16. Irvin TT: Abdominal pain: a surgical audit of 1190emergency admissions. Br J Surg 76:1121,1989

17. Jess P, Bjerregaard B, Brynitz S, et al: Prognosis of acute nonspecific abdominal pain: a prospectivestudy. Am J Surg 144:338, 1982

18. Gray DW, Collin J:Non-specific abdominal pain as acause of acute admission to hospital. Br J Surg 74:239,1987

19. Wilson DH,Wilson PD,Walmsley RG, et al: Diagno-sis of acute abdominal pain in the accident and emer-gency department.Br J Surg 64:249, 1977

20. Bender JS: Approach to the acute abdomen. MedClin North Am 73:1413, 1989

21. Telfer S, Fenyo G, Holt PR, et al:Acute abdominalpain in patients over 50 years of age. Scand J Gastro-enterol. Suppl 144:47, 1988

22. Dickson JAS,Jones A,Telfer S, et al:Acute abdomi-nal pain in children. Progress Report, 1986. Scand

J Gastroenterol. Suppl 144:43, 1988

23. Plewa MC: Emergency abdominal radiography.Emerg Med Clin North Am 9:827, 1991

24. Boleslawski E, Panis Y, Benoist S, et al: Plain abdomi-nal radiography as a routine procedure for acute ab-dominal pain of the right lower quadrant: prospectiveevaluation.World J Surg 23:262, 1999

25. Fritts LL, Orlando R: Laparoscopic appendectomy: asafety and cost analysis.Arch Surg 128:521, 1993

26. Hansen JB, Smithers BM, Schache D, et al:Laparo-scopic versus open appendectomy: prospective ran-domized trial.World J Surg 20:17, 1996

27. Schrenk P, Rieger R, Shamiyeh A, et al:Diagnostic la-paroscopy through the right lower abdominal inci-sion following open appendectomy. Surg Endosc 13:133,1999

28. Matsuda M, Nishiyama M, Hanai T, et al: Laparo-scopic omental patch repair for the perforated pepticulcer.Ann Surg 221:236,1995

29. Tate JJ, Dawson JW, Lau WY, et al: Sutureless laparo-scopic treatment of perforated duodenal ulcer. Br JSurg 80:235, 1993

30. Darzi A, Cheshire NJ, Somers SS, et al: Laparoscopicomental patch repair of perforated duodenal ulcerwith an automated stapler.Br J Surg 80:1552, 1993

31. Thomson HJ, Jones PF: Active observation in acuteabdominal pain. Am J Surg 152:522, 1986

32. Zoltie N, Cust MP: Analgesia in the acute abdomen.Ann R Coll Surg Engl 68:209, 1986

33. Boey JH: The acute abdomen. Current SurgicalDiagnosis and Treatment, 10th ed. Way LW, Ed.Appleton & Lange, Norwalk, Connecticut, 1994,p 441

34. Cuschieri A: The acute abdomen and disorders of the peritoneal cavity. Essential Surgical Practice.Cuschieri A, Giles GT, Moosa AR, Eds.Wright PSG,Bristol, 1982, p 885

35. Attard AR, Corlett MJ,Kidner NJ, et al:Safety of ear-ly pain relief for acute abdominal pain.BMJ 305:554,1992

36. Salky BA, Edye MB:The role of laparoscopy in thediagnosis and treatment of abdominal pain syn-dromes. Surg Endosc 12: 911,1998

37. Borgstein PJ, Gordijn RV, Eijsbouts QA, et al: Acuteappendicitisa clear-cut case in men, a guessinggame in young women: a prospective study on therole of laparoscopy. Surg Endosc 11:923, 1997

38. Chung RS, Diaz JJ, Chari V: Efficacy of routine lapa-roscopy for the acute abdomen. Surg Endosc 12:219,1998

39. Orlando R, Crowell KL:Laparoscopy in the criticallyill. Surg Endosc 11:1072,1997

40. Box JC, Duncan T, Ramshaw B, et al:Laparoscopy inthe evaluation and treatment of patients with AIDSand acute abdominal complaints. Surg Endosc 11:1026, 1997

41. Hobsley M: An approach to the acute abdomen.Pathways in Surgical Management, 2nd ed. EdwardArnold Ltd,London,1986

42. Larson FA, Haller CC, Delcore R, et al: Diagnosticperitoneal lavage in acute peritonitis.Am J Surg 164:449,1992

43. Cheung LY, Ballinger WF: Manifestations and diag-nosis of gastrointestinal diseases. Hardys Textbook of Surgery. Hardy JD, Ed. JB Lippincott Co, Philadel-phia,1983, p 445

44. McFadden DW, Zinner MJ: Manifestations of gas-trointestinal disease. Principles of Surgery, 6th ed.Schwartz SI, Shires GT,Spencer FC, Eds.McGraw-Hill,New York, 1994, p 1015

Acknowledgment

Figures 2 and 3 Tom Moore.

References

As noted [ see Tentative Differential Diagnosis, above ], mostpatients with acute abdominal pain presenting to the office orthe emergency department have an underlying nonsurgical con-dition and do not require operation. 2,4,5 Again, the single mostcommon diagnosis in these patients is NSAP. 5,12,16-19 Althoughthe natural history of NSAP has been well documented (harm-less abdominal pain that is relieved in a few days without any

treatment), there have been no prospective studies detailing thesymptomatology and physical findings associated with this dis-order. Furthermore, it remains unclear whether NSAP is in facta single disease entity or is simply the presenting symptom com-plex for many different minor and self-limited conditions. 18 Acomplete clinical history and physical examination, coupledwith careful in-hospital observation and a high index of suspi-

cion, will in most cases prevent unnecessary laparotomy inpatients with nonsurgical causes of acute abdominal pain. Onrare occasions, diagnostic laparoscopy may be employed to pre-vent unnecessary laparotomy.

Conclusion

In the management of patients with acute abdominal pain, itoccasionally happens that even with the aid of considerable clinicalacumen and liberal use of diagnostic tests, the surgeon cannotreadily determine whether a patient requires operation. In suchcases, laparotomy or diagnostic laparoscopy may constitute thedefinitive, as well as the safest, approach to the evaluation of acuteabdominal pain.

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