ABDOMINAL PAIN, ACUTE
ABDOMINAL PAIN, ACUTE: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the following questions:
- Where is the pain located? If it is diffuse, one should consider pancreatitis, mesenteric artery occlusion, or ruptured peptic ulcer. In addition, another viscus may be perforated, such as a ruptured ectopic, and there may be peritonitis. If it is focal, we need to know what quadrant it is in. For example, acute cholecystitis is in the right upper quadrant, whereas diverticulitis is usually in the left lower quadrant.
- What is the nature of the pain? Colicky abdominal pain suggests intestinal obstruction, renal calculus, and cholelithiasis or common duct stone, whereas constant pain is typical of pancreatitis, a ruptured peptic ulcer, appendicitis, diverticulitis, and a ruptured ectopic pregnancy.
- Does the pain radiate? The pain of acute cholecystitis typically radiates to the right scapular or right shoulder. The pain of a ruptured peptic ulcer may also radiate to the shoulder. The pain of acute renal calculus may radiate to the testicle.
- What are the associated signs and symptoms? Shock with generalized tenderness and rebound and diminished or absent bowel sounds should suggest a ruptured peptic ulcer or acute pancreatitis. However, acute right upper quadrant pain with nausea and vomiting should suggest acute cholecystitis. On the other hand, appendicitis is more insidious in onset and is associated with anorexia and nausea, rarely vomiting, as well as constipation. Renal colic presents with hematuria.
- Could this patient's abdominal pain be due to an extra-abdominal condition? Remember, lobar pneumonia, myocardial infarction, diabetic acidosis, and porphyria may be responsible for acute abdominal pain. There are numerous other conditions that need to be considered.
DIAGNOSTIC WORKUP
It is wise to consult a general surgeon at the outset. All patients with acute abdominal pain should have a stat, flat, and upright plate of the abdomen, a chest x-ray to rule out pneumonia, an electrocardiogram (EKG) to rule out myocardial infarction, and a complete blood count (CBC), urinalysis, amylase, and chemistry panel. Sometimes lateral decubitus films of the abdomen are necessary to show the step ladder pattern of intestinal obstruction. A pregnancy test is ordered when age and sex dictate it!
When these tests fail to confirm the clinical diagnosis, x-ray contrast studies or ultrasound may be necessary. For example, an intravenous pyelogram (IVP) can be done for a suspected renal calculus. Serial cardiac enzymes may confirm a myocardial infarction. Gallbladder ultrasound can be done to confirm cholecystitis and cholelithiasis. A nuclear scan of the gallbladder with iminodiacetic acid derivatives is very accurate in detecting acute cholecystitis. Ultrasonography may also help diagnose impending rupture of an abdominal aneurysm or ectopic pregnancy. A peritoneal tap may diagnose a ruptured ectopic pregnancy. Laparoscopy should also be considered. A urine porphobilinogen helps exclude porphyria. A double enema may help diagnose intestinal obstruction. A computed tomography (CT) scan of the abdomen is the next logical step.
If the diagnosis remains in doubt, an exploratory laparotomy must be done before the patient's condition deteriorates. The only case where this might be risky is acute pancreatitis. If this is suspected and the serum amylase is repeatedly normal, a quantitative urine amylase or peritoneal tap may confirm the diagnosis. Endoscopy may need to be done to diagnose a peptic ulcer, gastritis, gastric tumor, or reflux esophagitis. In obscure cases of appendicitis and diverticulitis, a contrast barium enema may help confirm the diagnosis. Angiography can diagnose an aneurysm or mesenteric infarction.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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