ABDOMINAL PAIN, GENERALIZED

ABDOMINAL PAIN, GENERALIZED: Excerpt from Differential Diagnosis in Primary Care

The GI tract is the only “organ” that really covers the abdomen from one end to the other. Anything that causes an irritation of all or a large portion of this “tube” may cause generalized abdominal pain. Thus, gastritis, viral and bacterial gastroenteritis, irritable bowel syndrome, ulcerative colitis, and amebic colitis fall into this category. The remainder of the causes of generalized abdominal pain can be developed by using the mnemonic ROS with the anatomy of the entire abdomen.

ABDOMINAL PAIN, GENERALIZED

When faced with a patient with diffuse abdominal pain, think of R for ruptured viscus. Now take each organ and consider the possibility of its having ruptured. Thus, the stomach and duodenum suggest a ruptured peptic ulcer; the pancreas, an acute hemorrhagic pancreatitis; the gallbladder, a ruptured appendix. The liver and spleen usually rupture from trauma, whereas the fallopian tube may rupture from an ectopic pregnancy. The colon ruptures from diverticulitis, ulcerative colitis, or carcinoma. What is the one thing that should make the physician suspect a ruptured viscus? Rebound tenderness is the answer. In addition, one or both testicles may be drawn up (Collins sign). If only the right testicle is drawn up, suspect a ruptured appendix or peptic ulcer. If only the left is drawn up, suspect a ruptured diverticulum. If both are drawn up, suspect pancreatitis or a generalized peritonitis.

Now take the letter O. This signifies intestinal obstruction. Think of adhesion hernia, volvulus, paralytic ileus, intussusception, fecal impaction, carcinoma, mesenteric infarction, regional ileitis, and malrotation. The best way to recall all these is with the mnemonic VINDICATE.

Next take the letter S. This signifies the systemic diseases that may irritate the intestines, the peritoneum, or both. Once again the mnemonic VINDICATE will remind one to recall the important offenders.

1. V—Vascular suggests the anemias, congestive heart failure (CHF), coagulation disorders, and mesenteric artery occlusion, embolism, or thrombosis.
2. I—Inflammatory includes tuberculous, gonococcal and pneumococcal peritonitis, and trichinosis.
3. N—Neoplasms should suggest leukemia and metastatic carcinoma.
4. D—Deficiency might suggest the gastroenteritis of pellagra.
5. I—Intoxication reminds one of lead colic, uremia, and the venom of a black widow spider bite.
6. C—Congenital suggests porphyria and sickle cell disease.
7. A—Autoimmune brings to mind periarteritis nodosa, rheumatic fever, Henoch–Schönlein purpura, and dermatomyositis.
8. T—Trauma would suggest the paralytic ileus of trauma anywhere, the crush syndrome, and hemoperitoneum.
9. E—Endocrine disease suggests diabetic ketoacidosis, addisonian crisis, and hypocalcemia.

Approach to the Diagnosis

If the onset is acute, a general surgeon should be consulted at the outset. Ominous signs include boardlike rigidity, rebound tenderness, and shock with nausea and vomiting. Hyperactive bowel sounds of a high-pitched tinkling character with distention and obstipation suggest intestinal obstruction. On the other hand, normal bowel sounds, little distention, good vital signs, and minimal tenderness suggest gastroenteritis or other diffuse irritation of the bowel.

It is wise to pass a nasogastric tube and attach to suction and proceed with a CBC, urinalysis, an immediate flat plate and upright of the abdomen, chest x-ray, serum amylase and lipase levels, and chemistry panel. Sometimes, lateral decubitus films are necessary to reveal the stepladder pattern of intestinal obstruction. A pregnancy test should be ordered if age and gender dictates it.

If these tests fail to confirm the clinical diagnosis and the patient’s condition is deteriorating, it is probably wise to proceed with an exploratory laparotomy immediately. If the patient’s condition is stable, one may order more diagnostic tests depending on the location of the pain and other symptoms and signs. For example, if the pain seems more localized to the RUQ, a gallbladder ultrasound or nuclear scan may be ordered. If it is still considered generalized, perhaps a CT scan of the abdomen and pelvis is indicated. Monitoring vital signs and doing repeated CBCs, serum amylase levels, and flat plates of the abdomen are useful in borderline cases.

Other Useful Tests

1. Quantitative urine amylase level
2. Four-quadrant peritoneal tap (peritonitis, pancreatitis, ruptured ectopic)
3. Urine porphobilinogen (porphyria)
4. IVP (renal calculus)
5. Serial cardiac enzymes (mycordial infarct)
6. Serial electrocardiograms (ECGs)
7. Double enema (intestinal obstruction)
8. Esophagoscopy (reflux esophagitis)
9. Gastroscopy (peptic ulcer)
10. Colonoscopy (diverticulitis, carcinoma)
11. Laparoscopy [ruptured viscus, pelvic inflammatory disease (PID)]
12. Culdocentesis (ruptured ectopic pregnancy)
13. Pelvic sonogram (ruptured ectopic pregnancy)
14. Angiogram (mesenteric thrombosis)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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