Acute Abdominal Pain
Differential Overview
Generalized/Periumbilical
❑ Gastroenteritis
❑ Obstipation
❑ Small bowel obstruction
❑ Large bowel obstruction
❑ Mesenteric ischemia
❑ Peritonitis
❑ Abdominal aortic dissection
❑ Sickle cell crisis
Right Upper Quadrant/Epigastrium
❑ Hepatitis
❑ Biliary colic
❑ Peptic ulcer disease
❑ Pyelonephritis
❑ Acute cholecystitis
Right Lower Quadrant
❑ Appendicitis
❑ Inflammatory bowel disease
❑ Salpingitis
❑ Rectus abdominus muscle strain
❑ Ureteral calculus
❑ Ruptured corpus luteum cyst
❑ Ruptured ectopic pregnancy
❑ Ovarian torsion
Left Upper Quadrant
❑ Pancreatitis
❑ Splenic infarction
❑ Pyelonephritis
❑ Myocardial infarction
Left Lower Quadrant
❑ Inflammatory bowel disease
❑ Diverticulitis
❑ Salpingitis
❑ Rectus abdominus muscle strain
❑ Ureteral calculus
❑ Ovarian torsion
❑ Ruptured corpus luteum cyst
❑ Ruptured ectopic pregnancy
❑ Sigmoid volvulus
Diagnostic Approach
Acute abdominal pain is a classic symptom that can herald conditions ranging from the trivial to the life-threatening. The accurate diagnosis and timely management of abdominal pain requires an understanding of the mechanisms of pain, recognition of typical patterns of clinical presentation, a broad differential of common causes, and an index of suspicion for variant presentations and unusual causes. The ultimate disposition decision may require a repeated history and physical examination over several hours. Narcotic analgesics should be withheld until a diagnosis is established because they can mask the expression of diagnostic characteristics of the disease. History indicates the diagnosis in 85% to 90% of cases. Consider organs located in the region of maximal pain and the time-course of onset. An intrathoracic source must always be considered with upper abdominal pain. Physical examination can demonstrate peritoneal inflammation and rebound tenderness by eliciting pain with gentle percussion of the abdomen as opposed to sharp release of the depressed hand. Muscular rigidity or “guarding” is an early sign of peritoneal inflammation. Auscultation may reveal silence, consistent with ileus or advanced peritonitis, hyperactive high-pitched sounds with early bowel obstruction, or a friction rub with splenic infarct or hepatic metastases. Pelvic and rectal examinations are mandatory in every patient who has abdominal pain.
Parietal pain, caused by inflammation of the parietal peritoneum, is
a sharp, steady, aching pain, well-localized over the inflamed area, and
accentuated by pressure. Tonic reflex spasm of the abdominal musculature is present. Visceral pain, caused by obstruction of a hollow viscera, is classically intermittent and cramping, but distension may produce dull, steady pain. The patient with visceral pain will writhe incessantly, while the patient with parietal pain lies still in bed. Referred pain is aching and perceived to be near the surface, accompanied by skin hyperalgesia and increased tone of the abdominal wall. Vascular occlusion can be recognized by severe pain out of proportion to physical findings in a patient with vascular disease or atrial fibrillation. Visceral pain is perceived at the level the nerves enter the spinal cord. An example is gallbladder pain which may be first perceived at the scapula, then later in the right upper quadrant when the somatically innervated overlying parietal peritoneum is inflamed.
If the patient is well one moment, then has excruciating pain, which is maximal at onset, consider a ruptured hollow viscera or a vascular event, such as myocardial infarction or ruptured aortic aneurysm.
Clinical Findings
Gastroenteritis The typical syndrome will consist of diffuse, cramping abdominal pain, fever, and nausea, with hyperactive bowel sounds and mild diffuse abdominal tenderness. Bacterial infections will cause higher fever, watery diarrhea, and foul-smelling, often bloody stools.
Obstipation The patient is distended with stool palpable through the abdominal wall and only mild abdominal tenderness. There will usually be a history of absence of bowel movements for several days although a small amount of diarrhea may pass around the fecal obstruction.
Small bowel obstruction The pain is colicky, severe, and poorly localized. Cramping pain occurs in short, intense waves followed by complete absence of pain. Short pain-free intervals occur in proximal obstruction, and longer ones in distal. The patient is restless. Vomiting, which may become feculent, is common in proximal obstruction. The abdomen is distended in distal obstruction, and the rectum has an empty, “ballooned” feel. Tenderness to palpation is not impressive unless perforation has occurred. High-pitched hyperactive bowel sounds are characteristic, but they may be hypoactive or absent in 25%. Most patients (80%) have a history of prior abdominal surgery.
Large bowel obstruction Constipation or change in bowel habits often precedes complete obstruction. Pain is felt below the umbilicus. Distension is prominent, but pain is less severe than with small bowel obstruction.
Mesenteric ischemia Acute vascular occlusion usually presents with severe midabdominal pain out of proportion to the physical findings. The pain begins as colic, then progresses. In later stages, fever and hypotension occur. An embolic substrate (atrial fibrillation, or acute MI) is a key clue. The stool should be hemoccult positive. “Intestinal angina” presents with recurrent colicky abdominal pain and distension occurring 20 to 30 minutes after a meal and lasting 2 to 3 hours. This may manifest itself as food aversion or a malabsorptive diarrhea/steatorrhea with prominent weight loss. There is often a bruit in the upper abdomen.
Peritonitis There will be early vomiting, board-like abdominal rigidity, rebound tenderness, fever, and a silent abdomen. The patient will lie absolutely still. The pain is often localized (e.g., appendicitis) before becoming generalized.
Abdominal aortic dissection The pain is migrating, severe, tearing, and radiating to the back. The patient will often be in early shock, hypotensive, and restless. There may be a pulsating, enlarged, tender aorta palpable through the abdomen. The femoral pulse may be absent. Loss of motor function and sensation in one leg suggests dissection with spinal artery compromise.
Sickle cell crisis Diffuse abdominal pain with peritoneal signs develops in a patient with sickle cell anemia.
Hepatitis Following a prodromal phase of anorexia and malaise, the icteric phase is dominated by right upper quadrant pain and tenderness, fever, jaundice, nausea, dark urine, and light stools.
Biliary colic Sudden onset of steady and severe pain lasting 15 minutes to hours occurs with acute obstruction of the common bile or cystic duct. Cystic duct obstruction causes right upper quadrant pain whereas common bile duct obstruction causes epigastric pain, early jaundice, and prominent emesis. Pain may radiate to the scapula.
Peptic ulcer disease Gnawing, aching, burning, or hunger pain in the epigastrium, relieved temporarily by food or antacids, suggests this diagnosis. Radiation to the back suggests perforation into the pancreas. Duodenal ulcer causes pain 1 to 2 hours after meals and at night.
Pyelonephritis Typically, the patient has dysuria, fever, nausea, and costovertebral angle tenderness although presentation with poorly localized abdominal pain is not uncommon either.
Acute cholecystitis Right upper quadrant pain radiates to the scapula and is accompanied by nausea, vomiting, and fever. Murphy sign (inspiratory arrest on palpation over the gallbladder) is present, and a distended gallbladder is palpable in 30%. There is often a background of biliary colic. Fever and rigors herald a suppurative cholangitis.
Appendicitis Classically, it begins as poorly localized visceral pain in the periumbilical region, moving to the right lower quadrant, where somatic pain is steadily progressive. There is localized tenderness over McBurney point, with or without rebound tenderness. Anorexia/nausea and low-grade fever are usually present.
Inflammatory bowel disease Pain, fever, and diarrhea with blood or mucus accompany flares. Terminal ileitis in young adults may simulate acute appendicitis. Crohn may be recognized by systemic signs, such as arthritis.
Salpingitis A sexually active woman presents with lower abdominal pain. Pelvic examination reveals yellow discharge from the cervix, cervical motion pain (chandelier sign), or tender adnexa. An exquisitely tender adnexal mass indicates a tubo-ovarian abscess.
Rectus abdominus muscle strain The history will suggest strain or overuse. The pain is constant and aching and is exacerbated by movement. There will be superficial tenderness over the rectus abdominis, and spasm may mimic guarding. A hematoma may simulate a localized mass.
Ureteral calculus Severe cramping flank pain radiates to the groin. The patient is pale and unable to find a comfortable position. The urine will be dipstick positive for blood.
Ruptured corpus luteum cyst Around the time of the menses, there occurs a sudden-onset, transient (hours), unilateral, lower abdominal and adnexal pain and tenderness. It is less severe and more diffuse than appendicitis, and it steadily improves on serial examination rather than worsening. A similar presentation during midcycle occurs with rupture of a graafian follicle (mittelschmerz).
Ruptured ectopic pregnancy A missed or late period (85%) with an adnexal mass may be the only clue; thus, a high index of suspicion is needed. Rupture is accompanied by acute pain that may project to the shoulder, accompanied by cervical bleeding, shock, and a full, boggy cul-de-sac. There is a prior history of PID in 25%.
Ovarian torsion The usual presentation is a young woman with acute onset of pain and a tender adnexal mass but no fever.
Pancreatitis Left upper quadrant pain boring through to the back, prominent nausea and vomiting, and a history of heavy alcohol use or cholelithiasis are important clues. The patient sits up and leans forward, or lies on the side in a knee-chest position. Rebound will be present just above the umbilicus, and costovertebral angle tenderness occurs with inflammation of the tail of the pancreas. Hiccups are often present.
Splenic infarction Left upper quadrant pleuritic pain and tenderness occur in the setting of atrial fibrillation, endocarditis, sickle cell anemia, or neoplastic splenic enlargement. There may be a localized friction rub.
Myocardial infarction Ischemia should be considered with upper abdominal pain although chest pain is usually present. Nausea can be seen with inferior ischemia.
Diverticulitis It presents subacutely with low-grade fever and left lower quadrant abdominal pain. A tender mass with indistinct borders may be palpable on abdominal or rectal examination.
Sigmoid volvulus Severe pain will suddenly occur while the patient is straining to defecate. Rapid, extreme left upper quadrant distension occurs, with vertical peristalsis.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Cramps
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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» Next page: Abdominal pain (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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