Abdominal Pain, Generalized
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.
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 cholecystitis. 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.
V—Vascular suggests the anemias, congestive heart failure (CHF),
coagulation disorders, and mesenteric artery occlusion, embolism, or
thrombosis.
I—Inflammatory includes tuberculous, gonococcal and pneumococcal
peritonitis, and trichinosis.
N—Neoplasms should suggest leukemia and metastatic carcinoma.
D—Deficiency might suggest the gastroenteritis of pellagra.
I—Intoxication reminds one of lead colic, uremia, and the venom of a
black widow spider bite.
C—Congenital suggests porphyria and sickle cell disease.
A—Autoimmune brings to mind periarteritis nodosa, rheumatic fever,
Henoch–Schönlein purpura, and dermatomyositis.
T—Trauma would suggest the paralytic ileus of trauma anywhere, the
crush syndrome, and hemoperitoneum.
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. In contrast, 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 immediately with
an exploratory laparotomy. 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
-
Quantitative urine amylase level
-
Four-quadrant peritoneal tap (peritonitis, pancreatitis,
ruptured ectopic)
-
Urine porphobilinogen (porphyria)
-
IVP (renal calculus)
-
Serial cardiac enzymes (mycardial infarct)
-
Serial electrocardiograms (ECGs)
-
Double enema (intestinal obstruction)
-
Esophagoscopy (reflux esophagitis)
-
Gastroscopy (peptic ulcer)
-
Colonoscopy (diverticulitis, carcinoma)
-
Laparoscopy (ruptured viscus, PID)
-
Culdocentesis (ruptured ectopic pregnancy)
-
Pelvic sonogram (ruptured ectopic pregnancy)
-
Angiogram (mesenteric thrombosis)
-
Breath test or stool tests for Helicobacter pylori (peptic ulcer)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
More About Causes of Cramps
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