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Abdominal Pain Emergencies
[edit]Below is a brief overview of abdominal pain emergencies.
| Condition | Presentation | Diagnosis | Management |
|---|---|---|---|
| Acute Appendicitis[1] | Abdominal pain, nausea, vomiting, fever
Periumbilical pain, migrates to RLQ |
Clinical (history & physical exam)
Abdominal CT |
Patient made NPO (nothing by mouth)
IV fluids as needed General surgery consultation Antibiotics Pain control |
| Acute Cholecystitis[1] | Abdominal pain (RUQ, radiates epigastric), nausea, vomiting, fever, Murphy's sign | Clinical (history & physical exam)
Imaging (RUQ ultrasound) Labs (leukocytosis, transamintis, hyperbilirubinemia) |
Patient made NPO (nothing by mouth)
IV fluids as needed General surgery consultation Antibiotics Pain, nausea control |
| Acute Pancreatitis[1] | Abdominal pain (sharp epigastric, shooting to back), nausea, vomiting | Clinical (history & physical exam)
Labs (elevated lipase) Imaging (abdominal CT, ultrasound) |
Patient made NPO (nothing by mouth)
IV fluids as needed Pain, nausea control Possibly consultation of general surgery or interventional radiology |
| Bowel Obstruction[1] | Abdominal pain (diffuse, crampy), bilious emesis, constipation | Clinical (history & physical exam)
Imaging (abdominal X-ray, abdominal CT) |
Patient made NPO (nothing by mouth)
IV fluids as needed Nasogastric tube placement General surgery consultation Pain control |
| Upper GI Bleed[1] | Abdominal pain (epigastric), hematochezia, melena, hematemesis, hypovolemia | Clinical (history & physical exam, including digital rectal exam)
Labs (complete blood count, coagulation profile, transaminases, stool guaiac) |
Aggressive IV fluid resuscitation
Blood transfusion as needed Medications: proton pump inhibitor, octreotide Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) |
| Lower GI Bleed[1] | Abdominal pain, hematochezia, melena, hypovolemia | Clinical (history & physical exam, including digital rectal exam)
Labs (complete blood count, coagulation profile, transaminases, stool guaiac) |
Aggressive IV fluid resuscitation
Blood transfusion as needed Medications: proton pump inhibitor Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) |
| Perforated Viscous[1] | Abdominal pain (sudden onset of localized pain), abdominal distension, rigid abdomen | Clinical (history & physical exam)
Imaging (abdominal X-ray or CT showing free air) Labs (complete blood count) |
Aggressive IV fluid resuscitation
General surgery consultation Antibiotics |
| Volvulus[1] | Sigmoid colon volvulus: Abdominal pain (>2 days, distention, constipation)
Cecal volvulus: Abdominal pain (acute onset), nausea, vomiting |
Clinical (history & physical exam)
Imaging (abdominal X-ray or CT) |
Sigmoid: Gastroenterology consultation (flexibile sigmoidoscopy)
Cecal: General surgery consultation (right hemicolectomy) |
| Ectopic Pregnancy[1] | Abdominal and pelvic pain, bleeding
If ruptured ectopic pregnancy, patient may present with peritoneal irritation and hypovolemic shock |
Clinical (history & physical exam)
Labs: complete blood count, urine pregnancy test followed with quantitative blood beta-hCG Imaging: transvaginal ultrasound |
If patient is unstable: IV fluid resuscitation, urgent obstetrics and gynecology consultation
If patient is stable: continue diagnostic workup, establish OBGYN follow-up |
| Ruptured Abdominal Aortic Aneurysm[1] | Abdominal pain, flank pain, back pain, hypotension, pulsatile abdominal mass | Clinical (history & physical exam)
Imaging: Ultrasound, CT angiography, MRA/magnetic resonance angiography |
If patient is unstable: IV fluid resuscitation, urgent surgical consultation
If patient is stable: admit for observation |
| Aortic Dissection[1] | Abdominal pain (sudden onset of epigastric or back pain), hypertension, new aortic murmur | Clinical (history & physical exam)
Imaging: Chest X-Ray (showing widened mediastinum), CT angiography, MRA, transthoracic echocardiogram/TTE, transesophageal echocardiogram/TEE |
IV fluid resuscitation
Blood transfusion as needed (obtain type and cross) Medications: reduce blood pressure (sodium nitroprusside plus beta blocker or calcium channel blocker) Surgery consultation |
| Liver Laceration[1] | After trauma (blunt or penetrating), abdominal pain (RUQ), right rib pain, right flank pain, right shoulder pain | Clinical (history & physical exam)
Imaging: FAST examination, CT of abdomen and pelvis |
Resuscitation (Advanced Trauma Life Support) with IV fluids (crystalloid) and blood transfusion
If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy |
| Splenic Laceration or Rupture[1] | After trauma (blunt or penetrating), abdominal pain (LUQ), left rib pain, left flank pain | Clinical (history & physical exam)
Imaging: FAST examination, CT of abdomen and pelvis |
Resuscitation (Advanced Trauma Life Support) with IV fluids (crystalloid) and blood transfusion
If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy and possible splenectomy If patient is stable: medical management, consultation of interventional radiology for possible arterial embolization |
Anatomy of Abdominal Pain
[edit]Abdominal pain can be referred to as visceral pain or peritoneal pain. To better understand the types of pain, it is important to understand the anatomy of the abdomen. The contents of the abdomen can be divided into the foregut, midgut, and hindgut.[2] The foregut contains the pharynx, lower respiratory tract, portions of the esophagus, stomach, portions of the duodenum (proximal), liver, biliary tract (including the gallbladder and bile ducts), and the pancreas.[2] The midgut contains portions of the duodenum (distal), cecum, appendix, ascending colon, and first half of the transverse colon.[2] The hindgut contains the distal half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal canal.[2]
Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord, traveling with the autonomic sympathetic nerves.[3] The visceral sensory information from the gut traveling to the spinal cord, termed the visceral afferent, is non-specific and overlaps with the somatic afferent nerves, which are very specific.[4] Therefore, visceral afferent information traveling to the spinal cord can present in the distribution of the somatic afferent nerve; this is why appendicitis initially presents with T10 periumbilical pain when it first begins and becomes T12 pain as the abdominal wall peritoneum (which is rich with somatic afferent nerves) is involved.[4]
| Region | Vascular Blood Supply[2] | Sympathetic Innervation[5] | Structures[2] |
|---|---|---|---|
| Foregut | Celiac Artery | T5 - T9 | Pharynx
Proximal duodenum |
| Midgut | Superior Mesenteric Artery | T10 - T12 | Distal duodenum
Proximal transverse colon |
| Hindgut | Inferior Mesenteric Artery | L1 - L3 | Distal transverse colon
Superior anal canal |
- ^ a b c d e f g h i j k l m Sherman, Scott C., Cico, Stephen John, Nordquist, Erik, Ross, Christopher, Wang, Ernest (2016). Atlas of Clinical Emergency Medicine. Wolters Kluwer. ISBN 978-1-4511-8882-0.
{{cite book}}: CS1 maint: multiple names: authors list (link) - ^ a b c d e f Moore BA, MSc, PhD, DSc, FIAC, FRSM, FAAA, Keith L (2016). "11". The Developing Human Tenth Edition. Philadelphia, PA: Elsevier, Inc. pp. 209–240. ISBN 978-0-323-31338-4.
{{cite book}}: CS1 maint: multiple names: authors list (link) - ^ Richard L. Drake PhD, FAAA, A. Wayne Vogl PhD, FAAA and Adam W.M. Mitchell MB BS, FRCS, FRCR (2015). "4: Abdomen". Grays Anatomy For Students, Third Edition. Churchill Livingstone Elsevier. pp. 253–420. ISBN 978-0-7020-5131-9.
{{cite book}}: CS1 maint: multiple names: authors list (link) - ^ a b Leigh Neumayer, Dale A. Dangleben, Shannon Fraser, Jonathan Gefen, John Maa, Barry D. Mann (2013). "11: Abdominal Wall, Including Hernia". Essentials of General Surgery, 5e. Baltimore, MD: Wolters Kluwer Health.
{{cite book}}: CS1 maint: multiple names: authors list (link) - ^ Hansen PhD, John T. (2019). "4: Abdomen". Netter's Clinical Anatomy, 4e. Philadelphia, PA: Elsevier. pp. 157–231. ISBN 978-0-323-53188-7.