ACUTE ABDOMINAL PAIN

 

I. Pertinent Hx:

  1. Menstrual history of patient is female of childbearing age
  2. Location of pain may help suggest location of the problem
  1. Diffuse Pain : ischemia, strangulation
  2. Midepigatric : stomach, duodenum, liver, biliary
  3. Periumbilical : appendix, ureters, testes, ovaries
  4. Lower Abd: lower ureter, colon, bladder, uterus
  1. Sudden Onset: consider perforated ulcer, ruptured aneurysm, ruptured ectopic pregnancy
  2. Associated sx to ask about: vomiting, hematemesis, hematuria, diarrhea, obstipation, cough, sputum

II. PMHx: PUD, gallstones, EtOH use, abdominal surgery, AAA, cardiac disease, arrhythmias

III. Diff Dx:

  1. Intra-abdominal :
  1. Hollow viscera--esophagitis, gastritis, PUD, cholecystitis, small bowel obstruction/infarction, IBD, appendicitis, colonic obstruction, pseudo-obstruction ("Ogilvie's syndrome"), diverticulitis, enteritis, malabsorption
  2. Solid organ--hepatitis, pancreatitis, splenic infarct, pyelonephritis, SBP
  3. Pelvic--PID, ruptured ectopic
  4. Vascular-Ruptured aneurysm, dissection, Mesenteric Ischemia
  1. Extra-abdominal :
  1. DKA
  2. Acute adrenal insufficiency (Addisonian Crisis)
  3. Acute porphyria
  4. Lower lobe pneumonia
  5. Pulm. embolus
  6. Pneumothorax
  7. SS crisis

Diagnosis of acute appendicitis in children with abdominal pain

 In a systematic review of studies comparing clinical findings with histologically confirmed appendicitis, the following were significantly associated with that diagnosis:

  1. Migration of pain to RLQ

  2. Vomiting

  3. RLQ rebound tenderness

  4. Abdominal guarding or rigidity

  5. WBC > 15k (likelihood ration 7.0)

 Not associated with sig. increased likelihood of appendicitis:

  1. Rectal tenderness

  2. Length of time that pain has been present

(Source: West. J. Med. 176:104, 2001--AFP)

IV. Px:

  1. Vitals, lungs, pelvic
  2. Abdomen
  1. Insp.--dist., ecchymoses, caput med., surg. scars
  2. Percuss - tympany, shift. dull., fluid wave, loss of liver dullness
  3. Palp.--guarding, rebound, CVAT, Murphy's sign, psoas sign, obturator sign
  4. Auscultate - bowel sounds
  1. Rectal

V. Workup

  1. CBC, lytes, glucose, creatinine, LFT's, lipase, amylase
  2. Consider CXR if Hx/Px suggests lower lobe pneumonia
  3. As indicated: ultrasound, CT (quite sensitive/specific for appendicitis), Ba enema/sm. bowel series, paracentesis, intravenous pyelography, endoscopy, angio, HIDA, Beta-hCG, ABG, U/A, cervical cultures
  4. CT had sensitivity of 99% and specificty of 95% for acute appendicitis in a case series of 63 children presenting to an ED with abdominal pain (Am. J. Roentgenol. 184:1802, 2005--JW)
  5. Ultrasound had sensitivity of 83% and specificity of 95% for acute appendicitis in a case series of 667 adults and children with suspected appendicitis (Am. J. Roentgenol. 184:1809, 2005--JW)

VI. Management:

  1. To OR STAT if--appendicitis, strangulated hernia, perforation, Meckel's diverticulitis, Boerhaave's, acute cholecystitis/cholangitis, hepatic abscess, ruptured spleen, ruptured ectopic, ruptured ovarian cyst, ruptured aneurysm, ischemic colitis, intra-abdominal abscesses
  2. If none of the above,
  1. Surgical consult
  2. NPO
  3. NG tube (for vomiting, obstruction suspected)
  4. Electrolyte/Fluid management
  5. Opioid analgesia as needed (contrary to popular belief, did not affect diagnostic accuracy in one randomized trial, see J. Am. Coll. Surg. 196:18, 2003--JW)
  6. In a study in 128 pts with partial small-bowel obstruction felt to be due to adhesions from prior surgery, randomized to conservative care vs. conservative care + (MgO, simethicone, and lactobacillus), incidence of not requiring surgery was sig. higher in the active-tx group (91% vs.76%) (CMAJ 173:1165, 2005--JW)
  7. Serial exams
  8. Neostygmine 2mg IV x 1 may help hasten resolution of colonic pseudo-bstruction (NEJM 341:137, 1999--JW)