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Trans Group: Nicanor Ong, E. Edited by: Marianne Sadaya
Subject: Topic: Lecturer: Date:
Surgery 3.1 Evaluation of Acute Abdominal Pain Dr. Alcedo
February 3, 2014
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Second Semester A.Y. 2013-2014
CASE 1. A 55 year old male consulted in the ER because of severe
pain which suddenly awakened him in the early hours of the morning
associated with generalized muscle guarding. He is most likely
suffering from which of the following:
A. Small bowel intestinal obstruction B. Acute cholecytitis C.
Ureteral colic D. Perforated peptic ulcer disease
Review of Anatomy maximal acid production is during hours in the
morning (also experienced by people with hyperacidity) Sudden,
generalized pain pouring acid in your GI will cause inflammation of
the peritoneal lining Involuntary muscle guarding even if patient
is asked to relax, he cannot soften his abdominal wall Question to
ask yourself: Is this life threatening? YES
OUTLINE
I. Introduction II. Acute Abdomen III. History IV. Physical
Examination V. Evaluation and Diagnosis
A. Laboratory B. Imaging
VI. Categories After Initial Evaluation VII. Algorithms for the
Approach to
Patients with Acute Abdominal Pain VIII. Differential Diagnosis
IX. Indicators for Urgent Laparotomy X. Laparotomy or
Laparoscopy
References: Recording - italicized Sabiston Textbook of Surgery,
19th edition, Chapter 47
I. INTRODUCTION
II. ACUTE ABDOMEN Abdominal pain undiagnosed for less than 7
days (some consider
up to 10 days as acute) Accounts for 1% of all hospital
admissions because majority are
discharged after initial examination while some would require
immediate surgery
Questions to ask yourself while examining: o Is this a surgical
abdomen?
If you miss the diagnosis, its either you manage a surgical
patient medically or a medical patient surgically. Either way the
consequences are somewhat unacceptable
o If it is, does it require immediate surgery or can it be done
a few days after?
Is this case very urgent? Delaying a surgery that is strongly
indicated can be lethal for a patient.
III. HISTORY Hollow viscus obstruction insidious onset of
diffuse dull aching
pain, associated with nausea and vomiting, unable to lie still,
no alleviating factors
Early inflammatory process of solid viscera diffuse dull ache
pain
Progression of inflammatory and obstructive process progression
in several hours into sharp and stabbing pain, aggravated by
movement, coughing, and relieved by lying still
Localized Peritonitis localized tenderness with rebound and
muscle guarding
Perforation, strangulation, spontaneous bleeding sudden onset of
pain with progression with minutes to a few hours; early sharp
localization, progressing to generalized tenderness with rebound
and rigidity; referred pain to the shoulder tip and scapula with
blood or pus in the sub-phrenic space
USE CLITAA IN TAKING THE HISTORY Characteristic: Somatic vs.
Visceral
o Let patient talk and provide his/her own description of the
pain before you suggest specific characteristics (e.g. burning,
sharp, etc)
Location: Where is it? Where does it radiate? Intensity use the
pain score (0 absence of pain; 10 equal to
the pain of labor; If you encounter such a patient, do not force
your patient to answer your questions.
Time course: Acute? Intermittent? Sudden vs. Progressive
Aggravating and Alleviating Factors Associated Signs and Symptoms
Elicited by direct irritation of the parietal peritoneum Mediated
by affarent somatic nerve fibers Localized in the dermatome
supplied by the segmental nerve
roots innervating the parietal peritoneum Sharp and
well-localized
A. Hollow Viscus Perforation (Sudden onset, severe)
When a seemingly healthy patient feels like the pain was
suddenly switched on
Can lead to neurogenic shock
Somatic Pain
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CASE 2. Appendicitis 25 year old male complaining of 10 hour
history of periumbilical pain which radiated initially to the right
upper quadrant and later on localized to the right lower quadrant.
Associated with fever, anorexia, vomiting. In PE there is rebound
tenderness. If a 2nd yr med student were to evaluate this patient
and CBC results are normal, urinalysis showed little RBC and WBCs;
will this affect your diagnosis? Clincial findings sometimes
contradict the clincial evaluation. Stick to clincal findings if
you know its right! CASE 3. Acute Cholecystitis Patient had 4th
attack today. Colicky right upper quadrant pain 3 times in the past
lasting for about 2-3h. Prenup of ultrasound showed acute
cholecyctitis. 26mm. site of initial pain: periumbilical pain bec
of distention of the appendix
Sudden onset of excruciating pain suggests intestinal
perforation, arterial embolism with ischemia, and other conditions
like biliary colic. o Ureteral colic (may be constant) o Perforated
ulcer o Ruptured aortic aneurysm
From the lecturer: Perforation of a hollow viscus resolve in the
spillage of the sulcus entericus into the the peritoneal cavity;
peritoneal signs indications for surgery B. Infectious Process
(Gradual progressive pain)
Worsens over time
o Cholecysitis o Hepatitis o Pancreatitis o Appendicitis o
Tubo-ovarian abscess or ectopic pregnancy o Diverticulitis at the
LLQ, are of sigmoid colon
From the lecturer: pancreatitis some surgical, some medical;
Abdominal pain that would present as surgical but actually
medical
C. Hollow Viscus Obstruction (Colicky, crampy, intermittent)
o Biliary colic RUQ; aggravated by a fatty meal, where
cholecystokinin stimulates gall bladder contraction and since
theres a stone obstructing the cystic duct, the pressure in the
gall bladder rises and produces pain
o Ureteral colic/Kidney Stones flank pain that goes down o Small
bowel obstruction periumbilical area o Colonic obstruction
hypogastric area From the lecturer: However, a patient with acute
gastroenteritis or diarrhea may present like this. Thats why its
important to diagnose before performing a surgery! Obstruction of a
hollow viscous - tumors in the colon can result to obstruction of
the sigmoid and if surgery is not done in an acute setting, the
bowel will perforate. The first portion that will perforate will be
the cecum because it has the largest diameter. Cecum surgery must
be done before perforation begins otherwise it will become
complicated
Caused by distension of organs
o Poorly localizing because it is innervated by autonomic nerve
fibers vague and poorly localized to the midline (epigastrium,
periumbilical region or hypogastrium) depending on the origin from
the primitive foregut, midgut or hindgut
Solid organ visceral pain in the abdomen is located in the
quadrant of the involved organ (e.g. liver pain is across the
RUQ)
Small Bowel Obstruction poorly localized periumbilical pain
Colonic Pain centered between umbilicus and pubis symphysis
Pancreatitis - epigastric pain radiating to the back Renal Colic -
colicky pain radiating to the groin
Visceral Pain
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Pain perceived at a site distant from the primary affected organ
Due to convergence of afferent fibres from separate areas in
the
posterior horn of the spinal cord o RIGHT SHOULDER liver, gall
bladder (cholecystitis), right
hemidiaphragm via C3 to C5 nerve roots o LEFT SHOULDER heart,
tail of pancreas (pancreatitis),
spleen, left hemidiaphragm o SCROTUM and TESTES ureter via
splanchnic nerves of T11-
L1 or hypogastric plexus of S2-S4
Diffuse, mild, dull discomfort Vomiting usually precedes the
onset of pain Diffuse, non-specific abdominal tenderness No rebound
tenderness and no muscle guarding
Relieved by antacids: Peptic Ulcer Disease o Will not be
relieved by Proton-Pump Inhibitors right away
Aggravated by movement: Peritonitis Aggravated by fatty food
intake: Biliary Tract Disease o Bile is released from the
gallbladder and if there is a stone
obstructing the cystic duct the pressure inside the gallbladder
increases and causes a colicky pain in the RUQ.
Eating worsens the pain: pain of bowel obstruction, biliary
colic, pancreatitis, diverticulitis, or bowel perforation
Eating relieves the pain: nonperforated peptic ulcer disease or
gastritis
NAUSEA, VOMITING, HEMATEMESIS
o Upper abdomen is distended, lower abdomen is scaphoid may be
due to gastric outlet obstruction patient will vomit (Vomitus is
white due to gastric acid. No staining of bile since the food has
not passed through the pylorus since there is an obstruction)
o Patient with pancreatic cancer, large enough to obstruct the
duodenum patient will vomit (Vomitus is bile-stained due to
secretion of bile by the gall bladder at the second part of the
duodenum; Importance: helpful in diagnosis and planning the
patients treatment. An obstruction in the duodenum will have a
harder surgical procedure - Whipples procedure)
o Relationship to other symptoms Medical Abdomen Vomit FIRST,
then PAIN
(Found in conditions like gastroenteritis) Surgical Abdomen PAIN
first, then VOMIT
(stimulation of the medullary efferent fibers that are triggered
by visceral afferent pain fibers); peritoneal irritation leads to
rebound tenderness and muscle guarding; thus, always an indication
for surgery!
FEVER - Sign of an inflammatory process (RLQ without fever - Not
appendicitis)
From the lecturer: The earlier, the more proximal the lesion:
obstruction in the esophagus, once patient swallows, vomit
immediately. If obstruction in the pylorus because of peptic ulcer
disease, will vomit only when stomach gets filled Not sure of
diagnosis? Need more observation this is the time to request for
diagnostic tests. However, if patient presents with a history
compatible with abdominal aortic anerysm, dont request for a CT
scan because patient will die in the CT scan room. Exigent time of
abdominal catastrophy BOWEL MOVEMENT
o Change in color of feces (Clay-colored: obstruction of the
biliary tree since bile cannot pass through)
o Consistency o Constipation: mechanical obstruction or
peristalsis o Diarrhea: infectious enteritis, inflammatory
bowel
disease or parasitic contamination o Bloody: as above or due to
ischemia o No need to smell
From the lecturer: Patient complains of pencil shaped stools:
obstructing lesion is in the descending colon (cecum: liquid stool;
rectum: solid stool because of small hole) URINARY SYMPTOMS
o Frequency o Hematuria o Change in color of urine (Tea-colored:
beginning
jaundice; ask for RUQ pain) ANOREXIA, WEIGHT LOSS From the
lecturer: 70 year old patient presents with colicky abdominal pain
(gradually progressive) distending abdomen with moderate to severe
weight loss for several weeks. Think of Malignancy: what tests:
colonoscopy or CT scan? Not only to diagnose the disease but to
help plan the mode of tratement. If surgery, when and what.
GYNECOLOGIC SYMPTOMS Sexual Activity Amenorrhea Vaginal Bleeding
Vaginal Dischage Amenorrhea Day of Cycle
Hypertension, Coronary Artery Disease: patient with
subendocardial infarcts usually presents with epigastric pain.
The worse thing that you can do is manage patient with peptic ulcer
dse instead of infarcts
Atrial fibrillation 10/10 abdominal pain with a soft abdomen; no
other physical examination findings (vascular emergency); if bowel
develops gangrene develop generalized muscle perforation guarding
and distended abdomen (important to diagnose patient with atrial
fibrillation: SURGERY!!)
o Infarction atrial fibrillation can throw an embolus into the
superior mesenteric artery infartcion of the small bowel
(important: past health history and medication history); pulse is
regularly irregular, severe pain without obvious peritoneal
irritation, think of a vascular problem because this will dictate
the tempo of how to manage the patient
Referred Pain
Non-surgical causes of Abdominal Pain
Aggravating and Alleviating Factors
Associated Signs and Symptoms
Menstrual History for women in the Reproductive age group
Medical History
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Pulmonary Disease Previous surgery colicky abdominal pain
presenting with
intestinal obstruction; 2-3 times surgery in the past;
intestinal obstruction secondary to adhesions
Alcohol history acute liver hepatitis might be mistaken for
gallstones
Smoking History Drug Abuse
IV. PHYSICAL EXAMINATION General Examination: Vital signs - will
tell you the degree of dehydration of patient
and possible atrial fibrillation. Patient vomiting with
tachycardia and hypotension means patient is severely
dehydrated.
Look for signs of pallor if suspecting ectopic pregnancy or
abdominal aneurysm
Acetone smell- medical emergency not sugrical Examination of
chest and heart Abdominal examintaion Patient is agitated nd unable
to lie still visceral pain;
suggestive of hollow viscus obstruction and strangulation
Patient is lying motionless in bed parietal pain; suggestive of
peritonitis Patient is drowsy with decreased responsiveness
suggestive of
hemodynamic instability and/or sepsis Expose from nipple to
mid-thigh Check for abdominal distention and/or swelling
Look for scars, fistulae, sinuses Check for istended superficial
veins Ecchymosis: Cullens sign hemmorahhguc pancretitis
Gray-Turners sign
Figure 5. Ecchymosis
Check for peritoneal irritation Presence of cough tenderness,
rebound tenderness (can also be
elicited by percussing), involuntary muscle guarding (for
children: tickle and then touch both sides of the abdomen; If left
side relaxes and right side remains hard involuntary)
Pinpoint the area of maximal tenderness Check for organomegaly
Check for the presence of tympani (presence of gas) Check for
shifting dullness
Figure 6. Palpation of the Abdomen
Perform superficial and deep palpation Use the pulp of the
fingers and not the tip Examine the most tender area last Perform
percussion if possible
Auscultate away from pain just like when you palpate to avoid
more pain the area
Watch out for incarcerated hernia (seen in the scrotum) in the
elderly with abdominal distention High-pitched tinkling sounds
suggestive of intestinal
obstruction Hypoactive bowel sounds enteritis and intstinal
ischemia Absent bowel sounds check for 1-2min (dont just
multipy;
listen for thw whole 2mins before declaring absent bowel
sounds)
V. EVALUATION AND DIAGNOSIS A. Laboratory Studies
Considered routine in evaluation of a patient with an acute
abdomen
Help in confirmation of inflammation or infection present Aid in
elimination of some of the most common nonsurgical
conditions o Hemoglobin level (CBC) and White blood cell count
with
differential valuable because most patients with acute abdomen
will
have leukoytosis or bandemia o Electrolyte, BUN, creatinine
levels
Assist in evaluating the effect of factors: vomiting or third
place fluid losses
May suggest an endocrine or metabolic diagnosis as the cause
o Amlyase and Lipase may suggest pancreatitis but can also be
elevated in
disorders, such as small bowel infarction or duodenal ulcer
perforation
normal levels do not exclude pancreatitis as a possible
diagnosis caused by effects of chronic inflammation on enzyme
production and timing factors
o Liver function tests (Total and direct bilirubin, serum
aminotransferase, alkaline phosphatase level) for evaluating
potential biliary tract causes
Inspection of the Abdomen
Palpation of the Abdomen
Auscultation of the Abdomen
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o Urinalysis In diagnosis of bacterial cystitis, pyelonephritis
and certain
endocrine abnormalities (e.g. diabetes, renal parenchymal
disease)
Urine culture- confirms suspected UTI and direct antibiotic
therapy but cannot be done in time to be helpful in the evaluation
of acute abdomen
o Urine human chorionic gonadotropin (HCG) level Suggest
pregnancy as a confounding factor in the patients
presentation or aid in decision making on therapy o Occult blood
test
Can be helpful in evaluation but nonspecific o Stool test
for ova and parasite evaluation C. difficile culture and toxin
assay
Helpful if diarrhea is a component of the patients
presentation
Improvements in imaging techniques resulted in more rapid
operative correction of the problem, with less morbidity and
mortality
No imaging technique can replace a careful history and physical
examination
X-Ray
Figure 1.1. Upright chest radiograph depicting moderate sized
pneumoperitoneum (Intestinal contents in chest space)consistent
with
perforation of abdominal viscus. Detects pneumoperitoneum (free
air in peritoneal cavity)
o In upper right chest radiographs as little as 1 ml o In
lateral decubitus (left side down) abdominal radiographs
in patients who cannot stand; 5- 10 ml o Air will insinuate in
between the liver and diaphragm, let
the patient stay in lateral decubitus for a few minutes so that
air can go up
o Helpful in patients suspected of having perforated duodenal
ulcer, 75% of these patients will have visible pneumoperitoneum
Show abnormal calcifications o 5% of appendicoliths
o 10% of gallstones o 90% renal stones o Pancreatic
calcifications with chronic pancreatitis,
calcification in abdominal aortic aneurysm, visceral artery
aneurysm, atherosclerosis in visceral vessels
Identifies gastric outlet obstruction and obstruction of
proximal, mid, or distal small bowel in upright and supine
abdominal radiographs (step ladder sign airfluid levels- only seen
in upright position)
Can also aid in determining if complete or partial small bowel
obstruction presence or absence of gas.
Differentiation of colonic gas from small intestinal gas,
obstruction of colon presence of haustral markings
Suggest volvulus of the cecum or sigmoid colon o Cecal comma
shape, with concavity facing inferiorly
and to the right o Sigmoid bent inner tube, with its apex in the
upper
quadrant
Figure 1.2. Upright abdominal x-ray with an obstructing sigmoid
adenocarcinoma. Note the haustral markings on the dilated
transverse colon that distinguished this from small
intestine
Figure 1.3. Supine abdominal x-ray (air fluid levels are not
seen). Patient with intestinal obstruction. Note distended (air
filled) loops of bowel with thickened bowel walls.
B. Imaging Studies
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Figure 1.4. Omega sign () Sigmoid volvulus
Figure 1.5. Upright abdominal x-ray with sigmoid colon volvulus.
Note the characteristic appearance of bent inner tube, with its
apex in the right upper
quadrant
Ultrasound Accurate for detecting gallstones and assessing
gallbladder wall
thickness and presence of fluid around the gallbladder
Determines diameter of extrahepatic and intrahepatic bile ducts
but limited to detect common bile stones
Detects intraperitoneal fluid Presence of intestinal air limits
the ability to evaluate the
pancreas or other abdominal organs Can differentiate gas from
fluid, like for diagnosing abscess
which is a fluid filled cavity with gas, gallbladder is also
fluid filled
Indications for Emergency Ultrasound o Detection of Acute
Cholecystitis, pancreatitis, liver abscess o Appendicitis,
appendicial abscess, diverticular abscess,
mesenteric cyst, tubo-ovarian abscess, pelvic abscess o Useful
in pregnant and young patient o Patients with suspected AAA
(Abdominal Aortic Aneurysm) o Diagnosis of free intraperitoneal
fluid
Figure 1.6. Thick walled, fluid filled appendix with
surrounding
inflammation
Figure 1.7. Large appendicular abscess containing gas
Figure 1.8. Pancreatic necrosis lack of gland enhancement
following IV contrast administration is diagnostic. Pancreas is
hardly visualized
Figure 1.9. Acute pancreatitis enlarged pancreas with indefinite
border and
infiltration of the surrounding fat (peri-pancreatic
stranding)
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CT scan More widely available and less likely to be hindered
by
abdominal air Secondary imaging modality of choice following
plain abdominal
radiography Well performed CT using oral, rectal, and IV
contrast is highly
accurate for evaluating disease such as appendicitis, while dual
contrast CT scanning for small bowel injury following blunt trauma
Excellent for differentiating mechanical small bowel
obstruction from paralytic ileus and identify transition point
in mechanical obstruction.
Figure 2.0. CT scan with partial small bowel obstruction. Note
presence of dilated small bowel and decompressed small bowel.
The decompressed bowel contains air, indicating a partial
obstruction
VI. CATEGORIES AFTER INITIAL EVALUATION
Patients with immediate life-threatening conditions Abdominal
Crisis abdominal problem is life-threatening to the
patient o Massive Intra-abdominal bleeding (aneurysm,
ruptured
ectopic pregnancy, spontaneous rupture of liver or colon) must
act immediately, lest patient might die of exsanguination
o Acute intestinal ischemia with hypovolemia with uncontrolled
acidosis the longer you wait -> the more extensive formation
gangrene -> might lose all of the bowel
o Intra-abdominal sepsis uncontrolled abdominal infection
Medical Crisis
o Myocardial infarction o Tension pneumothorax o Diabetic
ketoacidosis
Life-threatening conditions needs urgent laparotomy the more you
wait, the more peritoneal soilage will happen -> lead to shock
and death., so early operation is needed o Perforated hollow
viscera o Strangulated bowel o Intra-abdominal abscess with
generalised peritonitis
VII. ALGORITHMS FOR ACUTE ABDOMINAL PAIN A. ACUTE ONSET, SEVERE,
GENERALIZED PAIN
Figure 2.1: Algorithm for treatment of acute onset, severe,
generalized abdominal pain. NG nasogastric tube; NL normal study.
Peritoneal signs include: peritonitis, rebound tenderness,
involuntary muscle guarding
B. GRADUAL ONSET, SEVERE, GENERALIZED PAIN
Figure 2.2: Algorithm for the treatment of gradual onset,
severe, generalized abdominal pain. ERCP endoscopic retrograde
cholangiopancreatography;
LFT liver function tests.
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C. RIGHT UPPER QUADRANT PAIN (RUQ PAIN)
Figure 2.3: Algorithm for the treatment of right upper quadrant
abdominal
pain. US - ultrasound
Differential diagnoses for RUQ Pain: o Pyelonephritis or
nephrolithiasis, hepatic abscess,
pulmonary embolus, pneumonia or musculoskeletal o May include
other causes found in the epigastrial region:
cardiac origin, esophageal inflammation or perforation,
gastritis, PUD, biliary colic, pancreatitis
D. LEFT UPPER QUADRANT PAIN (LUQ PAIN)
Figure 2.4: Algorithm for the treatment of left upper quadrant
pain.
Differential diagnoses for LUQ Pain:
o Ruptured spleen, splenomegaly, gastric ulcer
E. RIGHT LOWER QUADRANT PAIN (RLQ PAIN)
Figure 2.5: Algorithm for the treatment of right lower quadrant
pain.
Differential diagnoses for RLQ Pain:
o Meckels diverticulum, Crohns disease, diverticulitis,
salpingitis, ectopic pregnancy
F. LEFT LOWER QUADRANT PAIN (LLQ PAIN)
Figure 2.6: Algorithm for the treatment of left lower quadrant
abdominal pain.
VIII. DIFFERENTIAL DIAGNOSIS
All patients must be seen, evaluated immediately on presentation
and reassessed at frequent intervals for changes in condition.
Requires a comprehensive knowledge of the medical and surgical
conditions that create acute abdominal pain.
Peritoneal lavage can provide information that suggests
pathology requiring surgical intervention. The lavage can be
performed under local anesthesia at the patients bedside. This can
provide sensitive evidence of hemorrhage or infection, as well as
some types of solid or hollow organ injury.
Patients having emergency or life threatening surgical disease
are taken for immediate laparotomy; urgent diagnoses allow time for
stabilization, hydration, and preoperative preparation, as
needed.
Hospitalized patients who do not go urgently to the OR must be
reassessed frequently, preferably by the same examiner, to
recognize potentially serious changes in condition that could alter
diagnosis or suggest development of complications.
Laboratory and imaging studies should never replace the bedside
clinical judgment of an experienced surgeon.
Patients are more likely to be seriously or fatally harmed by
delaying surgical treatment to perform confirmatory tests than by
misdiagnoses discovered at operation.
IX. INDICATORS FOR URGENT LAPAROTOMY
Increasing severe localized tenderness (e.g supperative
appendicitis becomes gangrenous -> lead to rupture)
Progressive tense abdominal distention when there is severe
obstruction
Spreading involuntary muscle rigidity peritoneal irritation is
spreading due to bowel movement, which will spread the
infection
High fever, tachycardia, confusion marked leukocytosis with
shift to the left pneumoperitoneum (see figure 1.1)
All of these need urgent laparotomy
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Serious conditions Needs early planned surgery or close
monitoring
o acute appendicitis depends on the stage; how long the patient
is having pain. Theres a need to hydrate the patient before doing
surgeryl for the patients optimal condition.
o diverticulitis, diverticular abscess, tubo-ovarian abscess
load the patient with antibiotics and hydrate the patient
o localized intra-abdominal or pelvic abscess o small bowel
obstruction o large bowel obstruction
Less serious conditions
which require conservative treatment o biliary colic, renal
colic o inflammatory bowel disease o non-specific abdominal pain o
gastroenteritis, infective colitis o urinary tract infection o
uncomplicated ovarian cyst o ruptured graaffian follicle o
uncomplicated diverticular disease o most medical causes of
abdominal pain
Some special Cases
Meckels Diverticulum o Presents as lower GI bleeding, sometimes
with pain just like
appendicitis o If a patient diagnosed to have appendicitis but
when
examined surgically to have a normal looking appendix, you have
to examine the distal 2 ft (ileum), especially in a young
patient
Volvulus of Meckels Diverticulum
o A gangrenous twisted Meckels diverticulum
Twisted Ovarian Cyst: Gangrenous
Ruptured Ectopic Pregnancy o Massive bleeding; patient will die
of insanguination
Sigmoid Volvulus
o Sigmoid becomes gangrenous due to loss of blood supply
Infarcted Bowel o Caused by an embolus in the tributaries o If
detected early, might save the bowel by doing an
embolectomy o A progressive gangrenous process
X. SUMMARY
Importance of accurate history taking and complete PE Early
decision whether the patient needs urgent surgery More important to
detect immediate life threatening
conditions than arriving at the correct diagnosis even if you
dont have the correct diagnosis, it is better to have a live
patient with an unsure diagnosis rather a dead patient
The diagnosis in an early abdominal pain is difficult. Need to
re-examine the patient after adequate resuscitation
Define surgical from non-surgical abdomen Make the patient
comfortable and pain-free if possible
give pain relievers
Opioids dont mask physical signs or prevent accurate
diagnosis
Think of the more common surgical conditions first not the 1%
incidence of abdominal pain. In UERM, most common surgery performed
is cholecystectomy which is presented as a RUQ pain.
SAMPLE QUESTIONS
1. This aspect in the physical examination of the abdomen is
done last in patients presenting with abdominal pain. a.
Auscultation b. Inspection c. Palpation d. Testing fluid wave
C 2. A 33 year old male came in for blood-streaked stools
associated with crampy abdominal pain, nausea and diarrhea. He has
mild direct and rebound tenderness over the left side of the
abdomen. Rectal examination shows blood-streaked mucoid stools in
the examining finger. He is most probably suffering from: a.
Diverticular disease of the colon b. Amoebic infection of the colon
c. Neoplasm of the colon d. Internal hemorrhoidal disease
C 3. A 55-year-old female who is diagnosed to have chronic
cholecystitis with lithiasis in the past presents with RUQ pain,
jaundice and fever. Which test will help in accurately determining
the present problem?
a. Elevated transaminases b. Reduced prothrombin time non
responsive to IV Vitamin K c. CBD dilation with intraluminal shadow
d. Elevated bilirubin levels
C 3. True of abdominal pain a. Always present in abdominal
diseases b. First symptom in abdominal problems that are medical in
nature c. Maybe the presenting symptom of myocardial infarct d.
Most common symptom seen in patients in emergency room
D 4. Midureteral stones are found in: a. Upper abdominal b.
Peri-abdominal c. Lower abdominal d. None of the above
C 6. Somatic type of chain is characterized by which of the
following? a. The sensation travels through the ANS. b. It is the
type of pain that one experiences when an inflamed appendix
touches the anterior parietal peritoneum. c. It is difficult to
localize. d. It usually precedes visceral pain in all inflammatory
conditions in the
abdomen. B
7. 45 y/o, male, with a history of exploratory laparoscopy 5
years PTA. Chief complaint is colicky abdominal pain. Which will
indicate that he has an infarcted bowel?
a. Hyperactive bowel sounds b. Distended abdomen c. Local area
of tenderness d. All of the above
8. A 45 y/o female with sudden crampy epigastric pain with right
upper quadrant pain which radiated to the right shoulder,
aggravated by deep inspiration. What is the best diagnostic
technique for this? a. Auscultation of bowel sounds b.
Determination of liver size and calculation of Liver Span c.
Eliciting Rovsings Sign d. Eliciting Murphys Sign
C
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9. Which of the following is the MOST common manifestation of
Peptic Ulcer Disease (PUD)? a. Early satiety b. Epigastric pain c.
Post prandial vomiting d. Gaseousness feeling after a meal
B 10. Which of the following can explain the occurrence of
referred pain? a. Stimulation of nerve fibers of the same
embryologic origin b. Stimulation of nerve fibers with similar
receptors c. Convergence of nerve fibers at the spinal cord d.
Stimulation of nerve fibers of an organ adjacent to the diseased
organ
C 11. A 55 year old alcoholic diagnosed to have a duodenal ulcer
by upper gastrointestinal endoscopy, complains of severe epigastric
pain which later becomes generalized. Which among the following
findings will help us in the diagnosis? a. Generalized ileus on KUB
b. A distended loop of bowel on the RLQ c. Lucency below the left
diaphragm above the gastric bubble d. Presence of a distended
stomach
C 12. A 50 year old male patient came in because of colicky
abdominal pain of several hours duration associated with decrease
in passage of flatus. Which of the following clinical findings can
help us in the diagnosis of the present condition? a. The presence
of a globular abdomen b. Hypoactive bowel sounds c. A midline
incision scar d. History of an alcoholic binge the night before
C 13. Visceral type of pain can be characterized by which of the
following: a. It can be localized easily by the patient b. It
usually is associated with a solid organ involvement c. May be due
to muscular contraction d. Is usually accompanied by fever upon
presentation
C 14. A 44-year-old female patient was diagnosed to have
gallstones in the gallbladder. The pain history of this patient
will most likely be characterized as: a. Waves of dull pain
associated with vomiting b. Acute wave of constricting pain c.
Sharp pain worsened by movement d.Tearing pain
B 15. A 65-year-old male woke up during the early hours of the
morning due to
severe epigastric pain. Based on the history alone, which of the
following is the most likely cause of his pain?
a. Ureteral colic b. Acute Pancreatitis c. Biliary colic d.
Perforated peptic ulcer disease
D 16. A 44-year-old female diagnosed to have gall bladder stones
by ultrasound
a year ago came in because of right upper quadrant pain after
eating a fatty meal which was later on associated with radiation to
the back after several hours. She might be suffering from:
a. Acute cholecystitis b. Choledocholelithiasis c. Biliary
pancreatitis d. Acute cholangitis
A 17. A 25 year old male presents with nausea and vomiting and
after three hours develops generalized abdominal pain. Based on
this history alone, this patient might be suffering from: a.
Typhoid ileitis b. Acute appendicitis c. Acute gastroenteritis d.
Urinary tract infection
C
18. A In a male patient who comes in for a possible acute
appendicitis, which of the following is more specific for acute
appendicitis
a. Presence of fever b. Presence of leucosytosis c. Presence of
RLQ direct and rebound tenderness with involuntary muscle
guarding d. Presence of generalized ileus seen of plain
abdominal x-ray exam
C 19. Right upper quadrant intermittent pain, jaundice and
acholic stools
suggest which of the following: a. Viral hepatitis b. Biliary
obstruction c. Pancreatitis d. Cholecystitis
B 20. A 53 year old male consults for epigastric pain associated
with nausea and
a feeling of gaseous distention relieved by burping after the
Christmas holidays. The appropriate approach in the management
is:
a. Treat symptomatically and work-up only if the symptoms
persist b. Obtain serum amylase and lipase levels c. Request for an
abdominal ultrasound d. Do an upper GI endoscopy and barium
swallow
A 21. A 65-year-old male woke up during the early hours of the
morning due to
severe epigastric pain. Based on the history alone, which of the
following is the most likely cause of his pain?
a. Ureteral colic b. Acute Pancreatitis c. Biliary colic d.
Perforated peptic ulcer disease
D 22. A 44-year-old female diagnosed to have gall bladder stones
by ultrasound
a year ago came in because of right upper quadrant pain after
eating a fatty meal which was later on associated with radiation to
the back after several hours. She might be suffering from:
a. Acute cholecystitis b.Choledocholelithiasis c. Biliary
pancreatitis d. Acute cholangitis
A
20 Things That Mentally Strong People Dont Do 1. Dwelling On The
Past 2. Remaining In Their Comfort Zone 3. Not Listening To The
Opinions Of Others 4. Avoiding Change 5. Keeping A Closed Mind 6.
Letting Others Make Decisions For Them 7. Getting Jealous Over The
Successes Of Others 8. Thinking About The High Possibility Of
Failure 9. Feeling Sorry For Themselves 10. Focusing On Their
Weaknesses 11. Trying To Please People 12. Blaming Themselves For
Things Outside Their Control 13. Being Impatient 14. Being
Misunderstood 15. Feeling Like Youre Owed (Life Owes You) 16.
Repeating Mistakes 17. Giving Into Their Fears 18. Acting Without
Calculating 19. Refusing Help From Others 20. Throwing In The
Towel
One reason people resist change is because they focus on what
they have to give up instead of what they have to gain.