Acute Abdominal Pain: Other causes Vishal Gupta, MCh Associate Professor Deptt Surg. Gastroenterology KGMU Definition Acute abdominal pain: Presentation of previously undiagnosed abdominal pain Lasting 1000 causes exist Non Specific AP (34%) Acute appendicitis (28%) Acute cholecystitis (10%) Small Bowel Obstruction (4%) Perforated PU (3%) Pancreatitis (3%) Diverticular disease (2%) Others (13%) Pathophysiology Visceral pain Distention, inflammation or ischemia in hollow viscous & solid organs Localization depends on the embryologic origin of the organ: Foregut to epigastrium Midgut to umbilicus Hindgut to the hypogastric region Pathophysiology Parietal pain : is localized to the dermatome above the site of the stimulus. Referred pain: produces symptoms, not signs e.g. tenderness Generalized AP Perforation Abdominal Aortic Aneurysm Acute pancreatitis DM: DKA Bilateral pleurisy Central AP Early appendicitis Small Bowel Obstruction Acute gastritis Acute pancreatitis Ruptured AAA Acute mesenteric thrombosis Epigastric pain Duodenal / gastric ulcer Esophagitis Biliary colic Acute pancreatitis AAA RUQ pain Gallbladder disease DU Acute pancreatitis Pneumonia Subphrenic abscess LUQ pain Gastric Ulcer Pneumonia Acute pancreatitis Subphrenic abscess Suprapubic pain Acute urinary retention UTIs Cystitis PID Ectopic pregnancy Diverticulitis RIF pain Acute appendicitis Mesenteric adenitis (young) Perforated duodenal ulcer Diverticulitis PID, Salpingitis Ureteric colic Meckels diverticulum Ectopic pregnancy Crohns disease LIF pain Diverticulitis Constipation Irritable Bowel Syndrome PID Rectal Ca Ulcerative colitis Ectopic pregnancy Loin pain Muscle strain UTIs Renal stones Pyelonephritis Key points on history Site of pain Nature & character Duration Intensity Precipitating & relieving factors Associated symptoms Associated symptoms Fever Nausea/vomiting Genitourinary Gynaecological Vascular History Previous episodes of Acute Pancreatitis Investigations Operations Chronic disease Immunosuppression Medications (NSAIDs) Physical examination Observation Bending Forward: acute Pancreatitis Jaundiced: CBD obstruction Dehydrated: Peritonitis, Small Bowel obstruction Systemic Examination Abdomen: Inspection - Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction) Systemic Examination Palpation Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like indicates peritonitis. Systemic Examination Local Right Iliac Fossa tenderness: Acute appendicitis Acute Salpingitis Low grade, poorly localized tenderness: Intestinal Obstruction Tenderness out of proportion to examination: Mesenteric Ischemia Acute Pancreatitis Flank Tenderness: Perinephric Abscess Retrocaecal Appendicitis Important Signs Sign Finding Association Cullens sign Bluish periumbilical discoloration Retroperitoneal haemorrhage Kehrs sign Severe left shoulder pain Splenic rupture Ectopic pregnancy rupture McBurneys Tenderness located 2/3 distance from anterior iliac spine to umbilicus on right side Appendicitis Murphys sign Abrupt interruption of inspiration on palpation of right upper quadrant Acute cholecystitis Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis Obturators sign Internal rotation of flexed right hip causing abdominal pain Appendicitis Grey-Turners Discoloration of the flank Retroperitoneal haemorrhage Chandelier sign Manipulation of cervix causes patient to lift buttocks off table Pelvic inflammatory disease Rovsings sign Right lower quadrant pain with palpation of the left lower quadrant Appendicitis Physical examination Auscultation Bowel Sounds 2min to confirm absent High pitched, hyperactive or tinkling Bruit in epigastrium Systemic Examination PR Examination: - tenderness - induration - mass - frank blood Systemic Examination PV Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour Initial management Resuscitation & analgesia (opioid IV) Full monitoring (including Urine Output) Low threshold in seeking senior help Investigations CBC Amylase, Lipase(Pancreatitis) LFTs KFT Serum Electrolytes Glucose ABG ECG Cardiac enzymes (if appropriate) Investigations Radiology Erect CXR Supine AXR USG X ray abdomen: acute intestinal obstruction ERECT SUPINE CT scan MRI/MRCP Imaging Laparoscopy Early diagnostic laparoscopy may result in: accurate, prompt, efficient management of AAP Re