Abdominal pain is common and often inconsequential. Acute and severe abdominal pain, however, is almost always a symptom of intra-abdominal disease. It may be the sole indicator of the need for surgery and must be attended to swiftly: Gangrene and perforation of the gut can occur < 6 h from onset of symptoms in certain conditions (eg, interruption of the intestinal blood supply due to a strangulating obstruction or an arterial embolus). Abdominal pain is of particular concern in patients who are very young or very old and those who have HIV infection or are taking immunosuppressants.
Textbook descriptions of abdominal pain have limitations because people react to pain differently. Some, particularly elderly people, are stoic, whereas others exaggerate their symptoms. Infants, young children, and some elderly people may have difficulty localizing the pain.
abdomen /ab·do·men/ (ab´dah-men) (ab-do´men) that part of the body lying between the thorax and the pelvis, and containing the abdominal cavity and viscera.
acute abdomen an acute intra-abdominal condition of abrupt onset, usually associated with pain due to inflammation, perforation, obstruction, infarction, or rupture of abdominal organs, and usually requiring emergency surgical intervention.
carinate abdomen , navicular abdomen scaphoid a.
abdomen obsti´pum congenital shortness of the rectus abdominis muscle.
scaphoid abdomen one whose anterior wall is hollowed, occurring in children with cerebral disease.
surgical abdomen
Pathophysiology
Visceral pain comes from the abdominal viscera, which are innervated by autonomic nerve fibers and respond mainly to the sensations of distention and muscular contraction—not to cutting, tearing, or local irritation. Visceral pain is typically vague, dull, and nauseating. It is poorly localized and tends to be referred to areas corresponding to the embryonic origin of the affected structure. Foregut structures (stomach, duodenum, liver, and pancreas) cause upper abdominal pain. Midgut structures (small bowel, proximal colon, and appendix) cause periumbilical pain. Hindgut structures (distal colon and GU tract) cause lower abdominal pain.
Somatic pain comes from the parietal peritoneum, which is innervated by somatic nerves, which respond to irritation from infectious, chemical, or other inflammatory processes. Somatic pain is sharp and well localized.
Referred pain is pain perceived distant from its source and results from convergence of nerve fibers at the spinal cord. Common examples of referred pain are scapular pain due to biliary colic, groin pain due to renal colic, and shoulder pain due to blood or infection irritating the diaphragm.
Peritonitis: Peritonitis is inflammation of the peritoneal cavity. The most serious cause is perforation of the GI tract (see Acute Abdomen and Surgical Gastroenterology: Acute Perforation), which causes immediate chemical inflammation followed shortly by infection from intestinal organisms. Peritonitis can also result from any abdominal condition that causes marked inflammation (eg, appendicitis, diverticulitis, strangulating intestinal obstruction, pancreatitis, pelvic inflammatory disease, mesenteric ischemia). Intraperitoneal blood from any source (eg, ruptured aneurysm, trauma, surgery, ectopic pregnancy) is irritating and results in peritonitis. Barium causes severe peritonitis and should never be given to a patient with suspected GI tract perforation. Peritoneo-systemic shunts, drains, and dialysis catheters in the peritoneal cavity predispose a patient to infectious peritonitis, as does ascitic fluid. Rarely, spontaneous bacterial peritonitis occurs, in which the peritoneal cavity is infected by blood-borne bacteria.
Peritonitis causes fluid shift into the peritoneal cavity and bowel, leading to severe dehydration and electrolyte disturbances. Adult respiratory distress syndrome can develop rapidly. Kidney failure, liver failure, and disseminated intravascular coagulation follow. The patient's face becomes drawn into the masklike appearance typical of hippocratic facies. Death occurs within days.
Etiology
Many intra-abdominal disorders cause abdominal pain (see Fig. 1: Acute Abdomen and Surgical Gastroenterology: Location of abdominal pain and possible causes.
); some are trivial but some are immediately life threatening, requiring rapid diagnosis and surgery. These include ruptured abdominal aortic aneurysm (AAA), perforated viscus, mesenteric ischemia, and ruptured ectopic pregnancy. Others (eg, intestinal obstruction, appendicitis, severe acute pancreatitis) are also serious and nearly as urgent. Several extra-abdominal disorders also cause abdominal pain (see Table 1: Acute Abdomen and Surgical Gastroenterology: Extra-Abdominal Causes of Abdominal Pain
).
); some are trivial but some are immediately life threatening, requiring rapid diagnosis and surgery. These include ruptured abdominal aortic aneurysm (AAA), perforated viscus, mesenteric ischemia, and ruptured ectopic pregnancy. Others (eg, intestinal obstruction, appendicitis, severe acute pancreatitis) are also serious and nearly as urgent. Several extra-abdominal disorders also cause abdominal pain (see Table 1: Acute Abdomen and Surgical Gastroenterology: Extra-Abdominal Causes of Abdominal Pain).
Fig. 1
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Table 1
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Abdominal pain in neonates, infants, and young children has numerous causes not encountered in adults, including meconium peritonitis, pyloric stenosis, esophageal webs, volvulus of a gut with a common mesentery, imperforate anus, intussusception, and intestinal obstruction caused by atresia.
or
Acute abdomen etiology
- Infection
- Amebiasis, hepatitis, falciparum malaria, pneumococcal pneumonia, rheumatic fever, salmonella gastroenteritis, staphylococcal toxemia, syphilis in 'tabetic crisis,' trichinosis, TB, typhoid fever, viral enteritides, herpes zoster, infectious mononucleosis, Whipple's disease
- Inflammation
- Appendicitis, cholangitis, cholecystitis, Crohn's disease, diverticulitis, gastroenteritis, hepatitis, SLE, mesenteric lymphadenitis, pancreatitis, peritonitis due to organ perforation, perinephric abscesses, pyelonephritis, ulcerative colitis, intestinal obstruction, rheumatoid arthritis, polyarteritis nodosa, Henoch-Schönlein disease
- Intoxication
- Black widow spider bite, heavy metals, mushrooms
- Ischemia
- Renal infarction, mesenteric arterial thrombosis
- Malignancy
- Pain due to organ infarction, Hodgkin's disease ('classically' associated with alcohol ingestion), leukemia, lymphoproliferative disorders
- Metabolic disease
- Adrenal insufficiency (Addisonian crisis), DKA, familial hyperlipoproteinemia, familial Mediterranean fever, hemochromatosis, hereditary angioneurotic edema, hyperparathyroidism, hyperthyroidism, acute intermittent porphyria, uremia, substance abuse withdrawal
- Ob/Gyn
- Twisted ovarian cyst, ectopic pregnancy, endometriosis, PD
- Referred pain
- Pneumonia, MI, pleuritis, pericarditis, myocarditis, hematomata of the rectal muscle, renal colic, peptic ulcer, nerve root compression
- Trauma
- Perforation/rupture–aortic aneurysm, spleen, bladder
Evaluation
Evaluation of mild and severe pain follows the same process, although with severe abdominal pain, therapy sometimes proceeds simultaneously and involves early consultation with a surgeon. History and physical examination usually exclude all but a few possible causes, with final diagnosis confirmed by judicious use of laboratory and imaging tests. Life-threatening causes should always be ruled out before focusing on less serious diagnoses. In seriously ill patients with severe abdominal pain, the most important diagnostic measure may be expeditious surgical exploration. In mildly ill patients, watchful waiting may be best.
History: A thorough history usually suggests the diagnosis (see Table 2: Acute Abdomen and Surgical Gastroenterology: History in Patients with Acute Abdominal Pain). Of particular importance are pain location (see Fig. 1: Acute Abdomen and Surgical Gastroenterology: Location of abdominal pain and possible causes.) and characteristics, history of similar symptoms, and associated symptoms. Concomitant symptoms such as gastroesophageal reflux, nausea, vomiting, diarrhea, constipation, jaundice, melena, hematuria, hematemesis, weight loss, and mucus or blood in the stool help direct subsequent evaluation. A drug history should include details concerning prescription and illicit drug use as well as alcohol. Many drugs cause GI upset. Prednisone
or immunosuppressants may inhibit the inflammatory response to perforation or peritonitis and result in less pain and leukocytosis than might otherwise be expected. Anticoagulants can increase the chances of bleeding and hematoma formation. Alcohol predisposes to pancreatitis.
). Of particular importance are pain location (see Fig. 1: Acute Abdomen and Surgical Gastroenterology: Location of abdominal pain and possible causes.) and characteristics, history of similar symptoms, and associated symptoms. Concomitant symptoms such as gastroesophageal reflux, nausea, vomiting, diarrhea, constipation, jaundice, melena, hematuria, hematemesis, weight loss, and mucus or blood in the stool help direct subsequent evaluation. A drug history should include details concerning prescription and illicit drug use as well as alcohol. Many drugs cause GI upset. Prednisoneor immunosuppressants may inhibit the inflammatory response to perforation or peritonitis and result in less pain and leukocytosis than might otherwise be expected. Anticoagulants can increase the chances of bleeding and hematoma formation. Alcohol predisposes to pancreatitis.
Table 2
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Known medical conditions and previous abdominal surgeries are important to ascertain. Women should be asked whether they are pregnant.
Physical examination: The general appearance is important. A happy, comfortable-appearing patient rarely has a serious problem, unlike one who is anxious, pale, diaphoretic, or in obvious pain. BP, pulse, state of consciousness, and other signs of peripheral perfusion must be evaluated. However, the focus of the examination is the abdomen, beginning with inspection and auscultation, followed by palpation and percussion. Rectal examination and pelvic examination (for women) to locate tenderness, masses, and blood are essential.
Palpation begins gently, away from the area of greatest pain, detecting areas of particular tenderness, as well as the presence of guarding, rigidity, and rebound (all suggesting peritoneal irritation) and any masses. Guarding is an involuntary contraction of the abdominal muscles that is slightly slower and more sustained than the rapid, voluntary flinch exhibited by sensitive or anxious patients. Rebound is a distinct flinch upon brisk withdrawal of the examiner's hand. The inguinal area and all surgical scars should be palpated for hernias.
Red flags: Certain findings raise suspicion of a more serious etiology:
Interpretation of findings: Distention, especially when surgical scars, tympany to percussion, and high-pitched peristalsis or borborygmi in rushes are present, strongly suggests bowel obstruction. Severe pain in a patient with a silent abdomen who is lying as still as possible suggests peritonitis; location of tenderness suggests etiology (eg, right upper quadrant suggests cholecystitis, right lower quadrant suggests appendicitis) but may not be diagnostic. Back pain with shock suggests ruptured AAA, particularly if there is a tender, pulsatile mass. Shock and vaginal bleeding in a pregnant woman suggest ruptured ectopic pregnancy. Ecchymoses of the costovertebral angles (Grey Turner's sign) or around the umbilicus (Cullen's sign) suggest hemorrhagic pancreatitis but are not very sensitive for this disorder.
History is often suggestive (see Table 2: Acute Abdomen and Surgical Gastroenterology: History in Patients with Acute Abdominal Pain). Mild to moderate pain in the presence of active peristalsis of normal pitch suggests a nonsurgical disease (eg, gastroenteritis) but may also be the early manifestations of a more serious disorder. A patient who is writhing around trying to get comfortable is more likely to have an obstructive mechanism (eg, renal or biliary colic).
). Mild to moderate pain in the presence of active peristalsis of normal pitch suggests a nonsurgical disease (eg, gastroenteritis) but may also be the early manifestations of a more serious disorder. A patient who is writhing around trying to get comfortable is more likely to have an obstructive mechanism (eg, renal or biliary colic).
Previous abdominal surgery makes obstruction from adhesions more likely. Generalized atherosclerosis increases the possibility of MI, AAA, and mesenteric ischemia. HIV infection makes infectious causes and drug adverse effects likely.
Testing: Tests are selected based on clinical suspicion.
Standard tests (eg, CBC, chemistries, urinalysis) are often done but are of little value due to poor specificity; patients with significant disease may have normal results. Abnormal results do not provide a specific diagnosis (the urinalysis in particular may show pyuria or hematuria in a wide variety of conditions), and they can also occur in the absence of significant disease. An exception is serum lipase, which strongly suggests a diagnosis of acute pancreatitis. A bedside urine pregnancy test should be done for all women of childbearing age because a negative result effectively excludes ruptured ectopic pregnancy.
An abdominal series, consisting of flat and upright abdominal x‑rays and upright chest x‑rays (left lateral recumbent abdomen and anteroposterior chest x‑ray for patients unable to stand), should be done when perforation or obstruction is suspected. However, these plain x‑rays are seldom diagnostic for other conditions and need not be automatically done. Ultrasound should be done for suspected biliary tract disease or ectopic pregnancy (transvaginal probe). Ultrasound can also detect AAA but cannot reliably identify rupture. Noncontrast helical CT is the modality of choice for suspected renal stones. CT with oral contrast is diagnostic in about 95% of patients with significant abdominal pain and has markedly lowered the negative laparotomy rate. However, advanced imaging must not be allowed to delay surgery in patients with definitive symptoms and signs.
Treatment
For symptom relief, mild analgesics may be prescribed to reduce pain, however many doctors forgo prescribing painkillers since details of the pain can be useful in determining its cause. Do not take any medication such as Tylenol or ibuprofen, and do not eat or drink until you have spoken with your doctor.
Talk with your doctor about the best treatment plan for you. Depending on the underlying condition causing your acute abdomen, treatment options may include:
- Antibiotics
- Avoidance of certain foods, beverages, or medicines
- Surgery-may be required for the majority of severe abdominal pains that last for at least six hours in previously healthy patients
Prehospital/emergency department care of suspected acute abdomen
- Keep patient nil by mouth.
- Apply oxygen as appropriate.
- Intravenous (IV) fluids: set up immediately if the patient is shocked and the equipment is available. Send blood for group and save/crossmatch and other blood tests as appropriate.
- Consider passing a nasogastric (NG) tube if there is severe vomiting, signs of intestinal obstruction or the patient is extremely unwell and there is danger of aspiration.
- Analgesia: the previous practice was to withhold analgesia until surgical review, but a surgical abdomen is very painful and is likely only to be adequately relieved by parenteral opiates, e.g. morphine. One recent review showed that opiate administration may alter physical examination findings, but these changes result in no significant increase in management errors.6 Another study showed that morphine safely provides analgesia without impairing diagnostic accuracy.7 A Cochrane review also supported the use of analgesia before assessment by a surgeon.8
- Antiemetic: avoid using this as a symptomatic treatment without considering a diagnosis in a community setting.
- Antibiotics: if systemic sepsis, or peritonitis, or severe urinary tract infection (UTI) is suspected. IVcephalosporin plus metronidazole are commonly used in acutely unwell patients in whom peritonitis is suspected.
- Arrange urgent surgical/gynaecological review as appropriate.
- Arrange investigations such as ECG if a medical cause is likely.
- Admit: if surgery is considered likely, if the patient is unable to tolerate oral fluids, for pain control, if a medical cause is possible or if IV antibiotics are required.
referensi
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