++
Classically, the initial symptom is poorly localized abdominal pain around the epigastrium or umbilicus. Later, the pain shifts from the periumbilical or epigastric region to the right lower quadrant over McBurney's point. Anorexia, nausea, vomiting, and a low-grade fever are typical features as well, but do not have to be present. Abdominal tenderness and guarding in the right lower quadrant are characteristic on physical examination. Variations from the classical picture are common, especially in retrocecal appendicitis, where the pain commonly remains poorly localized. Laboratory testing may show a moderately elevated white cell count. Individual clinical and laboratory descriptors are weak discriminators of appendicitis if used independently.
++
Abdominal CT has become a widely accepted tool in the evaluation of patients with possible appendicitis (see Figure 15–5C). The sensitivity and specificity of the abdominal CT scan with oral and IV contrast in the evaluation of appendicitis are 93 and 93%, respectively. Rectal contrast seems to show the highest sensitivity at 97%. Scans performed without any contrast have a sensitivity of 92.7%, with a specificity of 96.1%. Ultrasonography of the appendix may be helpful either as an initial test pre-CT or if the diagnosis is uncertain. Sensitivity and specificity are 83 and 93%, respectively. In skilled hands, a positive ultrasound may be used to avoid unnecessary CT scanning, but a negative one is insufficient to rule out the disease.
+++
Treatment and Disposition
++
The patient should be hospitalized and prepared for surgery. Administer appropriate analgesia and intravenous crystalloid solution to replace any volume deficits. For intact appendices, only perioperative antibiotics are required. However, a ruptured appendix will require IV antimicrobial therapy continuing well into the hospital stay.
Anderson BA, Salem L, Flum DR: A systemic review of whether oral contrast is necessary for the computed tomography diagnosis of appendicitis in adults. Am J Surg 2005;190(3):474–478
[PubMed: 16105539]
.
Doria AS, Moineddin R, Kellenberger CJ et al: US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 2006;241(1):83–94
[PubMed: 16928974]
.
Hlibczuk V, Dattaro JA, Jin Z et al: Diagnostic accuracy of noncontrast computed tomography for appendicitis in adults: a systematic review. Ann Emerg Med 2010;55(1):51–59
[PubMed: 19733421]
.
+++
Intestinal Obstruction
++
The patient usually complains of intermittent, poorly localized, crampy pain that tends to be associated with altered bowel function. Change in character to constant and severe pain may be a sign of perforation or bowel ischemia. Vomiting is frequently bilious and will be feculent with distal and long-standing obstruction. On examination, the abdomen is typically distended and tender with auscultation of high-pitched bowel sounds. Bowel sounds may be absent in ileus or distal obstruction. Dilated loops of bowel with air–fluid levels on flat and upright abdominal X-rays support the diagnosis (see Figure 15–3). Occasionally, X-ray findings are absent, and the diagnosis is based on clinical suspicion or abdominal CT scan with oral contrast.
+++
Treatment and Disposition
++
Nasogastric suction and intravenous hydration should be initiated with electrolyte monitoring. Early surgical consultation is important. The patient should be hospitalized for further evaluation and possible surgery. Some cases will resolve without surgery.
+++
Perforated Peptic Ulcer
++
Perforation of a peptic ulcer usually causes sudden severe upper abdominal pain. The pain of perforation may subside when peritoneal secretions dilute the leaking gastric contents. However, it will later return, progressively worsening. Referred shoulder pain may occur secondary to diaphragmatic irritation. The patient is usually in severe distress with shallow breathing and knees drawn up to the chest in an effort to minimize pain. Upper abdominal tenderness is accompanied by board-like rigidity of the abdomen. Evaluation of any perforation should include a three-view acute abdominal series including an upright chest, as well upright and lateral decubitus abdominal films. This may show free air under the diaphragm (Figure 15–6). When abdominal radiographs are non-diagnostic and perforation is suspected, abdominal CT scan with oral and intravenous contrast can be diagnostic (see Chapter 16).
++
+++
Treatment and Disposition
++
Insert a nasogastric tube for drainage of gastric acid. Administer crystalloid solution intravenously to correct volume depletion. Initiate broad-spectrum intravenous antibiotics (Table 15–1). Hospitalize for immediate surgery.
+++
Perforation of the Bowel
++
Perforation of the bowel is accompanied by sudden or explosive onset of severe, agonizing mid- or lower-abdominal pain. Shock may be present and can be profound. Nausea and vomiting are common. The abdomen is rigid and tender. Fever may be high and is often accompanied by leukocytosis. A history of diverticulitis can often be elicited. As above, a three-view abdominal series should be ordered and will show similar findings.
+++
Treatment and Disposition
++
Treat shock with intravenous crystalloids. Obtain blood and urine cultures. Begin antimicrobials (see Table 15–1). Hospitalize for immediate surgery.
Langell JT, Mulvihill SJ: Gastrointestinal perforation and the acute abdomen. Med Clin North Am 2008;92:599–625
[PubMed: 18387378]
.
++
Patients typically report lower abdominal pain that is gradual in onset. The pain tends to localize to the left lower quadrant with associated tenderness, but may be midabdominal or in the right lower quadrant. Fever is typically of low grade, and may be accompanied by a mild leukocytosis. Other findings may include abdominal tenderness, a palpable abdominal mass, alterations in bowel function (either constipation or frequent defecation), and heme-positive stools. Plain films are usually normal or nonspecific; the diagnostic procedure of choice is abdominal CT scan.
+++
Treatment and Disposition
++
Most patients should be hospitalized for administration of intravenous fluids, IV antimicrobial treatment (see Table 15–1), and further observation. A subset of reliable patients in which peritoneal signs, intractable vomiting, and signs of systemic infection are absent may be candidates for outpatient treatment with oral antibiotics provided good follow-up is possible. Both gram negative aerobic and anaerobic bacteria should be covered.
+++
Intestinal Strangulation
++
Intestinal strangulation occurs most frequently in volvulus or femoral hernia and occasionally in inguinal hernia. Onset of pain is usually rapid. Pain increases in severity and may be intermittent and colicky. The patient may complain of an urge to defecate. The abdomen is distended, rigid, and diffusely tender. Exquisite tenderness is present in the region of strangulation. Shock appears early. Other findings usually include nausea and vomiting, high fever, and leukocytosis. In the case of volvulus, findings on abdominal X-ray may be diagnostic. Additional imaging options include CT scan and barium enema.
+++
Treatment and Disposition
++
The patient should be hospitalized and prepared for surgery immediately.
++
++
The patient complains of mild to severe cramping and pain that may have come on gradually or abruptly. There may be nausea and vomiting, retching, and diarrhea, in any combination. These symptoms usually precede the onset of pain, in contrast to conditions requiring surgery, in which pain is usually the first symptom. Abdominal examination reveals generalized discomfort. Also in contrast to situations requiring surgery, involuntary guarding, localized tenderness, and peritoneal signs are absent. Fever is generally not present or mild, although patients with shigellosis typically have high fever and rigors. The patient may be dehydrated. Stool should be tested for blood, examined microscopically for leukocytes, and sent for culture if the patient has prolonged or severe diarrhea associated with fever.
+++
Treatment and Disposition
++
Severely ill or dehydrated patients should be hospitalized. Mild to moderately ill patients can be sent home with instructions for rehydration. If symptoms persist or worsen, patients should receive follow-up evaluation.
+++
Inflammatory Bowel Disease
++
The patient typically complains of abdominal cramps and intermittent bloody diarrhea. A history of previous episodes may be given, and a long history of colitis may be present. Weight loss, fever, and anemia may be present. Cramps may develop gradually or suddenly. Abdominal examination will vary with etiology and severity of disease. Infectious causes (eg, Shigella sp., Clostridium difficile, Campylobacter sp., Entamoeba histolytica) should be systematically ruled out.
+++
Treatment and Disposition
+++
For the Seriously Ill Patient or for Uncertain Diagnosis
++
Treat hypotension or shock with administration of intravenous crystalloids. Give nothing by mouth. Nasogastric suction may be helpful if the patient is vomiting, in addition to antiemetics. Abdominal radiographs or CT scan may provide important information about possible complications such as perforation, bowel obstruction, toxic megacolon, or intraperitoneal abscess. Hospitalize the patient for definitive diagnosis and treatment. Indications for hospitalization are uncertain diagnosis, shock, fever, toxic megacolon, anemia, or gross blood in the stool. Surgical consultation should be obtained for significant hemorrhage, perforation, abscesses, or toxic megacolon.
+++
For the Ambulatory Patient with Certain Diagnosis
++
For patients under the care of a gastroenterologist, discuss the options with the patient's physician regarding outpatient treatment with oral antibiotics, steroids, and other antiinflammatory medications such as sulfasalazine. Patients with mild to moderate disease may be restarted on maintenance therapy or have their currently therapy modified.
Baumgart DC, Sandborn WJ: Inflammatory bowel disease: clinical aspects and established and evolving therapies. Lancet 2007;369:1641–1657
[PubMed: 17499606]
.
+++
Hepatobiliary Disorders
++
Biliary colic is due to intermittent obstruction of the biliary tree, usually at the cystic duct, by stones. The pain occurs in discrete episodes (frequently after ingestion of food), which usually begin abruptly and subside gradually over a few hours. During an attack, persistent abdominal pain extends all the way across the upper abdomen but tends to be more severe on the right. Pain may be referred to the scapula. A careful history often reveals prior attacks of similar pain. Abdominal examination shows right upper quadrant tenderness and, occasionally, a palpable gallbladder. A right upper quadrant sonogram will show gallstones (see Figure 15–7) or a dilated gallbladder or cystic duct. Dilation of the common bile duct is commonly seen with choledocholithiasis.
++
+++
Treatment and Disposition
++
In the absence of acute cholecystitis, ascending cholangitis, choledocholithiasis, or pancreatitis, no specific immediate treatment is required. However, pain should always be brought under control. Patients must also be able to tolerate oral hydration and nutrition. Refer for possible elective cholecystectomy and provide appropriate analgesics and antiemetics.
++
Acute cholecystitis presents very similarly to biliary colic, but the patient's symptoms become persistent and more severe. The discomfort may be moderate to severe and prostrating with associated anorexia, nausea, and vomiting. Low-grade fever and leukocytosis are usually present. In some cases, the gallbladder is palpable.
++
Ultrasonography of the abdomen demonstrating gallstones, dilatation of the intra or extrahepatic bile ducts or thickening of the gallbladder wall, and pericholecystic fluid (if present) confirms the diagnosis of acute cholecystitis. Ultrasonography is the preferred diagnostic technique because it is sensitive, specific, rapid, inexpensive, and without adverse effects. A sonographic Murphy's sign, specific tenderness of the gallbladder noted during the ultrasound examination, has a sensitivity of 88% and a specificity of 80% for acute cholecystitis. A recent prospective analysis of bedside ultrasound showed similar sensitivity and specificity to that of an ultrasound done in radiology. Nonvisualization of the biliary tract on nuclear imaging (HIDA) is also diagnostic.
+++
Treatment and Disposition
++
Give nothing by mouth. Insert a nasogastric tube and attach it to continuous suction if the patient is vomiting. Anti-emetics typically have little effect in these patients. Give intravenous crystalloids and parenteral analgesics. Administer empiric antibiotics if the patient has systemic signs of infection such as fever. Hospitalize and obtain surgical consultation.
Caddy GR: Gallstone disease: symptoms, diagnosis and endoscopic management of common bile duct stones. Best Pract Res Clin Gastroenterol 2006;20(6):1085–1101
[PubMed: 17127190]
.
Summers SM, Scruggs W et al: A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med 2010;56:123–125
[PubMed: 20138397]
.
+++
Acute Suppurative Cholangitis
++
Acute suppurative cholangitis, a complication of cholecystitis, is a surgical emergency commonly accompanied by bacteremia and septic shock. Symptoms include abdominal pain, jaundice, fever, mental confusion, and shock. The classic Charcot triad of fever, jaundice, and right upper quadrant pain is seen in 50–70% of patients. The addition of shock and mental confusion (Raynaud's Pentad) is rare with an incidence of only 3.5–7.7%. Right upper quadrant sonography is the diagnostic procedure of choice and may show dilated, obstructed intrahepatic biliary ducts.
+++
Treatment and Disposition
++
Severity has recently been divided into three grades. Grade I responds to initial medical treatment. Grade II does not respond, but does not show signs of organ dysfunction. Grade III is associated with dysfunction in at least one organ system (ie requiring a vasopressor for blood pressure support).
++
Treat shock with intravenous crystalloids. Administer broad-spectrum antimicrobials intravenously. Insert a Foley catheter to monitor urine output. Emergent surgical consultation should also be obtained.
Lee JG: Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol 2009;6:533–541
[PubMed: 19652653]
.
Wada K, Takada T, Kawarada Y et al: Diagnostic criteria and severity assessment of acute cholangitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg 2007;14:52–58
[PubMed: 17252297]
.
++
When liver abscess results from other intra-abdominal infections (a pyogenic abscess), increasing toxicity with high fever, chills, nausea, vomiting, jaundice, and a deteriorating clinical picture are seen. Right upper quadrant pain may be present. Patients typically present acutely, however, a chronic onset with hepatomegaly may be seen.
++
With primary (amebic) liver abscesses (caused by E. histolytica), onset is insidious and it may be several weeks before the disease becomes fulminant. High fever and leukocytosis often accompany the abscess. The liver becomes enlarged and is often tender. Many patients with amebic liver abscesses do not have intestinal amebiasis; hence, stool examination for parasites is not helpful. Right upper quadrant sonography, CT scan, or liver scan is diagnostic. CT-guided aspiration also can assist in diagnosis.
+++
Treatment and Disposition
++
Hospitalize the patient immediately for evaluation and treatment by percutaneous drainage or surgical exploration. Obtain blood for culture and amebic serology and initiate antimicrobial therapy.
Krige JE, Beckingham IJ: ABC of diseases of the liver, pancreas, and biliary system, liver abscesses and hydatid disease. Br Med J 2001;322:537–540
[PubMed: 11230072]
.
++
The majority of cases of hepatitis are asymptomatic. When symptomatic, it is often manifested with anorexia, abdominal pain, malaise, nausea and vomiting, and dark urine. Fever, jaundice, and hepatomegaly are also usually present. Liver function tests show elevated bilirubin and hepatic enzymes (AST [SGOT], ALT [SGPT], and alkaline phosphatase). The white cell count is low or normal. Coagulation studies should also be checked as hepatitis can lead to coagulopathy. If acetaminophen toxicity is a possibility, serum levels should be ordered.
++
The most common causes are viral infection and alcohol. The history, physical examination, and amino-transferase levels can be used to differentiate viral and alcoholic hepatitis. In alcoholic hepatitis, AST (SGOT) levels are the same or higher than ALT (SGPT) levels. With viral hepatitis, the opposite is true.
+++
Treatment and Disposition
++
Most cases of hepatitis are treated symptomatically, giving fluids and antiemetics, as well as correcting any electrolyte imbalances. Stable patients can be referred to a primary-care physician and receive treatment at home. The patient should be instructed to maintain hydration, strict hygiene, and to avoid potential hepatotoxins (alcohol or acetaminophen). Severely ill patients with persistent vomiting, dehydration, hypoglycemia, hepatic encephalopathy, or significant coagulopathy (prothrombin time > 15) should be hospitalized. With suspected acetaminophen-toxicity, N-acetylcysteine should be given (see Chapter 47).
Stravitz TR: Critical management decisions in patients with acute liver failure. Chest 2008
;134:1092–1102
[PubMed: 18988787]
.
+++
Ruptured Aortic Aneurysm
++
Rupture of an abdominal aneurysm is accompanied by severe abdominal pain of sudden onset that often radiates into the back. In some patients, pain is confined to the flank, low back, or groin. Syncope, usually secondary to blood loss and lack of cerebral perfusion, often occurs as well. After the initial hemorrhage, pain may lessen and faintness may disappear, but these symptoms recur and progress until shock finally supervenes. While dissection is occurring, a discrete pulsatile abdominal mass or unequal lower extremity pulses may be palpated. If rupture occurs in the retroperitoneum, a poorly defined midabdominal fullness, periumbilical ecchymosis (Cullen sign), or flank ecchymosis (Grey–Turner's sign) may be noted. Bedside ultrasound can rapidly confirm the diagnosis (see Figure 15–8), but ruptured aneurysms are difficult to visualize and may still be missed. Most patients with a leaking or ruptured abdominal aortic aneurysm are too unstable to be diagnosed by CT scan. A chest X-ray should also be obtained to evaluate the thoracic aorta.
++
+++
Treatment and Disposition
++
++
Obtain intravenous access in the form of at least two large-bore peripheral catheters or a central venous catheter. Collect necessary laboratory studies, including type and crossmatch for packed red blood cells. Treat shock with intravenous crystalloids followed by whole blood as soon as available. Obtain immediate surgical consultation, as mortality is virtually 100% without surgical intervention.
Assar AN, Zarins CK: Ruptured abdominal aortic aneurysm: a surgical emergency with many clinical presentations. Postgrad Med J 2009;85:268–273
[PubMed: 19520879]
.
Chaikof EL, Brewster DC, Dalman RL et al: The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines. J Vasc Surg 2009;50(4 Suppl):S2–S49
[PubMed: 19786250]
.
++
The pain is abrupt in onset, of varying degrees of severity, and may be localized or diffuse. A history of similar attacks is often present. Most patients present with sudden cramping abdominal pain and diarrhea. Exam may reveal mild to moderate tenderness to palpation over the affected area. Rectal exam shows hemoccult positive stool. Severe colitis is usually accompanied by bloody diarrhea and may present with peritoneal signs. Ischemic areas may progress to gangrene if the ischemia is sufficiently severe; if ischemia is milder, the areas may heal, often with stricture formation.
++
Routine laboratory tests do not show specific abnormalities. Confirmatory studies include sigmoidoscopy or colonoscopy, barium enema, and visceral angiography. CT is the most often utilized imaging modality.
+++
Treatment and Disposition
++
Treat shock and hemoconcentration with intravenous crystalloids. Administer appropriate antimicrobials (see Table 15–1). Hospitalize for further diagnostic testing and possible surgery.
Theodoropoulou A, Koutroubakis IE. Ischemic colitis: clinical practice in diagnosis and treatment. World J Gastroenterol 2008;14(48):7302–7308
[PubMed: 19109863]
.
++
The patient usually complains of the sudden onset of severe, diffuse abdominal pain in the mid- or lower abdomen. The pain is poorly localized, out of proportion to examination, and severe, often not relieved by narcotics. Onset can be variable in thrombotic, versus embolic, source of ischemia. Nausea, vomiting, and diarrhea, with gross or occult blood in the stool, may be present. Initially, physical findings are frequently absent. As the condition progresses, abdominal distention and signs of systemic toxicity develop. Marked leukocytosis, hemo-concentration, azotemia, and acidosis are commonly associated with mesenteric ischemia. Whereas traditional angiography has been the historic gold standard, CT angiogram has increased in popularity since the onset of multi-row detector CT. Additional findings available by CT (such as bowel wall thickening or organ infarction) have lead to a sensitivity and specificity of 96 and 94%, respectively.
+++
Treatment and Disposition
++
Hospitalize and obtain immediate surgical consultation. Treat shock and hemoconcentration with intravenous crystalloids and administer antimicrobials (see Table 15–1).
Herbert GS, Steele SR, (et al): Acute and Chronic Mesenteric Ischemia. Surg Clin North Am. 2007; 87:115–1134, (PMID:17936478)
+++
Rupture of the Spleen
++
++
The spleen is the intra-abdominal solid organ most commonly injured in blunt trauma, with rupture usually due to trauma to the left lower rib cage. Occasionally, the spleen may rupture after trivial or overlooked injury, usually when pathologic enlargement has occurred (eg, infectious mononucleosis, AIDS, leukemia). Blood leaking into the peritoneal cavity causes abdominal pain and tenderness that may radiate to the left side of the neck or left shoulder (Kehr's sign). However, patients occasionally present without abdominal symptoms.
++
Tachycardia, hypotension, and falling hematocrit are present, and shock may develop. Palpation of the left upper quadrant or left 9th and 10th ribs may reveal tenderness. Splenomegaly is also a common feature. Emergent bedside ultrasound, specifically the FAST examination (Chapters 6 and 25), can rapidly identify intraperitoneal fluid, which in the setting of blunt trauma must be assumed to represent blood. CT scan of the abdomen is useful for diagnosis and grading of splenic injury severity in stable patients. CT may demonstrate active extravasation if ongoing bleeding is occurring.
+++
Treatment and Disposition
++
Obtain large-bore intravenous access, collect necessary laboratory studies, and treat shock with intravenous crystalloids. When available, administer packed red blood cells for further resuscitation. Hospitalize all patients with major splenic injury or rupture. Hemodynamically stable patients with less severe splenic injuries may be observed nonoperatively. Patients with hypotension and shock require emergent splenectomy.
Renzulli P, Hostettler A, Schoepfer AM et al: Systematic review of atraumatic splenic rupture. Br J Surg 2009;96(10):1114–1121
[PubMed: 19787754]
.
++
++
Renal colic is usually characterized by sudden, severe flank pain, often radiating laterally around to the groin, followed by hematuria. A constant, dull ache between episodes may be present. Associated nausea, vomiting, and restlessness are common. A history of passage of stones may be present. The patient is often in severe, writhing pain. Examination reveals costovertebral angle tenderness with a relatively benign abdominal examination. Urinalysis is the first step, providing useful information about the presence of blood, crystals, and/or infection. It can be followed by a urine culture if infection is suspected. Imaging is not always necessary if the patient has a history of stones and a clinical diagnosis can be made. Abdominal X-ray will frequently reveal renal calculi, as most, but not all, are radiopaque. Nonconstrast helical CT scan of the abdomen (with 5 mm or less slices) has replaced the intravenous pyelogram as the standard diagnostic modality for the evaluation of renal colic (Figure 15–9). It is helpful in identifying the size and location of ureteral stones. Another benefit of noncontrast CT scan is that alternative diagnoses such as appendicitis or diverticulitis may be identified.
++
+++
Treatment and Disposition
++
Pain can often be controlled with NSAIDs or narcotics. Oral (if possible) or IV fluids are also recommended. Absolute criteria for admission include obstructing stones with signs of infection, renal dysfunction related to bilateral obstruction, intractable nausea/vomiting, pain requiring parenteral analgesics, extravasation of urine, and hypercalemic crisis. Other, relative indications include obstruction high in the urinary tract, leukocytosis, renal disease, and comorbidities making outpatient treatment difficult. Patients with small stones (<5 mm) can receive treatment on an ambulatory basis, with appropriate oral analgesia, hydration, and follow-up care with a primary-care physician or urologist. Larger stones (>5 mm) may require urologic intervention.
Worcester EM, Coe FL: Nephrolithiasis. Prim Care 2008;35(2):369–391,vii
[PubMed: 18486720]
.
++
++
Patients with pyelonephritis typically have flank pain, dysuria, urinary urgency, urinary frequency, fever, and sometimes rigors. Malaise, nausea, and vomiting are commonly present as well. Tenderness is usually over the costovertebral angle or occasionally the abdomen. The pain is typically dull and gradual in onset. Urinalysis and urine culture should be obtained.
+++
Treatment and Disposition
++
A patient who is severely ill (vomiting, high fever, rigors), pregnant, very young, very old, immunocompromised, or who has known anatomic abnormalities of the genitourinary tract requires hospitalization for observation, intravenous hydration, and parenteral antibiotics. Out-patient therapy is appropriate for those who can be informed of the culture results, are tolerating oral intake and are reliable to return if their condition worsens. Sequential therapy using an initial parenteral dose of antibiotic followed by an oral regimen as an outpatient is often recommended.
Ramakrishnan K, Scheid D: Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician 2005;72(11):2182
[PubMed: 15768623]
.
++
Acute pancreatitis is characterized by acute onset of severe, unrelenting epigastric pain radiating to the back that tends to be worst when supine. Occasionally, pain can present in the right upper quadrant. Nausea and vomiting are usually present. In severe cases, the patient may be in shock. A predisposing condition (alcoholism, gallstones, glucocorticoid administration, or diabetes mellitus) may be present. Abdominal examination reveals decreased or absent bowel sounds and tenderness usually greatest in the epigastrium. Elevated serum amylase and lipase levels, mild fever, and leukocytosis are often present. As discussed previously, lipase has better specificity and sensitivity for pancreatitis than amylase. If the diagnosis is uncertain, abdominal CT scan can often demonstrate changes pathognomonic of pancreatitis with sensitivity and specificity of 87–90 and 90–92%, respectively.
+++
Treatment and Disposition
++
Initial treatment involves aggressive crystalloid infusion and appropriate parenteral analgesia. Obtain additional pertinent laboratory studies including CBC, electrolytes, glucose, calcium, LDH, and hepatic and renal function tests. Give nothing by mouth.
++
Patients with severe pain or persistent vomiting should be hospitalized for analgesia, intravenous hydration, and correction of electrolyte abnormalities. Even if they are not acutely ill, patients with no history of pancreatitis should be hospitalized for evaluation and treatment. Patients with chronic and recurrent pancreatitis may not require hospitalization if they can take fluids by mouth and do not require parenteral analgesics; these patients should be instructed to maintain a clear liquid diet and have close follow-up in 24–48 hours.
Frossard JL, Steer ML, Pastor CM: Acute pancreatitis. Lancet 2008;371(9618):143–152
[PubMed: 18191686]
.
+++
Gynecologic Disorders
++
+++
Ectopic Pregnancy with Rupture
++
An ectopic pregnancy should be considered in any woman of child-bearing age who presents with abdominal pain. The classic triad of symptoms in ectopic pregnancy (abdominal pain, amenorrhea, and vaginal bleeding or spotting) is not present consistently. Risk factors should be included in the history, including prior ectopic pregnancy, history of STDs (especially PID), smoking, IUD use, progestin-only birth control pills, and implanted progestin contraception. Prior to rupture the pain may be vague or intermittent and possibly difficult to localize. Once the ectopic has ruptured, the patient will experience sudden, continuous, and severe unilateral abdominal or pelvic pain that may be referred to the shoulder. There may be occasional nausea and vomiting, but usually no fever. Postural hypotension or shock may be found on initial examination. Pelvic examination often reveals a unilateral doughy mass and tenderness on movement of the cervix. Pelvic sonography has a sensitivity of 84.4% and a specifity of 98.9%. It may reveal free fluid and/or an adnexal mass. A quantitative serum hCG is positive in almost all cases. In the emergency department, it can be used to correlate with ultrasound results. Further, serial hCG levels can be used to followed suspected ectopic as an outpatient if diagnosis is uncertain.
+++
Treatment and Disposition
++
Treat shock or hypotension with intravenous crystalloids and blood if necessary. Hospitalize the patient for emergent surgical intervention (Chapter 38).
Nama V, Manyonda I: Tubal ectopic pregnancy: diagnosis and management. Arch Gynecol Obstet 2009;279:443–453
[PubMed: 19039599]
.
+++
Acute Salpingitis (Pelvic Inflammatory Disease)
++
++
There are a wide variety of presentations for salpingitis. Patients typically report a gradual onset of pelvic and lower abdominal pain frequently with associated vaginal discharge and/or bleeding. Headache, nausea and vomiting, and lassitude with high fever and tachycardia may also be present. Exquisite tenderness to bimanual examination is typical, particularly with cervical motion. Adnexal fullness or mass (tubo-ovarian abscess) may be present. However, these signs are neither highly sensitive nor specific. A pelvic sonogram showing a tubo-ovarian abscess is diagnostic. A serum pregnancy test should be performed in all patients.
+++
Treatment and Disposition
++
The CDC recommends empiric treatment in sexually active young women experiencing pelvic or lower abdominal pain if a cause cannot be found or if one of the following are present on pelvic exam:
++
- Cervical motion tenderness OR
- Uterine tenderness OR
- Adnexal tenderness
++
Hospitalization of patients with pelvic inflammatory disease is recommended for the following situations: diagnosis is uncertain (eg, cannot exclude appendicitis); abscess is suspected; patient has severe symptoms such as nausea, vomiting, or high fever; patient is pregnant; patient has failed outpatient treatment; patient is unable to follow up; or patient is immunocompromised (eg, HIV with low CD4 count). Surgery may be necessary if abdominal symptoms persist or if the patient's condition deteriorates.
++
See Chapter 42 for treatment regimens.
Haggerty CL, Ness RB: Diagnosis and treatment of pelvic inflammatory disease. Women's Health (Lond Engl) 2008;4(4):383–397
[PubMed: 19072503]
.
+++
Ruptured Ovarian Follicle Cyst
++
Patients with ruptured ovarian follicle cyst experience sudden, severe pelvic, or lower abdominal pain. Gastrointestinal symptoms are usually absent, and the patient is afebrile without leukocytosis. Tenderness may be elicited over the affected ovary. There should be no masses on pelvic examination, and the serum pregnancy test should be negative.
+++
Treatment and Disposition
++
Provide adequate analgesia and keep the patient under observation in the hospital until the diagnosis is confirmed. If the diagnosis can be confirmed by ultrasound and there are no other complicating factors, the patient may be discharged with close follow-up. Operation is not usually necessary.
Bottomley C, Bourne T: Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol 2009;23(5):711–724
[PubMed: 19299205]
.
++
Torsion of the ovary is characterized by sudden unilateral lower abdominal or pelvic pain of moderate or severe intensity that is often made worse by a change in position. The pain may radiate into the groin, back, or flank. Nausea and vomiting may be present. A history of ovarian abnormalities such as cysts or masses may be present. No imaging modality has been found to have excellent sensitivity or specificity. Currently, ultrasound with Doppler is the most-commonly utilized. However, negative imaging cannot rule out torsion, especially in cases with strong clinical suspicion. Surgical consultation is recommended in such cases.
+++
Treatment and Disposition
++
The patient should be hospitalized for observation and possible surgery.
Oltmann SC, Fischer A, Barber R et al: Cannot exclude torsion—a 15 year review. J Pediatr Surg 2009;44(6):1212–1217
[PubMed: 19524743]
.
++
Patients with endometriosis usually have a history of dysmenorrhea and previous cyclic attacks of cramps and pains in the lower abdomen and possibly in the flank. Pain is worse with menses. Onset of symptoms may be gradual or sudden if there is associated bleeding. Dyschezia and dyspareunia are often present. Aching pelvic discomfort and general tenderness on pelvic examination suggest endometriosis.
+++
Treatment and Disposition
++
If symptoms are mild, give the patient analgesics and refer her to the obstetrics and gynecology department for follow-up. If pain is severe, the patient should be hospitalized for evaluation and possible surgery.
Mounsey AL, Wilgus A, Slawson DC: Diagnosis and management of endometriosis. Am Fam Physician 2006;74(4):594–600
[PubMed: 16939179]
.
++
Primary peritonitis occurs almost exclusively in patients with preexisting large-volume ascites, especially those with cirrhosis or nephrotic syndrome. The symptoms and signs vary, but fever, abdominal pain, and tenderness are common. The most helpful tests are blood culture and abdominal paracentesis for Gram-stained smear, CBC, and fluid culture. A polymorphonuclear (PMN) cell count of more than 250/mm3 is highly suspicious for spontaneous bacterial peritonitis and is an indication for initiation of empiric antibiotics. Most cases of primary bacterial peritonitis demonstrate positive blood cultures, peritoneal fluid leukocyte counts over 1000/mm3 (with a predominance of PMNs), and bacteria on Gram-stained smears of culture. Peritoneal fluid smears and cultures may be negative when the disease process is present.
+++
Treatment and Disposition
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All patients with suspected or confirmed acute peritonitis should be hospitalized for diagnostic evaluation and treatment. Treat shock, if present, with intravenous crystalloids. Culture blood and peritoneal fluid first, then begin broad-spectrum parenteral antimicrobials.
Koulaouzidis A, Bhat S, Saeed AA: Spontaneous Bacterial Peritonitis. World J Gastroenterol 2010;15(9):1042–1049
[PubMed: 20143473]
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Retroperitoneal Hemorrhage
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Retroperitoneal hemorrhage is a rare condition that may occur with major trauma or secondary to minor trauma in individuals with defective clotting factors resulting from medication or disease. It may also occur after invasive femoral procedures, such as coronary artery catheterization. Back pain and abdominal pain may be present, and the psoas sign is often positive. Abdominal CT scan localizes the bleeding in most cases.
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Treatment and Disposition
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Treat shock with intravenous crystalloids and cross-matched whole blood as soon as available. Correct coagulation defects with administration of platelets or clotting factors as needed. Hospitalize patients with active hemorrhage, clotting abnormalities, or severe pain.