Chapter 15. Abdominal Pain

See Figure 15–1.

Perform a Brief Examination

First, determine if the patient is stable or not. Distinguishing stability or instability is best performed pragmatically through multiple, simultaneous steps.

1. Look at the patient and identify if the patient is ill appearing.

2. Evaluate responsiveness, focusing on eye opening, and verbal and motor responses.

3. Assess airway, breathing, and circulation.

4. Record and review a complete set of vital signs.

5. Gauge perfusion to the brain and extremities.

6. Continue the physical examination with inspection of the abdomen, looking for signs of an acute abdomen: rebound tenderness, board-like rigidity or guarding, or an obvious pulsatile mass.

7. If appropriate, perform a rectal examination earlier than later, inspecting for blood.

8. In the acute patient, emergency bedside ultrasound is helpful in identifying aortic aneurysm/dissection, intraperitoneal fluid, and/or IVC collapse (volume status).

9. If instability is confirmed, measures to stabilize the patient must be taken immediately.

Caution—A number of patients presenting to the ED with abdominal pain will have a source of that pain outside the abdomen, anatomically, as when epigastric or upper abdominal pain is caused by an acute myocardial infarction, pulmonary embolus, or pneumonia. Occasionally, abdominal pain is due to a metabolic derangement, as is the case with diabetic ketoacidosis. In brief, the differential diagnosis should extend beyond intra-abdominal pathology.

Identify Candidates for Urgent Surgery

Some patients with abdominal pain will require surgical evaluation. Those requiring early surgical evaluation or intervention include patients with an acute abdomen, a pulsatile abdominal mass, or shock with abdominal pain. If hypotension or hemodynamic instability is present with abdominal pain, especially with gastrointestinal bleeding or a rigid abdomen, there is a strong possibility of underlying life-threatening pathology, and surgical consultation should be immediately sought. One of the most critical decisions an ED physician can make is whether a surgeon should be involved or not. Therefore, it is of paramount importance to consider this question early and frequently throughout the evaluation.

Treat Shock

Treat hypotension or frank shock (Chapter 11).

1. Give oxygen at a rate of 2–10 L/min by nasal cannula or mask. Keep oxygen saturation above 95%.

2. Insert two large-bore (≥16-gauge) intravenous catheters in an upper extremity.

3. Obtain blood for a complete blood count (CBC) with differential, serum electrolyte measurements, lipase measurement, renal function tests, liver function tests, serum pregnancy test, serum lactate, and a rapid bedside glucose test. Also, send a tube of blood for typing and crossmatching.

4. Consider emergency bedside ultrasound to evaluate for free intraperitoneal fluid and aortic aneurysm.

5. Immediately begin rapid infusion of crystalloid solution. Titrate rate of infusion to the blood pressure; initially, give a 1-L bolus over 10–20 minutes (adult dose). Remember to exercise caution in patients with congestive heart failure.

6. Insert a urinary catheter to monitor urine output, a sensitive indicator of visceral blood flow. Send a urine sample for analysis.

7. Obtain a blood gas to assess the patient's acid–base status and overall physiologic condition.

8. Insert a nasogastric tube if the patient shows evidence of intestinal obstruction. Also consider NG placement if peritonitis, severe ileus, or gastrointestinal bleeding are suspected.

9. Obtain a 12-lead ECG and begin continuous cardiac monitoring.

10. If bacterial peritonitis or perforated viscous is suspected, begin broad-spectrum antibiotics after appropriate cultures have been obtained (Table 15–1).

Note: Persistent shock despite fluid resuscitation in the patient with acute abdominal pain requires urgent laparotomy. Some patients will not be such that they can be stabilized prior to surgical intervention and must be taken for emergency intervention despite instability. Early surgical consultation is imperative.

1This chapter is a revision of the chapter by Melissa Platt, MD, Samir Doshi, MD, & Eric Telfer, MD, from the 6th edition.

After the patient has been stabilized, reassess as described below unless immediate surgery is required (Table 15–2).

The importance of a good, thorough history cannot be overemphasized. The initial assessment and plan will be based on the physician's initial “stability” assessment and the meticulous history obtained thereafter. That history is crucial in helping the physician decide what laboratory and radiographic studies to acquire, what the differential diagnosis is, whether the patient needs surgical evaluation, whether the patient requires admission, etc.

History

The approach offered here is intended for nontraumatic abdominal pain. A history of abdominal trauma requires a different diagnostic approach, which has been discussed in Chapter 25. Pelvic pain in the female has been discussed in more detail in Chapter 38.

Mode of Onset of Abdominal Pain

See Figure 15–2 and Table 15–2.

Abrupt Onset

The abrupt onset of severe abdominal pain should suggest a vascular accident or a rupture of a hollow viscus, especially if its severity is maximal at onset. On the other hand, pain that begins abruptly, but is only moderately severe at the time of onset, and worsens rapidly with time suggests neprholithiasis, acute pancreatitis, mesenteric thrombosis, or small-bowel strangulation. If the pain is of lower abdominal or pelvic origin, ruptured ectopic pregnancy or ovarian follicle cyst should also be considered in females (Chapter 38).

Gradual Onset

Gradual onset of slowly worsening pain is the characteristic of peritoneal inflammation or infection. Patients with appendicitis or diverticulitis often report a gradual onset of pain that escalates.

Character of Pain

See Figure 15–2.

Severe Pain

Severe abdominal pain may be caused by many conditions, including renal colic, biliary colic, and various vascular conditions such as myocardial infarction, mesenteric ischemia, and rupture of an abdominal aortic aneurysm. Other conditions that cause severe pain include acute pancreatitis, perforation of a hollow viscus, and peritonitis.

Dull Pain

Dull, vague, poorly localized pain is typically gradual in onset. When these two findings are coupled, they suggest an inflammatory process or a low-grade infection, appendicitis, or diverticulitis, for example.

Intermittent Pain with Cramps

Intermittent, crampy abdominal pain is common in gastroenteritis. Crampy pain that occurs in regular cycles, rising and falling in a crescendo fashion, is more characteristic of a mechanical small-bowel obstruction, especially if pain-free intervals are present.

Absence of Pain

Occasionally, a patient will complain of a sense of abdominal fullness with a notion that a bowel movement will provide relief. A bowel movement, whether spontaneous or induced, usually fails to relieve discomfort, however. This is known as the “gas stoppage” sign and is characteristic of retrocecal appendicitis. It may also be present when any inflammatory lesion is walled off from the free peritoneal cavity.

Location of Pain

The parietal peritoneum is innervated by somatic nerve fibers, producing pain that is generally well localized. In contrast, pain arising from visceral fibers alone tends to be poorly localized. Common examples of conditions associated with visceral pain sensation are hollow viscus distention and visceral ischemia.

Localized Abdominal Pain

(See Table 15–2.) In general, when abdominal pain becomes localized, it does so over or near the involved viscus, the right lower quadrant pain of appendicitis or the right upper quadrant pain of cholecystitis, for example. On the other hand, anatomic variants (eg, retrocecal appendix) must be kept in mind, and one must maintain a wide differential, considering all the possible etiologies of the pain.

Radiation of Pain or Shift in Localization

Radiation of pain or shift in localization of pain has particular diagnostic significance.

Shoulder Pain

Ipsilateral diaphragmatic irritation by air, blood, or infection in the peritoneal cavity can cause shoulder pain. A classic example is cholecystitis, which may be associated with right shoulder pain.

Diffuse Periumbilical and Epigastric Pain

Diffuse periumbilical and epigastric pain that gradually localizes to the right lower quadrant is a classic sign of appendicitis. With early appendicitis, only the visceral peritoneum surrounding the appendix is inflamed, and the localization is therefore poor. As the inflammation spreads to the parietal peritoneum, the pain localizes to the right lower quadrant. The retrocecal appendix, which is found in 15% of cases, is an important exception, with pain remaining poorly localized secondary to lack of parietal peritoneum involvement.

Pain Radiating from the Flank

Pain radiating from the flank to the groin or genitalia usually signifies ureteral colic, as seen in urolithiasis. The physician must also consider testicular pathology such as testicular torsion in any male patient with abdominal pain, whether that pain radiates to the groin or not.

Anorexia, Nausea, and Vomiting

Anorexia, nausea, and vomiting are common with abdominal pain, especially abdominal pain having its source in the upper abdomen; nonetheless, severe intra-abdominal processes can occur without any of these symptoms. For example, one may retain a normal appetite with appendicitis if the appendix is isolated from the peritoneum, as may be the case with a retrocecal appendix or an appendix that is isolated by omentum.

Nausea and vomiting are infrequently the initial or dominant symptoms with surgical acute abdomen, making these symptoms preceding abdominal pain more indicative of less acute conditions such as food poisoning, gastroenteritis, acute gastritis, and acute pancreatitis. However, these symptoms may have developed after initial onset of pain in abdominal emergencies by the time the patient has sought medical attention.

Fever and Rigors

Fever is common with many causes of abdominal pain, usually suggesting infection. Fever with continual rigors is most common in infections of the biliary and urinary system (eg, cholangitis and pyelonephritis). Fever with chills, jaundice, and hypotension suggests suppurative cholangitis, a surgical emergency. High fever with peritoneal signs in a female patient with no apparent general systemic illness otherwise is suggestive of acute salpingitis with pelvic peritonitis. Interestingly, appendicitis with high fever and rigors is uncommon unless peritonitis, most likely from viscus perforation, has developed. Recall that absence of fever is common in the elderly and immunosuppressed patients.

Diarrhea, Constipation, and Obstipation

Constipation and obstipation may suggest intestinal obstruction or ileus but are usually not the primary symptoms in acute surgical intra-abdominal disease. Diarrhea, though common with gastroenteritis, is a nonspecific symptom that can be associated with colitis, diverticulitis, appendicitis, and salpingitis.

Physical Examination

The basic steps of the physical examination of the acute abdomen are outlined in Table 15–3. Remember that physical findings may be subtle in elderly or immuno-compromised patients.

Inspection

The abdominal examination starts with visual inspection of abdomen and external genitalia. Significant findings include masses, distention, pregnancy, previous surgical scars, ecchymosis, a board-like abdomen, and stigmata of severe hepatic disease.

Auscultation

While a silent abdomen, ie, complete absence of audible peristalsis, is thought to signify diffuse peritonitis, peristalsis may persist in the face of established peritonitis. Also, note that because peristalsis is related to meal intake, it may be necessary to listen for as long as 2–3 minutes to establish the absence of peristalsis, especially in those who have not eaten in quite a while. In general, it must be understood that auscultation may be less contributory to diagnosis, especially with findings of absent or normal bowel sounds. Even so, high-pitched bowel sounds can be suggestive of bowel obstruction.

Palpation

Examine Hernial Rings and Genitalia

Examine the inguinal and femoral canals and the genitalia, primarily looking for incarcerated hernias that may be causing intestinal obstruction. This must be done by asking the patient to cough but should be done gently so as to cause as little discomfort as possible. It is optimal if this portion of the examination can take place with the patient standing as well.

Elicit Cough Tenderness

In most acute inflammatory conditions arising within the abdomen, coughing elicits pain in the involved area. Directing the patient to point one finger to the area of pain provides objective localization of the lesion. With this information, the examiner can proceed to examine the abdomen and deliberately examine last the area now known to be most tender.

Feel for Spasm of Rectus Abdominis Muscle (Guarding)

The next step is to establish the presence or absence of true muscle spasm by gently depressing the rectus abdominis muscle without causing pain. Have the patient flex their knees at 90° to aid in relaxation of the abdominal muscles. The patient is then asked to take a long, slow breath. If the spasm is voluntary, the muscle will immediately relax underneath the gentle pressure of the palpating hand. If there is true spasm, the muscle will remain taut and rigid through the respiratory cycle. This maneuver alone may be sufficient to establish the presence of peritonitis.

Except for rare neurologic disorders, renal colic, or rectus muscle injury, only peritoneal inflammation produces abdominal muscle rigidity. In renal colic, the spasm is confined to the entire rectus muscle on the involved side. This distinction is important because marked rigidity of the entire length of one rectus muscle with relaxation of the opposite rectus cannot occur in peritonitis as the peritoneal cavity is not compartmentalized. In generalized peritonitis, both muscles are usually involved to the same degree.

Perform One-Finger Palpation

Abdominal tenderness must be assessed with one finger, because it is impossible to localize peritoneal inflammation accurately if palpation or tenderness is done with the entire hand. Careful one-finger palpation, beginning as far away as possible from the area of tenderness elicited by coughing and gradually working toward it, will usually enable the examiner to delineate the area of abdominal tenderness precisely. In early acute appendicitis, this area is often no larger than 2–3 cm in diameter. Diffuse abdominal tenderness without involuntary rigidity of musculature suggests gastroenteritis or some other inflammatory process of the intestines without peritonitis. It is helpful if the examiner divides the abdomen into four quadrants during this section of the examination and tries to localize the area of pain.

Do not test for peritoneal inflammation by looking for classic rebound tenderness (deep palpation of the abdomen with abrupt release). This maneuver yields little additional information, often causes considerable discomfort, and may limit further examination.

Look for Costovertebral Angle Tenderness

Gentle percussion of the costovertebral angles should follow palpation. This should elicit pain in individuals with pyelonephritis, retroperitoneal abscesses, and retrocecal appendicitis. Excessively vigorous percussion is not helpful in localizing tenderness and may limit further examination.

Perform Deep Palpation

Having established the presence or absence of muscular rigidity and localized the area of tenderness, the examiner now palpates more deeply for the presence of abdominal masses. Often, it is difficult to perform a reliable physical examination of the abdomen in an anxious patient. Some patients are so anxious that they begin to guard with voluntary contraction of the abdominal musculature before the examiner performs even light palpation. This barrier to palpation can occasionally be overcome by palpating with a stethoscope during auscultation of bowel sounds or by asking the patient to flex the legs at the hips and knees.

Among the more common lesions identifiable by careful palpation in patients with acute abdominal pain are the distended, tender gallbladder found in acute cholecystitis, the right lower quadrant tender mass of appendicitis with early abscess formation, the left lower quadrant mass of sigmoid diverticulitis, and the midline pulsatile mass of abdominal aortic aneurysm.

Percussion

Percussion aids in determining size and density of underlying matter. It can be used in estimation of liver, spleen, or bladder size and in differentiating etiologies of abdominal distention, specifically organomegaly, ascites, and obstruction.

Special Signs

Several maneuvers in physical examination may help localize an acute abdominal lesion.

Iliopsoas Sign

The patient flexes the thigh against the resistance of the examiner's hand. A painful response indicates an inflammatory process involving the psoas muscle.

Obturator Sign

The patient's thigh is flexed to a right angle and gently rotated, first internally and then externally. If pain is elicited, an inflammatory lesion involving the obturator muscle (pelvic appendicitis, diverticulitis, pelvic inflammatory disease) is present.

Murphy's Sign (Inspiratory Arrest)

As the patient takes a slow, deep breath, the examiner elicits an abrupt cessation in inspiration by deep palpation of the right upper quadrant. This finding is suggestive of cholecystitis.

Pelvic and Rectal Examination

The importance of pelvic and rectal examination cannot be overstressed. The pelvic examination in women provides essential information not revealed by other maneuvers. Evaluation of lower abdominal pain in women is discussed further in Chapter 38.

Examination of stool for gross or occult blood must be considered in patients with abdominal pain. Occult blood may result from intestinal tumors, inflammatory bowel disease, ischemic bowel disease, and lesions of the upper gastrointestinal tract. More specifically in men, rectal examination plus simultaneous lower abdominal palpation often reveals masses or localized pain not disclosed by abdominal examination alone.

Bedside Abdominal Ultrasound

Bedside ultrasound is increasingly used as an adjunct to the physical exam in the emergency department. It is now a required component of training for all emergency medicine residencies. Uses include:

1. Focused Abdominal Sonography for Trauma (FAST exam).

2. Identification of free peritoneal fluid including blood, pus, or ascites.

3. Measurement of the cross-sectional abdominal aortic diameter to identify dissection or aneurysm.

4. Transvaginal and/or transabdominal ultrasound for identification of an intrauterine pregnancy, ectopic pregnancy, and other anatomic gynecological pathologies.

5. Identification of gall stones, a dilated common bile duct, or pericholecystic fluid.

6. Evaluation for hydronephrosis.

7. Testing of IVC collapse to evaluate intravascular volume status.

Such testing will be increasingly widespread as the skills required become commonplace among emergency physicians.

Laboratory Examination

CBC with differential, lipase measurements, and urinalysis are indicated in most cases. Electrolyte determinations and tests of renal function are especially important if vomiting, diarrhea, hypotension, or shock are present. Liver function testing can be helpful in patients with suspected liver or gallbladder disease.

Blood Count

The hematocrit reflects changes both in plasma volume and red cell volume. It is diagnostically most useful if markedly elevated (indicating dehydration) or depressed (indicating anemia). Furthermore, the hematocrit can be followed to assess for, or estimate the degree of, blood loss. The hematocrit should be corrected toward normal values in preparation for surgery in hemodynamically unstable patients.

The white cell count may be helpful if it is significantly elevated. However, it is neither sensitive nor specific. Normal or even low counts can occur in established peritonitis or sepsis (although usually with a marked shift to the left), and elevated counts may occur in gastroenteritis. A shift to the left on a blood smear may be a clue to an inflammatory reaction in the presence of a normal or only moderately elevated white count. Recall that in elderly and immunosuppressed patients the count may be low or normal.

Serum Amylase and Lipase

Patients with abdominal pain and elevated lipase usually have acute pancreatitis. Although serum amylase is often still obtained, lipase is both more sensitive and specific than serum amylase and has greater diagnostic value. Serum amylase may also be elevated in other conditions such as obstruction, mesenteric ischemia, perforated viscus, renal failure, ectopic pregnancy. If pancreatitis is suspected, ordering lipase alone may be sufficient. Unfortunately, the degree to which either marker is elevated cannot predict the severity of the condition or any associated complications of pancreatitis.

Hepatic Function Tests

Hepatic function testing is indicated for patients who have right upper quadrant pain or tenderness, jaundice, light-colored stools, or tea-colored urine and for patients in whom hepatitis is a possibility.

Urine

Urinalysis (including microscopic examination of the sediment) is critical in ruling out urinary tract infection, urolithiasis, and uncontrolled diabetes. Low urine specific gravity associated with severe vomiting may be the earliest clue to renal disease. While hematuria strongly suggests urolithiasis, urolithiasis with complete obstruction of the ureter is occasionally associated with normal results on urinalysis.

Positive findings on urinalysis require cautious evaluation. Lower abdominal inflammatory conditions such as appendicitis or pelvic inflammatory disease can cause pyuria, and there are countless etiologies for hematuria.

Serum Electrolytes and Tests of Renal Function

Serum electrolyte determinations and tests of renal function are required to document the nature and extent of fluid losses if vomiting or diarrhea has been significant or if the illness has lasted for more than 48 hours with diminished oral intake. An elevated blood urea nitrogen may also be noted with gastrointestinal bleeding.

Pregnancy Test

A pregnancy test should be obtained in all women of childbearing age unless pregnancy is physically impossible (eg, complete hysterectomy and bilateral oophorectomy). Women with a history of pelvic infection, current intrauterine device use, prior ectopic pregnancy, and failed tubal ligation are at increased risk for ectopic pregnancy.

Electrocardiogram

A 12-lead ECG should be obtained in patients with epigastric or upper abdominal pain in whom no clear cause of the pain is identified and cardiac ischemia is a possibility. This is especially true in the elderly or other populations that may have atypical presentations.

Peritoneal Fluid

In peritoneal dialysis or chronic liver disease patients, examination of the peritoneal fluid is often warranted if abdominal pain, tenderness, and fever are present.

Radiologic Examination

Radiologic examination may provide important evidence for diagnosis of acute abdominal disease. Close cooperation between the radiologist and the emergency physician is essential.

Suggested Studies

Abdominal radiographs can be helpful in the evaluation of patients with suspected bowel obstruction, volvulus, or hollow viscus perforation and in children or mentally handicapped adults with possible foreign body ingestion. Renal stones > 3 mm in size may also be seen.

Interpretation

When the films are reviewed, the following questions should be asked: (1) Are the outlines of the liver, spleen, kidneys, and psoas muscles clearly defined? (2) Are the peritoneal fat lines identifiable? (3) Is the gas pattern in the stomach, small bowel, and colon within normal limits? (4) Is there evidence of air outside the bowel or beneath the diaphragm? (5) Is there air in the biliary ducts and ductules? (6) Are there abnormal opaque shadows such as gallstones, ureteral stones, fecaliths or calcification in lymph nodes, pancreas, aorta, or other soft tissue masses?

On the basis of these observations, the following important pieces of evidence may be obtained.

Gas Patterns

Dilated loops of small bowel with air–fluid levels and no gas in the colon are indicative of small-bowel obstruction (Figure 15–3).

Cecum and Sigmoid

Marked dilatation and rotation of the cecum or sigmoid are typical of volvulus.

Dilatations

Marked dilatation of the entire colon suggests colonic obstruction. Massive dilatation of the colon in acute colitis indicates toxic megacolon. Distention of both the small and the large bowel is characteristic of ileus, peritonitis, and pseudo-obstruction of the bowel (Figure 15–4). The differentiation between distended small and large bowel may at times be difficult. In advanced cases, the clinical signs may be more reliable than X-rays in the differentiation between intestinal obstruction and peritonitis.

Air in Abnormal Locations

Except following laparotomy, laparoscopy, or recent percutaneous gastrotomy tube placement, free air under the diaphragm usually indicates a perforated viscus, most commonly seen in perforated duodenal or gastric ulcer (Figure 15–5). Massive amounts of air beneath the diaphragm suggests colonic perforation. An encapsulated air shadow outside the contours of small or large bowel may indicate localized perforation of the intestine. Air in the biliary tract is diagnostic of a free communication between some portion of the gastrointestinal tract and the biliary tree; if evidence of intestinal obstruction is also present, this pattern is the characteristic of gallstone ileus. Rarely, free air in the peritoneum, presumably from the genital tract, may be seen in asymptomatic or minimally symptomatic women with no signs of apparent underlying disease.

Calcifications and Opacities

X-rays of the abdomen may establish the presence of gallstones, ureteral stones, pancreatic calcification, retroperitoneal calcification, and vascular calcification. Such findings must be carefully correlated with the history and physical examination to establish their significance.

Special Studies

(See Table 15–4.) Special X-ray contrast studies, ultra-sonography, or computed tomography (CT) scans may be helpful.

Barium Enema

In cases of intussusception, barium or air contrast enema is diagnostic and often therapeutic. Otherwise, avoid barium enema if possible in the presence of undifferentiated acute abdominal disease and peritonitis. In rare cases, a contrast enema is necessary to establish a diagnosis of sigmoid volvulus or colonic obstruction.

Ultrasonography

Ultrasonography is a useful, noninvasive technique for evaluating the gallbladder, biliary ducts, pancreas, appendix, kidneys, abdominal aorta, and portions of the male and female reproductive tract. It is probably the best single diagnostic test for evaluating patients with right upper quadrant pain (see Table 15–4).

Computed Tomography

CT scan has emerged as a frequently used modality for diagnosis of gastrointestinal, genitourinary, and vascular pathology. Studies can be performed with or without contrast. Options for contrast enhancement include oral, rectal, intravenous, and any combination thereof. A noncontrast renal stone protocol CT scan may be performed if a physician suspects renal stones.

CT scan of the abdomen is frequently obtained to gain information about not only the solid organs and retroperitoneal structures but also the hollow organs of the abdomen. There is currently much debate over the need to IV and/or oral contrast in abdominal CT scanning (see section on appendicitis).

Angiography

Angiography use has become less frequent in evaluation for abdominal aortic aneurysm and solid viscus injury with advent of CT scan. Nonetheless, mesenteric angiography remains useful in localization of massive lower gastrointestinal bleed.

Repeated Examination

Repeat abdominal examinations are essential for proper evaluation of abdominal pain in the emergency setting. While this is true for all patients with abdominal pain, it can form the cornerstone of the decision-making process when the diagnosis is uncertain. Frequent inquiries about progression or change in symptoms combined with repeated examinations of the abdomen and, occasionally, repeat laboratory tests can prevent unnecessary operations without risking dangerous delays.

Intravenous Fluids and Withholding Oral Intake

Intravenous fluids are indicated to replace volume deficiency, mainly secondary to gastrointestinal or vascular losses or poor intake, in most patients with abdominal pain. Also, it is recommended to withhold oral intake, at least initially.

Relief of Pain

Parenteral analgesics should be administered expeditiously to relieve severe pain. Evaluation of acute abdominal disease can be performed more accurately after severe pain is relieved and the patient can cooperate. In addition, studies have demonstrated no adverse effects on the ability to diagnose acute surgical conditions when patients with an acute abdomen receive narcotics. In fact, diffuse tenderness may become more localized and masses may become more obvious to palpation.

Emesis Control and Nasogastric Suctioning

In addition to adequate control of pain, patients will frequently require control of emesis. Initially, this may be in the form of parenteral antiemetics, but in refractory cases or in patients with high suspicion for obstruction, nasogastric suction is necessary.

Antimicrobials

Antimicrobial agents should be withheld until the diagnosis is at least tentatively established, except in the presence of obvious signs of systemic infection (high fever, rigors, hypotension). In obscure cases, antibiotic therapy may mask progression of disease and lead to serious complications with increased illness (eg, appendicitis).

Surgical Consultation

Early surgical consultation is helpful for both the patient and the surgeon. Because the surgeon, like the emergency physician, must rely on repeated examinations for diagnosis, the earlier the observation begins, the faster a definitive diagnosis can be made. Furthermore, delays in consultation may allow worsening of the condition, with possible disastrous sequelae.

Intestinal Disorders

Appendicitis

Clinical Findings

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.

Intestinal Obstruction

Clinical Findings

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

Clinical Findings

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

Clinical Findings

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.

Diverticulitis

Clinical Findings

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

Clinical Findings

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.

Gastroenteritis

See also Chapter 36.

Clinical Findings

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

Clinical Findings

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.

Hepatobiliary Disorders

Biliary Colic

Clinical Findings

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

Clinical Findings

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.

Acute Suppurative Cholangitis

Clinical Findings

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.

Hepatic Abscess

Clinical Findings

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.

Hepatitis

Clinical Findings

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).

Vascular Disorders

Ruptured Aortic Aneurysm

Clinical Findings

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

See also Chapter 40.

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.

Ischemic Colitis

Clinical Findings

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.

Mesenteric Ischemia

Clinical Findings

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).

Rupture of the Spleen

See also Chapter 25.

Clinical Findings

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.

Urinary Disorders

Renal Colic

See also Chapter 39.

Clinical Findings

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.

Pyelonephritis

See also Chapter 42.

Clinical Findings

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.

Acute Pancreatitis

Clinical Findings

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.

Gynecologic Disorders

See also Chapter 38.

Ectopic Pregnancy with Rupture

Clinical Findings

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).

Acute Salpingitis (Pelvic Inflammatory Disease)

See also Chapter 42.

Clinical Findings

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.

Ruptured Ovarian Follicle Cyst

Clinical Findings

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.

Ovarian Torsion

Clinical Findings

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.

Endometriosis

Clinical Findings

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.

Primary Peritonitis

Clinical Findings

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

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.

Retroperitoneal Hemorrhage

Clinical Findings

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.

Treatment and Disposition

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.

A variety of conditions not amenable to surgery may cause abdominal pain. Aside from common conditions such as pyelonephritis, salpingitis, myocardial infarction, lobar pneumonia, and diabetic ketoacidosis, a number of these conditions are capable of mimicking abdominal disorders requiring surgery. Most of these conditions simulate acute diffuse peritonitis. Helpful differential diagnostic tests are listed in Table 15–4.