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Review Fundamentals of Clinical Evaluation of Abdominal Pain
External Anatomy
Abdomen: Nipples, Anterior axillary line, Pubic symphysis, Transverse colon at level of umbilicus
Flank: anterior axillary line to posterior axillary line
Back: Posterior axillary line to posterior axillary line, scapular tips, crest of iliac wings
Internal Anatomy
Cavities
Peritoneal Cavity
- Visceral peritoneum: autonomic innervation
- Parietal Periotneum: somatic innervation
Retroperitoneal Cavity
Pelvis
Vasculature
- Celiac Artery supplies foregut
- SMA supplies midgut
- IMA supplies hindgut
History - Location, Character, Onset, Progression, Duration, Migration, Intensity, Associated Sxs, Hx of Similar Pain, Exacerbators, Alleviators
1. Location/Radiation
2. Character: visceral vs. somatic
Visceral Pain and Regions
Due to irritation of visceral peritoneum (ANS) from distention, limited inflammation, ischemia
Poorly Localized
Vague
Midline at one of 3 levels: epigastric, umbilical, hypogastric/suprapubic
- Epigastric pain: path in celiac distribution (foregut) - lower esophagus (esophagitis, perf), stomach (GU, Gastritis, CA), Duodenum (DU), Liver (hepatitis, CHF, Trauma), GB (cholecystitis), Pancreas (Pancreatitis, CA), Spleen (Splenic infarction, trauma), medical etiologies (MI, PNA)
- Periumbilical pain: path in SMA distribution (midgut) - small intestine (SBO, Crohn's, enteritis, mesenteric ischemia), proximal large intestine (appendicitis, LBO, CA, colitis)
- Suprapubic pain: path in IMA distribution (Hindgut) - distal colon (diverticulitis, CA, colitis), Rectum (proctitis, CA), Bladder (cystitis, etc.)
Somatic Pain and Quadrants
Results from Parietal Peritoneal Irritation, Produces Somatic Pain, Well Localized, Sharp, Directly over Pathology
Diffuse Irritation, Diffuse Pain, Diffuse Tenderness --> suggests perforation
Referred Pain
Result of Segmental anatomic relationships between ANS and Somatic Afferent Fibers
Eg: Scrotal pain --> ureterolithiasis; Infrascapular pain --> cholecystitis; R Shoulder Pain --> choledocholithiasis; Kerr's sign --> diaphragmatic irritation
Kerr’s Sign from Delayed Splenic Rupture: left upper quadrant pain that refers to the left shoulder
History
3. Onset
Gradual (minutes to hours) - visceral process of variable significance
Slow (days to months) - CA until proven otherwise
4. Progression – getting worse, staying the same, or getting better
5. Duration – Constant, Intermittent, Fleeting
Colicky pain: crampy, result of intense hollow viscus contractions: GI tract - bowel obstruction; Ureter - ureterolithiasis; Uterus - menstrual cramping; GB - biliary colic
6. Migration
7. Intensity
8. Hx of Similar Pain
9. Associated Sxs – nausea, vomiting, anorexia, change in bowel/bladder function, fever, chills, malaise, weight loss/gain
10. Exacerbators - Food, activity/movement
11. Alleviators - NSAIDs shouldn't relieve; relief with antiacids suggests inflammatory process in esophagus, stomach or duodenum
12. Don’t forget to consider medical causes: MI, LL PNA, Addisonian Crisis, Zoster, Herniated disk
Signs and symptoms in acute adrenocortical insufficiency ("adrenal crisis") - fever (70%), nausea and vomiting (64%), Abdominal pain (46%), Hypotension (36%), Abdominal distention (32%), obtundation/lethargy (25%), Hyponatremia (45%), Hyperkalemia (25%)
Physical Exam
Preparation: Relaxed patient, avoid quick movement, supine position, warm hands, expose nipple to symphysis, start away from site of pain, distract patient
Systematic Approach: inspection, auscultation, palpation, percussion, special maneuvers
1. Inspection
Patient Movement: Tossing/Turning = Colicky; Minimal = Peritonitis; Normal = Less worrisome
Scars
Rashes
Distension
Masses
2. Auscultation
Bowel Sounds: normal = 5- 34 per minute, hypoactive = ileus due to peritonitis or post-op, hyperactive = BO, Enteritis
Bruits: turbulent blood flow = AAA, mesenteric vascular disease
3. Palpation
Light --> Deep --> Eval. For Masses
Observe Face throughout
Distract to distinguish “subjective” vs. "objective”
Don't forget additional "palpation" via rectal and pelvic exams as appropriate
4. Percussion
Guarding to percussion = rebound guarding
Tones:
- tympany: underlying air (gastric air bubble, BO, ileus, pneumoperitoneum)
- dullness: underlying fluid or solid
CVA tenderness – c/w pyelonephritis
Terminology
Tenderness- pt c/o pain or winces with palpation
Guarding- contraction of abd wall muscles with palpation
Rigidity- extreme of guarding with abd wall in continual state of contraction
Rebound- tenderness or guarding which is worse with release of deep palpation - due to rapid movement of inflamed peritoneum, can use variations of heel tap and bed shake
Peritoneal Signs
Involuntary (Objective) Guarding
Percussion or Rebound Tenderness
Rigidity
Acute Abdomen
Abdominal Exam which demonstrates Peritoneal Signs
Indicates need for emergent operative intervention until proven otherwise - most notable exception = acute pancreatitis
Special Maneuvers
Appendicitis
Blumberg's Sign - rebound guarding at McBurney's Point
Rovsing's Sign - referred tenderness from LLQ to RLQ
Iliopsoas Sign - increased pain in RLQ with extension of R leg (due to retrocecal inflammation)
Obturator Sign - Increased pain in RLQ with internal rotation of R hip (due to pelvic inflammation)
Dunphy's Sign - pain/guarding in RLQ with coughing or refusal to cough because of inciting RLQ pain (heel tap and bed shake are similar in rationale)
Cholecystitis
Murphy’s Sign - Reflexive arrest of deep inspiration due to palpation in RUQ
Pancreatitis
1. Cullen’s Sign – Periumbilical Ecchymosis
2. Grey-Turner’s Sign - L Flank Ecchymosis
Both are reflective of retroperitoneal hemorrhage as with hemorrhagic pancreatitis
Abdominal Wall Pathology
Carnett's Sign - pain/tenderness persists or worsens with flexing of abdominal wall muscles
Fathergill's Sign - mass persists or worsens with flexion of abdominal wall muscles
Ascites
Shifting dullness
Fluid wave
Lab/Radiologic Adjuncts
CBC/diff, Chem 7, LFTs, Amylase. Lipase, UA, Urine HCG
EKG
Acute Abdominal series
CT as supplement to Hx and PE in select cases
Abdominal Pain: A Guide to Rapid Diagnosis
by Nyhus, Vitello, and Condon
Simon and Schuster