ACUTE ABDOMINAL

PAIN
EMERGENCY
CENTER
FIRST AFFILIATED
HOSPITAL
ZHENGZHOU
UNIVERSITY
 Definition of pain

• “An unpleasant sensory and

emotional experience associated
with either actual or potential
tissue damage, or described in
terms of such damage”
---- International Association for the
Study of Pain 
 Acute abdominal pain

comprises about one-third of the surgical

problems.Of patients presenting with abdominal
pain, approximately 15% to 30% will require a
surgical procedure. The most common diagnosis
made in patients with acute abdominal pain is
nonspecific abdominal pain for which no organic
disease can be found after an extensive work-up.
 Gastroenteritis is the second most common
diagnosis, followed by pelvic inflammatory
disease 、 urinary tract
disease 、 appendicitis 、 cholecystitis, and
bowel obstruction. Appendicitis is the most
common surgical diagnosis. Cholecystitis, bowel
obstruction 、 perforated ulcer 、 and
pancreatitis are common causes of surgical
abdominal pain in descending order of
frequency.
Neuroanatomy of Pain
Transmission

The diagnosis of abdominal pain is aided

by an understanding of the anatomy
and physiology of the peritoneum , the
intra-abdominal viscera , and the
neural pain pathways.
Classification

– Visceral pain

– Somatic pain

– Referred pain
 Visceral pain
The receptors located in the visceral
peritoneum surrounding hollow organs
and the capsules of solid organs.
Distention or ischemia of the abdominal
organs stimulates these receptors. Most
visceral pain is midline in nature.(Because
these organs are simultaneously innervated from
both sides of the spinal column .)
 Visceral pain
dull, crampy, and poorly
localized(Because visceral pain fibers are
bilateral and unmyelinated and enter the
spinal cord at multiple levels). It is often
associated with“ visceral” symptoms
such as nausea, vomiting, and
diaphoresis. It usually cannot be
localized to a certain organ.
 Somatic pain
The pain receptors located in the
parietal peritoneum and the roots of the
mesentery. This type of pain is more
sharp, and localized.(because Pain
produced by ischemia, inflammation or stretch of
the parietal peritoneum is transmitted through
myelinated afferent fibers to specific dorsal roots
ganglia on the same side and at the same
dermatomal level as the origin of the pain) .
 It is responsible for the physical
finding of tenderness to palpation,
guarding, and rebound . The finding of
somatic pain often allows anatomic
localization of pain to a specific organ.
Given somatic tenderness in a certain
quadrant, the differential diagnosis can
be narrowed down solely by anatomic
localization of organ.
 Referred pain
The pain that is felt at a cutaneous site
distant from the disease organ. For
instance, visceral afferents from the
diaphragm enter the spinal cord at C3-
C5. Pain from the diaphragm is thus
referred to the cutaneous distribution
of C3-C5 the lateral neck and posterior
shoulder.
 Because the lungs and abdomen
share the T9(thoracic nerve 9)
dermatome distribution, pulmonary
processes such as pneumonia and
pulmonary embolus can be perceived
as abdominal pain. Pelvic and inguinal
structures innervated by T11 and T12
can cause referred pain to the lower
abdomen.
DATA GATHERING
Key Notes in Interviewing of Pain

• Sites
• Character
• Causes
• Duration
• Radiation
• Accompanied symptoms
• Relaxing factors
 Despite all technologic advances, the
history and physical examination remain the
most important tools in the initial
assessment of a patient who complains of
abdominal pain. Although critically ill
patient may be more difficult to evaluate,
the data from their history and physical
examination are paramount, as this
information either determines a definitive
diagnosis or directs further evaluation.
 Pain
History
Onset. Rapid onset of severe pain is
more consistent with a vascular
catastrophe, rupture of a viscus,
ectopic pregnancy. Slower, insidious
onset is more typical of an inflammatory
process such as appendicitis or
cholecystitis.
 Pattern of Change

Pain that is steadily

increasing in intensity
is more likely to need
surgical intervention.
 Character of Pain

Pain that is dull, burning is more

likely to be visceral than somatic.
Pain that is sharp or stabbing is more
likely to be peritoneal or somatic in
nature. Crampy pain is classically
associated with obstruction of a
viscu.
 Severity
The patient’s quantification of pain is
notoriously unreliable. In general
nonspecific abdominal pain is less
severe than pain from surgical causes,
but there is considerable individual
variation. Severe pain out of proportion
to physical findings is classical for
mesenteric ischemia or pancreatitis.
 Location

The location of abdominal pain can vary with

time, especially as the pain progresses from a
visceral to a somatic origin. Periumbilical pain
that migrates to the right lower quadrant is
classic for appendicitis. Epigastric pain that
eventually localized during a period of several
hours to the right upper quadrant is characteristic
of cholecystitis.
 Common Diseases

Acute appendicitis
– Pain is initially localized
around the umbilicus
(visceral pain) and is
vague; As the inflammatory
response progresses to
involve the parietal
peritoneum, the main site
of pain shifts to the right
iliac fossa (parietal or
somatic pain)
– Usually accompanied by
fever
Acute Cholecystitis  

• Paroxysmal right
hypochondrium pain
• Accompanied by fever
sometimes
• Paroxysmal pain in right
infrascapular area
Acute Gastric Perforation

• Outburst acute severe

lancinating pain in umbilical

region or epigastrium
 Acute ileus

• Vomiting
• Cramping Abdominal
pain

• distension
• obstipation
 Ureter Calculi

• Paroxysmal
abdominal pain
• Referred pain to
the groin area of
the same side
• Hematuria
Rupture of the Liver or Spleen

• Pain in right or left hypochondrium

• Shock
• Anemia
 Radiation

Given the pain patterns already

discussed, involvement of certain
organs can be implicated based on the
radiating pattern of the pain.
 Aggravating or Alleviating
factors. What makes the pain better or
worse? Parietal peritoneal pain is
aggravated by movement , such as
hitting bumps on the ride to the hospital
or even walking. This finding is
particularly supportive of the diagnosis
of appendicitis, when it is
part of the differential diagnosis.
 Ulcer pain is usually relieved by
eating, whereas biliary colic is
aggravated by eating fatty foods. The
pain of pancreatitis is alleviated
somewhat by assuming a curled-up
posture.
 Prior pain history. The easiest
question to ask is: Have you ever
had this pain before? the majority of
patients with cholecystitis have had
similar pain with eating prior to
presentation. Ulcers tend to be
recurrent, as do pancreatitis.
 Pain treatment
What has the patient done to relieve the
pain? What has the response been? The
treatment gives some insight into the
medical sophistication of the patient.
The response can help measure the
severity and evolution of the pain.
 Associated
Symptoms
Nausea and vomiting. Almost any kind of
visceral abdominal pain will elicit nausea and
vomiting . But , excessive vomiting should
raise the suspicion of bowel obstruction . Pain
that Is present before vomiting is more likely
to have a surgical cause. Whereas vomiting that
precedes pain is more likely to occur in
patients with nonspecific abdominal pain or
gastroenteritis.
 Change in Bowel habits

The presence of diarrhea with vomiting

is almost always associated with
gastroenteritis. Is the patient unable to
pass gas or stool? Ileus from
inflammation and blockage from
mechanical obstruction are common
causes of this complaint.
 Past Medical History

Past surgery. Prior surgery not

only can eliminate many diagnosis
but can increase the risk of others .
For instance, abdominal surgery with
secondary adhesions is the most
common cause of intestinal obstruction
in adults.
 Medical Illness
Patient with diabetes, heart disease,
lung disease, liver disease,
hypertension, or renal disease are not
only at increased risk for certain
abdominal disorders but may also
require significantly different methods
of stabilization, treatment, and surgical
preparation
 Physical
Examination
 General appearance
The patient’s color and attitude in bed
are important . Patients who are pale and
diaphoretic and are lying perfectly still in bed
are generally more acutely ill and are more
likely to have local or diffuse peritonitis .
Patients who are agitated writhing in pain
are more likely to have visceral causes
of abdominal pain , nonspecific
abdominal pain, renal or biliary colic, or
mesenteric ischemia.
 Vital Signs

Temperature. The patient’s temperature

has been used as a general indicator of
the presence or absence of infection.

Blood Pressure and Pulse . These vital

signs are helpful in gauging the severity of
the disease process and the potential for
blood or fluid loss.
 Respiratory rate

Pneumonia , pulmonary embolism ,

and myocardial infarction can raise
the respiratory rate.
Extra-abdominal Examination

Before examining the

abdomen , the physician
should listen quickly to the
heart and lungs to avoid
missing an extra-
abdominal cause of
abdominal pain.
Abdominal Examination

Inspection : Signs of
distention ,symmetry , prior
surgery , large masses , bruises may
quickly narrow the differential
diagnosis.
 Auscultation
Decrease bowel sounds are heard in
peritonitis and other inflammatory
processes that cause an adynamic ileus.
Increased bowel sounds are heard in
patients with nonspecific abdominal
pain and gastroenteritis. Whereas high-
pitched sounds and rushes are classic
for bowel obstruction.
 Percussion
Gentle percussion of all four abdominal
quadrants can localize the site of pain
initially. Percussion the abdomen can often
provide information about the size of
certain organs and the origin of abdominal
distention, gaseous or solid. It is also
useful for determining bladder size from
urinary retention.
 Palpation
Most of the time and effort in the abdominal
examination is spent on palpation. It is important
to note the patient’s facial expressions during
palpation. A grimace is usually more significant
than the statement “ It hurts.” In pain of
visceral origin, localization of tenderness is
usually not possible . With somatic tenderness is
more likely, and the following associated
findings are assessed.
 Muscular Signs
Guarding is the reflex spasm of the abdominal
wall musculature in response to palpation.
Voluntary guarding is less significant than
involuntary guarding. Involuntary guarding is
elicited by asking the patient to take a deep
breath while firm pressure is held on the
tender area. If the spasm is not relieved,
involuntary guarding is present. If the muscles
relax, voluntary guarding is present.
 Rebound Tenderness
Rebound is classically the hallmark of
peritoneal Irritation. It is elicited by slow,
gentle, deep palpation of the tender area
followed by abrupt but discreet
withdrawal of the examiner’s hand.
Often this procedure is not necessary
because rebound can be discovered more
gently by asking the patient to cough, or
gentle percussing the area of tenderness.
 Special Techniques
Murphy’s Sign: While the physician
palpates deeply in the right upper
quadrant, the patient is asked to take a
deep breath. Abrupt cessation of
inspiration because of pain is consistent
with cholecystitis, hepatitis, or other
right upper quadrant abnormalities.
 Fist percussion

Gently percussion the costovertebral

angles of the back with a fist elicits
pain in patients with pyelonephritis
or obstructive uropathy.
 Related Examination

Rectal. This examination is needed to

search for occult blood, masses, and
prostate tenderness.

Pelvic. All women of childbearing age

with abdominal pain require a
pelvic examination.
DECISION
PRIORITIES AND
PRELIMINARY
DIFFERENTIAL
DIAGNOSIS
 After completing the
history and physical
examination , the preliminary
differential diagnosis for the
patient's abdominal pain is
developed according to the
following principles:
1. Is there a threat to life?
Even though life-threatening causes
of abdominal pain do not occur as frequently
as common causes, they always take
the highest priority. Important life
-threatening intra-abdominal causes of
acute abdominal pain include ruptured
leaking abdominal aortic aneurysm,
perforated viscus, acute pancreatitis ,
intestinal obstruction , and mesenteric
ischemia.
2. Is the pain acute and is there a potential
surgical cause for the pain?
Severe pain accompanied by
localized tenderness with peritoneal
findings are the hallmarks of serious and
possibly surgical disease. Usually the pain
will have been acute in onset , and there
will be accompanying abnormal vital
signs or laboratory test results to support
the suspicion of surgical disease.
 The other causes of abdominal
pain are acute appendicitis, biliary
tract disease, ureteral colic,
diverticulitis, peptic ulcer. All
have the potential for requiring
surgical intervention. .
DIAGNOSTIC ADJUNCTS

Laboratory
Studies
White Blood Cell Count and Differential

The white blood cell (WBC) count is a

relatively useful test in evaluating acute
abdominal pain . An elevated WBC count or a
left-shifted differential occurs in acute
appendicitis, pelvic inflammatory disease, and
cholecystitis. WBC counts are often higher in
patients with perforation, peritonitis,
fulminant pancreatitis or sepsis
.
 Amylase
The serum amylase level is often
considered the laboratory cornerstone in
the diagnosis of pancreatitis. As many as
20% of patients with proven pancreatitis
may present with normal serum amylase
values. In general, the amylase
concentration has remained a good test in
the diagnosis of pancreatitis despite these
shortcomings.
 Urinalysis
As a general rule, the presence of more
than 10 WBC per high-power field, in a
clean-catch urine sample is consistent
with a diagnosis of urinary tract
infection. Red cells in the urine are
consistent with infection, tumor,
trauma, or stone.
 Tests for Pregnancy

Any woman of childbearing age who

presents with acute abdominal pain,
especially if located in the lower
abdomen, deserves a pregnancy test.
The most important gynecologic
emergency that causes abdominal pain
is a ruptured ectopic pregnancy .
 Radiologic Imaging

Chest Radiograph. An upright chest

radiograph can help diagnose
pneumonia, and other pulmonary
causes of abdominal pain. It is also
the best view for detecting free
intraperitoneal air from a perforated
viscus.
Abdominal Radiograph
An Radiographic signs that are most
commonly looked for are dilated loops
of small or large bowel , air fluid
levels, abnormal calcifications in the
urinary tract system or vascular
calcifications outside of their usual
anatomic location ( aortic aneurysm ) ,
free air under the diaphragm, and
gallstones.
 Ultrasound
Ultrasound imaging can show multiple
organ systems including the biliary tract,
gallbladder. Pancreas, kidneys , aorta, and
uterus. The conditions commonly
detected by ultrasound include
gallstones, biliary obstruction, aortic
aneurysms, pancreatic pseudocysts,
ureteral obstruction, and intrauterine
versus ectopic pregnancies.
 Electrocardiogra
m
Because myocardial ischemia can cause
abdominal pain, most patients over 40
years old with abdominal pain deserve
an ECG. Particularly if the pain is
located in the upper abdomen.
PRINCIPLES OF
MANAGEMENT
 The main goals of the emergency
physician in managing patients with acute
abdominal disorders are to reverse the
systemic effects of the underlying disorder
and to prepare the patient for surgical
intervention, if necessary, Principles of
management include: volume repletion,
gastric emptying, control of emesis, and
pain relief.
 DISPOSITION AND FOLLOW-UP

There are two possible dispositions

available to an emergency physician for
patients with acute abdominal pain. It is
important to emphasize ,however , that each
patient must be treated individually, and no
recommendations for disposition are highly
specific or concrete.
Immediate Surgical Consultation

Localized or diffuse peritoneal signs

accompanies by historical and laboratory
findings consistent with a surgical disease
require an urgent surgical consultation .
Acute appendicitis, intestinal
obstruction ,perforated ulcer ,and acute
cholecystitis are the four most common
surgical causes of abdominal pain.
Male ,29 years, intestine necrosis
Emergency Department Observation

Patients who have no a potential

surgical cause of disease are often observed
in the emergency department .This strategy
of observation often allows the clinical
Situation to clarify as either the patient’s
condition worsens or more information is
gained to allow a decision on disposition
.
FINAL POINTS AND
SUMMARY
 1.Abdominal pain is a common
symptom of the large number of varied
organs that reside within the abdominal
cavity. Often the pain will remain
visceral in nature and therefore will not
progress to a more somatic component,
which would allow the examiner to elicit
specific tenderness over an inflamed
organ .
 2. It is the responsibility of the
emergency physician to be able to
recognize the 10%to 20%of patients
who have a surgical cause of their pain.
3.The physician’s most important
diagnostic tools are the history and
physical examination. Particular
emphasis is placed on palpation to elicit
specific tenderness.
 4. Laboratory and other
ancillary diagnostic procedures are
of limited value in the patient with
abdominal pain .The management
and disposition of the patient will
depend on the clinical
skill of the emergency physician
 5. One of the most significant factors
on the side of the physician in caring
for the patient with abdominal is
time and repeated examinations.
6.Patients who do not have an obvious
diagnosis are observed for a period of several
hours. This management strategy will allow
the physician to observe any significant
changes in the patient’s pain pattern and
overall medical condition.