ABDOMINAL PAIN

PCFM Report

Brillantes, Sheena Lyn L.

MD-2

A. Case Scenario

The patient is a 32-year-old male with no significant past medical history who presents to the
emergency room with abdominal pain. He states the pain began a few days ago in the right lower
quadrant of the abdomen, and now feels as though it is spreading to the mid-abdomen. He describes
the pain as coming on suddenly and sharp in nature.
He describes the pain as coming on suddenly and sharp in nature. Since onset, his pain started
to improve until the morning of presentation to the emergency department when it acutely
worsened. He says that the pain is much worse with movement. The patient is concerned for a possible
hernia as he does heavy lifting at work.

 Physical Examination
o Vital Signs
 Blood pressure: 120/73
 Heart rate (HR) 60
 RR 18
 Temperature: 35.6 C
 Oxygen saturation: 98% on room air
o General: Alert and oriented, in no apparent distress, although ambulates into
the emergency room holding his abdomen.
o HEENT: Normocephalic, atraumatic, sclera anicteric. Mucus membranes are moist.
o Cardiovascular (CV): Regular rate and rhythm, no murmurs, rubs, gallops
o Pulmonary: clear to auscultation bilaterally
o Abdomen: moderate tenderness to palpation in the right lower quadrant without
rebound, guarding, or rigidity. Bowel sounds are present throughout. Negative psoas
and obturator signs.
o Genitourinary (GU): genitalia examined in standing position with a normal external
exam, no masses felt with a cough, intact cremasteric reflex
o Back: No cerebrovascular (CVA) tenderness
o Neurological: No focal deficits
o Skin: Warm and dry, no rashes

 Review of Systems
o (-) anorexia
o (-) nausea or vomiting
o (-) testicular pain or swelling
o (-) urinary or bowel complaints
o (-) fever or chills
  Patient History
o Past Medical History:
 Patient denies prior abdominal surgeries
o Family History:
 No inherited medical conditions
o Personal & Social History:
 Smoke a half pack of cigarettes a day
 Social drinker
 Denies any recreational drug use

B. Introduction / Epidemiologic features

Description

Abdominal Pain is defined as a subjective feeling of discomfort in the abdomen. It may be caused by
luminal obstruction, an inflamed organ, ischemia, hollow viscous perforation, or bowel motility
disorders/multifactorial causes. It is a common chief complaint presented in the outpatient and
emergency room settings. Although most abdominal pain is benign, there are still cases that are serious
conditions and may require hospitalization.

Acute pain is when the duration of pain is less than 6 hours. It is defined as a “spectrum of surgical,
medical and gynecological conditions ranging from trivial to life threatening conditions which may
require hospital admissions, investigations and treatment.” Acute abdominal pain occurs between the
chest and pelvic regions. It can potentially be caused by microbial infections, organ dysfunction, disease,
trauma, or even in terms of normal physiology. Some causes, however are associated with high mortality
risk and therefore require immediate surgery. Chronic pain implies persistent or intermittent pain for at
least six months or longer and already affects the patient’s activities of daily living.

Incidence, Prevalence

Abdominal Pain is presenting complaint in:

◦ 1.5% of office-based visits
◦ 5% of emergency department visits

As many as 10% of patients in the emergency department setting and lesser percentage in the
outpatient setting have a severe or life-threatening cause, or require surgery

Most common causes of abdominal pain

 Non-specific: 24 – 44.3%
 Acute appendicitis: 15.9 – 28.1%: Most frequent condition leading to emergent abdominal
surgery in children
 Acute biliary disease: 2.9 – 9.7%
 Meckel’s Diverticulitis: 2%
 Gallstones
 Hollow viscus perforation
 Dyspepsia
 Peptic Ulcer Disease
  Pelvic Inflammatory

Classification

Visceral Pain
 It occurs when hollow abdominal organs (e.g., intestine or biliary tree) contract unusually
forcefully, or are distended or stretched.
o Solid organs (e.g., liver, kidneys) can also become painful when their capsules are
stretched
 It is a symmetric pain near the midline anteriorly, with or without associated vasomotor
phenomena.
 It is usually dull or poorly-localized
 It is commonly caused by distention, inflammation, or ischemia

Parietal Pain or Somatic Pain

 Originates from peritonitis (Inflammation of the parietal peritoneum)
 Steady, aching pain that is usually more severe than visceral pain
 Aggravated by movement or coughing
 Patients prefer to lie still

Referred Pain
 Felt in more distant sites, which innervate at approximately the same spinal levels as the
disordered structures
o Pain in the shoulder from a ruptured spleen (Kehr’s sign)
 Develops as the initial pain increases intensity and seems to radiate or travel from the initial site
 It may be palpated superficially or deeply but is usually localized
 Pain may be referred to the abdomen from the chest, spine, or pelvis, further complicating the
assessment of abdominal pain

C. Approach to Diagnosis

Clinical manifestations (History and Physical Examination)

History
 The physician should first, identify the pain whether it is surgical or non-surgical
 History of present illness should then describe the acute abdominal pain according to the
following parameters (PQRST method)
o Palliating or provoking factors
o Quality
o Radiation
o Severity
o Timing or mode of onset

Palliating or Provoking Factors

 Exacerbating or ameliorating factors linked to the patient’s dietary, urinary, and bowel habits
 For female patients: take note of obstetric and gynecologic history most especially the
menstrual cycle
  Daily activities (e.g., walking, running, eating)
 Previous abdominal surgeries for the development of adhesions
 Medications
o Corticosteroid use: promotes gastroduodenal ulceration and perforation
o Anticoagulant intake: internal bleeding

Quality of Pain
 Generalized pain: may be caused by stomach virus, indigestion, or gas
o Severe pain: blockage of the intestine
 Localized pain (Gradual, steady): may indicate acute cholecystitis, acute cholangitis, acute
hepatitis, appendicitis or acute salpingitis
 Abrupt, excruciating pain: may indicate Biliary colic, Ureteral colic, Perforated ulcer
 Intermittent Colicky pain (crescendo with free intervals): may indicate early pancreatitis, Small
bowel obstruction or Inflammatory bowel disease
 Rapid onset of severe, constant pain may indicate: Acute pancreatitis, Mesenteric thrombosis,
Strangulate bowel or Ectopic pregnancy

Radiation
 May be used as a valuable clue in investigating the cause of abdominal pain

 Pain Radiating to the Back may indicate:

o Ruptured abdominal aortic aneurysm
o Cholecystitis
o Pancreatitis
 Pain Radiating to the Shoulder
o Reflects irritation of the Diaphragm
o Intraperitoneal infection or hemorrhage
o Hepatitis
o Cholecystitis
 Pain Radiating to the Groin
o Aortic aneurysm
o Nephrolithiasis
 Pain along the medial aspect of the thigh to the knee (Howship-Romberg's Sign)
o ated obturator hernia
 Pain in the labia, testicle or shaft of the penis on the involved side
o Retrocecal appendicitis
o Retroperitoneal perforation of the duodenum
Severity
 Straightforwardly evaluated using the 1 to 10 pain scale or the visual analog pain scale.

Timing or Mode of Onset

 Timing or mode of onset of the abdominal pain may be sudden or progressive
 Sudden or explosive pain may be brought about by a free perforation of a viscus

 Progressively increasing pain within 1 – 2 hours

o Acute cholecystitis
o Acute pancreatitis
o Proximal small bowel obstruction
 Pain intensifies and later localizes
o Acute appendicitis
o Distal small bowel obstruction
o Colon obstruction
o Diverticulitis
 Cases of severe abdominal pain lasting for less than 6 hours are recommended for surgical
operation

Physical Examination

 A complete physical examination gives the physician essential data in coming up with a
diagnosis.

Inspection
 Ask for the patient’s consent
 Ask the patient to lie in a relaxed supine position
 Stand on the right side of the patient and fully expose the abdomen
 Examine the contour of the abdomen and note for signs of: distention, scars, hernias, masses
and abdominal wall effects

Auscultation
 Evaluation of bowel sounds
 Quiet abdomen or decreased abdominal motility (hypoactive) may indicate paralytic ileus or
generalized peritonitis
 Mechanical Obstruction: loud, rhythmical & synchronous w/ colicky pain
 Hypoactive or absent bowel sounds: later stages
Percussion
 Tenderness upon percussion indicates abdominal inflammation
 Fluid wave and shifting dullness: tests to determine existence of free fluid (ascites) within the
peritoneal spaces
 Dullness on percussion helps in determining the size of solid organs or masses

Palpation
 Light palpation: Aids in detection of abdominal tenderness, muscular resistance, and some
superficial organs and masses
 Deep palpation: Usually required to delineate the liver edge, kidneys, and abdominal masses

Direct Rectal Examination (Males)

 Inflamed retro-cecal appendix or psoas abscess produces pain when psoas is moved
 Fecal impaction, pelvic abscess, and neoplasm cause obstruction

Pregnancy Test and Pelvic examination (Females)

 Speculum examination: Detects presence of cervical discharge
 Urine pregnancy test: Vital in the diagnosis of ectopic pregnancy in female patients with acute
abdominal pain
 Bimanual pelvic examination: Checks for acute pelvic complications, and tubal/ovarian masses

Physical Examination Tests and Signs

 Fluid Wave
o Palpable impulse on the side opposite pressure
o Indication: Ascites
 Psoas Sign
o Abdominal pain on hip flexion and/or extension, secondary to irritation of psoas muscle
o Indication: Retrocecal Appendicitis
 Rovsing’s Sign
o Pain in lower right quadrant during left sided pressure
o Indication: Appendicitis
 Obturator Sign
o Right hypogastric pain on internal rotation of right hip suggests irritation of obturator
muscle
o Indication: Appendicitis
 Murphy’s Sign
o Sharp increase in right upper quadrant tenderness with a sudden stop in inspiratory
effort
o Indication: Acute cholecystitis
 McBurney’s Sign
o Sharp pain when applying pressure between the umbilicus and the anterior superior
iliac spine
o Indication: Appendicitis
 Blumberg’s Sign
o Rebound tenderness; there is pain upon removal of the pressure rather than when
applying it
 o Indication: Peritonitis, Appendicitis, Ulcerative Colitis
 Carnett’s Sign
o increased pain when a supine patient tenses the abdominal wall by lifting the head and
shoulders off the examination table
o Indication: Abdominal wall pain
 Cullen’s Sign
o Superficial edema with bruising in the subcutaneous tissue around the periumbilical
region
o Peri-umbilical ecchymosis
o Indication: Retroperitoneal hemorrhage, Hemorrhagic pancreatitis, may be secondary
to abdominal aortic aneurysm rupture
 Grey-Turner Sign
o Ecchymosis or discoloration of the flank
o Indication: Splenic fracture
 Kehr’s Sign
o Pain radiating to the shoulder from a ruptured spleen
o Indication: Ectopic pregnancy rupture

 Chandelier Sign
o Cervical Motion Tenderness (CMT)
o manipulation of cervix causes patient to lift buttocks of table
o Indication: Pelvic inflammatory disease (PID)

Differential Diagnosis

A stepwise approach to abdominal pain is

considering the pain location as a guide for differential
diagnosis. Several areas of the abdomen deserve
special attention because the clearest evidence for a
consistent work-up is in these areas.
D. Evaluation / Work –up

 Complete Blood Count

o Non-specific, but WBC count (15 x 109 cells/L) with differential count (PMN count >13 x
109 cells/L) is useful especially in patients 15-65 years old suspected of having
appendicitis
 Urinalysis
o Useful in detecting urinary tract infection, renal colic, or even pregnancy

 Serum Electrolyte
o To check electrolyte imbalance in patients with persistent vomiting, diarrhea, or any
other sign of dehydration
 Abdominal Ultrasound
o To evaluate hepatobiliary disease, abnormalities in the abdominal aorta, or pelvic
problems (e.g., ectopic pregnancy)
 Angiography
o To identify the source of GI-hemorrhage, and the vitelline artery branching off the
superior mesenteric artery, when present, is pathognomonic for Meckel's diverticulum
 Computed Tomography (CT) Scan
o Requested for patients with equivocal ultrasound findings
o Diagnostic modality of choice in intraperitoneal and retroperitoneal abscess,
diverticulitis, and determining the presence and extent of diverticula-related
complications
 Other Diagnostics (Endoscopy, Proctosigmoidoscopy, Colonoscopy)
o Useful in evaluating gastrointestinal problems
 Radionuclide Scanning
o Sodium Tc-pertechnetate
 Uptake by ectopic gastric tissue in a Meckel diverticulum enables diagnosis of
pathology related to diverticula

E. Approach to Management

 Treating abdominal pain depends on its cause

 Options include:
o Medications for inflammation, gastroesophageal reflux disease or ulcers
o Antibiotics for infection
o Diet modifications
o Local or spinal injections of numbing agents or corticosteroids by pain management
physicians
 In more severe cases like appendicitis and hernia, surgery is necessary

F. Case Discussion

Patient Information
 General data
o Age: 32 year old
o Sex: Male
  Chief Complaint
o Abrupt and sharp abdominal pain in RLQ
o Pain worsened with movement

History of Present Illness

 Pain started at RLQ few days ago and seem to spread to the mid-abdomen
 Days PTC: sudden and sharp in nature pain
 Morning PTC: pain acutely worsened

Physical Examination (Pertinent Findings)

 Moderate tenderness to palpation in the right lower quadrant without rebound, guarding or
rigidity
 Bowel sounds are present throughout

Differential Diagnosis
Here are the differential diagnosis based on patient’s information and history, and the symptoms
that rule in/out the conditions.

Diagnosis Rule In Rule Out

(-) Diarrhea
Abdominal Pain (-) Rectal Bleeding
Crohn's Disease RLQ Pain (-) Anorexia
(-) Fatigue
(-) Psoas Sign
Appendicitis Abdominal Pain and Cramping (-) Obturator Sign
Pain exacerbated by movement (-) Fever
RLQ Pain (-) Chills
(-) Nausea
(-) Vomiting
Lower abdominal pain (-) Testicular pain or swelling
Increase pain (-) A dull aching sensation
Hernia History of physical strenuous activity (-) A sense of feeling full or signs
(lifting) of bowel obstruction

Final Diagnosis

Diagnosis Rule In Rule Out

Age: <50 years old (-) Nausea
Male gender (-) Vomiting
Meckel's Diverticulum Abdominal pain (-) Bowel obstruction
RLQ pain radiating to mid-abdomen
Tenderness in RLQ

Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal
tract. It results from the failure of the vitelline duct to obliterate during the 5th week of fetal
development. It may present as symptomatic or asymptomatic and more common in males. It may
occur at all ages (rarely in adults), but more common in younger age (< 45-50y.o.)

Rule of 2's
 Found in 2% of population
 2 feet from the ileocecal valve
 2 inches long
 2 common forms of ectopic tissue
 2 years old: most common age presentation
Treatment and Management

 Factors taken to consideration in the decision of the management include:

o Age and sex of the patient
o Length of the diverticulum
o Diameter of the mouth or base of the diverticulum
 Ileal resection in the traditional treatment of choice for asymptomatic diverticulum
 Treatment of symptomatic Meckel's diverticulum is definitive surgery including
diverticulectomy, wedge resection and segmental resection and depends on:
o Integrity of diverticulum base and adjacent ileum
o Presence and the location of ectopic tissue within MD
 Laparoscopy should be considered in the diagnosis and treatment of Meckel's diverticulum
o The laparoscope can be used to remove an incidentally discovered diverticulum
 Complications
o 4 to 6% lifetime risk of developing a complication
o The major complications:
 Hemorrhage
 Obstruction
 Intussusception
 Diverticulitis
 Perforation
 Bleeding

Basic Principles of Meckel's Diverticulum Management

Indication Long Diverticula Short Diverticula
Simple Diverticulitis Diverticulectomy Wedge or segmental resection

Complicated diverticulitis Wedge or segmental resection

with inflamed or
perforated base
Complicated intestinal Wedge or segmental resection
obstruction
Bleeding Diverticulectomy Wedge or segmental resection

Incidentally discovered Diverticulectomy Wedge or segmental resection

Merkel's diverticulum
 G. Summary of Care/Approaches

Summary of Care/Approaches
Patient-centered Family-focused Community oriented
M/32 RLQ abdominal pain Family history of Meckel Understanding and
PE: moderate tenderness to Diverticulum awareness of Meckel's
Data Gathering palpation in the right lower diverticulum
quadrant without rebound,
guarding, or rigidity
Understanding of Meckel Risk of Meckel Awareness of the community
Analysis diverticulum and its Diverticulum in the family of underlying causes of
underlying symptoms and abdominal pain
management
Meckel diverticulum Good family support and Awareness of risk factors of
Assessment response upon onset of Meckel Diverticulum
symptoms
 Management of  Understanding the  Early consultation of
symptoms factors and prognosis patients upon onset of
 Assessment and of Meckel abdominal pain
Management thorough approach in Diverticulum  Health education about
diagnosis  Family intervention Meckel diverticulum
 Hospitalization and assistance of
 Surgery recovery
 Lifestyle intervention  Thorough monitoring
of patient after
discharge

H. References

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Additional input during Discussion