MANAGEMENT OF ACUTE ABDOMINAL PAIN Patrick McGonagill, MD, FACS 4/7/21 DISCLOSURES

• I have no pertinent conflicts of interest to disclose OBJECTIVES

• Define the pathophysiology of abdominal pain • Identify specific patterns of abdominal pain on history and physical examination that suggest common surgical problems • Explore indications for imaging and escalation of care ACKNOWLEDGEMENTS (1) HISTORICAL VIGNETTE (2) • “The general rule can be laid down that the majority of severe abdominal pains that ensue in patients who have been previously fairly well, and that last as long as six hours, are caused by conditions of surgical import.” ~Cope’s Early Diagnosis of the Acute Abdomen, 21st ed. BASIC PRINCIPLES OF THE DIAGNOSIS AND SURGICAL MANAGEMENT OF ABDOMINAL PAIN

• Listen to your (and the patient’s) gut. A well honed “Spidey Sense” will get you far. • Management of intraabdominal surgical problems are time sensitive • Narcotics will not mask peritonitis • Urgent need for surgery often will depend on vitals and hemodynamics • If in doubt, reach out to your friendly neighborhood surgeon. Septic Pain Sepsis Death Shock PATHOPHYSIOLOGY OF ABDOMINAL PAIN VISCERAL PAIN

• Severe distension or strong contraction of intraabdominal structure • Poorly localized • Typically occurs in the midline of the abdomen • Seems to follow an embryological pattern • Foregut – epigastrium • Midgut – periumbilical • Hindgut – suprapubic/pelvic/lower back PARIETAL/SOMATIC PAIN

• Caused by direct stimulation/irritation of parietal peritoneum • Leads to localized pain • Typically caused by bacteria, inflammatory fluid, GI contents, and/or blood WHAT IS PERITONITIS?

• Focal or diffuse irritation of the parietal peritoneum • Symptoms • Pain with movements • Feels every bump on the way to the office • Signs • Abdominal wall rigidity (involuntary guarding) • Voluntary guarding • Rebound tenderness • Not all peritonitis requires surgery, but most peritonitis needs a surgical evaluation CAUSES OF ABDOMINAL PAIN PERTINENT TO THE SURGEON

• Intraabdominal inflammatory conditions • Acute visceral perforation • Bowel obstruction • Bowel ischemia • Hemorrhage INTRAABDOMINAL INFLAMMATORY CONDITIONS

• Acute appendicitis • Acute cholecystitis • Acute pancreatitis • Uncomplicated colonic diverticulitis ACUTE APPENDICITIS

• Symptoms • Differential • Mid abdominal pain migrating to RLQ • Tubal pregnancy • May improve briefly with perforation • PID • Anorexia • Right-sided diverticulitis • Fever • Meckels Diverticulitis • Typical lasting 12-48 hours • UTI • Physical findings • Depends on position of appendix • Anatomical Signs • Rovsing’s sign ACUTE APPENDICITIS (3-5)

• Workup • Management • Laboratory • Operating room within 6-12 hours or • CBC and chemistries presentation • Urinalysis • Or antibiotics • Imaging • Recurrence / failure around 20-30% • Ultrasound • Increased risk of malignancy in patients >40 • CT • Higher failure rate if appendicolith • Or drainage for perforation w/ abscess • Consider c scope and interval appendectomy for patients >40 ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

• Symptoms • Often have preceeding biliary colic • Episodic cramping RUQ and epigastric pain typically a few hours after eating • Sometimes awakens in middle of night with pain • Associated with greasy/fatty/spicy foods • Persistent pain that does not stop after a few hours • Nausea/vomiting • Jaundice • Physical findings • RUQ and epigastric pain • + Murphy sign • Scleral icterus / cutaneous jaundice ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

• Differential • Management • Peptic ulcer disease • Cholecystitis Malignancy • • Admit for hydration and antibiotics Hepatitis • • Cholecystectomy at 24-48 hours • Workup • Choledocholithiasis / Cholangitis • Laboratory • Antibiotics and resuscitation • CBC, CMP, amylase, lipase • ERCP • Imaging • Cholecystectomy same admission • U/S • Biliary colic without improvement • HIDA Treat as with cholecystitis • MRCP • ACUTE PANCREATITIS

• Symptoms • Epigastric pain radiating to back • Vomiting • Physical findings • Diffuse pain, often focused on epigastrium • Upper abdominal rigidity • Jaundice • Differential • Pancreatic cancer • Perforated ulcer • Biliary disease pancreapedia.org ACUTE PANCREATITIS

• Management • Workup • Mild to moderate • Laboratory • Resuscitation • CBC, CMP, amylase, • Treat underlying cause lipase • ERCP • Imaging • Specific drug / EtOH cessation • U/S • Treatment of hyperlipidemia • CT • Secondary prevention • MRCP • Same admission cholecystectomy for gallstones • Severe • Same as above except delayed surgery • Management of secondary organ failure and pancreatic necrosis ACUTE VISCERAL PERFORATION

• Perforated peptic ulcer • Complicated perforated diverticulitis • Perforated appendicitis PERFORATED PEPTIC ULCER

• Symptoms • Differential • May have prodromal symptoms of ulcer • Pancreatitis/biliary obstruction disease • Ruptured AAA • Sudden onset of severe epigastric • Boerhaave’s syndrome abdominal pain • Other ruptured viscus • Nausea/vomiting • Physical findings • Focal epigastric tenderness with peritonitis • Diffuse peritonitis PERFORATED PEPTIC ULCER

Management • Workup • • Fluid resuscitation • Laboratory Rapid surgical exploration with repair of • CBC, CMP, amylase, • lipase perforation • Imaging • Abdominal X-ray • +/- CT pending hemodynamics

surgicalcore.org ACUTE COMPLICATED DIVERTICULITIS

• Symptoms • LLQ pain similar in character to appendicitis • May present with progress despite outpatient treatment • May have inflammatory or obstructive symptoms • Physical findings • LLQ tenderness with or without focal peritonitis • Abdominal distension • Pain or extrinsic compression on rectal examination (pelvic abscesss) • Differential • Imaging • Pitfalls and possiblities ACUTE COMPLICATED DIVERTICULITIS

Management • Differential • • Phlegmon • Inflammatory bowel disease • IV antibiotics • Repeat imaging if no improvement • Colon cancer • Abscess • PID • IV antibiotics • Workup • IR drainage • Laboratory panel • Diffuse peritonitis • Imaging • Sigmoidectomy • CT • Obstruction • Sigmoidectomy BOWEL OBSTRUCTIONS

• Small bowel obstruction • Incarcerated hernia SMALL BOWEL OBSTRUCTION

• Symptoms • Nausea • Vomiting • Distension • Spasmodic pain • Physical findings • Distension (may be asymmetric) • Presence or absence or prior surgical scars • Differential • Constipation • Gastric volvulus • Mesenteric ischemia SMALL BOWEL OBSTRUCTION

• Imaging • Management • Abdominal X-ray • No prior surgery (risk of cancer) • Consider exploratory surgery • CT with oral contrast • Partial Obstruction • Resuscitation • Observation • Small bowel follow-through at 48 hours • Complete obstruction or volvulus • Rapid surgical evaluation • Likely to urgent require surgery

radiopaedia.org INCARCERATED HERNIA

• Symptoms • Progressive distension • Nausea vomiting • Cramping pain • Physical findings • Tense, irreducible bulge • Overlying skin changes • Abdominal distension • Beware the incompletely reduced bulge on obese abdomens INCARCERATED HERNIA

• Differential • Management • Lymphadenopathy • Attempt reduction and observe if • Ascites successful • If femoral, should be repaired • Imaging during admission • CT • If irreducible, must evaluate bowel • Ultrasound viability (strangulation) MESENTERIC ISCHEMIA

• Symptoms • Prodrome of ongoing weight loss, postprandial pain, and food fear • Nonocclusive mesenteric ischemia may follow dehydration or acute GI illness • Can be indolent or acute worsening of pain • Mild nausea and vomiting • GI bleeding • Examination • Classically reported pain much worse than exam (pain out of proportion) • May have peritonitis (late finding) MESENTERIC ISCHEMIA

• Imaging • Management • CT • Acute vascular occlusion • Diagnostic angiogram • Resuscitation • Endovascular or open revascularization • Abdominal exploration • Nonocclusive mesenteric ischemia • Resuscitation • Serial examination • Exploration for worsening examination

radiopaedia.org HEMORRHAGE

• Traumatic bleeding • History of recent trauma • Impaired hemodynamics • Abdominal tenderness • Ruptured abdominal aortic aneurysm • Pulsatile abdominal mass • Mid abdominal pain • Impaired hemodynamics QUESTIONS? REFERENCES

1. Silen, W, ed. Cope’s Early Diagnosis of the Acute Abdomen, 21st ed. Oxford University Press. New York. 2005 2. Streck CJ and Maxwell PJ. “A brief history of appendicitis: familiar names and interesting patients”. The American Surgeon. 2014; 80(2): 105-108 3. Coda Collaborative. “A randomized trial comparing antibiotics with appendectomy for appendicitis”. NEJM. 2020; 383(20): 1907-1919. 4. Naar L, Kim P, Byerly S, et. al. “Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix greater than 10 mm on computed tomography: a post hoc analysis of an EAST multicenter study”. Surgery. 2020; 168(4): 701-706 5. Lu P, McCarty JC, Field AC, et. al. “Risk of appendiceal cancer in patientsundergoing appendectomy for appendicitis in the era of increasing nonoperative management”. J Surg Oncol. 2019; 120(3): 452-459.