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Acute Surgical Acute Surgical When a patient presents to the ED with acute abdominal The Basics pain, the emergency physician’s role in taking a history, performing an exam, selecting the appropriate imaging modality, and calling for surgical consultation, if needed, cannot be underestimated. The authors review the most common etiologies of acute surgical abdomen and the emergency physician’s pivotal responsibility in ensuring the best outcomes. Brian H. Campbell, MD, and Moss H. Mendelson, MD bdominal pain is a common complaint depending on the capabilities of the home institu- seen in emergency departments nation- tion. This article reviews key points in the evaluation wide. According to the CDC, stomach of adult patients with abdominal pain, discusses dis- and abdominal pain are the leading rea- ease processes that require emergent surgical evalu- Asons for visits to the ED, accounting for 6.8% of ation and treatment, and highlights the importance all visits in 2006.1 An adult patient with an acute of facilitating early surgical intervention. Although abdomen generally appears ill and has abnormal there are many causes of abdominal pain, this article findings on physical exam. Many of these patients will focus on etiologies that often lead to an acute need immediate surgery, as several of the underlying surgical abdomen, ie, those cases in which a patient disease processes that result in an acute abdomen needs emergent evaluation and treatment and likely are associated with high morbidity and/or mortal- requires emergent operative treatment. ity. The emergency physician must rapidly identify those patients who require early surgical interven- HISTORY tion and appropriately resuscitate them, order the Every clinician learns that history is the key to di- necessary tests, consult the surgical team early on, agnosing most illness, and this is especially true for and notify surgical staff or arrange for a transfer, patients with abdominal pain. The standard ques- tions of location, onset, frequency, quality, severity, Dr. Campbell is a resident in the department of radiation, exacerbating/relieving features, and pre- emergency medicine at Eastern Virginia Medical School in vious episodes and treatments are all pertinent in Norfolk. Dr. Mendelson is an associate professor in the department of emergency medicine at Eastern Virginia patients presenting with abdominal pain. Additional Medical School. questions should address nonabdominal diseases that Gorman Joe © 2010 6 EMERGENCY MEDICINE | JULY 2010 www.emedmag.com ACUTE SURGICAL ABDOMEN can present atypically with abdominal pain, such as to minimize guarding, which is a natural response pneumonia, acute myocardial infarction, and pulmo- to significant intra-abdominal discomfort, it is ben- nary embolism. eficial to begin palpation away from the area where It is important to consider the stage of the pa- the patient reports that the pain is located. tient’s disease process at the time of presentation, as Many patients with an acute surgical abdomen symptoms can change over time. Migration of pain, have peritoneal signs, which include involuntary for instance, can be characteristic of certain entities guarding, pain with light palpation, and rebound or disease progression. Consider the classic presen- tenderness. Patients may also describe symptoms tation of appendicitis, which starts as generalized suggestive of peritonitis during the history-taking or right-sided abdominal pain and then localizes to process. These include pain elicited by walking, McBurney’s point (one-third of the distance from the driving over bumps in the road, shaking of the bed right anterior superior iliac spine to the umbilicus). during rest, and/or coughing. In the absence of an With further disease progression (perhaps rupture), exam suggesting frank peritonitis, localizing the pain pain from appendicitis may again generalize as peri- on exam can help form and narrow the differen- tonitis develops. tial diagnosis. Furthermore, serial abdominal exams It is also important to ask about pertinent medical should be performed, especially in patients with an and family history, including vascular disease, hyper- uncertain diagnosis after initial evaluation. Changes tension, coagulation disorders, collagen vascular dis- in the exam findings can narrow the differential di- ease, previous surgeries, and history of gastrointesti- agnosis and also help determine appropriate timing nal illnesses (including Crohn’s disease and ulcerative of treatments and/or consultations. colitis). Social history should not be forgotten, as Additional components of the abdominal exam alcohol and smoking can contribute to many disease include auscultation, skin exam, and several specific processes. Patients often do not voluntarily report maneuvers. Auscultation for bowel sounds is not illicit drug use, so the physician should specifically specific or sensitive, but absent bowel sounds may ask about it. Muniz and Evans describe several cases suggest peritonitis and high-pitched bowel sounds of ischemic bowel associated with recent cocaine use may support diagnosis of an obstructive process. A that required bowel resection.2 Review of systems thorough skin exam is important, as some patients should also include questions regarding fever, nau- will have discolorations that point to a diagnosis. sea/vomiting, decreased appetite, pain/relief after Periumbilical ecchymosis (Cullen sign) and flank eating, pain/relief after bowel movement (BM), last ecchymosis (Turner sign) are suggestive of retro- normal BM, bloody BM, menstrual history/symp- peritoneal hemorrhage and, more specifically, pan- toms, dysuria, and hematuria. At times, the history creatic hemorrhage. Patients with acute appendicitis can be limited by the patient’s clinical condition or can exhibit Rovsing’s sign (rebound tenderness in the inability to adequately describe the pain due to poor right lower quadrant on palpation of the left lower localization and potential radiation of visceral pain. quadrant) and psoas sign (increased abdominal pain with resisted hip flexion, which suggests inflamma- EXAMINATION tion of the psoas muscle). The goals of the physical exam are to determine the Unfortunately, diagnosing the etiology of abdom- overall condition of the patient, assess the severity of inal pain can be frustrating due to nonspecific signs the intra-abdominal disease process, and identify the and symptoms, especially in the elderly. Sometimes likely cause of the pain. As always, vital signs help observation of disease progression, repeat physical differentiate a “sick” versus “not sick” patient. The examination, advanced imaging studies, and/or sur- abdominal exam can provide immediate feedback to gical exploration are needed to determine the exact the emergency physician regarding the severity and etiology of abdominal pain. Nonetheless, emergency underlying etiology of abdominal pain. Palpation physicians are regularly called upon to identify those yields the most useful information, particularly when patients with acute abdominal pain requiring surgi- it is performed by experienced physicians. Systemati- cal intervention. The remainder of this article will cally work your way around the abdomen, feeling for review specific causes of abdominal pain that require masses and localizing the pain. Sometimes, in order surgical intervention. www.emedmag.com JULY 2010 | EMERGENCY MEDICINE 7 ACUTE SURGICAL ABDOMEN TABLE 1. Selected Causes of Acute Surgical Abdomen Location/Quality Primary Laboratory Etiology of Pain Symptoms Tests Imaging Treatment Mesenteric General, out of Postprandial Lactate, CBC CT angiography Antibiotics Ischemia proportion to exam abdominal findings pain Appendicitis Periumbilical migrat- Anorexia, CBC CT Antibiotics ing to McBurney’s nausea, point vomiting Cholecystitis RUQ Pain, jaundice, Bilirubin, RUQ Antibiotics fever lipase ultrasonography measurement, liver function tests Diverticulitis LLQ Pain CBC CT Antibiotics Small Bowel Generalized Nausea, Basic metabolic Acute Nasogastric Obstruction vomiting, profile abdominal tube, IV fluids distention series, CT with oral contrast Abdominal Severe abdominal/ Pain CBC, CT angiography b-Blocker/ Aortic back pain coagulation CCB* Aneurysm studies CBC = complete blood count; CT = computed tomography; RUQ = right upper quadrant; LLQ = left lower quadrant; IV = intravenous; CCB = calcium channel blocker. * For systolic blood pressure of 120 to 130 mm Hg. CAUSES OF ACUTE SURGICAL ABDOMEN (AAS: upright chest radiograph, upright abdominal radiograph, and a flat abdominal radiograph) often Perforated Viscus shows free air and is diagnostic of perforated vis- Perforated viscus is a surgical emergency that can cus. Diseases that can progress to organ perforation lead to serious morbidity and, commonly, mortal- include mesenteric ischemia, diverticulitis, appendi- ity. To provide the best possible outcome, the emer- citis, bowel obstruction, cholecystitis, incarcerated/ gency physician must maintain a high level of clinical strangulated hernia, and peptic ulcer disease. Table suspicion for perforation in the patient with acute 1 highlights characteristic and important features of abdominal pain. Concurrent resuscitation and diag- some of these disease processes. nosis of the patient, along with mobilization of the appropriate resources (surgical consultation, operat- Appendicitis ing room team) are first-line goals. The abdominal Appendicitis occurs following obstruction of the lu- exam is often telling in these patients, but
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