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Home , Bowel obstruction, Fecalith, Psoas sign, Surgical emergency

Acute Surgical When a patient presents to the ED with acute abdominal The Basics , 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 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 , 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 , as several of the underlying surgical abdomen, ie, those cases in which a patient disease processes that result in an 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

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can present atypically with abdominal pain, such as to minimize guarding, which is a natural response , 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 , which starts as generalized suggestive of 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 , hyper- uncertain diagnosis after initial evaluation. Changes tension, coagulation disorders, collagen vascular dis- in the exam findings can narrow the differential di- ease, previous , and history of gastrointesti- agnosis and also help determine appropriate timing nal illnesses (including Crohn’s disease and ulcerative of treatments and/or consultations. ). 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 .2 thorough skin exam is important, as some patients should also include questions regarding fever, nau- will have discolorations that point to a diagnosis. sea/, 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 proportion to exam abdominal findings pain

Appendicitis Periumbilical migrat- Anorexia, CBC CT Antibiotics ing to McBurney’s , point vomiting

Cholecystitis RUQ Pain, , Bilirubin, RUQ Antibiotics fever lipase ultrasonography measurement, 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 that can cus. Diseases that can progress to organ perforation lead to serious morbidity and, commonly, mortal- include mesenteric ischemia, , appendi- ity. To provide the best possible outcome, the emer- citis, , , incarcerated/ gency physician must maintain a high level of clinical strangulated , and . 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 imaging men of the , typically secondary to a . must often be used to augment the clinical exam The obstruction leads to trapping of mucosal and and provide important information to the surgeon, bacterial fluids and a subsequent increase in appendi- who must plan the procedure. An upright chest ceal volume. Increased intraluminal pressure causes radiograph by itself or an acute abdominal series distention, resulting in visceral pain that is typically

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diffuse or periumbilical. Subsequent inflammation that develops around the appendix leads to perito- TABLE 2. Alvarado Scale neal irritation, which causes the pain to localize, typi- cally near McBurney’s point. Over time, continued pressure leads to appendiceal wall ischemia and the Exam Finding Point(s) possibility of rupture. History Patients often present with anorexia and ab- Migration of pain 1 dominal pain followed by vomiting. Unfortunately, Anorexia 1 atypical presentations are common as well. The most sensitive signs for appendicitis are right lower quad- Nausea/vomiting 1 rant pain (classically described as periumbilical pain Physical Exam migrating to the right lower quadrant), abdominal wall RLQ tenderness 2 rigidity, pain before vomiting, and a positive psoas Rebound 1 sign. Anatomical variations of the appendix play a role in atypical presentations and location of pain. Increased temperature 1 One study showed that 32% of pediatric patients do Laboratory Results not have the classically described right lower quad- Leukocytosis 2 rant pain, making the diagnosis difficult and pos- Left shift 1 sibly delaying definitive treatment.3 Therefore, the high clinical suspicion for appendicitis is warranted RLQ = right lower quadrant in the patient with acute abdomen. A recent study Adapted from Alvarado.6 by Frei et al demonstrated that delayed diagnosis of appendicitis declined following widespread use of CT scanning, decreasing from 7.8% in 1998 to higher should receive a surgical consultation without 3.0% in 2004.4 imaging (score sensitivity, 77%; specificity, 100%).7 Imaging, such as CT or ultrasonography, is com- Treatment for appendicitis is appendectomy, monly employed to facilitate diagnosis. On ultra- because the risks of rupture are well-known. It is sound, a noncompressible appendix greater than 6 important to start antibiotics in the ED. Other dis- mm is considered diagnostic of appendicitis, and orders can mimic appendicitis, so it is important to thickened appendiceal wall and periappendiceal fluid have a broad and to consider are highly suggestive.5 can be particu- other possibilities. In some hospitals, it is not uncom- larly useful in pregnant patients, but CT is often mon for an appendix to be found normal during sur- preferred in the ED because it is accessible and it gery for presumed appendicitis; thus, surgeons may can be used to evaluate other etiologies. Prudent CT request CT or another imaging modality to confirm scanning minimizes unnecessary exposure to ioniz- the diagnosis. This request depends on the surgeon’s ing radiation. On CT, an appendix dilated more than experiences and habits, patient age and history, and 6 mm, a thickened appendiceal wall, a fecalith, and/ other findings obtained during evaluation. or phlegmon, all suggest acute appendicitis in the proper clinical setting.5 When it is not readily ap- Mesenteric Ischemia parent whether CT should be ordered, the Alvarado Mesenteric ischemia can have one of four causes: scale can be used as an aid in decision making.6 The arterial emboli, arterial thrombus, vasospasm, and Alvarado scale assigns points for certain signs, symp- venous thrombus. Mesenteric ischemia is classically toms, and laboratory values, as noted in Table 2.6 described as causing abdominal pain out of propor- McKay and Shepherd concluded that to confirm a tion to exam findings in affected patients. Patients diagnosis of appendicitis, ED patients with Alvarado often report severe generalized or periumbilical pain. scores of 3 or lower probably do not need CT (score They may also have bloody bowel movements, nau- sensitivity, 96.2%; specificity, 67%), while those with sea, vomiting, food aversion, weight loss, abdominal scores of 4 to 6 should undergo CT (score sensitivity, distention, and peritoneal symptoms. Postprandial 35.6%; specificity, 94%), and those with scores of 7 or abdominal pain is the most prevalent preceding www.emedmag.com JULY 2010 | EMERGENCY MEDICINE 9 ACUTE SURGICAL ABDOMEN

symptom8 and is sometimes described as “intestinal fects of these processes (eg, bowel wall thickening, angina.” inflammation, perforation), as well as for evaluating Mesenteric ischemia can be either acute or other causes of abdominal pain. chronic, with the acute type presenting emergently. In a patient with peritoneal signs in whom mes- The natural history of mesenteric ischemia produces enteric ischemia is suspected, early surgical consul- a spectrum of clinical findings and abnormalities on tation is crucial, and the consult is often initiated workup, with individual presentation depending on before the diagnosis is established definitively. These the extent of disease progression. The exam may yield patients often require an emergent for significant findings or may reveal very little. The lat- resection of infarcted bowel in order to survive. For ter situation, unfortunately, can be falsely reassuring. patients without peritoneal signs, thrombolysis or Thus, when mesenteric ischemia is suspected but the vascular bypass may be considered by the consul- exam or initial workup provide little support for the tant surgeon. Anticoagulation therapy is indicated diagnosis, observation and serial examination and for acute mesenteric venous thrombosis, which may testing (usually in concert with a surgical consult) not be diagnosed until the patient is in the operat- may be of benefit. Mesenteric ischemia should be ing room. Early, empiric treatment is also part of the differential diagnosis in any patient with generally recommended.10 abdominal pain and a history of atrial fibrillation, hypercoagulable state, heart valve disease, recent co- Disease caine use, or vascular disease, even if the exam and Biliary tract disease is frequently diagnosed in the workup are relatively unremarkable. ED, with cholecystitis being much more common Diagnostic workup of patients with mesenteric than cholangitis. Right upper quadrant pain and ischemia can be frustrating. Some patients have vomiting, especially in the presence of fever, suggests leukocytosis and elevated amylase levels. Acidosis, if the potential for surgical consulatation for biliary present, generally indicates that the disease has pro- tract disease. On physical exam, the presence of Mur- gressed to a late stage and the patient already has full- phy’s sign suggests cholecystitis. Workup for biliary thickness bowel . Imaging is often used to aid tract disease includes , renal function, a in diagnosis. Although an- complete blood count, and measurements of serum >>FAST TRACK<< giography is the gold stan- bilirubin, alkaline phosphatase, and lipase levels. In Mesenteric ischemia dard exam, it is not available addition, imaging should be ordered, especially in should be part of the in many EDs. CT angiog- elderly patients. Ultrasonography of the right up- differential diagnosis raphy can be a useful tool per quadrant is the test of choice and is commonly in the diagnosis of mesen- utilized in the ED. in any patient with teric ischemia, with recent are common in American adults, and abdominal pain studies showing a sensitiv- the prevalence increases with age. Gallstones can and a history of ity of 96% and specificity lodge anywhere in the biliary tract, from the gall- atrial fibrillation, of 94%.9 Common findings bladder neck to the common . Prolonged hypercoagulable state, indicative of mesenteric obstruction leads to inflammation and promotes sub- heart valve disease, ischemia include pneuma- sequent bacterial invasion. In many cases, patients recent cocaine use, or tosis intestinalis, venous presenting with an acute surgical abdomen caused vascular disease, even if gas, superior mesenteric by biliary tract disease have had a delay in diagnosis. the exam and workup are artery (SMA) occlusion, ce- This occurs more often in elderly patients, as the relatively unremarkable. liac and inferior mesenteric early presentation of disease in this age-group can arterial occlusion with distal be subtle, and thus, the diagnosis is easily missed. If SMA disease, and/or arterial embolism. Alternatively, biliary tract disease is diagnosed as the cause of a bowel wall thickening combined with a finding of a patient’s acute abdomen, early antibiotics with fluid focal lack of bowel wall enhancement, solid organ resuscitation and surgical consultation are critical for infarction, or venous thrombosis also suggests the a favorable outcome. Patients who do not respond diagnosis.9 CT angiography is useful for evaluating to initial therapy may require emergent biliary de- arterial and venous occlusions and the secondary ef- compression.

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It is particularly important to recognize ascending ischemia and necrosis. This occurs most commonly cholangitis, as this form of biliary tract disease can in a closed loop obstruction. become fulminant if it is not treated appropriately. Patients tend to present with the classic triad of Charcot’s triad of right upper quadrant pain, fever, abdominal pain, vomiting, and obstipation. However, and jaundice is classically described in cholangitis because there is a continuum from partial to com- and can progress to Reynolds’ pentad with the ad- plete obstruction, the severity of dition of mental status changes and shock, which may vary. For example, early in the course of an SBO, represents the extreme of the spectrum. Ascending patients may still have some bowel movements and cholangitis typically results from obstruction of the gas in the . Laboratory testing in SBO has with subsequent migration of bac- limited diagnostic value in the ED setting, but it teria into the lymphatics and hepatic veins. Thus, it can be useful in identifying and elec- is important to maintain a high level of suspicion trolyte abnormalities that should be addressed prior for this disease. to surgery. Imaging is needed to assess whether the obstruction is partial or complete. An AAS is cost- Diverticulitis effective and provides useful diagnostic clues. If an Diverticulitis occurs when bacteria proliferate within obstruction is present, the AAS will show dilated a , a process that can lead to perfora- loops of small bowel, air-fluid levels, and a paucity tion and acute surgical abdomen. Diverticulitis is of air in the colon and rectum. Abdominal radio- more common in the elderly and often causes pain graphs were found to have a sensitivity of 82% and in the left lower quadrant but can occur through- specificity of 83% in diagnosing SBO, but accuracy out the colon. As the infection progresses, the wall was dependent on the radiologist’s level of experi- tension of the diverticulum can increase, leading to ence.13 CT is often employed, since it can localize a spontaneous rupture. The rupture can be relatively transition point and identify other intra-abdominal contained, forming an abscess, or it can be a large processes. Additionally, CT can help differentiate be- perforation leading to acute peritonitis. Interestingly, tween SBO, closed loop obstruction, , or colonic Issa et al found that recurrent bouts of diverticulitis obstruction. do not correlate with a more complicated clinical Therapy in the ED 11 >>FAST TRACK<< course. They found that patients without a previous generally includes fluid Therapy for small bowel ob- episode of diverticulitis had a higher rate of perfora- resuscitation, placement struction in the ED generally tion, while patients with a history of diverticulitis had of a nasogastric tube for a higher rate of phlegmon or abscess formation. CT decompression, analgesia, includes fluid resuscitation, of the abdomen and pelvis with IV contrast is useful , and a surgical placement of a nasogastric for assessing the extent of diverticulitis and evaluat- consult. With a complete tube for decompression, an- ing for abscess and/or perforation. Serial abdominal SBO, the risk of ischemia algesia, antiemetics, and a exams will ensure early recognition of disease pro- and perforation is signifi- surgical consult. gression and the need for surgical intervention, if cant. Thus, emergent sur- applicable. Antibiotics are essential in the treatment gical decompression is required. Patients with partial of diverticulitis, as well. SBO are often admitted and observed for progres- sion versus resolution of signs and symptoms over Small Bowel Obstruction the next 48 hours. Any evidence of developing peri- Small bowel obstruction (SBO) is a common surgi- tonitis should prompt urgent surgical intervention. cal disorder of the .12 Adhesions from previous surgeries account for the majority of SBO Abdominal Aortic Aneurysm cases, while other etiologies, including and Patients with a ruptured abdominal aortic aneurysm Crohn’s disease, are less frequently seen.12 With SBO, (AAA) often die prior to arrival in the ED, or after swallowed food, liquid, and air, as well as secretions arrival but before reaching the OR.14 Often, patients from the GI tract, progressively accumulate proxi- with an AAA are unaware of it prior to the onset of mal to the obstruction. Areas with high intraluminal symptoms; thus, a high index of suspicion on the part pressures can impair blood flow, causing intestinal of the emergency physician is paramount. Patients www.emedmag.com JULY 2010 | EMERGENCY MEDICINE 11 ACUTE SURGICAL ABDOMEN

with AAA frequently complain of sudden severe ab- pertinent information quickly in order to stabilize and dominal and/or back pain and may also note a syn- refer the patient is crucial. As always, proper manage- copal episode with the onset of pain, which likely ment from the outset of the patient’s contact with the represents the initial rupture. The patient presenting hospital provides the best possible outcome. ■ to the ED with a symptomatic AAA likely has a con- tained rupture and may initially be hemodynamically REFERENCES stable. Often, delays in diagnosis occur while other 1. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambula- causes of the abdominal pain are considered, particu- tory Medical Care Survey: 2006 emergency department sum- mary. Natl Health Stat Report. 2008(7):1-38. larly if the patient does not have a history of AAA. 2. Muñiz AE, Evans T. Acute gastrointestinal manifestations Patients in whom a ruptured AAA is suspected associated with use of crack. Am J Emerg Med. 2001; need an emergent vascular surgery consultation. 19(1):61-63. Quick, targeted bedside ultrasonography can be 3. Becker T, Kharbanda A, Bachur R. Atypical clinical features of pediatric appendicitis. Acad Emerg Med. 2007;14(2):124-129. useful in these patients if it is available and the pa- 4. Frei SP, Bond WF, Bazuro RK, et al. Appendicitis outcomes tient’s body habitus is favorable; however, imaging with increasing computed tomographic scanning. Am J Emerg should not delay consulta- Med. 2008;26 (1): 39-44. tion. Due to the instability 5. Rybkin AV, Thoeni RF. Current concepts in imaging of appendi- >>FAST TRACK<< citis. Radiol Clin North Am. 2007;45(3):411-422, vii. of these patients, CT gen- 6. Alvarado A. A practical score for the early diagnosis of acute Patients with AAA fre- erally should be reserved appendicitis. Ann Emerg Med. 1986;15(5):557-564. quently complain of sud- for cases in which the 7. McKay R, Shepherd J. The use of the clinical scoring system den severe abdominal and/ probability of rupture is by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med. 2007;25(5): or back pain and may also low. In addition to surgical 489-493. note a syncopal episode consultation, preoperative 8. Kolkman JJ, Mensink PB, van Petersen AS, et al. Clinical with the onset of pain, lab work (especially blood approach to chronic gastrointestinal ischaemia: from ‘intes- tinal angina’ to the spectrum of chronic splanchnic disease. which likely represents the typing and crossmatching) Scand J Gastroenterol Suppl. 2004;(241):9-16. initial rupture. and mobilization of the 9. Kirkpatrick ID, Kroeker MA, Greenberg HM. Biphasic CT with operating room team are mesenteric CT angiography in the evaluation of acute mesen- required. Tight regulation of blood pressure is cru- teric ischemia: initial experience. . 2003;229(1):91-98. 10. Wyers M. Acute mesenteric ischemia: diagnostic approach cial to limit the wall tension of the aneurysm and and surgical treatment. Semin Vascular Surg. 2010;23(1):9-20. decrease the risk for further damage. Decompensa- 11. Issa N, Dreznik Z, Dueck DS, et al. Emergency surgery tion should be anticipated: ensure adequate IV ac- for complicated acute diverticulitis. Colorectal Dis. 2009; cess, the availability of blood, and adequate patient 11(2):198-202. 12. Cappell MS, Batke M. Mechanical obstruction of the small monitoring. bowel and colon. Med Clin North Am. 2008;92(3):575-597, vii. 13. Thompson WM, Kilani RK, Smith BB, et al. Accuracy of CONCLUSION abdominal in acute small-bowel obstruction: does reviewer experience matter? AJR Am J Roentgenol. Emergency physicians are called upon every day to 2007;188(3):W233-238. diagnose patients who have an acute surgical abdomen. 14. Tekwani K, Sikka R. High-risk chief complaints III: abdomen and The ability to recognize the condition and to gather extremities. Emerg Med Clin North Am. 2009;27(4):747-765, x.

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