gastrointestinal tract and abdomen ABDOMINAL PAIN AND ABDOMINAL MASS Blake D. Babcock, MD, Mohammad F. Shaikh, MD, Alexander E. Poor, MD, and Wilbur B. Bowne, MD* Acute abdominal pain and abdominal masses are two clini- inguinal.3 Our preferred method divides the abdominal cal entities that are intimately interconnected. In many cases, cavity into four quadrants—right upper, right lower, left abdominal pain and abdominal mass clinically present upper, and left lower—and makes specifi c reference to the together. Therefore, the diagnostic process for evaluating epigastrium and the hypogastrium as necessary. This meth- abdominal pain and abdominal masses is largely the same od of description also includes masses discovered within and has been preserved since ancient times. The varied the retroperitoneum and the abdominal wall. For practical differential diagnosis of such pathology was discussed in purposes, the abdominal wall begins from the diaphragm the Ebers Papyrus (ca. 1500 bc).1 Egyptian medical scholars superiorly and continues inferiorly to the pelvic cavity kept detailed notes chronicling the conditions encountered through the pelvic inlet. The anterior, posterior, and lateral and describing the methods of abdominal examination that boundaries of the abdominal wall should be familiar to sur- were based on studies of basic anatomy and embalming geons. For accurate assessment of the origin and character of practices. Centuries later, in his Book of Prognostics, the Greek the abdominal complaints, it is essential to possess a thor- physician Hippocrates (ca. 400 bc) discussed the prognostic ough understanding of the normal anatomy, the anatomic signifi cance of various types of abdominal fi ndings: variations that may be observed, and the distortions that may be caused by the various potential disease processes, The state of the hypochondrium is best when it is free from pain, soft, and of equal size on the right side and the left. But both intraperitoneal [see Table 1] and extraperitoneal [see if infl amed, or painful, or distended; or when the right and Table 2]. Further anatomic detail is available in other sources 4,5 left sides are of disproportionate sizes; all of these appear- [see Figure 1]. ances are to be dreaded. A swelling in the hypochondrium, that is hard and painful, is very bad…. Such swellings at the clinical history commencement of disease prognosticate speedy death. Such A careful and method- swellings as are soft, free from pain, and yield to the fi nger, ical clinical history occasion more protracted crises, and are less dangerous than should be obtained in 2 others. the patient with abdomi- Along with the basic methods of clinical evaluation known nal complaints. Key since antiquity, the modern surgeon has an armamentarium features of the history of sophisticated diagnostic studies that aid in the detection, include the dimensions diagnosis, and appropriate treatment of these frequently of abdominal symptoms (i.e., mode of onset, duration, overlapping clinical entities. The primary goals in the man- frequency, character, location, chronology, radiation, and agement of patients with abdominal pain and/or an abdom- intensity) and the presence or absence of any aggravating or inal mass are (1) to establish a differential diagnosis through alleviating factors and associated symptoms. Often such a obtaining a clinical history, (2) to refi ne that differential history is more valuable than any single laboratory or x-ray diagnosis with a physical examination and appropriate fi nding and determines the course of subsequent evaluation studies, and (3) to determine the role of operative interven- and management. tion in the treatment or refi nement of the working diagnosis. Unfortunately, when the ability of clinicians to take an organized and accurate history has been previously studied, the results have been disappointing.6 For this reason, the use Diagnosis of standardized history and physical forms, with or without As has been said of many professions besides surgery, the aid of diagnostic computer programs, has been recom- “You must know the territory.” A sound understanding mended.7–10 A large-scale study that included 16,737 patients of the normal anatomy is essential for the evaluation of the with acute abdominal pain demonstrated that integration of abdomen as particular abnormalities tend to be associated computer-aided diagnosis into management yielded a 20% with particular regions or quadrants of the abdomen. improvement in diagnostic accuracy, as well as statistically In general, the term abdominal in relation to pain and signifi cant improvements in the delivery of quality care.7 An masses refers to processes that lie anterior to the paraspi- example of a structured data sheet is a standardized pain nous muscles in a region bordered by the costal margins, chart assessment developed by the World Organization of the iliac crests, and the pubic symphysis. One method of Gastroenterology (OMGE) [see Figure 2]. Because this pain description divides the abdomen into nine areas: epigastric, chart is not exhaustive, individual surgeons may want to umbilical, suprapubic, right hypochondriac, left hypochon- add to it; however, they would be well advised not to omit driac, right lumbar, left lumbar, right inguinal, and left any of the symptoms and signs on the OMGE data sheet from their routine examination of patients with acute 11 * The authors and editors gratefully acknowledge the contribu- abdominal pain. tions of the previous authors, Alex Nagle, MD, FACS, and The patient’s own words often provide important clues Michael E. Zenilman, MD, FACS, to the development and to the correct diagnosis. The examiner should refrain from writing of this topic review. suggesting specifi c symptoms, except as a last resort. Any Scientifi c American Surgery © 2014 Decker Intellectual Properties Inc DOI 10.2310/7800.2001 12/14 gastro abdominal pain and abdominal mass — 2 Patient presents with acute abdominal pain and mass Obtain clinical history Assessment of Assess mode of onset, duration, frequency, character, location, chronology, radiation, and intensity of pain. Acute Abdominal Pain Look for aggravating or alleviating factors and associated and Abdominal Mass symptoms. Use structured data sheets if possible. Generate working diagnosis Perform basic investigative studies Proceed with subsequent management on the Laboratory: complete blood count, hematocrit, electrolytes, basis of the working diagnosis. creatinine, blood urea nitrogen, glucose, liver function tests, amylase, lipase, urinalysis, pregnancy test, ECG Reevaluate patient repeatedly. If patient does (if patient is elderly or has atherosclerosis) not respond to treatment as expected, reassess working diagnosis and return to differential Imaging: plain abdominal radiographs, US, CT, MRI, PET diagnosis. Tissue Diagnosis: percutaneous image–guided biopsy or endoscopic ultrasound–guided biopsy Acute surgical abdomen Subacute surgical abdomen Conditions necessitating immediate laparotomy Conditions necessitating urgent include ruptured abdominal aortic or visceral laparotomy include perforated aneurysm, ruptured ectopic pregnancy, hollow viscus, appendicitis, Meckel spontaneous hepatic or splenic rupture, major diverticulitis, strangulated hernia, blunt or penetrating abdominal trauma, and mesenteric ischemia, and ectopic hemoperitoneum from various causes. pregnancy (unruptured). Severe hemodynamic instability is the essential Laparoscopy is recommended for indication. acute appendicitis and perforated ulcers (provided that surgeon has sufficient experience and Emergent laparotomy competence with the technique). Definitive operative management as indicated Urgent laparotomy or laparoscopy Definitive operative management as indicated Scientifi c American Surgery 12/14 gastro abdominal pain and abdominal mass — 3 Generate tentative differential diagnosis Remember that the majority of patients will turn out to have nonsurgical diagnoses. Take into account effects of age and gender on diagnostic possibilities. Perform physical examination Evaluate general appearance and ability to answer questions; estimate degree of obvious pain: note position in bed; identify area of maximal pain; look for extra-abdominal causes of pain and signs of systemic illness. Perform systematic abdominal examination: (1) inspection, (2) auscultation, (3) percussion, (4) palpation. Perform rectal, genital, and pelvic examinations. Evaluate an abdominal mass in terms of location, size, shape, consistency, contour, presence or absence of tenderness, pulsatility, and fixation. Indeterminate surgical Observation Nonsurgical abdomen abdomen Observe patient carefully Nonsurgical conditions causing Staging Laparoscopy: In select and reevaluate condition acute abdominal pain include patients, this strategy can avoid periodically. intraperitoneal [see Table 1] and the morbidity of a large Consider additional extraperitoneal [see Table 2] laparotomy and allow earlier disorders. initiation of systemic or investigative studies (e.g., locoregional therapy for CT, US, diagnostic peritoneal lavage, abdominal mass associated Patient should be hospitalized radionuclide imaging, with malignancy. and observed Diagnostic Laparoscopy: angiography, MRI, and Recommended when surgical GI endoscopy). Provide narcotic analgesia as cause of abdominal pain is appropriate. suspected but its probability Symptoms fail or Observe patient carefully and is not high enough to warrant investigative studies reevaluate condition open