Chapter 14. Abdominal Pain
Chapter 14. Abdominal Pain
Chapter 14. Abdominal Pain
Note: Large images and tables on this page may necessitate printing in landscape mode.
Mittelschmerz
Vascular disturbances
Embolism or thrombosis
Vascular rupture
Abdominal wall
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Inflammation of a viscus
Appendicitis
Typhoid fever
Typhlitis
Pain Referred from Extraabdominal Source
Cardiothoracic
Pulmonary embolus
Pleurodynia
Pneumothorax
Empyema
Esophageal disease, spasm, rupture, inflammation
Genitalia
Metabolic Causes
Diabetes
Uremia
Hyperlipidemia
Hyperparathyroidism
Porphyria
Neurologic/Psychiatric Causes
Herpes zoster
Tabes dorsalis
Causalgia
Functional disorders
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Psychiatric disorders
Toxic Causes
Lead poisoning
Snake bites
Uncertain Mechanisms
Narcotic withdrawal
Heat stroke
The diagnosis of "acute or surgical abdomen" is not an acceptable one because of its often misleading and
erroneous connotation. The most obvious of "acute abdomens" may not require operative intervention, and the
mildest of abdominal pains may herald an urgently correctable lesion. Any patient with abdominal pain of
recent onset requires early and thorough evaluation and accurate diagnosis.
The rate at which the irritating material is applied to the peritoneum is important. Perforated peptic ulcer may
be associated with entirely different clinical pictures dependent only on the rapidity with which the gastric juice
enters the peritoneal cavity.
The pain of peritoneal inflammation is invariably accentuated by pressure or changes in tension of the
peritoneum, whether produced by palpation or by movement, as in coughing or sneezing. The patient with
peritonitis lies quietly in bed, preferring to avoid motion, in contrast to the patient with colic, who may writhe
incessantly.
Another characteristic feature of peritoneal irritation is tonic reflex spasm of the abdominal musculature,
localized to the involved body segment. The intensity of the tonic muscle spasm accompanying peritoneal
inflammation is dependent on the location of the inflammatory process, the rate at which it develops, and the
integrity of the nervous system. Spasm over a perforated retrocecal appendix or perforated ulcer into the
lesser peritoneal sac may be minimal or absent because of the protective effect of overlying viscera. A slowly
developing process often greatly attenuates the degree of muscle spasm. Catastrophic abdominal emergencies
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such as a perforated ulcer may be associated with minimal or no detectable pain or muscle spasm in obtunded,
seriously ill, debilitated elderly patients or in psychotic patients.
The colicky pain of obstruction of the small intestine is usually periumbilical or supraumbilical and is poorly
localized. As the intestine becomes progressively dilated with loss of muscular tone, the colicky nature of the
pain may diminish. With superimposed strangulating obstruction, pain may spread to the lower lumbar region if
there is traction on the root of the mesentery. The colicky pain of colonic obstruction is of lesser intensity than
that of the small intestine and is often located in the infraumbilical area. Lumbar radiation of pain is common in
colonic obstruction.
Sudden distention of the biliary tree produces a steady rather than colicky type of pain; hence the term biliary
colic is misleading. Acute distention of the gallbladder usually causes pain in the right upper quadrant with
radiation to the right posterior region of the thorax or to the tip of the right scapula, and distention of the
common bile duct is often associated with pain in the epigastrium radiating to the upper part of the lumbar
region. Considerable variation is common, however, so that differentiation between these may be impossible.
The typical subscapular pain or lumbar radiation is frequently absent. Gradual dilatation of the biliary tree, as
in carcinoma of the head of the pancreas, may cause no pain or only a mild aching sensation in the
epigastrium or right upper quadrant. The pain of distention of the pancreatic ducts is similar to that described
for distention of the common bile duct but, in addition, is very frequently accentuated by recumbency and
relieved by the upright position.
Obstruction of the urinary bladder results in dull suprapubic pain, usually low in intensity. Restlessness without
specific complaint of pain may be the only sign of a distended bladder in an obtunded patient. In contrast,
acute obstruction of the intravesicular portion of the ureter is characterized by severe suprapubic and flank
pain that radiates to the penis, scrotum, or inner aspect of the upper thigh. Obstruction of the ureteropelvic
junction is felt as pain in the costovertebral angle, whereas obstruction of the remainder of the ureter is
associated with flank pain that often extends into the same side of the abdomen.
VASCULAR DISTURBANCES
A frequent misconception, despite abundant experience to the contrary, is that pain associated with
intraabdominal vascular disturbances is sudden and catastrophic in nature. The pain of embolism or thrombosis
of the superior mesenteric artery or that of impending rupture of an abdominal aortic aneurysm certainly may
be severe and diffuse. Yet, just as frequently, the patient with occlusion of the superior mesenteric artery has
only mild continuous diffuse pain for 2 or 3 days before vascular collapse or findings of peritoneal inflammation
appear. The early, seemingly insignificant discomfort is caused by hyperperistalsis rather than peritoneal
inflammation. Indeed, absence of tenderness and rigidity in the presence of continuous, diffuse pain in a
patient likely to have vascular disease is quite characteristic of occlusion of the superior mesenteric artery.
Abdominal pain with radiation to the sacral region, flank, or genitalia should always signal the possible
presence of a rupturing abdominal aortic aneurysm. This pain may persist over a period of several days before
rupture and collapse occur.
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ABDOMINAL WALL
Pain arising from the abdominal wall is usually constant and aching. Movement, prolonged standing, and
pressure accentuate the discomfort and muscle spasm. In the case of hematoma of the rectus sheath, now
most frequently encountered in association with anticoagulant therapy, a mass may be present in the lower
quadrants of the abdomen. Simultaneous involvement of muscles in other parts of the body usually serves to
differentiate myositis of the abdominal wall from an intraabdominal process that might cause pain in the same
region.
Referred pain of thoracic origin is often accompanied by splinting of the involved hemithorax with respiratory
lag and decrease in excursion more marked than that seen in the presence of intraabdominal disease. In
addition, apparent abdominal muscle spasm caused by referred pain will diminish during the inspiratory phase
of respiration, whereas it is persistent throughout both respiratory phases if it is of abdominal origin. Palpation
over the area of referred pain in the abdomen also does not usually accentuate the pain and in many instances
actually seems to relieve it. Thoracic disease and abdominal disease frequently coexist and may be difficult or
impossible to differentiate. For example, the patient with known biliary tract disease often has epigastric pain
during myocardial infarction, or biliary colic may be referred to the precordium or left shoulder in a patient who
has suffered previously from angina pectoris. For an explanation of the radiation of pain to a previously
diseased area, see Chap. 12.
Referred pain from the spine, which usually involves compression or irritation of nerve roots, is
characteristically intensified by certain motions such as cough, sneeze, or strain and is associated with
hyperesthesia over the involved dermatomes. Pain referred to the abdomen from the testes or seminal vesicles
is generally accentuated by the slightest pressure on either of these organs. The abdominal discomfort is of
dull aching character and is poorly localized.
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severe abdominal pain. Whenever the cause of abdominal pain is obscure, a metabolic origin always must be
considered. Abdominal pain is also the hallmark of familial Mediterranean fever (Chap. 323).
The problem of differential diagnosis is often not readily resolved. The pain of porphyria and of lead colic is
usually difficult to distinguish from that of intestinal obstruction, because severe hyperperistalsis is a prominent
feature of both. The pain of uremia or diabetes is nonspecific, and the pain and tenderness frequently shift in
location and intensity. Diabetic acidosis may be precipitated by acute appendicitis or intestinal obstruction, so if
prompt resolution of the abdominal pain does not result from correction of the metabolic abnormalities, an
underlying organic problem should be suspected. Black widow spider bites produce intense pain and rigidity of
the abdominal muscles and back, an area infrequently involved in intraabdominal disease.
NEUROGENIC CAUSES
Causalgic pain may occur in diseases that injure sensory nerves. It has a burning character and is usually
limited to the distribution of a given peripheral nerve. Normal stimuli such as touch or change in temperature
may be transformed into this type of pain, which is frequently present in a patient at rest. The demonstration
of irregularly spaced cutaneous pain spots may be the only indication of an old nerve lesion underlying
causalgic pain. Even though the pain may be precipitated by gentle palpation, rigidity of the abdominal muscles
is absent, and the respirations are not disturbed. Distention of the abdomen is uncommon, and the pain has no
relationship to the intake of food.
Pain arising from spinal nerves or roots comes and goes suddenly and is of a lancinating type (Chap. 16). It
may be caused by herpes zoster, impingement by arthritis, tumors, herniated nucleus pulposus, diabetes, or
syphilis. It is not associated with food intake, abdominal distention, or changes in respiration. Severe muscle
spasm, as in the gastric crises of tabes dorsalis, is common but is either relieved or is not accentuated by
abdominal palpation. The pain is made worse by movement of the spine and is usually confined to a few
dermatomes. Hyperesthesia is very common.
Pain due to functional causes conforms to none of the aforementioned patterns. Mechanism is hard to define.
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain and
altered bowel habits. The diagnosis is made on the basis of clinical criteria (Chap. 290) and after exclusion of
demonstrable structural abnormalities. The episodes of abdominal pain are often brought on by stress, and the
pain varies considerably in type and location. Nausea and vomiting are rare. Localized tenderness and muscle
spasm are inconsistent or absent. The causes of IBS or related functional disorders are not known.
Nothing will supplant an orderly, painstakingly detailed history, which is far more valuable than any laboratory
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or radiographic examination. This kind of history is laborious and time-consuming, making it not especially
popular, even though a reasonably accurate diagnosis can be made on the basis of the history alone in the
majority of cases. Computer-aided diagnosis of abdominal pain provides no advantage over clinical assessment
alone. In cases of acute abdominal pain, a diagnosis is readily established in most instances, whereas success
is not so frequent in patients with chronic pain. IBS is one of the most common causes of abdominal pain and
must always be kept in mind (Chap. 290). The location of the pain can assist in narrowing the differential
diagnosis (see Table 14-2); however, the chronological sequence of events in the patient's history is often
more important than emphasis on the location of pain. If the examiner is sufficiently open-minded and
unhurried, asks the proper questions, and listens, the patient will usually provide the diagnosis. Careful
attention should be paid to the extraabdominal regions that may be responsible for abdominal pain. An
accurate menstrual history in a female patient is essential. Narcotics or analgesics should not be withheld until
a definitive diagnosis or a definitive plan has been formulated; obfuscation of the diagnosis by adequate
analgesia is unlikely.
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In the examination, simple critical inspection of the patient, e.g., of facies, position in bed, and respiratory
activity, may provide valuable clues. The amount of information to be gleaned is directly proportional to the
gentleness and thoroughness of the examiner. Once a patient with peritoneal inflammation has been examined
brusquely, accurate assessment by the next examiner becomes almost impossible. Eliciting rebound tenderness
by sudden release of a deeply palpating hand in a patient with suspected peritonitis is cruel and unnecessary.
The same information can be obtained by gentle percussion of the abdomen (rebound tenderness on a
miniature scale), a maneuver that can be far more precise and localizing. Asking the patient to cough will elicit
true rebound tenderness without the need for placing a hand on the abdomen. Furthermore, the forceful
demonstration of rebound tenderness will startle and induce protective spasm in a nervous or worried patient
in whom true rebound tenderness is not present. A palpable gallbladder will be missed if palpation is so
brusque that voluntary muscle spasm becomes superimposed on involuntary muscular rigidity.
As in history taking, sufficient time should be spent in the examination. Abdominal signs may be minimal but
nevertheless, if accompanied by consistent symptoms, may be exceptionally meaningful. Abdominal signs may
be virtually or totally absent in cases of pelvic peritonitis, so careful pelvic and rectal examinations are
mandatory in every patient with abdominal pain. Tenderness on pelvic or rectal examination in the absence of
other abdominal signs can be caused by operative indications such as perforated appendicitis, diverticulitis,
twisted ovarian cyst, and many others.
Much attention has been paid to the presence or absence of peristaltic sounds, their quality, and their
frequency. Auscultation of the abdomen is one of the least revealing aspects of the physical examination of a
patient with abdominal pain. Catastrophes such as strangulating small intestinal obstruction or perforated
appendicitis may occur in the presence of normal peristaltic sounds. Conversely, when the proximal part of the
intestine above an obstruction becomes markedly distended and edematous, peristaltic sounds may lose the
characteristics of borborygmi and become weak or absent, even when peritonitis is not present. It is usually
the severe chemical peritonitis of sudden onset that is associated with the truly silent abdomen. Assessment of
the patient's state of hydration is important.
Laboratory examinations may be of great value in assessment of the patient with abdominal pain, yet with few
exceptions they rarely establish a diagnosis. Leukocytosis should never be the single deciding factor as to
whether or not operation is indicated. A white blood cell count >20,000/ L may be observed with perforation of
a viscus, but pancreatitis, acute cholecystitis, pelvic inflammatory disease, and intestinal infarction may be
associated with marked leukocytosis. A normal white blood cell count is not rare in cases of perforation of
abdominal viscera. The diagnosis of anemia may be more helpful than the white blood cell count, especially
when combined with the history.
The urinalysis may reveal the state of hydration or rule out severe renal disease, diabetes, or urinary infection.
Blood urea nitrogen, glucose, and serum bilirubin levels may be helpful. Serum amylase levels may be
increased by many diseases other than pancreatitis, e.g., perforated ulcer, strangulating intestinal obstruction,
and acute cholecystitis; thus, elevations of serum amylase do not rule out the need for an operation. The
determination of the serum lipase may have greater accuracy than that of the serum amylase.
Plain and upright or lateral decubitus radiographs of the abdomen may be of value in cases of intestinal
obstruction, perforated ulcer, and a variety of other conditions. They are usually unnecessary in patients with
acute appendicitis or strangulated external hernias. In rare instances, barium or water-soluble contrast study
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of the upper part of the gastrointestinal tract may demonstrate partial intestinal obstruction that may elude
diagnosis by other means. If there is any question of obstruction of the colon, oral administration of barium
sulfate should be avoided. On the other hand, in cases of suspected colonic obstruction (without perforation),
contrast enema may be diagnostic.
In the absence of trauma, peritoneal lavage has been replaced as a diagnostic tool by ultrasound, CT, and
laparoscopy. Ultrasonography has proved to be useful in detecting an enlarged gallbladder or pancreas, the
presence of gallstones, an enlarged ovary, or a tubal pregnancy. Laparoscopy is especially helpful in diagnosing
pelvic conditions, such as ovarian cysts, tubal pregnancies, salpingitis, and acute appendicitis. Radioisotopic
scans (HIDA) may help differentiate acute cholecystitis from acute pancreatitis. A CT scan may demonstrate an
enlarged pancreas, ruptured spleen, or thickened colonic or appendiceal wall and streaking of the mesocolon or
mesoappendix characteristic of diverticulitis or appendicitis.
Sometimes, even under the best circumstances with all available aids and with the greatest of clinical skill, a
definitive diagnosis cannot be established at the time of the initial examination. Nevertheless, despite lack of a
clear anatomic diagnosis, it may be abundantly clear to an experienced and thoughtful physician and surgeon
that on clinical grounds alone operation is indicated. Should that decision be questionable, watchful waiting
with repeated questioning and examination will often elucidate the true nature of the illness and indicate the
proper course of action.
FURTHER READINGS
Cervero F, Laird JM: Visceral pain. Lancet 353:2145, 1999 [PMID: 10382712]
Jones PF: Suspected acute appendicitis: Trends in management over 30 years. Br J Surg 88:1570, 2001
[PMID: 11736966]
Lyon C, Clark DC: Diagnosis of acute abdominal pain in older patients. Am Fam Physician 74:1537, 2006
[PMID: 17111893]
Silen W: Cope's Early Diagnosis of the Acute Abdomen, 21st ed, New York and Oxford: Oxford University Press,
2005
Tait IS et al: Do patients with abdominal pain wait unduly long for analgesia? J R Coll Surg Edinb 44:181, 1999
[PMID: 10372490]
BIBLIOGRAPHY
Attard AR et al: Safety of early pain relief for acute abdominal pain. BMJ 305:554, 1992 [PMID: 1393034]
Bugliosi TF et al: Acute abdominal pain in the elderly. Ann Emerg Med 19:1383, 1990 [PMID: 2240749]
Gatzen C et al: Management of acute abdominal pain: Decision making in the accident and emergency
department. J R Coll Surg Edinb 36:121, 1991 [PMID: 2051408]
Scott HJ, Rosin RD: The influence of diagnostic and therapeutic laparoscopy on patients presenting with an
acute abdomen. J R Soc Med 86:699, 1993 [PMID: 8308808]
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Taourel P et al: Acute abdomen of unknown origin: Impact of CT on diagnosis and management. Gastrointest
Radiol 17:287, 1992 [PMID: 1426841]
Weyant MJ et al: Interpretation of computed tomography does not correlate with laboratory or pathologic
findings in surgically confirmed acute appendicitis. Surgery 128:145, 2000 [PMID: 10922984]
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