Subject:

Topic:
Lecturer:
Date:

Surgery
3.1 Evaluation of Acute Abdominal Pain

Dr. Alcedo

February 3, 2014

OUTLINE

I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.

Introduction
Acute Abdomen
History
Physical Examination
Evaluation and Diagnosis
A. Laboratory
B. Imaging
Categories After Initial Evaluation
Algorithms for the Approach to
Patients with Acute Abdominal Pain
Differential Diagnosis
Indicators for Urgent Laparotomy
Laparotomy or Laparoscopy

References:
Recording - italicized
th
Sabiston Textbook of Surgery, 19 edition, Chapter 47

I.
INTRODUCTION



CASE 1. A 55 year old male consulted in the ER because of

severe pain which suddenly awakened him in the early hours

of the morning associated with generalized muscle guarding.

He is most likely suffering from which of the following:

A. Small bowel intestinal obstruction

B. Acute cholecytitis

C. Ureteral colic

D. Perforated peptic ulcer disease



Review of Anatomy maximal acid production is during hours

in the morning (also experienced by people with hyperacidity)

Sudden, generalized pain pouring acid in your GI will cause

inflammation of the peritoneal lining

Involuntary muscle guarding even if patient is asked to relax,

he cannot soften his abdominal wall

Question to ask yourself: Is this life threatening? YES


II.
ACUTE ABDOMEN

Abdominal pain undiagnosed for less than 7 days (some consider

up to 10 days as acute)

Accounts for 1% of all hospital admissions because majority are

discharged after initial examination while some would require
immediate surgery

Questions to ask yourself while examining:

o Is this a surgical abdomen?
If you miss the diagnosis, its either you manage a
surgical patient medically or a medical patient
surgically. Either way the consequences are somewhat
unacceptable
o If it is, does it require immediate surgery or can it be
done a few days after?
Is this case very urgent? Delaying a surgery that is
strongly indicated can be lethal for a patient.



Trans Group: Nicanor Ong, E.

Second Semester A.Y. 2013-2014

III.
HISTORY
Hollow viscus obstruction insidious onset of diffuse dull aching
pain, associated with nausea and vomiting, unable to lie still, no
alleviating factors
Early inflammatory process of solid viscera diffuse dull ache
pain
Progression of inflammatory and obstructive process
progression in several hours into sharp and stabbing pain,
aggravated by movement, coughing, and relieved by lying still
Localized Peritonitis localized tenderness with rebound and
muscle guarding
Perforation, strangulation, spontaneous bleeding sudden
onset of pain with progression with minutes to a few hours;
early sharp localization, progressing to generalized tenderness
with rebound and rigidity; referred pain to the shoulder tip and
scapula with blood or pus in the sub-phrenic space

Somatic Pain
USE CLITAA IN TAKING THE HISTORY

Characteristic: Somatic vs. Visceral

o Let patient talk and provide his/her own description of
the pain before you suggest specific characteristics
(e.g. burning, sharp, etc)

Location: Where is it? Where does it radiate?

Intensity use the pain score (0 absence of pain; 10 equal to

the pain of labor; If you encounter such a patient, do not force
your patient to answer your questions.

Time course: Acute? Intermittent? Sudden vs. Progressive

Aggravating and Alleviating Factors

Associated Signs and Symptoms

Elicited by direct irritation of the parietal peritoneum

Mediated by affarent somatic nerve fibers

Localized in the dermatome supplied by the segmental nerve

roots innervating the parietal peritoneum

Sharp and well-localized

A. Hollow Viscus Perforation (Sudden onset, severe)

When a seemingly healthy patient feels like the pain was
suddenly switched on
Can lead to neurogenic shock
Edited by: Marianne Sadaya

Page 1 of 10

Sudden onset of excruciating pain suggests intestinal

perforation, arterial embolism with ischemia, and other
conditions like biliary colic.
o Ureteral colic (may be constant)
o Perforated ulcer
o Ruptured aortic aneurysm

From the lecturer: Perforation of a hollow viscus resolve in the
spillage of the sulcus entericus into the the peritoneal cavity;
peritoneal signs indications for surgery

B. Infectious Process (Gradual progressive pain)

Worsens over time
o Cholecysitis
o Hepatitis
o Pancreatitis
o Appendicitis
o Tubo-ovarian abscess or ectopic pregnancy
o Diverticulitis at the LLQ, are of sigmoid colon
From the lecturer: pancreatitis some surgical, some medical;
Abdominal pain that would present as surgical but actually medical



CASE
2. Appendicitis

25 year old male complaining of 10 hour history of periumbilical

pain
which radiated initially to the right upper quadrant and later
localized to the right lower quadrant. Associated with fever,
on

anorexia,
vomiting. In PE there is rebound tenderness.
a 2nd yr med student were to evaluate this patient and CBC
If

results
are normal, urinalysis showed little RBC and WBCs; will

this affect your diagnosis? Clincial findings sometimes contradict
clincial evaluation. Stick to clincal findings if you know its
the

right!



CASE
3. Acute Cholecystitis
th

Patient had 4
attack today. Colicky right upper quadrant pain 3

times in the past lasting for about 2-3h. Prenup of ultrasound

showed
acute cholecyctitis. 26mm. site of initial pain:

periumbilical
pain bec of distention of the appendix


C. Hollow Viscus Obstruction (Colicky, crampy, intermittent)

Biliary colic RUQ; aggravated by a fatty meal, where

cholecystokinin stimulates gall bladder contraction and since
theres a stone obstructing the cystic duct, the pressure in the
gall bladder rises and produces pain
o Ureteral colic/Kidney Stones flank pain that goes down
o Small bowel obstruction periumbilical area
o Colonic obstruction hypogastric area
From the lecturer: However, a patient with acute gastroenteritis or
diarrhea may present like this. Thats why its important to diagnose
before performing a surgery!
Obstruction of a hollow viscous - tumors in the colon can result to
obstruction of the sigmoid and if surgery is not done in an acute
setting, the bowel will perforate. The first portion that will perforate
will be the cecum because it has the largest diameter. Cecum surgery
must be done before perforation begins otherwise it will become
complicated


Visceral Pain

Caused by distension of organs

o Poorly localizing because it is innervated by autonomic
nerve fibers vague and poorly localized to the midline
(epigastrium, periumbilical region or hypogastrium)
depending on the origin from the primitive foregut,
midgut or hindgut

Solid organ visceral pain in the abdomen is located in the

quadrant of the involved organ (e.g. liver pain is across the RUQ)

Small Bowel Obstruction poorly localized periumbilical pain

Colonic Pain centered between umbilicus and pubis symphysis

Pancreatitis - epigastric pain radiating to the back

Renal Colic - colicky pain radiating to the groin

Page 2 of 10

Referred Pain

Pain perceived at a site distant from the primary affected organ

Due to convergence of afferent fibres from separate areas in the
posterior horn of the spinal cord
o RIGHT SHOULDER liver, gall bladder (cholecystitis), right
hemidiaphragm via C3 to C5 nerve roots
o LEFT SHOULDER heart, tail of pancreas (pancreatitis),
spleen, left hemidiaphragm
o SCROTUM and TESTES ureter via splanchnic nerves of T11-
L1 or hypogastric plexus of S2-S4
Non-surgical causes of Abdominal Pain

Diffuse, mild, dull discomfort

Vomiting usually precedes the onset of pain
Diffuse, non-specific abdominal tenderness
No rebound tenderness and no muscle guarding
Aggravating and Alleviating Factors

Relieved by antacids: Peptic Ulcer Disease

Will not be relieved by Proton-Pump Inhibitors right away
Aggravated by movement: Peritonitis
Aggravated by fatty food intake: Biliary Tract Disease
o Bile is released from the gallbladder and if there is a stone
obstructing the cystic duct the pressure inside the gallbladder
increases and causes a colicky pain in the RUQ.
Eating worsens the pain: pain of bowel obstruction, biliary colic,
pancreatitis, diverticulitis, or bowel perforation
Eating relieves the pain: nonperforated peptic ulcer disease or
gastritis
o

NAUSEA, VOMITING, HEMATEMESIS

o

Associated Signs and Symptoms

Upper abdomen is distended, lower abdomen is
scaphoid may be due to gastric outlet obstruction
patient will vomit (Vomitus is white due to gastric
acid. No staining of bile since the food has not passed
through the pylorus since there is an obstruction)
Patient with pancreatic cancer, large enough to
obstruct the duodenum patient will vomit (Vomitus
is bile-stained due to secretion of bile by the gall
bladder at the second part of the duodenum;
Importance: helpful in diagnosis and planning the
patients treatment. An obstruction in the duodenum
will have a harder surgical procedure - Whipples
procedure)
Relationship to other symptoms

Medical Abdomen Vomit FIRST, then PAIN

(Found in conditions like gastroenteritis)

Surgical Abdomen PAIN first, then VOMIT

(stimulation of the medullary efferent fibers
that are triggered by visceral afferent pain
fibers); peritoneal irritation leads to rebound
tenderness and muscle guarding; thus,
always an indication for surgery!

FEVER - Sign of an inflammatory

process (RLQ without fever - Not
appendicitis)

From the lecturer: The earlier, the more proximal the lesion:
obstruction in the esophagus, once patient swallows, vomit
immediately. If obstruction in the pylorus because of peptic ulcer
disease, will vomit only when stomach gets filled
Not sure of diagnosis? Need more observation this is the time to
request for diagnostic tests. However, if patient presents with a
history compatible with abdominal aortic anerysm, dont request for a
CT scan because patient will die in the CT scan room. Exigent time of
abdominal catastrophy

BOWEL MOVEMENT
o Change in color of feces (Clay-colored: obstruction of
the biliary tree since bile cannot pass through)
o Consistency
o Constipation: mechanical obstruction or peristalsis
o Diarrhea: infectious enteritis, inflammatory bowel
disease or parasitic contamination
o Bloody: as above or due to ischemia
o No need to smell
From the lecturer: Patient complains of pencil shaped stools:
obstructing lesion is in the descending colon (cecum: liquid stool;
rectum: solid stool because of small hole)

URINARY SYMPTOMS
o Frequency
o Hematuria
o Change in color of urine (Tea-colored: beginning
jaundice; ask for RUQ pain)

ANOREXIA, WEIGHT LOSS

From the lecturer: 70 year old patient presents with colicky abdominal
pain (gradually progressive) distending abdomen with moderate to
severe weight loss for several weeks. Think of Malignancy: what tests:
colonoscopy or CT scan? Not only to diagnose the disease but to help
plan the mode of tratement. If surgery, when and what.

Menstrual History for women in the Reproductive age group

GYNECOLOGIC SYMPTOMS
Sexual Activity
Amenorrhea
Vaginal Bleeding
Vaginal Dischage
Amenorrhea
Day of Cycle
Medical History

Hypertension, Coronary Artery Disease: patient with

subendocardial infarcts usually presents with epigastric pain.
The worse thing that you can do is manage patient with peptic
ulcer dse instead of infarcts

Atrial fibrillation 10/10 abdominal pain with a soft abdomen;

no other physical examination findings (vascular emergency); if
bowel develops gangrene develop generalized muscle
perforation guarding and distended abdomen (important to
diagnose patient with atrial fibrillation: SURGERY!!)
o Infarction atrial fibrillation can throw an embolus into the
superior mesenteric artery infartcion of the small bowel
(important: past health history and medication history); pulse
is regularly irregular, severe pain without obvious peritoneal
irritation, think of a vascular problem because this will dictate
the tempo of how to manage the patient
Page 3 of 10

Pulmonary Disease
Previous surgery colicky abdominal pain presenting with
intestinal obstruction; 2-3 times surgery in the past; intestinal
obstruction secondary to adhesions
Alcohol history acute liver hepatitis might be mistaken for
gallstones
Smoking History
Drug Abuse

IV.
PHYSICAL EXAMINATION

General Examination:

Vital signs - will tell you the degree of dehydration of patient

and possible atrial fibrillation. Patient vomiting with tachycardia
and hypotension means patient is severely dehydrated.

Look for signs of pallor if suspecting ectopic pregnancy or

abdominal aneurysm

Acetone smell- medical emergency not sugrical

Examination of chest and heart

Abdominal examintaion

Patient is agitated nd unable to lie still visceral pain;

suggestive of hollow viscus obstruction and strangulation

Patient is lying motionless in bed parietal pain; suggestive of

peritonitis

Patient is drowsy with decreased responsiveness suggestive of

hemodynamic instability and/or sepsis

Expose from nipple to mid-thigh

Check for abdominal distention and/or swelling

Inspection of the Abdomen

Look for scars, fistulae, sinuses
Check for istended superficial veins
Ecchymosis: Cullens sign hemmorahhguc pancretitis
Gray-Turners sign

Figure 5. Ecchymosis

Check for peritoneal irritation

Presence of cough tenderness, rebound tenderness (can also be

Palpation of the Abdomen

elicited by percussing), involuntary muscle guarding (for
children: tickle and then touch both sides of the abdomen; If left
side relaxes and right side remains hard involuntary)
Pinpoint the area of maximal tenderness
Check for organomegaly
Check for the presence of tympani (presence of gas)
Check for shifting dullness

Figure 6. Palpation of the Abdomen

Perform superficial and deep palpation

Use the pulp of the fingers and not the tip

Examine the most tender area last

Perform percussion if possible

Auscultate away from pain just like when you palpate to avoid more
pain the area
Auscultation of the Abdomen
Watch out for incarcerated hernia (seen in the scrotum) in the elderly
with abdominal distention

High-pitched tinkling sounds suggestive of intestinal

obstruction

Hypoactive bowel sounds enteritis and intstinal ischemia

Absent bowel sounds check for 1-2min (dont just multipy;

listen for thw whole 2mins before declaring absent bowel
sounds)


V.
EVALUATION AND DIAGNOSIS
A. Laboratory Studies
Considered routine in evaluation of a patient with an acute
abdomen
Help in confirmation of inflammation or infection present
Aid in elimination of some of the most common nonsurgical
conditions

o Hemoglobin level (CBC) and White blood cell count with
differential
valuable because most patients with acute abdomen will
have leukoytosis or bandemia
o Electrolyte, BUN, creatinine levels
Assist in evaluating the effect of factors: vomiting or third
place fluid losses
May suggest an endocrine or metabolic diagnosis as the
cause
o Amlyase and Lipase
may suggest pancreatitis but can also be elevated in
disorders, such as small bowel infarction or duodenal ulcer
perforation
normal levels do not exclude pancreatitis as a possible
diagnosis caused by effects of chronic inflammation on
enzyme production and timing factors
o Liver function tests (Total and direct bilirubin, serum
aminotransferase, alkaline phosphatase level)
for evaluating potential biliary tract causes


Page 4 of 10

o Urinalysis
In diagnosis of bacterial cystitis, pyelonephritis and certain
endocrine abnormalities (e.g. diabetes, renal parenchymal
disease)
Urine culture- confirms suspected UTI and direct antibiotic
therapy but cannot be done in time to be helpful in the
evaluation of acute abdomen
o Urine human chorionic gonadotropin (HCG) level
Suggest pregnancy as a confounding factor in the patients
presentation or aid in decision making on therapy
o Occult blood test
Can be helpful in evaluation but nonspecific
o Stool test
for ova and parasite evaluation
C. difficile culture and toxin assay
Helpful if diarrhea is a component of the patients
presentation

Improvements in imaging techniques resulted in more rapid
operative correction of the problem, with less morbidity
and mortality
No imaging technique can replace a careful history and
physical examination
B.

o 10% of gallstones
o 90% renal stones
o Pancreatic calcifications with chronic pancreatitis,
calcification in abdominal aortic aneurysm, visceral artery
aneurysm, atherosclerosis in visceral vessels
Identifies gastric outlet obstruction and obstruction of proximal,
mid, or distal small bowel in upright and supine abdominal
radiographs (step ladder sign airfluid levels- only seen in
upright position)
Can also aid in determining if complete or partial small bowel
obstruction presence or absence of gas.

Differentiation of colonic gas from small intestinal gas,

obstruction of colon presence of haustral markings

Suggest volvulus of the cecum or sigmoid colon

o Cecal comma shape, with concavity facing inferiorly
and to the right
o Sigmoid bent inner tube, with its apex in the upper
quadrant

Imaging Studies

X-Ray

Figure 1.2. Upright abdominal x-ray with an obstructing

sigmoid adenocarcinoma. Note the haustral markings on the
dilated transverse colon that distinguished this from small
intestine

Figure 1.1. Upright chest radiograph depicting moderate sized

pneumoperitoneum (Intestinal contents in chest space)consistent with
perforation of abdominal viscus.

Detects pneumoperitoneum (free air in peritoneal cavity)

o In upper right chest radiographs as little as 1 ml
o In lateral decubitus (left side down) abdominal radiographs
in patients who cannot stand; 5- 10 ml
o Air will insinuate in between the liver and diaphragm, let
the patient stay in lateral decubitus for a few minutes so
that air can go up
o Helpful in patients suspected of having perforated
duodenal ulcer, 75% of these patients will have visible
pneumoperitoneum
Show abnormal calcifications
o 5% of appendicoliths

Figure 1.3. Supine abdominal x-ray (air fluid levels are not
seen). Patient with intestinal obstruction. Note distended (air
filled) loops of bowel with thickened bowel walls.

Page 5 of 10

Figure 1.4. Omega sign () Sigmoid volvulus

Figure 1.6. Thick walled, fluid filled appendix with surrounding
inflammation
















Figure 1.7. Large appendicular abscess containing gas

Figure 1.5. Upright abdominal x-ray with sigmoid colon volvulus. Note the
characteristic appearance of bent inner tube, with its apex in the right upper
quadrant

Ultrasound

Accurate for detecting gallstones and assessing gallbladder wall

thickness and presence of fluid around the gallbladder

Determines diameter of extrahepatic and intrahepatic bile

ducts but limited to detect common bile stones
Detects intraperitoneal fluid
Presence of intestinal air limits the ability to evaluate the
pancreas or other abdominal organs
Can differentiate gas from fluid, like for diagnosing abscess
which is a fluid filled cavity with gas, gallbladder is also fluid
filled

Indications for Emergency Ultrasound
o Detection of Acute Cholecystitis, pancreatitis, liver abscess
o Appendicitis, appendicial abscess, diverticular abscess,
mesenteric cyst, tubo-ovarian abscess, pelvic abscess
o Useful in pregnant and young patient
o Patients with suspected AAA (Abdominal Aortic Aneurysm)
o Diagnosis of free intraperitoneal fluid

Figure 1.8. Pancreatic necrosis lack of gland enhancement following
IV contrast administration is diagnostic. Pancreas is hardly visualized













Figure 1.9. Acute pancreatitis enlarged pancreas with indefinite border and
infiltration of the surrounding fat (peri-pancreatic stranding)

Page 6 of 10

VII.

CT scan

More widely available and less likely to be hindered by

abdominal air
Secondary imaging modality of choice following plain abdominal
radiography
Well performed CT using oral, rectal, and IV contrast is highly
accurate for evaluating disease such as appendicitis, while dual
contrast CT scanning for small bowel injury following blunt
trauma

Excellent for differentiating mechanical small bowel

obstruction from paralytic ileus and identify transition point
in mechanical obstruction.

ALGORITHMS FOR ACUTE ABDOMINAL PAIN

A. ACUTE ONSET, SEVERE, GENERALIZED PAIN

Figure 2.0. CT scan with partial small bowel obstruction. Note
presence of dilated small bowel and decompressed small bowel.
The decompressed bowel contains air, indicating a partial
obstruction

VI. CATEGORIES AFTER INITIAL EVALUATION

Patients with immediate life-threatening conditions
Abdominal Crisis abdominal problem is life-threatening to the
patient
o Massive Intra-abdominal bleeding (aneurysm, ruptured
ectopic pregnancy, spontaneous rupture of liver or colon)
must act immediately, lest patient might die of
exsanguination
o Acute intestinal ischemia with hypovolemia with
uncontrolled acidosis the longer you wait -> the more
extensive formation gangrene -> might lose all of the bowel
o Intra-abdominal sepsis uncontrolled abdominal infection
Medical Crisis
o Myocardial infarction
o Tension pneumothorax
o Diabetic ketoacidosis
Life-threatening conditions needs urgent laparotomy the
more you wait, the more peritoneal soilage will happen -> lead
to shock and death., so early operation is needed
o Perforated hollow viscera
o Strangulated bowel
o Intra-abdominal abscess with generalised peritonitis

Figure 2.1: Algorithm for treatment of acute onset, severe, generalized

abdominal pain. NG nasogastric tube; NL normal study. Peritoneal signs
include: peritonitis, rebound tenderness, involuntary muscle guarding

B. GRADUAL ONSET, SEVERE, GENERALIZED PAIN

Figure 2.2: Algorithm for the treatment of gradual onset, severe, generalized
abdominal pain. ERCP endoscopic retrograde cholangiopancreatography;
LFT liver function tests.

Page 7 of 10

C. RIGHT UPPER QUADRANT PAIN (RUQ PAIN)

F. LEFT LOWER QUADRANT PAIN (LLQ PAIN)

Figure 2.3: Algorithm for the treatment of right upper quadrant abdominal
pain. US - ultrasound

Figure 2.6: Algorithm for the treatment of left lower quadrant abdominal pain.

Differential diagnoses for RUQ Pain:

o Pyelonephritis or nephrolithiasis, hepatic abscess,
pulmonary embolus, pneumonia or musculoskeletal
o May include other causes found in the epigastrial region:
cardiac origin, esophageal inflammation or perforation,
gastritis, PUD, biliary colic, pancreatitis

D. LEFT UPPER QUADRANT PAIN (LUQ PAIN)

Figure 2.4: Algorithm for the treatment of left upper quadrant pain.

Differential diagnoses for LUQ Pain:

o Ruptured spleen, splenomegaly, gastric ulcer

E. RIGHT LOWER QUADRANT PAIN (RLQ PAIN)

VIII.
DIFFERENTIAL DIAGNOSIS
All patients must be seen, evaluated immediately on
presentation and reassessed at frequent intervals for changes in
condition.
Requires a comprehensive knowledge of the medical and
surgical conditions that create acute abdominal pain.
Peritoneal lavage can provide information that suggests
pathology requiring surgical intervention. The lavage can be
performed under local anesthesia at the patients bedside. This
can provide sensitive evidence of hemorrhage or infection, as
well as some types of solid or hollow organ injury.
Patients having emergency or life threatening surgical disease
are taken for immediate laparotomy; urgent diagnoses allow
time for stabilization, hydration, and preoperative preparation,
as needed.
Hospitalized patients who do not go urgently to the OR must be
reassessed frequently, preferably by the same examiner, to
recognize potentially serious changes in condition that could
alter diagnosis or suggest development of complications.
Laboratory and imaging studies should never replace the
bedside clinical judgment of an experienced surgeon.
Patients are more likely to be seriously or fatally harmed by
delaying surgical treatment to perform confirmatory tests than
by misdiagnoses discovered at operation.

Figure 2.5: Algorithm for the treatment of right lower quadrant pain.

Differential diagnoses for RLQ Pain:

o Meckels diverticulum, Crohns disease, diverticulitis,
salpingitis, ectopic pregnancy

IX.
INDICATORS FOR URGENT LAPAROTOMY
Increasing severe localized tenderness (e.g supperative
appendicitis becomes gangrenous -> lead to rupture)
Progressive tense abdominal distention when there is severe
obstruction
Spreading involuntary muscle rigidity peritoneal irritation is
spreading due to bowel movement, which will spread the
infection
High fever, tachycardia, confusion
marked leukocytosis with shift to the left
pneumoperitoneum (see figure 1.1)
All of these need urgent laparotomy





Page 8 of 10

Serious conditions
Needs early planned surgery or close monitoring
o acute appendicitis depends on the stage; how long the
patient is having pain. Theres a need to hydrate the patient
before doing surgeryl for the patients optimal condition.
o diverticulitis, diverticular abscess, tubo-ovarian abscess load
the patient with antibiotics and hydrate the patient
o localized intra-abdominal or pelvic abscess
o small bowel obstruction
o large bowel obstruction

Less serious conditions
which require conservative treatment
o biliary colic, renal colic
o inflammatory bowel disease
o non-specific abdominal pain
o gastroenteritis, infective colitis
o urinary tract infection
o uncomplicated ovarian cyst
o ruptured graaffian follicle
o uncomplicated diverticular disease
o most medical causes of abdominal pain

Some special Cases
Meckels Diverticulum
o Presents as lower GI bleeding, sometimes with pain just like
appendicitis
o If a patient diagnosed to have appendicitis but when
examined surgically to have a normal looking appendix, you
have to examine the distal 2 ft (ileum), especially in a young
patient

Volvulus of Meckels Diverticulum

o A gangrenous twisted Meckels diverticulum

Twisted Ovarian Cyst: Gangrenous

Ruptured Ectopic Pregnancy

o Massive bleeding; patient will die of insanguination

Sigmoid Volvulus
o Sigmoid becomes gangrenous due to loss of blood supply

Infarcted Bowel

o Caused by an embolus in the tributaries

o If detected early, might save the bowel by doing an
embolectomy
o A progressive gangrenous process
X.
SUMMARY
Importance of accurate history taking and complete PE
Early decision whether the patient needs urgent surgery
More important to detect immediate life threatening
conditions than arriving at the correct diagnosis even if
you dont have the correct diagnosis, it is better to have a
live patient with an unsure diagnosis rather a dead patient
The diagnosis in an early abdominal pain is difficult. Need to
re-examine the patient after adequate resuscitation
Define surgical from non-surgical abdomen
Make the patient comfortable and pain-free if possible
give pain relievers

Opioids dont mask physical signs or prevent accurate

diagnosis
Think of the more common surgical conditions first not
the 1% incidence of abdominal pain. In UERM, most
common surgery performed is cholecystectomy which is
presented as a RUQ pain.

SAMPLE QUESTIONS

1. This aspect in the physical examination of the abdomen is done last in
patients presenting with abdominal pain.
a. Auscultation b. Inspection c. Palpation d. Testing fluid wave
C
2. A 33 year old male came in for blood-streaked stools associated with
crampy abdominal pain, nausea and diarrhea. He has mild direct and rebound
tenderness over the left side of the abdomen. Rectal examination shows
blood-streaked mucoid stools in the examining finger. He is most probably
suffering from:
a. Diverticular disease of the colon
b. Amoebic infection of the colon
c. Neoplasm of the colon
d. Internal hemorrhoidal disease
C
3. A 55-year-old female who is diagnosed to have chronic cholecystitis with
lithiasis in the past presents with RUQ pain, jaundice and fever. Which test
will help in accurately determining the present problem?
a. Elevated transaminases
b. Reduced prothrombin time non responsive to IV Vitamin K
c. CBD dilation with intraluminal shadow
d. Elevated bilirubin levels
C
3. True of abdominal pain
a. Always present in abdominal diseases
b. First symptom in abdominal problems that are medical in nature
c. Maybe the presenting symptom of myocardial infarct
d. Most common symptom seen in patients in emergency room
D
4. Midureteral stones are found in:
a. Upper abdominal
b. Peri-abdominal
c. Lower abdominal
d. None of the above
C
6. Somatic type of chain is characterized by which of the following?
a. The sensation travels through the ANS.
b. It is the type of pain that one experiences when an inflamed appendix
touches the anterior parietal peritoneum.
c. It is difficult to localize.
d. It usually precedes visceral pain in all inflammatory conditions in the
abdomen.
B
7. 45 y/o, male, with a history of exploratory laparoscopy 5 years PTA. Chief
complaint is colicky abdominal pain. Which will indicate that he has an
infarcted bowel?
a. Hyperactive bowel sounds
b. Distended abdomen
c. Local area of tenderness
d. All of the above

8. A 45 y/o female with sudden crampy epigastric pain with right upper
quadrant pain which radiated to the right shoulder, aggravated by deep
inspiration. What is the best diagnostic technique for this?
a. Auscultation of bowel sounds
b. Determination of liver size and calculation of Liver Span
c. Eliciting Rovsings Sign
d. Eliciting Murphys Sign
C

Page 9 of 10

9. Which of the following is the MOST common manifestation of Peptic Ulcer

Disease (PUD)?
a. Early satiety
b. Epigastric pain
c. Post prandial vomiting
d. Gaseousness feeling after a meal
B
10. Which of the following can explain the occurrence of referred pain?
a. Stimulation of nerve fibers of the same embryologic origin
b. Stimulation of nerve fibers with similar receptors
c. Convergence of nerve fibers at the spinal cord
d. Stimulation of nerve fibers of an organ adjacent to the diseased organ
C
11. A 55 year old alcoholic diagnosed to have a duodenal ulcer by upper
gastrointestinal endoscopy, complains of severe epigastric pain which later
becomes generalized. Which among the following findings will help us in the
diagnosis?
a. Generalized ileus on KUB
b. A distended loop of bowel on the RLQ
c. Lucency below the left diaphragm above the gastric bubble
d. Presence of a distended stomach
C
12. A 50 year old male patient came in because of colicky abdominal pain of
several hours duration associated with decrease in passage of flatus. Which of
the following clinical findings can help us in the diagnosis of the present
condition?
a. The presence of a globular abdomen
b. Hypoactive bowel sounds
c. A midline incision scar
d. History of an alcoholic binge the night before
C
13. Visceral type of pain can be characterized by which of the following:
a. It can be localized easily by the patient
b. It usually is associated with a solid organ involvement
c. May be due to muscular contraction
d. Is usually accompanied by fever upon presentation
C
14. A 44-year-old female patient was diagnosed to have gallstones in the
gallbladder. The pain history of this patient will most likely be characterized
as:
a. Waves of dull pain associated with vomiting
b. Acute wave of constricting pain
c. Sharp pain worsened by movement
d.Tearing pain
B
15. A 65-year-old male woke up during the early hours of the morning due to
severe epigastric pain. Based on the history alone, which of the following
is the most likely cause of his pain?
a. Ureteral colic
b. Acute Pancreatitis
c. Biliary colic
d. Perforated peptic ulcer disease
D
16. A 44-year-old female diagnosed to have gall bladder stones by ultrasound
a year ago came in because of right upper quadrant pain after eating a
fatty meal which was later on associated with radiation to the back after
several hours. She might be suffering from:
a. Acute cholecystitis
b. Choledocholelithiasis
c. Biliary pancreatitis
d. Acute cholangitis
A
17. A 25 year old male presents with nausea and vomiting and after three
hours develops generalized abdominal pain. Based on this history alone, this
patient might be suffering from:
a. Typhoid ileitis
b. Acute appendicitis
c. Acute gastroenteritis
d. Urinary tract infection

C

18. A In a male patient who comes in for a possible acute appendicitis, which
of the following is more specific for acute appendicitis
a. Presence of fever
b. Presence of leucosytosis
c. Presence of RLQ direct and rebound tenderness with involuntary muscle
guarding
d. Presence of generalized ileus seen of plain abdominal x-ray exam

C
19. Right upper quadrant intermittent pain, jaundice and acholic stools
suggest which of the following:
a. Viral hepatitis
b. Biliary obstruction
c. Pancreatitis
d. Cholecystitis
B
20. A 53 year old male consults for epigastric pain associated with nausea and
a feeling of gaseous distention relieved by burping after the Christmas
holidays. The appropriate approach in the management is:
a. Treat symptomatically and work-up only if the symptoms persist
b. Obtain serum amylase and lipase levels
c. Request for an abdominal ultrasound
d. Do an upper GI endoscopy and barium swallow
A
21. A 65-year-old male woke up during the early hours of the morning due to
severe epigastric pain. Based on the history alone, which of the following
is the most likely cause of his pain?
a. Ureteral colic
b. Acute Pancreatitis
c. Biliary colic
d. Perforated peptic ulcer disease
D
22. A 44-year-old female diagnosed to have gall bladder stones by ultrasound
a year ago came in because of right upper quadrant pain after eating a
fatty meal which was later on associated with radiation to the back after
several hours. She might be suffering from:
a. Acute cholecystitis
b.Choledocholelithiasis
c. Biliary pancreatitis
d. Acute cholangitis
A

20 Things That Mentally Strong People Dont Do

1. Dwelling On The Past
2. Remaining In Their Comfort Zone
3. Not Listening To The Opinions Of Others
4. Avoiding Change
5. Keeping A Closed Mind
6. Letting Others Make Decisions For Them
7. Getting Jealous Over The Successes Of Others
8. Thinking About The High Possibility Of Failure
9. Feeling Sorry For Themselves
10. Focusing On Their Weaknesses
11. Trying To Please People
12. Blaming Themselves For Things Outside Their Control
13. Being Impatient
14. Being Misunderstood
15. Feeling Like Youre Owed (Life Owes You)
16. Repeating Mistakes
17. Giving Into Their Fears
18. Acting Without Calculating
19. Refusing Help From Others
20. Throwing In The Towel

One reason people resist change is because they

focus on what they have to give up
instead of what they have to gain.

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