Acute Abdomen

Definition/Etiology:

5-10% of ER visits are for abdominal pain.

Compared with younger patients, the elderly have a 6-8x increase in mortality with an acute abdomen.

Causes include:

• Ectopic pregnancy / placental abruption
• Pelvic inflammatory disease
• Ovarian torsion
• Endometriosis
• Testicular torsion
• Nephrolithiasis
• AAA
• MI
• Splenic rupture
• Sickle cell crisis
• Black widow bite (or other spider)
• Appendicitis / Peritonitis
• Mesenteric ischemia
• Bowel perforation (covered separately)
• Volvulus / bowel obstruction
• Gallbladder / pancreatitis
• Cancer
• Diverticular disease
• Food-borne illness
• Adhesions
• Irritable bowel syndrome
• Opiate withdrawal
• Toxic ingestion
• Pyelonephritis
• Incarcerated hernia
• Intra-abdominal abscess

Pathophysiology:

Abdominal pain can have many causes.  In general:

• Ischemic tissue (incarcerated hernia, mesenteric ischemia)
• Blood or bowel contents in the peritoneum
• Rupture (AAA, ectopic, etc)
• Obstruction (crampy, spasming, trying to move)

Clinical Presentation:

High-risk features:

• Sudden, severe onset
• Constant, unremitting
• Recent surgery
• Age >65
• Immunocompromised
• Major comorbidities (CAD, DM, cancer)
• Tense, rigid abdomen
• Involuntary guarding
• Shocky
• Pregnant
• Alcoholic

Take a good history. Have a system:

• Onset
• Location
• Duration
• Character
• Aggravating
• Relieving
• Treatments
• Severity

Collaborative Management:

Labs:

• CBC, CMP, amylase, lipase
• Blood cultures, lactate
• Type and cross
• Urinalysis, HCG

Imaging:

• FAST exam
• Formal abdominal ultrasound
• CT abdomen/pelvis

Other:

• NPO
• Nasogastric tube / stomach decompression / LIWS
• Pain management

Evaluation | Patient Monitoring | Education:

• Frequent vitals
• Monitor NG output
• Make sure it’s on LIWS
• Pain management
• Watch for shock
• Two large bore peripherals

Linchpins: (Key Points)

• Assume it’s bad.
• Practice your physical assessment.
• Take a good history.
• Try to figure it out before looking at the CT report.