Abdominal Emergencies

Estera Veer | In Articles | 2nd June 2020

Abdominal pain is a frequent complaint, most difficult to diagnose. It relies greatly on medical history and a physical exam is always necessary.

Pathophysiology of abdominal pain

• Bacterial/viral infection
• Chemical irritation
• Circulatory compromise
• Trauma
• Tumor
• Obstruction

Left upper abdominal quadrant

• Spleen
• Pancreas (retroperitoneal)
• Stomach
• Left kidney (retroperitoneal)
• Splenic flexure of colon

Right upper abdominal quadrant

• Liver
• Gall Bladder
• Head of pancreas
• Duodenum
• Right kidney (retroperitoneal)
• Hepatic flexure of colon

Left lower abdominal quadrant

• Small intestine
• Descending colon
• Left ovary, fallopian tube

Right lower abdominal quadrant

• Appendix
• Ascending colon
• Small intestine
• Right ovary, fallopian tube

Upper gastrointestinal bleeding

• Erosive gastritis
• Peptic ulcer disease
• Oesophageal varices
• Mallory-Weiss tear
• Esophagitis
• Duodenitis
• Drug ingestion

Peptic ulcer disease

• Ulcers in the lining of the oesophagus, stomach or duodenum - loss of protective effect
• 5 times more common after the age of 50
• If painful, it usually ceases after onset of severe bleeding
• 70-90% caused by Helicobacter pylori (bacteria that causes inflammation)
• Antibiotic therapy for the bacterial infection
• Pain usually located in the epigastrum or left upper abdominal quadrant
• May improve after taking antacids (medicines that neutralise acid in the stomach)
• Can cause an acute abdomen - abdominal rigidity
• Mortality 3-8%

Gastritis

• Inflammatory response - gastric erosions secondary to increased gastric acid secretion
• Associated with alcohol ingestion, drugs, stress
• Can cause epigastric pain, belching, indigestion
• Caused by: acetylsalicylic acid (aspirin), steroids, alcohol, non steroidal antiinflammatory drugs NSAIDs, burns, sepsis, trauma
• Abdominal pain improves after eating
• Gastric ulcer may develop
• Most common presentation: restless, pale, moist skin, hypotension

Esophageal varices

• Swollen veins in lower 1/3 of the oesophagus
• Secondary to portal hypertension (elevated pressures in the portal venous system)
• Most common cause: alcoholic cirrhosis
• Accounts for 10% of all hematemesis (vomiting blood), melena (black stools)
• Mortality 40-70%
• Drugs used to treat acute esophageal varices - beta blockers

Esophageal varices assessment

• Initial presentation: fatigue, jaundice, anorexia, pruritus, abdominal pain

• Esophageal varices rupture: abrupt discomfort in the throat, severe dysphagia, vomiting bright red blood, signs of shock

Esophagitis

It represents the inflammation of the oesophagus caused by infection, irritation and/or inflammation of the lining of the oesophagus. The most common cause is gastroesophageal reflux disease GERD.

• Common disorder but an uncommon cause of significant gastrointestinal bleeding
• Melena is a common presentation

Mallory - Weiss tear

• Laceration in the distal oesophagus or proximal stomach
• Most common causes: alcoholism, hiatal hernia, belching, vomiting, blunt trauma, seizures, coughing, multiple bouts of non-bloody emesis (vomiting) followed by sudden hematemesis (vomiting blood)
• Bleeding usually mild to moderate, stops spontaneously

Duodenitits

• Mean age of presentation 49-50 years
• Melena or hematemesis common
• Hemorrhage often self limited

Common symptoms

• Nausea
• Vomiting
• Burning pain or abdominal cramping
• Abdominal pain that goes through the back
• Indigestion
• Feeling full shortly after beginning to eat

Both gastritis and duodenitis have the same causes and treatments.

Upper gastrointestinal bleeding

• It can be acute/chronic
• Vomiting/hematemesis
• Stool/melena
• Meal history is important
• Chest pain/gas pain
• Altered mental status
• Pale, cool, moist skin

Most common presentation

• Acute
• Painless
• Nausea/vomiting/hematemesis
• Melena
• Hypotension
• Tachycardia
• Pale, cool, moist skin

Diagnosis

• Insert nasogastric tube
• early upper gastrointestinal endoscopy (endoscope is passed into the GI tract to view the internal parts)

Therapy

• Endoscopic methods
• Angiography (radiography of blood vessels carried out after introduction of a radiopaque substance)
• Surgery
• Medications such as proton pump inhibitors PPIs - omeprazole

Lower gastrointestinal bleeding

A. Diverticulitis

• Presents in 50% of patients over 60 years old
• Inflammation in or around the diverticula (small pouches which develop in the wall of the large intestine) - retention of food residue and bacteria
• Presents like apendicitis
• Abdominal pain, fever, vomiting, anorexia, tenderness
• Bleeding diverticulitis: painless rectal bleeding, commonly left sided abdominal pain

Treatment

• Antibiotics
• Diet changes
• Surgery
• Prevent shock due to bleeding

B. Angiodysplasia

• Small vascular malformation of the gut
• Arteriovenous malformations in 25% of patients over 65 years old
• Melena
• Difficult to diagnose
• 10-15% Mortality
• Common cause of GI bleeding and anaemia
• Lesions are often multiple, frequently involving the cecum or ascending parts of the colon, although they can occur in other places too

Treatment

• Colonoscopic interventions
• Angiography
• Embolisation (passage and lodging of an embolus - blood clot, air bubble, piece of fatty deposit, or other object which has been carried in the bloodstream)
• Medication such as Tranexamic acid
• Surgery

C. Carcinoma

• Uncommon cause of lower gastrointestinal bleed
• Painless rectal bleeding
• Weight loss
• Abdominal pain
• Treatment: prevention of shock

D. Rectal disease

• Most common cause of rectal bleed
• Bright red bleeding
• Inflamed veins of anal canal

OTHER ABDOMINAL EMERGENCIES

Gastroenteritis

• Causative organisms: many viruses, parasites
• Faecal-oral transmission, contaminated food, water
• Signs and symptoms: nausea, vomiting, fever, abdominal pain, cramping, anorexia, shock

Crohn's Disease/Ulcerative Colitis

Both are are idiopathic, chronic abdominal inflammatory diseases. Crohn's disease involves the rectum and small bowel while ulcerative colitis involves only the rectum.

Crohn's disease

• Increased inflammatory t-cels activity
• Rectal and small bowel lesions and fistulas
• Risk factors include family history and stress
• The patient generally presents with abdominal pain and distension, tenderness in the right upper quadrant, irritable bowel, diarrhoea, weight loss, severe malabsorption, fever
• Peak age: 15-40 years
• Autoimmune factors may play a role but there is not enough evidence
• Complications: intra-abdominal abscesses, intestinal fistulas and peritonitis

Appendicitis

• Obstruction of the appendiceal lumen
• Ulceration of the appendiceal mucosa (viral/bacterial)
• Peak incidence: 10-12 years
• The patient presents with acute onset abdominal pain
• Classic presentation, up to 70% of cases - periumbilical pain, migrates and localises to the right lower quadrant RLQ of the abdomen
• 26% of appendices are retrocecal and cause flank pain
• 4% of appendices are in the right upper quadrant RUQ of the abdomen
• Symptoms include nausea, vomiting, fever, anorexia, rebound tenderness (pain that occurs upon elimination of abdominal pressure), males may have testicular pain
• Treatment: fluid replacement, prevention of shock and surgery
• White blood cells are increased
• Urinalysis is abnormal in 19-40% of cases
• Xray findings: appendiceal fecalith (stone made of feces) or gas, localised ileus, blurred right psoas muscle, free air
• CT scan findings: pericecal inflammation, abscess, periappendiceal phlegmon (suppurative/purulent exudate) , fluid collection, localised fat stranding
• Sudden abdominal pain relieef may indicate appendix rupture!!!

Perforated abdominal organ

• Causes include perforated ulcers and diverticulum
• Classic presentation: sudden onset abdominal pain, generalised abdominal tenderness, rebound tenderness, abdominal rigidity, shock
• Tratment: IV fluids, antibiotics, surgery

Bowel obstruction

• Causes include tumours, ingestion of foreign bodies, prior abdominal surgeries, faecal impaction
• History: progressive anorexia, fever, chills, pale, cool and moist skin, peritonitis, nausea, vomiting, diarrhoea or constipation, hypotension, tachycardia
• Treatment: fluid replacement, prevention of shock, surgery

Pancreatitis

• Inflammation of the pancreas due to digestion of gland by its' own enzymes
• Associated with: autoimmunity, chronic alcohol abuse, elevated lipids, gallstones, trauma, steroid treatment, mumps, scorpion bite, drug abuse, endoscopic retrograde cholangio pancreatography ERCP (a diagnostic procedure used to examine diseases of the liver, bile ducts, and pancreas)
• Patient complaints: abrupt onset abdominal pain, mid-abdomen radiating to the back and shoulders, nausea, vomiting, hypotension, tachycardia, pale, cool and moist skin
• Treatment: IV fluids, abdominal pain medication, nasogastric tube insertion

Cholecystitis

• Inflammation of the gallbladder
• Obstruction by a gallstone in the neck of the gallbladder, cystic duct or common bile duct
• Signs and symptoms: jaundice, increased white blood cells, pain in the right upper abdominal quadrant RUQ which gets worse after meals especially high in fat, flank pain is also common, radiating to the genitals, pale, cool, moist skin, fever
• Antacids have no effect on the abdominal pain caused by cholecystitis
• Treatment: pain relief, surgery

Hepatitis

• Inflammation of the liver caused by viral infections, alcohol, substance abuse
• Signs and symptoms: dull right upper quadrant abdominal tenderness, decreased appetite, nausea, vomiting, fatigue, malaise, clay-coloured stool, dark urine, jaundice, skin rash, warm skin

Aortic aneurism

• excessive localised swelling of an arterial wall

• Usually associated with old age and Marfan syndrome (genetic disorder affecting the body's connective tissue)
• The patient complains of diffuse abdominal pain and severe back pain, tearing sensation, pulsatile abdominal mass
• Treatment: oxygen, fluid resuscitation, pain medication, surgery - open aneurysm repair or endovascular aneurysm repair

Renal calculi

• Urinary tract obstruction - kidney stones most common
• Age range: 20-50 years, 3 times more common in males
• Causes: urinary tract infections, immobilisation, increased calcium levels, gout, tumours
• Signs and symptoms: sudden, sharp, severe abdominal pain, may be intermittent due to stone movement, pain may radiate to the flank area and/or testicles in males, hematuria, dysuria, nocturia, frequent urination, nausea and vomiting
• Treatment: IV fluids, pain medication, surgery, ultrasound shock waves
• Complications: infection, total obstruction

Urinary tract infections UTI

• Cystitits most common (bladder infection)
• More common in females
• Can cause pyelonephritis (kidney infection)
• Signs and symptoms: fever, chills, flank pain, dysuria, hesitancy, discoloured urine, lower abdominal pain, altered mental status
• Treatment: antibiotics, fluids

Pyelonephritis

• Ascension of bacteria from a lower UTI into the renal parenchyma
• Women are more prone until the 5th decade of life
• The patient is typically febrile, flank or lower back pain, chills, tenderness below the 12th rib at vertebral level (costovertebral angle tenderness)
• Treatment: IV antibiotics

Acute kidney disease

• Signs and symptoms: onset within hours, normal kidney function rapidly deteriorates, oliguria, anuria, generalised oedema, acidosis, uremia (high concentration of uric acid and potassium), severe dyspnea, pulmonary oedema, hypotension, tachycardia, pericarditis rub, jugular vein distension, ascites, pulmonary rales at the base of the lungs, wasted appearance, skin pasty yellow, thin extremities, seizures, muscle twitching, urea crystals on the skin (late sign)
• Treatment: oxygen, correct dehydration, electrolyte abnormalities, fluid restriction when required, dialysis

Chronic kidney disease

• A progressive, systemic kidney disease
• Secondary to diabetes, hypertension, autoimmune disorders
• In later stages it requires dialysis and kidney transplant

Pelvic inflammatory disease

• Infection of the uterus, fallopian tubes, ovaries, adjacent structures
• Usually sexually transmitted
• The patient presents with fever, chills, lower abdominal pain, vaginal bleeding/discharge, pain on walking or intercourse
• Treatment: relief of acute symptoms, eradication of current infection, minimisation of risk of long term sequelae

Ruptured ectopic pregnancy

• Life threatening abdominal emergency!
• Cervical pregnancy: embryo implants in the cervix
• Tubal pregnancy: embryo implants in the fallopian tubes
• It can happen at any time during a female's fertile years
• Mimics the signs and symptoms of other abdominal emergencies

Ovarian cyst

• Generally. asymptomatic until complicated by haemorrhage, torsion, rupture or infection
• Fluid filled sac on ovaries: if ruptured, blood spills into the abdominal cavity
• The patient presents with abdominal pain, either gradual or rapid
• Rupture and abdominal pain triggered by exercise, intercourse, trauma or pelvic exam

Mittelschmerz

Mittelschmerz is one-sided, lower abdominal pain associated with ovulation. German for "middle pain", mittelschmerz occurs midway through a menstrual cycle — about 14 days before your next menstrual period.

• Caused by ovarian bleeding following ovulation
• Pain during ovulation
• Severe abdominal pain is rare

Testicular torsion

• Most patients have congenital abnormality of genitals, generally bilateral
• Twisting of the spermatic cord cutting off the blood supply
• Rotation occurs medially
• Vascular occlusion and infarction after 6 hours!!
• Usually in children and teenagers
• Previous testicular torsion predisposes to reoccurrence
• The patient presents with severe testicular pain, lower abdominal pain, swollen testicle, tender, higher in scrotum, knot may be palpated above testicle
• Usually sudden onset
• Treatment: pain medication, manual detorsion, surgery

Epididymitis

• Cellular inflammation begins in vas deferens and descends to lower pole of epididymis
• Inflammation of epididymis, secondary to gonorrhoea, syphilis, tuberculosis, mumps, prostatitis, urethritis, indwelling catheter
• The patient presents with fever, chills, inguinal pain, swollen epididymis
• 2/3 have epididymis  atrophy
• 30% of post pubertal boys with mumps