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| The Acute Abdomen - Part VI: Information on Common Causes for Physician Assistants and Nurse Practitioners |
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by Bob Blumm, MA, PA-C, DFAAPA - September 21, 2010
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What are the common causes of the acute abdomen? Since this is not a textbook, I will not have a complete list but suffice it to both say and think, there are certain problems that need to be the utmost in our thought process:
Appendicitis
Diverticulitis
Cholecystitis
Pancreatitis
Bowel Obstruction
Bowel Perforation
Perforated Ulcer
IBD
Ectopic Pregnancy
PID/TOA
Gastroenteritis
Mesenteric Ischemia
Nephrolithiasis
Abdominal Aortic Aneurysm
Appendicitis - The well-known triad in appendicitis is nausea/ vomiting, Anorexia and Periumbilical pain. Whereas this is a known triad 50% of the time, medicine and surgery also entertain unknowns! Nausea and anorexia are seen in 60-90% of the cases, anorexia alone in 75% of the cases. The single finding of Periumbilical pain radiating to McBurney’s point has a demonstrated sensitivity and specificity of 80%.The final aspect of RLQ pain is 95%. When looking at labs, a proven appendicitis will have elevated WBCs over 10,000, 85% of the time and, conversely, a negative triad is considered a WBC <10,000, neg C-reactive protein and less than 75% neutrophils. When your patient is pregnant or a pediatric patient, consider U/S. A CT with contrast has a sensitivity and specificity of 95-98% which is why it is the exam of choice in ERs across the land. These patients may have a positive Psoas and Obturator sign and are required to have rectal and pelvic exams.
Small Bowel Obstruction - The presentation of SBO differs proximally versus distally secondary to partial or complete obstruction. The early signs may be fetid breath, nausea, vomiting and diarrhea, with later signs being constipation. The usual etiology is prior surgery with the presence of intraabdominal adhesions or incarcerated hernias. Among the early and later signs is distention. Usually there is little tenderness early in the process as the obstruction is only partial whereas late the patient will exhibit signs of guarding and increased tenderness and Borborygmi. Examination of the patient will demonstrate hyperactive bowel sounds in its early phase and hypoactive later in the event. Look carefully for inguinal hernias, evidence of previous abdominal surgery and particularly for femoral hernias in females. Labs should consist of a CBC, electrolytes, Bun/Creatine and expect the patient to have an elevation of the WBC. The classic x-ray is distended loops of bowel with transverse linear densities across the entire bowel lumen (plicae circularis), multiple air fluid levels and stair stepping or J-loops.
Perforated Peptic Ulcer - You can almost set your watch to the time that the patient has become symptomatic, as there is sudden, sharp, burning epigastric pain aggravated by movement probably due to peritonitis. By history there is evidence of peptic ulcer disease, NSAID use, Coumadin use, steroids or having been critically ill. Most of these patients have a generalized peritonitis and require early fluid resuscitation and antibiotics free air is seen on the plain radiographs or CT scan. One of the hallmarks is that the pain is made worse by ingestion of food which makes this a good board question. There may be a history of melana and a history of ETOH use or abuse. The patient will present with a rigid, board like abdomen and hypoactive or silent bowel sounds, which are high indicators of perforation. An NG tube should be placed looking for blood or coffee ground exudates. The gold standard test is an Esophagogastrduedenoscopy (EDG) and if this is not available an upper GI study with barium swallow.
Diverticulitis - This is more common in females over the age of forty with a history of constipation, left lower quadrant pain and diarrhea. On early exam in its acute phase there is LLQ pain and a good clinician can palpate a mass during exam of the left colon. The pain is usually steady and the patient will have a low grade fever and perhaps has seen blood in her stool or diarrhea. A history is extremely important as steroid use can alert the surgeon of a cautious closure, perhaps using wire and an abdominal binder. When a patient does not disclose the steroid use or the examiner does not solicit the history it can cause an early evisceration leading to multi-organ failure and death as I saw with my father-in-law. Laboratory studies should consist of a CBC, electrolytes, glucose, Bun/creatine as this level may be helpful in risk stratification and in significantly ill patients. CT scans have 93% sensitivity and 100% specificity. A colonoscopy, if the bleeding from the rectum is not severe will be diagnostic.
Acute Pancreatitis - Hide the scalpel as this is not a surgical disease but a medical disease. Upon performing the history there may be a history of gallstone, ETOH abuse and pain radiating to the back. ETOH abuse is the leading cause in the United States while GBD is the leading cause worldwide. The hallmarks of pancreatitis are the radiating pain to the left or right upper back and the presence of nausea and vomiting. Examination will demonstrate pain in the upper abdominal region or epigastric region. Pancreatitis is associated with tachycardia and tachypnea and therefore a 12 lead EKG should be placed as patients with a past history of A-Fib may go back into this rhythm and this can cause significant increase in heart rate that the tachycardia can become uncontrolled and require ACLS. These patients may take the characteristic knee forearm position for pain relief. In severe cases Gray turners sign or Cullen’s sign may be present. On thoracic examination it is not unusual to hear basilar rales on the left side. Ransoms’ criteria should be evaluated to risk stratify patients Labs should have as a minimum a CBC and the expectation of an elevated WBC. Glucose, BUN/Creatine and an ABG. Serum lipase is the test of choice for diagnosis with a sensitivity nearing 100 %; specificity is 83-98 %. A CT of the abdomen should be performed to R/O abscess or phelgmon. These patients can be termed as having “exquisite pain.”
Cholecystitis - The common thought in relation to this common problem is “fat, female and forty.” I have seen this is pregnant women, postpartum, young ladies, older women (my mother in law waited until she was an Octogenarian), I have seen this in men, in short this is a common problem and should not be pigeon holed into the three “F” slogan. The common presenting signs are RUQ pain or epigastric pain after eating and particularly after eating a high fat meal which may radiate to the right scapula or shoulder. Fever is usually present symptoms such as nausea; vomiting and referred pain should raise suspicion of common bile duct distention. On exam besides the RUQ pain there may be a positive Murphy’s sign and the patient may be jaundice. Ultra sound will reveal a thick gall bladder wall. Indicated labs should be a CBC, LFT including amniotranferases, bilirubin, alkaline phosphate, serum lipase, and amylase. US imaging is the study of choice and is 94 % specific. If the US is negative a HIDA scan should be ordered. These cases are done open and closed but laparoscopic is the procedure of choice on most patients and can be performed quickly (my mother in law was scoped in fifteen minutes) and is a common procedure for the well trained surgeon. Past history, adhesions, other possible pathology and body habitus may cause your surgeon to decide on an open procedure.
I thought that I might be able to end here, but I think one more article will be helpful in dealing with some of the other diseases and will round out this series. As you can see from the content of Articles 1-6, it was an impossible task to do this as a 50 minute lecture but if needed for a conference in your state or specialty group, give me two hours including Q&A and I am sure that both you, your group and myself will walk away feeling a grasp of this intriguing subject. Acute Abdomen VII to follow in two weeks as I have a very heavy conference schedule over the next month.
 Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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