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Abdominal Pain

AMY LITTLE, MD

ALBANY MEDICAL CENTER

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GOALS

Review the anatomy of the abdomen Quadrants Peritoneal vs. Retroperitoneal Solid vs. Hollow organ Vascular structures

Assessment (History and Physical Exam) Management Abdominal trauma Special situations

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The Abdomen

Everything between diaphragm and pelvis

Injury and illness can be very difficult to assess because of large variety of structures

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Abdominal Anatomy

Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus

Organs can be located by quadrant

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Abdominal Anatomy

Right Upper Quadrant Liver Gall Bladder Right Kidney Ascending Colon Transverse Colon

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Abdominal Anatomy

Left Upper Quadrant Spleen Stomach Pancreas Left Kidney Transverse Colon Descending Colon

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Abdominal Anatomy

Right Lower Quadrant Ascending Colon Appendix Right Ovary (female) Right Fallopian Tube

(female)

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Abdominal Anatomy

Left Lower Quadrant Descending Colon Sigmoid colon Left Ovary (female) Left Fallopian Tube

(female)

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Abdominal Anatomy

Periumbilical area Located around (peri) the navel (umbilicus) Small bowel lies in all quadrants in periumbilical

area

Suprapubic area Located just above pubic bone Urinary bladder, uterus lie in this area

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Abdominal Cavity

Peritoneum = abdominal cavity lining

Divides abdomen into two spaces Peritoneal cavity Retroperitoneal space

(retro=behind)

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Abdominal Anatomy Retroperitoneal

Pancreas Kidney Ureter Inferior vena cava Abdominal aorta Urinary bladder Reproductive organs

Peritoneal Spleen Liver Stomach Gall bladder Bowel

NOTE: Disease or injury of retroperitoneal organs often causes

back pain.

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Abdominal Anatomy

REVIEW: Organs are classified by Quadrant, periumbilical, or suprapubic Peritoneal or retroperitoneal

Organs can also be classified as: Solid Hollow Major vascular

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Solid Organs

LiverSpleenKidneyPancreas

NOTE: When solid organs are injured, they bleed

heavily and cause shock.

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Solid Organs

Liver Largest abdominal organ Most frequently injured Fractures of ribs 8-12 on right side Bleeding can be either:

Slow, contained under capsule Free into peritoneal cavity

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Solid Organs

Spleen Frequently injured with

trauma ribs 9-11 on left side Bleeds easily Capsule around spleen tends

to slow development of shock Rapid shock onset when

capsule ruptures

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Solid Organs

Pancreas Lies across lumbar

spine Sudden deceleration

produces straddle injury Very little hemorrhage Leakage of enzymes

digests structures in retroperitoneal space, causes volume loss, shock

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Solid Organs

Kidney Retroperitoneal Vulnerable to trauma

(blunt & penetrating), infection, obstruction, chronic disease

Tenderness: Lower ribs, upper L-spine, flank

Pain: groin, shoulder, back, flank

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Hollow Organs

StomachGall bladderLarge, small intestinesUreters, urinary bladder, urethra

Rupture causes content spillage & inflammation of

peritoneum.

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Hollow Organs

Stomach Acid, enzymes Immediate

peritonitis Pain, tenderness,

guarding, rigidity

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Hollow Organs

Colon Spillage of bacteria May take 6 hrs to develop peritonitis

Small Bowel Fewer bacteria May take 24-48 hours to develop peritonitis

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Hollow Organs: Urinary System Ureters

Penetrating injury

Bladder Blunt injury (seatbelts, pelvic fracture)

Urethra Straddle injury

Signs and Symptoms Abnormal urination (Urgency, Inability, Dysuria,

Hematuria) Blood at external meatus Perineal bruising (butterfly bruise) Scrotal hematoma Shock Abdominal distension

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Major Vascular Structures

AortaInferior vena cavaMajor branches

Injury can cause severe blood loss; exsanguination

(bleeding out).

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QUESTIONS about Abdominal Anatomy?

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ASSESSMENT of Abdominal Pain

History

LOCATIONWhere do you hurt?

Know locations of major organsBut realize abdominal pain

locations do not always correlate well with source

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ASSESSMENT of Abdominal Pain

QUALITYWhat does pain feel like?

Steady pain - inflammatory processCrampy pain - obstructive process

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ASSESSMENT of Abdominal Pain

ONSETWas onset of pain gradual or

sudden?Sudden = perforation, hemorrhage,

infarctGradual = peritoneal irritation,

hollow organ distension

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ASSESSMENT of Abdominal Pain

RADIATIONDoes pain radiate (travel) anywhere?

Right shoulder, angle of right scapula = gall bladder

Left shoulder = spleen, stomachAround flank to groin = kidney,

ureter

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ASSESSMENT of Abdominal Pain

DURATION > 6 hour duration = ? surgical significance

ASSOCIATED SYMPTOM: Nausea &/or vomiting? Bloody? “Coffee

Grounds”?

Any blood in GI tract = Emergency until proven otherwise

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ASSESSMENT of Abdominal PainChange in urinary habits? Urine

appearance?

Change in bowel habits? Diarrhea? Appearance of bowel movements? Melena?

Regardless of underlying cause vomiting or diarrhea can be a problem because of

associated volume loss.

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ASSESSMENT of Abdominal Pain

Females Last menstrual period? Abnormal vaginal bleeding?

In females, abdominal pain = Gynecological problem until proven

otherwise.

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PHYSICAL EXAM

General Appearance Lies perfectly still inflammation = peritonitis Restless, writhing obstruction

Abdominal distension?Ecchymosis around umbilicus, flanks?

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PHYSICAL EXAMVital signs

Tachycardia = Early shock &/or pain (more important than BP)

Rapid shallow breathing = peritonitis

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PHYSICAL EXAM

Palpate each quadrant Work toward area of pain Warm hands Patient on back, knee bent (if possible) Note tenderness, rigidity, involuntary guarding,

voluntary guarding, masses

Bowel sounds (?)

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Management

AirwayHigh concentration O2

Anticipate vomitingAnticipate hypovolemia

Need PIV, IVFNothing by mouth except medications

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Management

Consider referred cardiac pain: Adults > 30 Diabetics History of cardiac problems

In females, consider gynecological problems, especially ruptured ectopic pregnancy (surgical emergency)

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QUESTIONS about general assessment or management?

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REVIEW: GOALS

Review the anatomy of the abdomen Quadrants Peritoneal vs. Retroperitoneal Solid vs. Hollow organ Vascular structures

Assessment (History and Physical Exam) Management

NEXT: Abdominal trauma Special situations

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Abdominal Trauma

Most survive to reach hospitalMost common factors leading to death

Failure to adequately evaluate Delayed resuscitation Inadequate volume replacement Inadequate/missed diagnosis Delayed surgery

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High Index of Suspicion in Trauma

MechanismUnexplained hypovolemic shock Signs of injured abdomen

Management

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Mechanism

Look for signs of injury Bruises Tire marks Obvious open injuries

Trauma to lower chest, back, flank, buttocks, and perineum

Injury above umbilicus also involves chest until proven otherwise

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Unexplained Shock

Assess vital signs; skin color, temperature; capillary refill

Tachycardia; restlessness; cool, moist skinIn trauma, signs of shock suggest

abdominal injury if no other obvious causes present

Assume any abdominal injury is serious until proven otherwise!

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Signs of Injured Abdomen

Diffuse tenderness

Pain Pain referred to shoulder =

Organ under diaphragm involved (?spleen)

Pain referred to back = Retroperitoneal organ involved (?kidney)

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Abdominal Trauma Management

Less important to diagnose exact injuryTreat clinical findings (open wounds,

hypotension/tachycardia)Management same regardless of specific

organ(s) injured

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Abdominal Trauma Management

AirwayC-Spine if mechanism indicates High flow O2

Assist ventilations if neededGive nothing by mouth(?) MAST may be helpful in slowing

intraabdominal bleeding with shock

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Special situations in Abdominal Pain

Impaled objectsEviscerationTrauma to the reproductive systemSexual assault

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Impaled Object

Leave in place Shorten if necessary for transport Leave part of object exposed

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Evisceration

With large laceration abdominal contents may spill out

Do NOT try to replace

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Evisceration

Cover exposed organs with saline moistened multi-trauma dressing

Do NOT use 4 x 4sCover first dressing with second DRY

dressing or aluminum foil

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Reproductive System Trauma

Can occur to both external and internal reproductive systems External

More common Pain, extensive bleeding

Internal Less frequently injured

Treat like blunt or penetrating soft tissue injuries elsewhere on body

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Male Genitalia Trauma

Usually NOT life-threatening

Very painful Great source of

concern to patient

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Male Genitalia Trauma

Avulsion of skin of penis, scrotum Cover with a moist,

sterile dressing

Complete amputation of penis Treat as any

amputated part

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Male Genitalia Trauma

Blunt trauma to penis, scrotum Apply ice pack

Urethral foreign bodies Do NOT remove

Penis entrapped in zipper If 1 or 2 teeth involved, try to unzip If more involved, cut zipper out of trousers,

transport

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Female Genitalia Trauma

Internal Rarely injured

External Can cause pain,

extensive bleeding Usually not life-

threatening

Treat with compresses, pressure

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Sexual Assault

Avoid examining genitalia unless obvious bleeding present

Ask patient to NOT wash, douche, urinate, defecate

Ask patient NOT to change clothesRecord history, but avoid extensive

questioning about incident

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SUMMARY: Abdominal Pain

Consider the anatomyIn general abdominal pain, note HISTORYIn trauma, think about mechanism

ManagementANTICIPATE! Vomiting=airway Hypovolemiaresuscitation Appropriate transport

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THANK YOU FOR YOUR ATTENTION!