Amelia Mangunereplied toShawna WilliamsMar 24, 2022, 6:26 PMUnreadReplies to Shawna Williams

Acute abdominal pain (specifically severe) demands a prompt assessment because a missed or delayed diagnosis may lead to significant morbidity and mortality (Greenberger, 2017). Greenberger (2017) also explains the initial step in determining whether the patient has a life-threatening basis of acute abdominal pain. Then, once stabilized, it must be determined whether an emergent surgery is warranted. The decision to obtain an emergency surgical consultation depends on the history and physical examination (with ancillary radiographic studies (such as CT, US) of secondary importance), and when signs and symptoms of an acute abdomen are present, a surgical consult should be requested.

Based on Kendall & Moreira (2020), the differential diagnosis is broad in many cases, varying from benign to life-threatening conditions. Causes include medical, surgical, intraabdominal, and extra-abdominal ailments. Associated symptoms frequently lack specificity, and atypical presentations of common diseases are frequent, further complicating issues. Kendall & Moreira (2020) also explain that older adults, the immunocompromised, and women of childbearing age pose particular diagnostic challenges. Older and diabetic patients often have imprecise, nonspecific complaints and atypical presentations of potentially life-threatening conditions leading to time-consuming workups. The immunocompromised patient may suffer from many illnesses, including uncommon and treatment-related disorders. Pregnancy leads to physiologic and anatomic shifts affecting the presentation of common conditions. 

Some of the differential diagnoses that could lead to an immediate surgical consultation are (1) Abdominal aortic aneurysm (AAA), (2) Mesenteric ischemia, and (3) Gastrointestinal perforation.

Kendall & Moreira (2020) further explain that AAA is a focal aortic dilation of at least 50% compared to normal, with any measurement > 3cm regarded as abnormal. Most AAAs remain quiescent until rupture, but some manifest as abdominal, back, or flank pain. Aneurysm rupture typically causes exsanguinating hemorrhage and profound, unstable hypotension. Some atypical presentations are noted for ruptured AAA, contributing to a misdiagnosis rate of up to 30%. AAAs can rupture into the retroperitoneum causing tamponade, enabling the patient to remain normotensive initially. In addition, AAAs can present with back pain and hematuria, leading to potential nephrolithiasis misdiagnoses. AAA is most common in men over 60 years, with risks for patients aged 60 and beyond. COPD, PVD, hypertension, smoking, and family history are associated with AAA. Mesenteric ischemia can be differentiated into 4 entities: arterial embolism (50%), arterial thrombosis (15%), nonocclusive mesenteric ischemia (20%), and venous thrombosis (15%). Mesenteric ischemia is associated with high mortality, and prompt diagnosis is crucial, although tricky. Acute mesenteric ischemia is classically said to present with rapid onset of severe periumbilical abdominal pain, often out of proportion to findings on PE. Nausea and vomiting are typical. Sudden pain associated with few abdominal signs and forceful bowel evacuation in a patient with risk factors should significantly increase suspicion for the diagnosis. The subset of patients with mesenteric venous thrombosis has a more indolent course and lower reported mortality. Risk factors include advanced age, atherosclerosis, low cardiac output states, cardiac arrhythmias (e.g., Afib), severe cardiac valvular disease, recent MI, and intraabdominal malignancy. There are many causes of GI perforation, but peptic ulcer disease (PUD) is the most common. Perforation can also complicate appendicitis, diverticulitis, ischemic bowel, and toxic megacolon. Ulcer perforation should be presumed in patients with a history of peptic ulcer manifestations who develop an abrupt onset of intense, diffuse abdominal pain. Kendall & Moreira (2020) also added that a thorough examination reveals a history of PUD or ulcer symptoms in most cases, a notable exception being older patients with NSAID-induced perforation. Perforation is more common and lethal among older adults. Delays in diagnosis greater than 24 hours substantially increase mortality. Esophageal perforation (Boerhaave syndrome), which can happen with severe retching, can present with severe and progressive epigastric abdominal pain.

References

Greenberger, N.J. (2017). Acute abdominal pain. In McKean, S.C., Ross, J.J. Dressler, D.D. & Scheurer, D.B. (Eds.). Principles and Practice of Hospital Medicine (2nd ed., Chap. 75, p. 559). McGraw-Hill Education. 

Kendall, J.L. & Moreira, M.E. (December 29, 2020). Evaluation of an adult with abdominal pain in the emergency department. UpToDate. https://www.uptodate.com/contents/evaluation-of-the-adult-with-abdominal-pain-in-the-emergency-department?search=acute%20onset%20of%20abdominal%20pain&source=search_result&selectedTitle=8~150&usage_type=default&display_rank=8#H1