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8. Weiner ID, Wingo CS. (1998) Hyperkalemia: A potential silent killer.
J Am Soc Nephrol 9(8): 1535–1543.
9. Gallay BJ et al. (2001) Screening for primary aldosteronism without
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ratio. Am J Kidney Dis 37(4): 699–705.
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R. K. Medapalli and M. J. Ross
Gastrointestinal\Liver
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Acute Abdominal Pain
in the Hospitalized Patient
Sarah Steinberg*, Sita Chokhavatia* and Imuetinyan Asuen*
Key Pearls
• Acute abdomen is a surgical emergency. Early surgical consultation is
mandated for the patient with abdominal rigidity and rebound tender-
ness, or if there is any indication of diverticulitis, cholecystitis or
bowel ischemia.
• Abdominal contrast enhanced CT scan is the best initial imaging
study for evaluating most patients with acute abdominal pain.
• Elderly patients often lack overt clinical findings and subacute pre-
sentations may lead to under diagnosis and treatment.
• Opiate pain management should be minimized in patients with
inflammatory bowel disease (IBD), untreated C. difficile diarrhea,
ileus and constipation.
• A pregnancy test is mandatory in all female patients of reproductive
age who present with acute abdominal pain.
Acute abdominal pain accounts for 4–6% of Emergency Room visits with
24–27% of these patients being admitted to the hospital.
1,2
The first step in
evaluation is identifying patients with acute abdomen, which is a surgical
emergency. Presence of abdominal rigidity or rebound pain in association
with nausea, vomiting, fever or leukocytosis suggests acute abdomen and
467
39
Chapter
*Mount Sinai School of Medicine, New York, NY, USA.
demands expedited imaging tests and an immediate surgical consult. The
best initial test for evaluating biliary disease is an ultrasound, and an
abdominal X-ray when ileus, obstruction or perforation is suspected. CT
scan is the best imaging modality for all other causes of acute abdominal
pain, with the exception of bowel ischemia, which is diagnosed with MR
or CT angiogram.
1
Early surgical consult should be obtained for suspected
diverticulitis, cholecystitis, appendicitis or mesenteric ischemia.
Determining the location (Table 1), quality of pain and associated
symptoms is essential to honing in on the correct diagnosis; age and
gender further narrow the differential diagnosis. Cholecystitis, appen-
adults <50-years old; diverticulitis in patients > 50-years old; and bowel
ischemia in patients >65-years old. The most common causes of acute
abdominal pain are discussed below. Small bowel obstruction, post-surgical pain, IBD, liver disease and acute GI bleeding will be addressed in
subsequent chapters.
468
S. Steinberg, S. Chokhavatia and I. Asuen
Table 1. Differential Diagnosis of Abdominal Pain by Location
Quadrant Right Right, Left, Midline Left
Upper Cholecystitis/biliary Herpes Zoster Acute pancreatitis
colic Lower lobe pneumonia Splenic abscess/
Perforated duodenal ulcer Myocardial ischemia rupture
Hepatic congestion/abcess
Lower Appendicitis (late) Inflammatory bowel
Diverticulitis disease
(Cecum, Meckel’s) Gynecological
Urological
Incarcerated/strangulated Diverticulitis
hernia (Sigmoid)
Diffuse Peritonitis
Gastroenteritis
Appendicitis (early)
Mesenteric ischemia
Bowel obstruction
Sickle cell crisis
Appendicitis
Appendicitis is the most common GI cause of acute abdominal pain in18to 50-year-old patients and constitutes 14–27% of acute abdominal pain
patients seen in the Emergency Room.
1,2
Clinical Presentation
Patients initially report periumbilical pain that later localizes to the right
lower quadrant, and associated symptoms of nausea, vomiting and fever.
Peritoneal signs of guarding and rebound tenderness may be elicited on
examination.
Management
Initial management of suspected appendicitis should include supportive
care, including intravenous fluids, pain management, and antibiotics.
Early surgical consultation is required and a contrast enhanced CT can be
done to confirm the diagnosis before surgery. CT criteria for acute appendicitis include an appendix larger than 6 mm and fat stranding.
1
Acute Cholecystitis
Most commonly encountered in overweight/obese women of reproductive
age and during pregnancy, acute cholecystitis also occurs in men with central
obesity. Risk factors for gall bladder stones include cirrhosis, Crohn’s disease,
rapid weight loss, certain drugs (ceftriaxone, statins) and advanced age.
3
Elderly patients with cholecystitis are more likely to have subacute presentations and higher mortality than their younger counterparts.
Clinical Presentation
Patients rarely present with the classic clinical triad of right upper quadrant
(RUQ) tenderness, fever and leukocytosis.
1
The Tokyo guidelines define
469
Acute Abdominal Pain in the Hospitalized Patient
three clinical criteria for cholecystitis: one local sign of inflammation
(Murphy sign, mass or RUQ tenderness); one systemic sign of inflammation (fever, elevated C-reactive protein, elevated white blood cell count);
and confirmatory imaging.
4
Management
Abdominal RUQ ultrasound is the initial imaging study of choice for suspected cholecystitis. In the case of equivocal results or a study impaired by
a patient’s body habitus, an MRCP may be indicated, particularly if there
is a suspicion of biliary obstruction. Initial management includes intravenous fluids, antibiotics, surgery and gastroenterology consultation.
Ideally, cholecystectomy is done after the acute inflammation has subsided, but if the patient fails conservative management, either percutaneous
drainage or cholecystostomy may be required.
Diverticulitis
Diverticulitis is a common cause of abdominal pain in patients 50 years
and older. Approximately 90% of cases are left sided.
5,6
Clinical Presentation
In addition to left lower quadrant pain, patients may report nausea,
vomiting, constipation, diarrhea and urinary frequency. Peritoneal signs
suggest perforation and systemic signs of inflammation such as fever and
leukocytosis may be present.
6
Management
Most patients respond to conservative management. CT scan or MRI can
localize the site of inflammation. Colonoscopy is contraindicated due to
risk of perforation. Surgery is indicated for recurrent diverticultis or diverticular disease complicated by perforation, abscess not amenable to
470
S. Steinberg, S. Chokhavatia and I. Asuen
percutaneous drainage or stricture causing colon obstruction. Diverticular
bleeding rarely occurs with acute diverticulitis. Colonoscopy is indicated
one to two months after resolution of inflammation as sigmoid colon
cancer can present with symptoms similar to acute diverticulitis.
6
Bowel Ischemia
Bowel ischemia is a rare but potentially fatal cause of acute abdominal pain
in patients ≥65-years old. The majority of cases are colonic ischemia (75%),
followed by acute mesenteric ischemia (25%), focal segmental ischemia
(<5%) and chronic mesenteric ischemia (<5%).
5
Mesenteric ischemia is
more likely to be occlusive and should be suspected in elderly patients with
cardiovascular disease or younger patients with decreased blood flow to the
mesentery secondary to vasculitis or a coagulation disorder.
Acute Mesenteric Ischemia
Clinical Presentation
Acute mesenteric ischemia of the small bowel presents as diffuse or focal
abdominal pain with or without bloody diarrhea. The pain is often disproportionate to the physical exam. Leukocytosis, metabolic acidosis and elevated lactic acid indicate impending small bowel infarction, but are markers
of advanced disease, so normal values cannot be used to rule out the diagnosis. Mesenteric ischemia may also present as a small bowel obstruction.
Management
CT or MR angiography can detect mesenteric vein obstructive emboli or
thrombi but are not diagnostic for non-occlusive ischemia. All patients
with suspected mesenteric ischemia should receive immediate fluid resuscitation, broad-spectrum antibiotic therapy and appropriate cardiac optimization. Although antibiotic treatment has not been well studied, it is an
accepted component of standard care for mesenteric ischemia.
5
471
Acute Abdominal Pain in the Hospitalized Patient
Angiography, if performed early in a stable patient, can identify the location of ischemia, which will determine the surgical and therapeutic course.
In critically ill patients who are too unstable for either angiography or
surgery, diagnostic interventions are often deferred in favor of conservative management, including fluid resuscitation, antibiotic therapy and
treatment of underlying illness. Thrombolytic therapy is controversial as
a primary treatment but is commonly used in conjunction with embolectomy or arterial reconstruction.
5
Colonic Ischemia
Clinical Presentation
Colonic ischemia presents with sudden onset left lower quadrant
cramping pain followed by defecatory urgency and bloody diarrhea
within 24 hours. Acute change in mental status is common in elderly
patients.
5
The majority of colonic ischemia is secondary to hypoperfusion and usually resolves with supportive care and maintenance of
hemodynamic stability.
Management
In patients with colonic ischemia, treatment of the underlying illness is
key. Less common causes of colonic ischemia include acute pancreatitis,
amyloidosis, coagulopathy, vasculitis, infection (E. coli 0157, parasites,
hepatitis B, hepatitis C, cytomegalovirus), medications, surgical procedures and trauma.
5
Iatrogenic Abdominal Pain
Abdominal pain due to iatrogenic causes can occur in all age groups. Prior
surgery may be associated with the development of adhesions. Abdominal
surgical scars should raise concern for adhesions and intestinal obstruction.
Postoperative ileus or narcotic bowel syndrome can lead to constipation
472
S. Steinberg, S. Chokhavatia and I. Asuen
and increased abdominal pain. Patients requiring opioid analgesics should
be treated prophylactically with stool softeners and laxatives. Osmotic laxatives such as lactulose can cause bloating and abdominal pain. A bowel
regimen and appropriate low gas diet should be included in the systematic
checklist for every hospitalized patient. Inpatients with abdominal pain
should be put on a soft lactose-free diet.
Urological/Renal or Gynecological Causes of Abdominal Pain
A detailed obstetric and gynecological history is essential in the workup
of all women. A pregnancy test is mandatory in all women of childbearing age prior to radiologic evaluation. Abdominal pain may be the presenting symptom in women with ectopic or intrauterine pregnancy,
ovarian cyst, endometriosis, mittleshmerz and fibroids.
Urinary tract infections and nephrolithiasis are common causes of
abdominal pain in young women and men respectively, with obstructive
uropathy being more common in older men. Initial studies include urine
analysis and culture for UTI and non-contrast CT for nephrolithiasis.
Relief of abdominal pain with catheterization resulting in significant
urinary output supports a diagnosis of obstructive uropathy.
General Concerns
Pain Management
Treatment with opiates can mask worsening pain or evolution of an acute
abdomen, but as there is no difference in mortality when administered
judiciously, opioid analgesics need not be withheld from patients requiring them for pain control.
7
Opiates should always be given with an aggressive bowel regimen to prevent ileus or constipation that may lead to
further abdominal pain. Pre-existing ileus and severe constipation should
deter initiation of opioid analgesics. Opiates should also be avoided in
patients with untreated C. difficile colitis and inflammatory bowel disease
as they are at high risk of developing toxic megacolon and perforation.
473
Acute Abdominal Pain in the Hospitalized Patient