Thank you to Dr. Mannion for presenting an interesting case of an older woman with abdominal pain and altered mental status.
What is urgent or emergent abdominal pain?
Unstable vital signs
Evidence of peritonitis
- Abdominal rigidity: note, this may be lacking in the elderly given abdominal laxity. This was only present in 21% of patients over 70yo with PUD perforation.
- Rebound tenderness: sensitivity 80%, specificity 40-50% for peritonitis; the “cough test” has sensitivity 78% and specificity 79% for peritonitis
- Pain that worsens with light bumping of the bed/stretcher
Concern for life threatening condition
Some “big, bad, scary” conditions associated with abdominal pain include:
- Acute bowel obstruction: illness script includes distention, cramping, vomiting, lack of flatus
- Acute mesenteric ischemia: nausea, vomiting, periumbilical pain out of proportion to exam
- Perforation (PUD, bowel, esophagus- Boerhaave, appendix): PUD leading to perforation is the most common and lethal in the elderly
- Kehr’s Sign: diaphragmatic irritation from free air or intraperitoneal blood resulting in shoulder pain
- Volvulus: may have fever and peritonitis if gangrenous
- Acute MI: consider this in women who can have atypical presentations of angina
- AAA rupture: illness script often involves hypotension, abdominal and flank pain
- Grey’s Sign: flank ecchymosis suggestive of retroperitoneal bleed
- Cullen’s Sign: bluish umbilicus suggestive of intraperitoneal bleed
- Splenic rupture: consider if EBV infection, leukemia or trauma
- “-itis” (pancreatitis, cholecystitis, cholangitis, diverticulitis, appendicitis, pyelonephritis)
- Intra-abdominal Hematoma: “Page Kidney” is hypertension related to pressure-induced ischemia from a larger subcapsular hematoma leading to persistent activation of the renin-angiotensin system
- Intra-abdominal Abscess:
- Aortic Dissection:
- Incarcerated Hernia:
- SBP: consider if cirrhosis
- Pregnancy Complications (ectopic pregnancy, placental abruption, preeclampsia_
- Adnexal Torsion:
- Testicular Torsion:
- Ruptured Ovarian Cyst:
- Tubo-ovarian Abscess:
Rapid Assessment: In those circumstances, rapid assessment is necessary. This includes re-examination and stabilization in addition to labs and imaging. Some labs that may be useful include CBC, CMP, lactate, troponin and D-Dimer. In a 2007 systematic review and prospective cohort study published in the European Heart Journal, D-Dimer of <0.1ug data-preserve-html-node="true" per ml was 100% sensitivity in excluding acute aortic dissection. And, in thinking about your imaging strategy of choice, a 2005 study published in Radiology found that a helical CT yielded an overall sensitivity, specificity and accuracy of 96%, 95.1% and 95.6% respectively and found that abdominal plain film series were insensitive with overall sensitivity, specificity and accuracy of 30%, 87.8% and 56% respectively in evaluation of nontraumatic acute abdominal pain in adults. Similarly, while ultrasound is the diagnostic tool of choice for detecting AAA, a FAST bedside ultrasound is not a sensitive test to differentiate ruptured or unruptured aortic aneurysms. Free fluid on a FAST exam could represent a ruptured aneurysm. But, as was brought up in report today, the majority of AAAs rupture into the retroperitoneum. Thus, it is challenging to detect on FAST. Some solutions mentioned include use of microbubbles on contrast enhancement. For additional information, please see An Evidence-Based Approach to Emergency Ultrasound. Sonography had a 4% sensitivity in showing retroperitoneal hematoma. But, combining the symptoms and presence of aneurysms, led to appropriate surgical decision making in 21 of 22 patients in a case series.