1 Define the acute abdomen. What physical examination signs suggest its presence?

Acute abdomen generally refers to an inflamed peritoneum (peritonitis), which is often because of a surgically correctable problem. Patients with an acute abdomen often receive a laparotomy and/or laparoscopy because it signifies a potentially life-threatening condition. The best physical examination confirmations of peritonitis are rebound tenderness and involuntary guarding. Rebound tenderness is elicited by letting go quickly after deep palpation of the abdomen; acute pain occurs in the area of palpation (with generalized peritonitis) or at the location of localized inflammation (e.g., Rovsing sign in appendicitis). Involuntary guarding describes abdominal wall muscle spasms that cannot be controlled. Voluntary guarding (person reflexively or willfully tenses their abdomen during attempted palpation) and tenderness to palpation are softer signs often present in benign diseases.

2 What should you do if you are not sure whether a stable patient has an acute abdomen?

When you are in doubt and the patient is stable, use minimal as needed pain medications (to avoid masking symptoms before you have a diagnosis), perform serial abdominal examinations, and consider a computed tomography (CT) scan. If the patient becomes unstable, proceed to laparoscopy and/or laparotomy.

3 Name a few causes of peritonitis that do not require laparotomy or laparoscopy.

Pancreatitis, many cases of diverticulitis, and spontaneous bacterial peritonitis.

4 Specify which conditions are associated with pain and peritonitis in the listed abdominal areas.

5 What are the classic symptoms and signs of gallstone disease?

Classic gallstone symptoms include postprandial, colicky pain in the right upper quadrant with bloating and/or nausea and vomiting. The pain usually begins 15 to 60 minutes after a meal (especially a fatty meal). Look for Murphy sign (palpation of the right upper quadrant under the rib cage causes arrest of inspiration as a result of pain) as the main physical examination finding for cholecystitis.

6 What are the six Fs of cholecystitis? How are the demographics of patients with pigment stones different from those with cholesterol stones?

The first five Fs summarize the demographics of people with cholesterol gallstones: fat, forty, fertile, female, and flatulent; the sixth F is febrile, which indicates that such patients have now developed acute cholecystitis. Patients with pigment (i.e., calcium bilirubinate) stones are classically young patients with hemolytic anemia (e.g., sickle cell disease, hereditary spherocytosis).

7 How is a clinical suspicion of cholecystitis confirmed and treated?

Ultrasound is the best first imaging study for suspected gallbladder disease (Fig. 13-1). It may show gallstones, a thin layer of fluid around the gallbladder, and/or a thickened gallbladder wall. A more specific ultrasonographic Murphy sign using direct visualization of the gallbladder can be obtained (variant anatomy and significant obesity can create uncertainty). A nuclear hepatobiliary scintigraphic study (e.g., hepato-iminodiacetic acid [HIDA] scan) clinches the diagnosis with nonvisualization of the gallbladder (Fig. 13-2). The treatment is pain control and cholecystectomy (antibiotics may be indicated if infection is suspected); a laparoscopic approach is generally preferred over an open procedure.

8 Define cholangitis. How does it differ from cholecystitis? How is it treated?

Cholangitis is an inflammation of the bile ducts, whereas cholecystitis is an inflammation of the gallbladder. Cholangitis is classically caused by biliary obstruction with subsequent bile stasis and infection. Choledocholithiasis (a gallstone in the common bile duct) and malignancy are common causes of obstruction. Autoimmune cholangitis (e.g., sclerosing cholangitis) and primary infection (e.g., Clonorchis sinensis and other parasite infections common in some parts of Asia) are other causes. Cholangitis classically presents with Charcot triad: (1) right upper quadrant pain, (2) fever or shaking chills, and (3) jaundice. Patients may have a history of gallstones. Start broad-spectrum antibiotics to cover bowel flora (e.g., piperacillin with tazobactam); then manage more definitively depending on the circumstances (e.g., cholecystectomy with evacuation of any common duct stones for gallstone disease, biliary stent placement for unresectable malignant obstruction).

9 Describe the classic presentation of appendicitis. How is it treated?

Appendicitis classically presents in 10- to 30-year-olds with a history of crampy, poorly localized periumbilical pain followed by nausea and vomiting. Then the pain localizes to the right lower quadrant, and peritoneal signs develop with worsening of nausea and vomiting. It is said that a patient who is hungry and asking for food does not have appendicitis (called the “hamburger” sign). A classic clue to the diagnosis is Rovsing sign: when you palpate a different quadrant and then quickly release your hand, the patient feels pain at McBurney point (two thirds of the way from the umbilicus to the anterior superior iliac spine). McBurney point is the area of maximal tenderness in the right lower quadrant and the site where an open appendectomy incision is made. CT is increasingly used to confirm the diagnosis before surgery in stable patients (Fig. 13-3).

10 What is the cause of left lower quadrant pain and fever in a patient older than 50 years until proved otherwise? How is it treated?

Diverticulitis. Treat medically with broad-spectrum antibiotics (e.g., ciprofloxacin plus metronidazole), avoidance of eating, and a nasogastric tube if nausea and vomiting are present. For disease that recurs or is refractory to medical therapy, consider sigmoid colon resection.

11 What tests should and should not be done to confirm possible cases of diverticulitis? What test does every patient need after a treated episode of diverticulitis?

Colonoscopy should not be performed in the acute setting because colon rupture may occur; barium enema is also avoided for the same reason. However, one of these tests should be done in every patient after treatment to exclude colon carcinoma. Order a CT scan, if necessary, to confirm a diagnosis of diverticulitis (Fig. 13-4).

12 Describe the typical history, physical examination, and laboratory findings of pancreatitis. How is it treated?

Look for epigastric pain that radiates to the back in an alcohol abuser or a patient with a history of (or risk factors for) gallstones. Serum amylase and/or lipase should be elevated. If these values are not given, order them. Other common signs include decreased bowel sounds, localized ileus (“sentinel” loop of bowel on abdominal radiograph) and nausea, vomiting, and/or anorexia.

Treat pancreatitis supportively; narcotics are often needed for pain control; hydromorphone or fentanyl are common choices these days; meperidine, which has a risk of seizures, has traditionally been favored over morphine because of the concern about sphincter of Oddi spasm, although clinical evidence of this is lacking. Do not feed the patient initially; place a nasogastric tube as needed for nausea and vomiting; and give intravenous (IV) fluids as well as other needed supportive care. Watch for the complications of pseudocyst and pancreatic abscess, both of which can be diagnosed by CT scan and may require surgical intervention.