Location and migration

Whether abdominal pain is generalised or localised to an abdominal segment is the most important piece of information to obtain first. Migration of abdominal pain also often assists in diagnosis (Fig 7.1). Central or generalised abdominal pain is a common initial symptom of many diseases (appendicitis, bowel obstruction, visceral perforation). Persisting severe generalised abdominal pain suggests generalised peritonitis. Epigastric or right upper quadrant pain extending in a band around the abdomen suggests a biliary origin (‘colic’). Migration of central pain to the right iliac fossa over the course of several hours indicates appendicitis. This is an example of visceral pain evolving into a somatic pattern as local peritonitis develops with pathological progression of appendicitis. Another example of this phenomenon is migration of pain from the left iliac fossa to the whole abdomen may be associated with initial sigmoid diverticulitis with subsequent perforation and the development of generalised peritonitis.

Figure 7.1 Migration of pain in common abdominal conditions

A: biliary pain — migration to below the top of the right scapula (‘wing sign’); B: perforated ulcer — down the right paracolic gutter; C: acute appendicitis — to the right iliac fossa; D: perforated diverticulitis — over the abdomen starting from the left iliac fossa; E: renal colic — from loin to groin

Onset and duration

The time, pattern and character of onset and the duration of symptoms are elicited. Acute abdominal pain that persists for six or more hours suggests the presence of a surgical abdomen; so does a history of awakening at night with the pain, especially if pain precedes other symptoms such as vomiting or diarrhoea. A sudden and dramatic onset of pain suggests rupture of a previously intact structure (e.g. duodenum, colonic diverticulum, splenic capsule, aortic aneurysm). A gradual onset, progressively worsening over hours or days, correlates with inflammation. The onset after excessive alcohol intake suggests pancreatitis. A history of abdominal injury may be of importance. A latent period can exist between the time of trauma and presentation, as is seen with delayed rupture of the spleen. A latent period can also be seen in other acute abdominal conditions such as perforated peptic ulcer, intussusception, large bowel obstruction, gallstone ileus and intestinal infarction. Sometimes such a latent period gives the illusion of resolution of the problem and can delay or obscure diagnosis.

Type and intensity

The character of the pain is subjective. Patients often relate pain to previous or imagined occurrences (‘stabbed by a knife’, ‘struck by lightning’, ‘burning’). It is important to establish whether the pain has been constant and unremitting since onset or is periodic. If periodic, is it a true colic? Colic causes a spasmodic, gripping abdominal pain that returns every few minutes with a crescendo rise and fall in intensity often described by women as similar to labour pains. Colic associated with an urge to defaecate or pass flatus and with abdominal borborygmi is pathognomonic of intestinal colic due to obstruction or irritation. The colicky pain of obstruction is usually more severe than is found with gastroenteritis. Severe colicky pain that becomes constant suggests ischaemic bowel. Constant pain often varies in severity during the course of the illness, but careful questioning will distinguish this from a true colic. The need for narcotics to control upper abdominal pain is suggestive of renal or biliary pain. Severe pain persisting without relief requires hospital admission.

Severity is also subjective and best assessed by the effect of pain on the patient, the response to the suggestion that an operation may be necessary and the necessity for and whether relief from analgesics already administered has occurred. Inability to sleep because of pain suggests a surgical problem.

Severe unremitting pain may be due to localised peritonitis because of appendicitis, cholecystitis or diverticulitis, or due to widespread peritonitis from visceral rupture or mesenteric ischemia. Biliary pain tends to plateau, after a gradual onset; it is continuous but fluctuates in severity. Acute renal pain is a very severe and constant pain. Neither is a true colic.

Radiation

Radiation or referral is extension of the pain to another site while the initial pain persists. Occasionally the site of referral may be dominant and simulate disease in another organ. Biliary pain may be felt primarily in the back or in the precordium, simulating angina. Pain from a penetrating duodenal ulcer (or from pancreatitis) and from carcinoma of the pancreas often pass directly through to the back. Renal pain radiates from the flank (loin) to groin, testis or thigh. Conversely, the pain of testicular torsion may sometimes be referred to the hypogastric region. Segmental nerve root pain is referred to the appropriate dermatome. Shoulder pain can be referred from the mediastinum or result from diaphragmatic irritation from an abdominal cause — for example, blood or intestinal contents beneath the diaphragm.

Associated symptoms

Nausea, vomiting and anorexia often precede pain of non-surgical origin: profuse vomiting as a main feature suggests upper small bowel obstruction; persistent anorexia following pain favours an organic cause; persistent vomiting from any cause can occasionally give haematemesis from a Mallory-Weiss tear in the lower oesophagus.

Nausea, diarrhoea and vomiting preceding colicky pain is a feature of gastroenteritis; diarrhoea may be due to pelvic appendicitis or abscess.

An association with menstrual disorders often indicates gynaecological disease. Abnormal menstrual loss before pain suggests abortion, or after pain suggests ectopic pregnancy. A missed period implies the possibility of a complication of pregnancy. Intermenstrual pain and bleeding may be associated with ovarian problems and vaginal discharge with salpingitis. Urinary symptoms such as frequency, scalding or haematuria suggest pyelonephritis, cystitis or stone. Chills and rigors hint at significant infective conditions such as pyelonephritis, salpingitis or viral gastroenteritis.

Offsetting factors

The factors that relieve pain may clarify the diagnosis. Relief of pain by food and alkali suggests peptic ulceration. Certain movements can relieve pain; the pain of pancreatitis may be relieved by sitting forward. A hot-water bottle is often used for biliary pain and nonsteroidal anti-inflammatory agents commonly relieve musculoskeletal pain. Relief of pain by vomiting indicates possible ulcer disease and relief of pain by defaecation or passage of flatus suggests gastroenteritis or functional bowel disease. Biliary and renal pain often require analgesic injection for relief.

Factors that worsen pain, such as movement, may indicate that the pain is musculoskeletal in origin. However, the pain of peritonitis is worsened by abdominal movement, deep breathing or coughing, as is pain from diaphragmatic irritation. If food worsens the pain, conditions such as benign or malignant gastric ulceration need consideration.

Past history

Previous episodes of pain, previous abdominal operations, a history of previous trauma, past and current drug treatment and alcohol intake are commonly relevant to the assessment of the current presentation of abdominal pain.

Examination of the periphery

The hands are examined. Nail changes include clubbing, which may be found in a number of gastrointestinal conditions, chronic liver disease, inflammatory bowel disease and malabsorption. Other changes such as leuconychia, indicating malnutrition and hypoproteinaemia, or koilonychia, suggesting iron deficiency, may be present. Palmar erythema, spider naevi and Dupuytren’s disease (palmar nodules, bands, contractures, pits and sinuses and knuckle pads) suggest alcoholic liver disease (Fig 7.2). Asterixis is a flapping tremor best seen with the hands in extension and is found in patients with portal systemic encephalopathy.

The head and neck are then examined for abnormal pigmentation, spider naevi, xanthelasma of the eyelids, scleral jaundice or pallor and parotid enlargement. The neck is examined for cervical lymphadenopathy, especially left supraclavicular nodal enlargement (Troisier’s sign) as a sign of metastatic node involvement from carcinoma of the stomach.

The mouth is then examined for the smell of fetor hepaticus suggesting encephalopathy, mucosal thickening and ulceration, atrophy or erythema, gingivitis and angular stomatitis. A ketotic breath and coated tongue is suggestive of appendicitis or related conditions. Angular stomatitis (‘perlèche’) is seen frequently in patients with iron deficiency and malnutrition. Glossitis occurs in patients with iron, folate and vitamin B12 deficiency. Mouth ulceration may be present. The hydration status (i.e. skin turgor and moistness of mucous membranes) should be assessed at this time, especially in the acute setting.

Abdominal examination

The patient lies supine with arms by the side and with groin and hernial orifices exposed. The examination should be performed in a good light. The abdomen is inspected for abnormal contour, either distension or scaphoid appearance, for generalised or localised distension, for scars, discolouration, pigmentation or striae, for distended veins radiating from the umbilicus (caput medusae) and for visible pulsations or peristalsis. The patient is then asked to breathe deeply in and out through the mouth, to see if the contour changes or if a mass moves or becomes more obvious and to see if respiratory movement is painful. The patient is asked to cough and scars and the hernial orifices are watched to detect an expansile impulse. The patient is asked to lift the legs or shoulders from the bed and similar observations are made for an impulse. With this manoeuvre a visible mass, if subcutaneous, will become more prominent, an intra-abdominal mass less so.

Figures 7.3 and 7.4 depict anterior and posterior surface markings of the abdominal viscera.

Figure 7.3 Anterior surface markings of upper abdominal viscera

Figure 7.4 Posterior surface markings of abdominal viscera

A: lung; B: pleura; C: kidney; D: pancreas; E: spleen

After inspection, the patient is asked if there is any tenderness and, if there is, its site. Palpation is started gently with the hand flat, at a site away from the site of maximal tenderness and then in all quadrants (Fig 7.5).

Figure 7.5 Region of the abdomen

A: epigastrium; B: right hypochondrium; C: lumbar region; D: periumbilical region; E: right iliac fossa; F: hypogastrium

Then the abdomen is palpated more deeply using the flexor surface of the fingers — the use of two hands often helps to define masses (Fig 7.6).

Figure 7.6 Method of palpating the spleen

The hernial orifices and genitalia are examined. It is important to distinguish normally palpable structures from abnormal masses (Fig 7.7).

Figure 7.7 Palpable normal abdominal structures

1: xiphoid process; 2: liver; 3: edge of rectus abdominis; 4: lower pole of right kidney; 5: caecum; 6: aorta; 7: ala of sacrum; 8: pregnant uterus; 9: full bladder; 10: sigmoid colon; 11: faecal loading

Routine examination for ascites is essential in the distended abdomen, by eliciting shifting dullness or a fluid thrill. Shifting dullness is shown to be present by rotating the patient about the long axis and demonstrating a change in the ‘Plimsoll line’ or transition line of dullness to percussion (Fig 7.8). Fluid thrill is detected by flicking the side of the abdomen and palpating for a transmitted impulse on the other side. Transmission of the impulse via the abdominal wall is blocked by another hand placed on the midabdomen.

Figure 7.8 Shifting dullness

Area 1 is resonant when supine and dull in lateral position. Area 2 is dull when supine and resonant in lateral position.

Based on Burkitt, 2007

The following physical signs are sought: tenderness or resistance on palpation (voluntary or involuntary guarding); rigidity (extreme guarding); and rebound tenderness (best assessed by gentle percussion). A full description of any detected mass is often most usefully recorded as a simple schematic sketch in the medical record. The edge of a mass may be best delineated by deep palpation during inspiration (liver and spleen) or by percussion (Table 7.1). The site and depth of a mass are very important diagnostic features. Other important features include shape and consistency and whether the mass is mobile or fixed. Faecal masses are indentable.

Anorectal examination

Anorectal examination is usually performed on patients in the left lateral position if there are appropriate symptoms requiring this to assess the clinical problem. It is not required as part of all abdominal examinations. The spine and hips are fully flexed; the knees are flexed to a little less than 90° to obtain better access for sigmoidoscopy. The equipment required is a good light, examination gloves, lubricating jelly and paper tissues to clean the anus after examination. Proctoscopy (anoscopy) and sigmoidoscopy (rectoscopy) should be part of a routine office or outpatient examination by appropriately trained practitioners. The proctoscope permits visualisation of the anal canal up to 10 cm; the standard rigid sigmoidoscope up to 30 cm. The flexible sigmoidoscope is a specialist instrument, visualising up to 50 cm from the anal verge. Long biopsy forceps are also necessary should sampling for histology be necessary. Neither form of sigmoidoscopy is part of a standard non-specialist examination. Bowel preparation is not usually necessary for routine anorectal examination.

Initial inspection may reveal prolapsed haemorrhoids, perianal haematomas, external openings of fistulas and the dry or moist skin changes of pruritus. Examination of the anus during straining will be necessary to reveal prolapsing haemorrhoids or rectal prolapse. Anal fissures are normally not initially obvious on inspection, as they are located above the anal verge. Most fissures are seen in the midline posteriorly. Laterally placed fissures suggest an association with inflammatory bowel disease. Gentle retraction of the anal verge will usually expose the lower edge of a posterior fissure. Rectal examination (Fig 7.10) and proctoscopy may not be possible in such instances because of painful anal spasm. Palpation commences using the pulp of the index finger introduced slowly into the anorectum. The finger will usually reach 10 cm with a little pressure on the perineum or with the assistance of bimanual compression of the lower abdomen. As the finger is withdrawn the whole circumference of the rectum is examined. The indurated, elevated and ulcerated lesion of a carcinoma is characteristic. The capacity of the rectum should be noted. Masses outside the rectum in the pouch of Douglas may be palpable anteriorly. Anteriorly in the male the normal prostate is a firm rubbery bilobed structure about 3 cm in diameter. A shallow central sulcus may be palpated and the mucosa over the prostate should be freely mobile. In the male it is difficult to define anatomical structures above the base of the prostate. The prostate feels larger on examination if performed while the patient has a full bladder. In the female the cervix of the uterus or a vaginal tampon may be palpable anteriorly and should not be mistaken for a mobile extrarectal tumour. Faecal pellets in an intrapelvic sigmoid colon can simulate abnormal extrarectal lumps but faeces are regular and indentable. The glove should be examined for blood after completion of the digital examination.

Figure 7.10 Rectal examination

Digital detection of a carcinoma of the rectum at about 10 cm from the anal verge. The characteristics on palpation are induration, elevation and ulceration. Blood may be seen on the glove after completion of the examination.

Figure 7.9 Anatomy of the anorectum

The anal canal extends from the anorectal ring, which is formed by the puborectalis, down to the anal verge, a distance of about 3 cm. 1: puborectalis muscle 2: inferior haemorrhoidal plexus or cushion; 3: anal crypt; 4: dentate line; 5: interhaemorrhoidal groove; 6: anal verge; 7: external haemorrhoidal plexus; 8: external haemorrhoidal artery; 9: internal sphincter; 10: external sphincter

Proctoscopy is the best method of diagnosing haemorrhoids, as these lesions are impalpable on digital examination unless thrombosed. Proctoscopy also provides a means of close viewing of tumours in the lower third of the rectum for biopsy and for the office treatment of haemorrhoids.

1. Acute appendicitis with perforation (see also acute right iliac fossa pain)

Perforation, with presentation as an acute abdomen, is seen most frequently in the young, the old and in patients with diabetes. In many series, perforation at the time of appendicectomy has occurred in almost half those patients under 10 years and over 50 years. It is unusual for the acutely inflamed appendix to perforate within the first 12 hours. Pain in appendicitis is often initially central and diffuse, followed by a shift to the right iliac fossa within a few hours. Pain is deep-seated, continuous and gradually increases in intensity. Nausea and vomiting are common, but vomiting is rarely pronounced or persistent and is rarely the first symptom. Diarrhoea is also rarely the first symptom (Table 7.2). Its presence suggests pelvic appendicitis. The development of perforation is accompanied by more severe generalised abdominal pain and higher fever.

Table 7.2 Comparison of clinical features of perforated pelvic appendicitis and gastroenteritis

Signs. With general peritonitis, there is diffuse abdominal tenderness with guarding, which is often maximal in the right iliac fossa. The degree of guarding depends upon the rapidity of onset of the peritonitis. Bowel sounds often persist for some time. If untreated the abdomen becomes silent and progressively distends, with diminution of tenderness as exudate accumulates. High fever, toxicity and eventually septic shock develop. A tender local mass may be felt in the right iliac fossa suggesting abscess formation. In such a case the patient is usually toxic and febrile due to irritation of the rectum. In pelvic appendicitis, abdominal signs are often delayed or less marked but rectal examination may reveal the presence of pelvic tenderness and peritonitis.

2. Severe acute (haemorrhagic) pancreatitis

A small but important proportion of patients with severe acute pancreatitis present with an acute abdomen. The remaining patients with less severe disease present with localised acute upper abdominal pain (Ch 7.3). The most severe haemorrhagic form of the disease is associated with collapse and shock.

The onset of symptoms is occasionally explosive and can mimic a visceral perforation. Usually, however, increasingly severe pain develops over a period of several hours and spreads from the epigastrium throughout the whole abdomen and through to the back. Progressive dyspnoea and prostration (shock) are common. Persistent vomiting is often a feature of the illness (Table 7.3). Change of posture may aggravate or relieve the pain. Fever is variable.

Table 7.3 Comparison of perforated duodenal ulcer with acute pancreatitis

Signs. Signs of generalised peritonitis are present. There is often a ‘doughy’ feel to the abdomen and the signs of peritonitis and muscle rigidity are less than one would expect from the severity of the pain and the degree of prostration (an important point of differentiation from perforated ulcer). Disparity between the signs of peritonitis and the severity of pain is sometimes a feature of bowel ischaemia.

Prostration and shock, dyspnoea, ventilatory insufficiency and cyanosis indicate a severe attack with poorer prognosis. Extraperitoneal fluid and blood extravasation may be indicated by staining in the flanks (Grey-Turner’s sign) or around the umbilicus (Cullen’s sign).These signs are typically delayed in onset and may not be present at the initial presentation. The common predisposing causes of severe pancreatitis are gallstones and alcohol. In alcoholic pancreatitis the patient may be agitated and confused, indicating imminent delirium tremens.

3. Perforated peptic ulcer

The history is usually typical, with a sudden onset of very severe abdominal pain spreading from the epigastrium to the whole abdomen; radiation to the back and shoulder is less common. The patient is anxious, grey, sweaty and still. Movement and coughing exacerbate the pain. Breathing is shallow and is inhibited by pain. Many patients have a past history of peptic ulcer.

Signs. The clinical signs are usually unmistakable. Generalised peritonitis is present, with board-like rigidity in the epigastrium and elsewhere. The term is very appropriate and, once felt, is difficult to confuse with anything else. The abdomen is silent and loss of liver dullness to percussion may be elicited. Pulse, temperature and blood pressure are all likely to be normal. Shock does not develop until a late stage. The delayed ‘stage of reaction’ or of ‘masked’ peritonitis takes several hours to develop. This should not confuse the careful observer, as rigidity and ileus persist. More difficulty is found with a localised duodenal leak when the history is less typical and the abdominal signs are restricted to local tenderness in the upper abdomen (Ch 7.3).

4. Diverticulitis with perforation

Acute abdomen from diverticulitis results usually from the rupture of a pericolic abscess. Sometimes faecal peritonitis results from sudden rupture of an uninflamed diverticulum. Thus the onset may be without warning or after a recent history of acute diverticulitis. In many cases, a long history of bowel upset and episodic lower abdominal distension and discomfort precedes the acute attack. Very severe widespread pain originating from the left iliac fossa with prostration suggests perforated diverticulitis.

Signs. General peritonitis is present with maximum tenderness and guarding in the left iliac fossa. A tender mass due to a peridiverticular phlegmon or abscess may be palpable. Fever and toxicity are common associated features: they suggest a septic cause for the acute abdomen and help to distinguish diverticulitis from perforated ulcer.

5. Strangulating intestinal obstruction

Simple intestinal obstruction is usually readily diagnosed on clinical assessment and a plain X-ray film of the abdomen and is discussed in more detail in Chapter 7.9. Strangulating obstruction is a complication of simple obstruction; it can be notoriously difficult to diagnose and is lethal without prompt surgery. In simple small bowel obstruction the abdominal pain is colicky and periumbilical. If the pain becomes continuous, strangulation should be suspected.

Obstruction with ischaemia or strangulation is also seen in the large bowel. In an important minority of patients with malignant large bowel obstruction, the ileocaecal valve is competent and prevents regurgitation into the small bowel and decompression of the large bowel so that a ‘closed loop’ obstruction develops. The main danger is then progressive distension and perforation of the caecum. Such patients may present with right-sided pain and tenderness with distension and will require urgent surgical treatment to prevent caecal perforation and the consequent faecal peritonitis. Sigmoid or caecal volvulus is of more abrupt onset with severe constant pain due to early ischaemia and rapid massive distension and imminent perforation.

In malignant large bowel obstruction, a history of altered bowel habit often precedes complete constipation for faeces and flatus. This is often due to left-sided colonic stenotic lesions. Pain is often late and is felt in the lower abdomen or back. Nausea is common, but vomiting is generally a late feature.

Signs. Although certain clinical features can create a suspicion that strangulation is present (Box 7.1), no clinical or laboratory findings exist that exclude with certainty the possibility of strangulation. In small bowel obstruction the bowel sounds are hyperactive. Signs of local peritonitis and a palpable mass strongly suggest strangulation. A strangulated external hernia (femoral, inguinal, umbilical or incisional) will be tense, tender, irreducible and will have lost the cough impulse. Always search for a hernia, even in the patient who has had previous abdominal operations. Signs of interstitial fluid and blood volume depletion will be present when bowel obstruction has persisted for one or more days. Early shock or poor response to resuscitation suggests the presence of strangulation.

In large bowel obstruction, distension is particularly marked in the flanks and in the right iliac fossa. Signs of fluid depletion are late. The distension is predominantly gaseous and signs of shock or peritonitis suggest that perforation has occurred. Careful sigmoidoscopy may reveal the cause of the obstruction.

6. Vascular catastrophes

Ruptured aortic aneurysm usually presents in elderly men with the sudden onset of central abdominal pain radiating to the back and/or groin, associated with collapse, pallor and severe shock. There may be previous knowledge of a pulsatile abdominal swelling. The patient with ruptured aortic aneurysm is pale and sweating with collapsed veins, the signs of haemorrhagic shock. The majority of patients have ‘contained retroperitoneal haematoma’ rather than a free intraperitoneal rupture. A poorly defined pulsatile upper abdominal swelling is present in the epigastrium to the left of the midline. Femoral pulses may be weak or absent, but this is not diagnostic. Ruptured visceral artery aneurysms should be considered as well in patients with hypotension and severe sudden upper abdominal pain.

Aortic dissection presents with sudden severe tearing pain felt in the interscapular region or lower chest, radiating to the back and abdomen. Signs of distal vascular insufficiency in the limbs with absent or diminished peripheral pulses may be present, depending on the anatomy of the dissection, with possible anuria and with mild general abdominal tenderness. The patient is not always elderly in contrast to most patients with ruptured abdominal aortic aneurysms.

Acute mesenteric ischemia is typified by the presence of generalised severe, continuous abdominal pain of sudden with surprisingly few abdominal signs initially. The development of peritonism and mental confusion, associated with gross prostration and often dark rectal bleeding is usually associated with a grave outcome. Often evidence of an underlying embolic focus exists — such as atrial fibrillation or a recent myocardial infarct. The triad of pain, rectal bleeding and prostration in an elderly patient with fibrillation is suggestive of the diagnosis.

7. Ruptured ectopic pregnancy

Acute lower abdominal and shoulder-tip pain associated with pallor, prostration or fainting in a woman of child-bearing age is the characteristic presentation. Gastrointestinal symptoms are unusual. Rupture usually occurs between six and eight weeks’ gestation, so a missed period is common but not invariable. Death of the embryo causes the pain to be followed by dark, withdrawal vaginal bleeding in most but not all cases. This contrasts with the acute, bright, copious bleeding of abortion that often precedes pain. Acute abdomen from a ruptured ectopic pregnancy usually results from the rupture of isthmial implantations — in contrast to the problem of acute pelvic pain seen with a leak from an ampullary implantation.

Signs. The patient is pale and shocked, with a tender silent lower abdomen that may be mildly distended. There are usually no obvious signs of pregnancy such as breast enlargement but vaginal examination shows a soft cervix that is exquisitely tender to palpation. A tender pelvic mass may be present in one or other fornix.

8. Gastroenteritis

This non-surgical cause of an acute abdomen presents a problem in diagnosis, particularly in general practice. The main difficulty is the exclusion of appendicitis (particularly in infants), pelvic appendicitis and intestinal obstruction (in adults). In gastroenteritis, nausea, vomiting or diarrhoea precede the pain in contrast to the sequence of events in appendicitis, for example. The pain is less severe (though it may be colicky) than with obstruction. Early high fever is more suggestive of a viral illness, as are the presence of diffuse myalgias, photophobia and headache.

Signs. Abdominal tenderness tends to be poorly localised and diffuse. Abdominal guarding is not a feature of the illness and bowel sounds are hyperactive. Early high fever is a feature. As well as the common viral aetiology, enteritis may be caused by bacteria such as Yersinia, Salmonella or Campylobacter.

9. Less common causes

Primary peritonitis is now mainly found in association with alcoholic liver disease and ascites and can lead to a ‘negative’ laparotomy or laparoscopy. Foreign body perforation is not rare and may be difficult to locate at laparotomy. Periodic peritonitis (familial Mediterranean fever), gonococcal peritonitis, tuberculous peritonitis and granulomatous peritonitis, are other causes to be considered in the differential diagnosis of the acute abdomen. Complications of inflammatory bowel disease need to be considered.

The pain of renal infection can mimic an acute abdomen. Associated urinary frequency, dysuria and pyuria usually suggest the diagnosis. Rupture of an inferior epigastric vessel may be associated or follow treatment with oral anticoagulants. Rectus sheath haematoma may be spontaneous or precipitated by minor trauma and can mimic an acute abdomen or appendicitis. Similarly, ‘spontaneous’ retroperitoneal haematoma can occur in anticoagulated patients and present with lateralised abdominal or flank pain.

Medical conditions do not usually simulate an acute abdomen to the degree where surgical intervention is necessary. Basal pneumonia, however, can present difficulties. In these patients respiratory signs may be minimal, although respiratory distress is often the clue that suggests the diagnosis. Myocardial infarction is rarely a cause of an acute abdomen, but the initial pain may be in the epigastric region. Acute painful hepatic engorgement secondary to acute right ventricular failure may give rise to diagnostic confusion such as occurs in large pulmonary embolism. Acute porphyria, precipitated by barbiturates and diabetic ketosis with abdominal pain and vomiting, are occasionally problems in diagnosis, especially when associated with collapse and a confused mental state.

Urine examination

All patients should have a dipstick test on admission. Haematuria may accompany renal colic. Proteinuria, pus cells and organisms on microscopy suggest urinary infection. Urinary polymorphs may also accompany retrocaecal or pelvic appendicitis. Bile suggests acute cholecystitis or pancreatitis. Urinary glucose testing will detect the undiagnosed diabetic. The additional presence of acetone makes diabetic ketosis a possible cause of abdominal pain. Urine osmolality may be useful in assessing fluid depletion. A specific urine β-HCG should be done in all female patients of reproductive age.

Haematological examination

Haemoglobin and white cell count are often useful. Anaemia suggests that peritonitis may be due to blood in the peritoneal cavity or that there is underlying malignant or benign ulceration of the gastrointestinal tract. Leucocytosis (greater than 11 × 10∧9 per litre) suggests sepsis or inflammation. If very high (over 20) an abscess is likely. High white cell count suggests also the possibility of strangulated bowel and makes a diagnosis of perforated ulcer, pancreatitis and gastroenteritis less likely. Leucopenia may occur with severe sepsis. Blood culture is indicated for any patient with a suspected septic cause.

An elevated haemoglobin or haematocrit level is indicative of plasma volume depletion. Diminished levels indicate pre-existing anaemia or blood loss.

Biochemistry

Few tests are specifically helpful in making a diagnosis but several are useful in monitoring the treatment of metabolic and ventilatory disturbances.

Serum lipase levels over 100 iu/L are very suggestive of pancreatitis. Lipase is much more specific for pancreatitis than serum amylase where moderate elevations up to 1000 iu/L may occur with intestinal obstruction, strangulation or perforation. Serum electrolyte, urea and creatinine levels help assess fluid and electrolyte requirements. Urea elevation is commonly due to isotonic extracellular fluid (‘saline’) depletion.

Arterial blood gas analysis is important in monitoring shocked patients, those with ventilatory problems or with pancreatitis. Serum lactate levels are often disproportionately high in mesenteric vascular occlusion. Liver function tests rarely influence early operative management but are useful baselines in jaundiced patients and in alcoholics.

Imaging techniques

These include plain radiology, ultrasound, contrast and computed tomography (CT scan) and are very often valuable. Erect chest X-ray (Fig 7.11), together with erect and supine films of the abdomen, are indicated in nearly all patients. (For patients too moribund to undergo an erect chest X-ray, a lateral decubitus film may be requested.) These X-rays may show primary chest pathology (pneumonia) or basal changes secondary to a subdiaphragmatic condition such as pancreatitis. Free gas under the diaphragm indicates a perforated viscus, usually a perforated ulcer or perforated diverticulitis. A grossly dilated stomach may be seen in patients in diabetic coma, falsely suggesting the possibility of a surgical condition.

Figure 7.11 Chest X-ray with gas under the diaphragm

Based on Burkitt, 2007

If small bowel obstruction is suspected, erect and supine views show significant distension of the small bowel with gas fluid levels and a ladder pattern (Fig 7.12). In large bowel obstruction, the colon is distended down to the site of obstruction and small bowel dilatation may coexist. If the ileocaecal valve is incompetent specific causes such as sigmoid or caecal volvulus may show localised distended large bowel loops. Gastroenteritis can be associated with small gas–fluid levels with moderate intestinal distension. Air swallowing in association with severe pain and recent injury may cause confusion. The absence of free gas does not exclude perforated viscus, nor does the absence of fluid levels in the bowel exclude strangulation. Free gas is seen in only about two-thirds of cases of perforated peptic ulcer. In appendicitis, distended bowel with fluid levels on plain X-ray often indicates a localised ileus in the right iliac fossa. Pancreatic calcification or lithiasis or a sentinel small bowel loop in the region of the pancreas or a colonic ‘cut-off’ sign may be seen in pancreatitis. More commonly, generalised ileus is present, with evidence of ascites. Distended, gas-filled, small and large bowel loops with fluid levels are present and large bowel gas extends to the rectum. Mesenteric infarction causes a diffuse small bowel ileus. In ruptured aortic aneurysm a rim of calcium may be seen in the aneurysm, particularly in the lateral decubitus films. Radio-opaque gallstones may be seen in cholecystitis (20%); urinary calculi are usually visible (80%).

Figure 7.12 Films of small bowel obstruction

A: supine abdominal X-ray with dilated small bowel loops; B: erect abdominal X-ray with multiple air fluid levels (arrowed); C: typical ’ladder’ pattern (arrowed) on supine abdominal X-ray

From Feldman, 2006

Contrast-enhanced X-rays may be required in special instances to diagnose bowel leakage. A gastrografin meal or enema will not damage the peritoneum and can be very useful, especially if combined with a CT scan at the same time. A limited contrast enema is often used to confirm the diagnosis and the site of a large bowel obstruction prior to operation.

Ultrasound is the investigation of first choice in the diagnosis of gallstones and hepatobiliary conditions.

Aortic aneurysms are readily diagnosed with ultrasound and CT angiography may be useful in diagnosis of ruptured aortic aneurysm or dissecting aneurysm if the diagnosis is not clear, the patient is stable and renal function known to be satisfactory. When a focus of infection is suspected, CT scan with oral contrast can both facilitate the diagnosis and direct interventional or surgical treatment. Ascites may be seen in pancreatitis — aspiration and amylase level on the fluid may be diagnostic.

Catheter angiography is rarely required, apart from the context of mesenteric vascular insufficiency.

Peritoneal tap and lavage

Peritoneal tap or lavage is much less commonly used to assess the acute abdomen than in assessing blunt abdominal trauma. Abdominal distension and previous incisions are contraindications. False negative results can mislead and most surgeons prefer to explore the abdomen by laparoscopy or laparotomy if a surgical cause cannot be excluded by other means.

1. Acute appendicitis with perforation

Appropriate antibiotics are given perioperatively prior to surgery. The appendix is exposed and removed through a skin crease right iliac fossa incision if not done via laparoscopy. Thorough peritoneal lavage is performed in patients with general peritonitis. Antibiotics may be continued intravenously. (This may also be managed laparoscopically in selected cases by those with appropriate expertise, although the incidence of postoperative intra-abdominal abscess may be higher.)

If a localised appendiceal abscess is found, the appendix is removed and the abscess is drained. The wound may be left open for later delayed closure if there is contamination of the wound.

2. Acute severe (haemorrhagic) pancreatitis

Exploratory operation is occasionally unavoidable because another surgical condition (e.g. perforated ulcer, bowel obstruction, appendicitis) cannot be excluded (Box 7.2). Diagnosis is confirmed by finding an inflammatory pancreatic mass with fat necrosis and ascites (‘beef-tea’ fluid). A peritoneal dialysis catheter can be left in situ for subsequent lavage.

Treatment of pancreatitis otherwise is initially conservative:

Table 7.4 Indicators of severity of acute pancreatitis (Glasgow system)

Figure 7.13 Common complications of acute pancreatitis

A: pseudocyst of the pancreas in the lesser sac secondary to a leak from the main pancreatic duct; B: necrosis, haemorrhage and sepsis extends to the retroperitoneum. 1: inferior surface of the right lobe of the liver; 2: gall bladder; 3: stomach; 4: greater omentum; 5: transvese colon; 6: third part of the duodenum

3. Perforated peptic ulcer

Nasogastric suction is accompanied by early operation. On most occasions, and particularly in the poor risk case (Box 7.3), the ulcer is covered with an omental plug and peritoneal washout is performed (Fig 7.14). The patient is commenced on H. pylori eradication postoperatively and risk factors addressed. For the unusual combination of perforation with serious bleeding, or for very large ulcers, partial gastrectomy may be necessary. A perforated gastric ulcer may be a carcinoma and should be biopsied and preferably treated by definitive partial gastrectomy.

Figure 7.14 Simple closure of a perforated anterior duodenal ulcer (Roscoe-Graham method)

Sutures are passed deep to the ulcer and tied over the omentum.

4. Perforated diverticulitis

Perioperative antibiotics are given. The effected segment of colon (usually sigmoid) is resected. A restorative anastomosis is usually not performed in the presence of sepsis. The two ends of the bowel may be exteriorised as a double-barrel colostomy (Paul-Mikulicz) or, more commonly, the proximal end is brought out and the distal end is closed and left within the pelvis. This is Hartmann’s procedure (Fig 7.15). It is essential that the septic focus of diverticulitis is excised and not simply drained — drainage alone will not control infection. Later, a rectosigmoid anastomosis is performed electively when the patient is considered fit for the procedure.

Figure 7.15 Hartmann’s procedure

Resection of the site of complicated diverticular disease is usually necessary if infection is to be controlled in patients with perforation. After excising the diseased segment, the risk of immediate bowel anastomosis in continuity is avoided by an end sigmoid colostomy (1) with closure of the rectal stump (2).

5. Strangulating intestinal obstruction

An operation becomes urgent when strangulation is suspected. Preoperative resuscitation aims to restore at least the blood volume prior to exploration but must not delay surgery.

At operation for small bowel obstruction the cause is relieved and necrotic or doubtful bowel is resected, with primary anastomosis.

Decompression of the proximal large bowel is indicated in large bowel obstruction because of the danger of progressive distension and perforation of the caecum. At operation, the obstructing lesion is usually removed, but it is almost always unsafe and unwise to perform primary anastomosis of obstructed large bowel.

6. Vascular catastrophes

Urgent operation is necessary for ruptured aortic aneurysm. Bleeding is controlled by proximal and distal aortic clamping. The aneurysm is replaced by an in situ prosthetic graft. Perioperative intensive care is essential.

In aortic dissection with deterioration, despite control of hypertension, an operation is required, often using endovascular techniques to limit further dissection and end-organ compromise.

For mesenteric vascular occlusion, nonviable bowel is resected at operation. If a large proportion of the small bowel is lost, it is prudent to exteriorise the ends of bowel as enterostomies. Alternatively, a planned second-look laparotomy may be performed after 24 hours to check the viability of the remaining small bowel. Anastomosis is deferred until the patient’s condition improves. If the entire small bowel is infarcted from the duodenojejunal flexure, excision and permanent intravenous feeding can be considered in younger patients without gross associated pathology.

7. Ruptured ectopic pregnancy

Immediate surgery to control bleeding may be necessary in the shocked patient. The affected fallopian tube may be excised. The patient is at risk of a further ectopic implantation in future pregnancies, but sometimes repair of the tube is possible after removal of the ectopic tissue.

8. Gastroenteritis

Appropriate medical treatment is required. A major difficulty is differentiating non-surgical causes of abdominal pain (e.g. nonspecific abdominal pain, mesenteric adenitis, gastroenteritis, urinary infection) from appendicitis. When this differentiation cannot be made with certainty and pain and tenderness persist, a diagnostic laparoscopy may be performed. Most surgeons accept the necessity of removing a small number of normal appendices (∼10%) to avoid missing early appendicitis. Faecal culture may reveal a specific organism and thus specific treatment may be instituted. Organisms, such as Salmonella, Yersinia and Campylobacter, may require appropriate antibiotic therapy and consultation with infectious diseases physicians.

The remaining miscellany of causes of abdominal pain will require appropriate treatment.

1. Acute gastritis and nonulcer dyspepsia

Acute gastritis may be due to bacterial or viral infection or to duodenal reflux gastritis. These patients may be admitted to hospital with burning epigastric pain of sudden onset, often with a provisional diagnosis of perforated ulcer. In the past ‘abdominal pain of unknown cause’ was often the eventual diagnosis in patients who recovered without surgery. Nowadays, subsequent endoscopy reveals that many of those patients have gastritis secondary to bacterial infection. Viral and bacterial gastroenteritis may have acute epigastric pain and vomiting as the main symptoms; diarrhoea is less prominent. Pain may also be triggered by substances toxic to the gastric mucosa, such as alcohol and analgesic agents. On occasions, after cholecystectomy or partial gastrectomy, acute epigastric pain is secondary to bile reflux gastritis.

2. Acute exacerbation of duodenal ulcer

Complicated duodenal ulcer can present with acute upper abdominal pain due to an acute exacerbation or to a localised perforation. In many instances gastric risk factors, such as alcohol, nonsteroidal anti-inflammatory drugs (NSAIDS) and bacterial or bile gastritis, have triggered the relapse. About three-quarters of the patients have a past history of ulcer. Sealing of a small perforation is more common in patients who have had past abdominal surgery, but a scar should also suggest that other causes for the pain are possible, such as adhesive small-bowel obstruction or postgastrectomy bile gastritis. Details of any previous operative procedure performed should be sought from previous records as the patient’s account is frequently inaccurate or incomplete.

In about a third of cases with an acute abdomen from perforated ulcer, a prodromal period exists during which a small leak initially localises before free perforation occurs. This period can last for several hours and should be borne in mind when seeing a patient in the emergency department with acute epigastric pain that has partially resolved.

The presence of H. pylori should be considered as a causative agent for gastroduodenal ulcer disease, the diagnosis confirmed and eradication therapy instituted.

3. Biliary ‘colic’ and acute cholecystitis

Most episodes of biliary ‘colic’ last for no more than a few hours but recur intermittently. Many of these patients see a doctor electively with the problem of chronic episodic epigastric pain. Biliary colic is distinct from an episode of acute cholecystitis where the patient has severe persisting acute pain, will call a doctor or present at hospital. Narcotic analgesics are usually necessary for pain relief once the diagnosis of acute biliary pain has been made. Biliary pain has an abrupt onset, is felt in the epigastrium or the right hypochondrium and can fluctuate in severity. The pain is often referred to the back. Most patients have a past history of attacks of biliary colic; an attack of persisting acute cholecystitis as the first clinical evidence of gallstones is less common.

When rapid resolution of symptoms occurs, the patient can be investigated electively with ultrasound for gallstones. Continued pain for more than 12 hours suggests acute cholecystitis. Bacteria can be cultured from the bile in only 70% of patients with established cholecystitis. Admission to hospital is necessary for persistent pain and for associated systemic effects. In 95% of patients, acute cholecystitis results from persistent obstruction of the cystic duct by a gallstone impacted in Hartmann’s pouch. The natural history of acute cholecystitis depends upon whether the obstruction is relieved, whether there is secondary bacterial infection, the age of the patient and the presence of concurrent medical illness (particularly diabetes mellitus). Most attacks will resolve spontaneously in hospital; some progress to abscess formation and occasionally to free perforation with generalised peritonitis (Fig 7.16). Jaundice occurs in only 10% of patients and suggests stone in the bile duct, acalculous cholecystitis or gangrenous cholecystitis. Jaundice with high fever suggests ascending cholangitis.

Figure 7.16 Pathology and natural history of gallstones

A: asymptomatic gallstones; B: biliary pain (chronic cholecysitis); B1:obstructive jaundice; B2: pancreatitis secondary to small stones; B3: ascending cholangitis. C: acute cholecystitis; C1: mucocele of gall bladder; C2: perforated empyema — with pericholecystic abscess; C3: free perforation. D: chronic cholecystitis; D1: cancer of gall bladder; D2: cholecysto-duodenal fistula and gallstone ileus

Acute acalculous cholecystitis usually occurs in the postoperative, posttraumatic or severely ill hypotensive patient. Gangrene may proceed to perforation, which may be fatal. Physical signs may be minimal. The diagnosis is notoriously difficult to make (or to think of) in the seriously ill patient with multiple coexisting problems.

4. Acute (oedematous) pancreatitis

In about 80% of cases acute pancreatitis is of modest severity and presents as localised acute upper abdominal pain, without systemic effects. The prognosis in these cases is good and a fatal outcome unusual. The remaining 20% of patients present with the more severe acute haemorrhagic pancreatitis with necrosis. Collapse and shock occur and the presentation is that of an acute abdomen (Ch 7.2) — a potentially lethal situation with a mortality rate of 30%.

Attacks of pancreatitis frequently follow an alcoholic binge or large meal. The pain is abrupt in onset, severe and persistent and often radiates through to the back. Persistent vomiting is a feature. The majority of cases of mild or moderate oedematous pancreatitis settle down rapidly in hospital.

Acute oedematous pancreatitis is often secondary to gallstones. A past history of biliary pain may be present. With pancreatitis, the pain tends to be central rather than right-sided and the illness more severe and prostrating. Most attacks resolve, as small stones pass through the sphincter of Oddi and are passed unnoticed in the faeces. Stones in the bile duct are found in only about 10% of patients when investigations are delayed for more than a week after the attack of pancreatitis. The earlier the duct is investigated (by surgery or endoscopic retrograde cholangiopancreatography: ERCP), the more patients are found who have stones in the bile duct. The pathology of gallstone pancreatitis is characterised by the presence of small stones in a functioning gall bladder with a patent, large cystic duct and stones can be found in the faeces, if diligently sought.

Gastritis and duodenal ulcer

In acute gastritis moderate epigastric tenderness is present. In patients with sealed perforation, muscle tenderness and guarding are present to a greater extent than in patients with acute oedematous pancreatitis. Unless a periduodenal abscess has developed, patients with an acute exacerbation of duodenal ulcer have no systemic signs of toxicity.

Cholecystitis

Right upper quadrant tenderness and guarding are present. Tenderness beneath the right costal margin on inspiration is characteristic (Murphy’s sign). In about a third of patients the inflamed gall bladder is palpable. A palpable mass is found more frequently after the first 24 hours; before this, the abdominal tenderness often masks the presence of the gall bladder mass (Fig 7.17). Mild fever is common, as are moderate tachycardia and leucocytosis. In contrast, patients with biliary colic have no significant findings on examination.

Figure 7.17 Acute cholecystitis

An acutely tender, palpable gall bladder is virtually diagnostic of acute cholecystitis. The gall bladder enlarges laterally rather than towards the umbilicus.

High fever and chills are uncommon and suggest either the presence of empyema of the gall bladder, in which case the diagnosis is incorrect, or that common duct stone with cholangitis is a complication.

Acute pancreatitis

The signs found depend upon the severity of the disease. Despite severe pain, examination of the abdomen usually reveals that guarding is not as marked as would be expected in a patient with comparable pain due to perforated ulcer. An epigastric abdominal mass may be found. A mass is due to inflammatory oedema of the pancreas, rather than to the necrotic mass with slough that occurs with more severe forms of acute haemorrhagic pancreatitis. Peripheral circulatory and respiratory failures are uncommon — these, also, are features of the more severe form of acute pancreatitis (Ch 7.2). The temperature is usually normal or slightly elevated; leucocytosis, if present, is of moderate degree. Clinical evidence of secondary basal atelectasis and pleural effusion on the left side of the chest are common. In most cases with mild disease the patient’s clinical condition rapidly settles with treatment, with complete resolution of physical signs.

Haematological and biochemical examination

In acute pancreatitis the serum lipase usually rises to above 100 iu/L within six hours of the onset of an acute episode and remains elevated for about two days. The serum lipase is usually a reliable test for diagnosing acute pancreatitis. A mild elevation can occur in other diseases causing acute abdominal pain, particularly those associated with ischaemia or perforation of bowel. The serum lipase may be normal in the hyperlipidaemic patient or because the level has returned to normal before the estimation was carried out.

A transitory rise in serum bilirubin is common in patients with gallstone pancreatitis. Urinary bilirubin is often present in patients with acute cholecystitis or pancreatitis and is a helpful diagnostic clue. Daily review of electrolytes, calcium, glucose and renal function is essential.

The full blood count is normal in most patients presenting with acute upper abdominal pain. Marked leucocytosis suggests the presence of sepsis — as is found with empyema of the gall bladder, paraduodenal abscess or a high-retrocaecal appendicitis with abscess. Mild or moderate leucocytosis can occur in uncomplicated acute pancreatitis or acute cholecystitis. Hypochromic anaemia suggests blood loss from peptic ulcer or a colonic malignancy.

Radiology: plain erect film of chest and abdomen

In cases of perforated ulcer, where the leak of gastric contents is confined to the upper abdomen, free gas under the diaphragm on an erect chest X-ray may not be found. In pancreatitis, X-ray changes of left basal pulmonary atelectasis and effusion are often seen. Plain film of the abdomen may also reveal opaque gallstones or pancreatic calcification. About 20% of gallstones are radio-opaque. An ileus pattern on the plain film, localised to the right upper quadrant, suggests cholecystitis or pancreatitis. A localised small bowel loop (‘sentinel loop’) or large bowel ileus (‘colonic cutoff’ sign) over the pancreas may occur.

Ultrasound and CT scanning

Ultrasound is the best method of detecting gallstones in patients with acute upper abdominal pain. It is sometimes difficult to detect gallstones by ultrasound in patients with pancreatitis because the distended bowel gas of ileus makes ultrasound examination more difficult. Ultrasound is also a valuable method of detecting and following a pancreatic mass and the evolution of pseudocysts, especially in the thin patient. Ultrasound can show the increased thickness and oedema of the gall bladder wall that is a feature of acute cholecystitis and thus can be of considerable diagnostic value in patients with acalculous cholecystitis. Ultrasound is less effective in the obese patient with excess gastrointestinal gas. Occasionally in such patients, a CT scan is a better examination — CT imaging of the gall bladder is not as satisfactory as ultrasound, but CT imaging with contrast of the pancreas can be highly discriminatory in patients with acute pancreatitis.

Radionuclide excretion scan

When a policy of early surgery for acute cholecystitis is being followed, a firm diagnosis of the presence of gallstones, and preferably of lack of function of the gall bladder, is very valuable. The diagnosis on clinical grounds will be wrong in 10–20% of cases. Ultrasound and radionuclide (99Tcm CHIDA) scan make accurate diagnosis possible in most cases. HIDA scan of the gall bladder, if available, is a useful method of diagnosing the presence of acute cholecystitis, by demonstrating nonfunction of the gall bladder.

Gastrografin swallow and meal

An early, water-soluble contrast study of the upper gastrointestinal tract is indicated in the patient suspected of having a localised perforation of an ulcer. Indications include a past history of ulcer in a patient with persistent pain and moderate tenderness with a negative plain X-ray. A localised pool of contrast connected to and lying outside the duodenum confirms the diagnosis of a sealed perforation.

Late endoscopy and ERCP

Endoscopy should be delayed in the undiagnosed case until resolution of symptoms occurs. In patients with acute gastritis or nonulcer dyspepsia, biopsy and silver stain of antral mucosa may reveal the presence of H. pylori. ERCP may be indicated in the patient with postcholecystectomy pain if a stone in the bile duct is suspected, particularly in patients with dilated extrahepatic ducts and altered liver function.

1. Acute gastritis and non-ulcer dyspepsia

These patients are observed in hospital until they settle down, at which time gastroscopy is performed to exclude ulcer. The later treatment of non-ulcer dyspepsia includes measures used in the treatment of functional bowel disease and a course of eradication treatment of helicobacter if appropriate.

2. Acute exacerbation of duodenal ulcer

For exacerbation of ulcer, conservative treatment is indicated and the symptoms resolve in a few days. Local perforation is an indication for elective surgery, especially in patients with a long history, previous complications or associated stenosis. If free perforation occurs in hospital (and a diagnosis is made promptly), laparoscopy and/or laparotomy is performed. The ulcer can be oversewn with an omental plug.

3. Biliary ‘colic’ and acute cholecystitis

Intravenous fluids and antibiotics are commenced.

With acute cholecystitis, pain and tenderness often resolve within 48 hours in about two-thirds of cases. In the past it was recommended that these cases have an interval cholecystectomy after two to three months. Clinical trials have shown that early operation before discharge from hospital can be performed safely, providing the surgeon is experienced and satisfactory control of any concurrent disease can be achieved. Most patients are therefore best operated upon at the first convenient opportunity.

Ideally, operative cholangiography should be performed routinely. The incidence of a clinically undetected stone in the bile duct is about 5%. Bile duct stones may be removed during surgery using specialised retrieval devices via the cystic duct or directly from the common bile duct. Sometimes it is safer to leave duct stone removal for a postoperative ERCP/sphincterotomy.

4. Acute (oedematous) pancreatitis

Most patients with oedematous pancreatitis settle down rapidly in hospital with conservative treatment. The principles of treatment are:

In gallstone pancreatitis, current opinion favours performing a cholecystectomy during the initial hospital stay so that the risk of another attack is avoided. In aged patients, endoscopic sphincterotomy may be a safer alternative initial form of treatment.

5. Less common causes

These may be gastrointestinal or nongastrointestinal. Pain from preicteric hepatitis can be confused with acute cholecystitis. Prodromal symptoms of nausea and anorexia and signs of tender hepatomegaly with disordered liver function tests help make the diagnosis. Pain from hydronephrosis is often felt in the epigatrium. Occasionally, silent myocardial infarction, with acute right ventricular failure causing painful hepatic engorgement, can present with acute upper abdominal pain.

Basal pneumonia may present, especially in the young, with upper abdominal pain and guarding. An important sign of abdominal pain due to respiratory infection is associated respiratory distress. Chest signs may be minimal, consisting only of occasional basal crepitations.

Nerve root pain (T6–10) can cause acute upper abdominal pain. In most cases the clue to the diagnosis is radiation of the pain from the back. Osteoarthritis with spur formation and shingles are the most common causes of root pain.

Splenic infarction may present with acute left hypochondrial pain. Splenic infarcts occur in association with bacterial endocarditis, lymphoma and in patients with splenomegaly secondary to alcoholic cirrhosis of the liver. Occasionally, blood from the pelvis may produce signs primarily in the upper abdomen with left shoulder tip pain, as may delayed rupture of the spleen occurring some days after injury.

Sometimes aortic aneurysm presents with acute epigastric or left hypochondrial pain when rupture is imminent. More commonly the problem presents as an acute abdomen (Ch 7.2). An interval of several hours may exist between the first episode of self-limited bleeding and later retroperitoneal rupture.

Appendicitis in a high retrocaecal position beneath the liver can closely mimic acute cholecystitis, as may obstructing carcinoma of the right transverse colon with a mass. Obstructing carcinomas of the transverse colon can present with colicky upper abdominal pain or lesser discomfort that is made worse or triggered by the ingestion of food. These patients often have an iron deficiency anaemia — an important clue that can suggest the diagnosis.

Occasionally, patients with alcoholic liver disease develop acute epigastric pain, probably because of low-grade infected ascites or primary peritonitis.

1. Acute appendicitis

Acute appendicitis can occur in infants and the old but most cases are found during adolescence and early adult life. Appendicitis at the two extremes of age is more difficult to diagnose. The symptoms usually begin with pain that is central, symmetrical and often colicky. As with many other viscera, the early pain of appendicitis is often referred to the somatic dermatome of the midgut — around the umbilicus. The patient is often awakened in the early morning by vague abdominal discomfort progressing to central or epigastric cramping pain, followed some time later by increasing nausea, anorexia and indigestion. Neither vomiting nor diarrhoea is an early symptom. An illness starting with nausea or diarrhoea, progressing to abdominal pain, suggests that the diagnosis is gastroenteritis, not appendicitis (Table 7.2). Early rigor and high fever are also uncommon and favour another diagnosis, such as urinary tract infection. Absence of fever must not preclude the diagnosis of appendicitis. Fever is absent throughout the course of the disease in a significant number of patients with appendicitis. Within several hours the pain shifts and becomes localised in the right iliac fossa; the patient can often point to the site of tenderness with one finger. Movement and coughing increase the abdominal discomfort.

Examination, when pain is localised to the right iliac fossa, usually reveals sharply localised tenderness, accompanied by mild or moderate involuntary guarding. Coughing often elicits local pain (‘cough tenderness’) and is a helpful sign. Tenderness is usually localised over the appendix: the site may be at McBurney’s point but is often at some other site in the right iliac fossa. Rebound tenderness on percussion may be found in the same area. The patient often looks flushed and unwell, with a rapid pulse, furred tongue and abdominal breath. From this stage the inexorable progression of untreated appendicitis usually continues, although resolution can occur at any stage with milder attacks. Many patients are severely ill and toxic (because of peritonitis or abscess) by 72 hours from the onset of the illness.

Tenderness on rectal examination is very significant in the diagnosis of pelvic appendicitis. Abdominal tenderness is often not prominent with pelvic appendicitis.

Most atypical presentations of appendicitis are due to appendicitis in an anomalously positioned appendix (Fig 7.18).

Figure 7.18 Anatomy of the appendix

The caecum may be high (A) normal (B) or low (C) in position. The appendix may be free lying, paracaecal or retrocaecal, pre-ileal or postileal, or pelvic in position.

In rectrocaecal or paracaecal appendicitis the pain can be confined to the epigastrium or right upper abdomen without moving to the right lower quadrant or pain may shift to a more lateral point in the flank than is usually the case. The appendix may lie against the ureter and the psoas muscle, causing urinary frequency with red and white cells in the urine and pain that radiates to unusual sites such as the right testis and front of the thigh. Retrocaecal appendicitis can closely resemble acute cholecystitis or acute pyelonephritis. The patient often presents with a limp due to painful hip flexion, even suggesting hip disease.

Pelvic appendicitis is probably the most sinister form of the disease. Pain and tenderness are often suprapubic and abdominal tenderness less marked. Abdominal tenderness may be absent during the first 48 hours of the illness or until general peritonitis ensues. The early diagnosis often made in these cases is gastroenteritis, cystitis or salpingitis. The diarrhoea of pelvic appendicitis, however, is usually late. The diagnosis of pelvic appendicitis depends on performing a rectal examination.

Retro-ileal appendicitis may produce a classic picture of small bowel obstruction. This unusual form of appendicitis can be associated with early vomiting and diarrhoea. Meckel’s diverticulitis can produce a similar clinical picture.

Young children and the aged tend to have a more rapid and severe course with early peritonitis or early abscess formation and poor localisation of infection. A similar natural history is often found in obese patients. Appendicitis is a particularly dangerous condition in psychiatrically disturbed patients and in infancy. One must always be aware of the possibility of appendicitis in an infant who is lethargic, irritable and difficult to examine, especially when vomiting and abdominal distension are present. The younger the patient, the more appendicitis appears to resemble gastroenteritis.

Appendicitis in pregnancy can also be extremely difficult to diagnose because the appendix is in a higher position than usual and the infective process tends to localise poorly. Appendicitis mainly occurs during the second trimester and must be distinguished from other common causes of abdominal pain at that time — including degeneration of fibromyoma, acute pyelitis, cholecystitis, nonulcer dyspepsia and reflux oesophagitis.

2. Acute mesenteric adenitis and acute Meckel’s diverticulitis

These conditions are considered together as they can closely mimic appendicitis and are usually best treated by surgical exploration, often with laparoscopy.

Acute mesenteric adenitis. This condition is more common in children and adolescents and often follows or accompanies an upper respiratory viral illness. The clinical course of abdominal pain and tenderness is very similar to appendicitis. Pain tends to be more generalised and less severe. Tenderness is less well localised and less constant in position. Fever can be higher and constitutional signs less. There may be evidence of a coexisting viral illness. The disease is self-limiting and nonprogressive. Some patients who are seen at the stage of resolution with minimal abdominal and general signs are obviously getting better; conservative treatment and observation are indicated. In other cases the safest treatment is early laparoscopy and possible appendicectomy. The diagnosis is established at operation by finding a normal appendix and enlarged succulent nodes in the ileal mesentery with a serous exudate.

Acute Meckel’s diverticulitis. Meckel’s diverticulitis can also simulate acute appendicitis very closely. Other forms of presentation are intestinal obstruction, gastrointestinal haemorrhage or an umbilical fistula. Presentation in childhood is more common than in adults and the diagnosis will usually be made only at operation. Occasionally the clinical features of appendicitis, together with rectal haemorrhage, will suggest the diagnosis, as will associated low small bowel obstruction.

3. Nonspecific acute right iliac fossa pain

Although called nonspecific, a more precise presumptive diagnosis can be made in many cases. Conditions causing nonspecific right iliac fossa pain separate into two main groups: those due to viral or bacterial gastroenteritis and those due to functional bowel disease (irritable colon).

Gastroenteritis secondary to infection is probably a more common cause of acute right iliac fossa pain than functional bowel disease. Severe vomiting and diarrhoea start early in gastroenteritis in contrast to appendicitis, which usually has a more insidious onset with pain as the first symptom. An early high fever is common and tenderness is more diffuse than is found in acute appendicitis. Signs of upper respiratory tract infection are frequently found. This condition is perhaps the most common reason for a negative appendicectomy.

Functional bowel disease. Patients with functional bowel disease usually do not appear ill. Symptoms and signs are less than is found with gastroenteritis or appendicitis. A recent history of anxiety and depression is common, as is a past history suggestive of functional bowel disease — particularly constipation. On examination there is mild diffuse tenderness and voluntary guarding. A scar, through which a normal appendix was removed in the past, is common.

4. Gynaecological disorders

Salpingitis. Women with salpingitis generally present with poorly localised pain, often starting in the lower right abdomen and then becoming more diffuse. Most patients have associated urinary frequency. Early high fever is common, with diffuse lower abdominal tenderness and guarding, tenderness in both lateral fornices (especially on rocking the cervix) and vaginal discharge.

Complicated ovarian cyst. An acute torsion of an ovarian cyst may be difficult to distinguish from acute pelvic appendicitis. The pain is severe and usually more diffuse. Pain may radiate to the flank or thigh. It may not be possible to examine the patient adequately because of exquisite pelvic tenderness. The temperature is usually normal but the patient looks ill. A ruptured ovarian follicle (mittelschmerz) can mimic appendicitis. The history usually reveals that the onset of the pain is mid-cycle. The pain rapidly settles and, as with most gynaecological causes of acute right iliac fossa pain, gastrointestinal symptoms are insignificant. In addition these patients do not look as ill as patients with appendicitis and the condition is often resolving when seen.

Ectopic pregnancy. Ectopic pregnancy is an important condition that can resemble acute appendicitis, particularly the subacute presentation that follows ampullary implantation. In these patients there may not be a history of missed period. On examination, as well as poorly localised tenderness in the right lower abdomen, the cervix is tender and soft and the uterus is enlarged. An elevated beta HCG is often helpful in the diagnosis.

5. Urinary tract stone, infection or hydronephrosis

Urinary stone. In most patients with pain due to urinary tract stone the diagnosis is obvious. Typical renal colic is associated with severe loin pain often radiating to the ipsilateral groin. There may be haematuria and frequency. Difficulty may arise in cases without classic pain or a stone later impacted in the lower right ureter may cause an acute periureteral inflammatory reaction with local tenderness and guarding.

Renal tract infection. Renal tract infection and perinephric abscess are more frequent causes of pain that resembles high retrocaecal appendicitis. Classically the patient with urinary tract infection has an early high fever, rigors and frequency, and dysuria from the time of onset of the pain. Pyuria is found on urine examination. The diagnosis may be especially difficult in children with a ‘closed’ infected hydronephrosis and thus no pyuria.

Hydronephrosis. Hydronephrosis is an important cause of intermittent attacks of abdominal pain that can mimic appendicitis. Renal tenderness is usually present and the disease is not usually progressive. Occasionally, abdominal signs are so marked that appendicitis is difficult to exclude.

Full blood count

This may reveal a moderate leucocytosis typical of appendicitis. Anaemia suggests the possibility of an unusual cause of right iliac fossa pain, such as carcinoma of the right colon. In a patient with equivocal symptoms and signs, and in whom pain has been present for 72 hours or more, a normal white cell count is helpful and supports the decision to treat the patient by observation and review. It cannot be too strongly stressed that a normal white cell count in the first two to three days of the clinical history does not exclude appendicitis. If a white cell count is done and found to be normal in a patient with a clinical diagnosis of acute appendicitis, operation should proceed without delay on the basis of the clinical findings.

Urine examination

This is essential and may detect the presence of sugar and diagnose diabetes. Leucocytes and red cells may be present in the urine in renal tract infection and in some cases of retrocaecal appendicitis. Again, positive urinary findings, when the diagnosis is clinically suggestive of appendicitis, should not delay operation.

Cervical swab and culture

This is indicated when a vaginal discharge suggests the possibility of salpingitis. This is especially so if a sexually transmitted disease (e.g. gonorrhoea) is suspected.

Plain X-ray

This may be indicated when renal stone is suspected or diagnostic doubt exists for other reasons. Acute appendicitis is diagnosed without radiographic studies in most young patients. Plain films of the abdomen may be valuable in atypical cases, especially in the very young and very old. In about 50% of patients with appendicitis, evidence of localised ileus in the right iliac fossa is seen on X-ray. The visualisation of a faecolith on plain abdominal X-ray in a patient with acute right iliac fossa pain is typically diagnostic of appendicitis.

Ultrasound

This technique is more helpful in the diagnosis of gallstones or of hydronephrosis — it can be useful confirming these diagnoses in equivocal presentations. Pelvic and/or transvaginal ultrasound can be very helpful in confirming gynaecological abnormalities such as ovarian cyst, salpingitis or ectopic pregnancy.

CT scan

CT scan may be of value in the neglected case referred with gastrointestinal disease for diagnosis. It should be noted also that, in many centres, it is the investigation of choice for appendicitis where clinical features are not typical.

Laparoscopy

This is a useful procedure in cases of doubt and is a particularly important diagnostic procedure in the patient suspected of having a gynaecological cause of acute right iliac fossa pain, especially in those who have missed a period and ectopic pregnancy is suspected.

In many cases a safe appendicectomy can be performed by laparoscopy. If the appendix is normal many of the other possible surgical conditions can be seen and treated laparoscopically.

If a mass is palpable under general anaesthesia, the procedure should be converted to an ‘open’ appendicectomy performed through a transverse, muscle-splitting, right lower quadrant abdominal incision.

HCG pregnancy test

Urinary hormonal (β-HCG) testing for pregnancy usually becomes positive by 14 days from conception. It is prudent to perform the test in women of child-bearing age with acute right iliac fossa pain when the pattern is not typical of appendicitis. The test should be routine if complications of pregnancy are suspected.

1. Acute appendicitis

Most cases of typical acute appendicitis occur in young fit patients; appendicectomy can be performed promptly with safety. Perioperative antibiotics are given (usually in conjunction with preoperative pain relief/sedative). Preoperative resuscitation is usually not required, although special care must be taken with infants. Resuscitation is necessary in patients with advanced disease, prolonged vomiting and peritonitis. The extent of resuscitation depends upon the patient’s response to intravenous infusion and the urgency of surgery. Under anaesthesia the abdomen is palpated to detect the presence of a mass.

In most cases the appendix can be removed laparoscopically. The open approach is performed through a muscle-splitting right lower abdominal incision. The incision is centred on a mass if one is palpable. If the appendix is found to be normal, further laparoscopic examination (or, in the open case, a limited laparotomy) is performed to exclude other pathology. Whether inflamed or not, the appendix is removed if an incision has been made in the right lower quadrant. Peritoneal drainage is unnecessary unless there is local abscess formation. Intravenous antibiotics are continued postoperatively only in patients with abscess or peritonitis.

2. Acute mesenteric adenitis and Meckel’s diverticulitis

The diverticulum is removed and bowel continuity restored. The appendix is also removed.

3. Nonspecific acute right iliac fossa pain

These patients may be admitted and kept under careful observation in hospital until their symptoms settle down. Surgery is indicated with deterioration or when appendicitis cannot be excluded in the patient with persistent pain and tenderness. Laparoscopy can be a helpful diagnostic procedure that allows therapeutic interventions if appropriate pathology is encountered.

4. Gynaecological disorders

When an acute gynaecological disorder is suspected, laparoscopic confirmation is indicated in most cases. Patients with anaemia and a diagnosis of ectopic pregnancy may need blood to be cross-matched and available for transfusion. Open laparotomy may be required.

5. Acute urinary tract stone, infection or hydronephrosis

Renal tract infections are treated conservatively with antibiotics. Subsequent investigation of the urinary tract may be necessary to discover the cause of hydronephrosis.

6. Less common causes

These are numerous. Perforated ulcer may present with acute pain in the right iliac fossa due to gastric fluid tracking down the right paracolic gutter. Carcinoma of the right colon or caecum may present acutely, like appendicitis, with a complication such as obstruction or localised perforation. A mass in the right iliac fossa with accompanying anaemia suggests the diagnosis. Crohn’s disease may present with acute right iliac fossa pain. There is usually a history of altered bowel habit and general deterioration in health with weight loss. Occasionally acute regional ileitis (which may be the earliest phase of Crohn’s disease) presents de novo with acute right iliac fossa pain. At operation in these cases, a copious straw-coloured intraperitoneal fluid discharges on opening the peritoneum. The appendix is normal and an acutely inflamed distal ileum is found. Appendicectomy is usually necessary in these cases and, if performed with care, will not lead to a faecal fistula. If the appendix is not removed, the presence of a right iliac fossa incision may delay necessary surgery at a later date. Diverticulitis in a redundant sigmoid colon in the right iliac fossa; an isolated caecal diverticulitis or benign caecal ulcer are occasional causes of acute right iliac fossa pain. Right basal pneumonia may also present with predominantly right-sided abdominal pain and guarding. The diagnosis may be difficult, but the clue to the diagnosis is the presence of respiratory distress even though clinical signs on chest examination may be minimal. Herpes zoster (shingles) can mimic appendicitis but the pain follows the nerve root distribution. Often a heraldic vesicle will be found on careful examination, in which case non-surgical observation and review confirm the diagnosis.

1. Diverticulitis

Acute colonic peridiverticulitis results from obstruction, inflammation and sometimes localised rupture of a diverticulum. The pain is of gradual onset, its site depending upon the position of the sigmoid colon (which often lies in the pelvis) and how well localised the inflammatory process is. A history of previous bowel irregularity and lower abdominal discomfort and distension, partially relieved by defaecation, is common. Fresh rectal bleeding is not a feature of diverticular disease and when present indicates that another condition such as haemorrhoids or carcinoma is likely to be present. However, profuse rectal bleeding can occur with diverticular disease — but rarely, if ever, with acute diverticulitis (Fig 7.19). Diverticulitis adjacent to the bladder may produce dysuria. In younger patients a very similar acute clinical picture may be due to spastic colon or functional bowel disease but, more commonly, this condition causes chronic pain in the lower abdomen.

Figure 7.19 Complicated diverticulitis

Acute abdomen due to: A: perforation of a pericolic abscess (purulent peritonitis); or B: perforation of an uninflamed diverticulum (faecal peritonitis).

Large bowel obstruction due to diverticular disease (i.e. diverticular stricture) is uncommon. Associated small bowel obstruction, however, may occur due to adhesion of a loop of small bowel to the area of sigmoid diverticulitis.

Four main forms of presentation of diverticulitis can be defined. They are associated with acute lower abdominal pain of increasing severity:

The localised forms of disease (stage 1 or 2) present as acute lower abdominal or pelvic pain often localised to the left iliac fossa. Patients with stage 3 or 4 disease present with an acute abdomen (Ch 7.2).

With stage 1 or 2 diverticulitis, left lower abdominal tenderness and local peritonitis are present. A tender mass can often be felt abdominally or as an extrarectal mass on rectal examination. When spastic colon causes acute pain, no mass can be felt. Sigmoidoscopy is usually normal in diverticular disease, although the instrument can rarely be passed beyond the rectosigmoid junction. Occasionally, pus may be seen in the lumen at the limits of sigmoidoscopy. A low-grade fever is often present with a leucocytosis.

2. Carcinoma of the colon

Carcinoma may sometimes mimic diverticular disease. Partial obstruction of the left colon usually develops insidiously and the presenting symptom is usually altered bowel habit rather than pain (Ch 7.20). Sometimes, however, acute deep-seated lower abdominal cramping pain is the predominant initial symptom. The pain of partial obstruction is usually felt in the hypogastrium, often more so on the left side and sometimes in the back. Complete large bowel obstruction may develop soon after the onset of colicky pain. These cases usually reveal a short history of constipation and distension, partially relieved by defaecation. Rectal bleeding may have been noted by the patient.

Sometimes a locally advanced carcinoma of the distal colon may perforate at or near the site of the tumour, thus presenting with left iliac fossa peritonitis and a mass that very closely resembles the clinical pattern of a perforated diverticular abscess or advanced pelvic appendicitis.

Abdominal examination may demonstrate some abdominal distension. The colonic carcinoma is rarely palpable on abdominal examination. Liver enlargement may indicate the presence of metastatic disease. Rectal examination is usually normal but a mass may be felt extrarectally. Flexible sigmoidoscopy or colonoscopy may show an obstructing carcinoma. Blood in the lumen of the bowel suggests a carcinoma above the limit of the sigmoidoscope.

3. Pelvic appendicitis

When the appendix becomes inflamed in a pelvic site, the usual presentation is acute lower abdominal or pelvic pain, progressing later to iliac fossa peritonitis. The diagnosis of appendicitis can be difficult because abdominal tenderness may be absent or minimal until late in the illness. Diarrhoea follows well after the onset of pain, in contrast to gastroenteritis where diarrhoea is a presenting symptom. The diarrhoea of pelvic appendicitis with a pelvic abscess comprises the frequent passage of small volumes of mucus and liquid faeces associated with severe tenesmus.

Signs of lower abdominal peritonitis are variable. The key to the diagnosis of pelvic appendicitis is tenderness on rectal examination. A tender pelvic mass may also be palpable. In late cases with an established pelvic abscess, oedematous mucosa can be felt over a boggy swelling in the pouch of Douglas.

4. Gynaecological disorders

Acute lower abdominal and pelvic pain in a young woman immediately suggests the possibility of gynaecological disease, especially when the pain is associated with a menstrual disorder. The pain is mainly felt deep in the pelvis or suprapubically. Acute abdominal pain in pregnancy forms a special group. The causes are shown in Table 7.5.

Table 7.5 Acute abdominal pain in pregnancy

* Haemolysis. Elevated liver enzymes. Low platelets. A pre-eclamptic condition presenting with acute epigastric pain.

Salpingitis. This is characterised by high fever, chills and a mucopurulent vaginal discharge. The inflammation generally affects both tubes. There is diffuse, lower abdominal suprapubic tenderness and rebound tenderness. Extreme pelvic tenderness may prevent the palpation of uterine adenexa, but a purulent discharge can be seen issuing from the external cervical os.

Acute rupture of an ectopic pregnancy. This presents with acute pain, which may be referred to the shoulder from diaphragmatic irritation, progressing to pallor and shock. The cervix is soft and extremely tender to palpation and dark vaginal bleeding of modest amount occurs, usually after two or three months of amenorrhoea. Ectopic pregnancy may be difficult to distinguish from appendicitis. Ectopic pregnancy with ampullary implantation has a more benign course than acute tubular rupture associated with implantation in the isthmus. A more gradual onset of lower abdominal and pelvic pain precedes dark vaginal bleeding after variable amenorrhoea (Fig 7.20). Blood also passes retrogradely into the peritoneum to collect in the pouch of Douglas forming a pelvic haematocele. The temperature may be normal or elevated. On vaginal examination dark blood may be seen escaping from the external os. Extreme tenderness elicited by movement of the soft cervix makes palpation of any tubal swelling difficult — signs that are not found with mittelschmerz.

Figure 7.20 Sites of ectopic pregnancy implantation

1: interstitial 4%; 2: isthmial 18%; 3: ampullary 55%; 4: abdominal cavity 1%; 5: fimbrial 20%; 6: ovarian 2%

Bleeding corpus luteum cyst or ovulatory bleeding (mittelschmerz). These are commoner causes of haemoperitoneum than ectopic pregnancy. The clinical features are less dramatic and signs of local peritoneal irritation less intense. A history of mid-cycle pain may be obtained.

Torsion of an ovarian cyst results in severe sustained pain of sudden onset, usually over a wide area from loin to groin and is usually accompanied by vomiting. Pelvic tenderness is extreme and a very tender mass may be palpable. There is usually no fever or leucocytosis.

Full blood count, blood grouping and pregnancy test

Anaemia suggests blood loss or severe sepsis. Leucocytosis suggests the presence of inflammation, particularly salpingitis, appendicitis and diverticulitis.

The pregnancy test for human chorionic gonadotrophic in urine or serum is highly sensitive and becomes positive within 10 to 12 days of conception. The test may therefore be positive before the expected next period.

Urine microscopy and analysis

This checks for renal tract infection and haematuria. Swab, microscopy and culture of any vaginal discharge must also be performed.

Plain X-ray of the abdomen

This may show evidence of large bowel dilatation. Sometimes the short ‘shouldered’ stricture of a carcinoma of the left colon is outlined with gas. Gas may be seen to have collected within a peridiverticular abscess with a characteristic ‘soap bubble’ appearance outside the bowel gas limits. Calcification within the aorta or iliac arteries revealing aneursmal changes may also be evident. Plain X-ray should be avoided if pregnancy is a possibility.

Pelvic ultrasound

Pelvic ultrasound and expertly performed transvaginal studies can be particularly valuable in women when the pregnancy test is positive but no pregnancy is detectable in the uterus although fluid is detected in the pouch of Douglas. In these patients ectopic pregnancy is highly likely. Ovarian cysts show up easily on ultrasound, but ectopic pregnancies are less easy to visualise. The presence of cysts up to 30 mm in diameter within the ovary is normal. Excision of simple ovarian cysts of less than 50 mm diameter is inadvisable. Drainage of cysts at laparoscopy is a treatment that may relieve pelvic pain.

Laparoscopy

This is indicated in patients where a gynaecological disorder is suspected and will help to exclude appendicitis and diverticulitis in difficult cases (Fig 7.21).

Figure 7.21 Laparoscopy

The uterus is stabilised per vaginum. The pelvis is inspected after insufflation of CO₂ into the peritoneal cavity. An ectopic pregnancy is diagnosed here.

Laparotomy is necessary for diagnosis and treatment in patients with clinical deterioration, with peritonitis or with a pelvic mass.

CT contrast study

The assessment of diverticular disease and its complications is often best pursued with a CT scan with rectal gastrograffin contrast. This may reveal complicated diverticular disease such as:

There may also be evidence of additional diverticula, segmental spasm and narrowing of the lumen with a sawtooth appearance of the colonic mucosa.

Colonoscopy

Colonoscopy may be performed at a later time. It should not be encouraged in the acute setting due to the risk of perforation

1. Diverticulitis

Patients with acute diverticulitis (stage 1) are treated by fasting, intravenous fluids and broad-spectrum antibiotics covering anaerobes and both Gram-positive and -negative bacteria. Many episodes settle down within 48 hours. After the acute attack has settled, the basis of treatment is a lifelong high-fibre diet to reduce the incidence of further acute attacks. Elective investigations, such as colonoscopy performed at least a month later, are essential to confirm the diagnosis and exclude carcinoma. Contrast CT studies can complement colonoscopy to exclude malignancy with certainty.

Elective surgery. The indications for elective resection are:

Urgent surgery is indicated when there is failure to improve within 48 hours from admission or if the patient deteriorates prior to this. Primary resection and anastomosis with a defunctioning loop ileostomy can be considered for stages 1 and 2 disease — especially in fit patients and in those in whom systemic sepsis is controlled.

Patients with stage 3 or 4 diverticular disease present with an acute abdomen. They require exteriorisation–resection without anastomosis and are discussed in Chapter 7.2.

2. Carcinoma of the colon

The basis of treatment for impending obstruction due to carcinoma is to resect the lesion after adequate preoperative preparation. Efforts are made to relieve the obstruction and to prepare the patient for semi-elective surgery, rather than being forced to operate as an emergency for complete obstruction. Preoperative measures include: the control of concurrent illness; enemas and bowel washouts to relieve obstruction and produce a clean colon; prophylactic perioperative antibiotics to prevent infection; CT scan with IV contrast to determine whether ureteric obstruction is present; and correction of anaemia by transfusion of packed cells — preferably given at least 48 hours before surgery. Some patients benefit from urgent distal colonic stenting to alleviate obstructive symptoms while their general condition is assessed and optimised.

Where operation is performed in the presence of partial obstruction, it is often prudent to form a loop ileostomy to protect the anastomosis after resection of the tumour, especially if there is inadequate bowel washout and technical difficulty because of obesity.

3. Pelvic appendicitis

Early appendicectomy should be performed laparoscopically or through an iliac fossa or midline incision. The peritonium is washed out and perioperative antibiotics are given. An associated pelvic abscess will require formal drainage as well. The drainage tube is preferably brought out through a separate stab incision.

4. Gynaecological disorders

If the diagnosis is equivocal it is helpful to perform laparoscopy, proceeding immediately to laparotomy if indicated.

Salpingitis is treated with antibiotics; mittelschmerz is treated conservatively; ectopic pregnancy and torsion of an ovarian cyst by early surgery.

Persisting haemorrhage from a ruptured ovarian cyst is treated by laparoscopic aspiration and diathermy or by local oversewing of the cyst. Meticulous pelvic toilet at operation and a gentle operative technique using fine atraumatic synthetic sutures help minimise the risk of tubal adhesions and later infertility.

5. Less common causes

Unusual causes of acute lower abdominal pain include acute pelvic congestion syndrome, perinephric abscess, pancreatic abscess or necrosis extending down the left paracolic gutter, small bowel obstruction secondary to diverticulitis, Crohn’s colitis of the left colon and spontaneous rupture of the inferior epigastric artery in patients on oral anticoagulants. Contained rupture of an iliac artery aneurysm may also present with sudden severe lower abdominal pain and requires emergency surgical intervention. Laparoscopy may be indicated because of persistent signs of peritonitis in the absence of a firm diagnosis in some of these conditions.

1. Nonulcer dyspepsia

Nonulcer dyspepsia is a diagnosis of exclusion applied to a heterogeneous group of patients with chronic epigastric pain without proven ulcer or other extragastric pathology. Other terms used include functional dyspepsia, pylorospasm, nervous dyspepsia and gastritis. When the pain is situated in the right hypochondrium and resembles biliary pain, the condition is often labelled biliary dyskinesia. The symptoms can be identical to duodenal ulcer but usually the illness lacks a clear descriptive focus and the pain fits no definite pattern. Bloating is a characteristic symptom that many patients find quite disabling. Many patients have a long history of poor response to antacids, prolonged medical treatment and negative investigations. Alcoholism and depressive illness are common associated problems. Other features of functional bowel disease can coexist. Patients may have a history of intermittent change in bowel habit, lower abdominal distension, flatulence and straining at stool. Symptomatic gastritis secondary to bile reflux may also develop in both the postcholecystectomy and postgastrectomy patient. Such patients often have a history of early morning pain, anorexia, flatulence with bile vomiting and diarrhoea with urgency.

2. Gallstones and chronic cholecystitis

Patients with gallstones frequently present with episodic upper abdominal pain. Biliary pain (‘colic’) begins abruptly and subsides gradually over a period of hours and is usually felt in the epigastrium or right hypochondrium. It can be postprandial or nocturnal and commonly radiates around the costal margin to the back with a sometimes severe and usually constant nature. Patients have often had a number of similar attacks requiring narcotic analgesics or admission to hospital. The pain may occasionally be felt in the left hypochondrium or precordially, making it difficult to distinguish from oesophageal pain or angina. The acute upper abdominal pain of acute cholecystitis usually leads to hospital admission (Ch 7.3) and early cholecystectomy and is related to persistent rather than transitory obstruction of the cystic duct by stone.

Chronic or recurrent dyspeptic symptoms are also common. These may have been present for many years and are associated with flatulence, abdominal distension, nausea and fatty food intolerance.

3. Duodenal ulcer

Characteristically, patients with duodenal ulcer have a chronic, fluctuating, remitting and relapsing natural history. The pain is felt in the epigastrium and is described as dull, boring, aching, burning, gnawing or hunger-like. The pain is generally relieved by antacids, food and milk. A high intake of milk may produce weight gain, but occasionally food or alcohol can make the pain worse, with associated weight loss. Occasionally the patient localises the pain precisely in the epigastrium just to the right of the midline. Radiation directly to the back in the interscapular region suggests posterior penetration of the ulcer. This complication generally causes loss of the cyclical character of the pain, loss of response to antacids and vomiting.

Periodicity and relapse of symptoms is classic. Relapse is often triggered by smoking, stress or nonsteroidal anti-inflammatory agents. During relapse, attacks of pain come on each day, from half an hour to three hours after meals. Relapses and remissions follow each other in cycles. Relapses last for days or weeks and often occur during spring and autumn. Remissions last from weeks to months. In about half the patients, the daily cycle of pain during a relapse may occur so close to the next meal that it is described as ‘hunger’ pain. Nocturnal pain is a common complaint, usually wakening the patient in the early morning hours and also relieved by food and alkali.

The basis of over 90% of duodenal ulcers has been proven to be due to H. pylori and the basis of modern diagnosis and treatment is to confirm the presence of H. pylori and then institute eradication therapy.

The Zollinger-Ellison syndrome (gastrinoma of the pancreas) should be considered when a severe and resistant ulcer diathesis is present. Features suggesting the diagnosis include ulcers situated more distally, multiple and recurrent ulcers, severe diarrhoea (found in 30% of cases) and the combination of severe upper and lower abdominal symptoms (Box 7.4).

Box 7.4

Causes of combined upper and lower gastrointestinal symptoms

Functional bowel disease (dyspepsia and altered bowel habit)

Zollinger-Ellison syndrome (vomiting, epigastric pain and diarrhoea)

Carcinoma of the caecum (indigestion and diarrhoea)

Crohn’s disease (vomiting and diarrhoea)

Pyloric stenosis (constipation and vomiting)

Thyrotoxicosis (vomiting and diarrhoea)

Chronic pancreatitis (epigastric pain and diarrhoea with steatorrhoea)

4. Gastric ulcer

The history of patients with gastric ulcer is very similar to that of duodenal ulcer (Table 7.7). Pain, however, tends to be more severe, more loss of work occurs and relapse is more frequently triggered by analgesic agents. Relapses last longer, generally from one to two months. Food and alcohol appear to worsen the pain, which generally occurs within 30 minutes of a meal. Anorexia and weight loss are also more common. Associated gastritis is a feature of gastric ulcer and contributes to weight loss. Vomiting is more common and more likely to relieve the pain.

Table 7.7 Comparison of the clinical features of duodenal and gastric ulcers

5. Carcinoma of the stomach

Stomach cancer should be suspected when dyspepsia starts for the first time in a patient aged over 40 years. Early gastric cancer, with minimal mucosal changes, needs to be diagnosed if prognosis is to be improved. Unfortunately many patients present (or are diagnosed) late in Western countries.

Symptoms usually begin with lethargy and vague postprandial heaviness, discomfort and fullness: a symptom complex usually described as indigestion or dyspepsia. Anorexia is an early symptom (especially to meat) leading to early weight loss. Early satiety is a common feature, with distortion of the senses of smell and taste. Most patients have lost more than 5% of their normal body weight on presentation. Eventually continuous intractable epigastric pain is present.

Complications may cause additional symptoms, depending on the site of the tumour. Nausea and vomiting can result from pyloric obstruction (10–20% of patients) or there may be dysphagia due to oesophageal obstruction (10% of patients). Haematemesis and melaena is unusual, but iron deficiency anaemia from chronic blood loss is found on investigation in almost half the patients. Anaemia may be the sole form of presentation (Ch 7.18) in a small proportion of patients.

Blood examination

Iron deficiency anaemia suggests carcinoma of the stomach. Carcinoma of the right colon should also be considered in the anaemic patient when dyspeptic symptoms are vague.

Ultrasound

This is the preferred examination for gallstones. In 80% of cases gallstones are radiolucent and will not be detected on plain X-ray examination. If ultrasound is negative but clinical suspicion of biliary disease is strong a, HIDA study of the gall bladder may be helpful in assessing function.

Endoscopy

This is the preferred investigation for the diagnosis of duodenal or gastric ulcer. Biopsy and brush cytology are necessary additions for the differentiation of benign gastric ulceration from carcinoma of the stomach. Early gastric cancer may require multiple biopsies of the gastric mucosa, as field malignant change is common. Endoscopic and histological features of reflux oesophagitis may be difficult to interpret; oesophageal motility studies may be helpful. No abnormality or antral gastritis is found with nonulcer dyspepsia. Helicobacter pylori may be found on biopsy. Biopsy should be routinely performed if the endoscopy is being performed for the investigation of epigastric pain.

Contrast radiology

Distinguishing benign from malignant gastric ulcers is often difficult; endoscopy is usually necessary to obtain a definitive diagnosis. Barium swallow is the preferred initial investigation for gastrointestinal symptoms only if dysphagia is the major presenting problem and an oesophageal or pharyngeal lesion is suspected (Ch 7.12). Endoscopy will usually be required subsequently to confirm the radiological findings. Contrast study of the small bowel (small bowel enema) is indicated in the occasional patient where chronic small bowel obstruction is suspected to be the cause of epigastric pain. Abdominal CT examination with contrast is most useful when a pancreatic lesion is suspected and for the diagnosis and the definition of focal lesions in the liver. For the latter lesions, a triple phase CT angiography study can delineate lesions very clearly

MRCP, CT cholangiography and ERCP

MRCP and CT cholangiography are newer, noninvasive modalities of imaging the hepatopancreaticobiliary system with great clarity. These investigations allow precise planning of treatment for various ductal conditions.

ERCP is indicated in the occasional patient with persistent pain where the diagnosis remains in doubt after the above investigations or treatment has failed. ERCP has a special place is diagnosing pancreatic carcinoma or inflammation. In suspected biliary disease this investigation is generally reserved for those patients with unexplained abnormalities in liver function tests or intractable postcholecystectomy pain, especially those with bile duct dilatation on ultrasound.

Where diagnosis is obscure or the clinical pattern is unusual, additional tests may be performed. These include serum amylase (or lipase), serum gastrin, hydatid serology, colonoscopy or barium enema.

1. Nonulcer dyspepsia

There are two main avenues of treatment for nonulcer dyspepsia. Attention should first be given to control of gastric risk factors, particularly alcohol intake, smoking and dietary irregularity. Written instructions can be given to the patient as set down in Box 7.5. Drug treatment may also be required. Proton-pump inhibitors are superior to H₂-receptor antagonists in relieving symptoms. Helicobacter pylori eradication should occur if biopsies are positive.

Box 7.5

General instructions for relief of symptoms from gastritis or dyspepsia

Specific medicines or tablets may be prescribed by your doctor. In addition to medical treatment, changes in lifestyle can help reduce the severity of symptoms and the chances of recurrence.

Avoid the use of aspirin or aspirin-like drugs.

Stop smoking.

Reduce alcohol intake.

Eat regular meals. Breakfast is particularly important.

Regular exercise such as walking can improve your fitness and general resistance.

2. Gallstones and chronic cholecystitis

There is no satisfactory medical treatment for gallstones. Bile salts have limited usefulness and limited ability to dissolve gallstones in the long term. Shock wave lithotripsy is contraindicated. The treatment is by elective cholecystectomy after control of any concurrent disease. In about 5% of cases unsuspected stones are found in the bile duct, so operative cholangiography should be a routine (Fig 7.22). Percutaneous laparoscopic cholecystectomy is the operation of choice but open operation may be necessary if the gall bladder is very thickened or contracted or not properly visible because of chronic adhesions.

Figure 7.22 Cholecystectomy — normal operative cholangiogram

No filling defects, normal duct anatomy and diameter, free flow of contrast into the duodenum, lower and upper reaches of duct well visualised.

The small group of patients with biliary dyskinesia is treated symptomatically — similarly to patients with functional bowel disease. The results of surgical treatment tend to be disappointing.

3. Duodenal ulcer

Most duodenal ulcers have a chronic, fluctuating, periodic natural history. The key decision in patients with significant and disabling symptoms is between long-term drug therapy and surgery. Medical management consists of attention to risk factors — particularly smoking, dietary irregularity, stress, nonsteroidal anti-inflammatory agents, coffee ingestion and alcohol. The treatment of H. pylori involves the use of a proton pump inhibitor and two antibiotics (e.g. clarithromycin plus metronidazole). Modern medical treatments heal most ulcers.

Surgical procedures are rarely required and aim to reduce acid secretion. Previously a satisfactory elective surgical procedure in most instances was highly selective vagotomy (HSV) but this is seldom required in the era of proton-pump inhibitors and H. pylori eradication. For rarer cases where duodenal ulcers are intractable due to Zollinger-Ellison syndrome, gastrinoma should be searched for, usually in the pancreas, and resected.

4. Gastric ulcer

The main issue after diagnosis of gastric ulcer is to exclude malignancy. The complications of gastric ulcer are also more serious than for duodenal ulcer. The surgical approach to this problem is therefore more active. Medical treatment is the same as for duodenal ulcer and is directed at H. pylori eradication. Repeat endoscopy after six to eight weeks of medical management must confirm that healing has occurred. Biopsy and/or brush cytology and lack of recurrence at a further endoscopy after a second similar follow-up period is also essential. Partial or complete healing, with relief of symptoms and negative biopsy, may occur initially with medical management, even though the gastric ulcer is malignant. Surgery is indicated if the ulcer has not completely healed within six to eight weeks and for any recurrent ulcers.

5. Carcinoma of the stomach

Local control of the disease is best obtained by surgery (Box 7.6). Surgery should, if possible, completely excise the gastric lesion so that recurrence does not occur at this site during the life of the patient (Fig 7.23). Symptoms due to anastomotic recurrence represent a surgical failure.

Figure 7.23 Surgical management of carcinoma of the stomach

A: antral tumours often present with vomiting and are managed by partial gastrectomy; B: body tumours present with chronic epigastic pain; total gastrectomy is usually required; C: tumours of the cardia present with dysphagia; oesophagogastrectomy required

The decision as to whether the tumour is resectable usually requires laparotomy. The major reason for inability to resect the lesion is posterior fixation. Laparotomy is superior to CT scanning in deciding whether resection is feasible, especially in wasted patients where loss of fat planes makes the extent of the tumour difficult to determine on scan. Total gastrectomy (Fig 7.24) is preferred in patients who have satisfactory general health. Total gastrectomy is also indicated with diffuse or desmoplastic tumours at any site and in tumours with associated atrophic gastritis. Ivor Lewis oesophagogastrectomy is indicated in resectable carcinoma of the cardia. About half those coming to operation can have the tumour resected. Half the resections can be considered potentially curable, there being no apparent macroscopic spread beyond resected tissue. Adjuvant chemotherapy may further improve survival after resection. The total five-year survival rate in Western countries remains poor and is about 15%.

Figure 7.24 Total gastrectomy

Total gastrectomy achieves best local control of disease. Reconstruction is by Roux-en-Y oesophagojejunostomy. The letters indicate the arrangement of structures before and after the gastrectomy and reconstruction.

6. Less common causes

Gastrointestinal causes

Reflux oesophagitis. These patients are usually identified by the dominant presenting symptom of postural heartburn and regurgitation. Retrosternal oesophageal pain is characteristically related to swallowing. The pain may be precordial and difficult to distinguish from angina (Ch 7.11). When felt lower down — behind the xiphoid process or in the epigastrium — reflux oesophagitis can be difficult to differentiate from other causes of chronic epigastric pain. Associated symptoms of fluid regurgitation suggest that reflux oesophagitis is the primary cause of the problem. Surgery is indicated for failed medical management, especially when there are complications such as aspiration pneumonitis.

Chronic pancreatitis. Epigastric pain is often vague, deep-seated and nauseating, and may radiate through to the back. The patient characteristically assumes a sitting position with spinal flexion in an attempt to relieve pain. Weight loss is likely to be more profound if carcinoma is present. Chronic pancreatitis affects a different set of patients from acute pancreatitis, the latter presenting with acute upper abdominal pain (Ch 7.3). There is considerable overlap between acute and chronic pancreatitis, particular where the aetiological factor is alcohol. Both conditions are associated with heavy alcohol consumption. In about half the patients with chronic pancreatitis the disease presents with recurrent episodes of epigastric pain and the complications of malabsorption and diabetes should be considered.

The principles of medical treatment of chronic pancreatitis include abstinence from alcohol (which is rarely effective for late disease with continuous pain), narcotic analgesics, splanchnic nerve block, nutritional support, pancreatic enzymes plus antacids and the control of diabetes (which is found in about a third of cases). Surgical treatment is indicated for intractable pain. Alcoholism should not necessarily influence the decision but indicates the need for careful preoperative preparation. Most surgeons would in fact stipulate abstinence as a prerequisite for surgery. Duodenal ulcer is often associated with chronic pancreatitis and should be excluded by endoscopy. Duct dilatation is found on ERCP in 30–40% of cases. In these patients a Roux-en-Y pancreaticojejunostomy (often combined with resection of the pancreatic head) is the surgical treatment of choice (Fig 7.25).

Figure 7.25 Puestow’s operation

Puestow’s operation (side-to-side Roux-en-Y pancreaticojejunostomy): for painful chronic pancreatitis with duct dilatation.

Pseudocyst may be a factor in clinical deterioration and pain and is an indication for internal surgical drainage of the cyst into the stomach or small bowel. Pseudocysts in chronic pancreatitis do not have the same significance as those seen following an attack of acute pancreatitis. Surgical drainage of small pseudocysts is not advocated, as they are unlikely to be the cause of pain.

Carcinoma of the body of the pancreas. Management is unsatisfactory. The disease usually presents late with locally advanced disease or metastases. Careful preoperative planning, with percutaneous fine needle aspiration biopsy to establish the diagnosis and CT scanning to determine the extent of disease, is desirable. Resection is restricted to the occasional case with potentially curable disease.

Hepatic diseases — including hydatid disease, primary and secondary carcinoma and congestive hepatomegaly secondary to heart failure — can present with chronic epigastric pain.

Post-cholecystectomy syndrome. This term is applied to patients who complain of biliary pain, dyspepsia, flatulence and fatty food intolerance after cholecystectomy (Box 7.7). Retained common duct stone should be excluded by CT cholangiogram or MRCP. If stones are found, they are extracted with a basket after ERCP sphincterotomy. Other causes of pain, such as peptic ulcer and bile reflux gastritis, may be seen on endoscopy. Occasionally post-cholecystectomy pain may be due to stones in a cystic duct remnant. In patients who have had a cholecystectomy for biliary dyskinesia — that is, no stones were found at the original operation — the diagnosis usually proves to be functional bowel disease. Spasm of the sphincter of Oddi can produce a dilated bile duct and episodes of pain, but the results of sphincterotomy are unpredictable in these cases.

Box 7.7

Causes of post-cholecystectomy syndrome

Incorrect diagnosis

Functional bowel disease (biliary dyskinesia, stenosis of the sphincter of Oddi)

Peptic ulcer

Chronic pancreatitis

Retained stone in the bile duct

Bile duct injury

Liver pathology (e.g. hydatid disease)

Carcinoma of the transverse colon. Partially obstructing colonic cancers may be associated with postprandial pain. Patients with right colonic tumours may complain of dyspepsia in the absence of obstruction. Anaemia, with a normal gastroscopy, suggests the diagnosis of carcinoma of the colon. Chronic upper small bowel obstruction, especially the partial form seen with small-bowel tumours (mainly lymphomas) or Crohn’s disease, can occasionally cause chronic upper abdominal pain.

Post-gastrectomy syndromes can in most cases be treated conservatively (Table 7.8).

Table 7.8 Postgastrectomy syndromes: management

Syndrome	Medical treatment	Surgical treatment
Dumping	Beta-blocker	Roux-en-Y bile diversion
Early	Small, frequent dry meals, low sugar intake, rest after meals
Late	Sugar at two hours after meals
Bile reflux and vomiting, with epigastric pain	Exclude recurrent ulcer	Roux-en-Y diversion plus vagotomy or stomal reconstruction
	H2 receptor antagonist
	Bile salt binding agents
	High-fibre diet
	Avoid risk factors
Diarrhoea	As for irritable colon	Reversal of pyloroplasty or reversed ileal loop