Acute abdominal pain in adults is one of the main reasons for emergency consultation, both among general in hospital emergencies.
Acute abdominal pain in adults represent approximately 20% of emergency admissions to hospital. A third of these emergencies represent a surgical treatment of the affection the fastest possible recognition improves the prognosis.
It is in this anxiety of a potential surgical emergency that the patient and doctor are considering the issue. The large number of potential etiologies of acute nontraumatic abdominal pain in adults sometimes makes difficult the diagnostic process. The classic exploratory laparotomy for our seniors has nevertheless seen its indications melt or disappear, thanks to advances in imaging the center of which is placed in the context of urgency, abdominal scanner. Through the judicious use of different imaging currently available to us, unnecessary interventions become rare.
The fact remains that a rigorous semiological analysis with an examination and a clinical examination in most cases to evoke a diagnosis, and does not make systematic recourse to imagery that serves primarily to disentangle atypical situations.
DIAGNOSIS:
Discrimination between a medical emergency and a surgical emergency is not always easy and often a bundle of arguments both clinical and laboratory that determines whether it is necessary to make a surgical decision.
Examination:
This is probably the most important step to apply rigorously.
The interrogation begins after verifying the absence of vital urgency (collapse, hemorrhage, severe sepsis).
It seeks to clarify the medical or surgical history and the idea of taking medication (anti-inflammatory drugs, aspirin, anticoagulants, antibiotics). It also checks for recent or semi-recent trauma.
Analysis of the pain must be done with precision: its mode of installation, acute or insidious, its original seat, its permanent or intermittent, intensity, potential triggers, or analgesics positions that the patient found spontaneously .
It is important to note if similar painful crises occurred in the days or months.
The intensity of pain is a policy element, but that is not to define the absolute seriousness of the etiological diagnosis. It also notes the symptoms that are associated with this pain vomiting, faintness, gastrointestinal hemorrhage, intestinal transit (when the last seat). The existence of urinary disorders Wanted. The last menstrual period for women of childbearing is noted as the existence or otherwise of abnormal losses. The temperature is taken as the pulse and blood pressure.
Clinical examination:
It focuses primarily on the patient’s general appearance, looking pale conjunctiva, appreciates the state of consciousness, the existence of sweats. The inspection of the abdomen search any abdominal scars, there is a bloating or persistence of respiratory movements noticeable in the abdominal wall.
Palpation which should be soft starting with the least painful areas slurring research, defense or contracture which immediately brings to mind the existence of peritonitis. The trusses holes must be checked.
Percussion can be useful, the absence of hepatic dullness area evoking a pneumoperitoneum.
Auscultation research the existence or not of hydroaeric noise and the existence of vascular murmur.
The pelvic touches in this context are mandatory and pain when looking DRE at the cul-de-sac and are used to verify the color of stool.
The vaginal examination is to be carried out, looking for a pain in the vaginal cul-de-sac evokes a gynecological infection.
A dipstick is useful to search for a urinary tract infection.
Following this review, a biology can be requested as well as imaging.
Laboratory tests:
Complete blood count (CBC), C-reactive protein (CRP), urea and electrolytes with creatinine, liver function tests and determination of blood amylase and lipase usually allow to quickly manage the situation.
An electrocardiogram should be systematic before any unexplained abdominal pain without surgical indication, especially in elderly patients with vascular history.
Imaging:
This is certainly the area where changes in technology have revolutionized diagnostic and therapeutic attitudes.
The abdomen without preparation with the indication was almost systematic once before an acute abdomen is much more limited today and is reduced to finding a pneumoperitoneum (domes centered cliché) or occlusion.
Abdominal ultrasound is often requested as first line if it is accessible because it allows a good analysis of the liver, biliary tract and examine in favorable situations kidney, great vessels, the pelvis. It allows to assess the existence of an effusion and can usually analyze ileo- caeco-appendicular region.
Abdominal CT became best examination able to cope with difficult situations where clinical biology and do not allow a precise guidance of the diagnosis.
The review can take place in different ways and it is important to guide the radiologist on preferential etiologic research to determine whether or not an injection of a contrast medium, achieving an enema for better view intestinal walls.
If active bleeding, a series of pictures without contrast followed by a series of portal blood and optimize the chances of viewing the bleeding sites.
The scanner perfectly visualizes the pneumoperitoneum and better still rétropneumopéritoine.
In case of obstruction, besides the positive diagnosis, it often sets the level of the obstacle and sometimes his nature.
Differential diagnosis:
The same severe abdominal pain are not always synonymous with surgical emergency.
The diagnosis of a functional disorder is always to keep in mind.
Non visceral pain can be evoked: muscle origins (psoas contracture), or parietal (Cyriax syndrome, hernia Spiegel earlier projection discovertebral pain).
Acute pneumonia abdominal shape is classic and necessitates a complete and careful clinical examination. In rare cases, these pneumonias may be responsible for spontaneous peritonitis (hematogenous), particularly with the pneumococcus.
Myocardial infarction in abdominal shape, especially back seat, is well known and doubt imposes an electrocardiogram practice (ECG) and enzyme assays.
The abdominal epilepsy form exists very rarely (less than 1% of epileptic forms) and its diagnosis reports to the specialist.
ETIOLOGY:
Because of the multiplicity of diagnoses, and to simplify the presentation, we opted for the analysis of etiologies depending on the topography of pain when the latter is not diffused. The list of diagnoses after the ana lysis 9,500 emergency admissions by Flamingo (Table I) should be read in light of the age. Appendicitis, for example, are of course more common in young patients, diverticulitis in subjects over 50 years.
Pain in the right iliac fossa:
This is the most common location of abdominal pain.One in two patients sent in surgery for acute abdomen pain that this lie in the right iliac fossa. The hypothesis that comes to mind immediately is the diagnosis of appendicitis (Box 1).
Box 1. Etiology of pain in the right iliac fossa
Appendicitis
Terminal ileitis
Cecal diverticulitis
Appendicitis omental
Cecal tumor
Tubo-ovarian abscess
Out of ectopic pregnancy
Ovarian torsion
Hemorrhagic corpus luteum
Pneumonia of the right lung base
Acute appendicitis:
The management of pain syndromes of the iliac fossa has benefited a lot of imaging improvements. Previously, uncertainty diagnosis determined an unnecessary appendectomy rate very high, on the order of 20 to 30% in men, even 40 to 50% in women.
Acute pain with defense of the right iliac fossa in young patients associated with an inflammatory syndrome, vomiting and leukocytosis greater than 11,000 to the blood count does not, in principle, to further investigation and the patient can directly be sent to the surgeon.
In contrast, atypical forms, so frequent, give full imaging interest centers on two tests: ultrasound, often easier to obtain in an emergency, and scanner.
Ultrasound performance is good, but depend on the patient’s morphology and above the operator’s experience.The diagnosis of acute appendicitis based on the discovery of a tubular structure without peristalsis blind end which is implanted in the shallow cecal and whose transverse diameter is greater than 6 mm and is painful to pass the probe. The sensitivity of ultrasonography is about 80% in case of uncomplicated appendicitis, but decreases in case of perforated appendicitis (Fig. 1).
The scanner, in difficult cases, has its place. The dominant criterion is also an appendiceal diameter greater than 6 mm. We can highlight a stercolith appendix, which can still be missed, and an infiltration of péricæcale fat, as well as a localized thickening of the cecal wall.
The reliability of the scanner is in the order of 90% and more so since the subject is masculine and bold sex is to say the inverse favorable conditions than ultrasound (Fig. 2 and 3 ).
The technique of the scanner varies physicians: a single spiral without injection may be envisaged but, to optimize the diagnostic value, the injection of a contrast medium and optionally carrying out a water washing are certainly useful but complicate even the exam.
The other major advantage of the scanner is to make a differential diagnosis when appendicitis is not involved.One of the frequent causes at this level is the existence of a terminal ileitis that can perfectly simulate appendicitis.
The treatment is surgical.
Terminal ileitis:
It may correspond to an acute infection (yersiniosis) or constitute a form of revelation of a true ileocecal Crohn’s disease localization.
The scanner allows, again, very easy to show the thickening of the last ileal loop. Satellite lymph nodes can also be well visualized.
Treatment depends on the cause.
Cecal diverticulitis:
Much rarer than outbreaks of diverticulitis sitting in the sigmoid, they may have a painful picture of the right iliac fossa associated with an inflammatory syndrome, difficult to separate clinically appendicitis.
The diagnosis can be suspected in an aspect of the cecal diverticulitis pendant on the scanner, best done with an enema with water and injected.
The treatment is conceivable that surgical environment.
Cecal tumor:
A cecal tumor can be on an acute mode and there may also be mentioned on the data scanner best achieved with a water enema. Colonoscopy confirms course later this diagnosis.
The treatment is surgical.
Abscess genital annexes:
Abscesses genital annexes must be systematically evoked in young women.
Mentioned on the data of a gynecological exam and examination, they may be confirmed by ultrasound completed if necessary to examination by transvaginal probe.
The patient is entrusted to the gynecologist.
Sorrows of the right iliac fossa nonspecific etiology:
A simple push of irritable bowel syndrome can perfectly simulate appendicitis table, but then fever, inflammation and defense are absent in principle. The right iliac fossa is the most common site of origin of functional pain. A suggestive orientation element is the priority of similar crises self-limiting.
Pain in the right upper quadrant:
The first hypothesis to pain at this level is a biliary origin (Box 2).
Box 2. Etiology of right upper quadrant pain
Cholecystitis
Biliary colic
Portal thrombosis
Perihepatitis Chlamydia
Renal colic
Pyelonephritis
Liver abscess
Renal infarction
Appendicitis rétrocæcale
Acute cholecystitis:
Acute cholecystitis remains easy to evoke and document by a simple ultrasound which demonstrates a gallstone usually in thickened walls bladder. Clinically, there is a defense that may be lacking in the elderly, sometimes with the classic sign of Murphy. Biologically, there is an inflammatory syndrome often important. Liver biology can not be changed if there is no obstacle in the bile ducts.
Treatment relies on antibiotics and surgery.
Liver abscess:
A single or multiple liver abscess, more rare, can occur in the same way. There is often a pain in the liver disturbance. The notion of traveling in endemic countries is strongly evoke the hypothesis of an amebic abscess.Ultrasound and CT scan in principle allow a simple diagnostic (Fig. 4).
A liver abscess commonplace germ documented by ultrasound guided aspiration must search for intra-abdominal sepsis, including appendicitis, diverticulitis, or gallbladder.
Colic:
Biliary colic reflecting the migration of a calculation of the gallbladder to the bile determines painful crises of sudden onset, often postprandial and whose topography may be right subcostal but epigastric.
The existence of a pancreatic reaction is always possible, resulting in epigastric pain after irradiation.
These biliary colic attacks are often accompanied by vomiting and are of limited time duration, the migrant calculation spontaneously. The reflex is to ask, if migration is suspected, liver biology associated with a dosage of the amylase and lipase blood. The anomalies that are always present in case of migration may regress quickly, so that additional negative balance away from a crisis does not eliminate the diagnosis. By cons, normal liver and pancreatic biology at a time of crisis is not in favor of a migration.
Note that transparietal ultrasound, which is the best examination to detect gallbladder gallstone pathology, can be faulted if microlithiasis. In case of strong suspicion on clinical and laboratory data, lack of calculation to transparietal ultrasound may indicate biliary endoscopic ultrasonography in search of these microcalculi more visible by the more invasive technique.
Treatment is cholecystectomy.
Perihepatitis Chlamydia:
It determines a pseudochirurgical table cholecystitis with infl ammatory syndrome, but in contrast to a normal imaging (ultrasound or CT).
The diagnosis should be considered in a young woman, with ancient or recent history of genital infections. Definitive diagnosis can be obtained by laparoscopy adhesions that visualizes “violin strings” around the liver. Seropositive or vaginal swabs cultures can sometimes avoid this invasive investigation. Formerly, the same table was observed with gonococcal infection.
The treatment of chlamydial infection relies on antibiotic therapy (eg oral doxycycline 100 mg × 2 / day, 15 to 20 days).
Portal thrombosis:
The portal vein thrombosis, idiopathic or secondary to locoregional disease, can lead to pain in the right upper quadrant.
His formerly difficult diagnosis became easier with CT angiography.
Treatment depends on the cause and the land on which it is incurred.
Renal colic:
Renal colic in its typical presentation is easily evoke the diagnosis and this all the patient has previously made similar crises. A simple spiral without injection or ultrasound scanner often allows to visualize the urinary tract dilatation and computation.
In particular injectable NSAIDs are often effective. The management is urology.
Note that renal colic can sometimes determine a reflex ileus which can give a false profile to a true digestive renal colic.
Pain in the left upper quadrant:
The three bodies concerned in this painful topography pancreas, colon and spleen (Box 3).
Box 3. Etiology of pain in the left upper quadrant
Diverticular
Pancreatitis caudal
Renal colic
Pyelonephritis
Renal infarction
Splenic infarction
Splenic abscess
Ruptured spleen
Ischemic colitis
A caudal pancreatitis can give a left subcostal pain.
Caudal pancreatic tumors are unfortunately often clinically silent.
The rupture of the spleen, which must always be considered, even in the absence of recent trauma, is easy to document by imaging.
Ischemic colic which frequently manifested by intense pain followed by a triad quickly bloody diarrhea should be suspected, particularly in elderly and vascular topic.
The most frequent diagnosis in this topography remains irritable bowel syndrome.
Pain of the left iliac fossa:
At this level, the two main diagnoses are related infection diverticulitis or diverticular (Box 4).
Box 4. Etiology of pain in the left lower quadrant
Diverticular
Ischemic colitis
Appendicitis omental
Tubo-ovarian abscess
Torsion Schedule
Ectopic pregnancy
Sigmoid diverticulitis:
Diverticular sigmoiditis whose prevalence increases in Western countries is the first diagnosis of appendicitis suspected in a table located in the left iliac fossa (FIG). The pain is often elective with, pressure, a defense. This pain can be located above the left flank by location diverticula inflammatory.
Inflammation of the pelvic sigmoid can generate a table fairly speaking on abdominal plan. The pelvic touch is important for diagnosis because it most often triggers a pain. Biology remains essential for differentiating irritable bowel syndrome from a banal pushing a sigmoid due to the existence of an inflammatory syndrome.
Consideration to propose, if there is an inflammatory syndrome, is a scanner with concomitant enema which displays both diverticula, wall thickening and the existence or not of an abscess.
The treatment is hospital (fasting then free diet, antibiotics); Surgery should be considered from the second episode.A transparietal drainage (under scanner) or surgery may be needed urgently if abscess.
Gynecological original pain:
The original gynecological pain are the main differential diagnoses: after considering systematically ectopic pregnancy, where the context permits, we must think of an adnexal torsion easy to document by ultrasound or pelvic inflammatory disease.
FIG’s pains are often related to a trivial irritable bowel syndrome whose intensity often simulates a surgical or gynecological emergency. The examination frequently reveals in this case resolutives similar episodes. If in doubt, a simple NFS and normal CRP often prevent an escalation of investigations.
Epigastric pain:
The primary cause of epigastric pain is likely to be functional: dyspepsia.
This diagnosis should nevertheless be retained after eliminating other etiologies may require a specific treatment (Box 5).
Box 5. Etiology of pain in the upper abdomen
Peptic ulcer
Pseudo-ulcer dyspepsia
Gall Migration
Acute pancreatitis
Peptic ulcer:
The ulcer syndrome is well known with epigastric pain, periumbilical sometimes, whose pace in relation to meals is evo er, relieved by these but reappearing several hours later. Night pain is also suggestive (when the patient is fasting).
However, there are pseudoulcéreuses dyspepsia and the only way to make sense of things is to propose a gastroduodenal endoscopy.
It is of course necessary in this context to ensure the absence of decision gastrotoxic drugs (aspirin, anti-infl ammatory non-steroidal drugs [NSAIDs]) that can trigger the same clinical picture. An alternative to endoscopy in case of atypical ulcer syndrome in young adults (age 45) is the realization of a urea breath test
labeled C13 (Hélikit®) for asserting the presence or absence of Helicobacter. Its absence eliminates ulcer disease unrelated to NSAIDs or aspirin.
Treatment is based on PPIs associated with antibiotics for 7 days and double dose for Helicobacter pylori infection.In case of bleeding, endoscopic treatment has replaced surgery.
Gastroesophageal reflux:
Gastroesophageal reflux, easy to recognize in its typical form, can manifest as epigastric pain high, not upward, often with a posterior irradiation.
Treatment is based on the classic lifestyle changes, the Gaviscon® like antacids and PPIs.
Acute Pancreatitis:
It occurs in an alcoholic context or related to cholelithiasis, acute pancreatitis often results in epigastric pain, sudden onset, stabbing at subsequent irradiation. The ultrasound in this case can visualize abnormal pancreas and enables especially looking for gallstones which is in this case the most likely etiology.
The scanner has a major role in this context to confirm the diagnosis and above all, thanks to the contrast medium injection enables searching beaches of necrosis and necrosis cast in colic gutters. Treatment is hospitable.
There are rarer forms of non-alcoholic non-recurring pancreatitis and biliary whose etiological diagnosis is more difficult and is the specialist consultation.
Periumbilical pain:
The main causes are presented in Box 6.
Box 6. Etiology of pain in the umbilical region
Acute pancreatitis
Peptic ulcer
Diverticulitis
Gynecological infection
Aortic dissection
Small bowel obstruction or colon
Aortic dissection:
At this crossroads of topography can correspond to several etiologies already mentioned. It should nevertheless think especially to the aortic dissection whose urgency is obvious.
The land, the concept of a known aneurysm, the existence of a breath or abdominal auscultation at the femoral can evoke the diagnosis and propose emergency ultrasound or CT scan. This is a surgical emergency most often.
Intestinal obstruction:
Intestinal obstruction often manifest as pain rather central, joining in a more or less bloating, vomiting in case of high occlusion or a cessation of materials and gas in case of low occlusion. The diagnosis of occlusion mentioned, it is easy to document with a simple abdomen without preparation (ASP) who finds out one of his good indications. It is supplemented or replaced by a scanner that allows to affirm both the occlusion level and often the nature of the obstacle. Depending on the case, the treatment is medical (hospitalization, fasting, aspiration) or chirugical.
Small bowel obstruction:
The small bowel obstruction is the most common, and 60% of small bowel obstruction related to flanges mentioned if with previous surgery, scanner, a dilated small segment to which no visible obstacle succeeds another small segment Non dilated. The existence of signs of suffering at the volvulées handles facilitates the surgical indication in this situation. Other rarer causes occlusion of hail are linked to Crohn’s disease or benign or malignant tumors which often prove an episode of intussusception.
Colonic obstruction:
The occlusion colic, rarer, often unrecognized cancer, can determine a significant colonic distention with a risk of perforation that preferentially seat at the cecum due to Laplace. The parietal suffering signs are there both visible to the scanner and can determine prompt surgical decision.
Occlusion sigmoid volvulus:
Occlusion by sigmoid volvulus is easy to evoke the ASP before a monstrous expansion of the volvulée handle.Previous sub-spontaneously-limiting episodes of volvulus are often noted at the interrogation. The scanner confirms the diagnosis by viewing the dilated loop and especially the torsion coil of the foot of the loop (Fig. 5). The emergency colonoscopy often allows untwisting.
Occlusion linked to a strangulated hernia:
The occlusion may be related to a strangulated hernia, inguinal humans, usually inguinal women. Examination of holes hernia is essential in this situation because of its influence on the operative first track.
The scanner can confirm the diagnosis (Fig. 6).
Mesenteric ischemia:
The mesenteric ischemia frequently gives a painful bastard table with vague periumbilical pain, often associated with diarrhea that is not always bloody.
Once again, the scanner with opacification allows to objectify the suffering of coves, and sometimes visualize the occlusion of mesenteric vessels after injection.
Hypogastric pain:
They are frequently gynecological origin.
Ectopic pregnancy is of course the first diagnosis to evoke and to eliminate by a directed examination and doubt by the use of additional tests, including an ultrasound that allows to put the indication for surgery (Box 7).
Box 7. Etiology of hypogastric pain
Ectopic pregnancy
Gynecological infection
Occlusion
Diverticulitis
Peritonitis
Gynecological infections are frequent, often giving abdominal signs.
It is the interest of the gynecological examination with mobilization of the uterus and its annexes that can suggest the diagnosis to be confirmed by the investigations. Gynecologists often use in difficult cases either pelvic MRI is an exploratory laparoscopy to document including endometriosis. This diagnosis is considered in patients rhythmic pain by the rules.
Diffuse abdominal pain:
The diffuse abdominal pain is strongly evoke the diagnosis of peritonitis. In this situation it is important to try to find out whether this diffuse syndrome was not preceded by a more localized pain that can guide diagnosis. The management is surgical.
Faced with a widespread contraction in a little algic and mobilized patient, the surgical indication is not generally in doubt.
When it is accessible without delay the procedure, the scanner has the merit of allowing the most part an etiologic diagnosis can facilitate the choice of surgical approach by the surgeon.
The perforation of a duodenal ulcer may be raised by the initial onset of pain in the upper abdomen.Pneumoperitoneum principle is easy to demonstrate by a simple ASP focuses on the domes or by a scanner.
The pneumoperitoneum can also be linked to a diverticular perforation.
A rétropneumopéritoine is better objectified by the scanner in connection with a duodenal perforation or a perforated lesion rectosigmoid.
Rare etiologies of abdominal pain:
Some causes are difficult to evoke immediately before a little different often painful abdominal table previously considered etiologies. Nevertheless, development of the imagery is sometimes possible to recognize without having been initially discussed.
Appendicitis primitive omental:
This table is painful inflammation of omental appendix spontaneously by twisting or ischemia. The most common are localized in the sigmoid, but also in the cecum. Most patients are between 30 and 50 years. Overweight and intense physical effort are contributing factors. Abdominal pain is often located in a dial of the abdomen, often associated with localized defense. Its intensity is variable, sometimes intense. The general condition is still kept. There is usually no fever or leukocytosis. The two differential diagnoses are of course appendicitis right sigmoid diverticulitis and left.
The ultrasound may reveal a solid mass hyperechoic hypoechoic halo surrounded by a showing of a local inflammatory reaction. Semiotics scanner consists of a rounded oval mass, fat density, but denser than the mesenteric fat, surrounded by a peripheral ring of variable thickness, with enhancement after contrast administration.The differential diagnosis is that of myocardial greater omentum.
The usual attitude is conservative treatment based analgesics. Spontaneous regression within eight days is generally obtained.
Segmental infarction of the greater omentum:
Segmental necrosis of the greater omentum is very rare and of unknown etiology. Obesity, cardiovascular disease, male gender are the predisposing factors. The pain is often intense, but in contrast to a general state. Biology often shows leukocytosis with moderate inflammation. This is the ultrasound, and especially computed tomography (CT), which shows a fat content in heterogeneous, circumscribed by a hyperdense border. This condition is similar to appendicitis but omental lesion is larger: the evolution is the same and medical treatment should be when the diagnosis is known .
Internal hernias:
They are difficult to diagnose and again the scanner often brings the solution. They correspond to a protrusion of the abdominal structures through the zones of defects of the peritoneum or the mesentery. There are several types, the most common is paraduodénal seat through the hiatus of Winslow or the ligament of Treitz region. These hernias occur mainly during episodes of incarceration by a painful abdominal syndrome or occlusive. The treatment is surgical.
Intussusception:
In adults, unlike children, intussusception is usually related to a benign or malignant tumor in the hail. The image is a CT appearance rather characteristic rosette.
The treatment is surgical.
Gallstone ileus:
The diagnosis can be evoked on the ASP before the aerobilia triad, dilated bowel loops and presence of calcified gall stones in the small intestine. The scanner is useful to confirm the diagnosis. The treatment is surgical.
Spontaneous hematoma of the small intestine:
This is a complication that occurs most often in cases of overdose anticoagulants It can also be in hemophilia during an idiopathic thrombocytopenic purpura, a hematologic malignancy or undergoing chemotherapy . Occlusion is often indicative of this complication. This is the scanner that allows diagnosis by viewing a hematoma usually localized in the submucosa of the small intestine: its location is in order of frequency jejunum, ileum and duodenum.
Bruising colon are rare. The collection is displayed in the photographs of CT without injection as a hyperdense mass.
Its recognition should prevent surgical indication is useless, evolution is doing in general to a spontaneous resolution after correction of coagulation disorders when they exist.
Volvulus of intra-abdominal organs:
It is generally adjoined defect that determines an abnormal mobility of intra-abdominal organs:
– Volvulus of the right colon;
– Volvulus of the gall bladder;
– Splenic volvulus.
The treatment is surgical.
Medical causes of acute abdominal pain tables:
Apart from particular functional bowel disorders that are, let us repeat, one of the main causes of acute abdominal pain sometimes pseudochirurgicales, there are several infrequent medical situations but should be known as they are potentially responsible for pseudochirurgicaux tables.
You should know evoke after removing a surgical emergency. Standard laboratory tests and imaging are usually contributing little effect.
Abdominal pain of metabolic origin:
It is not uncommon for an ionic disorder is revealed by an acute abdominal syndrome.
The primary or secondary acute adrenal insufficiency prolonged corticosteroid therapy can be severe abdominal pain often associated with diarrhea, nausea and vomiting and an array of collapse. Serum electrolytes typically shows hyponatremia with hyperkalemia, which should suggest the diagnosis. Treatment is based on the emergency hospitalization in intensive care, the massive hydration and hydrocortisone intake.
Another metabolic cause of acute abdominal pain is the hypercalcemia which may be responsible vomiting, abdominal distension. The painful picture is sometimes intense and partners with general signs (polyuropolydipsie) and neuropsychiatric with disorientation and agitation. The patient must be hospitalized and rehydrated. The treatment is detailed in Chapter hypercalcemia.
Acute porphyria:
Porphyria are inherited autosomal dominant disease potentially severe because of their neurological complications.
They can occur in particular in the case of acute intermittent porphyria, which is the most common, by neuroviscéraux signs that may lead to a painful abdominal pseudochirurgical table. Think about it in the young woman with severe abdominal pain, unlocated.
The clinical discovers a patient irritable, anxious, but abdominal examination is normal.
Typically, the diagnosis is suggested if the urine which are exposed to light for extended turn red. However, in the era of modern toilets, this classic sign is rarely noted. There is often a triggering factor: menstrual period, certain medications can trigger the crisis (the list of drugs available in French Porphyria Centre, Hôpital Louis Mourier, Colombes). The standard complementary exams and morphological examinations are always negative. Diagnosis can be easily carried by the research of porphyrins in the urine. In the absence of diagnosis, severe neurological complications can occur. The treatment consists of heme administration by intravenous infusion (Normosang®).
Lead poisoning has become rare with the renewal of household plumbing has the effect of blocking the synthesis of certain enzymes involved in the production of heme, which leads to an accumulation of porphyrin derivatives. The clinical picture is very similar to the acute porphyria crisis.
Edema hereditary angioneurotic:
This syndrome is caused by a congenital cit challenge, most of the time, by C1 esterase inhibitor.
This deficit is sometimes acquired (some medications such as angiotensin, certain autoimmune diseases).
In his abdominal form, it can achieve a painful picture, sometimes intense, with serous effusion, ascites (visible to the scanner). Being associated with a diffuse or laryngeal edema or the existence of previous crises may suggest the diagnosis. This is based on research deficiency of C1 esterase. The change is most often spontaneously favorable.The treatment is detailed in Chapter Edema.
Periodic disease or Mediterranean fever:
This rare hereditary disease is linked to a mutation on a gene identified on chromosome 16 (the research is now possible). It often presents with an acute abdominal pseudochirurgical table associated with an inflammatory syndrome and polynucleosis which often determines an emergency laparotomy, white. We have to think in cases of domestic concept to ethnic origin (Armenians, Sephardic Jews), and because of previous crises resolvent associated with arthralgia, pleural pain. Preventive treatment is based on colchicine which allows prevention of crises and prevents the occurrence of amyloidosis.
Vasculitis:
All vasculitis may be an acute abdomen secondary to ischemia that can affect all organs: bladder, small intestine, colon. The diagnosis is difficult preoperatively, but surgical complications often require a resection.
It is the analysis of the specimen to give the diagnosis.
These vasculitis, note the possibility of HSP that can occur only in an abdominal form with thickening of intestinal loops, sometimes a source of intussusception (common etiology in children).
The diagnosis in this case is difficult.
Abdominal pain in pregnant women:
Pregnant women may have a trivial surgical emergency it is often difficult to recognize in advanced pregnancy and because of the cons-indications of radiological imaging.
Acute appendicitis is rare but possible.
The revelation of Crohn’s disease can also occur during pregnancy by intestinal obstruction.
A twist of an ovarian cyst can be observed.
The rupture of a gravid uterus is considered late in pregnancy.
If gestational hypertension, preeclampsia is frequently manifested by a very intense epigastric pain syndrome.
Emergency Hospitalization is required.
On the medical front, we must think of the possibility of gallstone pancreatitis and search before a painful picture supramesocolic gallstones on ultrasound.
On the urinary level, renal colic and urinary tract infections are of course to eliminate systematically.
ABDOMINAL PAIN TREATMENT:
The abdominal pain treatment principles are obviously based on the etiology, particularly if they require the use of surgery.
In case of occlusion:
In case of obstruction, the development aspiration and correction Electrolyte disturbances is needed before the possible intervention.
In the event of intra-abdominal sepsis:
In the event of intra-abdominal sepsis, antibiotics may precede surgical treatment or allow to delay it.
The choice of antibiotic therapy is of course guided by the location of the infection:
– In case of diverticulitis, is to be preferred antibiotics active on enterobacteria and anaerobes (amoxicillin, metronidazole, quinolones if penicillin allergy);
– In case of biliary infection (after blood cultures), we can offer third-generation cephalosporins (C3G), and possibly the Flagyl® amoxicillin;
– In case of gynecological infection (after local levies), the choice is more difficult since bacterial infections are often multi.
Flagyl® and C3G may be proposed or quinolones ( Chlamydia );
– Hepatic or diverticular abscess can have a guided paracentesis by CT or ultrasound.
Symptomatic treatment of pain:
Symptomatic treatment of pain, when not linked to the occlusion or infection, of course depends on the etiology and these treatments were considered as and extent in the overlying text or well in other chapters. Opioids that slow transit should be avoided until you have an accurate diagnosis.
Functional origin of pain:
It remains functional origin of pain, which are the most everyday problem. They are difficult to treat because of the frequent ineffectiveness of various solutions proposed or exhaustion of their effect. Antispasmodics (trimebutine, mebeverine …) are of course to offer in combination with regulators of transit (see Chapter Diarrhea and constipation). Dietary advice are important, rather favoring regimes without residue in diarrhea and high fiber diets (if supported) in case of constipation.
CONCLUSION:
The multiplicity of potential diagnoses to raise with acute abdominal pain in adults should not forget that a simple clinical approach enables the most part, taking into account age and land, reduce the number of assumptions one or two, a complementary balance can quickly support. Abdominal CT scan has become indispensable in difficult or unusual cases of acute abdomen.