Abdominal Pain Emergencies - Causes and Management

Introduction:

Abdominal pain is one of the common causes of getting admitted to an emergency department. The diagnosis and management of abdominal pain should have a proper history, complete physical examination, imaging modalities, and laboratory tests. Factors that should be considered while treating are age, social habits, the onset of pain, duration of pain, location of pain, radiation, relieving factors, and aggravating factors.

What Are the Causes of Abdominal Pain Emergencies?

The common causes of acute abdominal pain that cause generalized abdominal tenderness include:

• Peritonitis (a condition in which a membrane that covers the abdominal cavity gets inflamed).

• Bowel obstruction.

• Pancreatitis (inflamed pancreas).

• Bowel ischemia (reduced blood flow to the intestines).

• Aortic aneurysm (bulged out aorta).

The common causes of acute abdominal pain that cause supra-pubic (below the abdomen) tenderness are:

Colonic Causes:

• Appendicitis (inflamed appendix).

• Colitis (inflamed colon).

• Diverticulitis (inflammation of the pouches that are formed from the walls of the bowels).

• Irritable bowel syndrome.

• Inflammatory bowel disease.

Gynecology Causes:

• Fibroids (benign tumors around the uterus).

• Ovarian mass.

• Ectopic pregnancy (the embryo attaches itself outside the womb, mostly in the fallopian tube).

• Torsion (twisted fallopian tube or ovary).

• Pelvic inflammatory disease (PID, infection of the reproductive system).

Renal Causes:

• Cystitis (inflamed bladder).

• Nephrolithiasis (kidney stones).

• Pyelonephritis (inflamed kidney).

The common causes of acute abdominal pain that cause epigastric (puper abdomen) pain are:

Biliary Causes:

• Cholelithiasis (gallstones).

• Cholangitis (inflamed bile ducts).

• Cholecystitis (inflamed gallbladder).

Gastric Causes:

• Esophagitis (inflamed esophagus).

• Peptic ulcer.

• Gastritis (inflamed stomach lining).

Pancreatic Causes:

• Pancreatitis (inflamed pancreas).

• Mass in the pancreas.

Cardiac Causes:

• Pericarditis (inflamed outer layers of the heart).

• Myocardial infarction (heart attack).

Vascular Causes:

• Aortic dissection (tear in the aorta).

• Mesenteric ischemia (decreased blood flow to the small intestine).

The common causes of acute abdominal pain that causes pain in the right upper quadrant can be due to cardiac, biliary, colonic, and renal issues, other causes are:

Pulmonary Causes:

• Emboli (A clot in the lung arteries).

• Pneumonia (infection of the lung).

Hepatic Causes:

• Hepatitis (inflamed liver).

• Abscess.

• Mass.

The common causes of acute abdominal pain in the left upper side can occur due to cardiac, pancreatic, gastric, vascular, renal, and pulmonary issues, other causes are:

Splenic Causes:

• Infection.

• Abscess.

The common causes of acute abdominal pain are pain in the right lower and left lower quadrant, which can be due to colonic, renal, and gynecological issues.

What Is the Management of Abdominal Pain Emergencies?

Management of some of the emergency abdominal pain includes:

Aortic Aneurysm:

• It bulges out of the aorta, which is more than three centimeters in diameter, and is the largest artery that supplies blood from the heart to the chest and abdominal area.

• It can be a rupture (complete burst that causes bleeding inside the body) or dissection (splitting of the aortic layers causing leakage of the blood).

• This is most common in patients above 60 years of age who present with pain in the abdomen, back, and flank region associated with limb ischemia, and a pulsatile abdominal mass can be felt. Less commonly, the pain can be radiated to the groin or thigh region. If ruptured, the patient undergoes shock.

• In the case of previously treated abdominal aortic aneurysms, endoleaks from the grafts should be considered.

• In such cases, intravenous access should be established for the administration of blood, crystalloids, and medications.

• Normal blood pressure cannot be maintained. Therefore, a systolic blood pressure of 80 to 90 mm Hg is maintained.

• In case of severe hypertension, Esmolol is given, which can drop the blood pressure.

• After the diagnosis is made, the patient should be transferred to a surgeon for an emergency repair.

Acute Pancreatitis:

• It is the inflammation of the pancreas, which can be mild or severe, associated with necrosis or multiple organ failure.

• The patient presents with generalized abdominal pain that can radiate to the back. This can be associated with abdominal distension, vomiting, nausea, and diaphoresis (increased sweating).

• In case of severe inflammation, there is bluish discoloration around the umbilicus or flank, along with hypotension. Sometimes, it can be associated with bleeding. In such cases, early aggressive management should be started.

• Management should include supportive care, such as the administration of analgesia and intravenous fluids (four liters of crystalloids should be administered in the first 24 hours). Antibiotics should be given, proton pump inhibitors (PPI), and venous thromboembolism (VTE) prophylaxis should be given.

• Enteral feeding should be started as early as possible.

• Complications such as pancreatic necrosis, pancreatic abscess, sepsis, shock, renal failure, or respiratory failure should be treated.

Bowel Obstruction:

• This occurs when the intraluminal contents are blocked; it can occur in the small or large intestine. It can be mechanical (in most cases) or functional.

• It can be a partial obstruction or a complete obstruction. A complete obstruction is generally associated with peritonitis and is associated with intestinal ischemia, perforation, or gangrene.

• A patient with small bowel obstructions presents with pain, bloating, vomiting, nausea, high-pitched bowel sounds, and a hernia (bulging out of the muscle or tissue).

• A patient with large bowel obstruction can present with pain, bloating, rectal bleeding, tenesmus (feeling of the passage of stool), nausea, vomiting, and weight loss.

• Supportive care such as administration of intravenous fluids and analgesics should be given, urine output should be monitored, antiemetics should be given in case of nausea, and nasogastric tubes (NG) should be given for gastric decompression.

• Preoperative antibiotic prophylaxis should be given, and nil by mouth (NBM) should be started before surgery.

• Emergency surgery is indicated in case of perforated or strangulated bowel.

Diverticulitis:

• It is the infection or inflammation of the pouches that are formed from the walls of the bowels.

• The patient presents with sharp pain in the abdomen, abdominal distension, bloating, fever, nausea, vomiting, and fever. On examination, there is tenderness in the right lower quadrant of the abdomen, a palpable mass in case of abscess formation, and in women with colo-vaginal fistula, there can be purulent vaginal discharge.

• In case of severe diverticulitis, which is associated with perforation, IV fluids should be administered, broad-spectrum intravenous antibiotics such as Gentamicin 5mg/kg IV, Amox/Ampicillin 2g IV 6 hourly, and Metronidazole 500mg IV 12 hourly can be given. Iv morphine is given to relieve pain. Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided, which can cause perforation.

• Percutaneous drainage should be done with the help of a CT scan in case of peri diverticular abscesses more than four centimeters in diameter.

Ischemic Bowel:

• Ischemia can occur in small or large bowels and is caused by arterial thromboembolism, venous thrombosis, and non-occlusive ischemia.

• Patients with small bowel or acute mesenteric ischemia present with severe abdominal pain may undergo shock due to dehydration and loss of fluids.

• Management includes early patient transfer to the ICU (intensive care unit), early arteriography, or laparotomy. Broad-spectrum IV antibiotics such as Gentamicin or Ampicillin are given. IV heparin is given in case there is no anticoagulation.

• Treatments such as administration of oxygen, fluid resuscitation, NG tube for gastric decompression, and administration of analgesics are given.

Acute Appendicitis:

• Appendicitis is the infection of the appendix, which is a narrow long projection of the colon (part of the large intestine) that is present on the right side of the abdomen in pediatric patients who are between 5 to 19 years old. This condition requires urgent surgical treatment.

• Management includes, nil by mouth (NBM) preparation should be started, and IV access should be made for the administration of analgesics and fluids. IV antibiotics are given in case of infection. Appendectomy is the standard treatment that is started as early as possible.

Acute Cholecystitis:

• It is an infection of the gallbladder and the patient presents with right upper quadrant pain, leukocytosis, and fever.

• Management includes administration of IV antibiotics such as Gentamicin and ampicillin.

• Supportive treatment such as fluid resuscitation, monitoring of urine output, and administration of analgesics should be given.

Conclusion:

Abdominal pain is one of the common reasons that require emergency treatment. Early diagnosis and pre-hospital management can reduce morbidity and mortality rates. Healthcare providers must be knowledgeable about the clinical features and diagnostic evaluation of these abdominal pain emergencies to provide timely and effective care. Continuous education and training are essential for maintaining the highest standards of care in such critical situations.