Free Rosen & Barkin's 5-Minute Emergency Medicine Consult by Jeffrey J. Schaider, Adam Z. Barkin, Roger M. Barkin, Philip Shayne, Richard E. Wolfe, Stephen R. Hayden, Peter Rosen Page B

2012;125(13):1617–1625.
Lederle FA, Freischlag JA, Tassos C, et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm.
N Engl J Med
. 2012;367:1988–1997.
Rogers RL, McCormack R. Aortic disasters.
Emerg Med Clin N Am
. 2004;22:887–908.
Tibbles C, Barkin A. The aorta. In: Cosby K, Kendall J.
Practical Guide to Emergency Ultrasound
. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:219–236.
See Also (Topic, Algorithm, Electronic Media Element)
Aortic Dissection
Peripheral Artery Disease
CODES
ICD9
ICD9
441.3 Abdominal aneurysm, ruptured
441.4 Abdominal aneurysm without mention of rupture
    ICD10
I71.3 Abdominal aortic aneurysm, ruptured
I71.4 Abdominal aortic aneurysm, without rupture

ABDOMINAL PAIN
Saleh Fares
BASICS
DESCRIPTION
Parietal pain:
Irritating material causing peritoneal inflammation
Pain transmitted by somatic nerves
Exacerbated by changes in tension of the peritoneum
Pain is sharp, well localized with abdominal, rebound tenderness and involuntary guarding
Visceral pain:
Afferent impulses result in poorly localized pain based on the embryologic origin rather than true location of an organ.
Pain of foregut structures to the epigastric area
Pain from midgut structures to the periumbilical area
Pain from hindgut structures to the suprapubic region
Distention of a viscous or organ capsule or spasm of intestinal muscularis fibers
Pain is constant and colicky
Inflammation:
Focal tenderness develops once the inflammation extends to the peritoneum
Ischemia from vascular emergencies:
Pain is severe and diffuse
Referred pain:
Felt at distant location from diseased organ
Due to an overlapping supply by the affected neurosegment
Abdominal wall pain:
Constant, aching with muscle spasm
Involvement of other muscle groups
ETIOLOGY
Peritoneal irritants:
Gastric juice, fecal material, pus, blood, bile, pancreatic enzymes
Visceral obstruction:
Small and large intestines, gallbladder, ureters and kidneys, visceral ischemia, intestinal, renal, splenic
Visceral inflammation:
Appendicitis, inflammatory bowel disorders, cholecystitis, hepatitis, peptic ulcer disease, pancreatitis, pelvic inflammatory disease, pyelonephritis
Abdominal wall pain
Referred pain: (e.g., intrathoracic disease)
DIAGNOSIS
SIGNS AND SYMPTOMS
History
Pain
Nature of onset of pain
Time of onset and duration of pain
Location of pain initially and at presentation
Extra-abdominal radiations
Quality of pain (sharp, dull, crampy)
Aggravating or alleviating factors
Relation of associated finding to pain onset
Anorexia
Nausea
Vomiting (bilious, coffee-ground emesis)
Malaise
Fainting or syncope
Cough, dyspnea, or respiratory symptoms
Change in stool characteristics (e.g., melena)
Hematuria
Changes in bowel or urinary habits
History of trauma or visceral obstruction
Gynecologic and obstetric history
Postoperative (e.g., cause ileus)
Family history (e.g., familial aortic aneurysm)
Alcohol use and quantity
Medications: (e.g., aspirin and NSAIDs)
Physical-Exam
General:
Anorexia
Tachycardia
Tachypnea
Hypotension
Fever
Yellow sclera (icterus)
Distal pulses and pulse amplitudes between lower and upper extremities
Abdominal:
Distended abdomen
Abnormal bowel sounds:
High-pitched rushes with bowel obstruction
Absence of sound with ileus or peritonitis
Pulsatile abdominal mass
Rebound tenderness, guarding, and cough test for peritoneal irritation (e.g., appendicitis, peritonitis)
Rovsing sign, suggestive of appendicitis:
Palpation of left lower quadrant causes pain in right lower quadrant (RLQ).
Psoas sign suggests appendicitis (on right)
Pain on extension of thigh
Obturator sign suggests pelvic appendicitis (on the right only)
Pain on rotation of the flexed thigh, especially internal rotation
McBurney point tenderness associated with appendicitis:
Palpation in RLQ 2/3 distance between umbilicus and right anterior superior iliac crest causes pain.
Murphy sign, suggestive of cholecystitis:
Pause in inspiration while examiner