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Acute Abdominal Emergencies
Acute Abdominal Emergencies R. W. POSTLETHWAIT, M.D., F.A.C.S. Professor of Surgery, Duke University; Chief of Surgical Service, Durham Veterans Administrat'ion Hospital
M. L. DILLON, M.D. Associate Professor of Surgery, Duke University; Assistant Ch'ieJ oJ Surgical Service, Durham Veterans Administration Hospital
D. L. STICKEL, M.D. Resident in Surgery, Duke University and Durham Veterans Administration Hospital
THE DIAGNOSIS AND TREATMENT of the patient with acute abdominal pain is one of the most interesting, and frequently most difficult, of all the problems in medicine. The number of diseases that may begin with acute abdominal pain is large and a comprehensive description of these lesions would require a huge volume. For this reason, only brief consideration can be given in this discussion to a few selected diseases. The classical symptoms and signs of acute peritonitis and of acute intestinal obstruction are so well known that further description is unnecessary. Massive gastrointestinal hemorrhage will be mentioned only briefly. One approach to the problem of acute abdominal pain has been a consideration by organs or systems, and this will be followed here.
Esophagus
Although hiatal hernia with esophagitis commonly causes epigastric pain, this is infrequently so acute and severe as to be considered in the category of the usual acute abdomen. Spontaneous rupture of the esophagus, however, may present almost entirely with acute abdominal symptoms and signs and, among the reported cases, a number, of the patients were operated upon with an erroneous diagnosis of perforated peptic ulcer. The presence of any objective findings of mediastinal or pleural involvement should direct attention to the esophagus .. The absence of intra-abdominal air and of rebound tenderness and the presence of rigidity out of proportion to the degree of tenderness should arouse suspicion. Other than these findings, spontaneous rupture of the esophagus may mimic perforated peptic ulcer in all manifestations.
52l
522
R. W.
POS'rLE'l'HWAI'f,
M. L.
DILLON,
D. L.
S'l'ICKEL
Stomach
In a general practice, acute gastroenteritis is undoubtedly the most common cause of acute abdominal pain. This may vary from a benign, self-limited disturbance to the serious staphylococcal food poisoning. Peptic ulcer, usually penetrating or perforated, is encountered more often in a hospital practice but frequently enough by the general physician. Diagnosis is not difficult when the classical symptoms and signs are present, which is usually the case, so that perforated ulcer is missed much less often than it is diagnosed erroneously. The past history may or may not suggest the presence of peptic ulcer. Sudden, severe epigastric pain, radiating soon into the right lower quadrant and then becoming generalized, and faintness without vomiting are the usual symptoms. The patient appears ill, prefers not to move, and breathes with short, quick gasps. The pulse is rapid and of diminished volume. The abdomeu moves little, tenderness may be maximal in the epigaHtrium and right lower quadrant, with marked rebound tenderness and muscle spasm. Liver dullness is frequently replaced by tympany, and peristalsis is absent. Fever, air under the diaphragm radiographically, and leukocytosis complete the picture of perforated ulcer. An interesting lesion that may present with a picture similar to perforated ulcer;.i,s acute alcoholic gastritis. The history may be confused. The patient may describe only the intake of alcohol and the acute onset of severe abdominal pain. Marked tenderness and muscle rigidity are impressive but rebound tenderness is minimal or absent and peristalsis may be increased. Leukocytosis is usually not present. With intra venom; fluids, improvement is rapid, which may be of some diagnostic importance. Liver Although the liver may slowly attain considerable enlargement without pain, the disorders that cause a rapid increase in size may produce marked abdominal pain. Cardiac decompensation, acute hepatitis and infectious mononucleosis are among the latter. Seldom, however, do these patients present as an acute abdominal emergency. Liver abscess and pylephlebitis are now rare in this country. An interesting catastrophe is the patient with acute massive intra-abdominal hemorrhage from a hepatoma of the liver. Metastatic tumor to the liver rarely exhibits this complication but hepatoma will occasionally present with hemorrhage as the initial manifestation. The stigmata of cirrhosis, the general signs of acute blood loss and the abdominal findings of intraperitoneal hemorrhage should suggest the possibility.
Gallbladder The incidence of disease of the gallbladder is so high that the acute exacerbations or complications constitute one of the most frequent
Acute Abdominal Emergencies
523
causes of acute abdominal emergencies. The seriousness varies from the patient with acute colic which rapidly subsides to the one with acute perforation which soon terminates fatally. When only the gallbladder is involved in the pathologic process, diagnosis usually is not difficult. Concomitant disturbances are frequently present, however, and alter the clinical picture. These include hepatitis, cholangitis, pancreatitis, lymphadenitis, and involvement of the extrahepatic ductal system. Common duct ohstruct.ion may further compound the diagnostic diffi!"ultieR. The average patient. will give a past history suggesting gallbladder disease, one of the most dependable symptoms in the elusive case being right upper quadrant soreness for a day or two after a bout of indigestion. A severe acute cholecystitis, however, may be the initial manifestation, particularly in the older age group. Typically, the right upper quadrant pain rapidly increases in severity, may radiate around the right costal margin and to the scapula, and is accompanied by nausea and vomiting. The signs of severe peritoneal irritation are usually fairly well localized to the right upper quadrant and the increase in tenderness with deep inspiration is noteworthy. The gallbladder will be felt in only about a fifth of the cases. Fever, tachycardia and leukocytosis are present. Clinical jaundice may not be evident but the bilirubin will almost always be elevated. A scout film of the abdomen may show stones. Perforation of the gallbladder most often is walled off by contiguous tissues or by fistula formation into a hollow viscus. Occasionally, perforation into the free peritoneal cavity occurs. The resulting acute chemical peritonitis is fulminating in its course. Beeause of the location of the perforation and of the drainage along the right colic gutter, an erroneous diagnosis of perforated peptic ulcer or appendicitis may be made. More seriously, the acute peritonitis may be thought to be due to pancreatitis and, if treated without operation, the diagnostic error will be unreeognized. Usually, earlier symptoms will focus attention on the gallbladder, but the free perforation may be the first diffieulty. Pancreas
Acute pancreatitis and the acute exacerbations of chronic pancreatitis present with severe pain, frequently radiating through to the back, nausea, vomiting, and signs of a severe peritonitis. In spite of the other lesions which have been found to increase the serum amylase, this test remains exceedingly helpful in confirming the diagnosis of acute pancreatitis. Peritoneal aspiration has been of value occasionally, as the amylase level of the aspirate may reach extremely high levels. Prompt relief of the pain by splanchnic nerve block has some diagnostic value, as well as very definite therapeutic benefit. At times the diagnosis of acute pancreatitis must be presumptive on the basis of excluding other lesions. The necessity for following these patients carefully is obvious.
524
R. W.
POSTLETHWAIT,
M. L.
DILLON, D.
L.
STICKEL
Blunt trauma to the abdomen producing laceration of the pancreas will be practically impossible to diagnose with confidence preoperatively. Occasionally, the trauma apparently causes a small laceration so that the initial symptoms are not severe. Later a pseudocyst forms, the latter being slow in its development, but at times producing acute abdominal symptoms. The history of trauma, the presence of a mass, and the displacement of neighboring structures should suggest the presence of a pseudocyst. Carcinoma of the head of the pancreas is nearly always insidious in onRet, hut may first cause acute, severe, right upper quadrant. pain. Malignan~.v in t.he hody or tail ~ommonly causes pain hut not often acut.ely. Spleen
Such unusual disturbances as twisted splenic pedicle and spontaneous rupture of an enlarged spleen have been recorded. Splenic infarction is not infrequent, particularly accompanying subacute bacterial endo~ar ditis, and the pain and peritoneal irritation may be severe enough to overshadow other lesions. Surgically, a frequent pitfall for the unwary is delayed hemorrhage from a ruptured spleen. The trauma may be seemingly minor and so be overlooked, either by patient or physician. The secondary hemorrhage usually occurs within two weeks, but may be delayed considerably longer. Sudden abdominal pain, either localized or generalized, with or without radiation to the left shoulder, will he accompanied by the symptoms and signs of hemorrhage. Elevation of the left hemidiaphragm, tenderness and a mass in the left upper quadrant, signs of peritoneal irritation, and fixed dullness on the left with shifting dullness on the right point to rupture of the spleen. The typical displacement of the stomach with serrations along the greater curvature seen radiographically is of great value in diagnosis. Peritoneal aspiration will also be of aid. Unfortunately, such helpful signs as flank or umbilical discoloration due to extraperitoneal blood are not often present. Small Bowel
The small bowel is infrequently involved in disorders producing an acute abdominal emergency but the lesions which do occur include Meckel's diverticulum, regional ileitis, intussusception, solitary ulcer, internal hernia, malrotation, and obstruction due to various types of bands, adhesions, benign and malignant tumors. One of the most difficult lesions to diagnose is perforation of the small bowel by a foreign body. Ingestion of an object such as a fish bone, pin or toothpick may pass unnoticed or be forgotten by the patient. A diagnosis only of perforated viscus may be possible prior to operation. Small bowel obstruction, due most commonly to adhesions or hernia, may be emphasized on several points. The mortality rises sharply when
Acute Abdominal Emergencies
525
a loop of bowel progresses to gangrene. No clear picture of imminent gangrene appears ; the only effective measure in the prevention of gangrene is early diagnosis and early operation. Despite the usefulness and effectiveness of adjunctive measures consisting of intravenous fluids, long intestinal tubes and (in those with a gangrenous loop) antibiotics, early surgery is the mandatory treatment. The only important exception is the patient with obstruction due to fibrinous adhesions in the early postoperative period. Finally, early surgery is especially important in the elderly who tolerate nutritional, water and electrolyte disturbances and gangrene especially poorly. Appendix
The problems of the diagnosis of acute appendicitis are so well known that further comment would be superfluous. Most of the lesions that cause an acute surgical abdomen have been mistaken for appendicitis, and the reverse is also true. Although administrators and tissue review boards frown when a pathologic diagnosis of normal appendix is made after an emergency appendectomy, diagnostic acumen is still such that about 25 per cent of these appendices will (and should) be normal. If one must give favorite symptoms and signs in the diagnosis of acute appendicitis, several may be suggested with the understanding that these are not infallible. Minimal peritoneal irritation may be described by the patient more easily than elicited by palpation. Sudden momentary pain on stepping down a stair, with cough, or a similar quick or jarring motion may be helpful. Anorexia is rarely absent. Point tenderness is of positive importance and the presence of palpable gas in the cecum usually indicates the absence of appendicitis. Rectal tenderness on the right is obviously of aid in diagnosis. The white cell count may be of interest but has assumed a significance far beyond its value. An inflamed appendix in the retrocecal region may give minimal or no signs in the anterior abdominal wall. One lesion that mimics acute appendicitis almost routinely is acute mesenteric lymphadenitis. In our opinion, acute mesenteric lymphadenitis is an operative diagnosis. Except in the patient who has had an appendectomy, a clinical diagnosis of acute mesenteric lymphadenitis is the equivalent of a diagnosis of acute appendicitis and prompt operation is accordingly indicated. Statistically, in large groups of cases, certain differences are evident, such as the intermittent colicky pain and the extension of the tenderness along the course of the root of the mesentery. In the individual patient, however, these differences lose their value. Colon
Diverticulitis and carcinoma are the lesions most frequently responsible for an acute abdominal emergency on the basis of colon disease.
526
R. W.
POSTLETHWAIT,
M. L.
DILLON, D.
L.
STICKEL
Diverticulitis is usually fairly typical although proof short of operation may be difficult. Of those patients with diverticula of the colon, approximately 15 per cent of those who become symptomatic do so by bleeding. This is seldom minor but usually a fairly massive hemorrhage. While the bleeding usually ceases spontaneously, emergency operation may be necessary. Carcinoma may perforate or intussuscept but more often, and usually in the sigmoid, will be the source of acute intestinal obstruction. These patients may have few or no antecedent symptoms; then develop complete obstruction in a matter of a few hours. Edema, perforation, impaction and ileus in the proximal colon are possible causes. A closed loop type obstruction is produced, however, and the patient may rapidly progress from a relatively normal state into the acute obstruction, then into shock soon followed by circulatory collapse and death. Time should not be wasted by attempts to intubate down through the small bowel, as this will seldom be successful. After a brief period of preparation, colostomy or cecostomy should be performed. Chronic ulcerative colitis may become an emergency situation because of hemorrhage, perforation, obstruction or an acute fulminating exacerbation. The diagnosis is seldom difficult but it should be remembered that carcinoma occurs with greater frequency in chronic ulcerative colitis and may be the cause of the hemorrhage or obstruction. An interesting complication of ulcerative colitis, termed impending perforation, may present as an acute abdomen and is at least an urgent indication for operation. An acutely involved segment of the affected colon (sigmoid in our cases) is the source of marked local signs of peritoneal irritation and the segment appears and remains distended on radiographic examination. One lesion which causes considerable diagnostic difficulty, even at operation, is a perforated diverticulum of the cecum. This may be solitary or one of many. The perforation is usually walled off. The mass preoperatively is indistinguishable from appendiceal abscess or perforated carcinoma. At operation, the normal appendix will be evident and an erroneous diagnosis of carcinoma may lead to immediate right colon resection. Heart and Lung
These patients come to the attention of the surgeon infrequently, but a mistaken diagnosis followed by laparotomy obviously may have serious consequences. Myocardial infarction, acute congestive heart failure, acute rheumatic fever and acute pericarditis are four disorders that may present primarily because of acute abdominal pain. Pneumonia, pleurisy and pulmonary embolism may have a similar onset. The history, the presence of abnormal physical findings in the heart or lungs, the
Acute Abdominal Emergencies
527
lack of or the atypical abdominal signs, and the aid provided by radiologic, electrocardiographic and laboratory examinations will almost invariably identify the underlying cause of the pain. Vascular
With the development of vascular surgery, rupture of an abdominal aortic aneurysm need not be invariably fatal. The aneurysm per se may be asymptomatic although the typical pulsatile mass will be palpable and frequently the walls outlined by calcium on the x-ray film of the abdomen. Fortunately, rupture often causes limited, even though appreciable, hemorrhage which acts as a warning. This produces acute abdominal pain, usually radiating into the back. Other symptoms may appear dependent upon involvement of the intra-abdominal organs or peripheral vessels. The patient or his physician may note a mass for the first time, or the known abdominal mass may rapidly enlarge. Operation should not be delayed, for massive hemorrhage and death almost invariably follow the first bleeding. Dissecting aneurysm most frequently is manifested by thoracic symptoms and signs, but the dissection may produce primarily abdominal symptoms. Low back and abdominal pain are present, with signs of vascular insufficiency in the legs. Other intra-abdominal manifestations will be dependent on the vessels and structures involved by the dissection. Aortography may be necessary for diagnosis and should be performed in view of the increasingly favorable results from operation. Mesenteric thrombosis has long been a well recognized acute abdominal catastrophe but its frequent predecessor, abdominal angina, is less well known. Although abdominal angina will seldom present as an acute abdominal emergency, the characteristic symptoms of postprandial pain, constipation and weight loss should be noted here. In addition, it is conceivable that the arteriosclerotic plaques in the celiac and superior mesentery arteries may occasionally be the source of emboli. Occlusion of a smaller mesenteric vessel by the embolus might account for some of the unexplained solitary ulcers or areas of gangrene in the .small or large bowel which are occasionally seen. Certainly such emboli from arteriosclerotic plaques in the aorta or iliac vessels have obstructed the popliteal or tibial arteries. Gynecologic and Urologic
The pelvic organs of the female provide a fertile area for the development of lesions which will cause an acute abdominal emergency. Mittelschmerz is undoubtedly the most common of these and can usually be identified by the relationship of the illness to the menstrual cycle, the pelvic location of the pain and tenderness, and the absence of systemic manifestations. Unfortunately, however, a teaspoonful of blood from
528
R. W.
POSTLETHWAIT,
M. L.
DILLON, D.
L.
STICKEL
the ruptured follicle may produce all the symptoms and signs of an acute appendicitis. Only an operative diagnosis can then be made. Acute salpingitis, ruptured ectopic pregnancy, and twisted ovarian cyst pedicle are causes of acute abdominal pain which in their typical form may cause little difficulty in diagnosis. The atypical group obviously requires careful inquiry into the menstrual history and evaluation of the pelvic examination. Endometriosis similarly may present in typical form but may produce variable symptoms, ranging from acute peritonitis due to rupture of an endometrial cyst to intestinal obstruction caused by involvement of the bowel in the pathologic process. The urinary tract is subject to stone, infection, retention, obstruction, tumor and trauma and may be the basis for an acute abdominal emergency. As noted for the gynecologic lesions, the patients with genitourinary system involvement whose manifestations are typical should not cause great difficulty in diagnosis. The endoscopic and radiographic techniques in the hands of the urologists permit remarkably accurate identification and localization of the disorder. Hematopoietic and Metabolic
Little more than listing of these diseases is possible. Sickle cell anemia is the outstanding example of a disease of the blood in which acute abdominal pain may be impossible to differentiate from a common lesion such as appendicitis, particularly when this occurs in very young children. The various types of poisoning or intoxication are probably best represented by lead colic as the cause of acute abdominal pain. Retroperitoneal lymph node involvement by lymphosarcoma or Hodgkin's disease may cause acute pain. Abdominal Hodgkin's disease may cause acute abdominal pain, particularly if the patient partakes of alcohol. Acute idiopathic hyperlipemia and acute porphyria also may produce severe abdominal distress. : Diabetes and thyrotoxicosis may have severe abdominal complaints as a part of the symptomatology. The abdominal eramps dtw to salt loss in heat exhaustion are an example of chemical alteration producing abdominal complaints. Miscellaneous
Many infectious diseases, particularly the childhood diseases, may begin with acute abdominal pain. Serum sickness may begin with severe abdominal pain. Tabetic crises and periteritis nodosa may also cause severe abdominal pain. Herpes zoster and black widow spider bite remain time-honored traps for the unwary. Iatrogenic causes for acute abdominal pain, particularly drugs, are continued sources of concern. The steroids, among the latter, are now an acknowledged even though poorly understood cause for ulceration in the gastrointestinal tract as well as masking agents occasionally of another lesion. In addition,
Acute Abdominal Emergencies
529
certain procedures such as vagotomy may alter the manifestations of intra-abdominal lesions which develop later. Finally, the diagnosis of acute abdominal emergencies in pediatric patients presents a special group of problems. The newborn may have an omphalocele, atresia, malrotation, meconium ileus, meconium peritonitis, imperforate anus or other anomalies. Intussusception, Meckel's diverticulum, appendicitis and mesenteric lymphadenitis are possible causes of acute abdominal pain in children. Worms may also cause acute distress and should be suspected if eosinophilia is found in the differential count. TREATMENT
Only brief reference has been made to treatment in the preceding discussion as, again, the details are too extensive for the space available. Several points, however, should be mentioned. The majority of patients presenting with an acute abdominal emergency will require immediate operation. A period of preparation for correction of fluid and electrolyte imbalance, to restore blood volume, to pass the nasogastric tube, to obtain basic laboratory tests, etc., is not only justifiable but necessary. Procrastination by indecision or for elaborate studies is usually indefensible, however. One is loath to advise operation without a reasonably accurate diagnosis but occasionally the only honest diagnosis that can be made is "the patient needs operation." In addition to those medical conditions which obviously do not require operation, there are certain surgical lesions in which delay may be advisable and others in which a certain amount of controversy still exists as to whether immediate or delayed operation is best. For example, the remarkable response of selected patients with appendiceal abscess to a nonoperative regimen is noteworthy. Another example is acute eholecystitis, particularly in the older age group, which may best be treated by delayed or interval operation. When nonoperative treatment iH elected in these diseases, however, one assumes the responsibility of following the patient almost hour by hour, as failure to improve or regression must be recognized promptly. SUMMARY
The numerous diseases which are the basis for acute abdominal emergencies have one fact in common: a lesion that causes typical manifestations can usually be identified or at least strongly suspected but the symptoms, the signs or the laboratory findings are so often atypical that diagnosis is less accurate than we might wish. Under these circumstances, operation may be necessary for diagnostic as well as
530
R. W.
POSTLETHWAIT,
M. L.
DILLON,
D. L.
STICKEL
therapeutic purposes. Generally, when operation is indicated, procrastination will be a disservice to the patient who has an acute abdominal emergency. Finally, elaborate diagnostic procedures may at times be required but, on the whole, a careful evaluation of symptoms and signs are the most important factors in proper care of the patient.
M. L. DILLON, M.D. Associate Professor of Surgery, Duke University; Assistant Ch'ieJ oJ Surgical Service, Durham Veterans Administration Hospital
D. L. STICKEL, M.D. Resident in Surgery, Duke University and Durham Veterans Administration Hospital
THE DIAGNOSIS AND TREATMENT of the patient with acute abdominal pain is one of the most interesting, and frequently most difficult, of all the problems in medicine. The number of diseases that may begin with acute abdominal pain is large and a comprehensive description of these lesions would require a huge volume. For this reason, only brief consideration can be given in this discussion to a few selected diseases. The classical symptoms and signs of acute peritonitis and of acute intestinal obstruction are so well known that further description is unnecessary. Massive gastrointestinal hemorrhage will be mentioned only briefly. One approach to the problem of acute abdominal pain has been a consideration by organs or systems, and this will be followed here.
Esophagus
Although hiatal hernia with esophagitis commonly causes epigastric pain, this is infrequently so acute and severe as to be considered in the category of the usual acute abdomen. Spontaneous rupture of the esophagus, however, may present almost entirely with acute abdominal symptoms and signs and, among the reported cases, a number, of the patients were operated upon with an erroneous diagnosis of perforated peptic ulcer. The presence of any objective findings of mediastinal or pleural involvement should direct attention to the esophagus .. The absence of intra-abdominal air and of rebound tenderness and the presence of rigidity out of proportion to the degree of tenderness should arouse suspicion. Other than these findings, spontaneous rupture of the esophagus may mimic perforated peptic ulcer in all manifestations.
52l
522
R. W.
POS'rLE'l'HWAI'f,
M. L.
DILLON,
D. L.
S'l'ICKEL
Stomach
In a general practice, acute gastroenteritis is undoubtedly the most common cause of acute abdominal pain. This may vary from a benign, self-limited disturbance to the serious staphylococcal food poisoning. Peptic ulcer, usually penetrating or perforated, is encountered more often in a hospital practice but frequently enough by the general physician. Diagnosis is not difficult when the classical symptoms and signs are present, which is usually the case, so that perforated ulcer is missed much less often than it is diagnosed erroneously. The past history may or may not suggest the presence of peptic ulcer. Sudden, severe epigastric pain, radiating soon into the right lower quadrant and then becoming generalized, and faintness without vomiting are the usual symptoms. The patient appears ill, prefers not to move, and breathes with short, quick gasps. The pulse is rapid and of diminished volume. The abdomeu moves little, tenderness may be maximal in the epigaHtrium and right lower quadrant, with marked rebound tenderness and muscle spasm. Liver dullness is frequently replaced by tympany, and peristalsis is absent. Fever, air under the diaphragm radiographically, and leukocytosis complete the picture of perforated ulcer. An interesting lesion that may present with a picture similar to perforated ulcer;.i,s acute alcoholic gastritis. The history may be confused. The patient may describe only the intake of alcohol and the acute onset of severe abdominal pain. Marked tenderness and muscle rigidity are impressive but rebound tenderness is minimal or absent and peristalsis may be increased. Leukocytosis is usually not present. With intra venom; fluids, improvement is rapid, which may be of some diagnostic importance. Liver Although the liver may slowly attain considerable enlargement without pain, the disorders that cause a rapid increase in size may produce marked abdominal pain. Cardiac decompensation, acute hepatitis and infectious mononucleosis are among the latter. Seldom, however, do these patients present as an acute abdominal emergency. Liver abscess and pylephlebitis are now rare in this country. An interesting catastrophe is the patient with acute massive intra-abdominal hemorrhage from a hepatoma of the liver. Metastatic tumor to the liver rarely exhibits this complication but hepatoma will occasionally present with hemorrhage as the initial manifestation. The stigmata of cirrhosis, the general signs of acute blood loss and the abdominal findings of intraperitoneal hemorrhage should suggest the possibility.
Gallbladder The incidence of disease of the gallbladder is so high that the acute exacerbations or complications constitute one of the most frequent
Acute Abdominal Emergencies
523
causes of acute abdominal emergencies. The seriousness varies from the patient with acute colic which rapidly subsides to the one with acute perforation which soon terminates fatally. When only the gallbladder is involved in the pathologic process, diagnosis usually is not difficult. Concomitant disturbances are frequently present, however, and alter the clinical picture. These include hepatitis, cholangitis, pancreatitis, lymphadenitis, and involvement of the extrahepatic ductal system. Common duct ohstruct.ion may further compound the diagnostic diffi!"ultieR. The average patient. will give a past history suggesting gallbladder disease, one of the most dependable symptoms in the elusive case being right upper quadrant soreness for a day or two after a bout of indigestion. A severe acute cholecystitis, however, may be the initial manifestation, particularly in the older age group. Typically, the right upper quadrant pain rapidly increases in severity, may radiate around the right costal margin and to the scapula, and is accompanied by nausea and vomiting. The signs of severe peritoneal irritation are usually fairly well localized to the right upper quadrant and the increase in tenderness with deep inspiration is noteworthy. The gallbladder will be felt in only about a fifth of the cases. Fever, tachycardia and leukocytosis are present. Clinical jaundice may not be evident but the bilirubin will almost always be elevated. A scout film of the abdomen may show stones. Perforation of the gallbladder most often is walled off by contiguous tissues or by fistula formation into a hollow viscus. Occasionally, perforation into the free peritoneal cavity occurs. The resulting acute chemical peritonitis is fulminating in its course. Beeause of the location of the perforation and of the drainage along the right colic gutter, an erroneous diagnosis of perforated peptic ulcer or appendicitis may be made. More seriously, the acute peritonitis may be thought to be due to pancreatitis and, if treated without operation, the diagnostic error will be unreeognized. Usually, earlier symptoms will focus attention on the gallbladder, but the free perforation may be the first diffieulty. Pancreas
Acute pancreatitis and the acute exacerbations of chronic pancreatitis present with severe pain, frequently radiating through to the back, nausea, vomiting, and signs of a severe peritonitis. In spite of the other lesions which have been found to increase the serum amylase, this test remains exceedingly helpful in confirming the diagnosis of acute pancreatitis. Peritoneal aspiration has been of value occasionally, as the amylase level of the aspirate may reach extremely high levels. Prompt relief of the pain by splanchnic nerve block has some diagnostic value, as well as very definite therapeutic benefit. At times the diagnosis of acute pancreatitis must be presumptive on the basis of excluding other lesions. The necessity for following these patients carefully is obvious.
524
R. W.
POSTLETHWAIT,
M. L.
DILLON, D.
L.
STICKEL
Blunt trauma to the abdomen producing laceration of the pancreas will be practically impossible to diagnose with confidence preoperatively. Occasionally, the trauma apparently causes a small laceration so that the initial symptoms are not severe. Later a pseudocyst forms, the latter being slow in its development, but at times producing acute abdominal symptoms. The history of trauma, the presence of a mass, and the displacement of neighboring structures should suggest the presence of a pseudocyst. Carcinoma of the head of the pancreas is nearly always insidious in onRet, hut may first cause acute, severe, right upper quadrant. pain. Malignan~.v in t.he hody or tail ~ommonly causes pain hut not often acut.ely. Spleen
Such unusual disturbances as twisted splenic pedicle and spontaneous rupture of an enlarged spleen have been recorded. Splenic infarction is not infrequent, particularly accompanying subacute bacterial endo~ar ditis, and the pain and peritoneal irritation may be severe enough to overshadow other lesions. Surgically, a frequent pitfall for the unwary is delayed hemorrhage from a ruptured spleen. The trauma may be seemingly minor and so be overlooked, either by patient or physician. The secondary hemorrhage usually occurs within two weeks, but may be delayed considerably longer. Sudden abdominal pain, either localized or generalized, with or without radiation to the left shoulder, will he accompanied by the symptoms and signs of hemorrhage. Elevation of the left hemidiaphragm, tenderness and a mass in the left upper quadrant, signs of peritoneal irritation, and fixed dullness on the left with shifting dullness on the right point to rupture of the spleen. The typical displacement of the stomach with serrations along the greater curvature seen radiographically is of great value in diagnosis. Peritoneal aspiration will also be of aid. Unfortunately, such helpful signs as flank or umbilical discoloration due to extraperitoneal blood are not often present. Small Bowel
The small bowel is infrequently involved in disorders producing an acute abdominal emergency but the lesions which do occur include Meckel's diverticulum, regional ileitis, intussusception, solitary ulcer, internal hernia, malrotation, and obstruction due to various types of bands, adhesions, benign and malignant tumors. One of the most difficult lesions to diagnose is perforation of the small bowel by a foreign body. Ingestion of an object such as a fish bone, pin or toothpick may pass unnoticed or be forgotten by the patient. A diagnosis only of perforated viscus may be possible prior to operation. Small bowel obstruction, due most commonly to adhesions or hernia, may be emphasized on several points. The mortality rises sharply when
Acute Abdominal Emergencies
525
a loop of bowel progresses to gangrene. No clear picture of imminent gangrene appears ; the only effective measure in the prevention of gangrene is early diagnosis and early operation. Despite the usefulness and effectiveness of adjunctive measures consisting of intravenous fluids, long intestinal tubes and (in those with a gangrenous loop) antibiotics, early surgery is the mandatory treatment. The only important exception is the patient with obstruction due to fibrinous adhesions in the early postoperative period. Finally, early surgery is especially important in the elderly who tolerate nutritional, water and electrolyte disturbances and gangrene especially poorly. Appendix
The problems of the diagnosis of acute appendicitis are so well known that further comment would be superfluous. Most of the lesions that cause an acute surgical abdomen have been mistaken for appendicitis, and the reverse is also true. Although administrators and tissue review boards frown when a pathologic diagnosis of normal appendix is made after an emergency appendectomy, diagnostic acumen is still such that about 25 per cent of these appendices will (and should) be normal. If one must give favorite symptoms and signs in the diagnosis of acute appendicitis, several may be suggested with the understanding that these are not infallible. Minimal peritoneal irritation may be described by the patient more easily than elicited by palpation. Sudden momentary pain on stepping down a stair, with cough, or a similar quick or jarring motion may be helpful. Anorexia is rarely absent. Point tenderness is of positive importance and the presence of palpable gas in the cecum usually indicates the absence of appendicitis. Rectal tenderness on the right is obviously of aid in diagnosis. The white cell count may be of interest but has assumed a significance far beyond its value. An inflamed appendix in the retrocecal region may give minimal or no signs in the anterior abdominal wall. One lesion that mimics acute appendicitis almost routinely is acute mesenteric lymphadenitis. In our opinion, acute mesenteric lymphadenitis is an operative diagnosis. Except in the patient who has had an appendectomy, a clinical diagnosis of acute mesenteric lymphadenitis is the equivalent of a diagnosis of acute appendicitis and prompt operation is accordingly indicated. Statistically, in large groups of cases, certain differences are evident, such as the intermittent colicky pain and the extension of the tenderness along the course of the root of the mesentery. In the individual patient, however, these differences lose their value. Colon
Diverticulitis and carcinoma are the lesions most frequently responsible for an acute abdominal emergency on the basis of colon disease.
526
R. W.
POSTLETHWAIT,
M. L.
DILLON, D.
L.
STICKEL
Diverticulitis is usually fairly typical although proof short of operation may be difficult. Of those patients with diverticula of the colon, approximately 15 per cent of those who become symptomatic do so by bleeding. This is seldom minor but usually a fairly massive hemorrhage. While the bleeding usually ceases spontaneously, emergency operation may be necessary. Carcinoma may perforate or intussuscept but more often, and usually in the sigmoid, will be the source of acute intestinal obstruction. These patients may have few or no antecedent symptoms; then develop complete obstruction in a matter of a few hours. Edema, perforation, impaction and ileus in the proximal colon are possible causes. A closed loop type obstruction is produced, however, and the patient may rapidly progress from a relatively normal state into the acute obstruction, then into shock soon followed by circulatory collapse and death. Time should not be wasted by attempts to intubate down through the small bowel, as this will seldom be successful. After a brief period of preparation, colostomy or cecostomy should be performed. Chronic ulcerative colitis may become an emergency situation because of hemorrhage, perforation, obstruction or an acute fulminating exacerbation. The diagnosis is seldom difficult but it should be remembered that carcinoma occurs with greater frequency in chronic ulcerative colitis and may be the cause of the hemorrhage or obstruction. An interesting complication of ulcerative colitis, termed impending perforation, may present as an acute abdomen and is at least an urgent indication for operation. An acutely involved segment of the affected colon (sigmoid in our cases) is the source of marked local signs of peritoneal irritation and the segment appears and remains distended on radiographic examination. One lesion which causes considerable diagnostic difficulty, even at operation, is a perforated diverticulum of the cecum. This may be solitary or one of many. The perforation is usually walled off. The mass preoperatively is indistinguishable from appendiceal abscess or perforated carcinoma. At operation, the normal appendix will be evident and an erroneous diagnosis of carcinoma may lead to immediate right colon resection. Heart and Lung
These patients come to the attention of the surgeon infrequently, but a mistaken diagnosis followed by laparotomy obviously may have serious consequences. Myocardial infarction, acute congestive heart failure, acute rheumatic fever and acute pericarditis are four disorders that may present primarily because of acute abdominal pain. Pneumonia, pleurisy and pulmonary embolism may have a similar onset. The history, the presence of abnormal physical findings in the heart or lungs, the
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lack of or the atypical abdominal signs, and the aid provided by radiologic, electrocardiographic and laboratory examinations will almost invariably identify the underlying cause of the pain. Vascular
With the development of vascular surgery, rupture of an abdominal aortic aneurysm need not be invariably fatal. The aneurysm per se may be asymptomatic although the typical pulsatile mass will be palpable and frequently the walls outlined by calcium on the x-ray film of the abdomen. Fortunately, rupture often causes limited, even though appreciable, hemorrhage which acts as a warning. This produces acute abdominal pain, usually radiating into the back. Other symptoms may appear dependent upon involvement of the intra-abdominal organs or peripheral vessels. The patient or his physician may note a mass for the first time, or the known abdominal mass may rapidly enlarge. Operation should not be delayed, for massive hemorrhage and death almost invariably follow the first bleeding. Dissecting aneurysm most frequently is manifested by thoracic symptoms and signs, but the dissection may produce primarily abdominal symptoms. Low back and abdominal pain are present, with signs of vascular insufficiency in the legs. Other intra-abdominal manifestations will be dependent on the vessels and structures involved by the dissection. Aortography may be necessary for diagnosis and should be performed in view of the increasingly favorable results from operation. Mesenteric thrombosis has long been a well recognized acute abdominal catastrophe but its frequent predecessor, abdominal angina, is less well known. Although abdominal angina will seldom present as an acute abdominal emergency, the characteristic symptoms of postprandial pain, constipation and weight loss should be noted here. In addition, it is conceivable that the arteriosclerotic plaques in the celiac and superior mesentery arteries may occasionally be the source of emboli. Occlusion of a smaller mesenteric vessel by the embolus might account for some of the unexplained solitary ulcers or areas of gangrene in the .small or large bowel which are occasionally seen. Certainly such emboli from arteriosclerotic plaques in the aorta or iliac vessels have obstructed the popliteal or tibial arteries. Gynecologic and Urologic
The pelvic organs of the female provide a fertile area for the development of lesions which will cause an acute abdominal emergency. Mittelschmerz is undoubtedly the most common of these and can usually be identified by the relationship of the illness to the menstrual cycle, the pelvic location of the pain and tenderness, and the absence of systemic manifestations. Unfortunately, however, a teaspoonful of blood from
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the ruptured follicle may produce all the symptoms and signs of an acute appendicitis. Only an operative diagnosis can then be made. Acute salpingitis, ruptured ectopic pregnancy, and twisted ovarian cyst pedicle are causes of acute abdominal pain which in their typical form may cause little difficulty in diagnosis. The atypical group obviously requires careful inquiry into the menstrual history and evaluation of the pelvic examination. Endometriosis similarly may present in typical form but may produce variable symptoms, ranging from acute peritonitis due to rupture of an endometrial cyst to intestinal obstruction caused by involvement of the bowel in the pathologic process. The urinary tract is subject to stone, infection, retention, obstruction, tumor and trauma and may be the basis for an acute abdominal emergency. As noted for the gynecologic lesions, the patients with genitourinary system involvement whose manifestations are typical should not cause great difficulty in diagnosis. The endoscopic and radiographic techniques in the hands of the urologists permit remarkably accurate identification and localization of the disorder. Hematopoietic and Metabolic
Little more than listing of these diseases is possible. Sickle cell anemia is the outstanding example of a disease of the blood in which acute abdominal pain may be impossible to differentiate from a common lesion such as appendicitis, particularly when this occurs in very young children. The various types of poisoning or intoxication are probably best represented by lead colic as the cause of acute abdominal pain. Retroperitoneal lymph node involvement by lymphosarcoma or Hodgkin's disease may cause acute pain. Abdominal Hodgkin's disease may cause acute abdominal pain, particularly if the patient partakes of alcohol. Acute idiopathic hyperlipemia and acute porphyria also may produce severe abdominal distress. : Diabetes and thyrotoxicosis may have severe abdominal complaints as a part of the symptomatology. The abdominal eramps dtw to salt loss in heat exhaustion are an example of chemical alteration producing abdominal complaints. Miscellaneous
Many infectious diseases, particularly the childhood diseases, may begin with acute abdominal pain. Serum sickness may begin with severe abdominal pain. Tabetic crises and periteritis nodosa may also cause severe abdominal pain. Herpes zoster and black widow spider bite remain time-honored traps for the unwary. Iatrogenic causes for acute abdominal pain, particularly drugs, are continued sources of concern. The steroids, among the latter, are now an acknowledged even though poorly understood cause for ulceration in the gastrointestinal tract as well as masking agents occasionally of another lesion. In addition,
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certain procedures such as vagotomy may alter the manifestations of intra-abdominal lesions which develop later. Finally, the diagnosis of acute abdominal emergencies in pediatric patients presents a special group of problems. The newborn may have an omphalocele, atresia, malrotation, meconium ileus, meconium peritonitis, imperforate anus or other anomalies. Intussusception, Meckel's diverticulum, appendicitis and mesenteric lymphadenitis are possible causes of acute abdominal pain in children. Worms may also cause acute distress and should be suspected if eosinophilia is found in the differential count. TREATMENT
Only brief reference has been made to treatment in the preceding discussion as, again, the details are too extensive for the space available. Several points, however, should be mentioned. The majority of patients presenting with an acute abdominal emergency will require immediate operation. A period of preparation for correction of fluid and electrolyte imbalance, to restore blood volume, to pass the nasogastric tube, to obtain basic laboratory tests, etc., is not only justifiable but necessary. Procrastination by indecision or for elaborate studies is usually indefensible, however. One is loath to advise operation without a reasonably accurate diagnosis but occasionally the only honest diagnosis that can be made is "the patient needs operation." In addition to those medical conditions which obviously do not require operation, there are certain surgical lesions in which delay may be advisable and others in which a certain amount of controversy still exists as to whether immediate or delayed operation is best. For example, the remarkable response of selected patients with appendiceal abscess to a nonoperative regimen is noteworthy. Another example is acute eholecystitis, particularly in the older age group, which may best be treated by delayed or interval operation. When nonoperative treatment iH elected in these diseases, however, one assumes the responsibility of following the patient almost hour by hour, as failure to improve or regression must be recognized promptly. SUMMARY
The numerous diseases which are the basis for acute abdominal emergencies have one fact in common: a lesion that causes typical manifestations can usually be identified or at least strongly suspected but the symptoms, the signs or the laboratory findings are so often atypical that diagnosis is less accurate than we might wish. Under these circumstances, operation may be necessary for diagnostic as well as
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therapeutic purposes. Generally, when operation is indicated, procrastination will be a disservice to the patient who has an acute abdominal emergency. Finally, elaborate diagnostic procedures may at times be required but, on the whole, a careful evaluation of symptoms and signs are the most important factors in proper care of the patient.