Chapter 13

The correct interpretation of acute abdominal pain is challenging. Few other clinical situations demand greater judgment, because the most catastrophic of events may be forecast by the subtlest of symptoms and signs. A meticulously executed, detailed history and physical examination are of the greatest importance. The etiologic classification in Table 13-1, although not complete, forms a useful basis for the evaluation of patients with abdominal pain.

Table 13-1 Some Important Causes of Abdominal Pain

The diagnosis of “acute or surgical abdomen” is not an acceptable one because of its often misleading and erroneous connotation. The most obvious of “acute abdomens” may not require operative intervention, and the mildest of abdominal pains may herald an urgently correctable lesion. Any patient with abdominal pain of recent onset requires early and thorough evaluation and accurate diagnosis.

### Some Mechanisms of Pain Originating in the Abdomen

#### Inflammation of the Parietal Peritoneum

The pain of parietal peritoneal inflammation is steady and aching in character and is located directly over the inflamed area, its exact reference being possible because it is transmitted by somatic nerves supplying the parietal peritoneum. The intensity of the pain is dependent on the type and amount of material to which the peritoneal surfaces are exposed in a given time period. For example, the sudden release into the peritoneal cavity of a small quantity of sterile acid gastric juice causes much more pain than the same amount of grossly contaminated neutral feces. Enzymatically active pancreatic juice incites more pain and inflammation than does the same amount of sterile bile containing no potent enzymes. Blood and urine are often so bland as to go undetected if their contact with the peritoneum has ...

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