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ESSENTIAL CONCEPTS

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ESSENTIAL CONCEPTS

  • The diagnosis and management of acute abdominal pain have improved with advances in clinical decision making and imaging but can be influenced by race.

  • Acute abdominal pain may present atypically in the elderly, immunosuppression, pregnancy, or narcotic use.

  • Nonsurgical causes of acute abdominal pain simulating an acute abdomen account for up to 30% of patients requiring hospital admission.

  • Irritable bowel syndrome, functional abdominal pain syndrome, and opiate-induced bowel disease may confound accurate diagnosis and are associated with unnecessary admission, negative appendectomy, and excessive testing.

  • Sexual or physical abuse should always be considered in patients with recurrent unexplained abdominal pain, regardless of the patient’s age or gender.

  • The reduction of cumulative ionizing radiation, particularly in inflammatory bowel disease (IBD), remains a priority.

  • Multidetector-row computed tomography (MDCT) is the benchmark imaging modality in the evaluation of acute abdominal pain except in women fewer than 25 weeks’ pregnant.

  • Ultrasound is readily available, transportable, and has no ionizing radiation but it is relatively insensitive with obesity, intrinsic bowel or retroperitoneal disease, and yields few secondary findings.

  • Magnetic resonance imaging (MRI) remains ideal for assessing bowel wall inflammation and has no ionizing radiation, but remains difficult to interpret, cumbersome and threefold more expensive than MDCT. Gadolinium may not be used before the 25th week of pregnancy.

  • Right upper quadrant (RUQ) pain, with or without abnormal liver function tests (LFT), is best assessed by ultrasound and MRI. The choice should be based on patient’s clinical status, instrument availability, and institutional expertise.

  • Always perform preoperative imaging in acute appendicitis.

  • Narcotic pain medication will not obscure the recognition of key physical findings and may improve diagnostic accuracy by relaxing the patient; it should not be withheld from a patient with abdominal pain.

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General Considerations

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Acute abdominal pain is defined as severe pain of more than 6 hours’ duration in a previously healthy person that requires timely diagnosis and aggressive treatment, frequently surgical.

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This chapter focuses on the basic principles and challenges in the evaluation and diagnosis of acute, nontraumatic abdominal pain in the adult patient. Emphasis is placed on recent advances in the medical literature and the appropriate tools currently available for improving diagnostic accuracy. The patient with acute abdominal pain remains a clinical challenge for every gastroenterologist. Successful management must always begin with the physician’s clear understanding of the anatomy and physiology of gastrointestinal pain and a commitment to an independent and thorough medical history and physical examination of each patient. Clinical scoring systems can be helpful in determining and measuring disease severity and guiding further evaluation, particularly in acute pancreatitis and IBD. An understanding of the appropriate application of current imaging technologies is essential. The clinician should be conditioned to seek the advice of colleagues, to “think outside of the box” and consider the atypical presentation of common nongastrointestinal and extra-abdominal disorders.

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Acute Appendicitis is an ideal example of how the general ...

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