ABDOMEN- QUADRANTS

ABDOMEN- O R G A N S
ABDOMINAL PAIN- C AUS ES
 ABDOMINAL PAIN- C AUS ES

 Inflammation of a viscus
 Perforation of a viscus
 Obstruction of a viscus
 Infarction of a viscus
 Intra-abdominal hemorrhage or retroperitoneal hemorrhage
 Extra-abdominal or medical causes for acute abdominal pain
like lower lobe
 Pneumonia and inferior wall M I
ABDOMINAL PAIN- HISTORY PAIN
ABDOMINAL

SOCRATES
 “S” stands for “site”. Which region/quadrant?
 “O” stands for “onset”. When did the pain start? Acute or insidious?
 “C ” stands for “characteristics”. The pain may be sharp, dull, heavy, etc. or a
combination of descriptions.
 “R”, which represents “radiation”. Ask if the pain stays at the site they are
describing or if it travels somewhere else in the body. Ex:Ureteric colic
 A” stands for associated symptoms. What other symptoms are present and
associated with the pain? Ask do they also have nausea and/or vomiting?
 "T" stands for ti ming. When does the pain occur? Does it happen at specific
times of the day, or is it constant?
 “E” represents “exacerbating” factors; grouped within this is also alleviati ng factors.
The pati ent should be probed as to what makes their pain better or worse. Certain
physical positions, medications, etc. These factors can all provide historical clues
about the root cause.
 “S” stands for “severity”. In most hospitals this is formulated on a 1 to 10 scale
with 10 being the most severe pain they’ve ever experienced.
 ABDOMINAL PAIN

 Visceral pain:
 Somati c pain:
 Originate from internal organs
 Originate from abdominal wall
and visceral peritoneum
and parietal peritoneum
 Achy and crampy
 Sharper and more distinct
 Bett er localized  Variable localization and
sensation
 Sensiti ve to cutti ng,tearing,
 Not sensitive to cutti ng,
burning and crushing
tearing,
burning or crushing
 Sensiti ve to stretching of walls of
hollow organs and capsule of solid
organs
 ABDOMINAL PAIN

 Shift ing pain: E x : Periumbilical pain shift ing to R L Q in

[Link] s
 Radiati ng pain: E x : Pain radiati ng from loin to groin in ureteric colic
 Reffered pain: E x : Pain felt at L t shoulder in case of splenic rupture

G rad in g
 I t is done by comparing a10cm line numbered 0 to 10 and this is called Visual
Analogue Scale- V A S
 Minimum 0 means no pain
 2 is mild pain
 4 is discomforting pain
 6 is distressing pain
 8 is intense pain
 ABDOMINAL PAIN-RLQ PAIN
A 28-year-old female presents with a 2-day hx of vague periumbilical
pain. Today the patient has lower abdominal pain (right greater than left), which is associated
with new onset of urinary frequency. She also vomited twice today. She is sexually active and her
menstrual cycle tends to be irregular. Her last menstrual period was 6 weeks ago (2 weeks late).

VS: T = 100.2, HR = 90, BP = 110/68.

Labs: H/H = 12.0/36.3, WBC = 11,300, U/A: 5 RBCs, 10–15 WBCs

Physical examination: RLQ tenderness, guarding, and

rebound. Pelvic examination without cervical motion
tenderness

What would be your differential dx and plan for further

evaluation?
RLQ PAIN-Differential Diagnosis

D/D in Adult males

RLQ PAIN-Differential Diagnosis

D/D in Females

D/D in Children
 ABDOMINAL PAIN-RLQ PAIN

 This patient has the characteristic prodrome for appendicitis with periumbilical pain
migrating to the RLQ and associated with localized peritoneal findings.
 Check the β-hCG before proceeding with appendectomy particularly in light of the patient’s
delayed menstrual period. Ectopic pregnancy must be r/o.
 The abnormal U/A result may relate to bladder irritation from an inflamed appendix or
represent the additional problem of a UTI.
 Though the clinical picture is most consistent with appendicitis, preoperative USG/CT Abd
should be done if the β-hCG is normal.
 Diagnostic Priorities: Ac Appendicitis, R/O UTI and ectopic pregnancy.
 RLQ PAIN-Ac. Appendicitis
 History- Symptoms
 • Anorexia (hamburger sign), nausea, vomiting
 • Vague periumbilical pain that shifts to the RLQ- “ Murphy’s Triad”
 Physical Exam- Signs
 • McBurney’s point tenderness and rebound tenderness
 • Cutaneous hyperesthesia, Rovsing’s, psoas, and obturator signs
 Laboratory
 • Elevated WBC with left shift
 • C-reactive protein
 • Pregnancy test
 • Urinalysis: sterile pyuria
 Diagnosis
 • Often times is a clinical diagnosis
 Pathophysiology
 • Closed-loop obstruction
 • Fecolith in adults, lymphoid hyperplasia in children
 Imaging
 • None needed with classic H&P and leukocytosis
 • US: women and children
 • Avoid CT in children (increased risk of malignancy) and pregnancy (risk to fetus)
 • CT: if diagnosis is equivocal in men and nonpregnant women
 • MRI: pregnant women
 Management
 • Appendicectomy (open or laparoscopic)
RLQ PAIN-Ac. Appendicitis

 USG Abdomen:
 Tubular structure
 More than 6mm in diameter
 Non compressible

CT Abdomen: Thickened
appendix, Fecolith, Fat
stranding
 ABDOMINAL PAIN-RUQ PAIN
HISTORY:
A 40-year-old moderately obese female presents to the emergency department with a 1-day history of
constant epigastric and right upper quadrant (RUQ) pain. She describes the severity of the pain as a 7
out of 10. The pain began after eating fried pork. She reports that the pain also seems to affect the
right side of her back near her scapula. She feels nauseated and has vomited twice. She has had
similar pain, but of lesser severity, about once a month for the past year. The pain comes on after
eating fried or spicy foods, but previously it has resolved after an hour. She is gravida six and para six.
On physical examination, her temperature is 100 °F, heart rate is 110/min, and her blood pressure is
120/80 mmHg. She has marked tenderness in the RUQ of the abdomen to palpation. When the RUQ
is palpated while she is taking a deep breath, she abruptly ceases inspiration secondary to pain
Murphy’s Sign+ve

Laboratory values are significant for WBC count of 14 × 10 3 /μL (normal 4.1–10.9 × 10 3 /μL),
Total Bilirubin 1.0 mg/dL (0.1–1.2
mg/dl), Alkaline phosphatase70
units/L (33–131 u/L),
Amylase 60 units/L (30–110 u/L),
and Lipase 30 units/L (7–60 u/L).

What would be your differential dx

RUQ PAIN-Differential Diagnosis
 ABDOMINAL PAIN-RUQ PAIN

 With her current history of severe persistent abdominal pain following ingestion of fatty foods,
nausea and vomiting, and associated right upper quadrant tenderness to palpation, the etiology
is most likely of biliary origin.
 The patient’s prior history is consistent with symptomatic cholelithiasis
 With a positive Murphy’s sign, fever, tachycardia, and elevated WBC count, the most likely
current diagnosis is acute cholecystitis.
 With a normal total bilirubin and alkaline phosphatase, choledocholithiasis and acute
cholangitis are less likely.
 Similarly, a normal amylase and lipase rule out gallstone pancreatitis.
 RUQ PAIN-Ac. Cholecystitis
 History
 • RUQ pain in obese, multiparous female
 Physical Exam
 • Murphy’s sign for acute cholecystitis
 Pathology/Pathophysiology
 • Acute cholecystitis triggered by persistent cystic duct obstruction by gallstone
 Diagnosis
 • RUQ US: gallstones, pericholecystic fluid, thickened gallbladder wall, and sonographic
Murphy’s sign
 • HIDA scan if RUQ ultrasound is nondiagnostic
 • KUB not helpful: only 10 % of gallstones are radio-opaque
RUQ PAIN-Ac. Cholecystitis

Manifestations of Gall Stones

RUQ PAIN-Ac. Cholecystitis

Biliary Colic Vs Ac Cholecystitis

 RUQ PAIN-Ac. Cholecystitis
 Management
 • Asymptomatic gallstones: cholecystectomy not indicated
 • Symptomatic cholelithiasis (biliary colic): elective lap cholecystectomy
 • Acute cholecystitis: urgent (within 48 h) lap cholecystectomy
 • Acute acalculous cholecystitis: cholecystostomy tube if critically ill
 • Emphysematous cholecystitis: emergent cholecystectomy
 • Gallstone ileus: remove large impacted gallstone from terminal ileum (leave gallbladder alone)
 Postoperative
 • If a patient presents within the first week after cholecystectomy with abdominal pain, distention,
and anorexia, consider a biloma (cystic duct stump leak, CBD injury)
 • Cystic duct stump leak readily treated with ERCP and stenting of the sphincter of Oddi
 • CBD injury may require hepaticojejunostomy/choledochojejunostomy
 Additional Important Facts
 • Ursodeoxycholic acid could be employed as conservative management for patients with
cholelithiasis
 • Calcified gallbladder (porcelain): increased risk of malignancy, perform cholecystectomy
 • Choledochal cysts are congenital dilations of the biliary tree; prone to cholangitis, risk of associated
malignancy, need to excise (if intrahepatic ducts are involved (Caroli’s disease), and may need liver
transplantation
 • Hemolytic anemia in childhood: high risk of black pigment gallstones
 • Gallbladder cancer: associated with gallstones
 • Gallbladder polyps: > 1 cm suspicious for cancer; >2 cm high likelihood of cancer
RUQ PAIN-Ac. Cholecystitis

 Cholesterol gallstones form

when the concentration of
cholesterol in the bile exceeds
its solubility

 Black stones are often

associated with hemolytic
disease

 Brown stones usually are “Gall Stone is the

associated with bacterial
infection and parasites tombstone erected
in the memory of
dead bacteria
inside”
RUQ PAIN-Ac. Cholecystitis

USG Abdomen:
Hyperechoic Gall stone shadow
Posterior acoustic shadowing
GB wall thickness > 3mms
Pericholecystic fluid collection

HIDA Scan:
Fig 1: Visualisation of GB Fig
2: Non visualization of GB-
Acute Cholecystitis
 ABDOMINAL PAIN-RUQ PAIN

HISTORY:
A 40-year-old female presents with a 24 hour history of right upper quadrant (RUQ) and
epigastric pain, associated with nausea and vomiting. She has had similar pain in the past,
particularly after eating greasy foods. According to her family, over the last few hours, the
patient has become slightly confused. Past medical history is negative.

PHYSICAL EXAM:
Temperature of 102.5 °F, a heart rate of 110 beats/min, respiratory rate of 16/min, and a blood
pressure of 90/60mmHg. She is moderately tender in the RUQ to deep palpation. She has slight
scleral icterus. She has noted dark- colored Urine. The remainder of her abdominal exam is negative.

Laboratory Values:
White blood count of 15 × 10 3 /μL (normal 4.1–10.9 × 10 3 /μL), Total bilirubin of 4.0 mg/dl (0.1–
1.2 mg/dl),
Alkaline phosphatase (AP) of 350 μ/L (33–131 μ/L), Aspartate aminotransferase (AST) of
300 μ/L (5–35 μ/L) Alanine aminotransferase (ALT) of 280 μ/L (7–56 μ/L),
Gamma-glutamyl transpeptidase (GGT) of 330 μ/L (8–88 μ/L), Amylase of 100 μ/L (30–110 μ/L).
Urine is positive for bilirubin.

What would be your differential dx and plan for further evaluation?

RUQ PAIN-Differential Diagnosis
 ABDOMINAL PAIN-RUQ PAIN

 The most likely diagnosis in a patient with a 1-day history of RUQ pain worsened with
greasy foods, nausea, jaundice, and fever is acute cholangitis secondary to gallstone
impaction Charcot’s Triad

 Additionally, she has leukocytosis, hypotension, altered mental status, elevated bilirubin, and
deranged liver function tests, all of which are consistent with the suppurative cholangitis
Reynold’s Pentad

 The Tokyo guidelines have been proposed as diagnostic criteria for acute cholangitis. Patients
should have evidence of systemic inflammation (fever and/or leukocytosis), cholestasis
(jaundice and/or abnormal liver enzymes), and biliary obstruction (dilated bile ducts on
ultrasound).
 RUQ PAIN-Ascending Cholangitis

History and Physical

• Charcot’s triad RUQ pain, fever and jaundice
• Reynold’s pentad + hypotension and altered mental status
• Look for evidence of SIRS
• Elderly patients may be hypothermic and leukopenic (are relatively immunosuppressed)

Etiology/Pathophysiology
• Biliary obstruction with bacterial infection
•Bacteria enter bile either via bloodstream from the portal vein or retrograde from the
duodenum
• Most commonly caused by gallstone obstruction of the distal CBD
• Other causes: biliary stricture, cancer, parasites
• Suppurative cholangitis: acute cholangitis complicated by septic shock
 RUQ PAIN-Ascending Cholangitis

Diagnosis
• Elevated WBC
• AP, ALT, AST, GGT rise proportion
• Aggressive IV fluids, blood cultures, broad-spectrum antibiotics
• Admit to ICU
• Urgent biliary decompression via ERCP
• PTC if ERCP fails PTBD
• Open surgery (insert T-tube into CBD) if PTC fails
•Cholecystectomy after sepsis resolves to prevent further biliary complications
Watch Out
•The diagnosis of acute cholangitis may be missed in the elderly and immunosuppressed (e.g.
steroids)
• Think sclerosing cholangitis if also having symptoms of IBD
 RUQ PAIN-Ascending Cholangitis

ERCP- Stone Extraction

ERCP PTBD

PTBD

ERCP- Stent Placement

EU
 ABDOMINAL PAIN-EPIGASTRIC
H I S T O R Y: PAIN
A 56-year-old male with a history of gastroesophageal refl ux disease (GERD),
hypertension, and diabetes presents to the emergency room complaining of severe upper
central abdominal pain. The pati ent reports epigastric pain for months, but it has just
acutely become intolerable over the last 8 hrs. H e states that the chronic pain has been a
“gnawing” pain that comes on aft er eati ng. H e thought he was just having some
indigestion and would take some antacids for relief. Late last night, the pain became
excruciating and now he is having trouble moving.
O n physical examinati on, blood pressure is 130/70 mmHg , heart rate is 110
bpm, and temperature is 101.5 ° F. H e appears to be in severe distress
secondary to pain. The pati ent refuses to straighten his legs because it hurts too much.
H e almost jumps off of the table when you press on his abdomen. H e has diffuse
guarding and rebound tenderness.

Laboratory values: W B C of 15 (normal 4.1–10.9 × 10 3 /μL), B U N of 35 (7–20

mg/dL), creatinine of 1.8 (0.5–1.4 mg/dL), serum amylase of 70 (30–110 μ/L), and
lipase of 60 (7–60 u/L).
An upright C X R demonstrates free air under the right diaphragm.
What would be your differential dx and plan for further evaluation?
 Epigastric Pain- Differential Diagnosis

 Biliary causes:
 Cholelithiasis, cholecystitis, and cholangitis

 Cardiac causes:
 Myocardial infarction, or pericarditis

 GI causes:
 Esophagitis, functional dyspepsia, GERD, peptic ulcer, gastritis
 Gastric outlet obstruction, or malignancy
 Early appendicitis could be a colonic cause
 Pancreatic causes – mass or pancreatitis

 Vascular causes:
 Aortic aneurysm, or mesenteric ischemia

 Other: herpes zoster, muscle strain, hernia, pneumonia

 ABDOMINAL PAIN-Epigastric Pain
 The free air under the diaphragm indicates that the pati ent has a perforated
viscus.
 This is supported by evidence of diffuse peritonitis on physical exam.
 The most common causes of free air under the diaphragm are perforated ulcers and
perforated diverticulitis.
 Given the longstanding history of epigastric pain relieved by antacids, the most likely
diagnosis is a perforated ulcer
 History and Physical:
 Sudden onset severe epigastric pain that becomes diffuse
 History of peptic ulcer disease (PUD), H . pylori, smoking, chronic N S A I D use
 Evidence of S I R S
 Pati ent lying motionless in bed
 Abdominal guarding, rigidity, and rebound tenderness
 Pathophysiology:
 Acid hypersecretion, defective mucosal defense or [Link] infection
 Five types of gastric ulcers- Modified Johnson’s classification
 Type I ulcers are on the lesser curve of the stomach
 Type I I ulcers are in the stomach and duodenum
 Type I I I ulcers are pre-pyloric
 Type I V ulcers are located proximally near the cardia
 Type V ulcers are anywhere secondary to N S A I D use
 Epigastric Pain- DU perforation
 Workup:
 Leukocytosis with left shift
 Upright C X R : free air under diaphragm
 C T with oral gastrografi n
 Management:
 Duodenal perforation
 – Primary closure with an omental patch
 Gastric perforation
 – Primary closure, biopsy, omental patch vs. wedge resection
 – Must rule out malignancy
 Triple therapy: clarithromycin, amoxicillin, and a P P I for 14 days (if H . pylori positive)
 Additi onal acid reduction surgery rarely needed
 Epigastric Pain- DU perforation
Pneumoperitoneum DU Perforation Graham’s Patch- Omentopexy
 ABDOMINAL PAIN-Epigastric Pain
ABDOMINAL PAIN-Epigastric Pain
H I S T O R Y:
A 41-year-old woman presents to the emergency department complaining of severe and
continuous epigastric pain for the past 24 hours. The pain radiates straight through to her
back. She has had progressive nausea with vomiting. The vomitus is bile stained without
blood. She has had similar but less severe episodes in the past, usually aft er eati ng heavy
meals, but they always resolved within a few hours. She is married, with two children,
and does not consume any alcohol.
PHYSICAL EXAM:
O n exam, she is afebrile, heart rate is 115/min, blood pressure is 128/86 m m Hg , and she
has a normal respiratory rate. Her abdomen is not distended. She has no surgical scars
on her abdomen and no obvious masses visible. She has no bruising around her
umbilicus or along her fl ank. Bowel sounds are hypoactive. She has marked tenderness
to palpation in her epigastrium, without guarding or rebound.
The remainder of her abdomen is soft and non-tender to palpati on. No masses or
organomegaly are appreciated.
 ABDOMINAL PAIN-Epigastric Pain
ABDOMINAL PAIN-
Laboratory Values:
Epigastric Pain
W B C count of 17.2 × 10 3 cells/μL (normal 4.1–10.9 × 10 3 cells/uL),
Amylase of 1,545 u/L (normal 30–110 u/L),
Lipase of 1,134 u/L (normal 7–60 u/L),
A LT of 245 u/L (7–56 u/L), A S T of 263 u/L (5–35 u/L),
Serum glucose of 156 mg/dl (65–110 mg/dL), and L D H 180 u/L (0–250 u/L)

A n abdominal series demonstrates gas throughout the small and large bowel, and a
focal dilated loop of proximal small bowel without air fl uid levels- sentinel loop++. There
is no free air under the diaphragm.

What would be your differential dx and plan for further evaluation?

 ABDOMINAL PAIN-Epigastric Pain
ABDOMINAL PAIN-Epigastric Pain
 Diagnosis most probably Acute Pancreati ti s
 This pati ent has the classic presentation which consists of epigastric abdominal pain
radiati ng straight through to the back with nausea and vomiti ng.
 She has had prior episodes of pain, which have resolved within a few hours, aft er
eati ng heavy meals, which is characteristic of symptomatic gallstones.
 Since the vast majority of pancreatitis cases are due to gallstones or alcohol and
this pati ent does not consume alcohol, we can conclude that her symptoms are most
likely related to gallstones.
 Finally, the amylase and lipase are elevated
 Epigastric Pain-Acute Pancreatitis
History and Physical
•Nonsurgical conditions that mimic an acute abdomen: gastroenteritis, acute adrenal
insuffi ciency, sickle cell crisis, diabetic ketoacidosis, acute porphyria, pelvic infl ammatory
disease, kidney stones, and pyelonephritis
•Pati ents with pancreatitis typically present with epigastric pain radiati ng to the
back, nausea, vomiting, anorexia, fever,tachycardia.

Pathophysiology
• The initi al event in pancreatitis is the inappropriate activation of pancreatic
enzymes
• Gallstones and alcohol are the most common causes of acute pancreatitis

Diagnosis
• Most cases can be diagnosed with just a history, physical, and abnormal
amylase/lipase
•Ranson criteria are used to predict severity based on parameters during initial
admission and at 48 hours after
Workup
• Amylase/lipase levels do not correlate with severity of pancreatitis
• In the absence of a history of alcohol abuse, start with a R U Q ultrasound to look
for gallstones
 Epigastric Pain-Acute Pancreatitis

Management
•Pati ents should initi ally be managed conservatively with I V fl uids, N P O , and
narcotic analgesia
• Gallstones
– urgent E R C P if concomitant cholangitis
– early cholecystectomy if mild pancreatitis
– late cholecystectomy if severe pancreati ti s
• If pati ents do not clinically improve aft er 3 days of conservative management, get
a C T scan with contrast to look for any underlying complications (i.e., necrosis)
• Begin enteral nutriti on in pati ents with prolonged N P O status or in severe acute
pancreatitis
• Refractory persistent abdominal pain is the main indication for surgery in chronic
pancreatitis
 Epigastric Pain-Acute Pancreatitis
ETIOLOGY COMPLICATIONS
“I GET SMASHED”: • Systemic
Idiopathic – Early (1st week)
Gallstones – Multi -organ failure
Ethanol • Local
Trauma – Late (3 weeks)
Scorpion bite – Pancreati c abscess
Mumps (viruses) – Pancreati c pseudocyst
Autoimmune – Pancreati c necrosis
Steroids
Hyperlipidemia
ERCP
Drugs
Acute Pancreatitis-Glasgow- Imrie Scoring
Acute Pancreatitis- AXR
 Acute Pancreatitis- C E C T

CECT: Acute Phlegmon / Acute Pancreatitis / Pancreatic

Pancreatitis Inflammatory Mass Necrosis Arrow: No enhancement
Diffusely enlarged pancreas White arrowheads: of pancreas with IV contrast
with low Phlegmon Arrowheads: Normal
density from edema Black arrowhead: Pancreatic enhancement in the tail of
calcification Large Arrow: Pancreas.
Peripancreatic fascial infiltration
 ABDOMINAL PAIN-LLQ Pain
HISTORY:
A 55-year-old obese female presents with a 2-day history of left lower quadrant pain, nausea, anorexia,
and low-grade fever. The patient states that the pain is constant, moderately severe, and does not
radiate anywhere. No H/O aggravating/relieving factors. She denies vomiting and bloody or black
stools and has no recent change in bowel habits, though she says she’s been constipated most of her
life. She has noted similar pain in the past,but never this severe, and has never sought medical
attention before. She has never had a screening colonoscopy or prior surgery.
PHYSICAL EXAM:
Abdominal exam reveals mild distention, no surgical scars, and no masses. Bowel sounds are absent.
The left lower quadrant is moderately tender to palpation with guarding and no rebound tenderness.
Rectal exam is unremarkable. Pelvic exam reveals no cervical motion tenderness and no adnexal
masses.
LABS: TWBC- 16,000; Hb-13Gm; Hct- 39%
What would be your differential dx and plan for further evaluation?
LLQ PAIN-Differential Diagnosis
 ABDOMINAL ABDOMINAL
PAIN-LLQ PainPAIN-LLQ Pain

 Diagnosis most probably Acute Diverticulitis

 Given the patient’s left lower quadrant (LLQ) pain and tenderness on exam, associated with
fever and leukocytosis, acute diverticulitis is the most likely diagnosis.
 Obesity, diet low in fiber and high in fat and red meat, and advanced age are risk factors for the
formation of diverticulosis.
 Rectal diverticula are extremely rare. It is hypothesized that they almost never occur because the
taenia coli, the longitudinal bands of smooth muscle along the colon, unite into a circumferential
band around the rectum, thereby eliminating points of weakness that precede a diverticulum.
 LLQ Pain-Acute Diverticulitis

History and Physical

• Major risk factors are obesity, advanced age, and diet low in fiber, high in fat and red meat

•Diverticulitis is a clinical diagnosis (LLQ pain and tenderness, fever, leukocytosis)

Pathophysiology
• The sigmoid colon is the most common site
•Complicated diverticulitis: abscess, free perforation, fistula, stricture, and obstruction
Diagnosis
• CT scan is the first-line imaging modality
• Avoid barium enema and colonoscopy in acute presentation because of increased risk of
perforation
• Determine if complicated or uncomplicated and with or without SIRS
 LLQ Pain-Acute Diverticulitis
LLQ Pain-Acute Diverticulitis
Management
• Uncomplicated diverticulitis without SIRS
– Treated as outpatient
– Oral antibiotics and clear liquids
• Uncomplicated diverticulitis with SIRS
– Admit to hospital
–NPO, IV fluids, IV antibiotics, and analgesia
–Follow up with colonoscopy 4–6 weeks after acute episode to rule out malignancy and
Inflammatory Bowel Disease.
•Complicated diverticulitis usually requires surgery
–Resect the affected colon and construct end colostomy if urgent
–Sigmoid colectomy with primary anastomosis if not urgent
LLQ Pain-Acute Diverticulitis
 LLQ Pain-Acute Diverticulitis
Etiopathogenesis

• l .Colonic diverticula are mucosal out pouchings through the

submucosa and the muscular layer of the colon.
• 2 .They occur most commonly in the sigmoid colon, and in
10% of patients, they involve the entire colon.
• 3.A disorder of modern civilization and is associated with
consumption of refined food products. It is rare in rural
African and Asian populations where dietary fiber is high.
• [Link] standing constipation increases the stool transit time
and intraluminal pressure and causes diverticulosis.
• [Link] arise between antimesenteric taenia and the mesenteric
taenia at the site of entry of the blood vessels.
 ABDOMINAL PAIN-LLQ Pain

HISTORY:
An 80-year-old male presents with severe abdominal distention and no bowel movement or gas per
rectum for 3 days, as well as recent onset of vomiting. He has Parkinson’s disease and chronic
constipation and lives in a nursing home. His medications include levodopa and benztropine, which he
has been taking for several years.
PHYSICAL EXAM:
Patient’s vital signs are T 37°C, heart rate 90/min, blood pressure 116/70 mmHg, and respiratory rate
22/min. Patient is tachypnic but nontoxic, with mental status unaltered. His abdomen is severely
distended. He does not have any abdominal surgical scars. He is tympanitic but has no significant
tenderness to palpation. There are no palpable hernias, and rectal exam demonstrates an absence of
stool with no palpable masses or strictures.
 ABDOMINAL PAIN-LLQ Pain
AB DOMINAL PAIN-LLQ Pain
LABS:
BUN 26 mg/dL; Creatinine 1.4 mg/dL, Electrolytes within
normal limits, TWBC:6800/dL; ABG- pH 7.48//PaCO2
30//PaO2 80//HCO3 24//SpO2 99 %.
IMAGING:
Plain upright abdominal radiograph shows a massively
dilated loop of sigmoid with the apex pointing toward the
right upper quadrant, consistent with the “coffee bean” or
“bent-inner tube” sign; upright chest radiograph shows no
free air under the diaphragm.
What would be your differential dx and plan for further
evaluation?
LLQ PAIN-Differential Diagnosis
 ABDOMINAL PAIN-LLQ Pain

 Diagnosis most probably Sigmoid Volvulus

 The massive, slowly progressive abdominal distention, combined with obstipation, and X-ray
findings are consistent with large bowel obstruction. The radiologic appearance is most consistent
with a sigmoid volvulus.
 Large bowel obstruction-LBO- is more likely to be associated with more pronounced
distention, less or late onset vomiting, and decreased bowel sounds.
 Small bowel obstruction- SBO- SBOs tend to be associated with more pronounced vomiting. In an
early SBO, bowel sounds are hyperactive, with “rushes and tinkles”- Borborygmi. In late SBO- absent
bowel sounds- silent abdomen.
 LLQ Pain-Sigmoid Volvulus

History and Physical

• LBO – gradual and severe abdominal distention, obstipation, and vomiting
• Uncomplicated volvulus – normal vitals, normal mental status, and non-tender abdomen
•Complicated volvulus – severe abdominal pain, fever, tachycardia, toxic appearance, peritoneal signs,
and leukocytosis
•Look for abdominal scars and hernias and perform a rectal exam to assess other differential
diagnoses
Etiology/Risk Factors:
• Most common causes of LBO: Cancer, Diverticulitis & Volvulus
• Sigmoid Volvulus – acquired stretching of the sigmoid
– Neuropsychiatric disease, institutionalization, chronic constipation, long-term anticholinergic use,
highfiber diet, and pregnancy
• Cecal Volvulus – congenital failure of fixation of the cecum
 LLQ Pain-Sigmoid Volvulus

Diagnosis
•Compared to LBO, SBO has faster onset and more likely to cause vomiting and high-pitched bowel
sounds
•Patients with Ogilvie’s syndrome are more likely to be already hospitalized and bedridden, often
in the postoperative setting
• Abdominal X-ray
– Sigmoid volvulus –“coffee bean”, “omega”, or “bent inner tube”, “kidney-bean” sign
– Cecal volvulus –“comma” or “kidney bean” sign- Human embryo sign
• CT scan if equivocal X-ray findings
• Contrast enema may be diagnostic (“bird’s beak” sign) and therapeutic in reducing the volvulus
–Water-soluble contrast (Gastrografin) rather than barium, to avoid peritonitis and scarring in case
of perforation
–Bowel wall thickening, mesenteric edema, pneumatosis, and portal venous gas suggest
ischemic bowel
 LLQ Pain-Sigmoid Volvulus

Management
• Therapy differs based on the location and severity of complication
– Uncomplicated sigmoid volvulus – endoscopic detorsion followed by semi-elective resection
– Complicated sigmoid volvulus – no detorsion attempted; emergent laparotomy with resection
– Cecal volvulus – no detorsion attempted; take to OR for right colectomy
•Complications of surgery – wound infection, anastomotic leak, and recurrence. Without
detorsion or resection – ischemia,
perforation, and sepsis