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Emergency Medicine - Abdominopelvic Emergencies - Fast Facts | NEJM Resident 360

In this section, we cover the following abdominopelvic emergencies:

Acute Abdomen Appendicitis Nephrolithiasis/Urolithiasis Ectopic Pregnancy Ovarian Torsion

Preeclampsia/Eclampsia/HELLP Syndrome Priapism Phimosis/Paraphimosis Testicular Torsion

Other topics related to abdominopelvic emergencies are covered in the following rotation guides:

• Diverticulitis, Inflammatory Bowel Disease, Pancreatitis, Gastrointestinal Bleeding, Mesenteric Ischemia, Biliary Disease(Gastroenterology)

• Acute Kidney Injury(Nephrology)

• Hyperglycemic Emergencies(Endocrinology)

• Pregnancy and Abortion, Sexually Transmitted Infections, Menstrual Disorders(Women’s Health)

• Nephrolithiasis/Urolithiasis (Nephrology)

Acute Abdomen

Acute abdomen is defined as conditions of the abdomen that demand prompt and decisive action. Pain is caused by multiple mechanisms and manifested by sudden onset of abdominal pain and varying degrees of local and systemic reaction. Some causes require urgent treatment, often including emergency surgery.

While gathering the evidence, signs and symptoms should be evaluated broadly, and attention must be given to the need for supportive measures while workup is underway.

Causes of an Acute Abdomen

General Causes	Examples
Inflammatory	Bacterial (acute appendicitis, diverticulitis, or pelvic inflammatory disease)

Chemical (perforation of a peptic ulcer or toxic ingestion) | | Mechanical | Obstructive conditions (e.g., hernia, adhesions, intussusception, large-bowel obstruction, volvulus, gallbladder or renal stone) | | Neoplastic | Carcinoma of the colon or any other abdominopelvic organ | | Vascular | Mesenteric thrombosis, embolism, testicular or ovarian torsion, abdominal aortic aneurysm | | Congenital defects | Malrotation of the gut, duodenal atresia, omphalocele or diaphragmatic hernia; Meckel diverticulum (bleeding or perforation) | | Traumatic | Stab and gunshot wounds or blunt abdominal injury | | Iatrogenic | Perforation after endoscopy/colonoscopy or complications of surgery |

Abdominal Pain Differential Diagnosis

Remember that clinical presentation may be different in older and immunocompromised patients.

Appendicitis

Appendicitis is a clinical emergency and one of the more common causes of acute abdominal pain. The condition is usually caused by obstruction (e.g., lymphoid hyperplasia, fecalith, cancer). Typical presentation of appendicitis is not “classic,” so be aware and keep appendicitis in the differential. 

Diagnosis

**Diagnostic score for appendicitis:**The Alvarado score estimates the possibility of appendicitis in patients presenting with abdominal pain.

Patient History

Classic history and symptoms:

• abdominal pain (most common symptom)

  • migration of pain (periumbilical to right lower quadrant [RLQ])

• anorexia

• nausea

• vomiting

Classic signs (but not necessarily typical):

• RLQ pain on palpation and percussion (most sensitive sign)

• low-grade fever (38°C [100.4°F], but can present without)

• guarding

• peritoneal signs (absence of these signs does not exclude appendicitis)

• psoas sign (pain on extension of right thigh)

• obturator sign (pain on internal rotation of right thigh)

• Rovsing sign (pain in RLQ with palpation of left lower quadrant)

• Dunphy sign (increased pain with coughing)

• flank tenderness in RLQ

Workup

Labs

• Nonspecific findings include:

• • leukocytosis

  • neutrophilia

  • elevated band count

  • elevated C-reactive protein (CRP) level

  • urinalysis changes — can include mild pyuria, proteinuria, and hematuria

• Evidence suggests that acute appendicitis can be ruled out when white blood cell (WBC), C-reactive protein (CRP), and polymorphonuclear (PMN) ratios are all within normal limits (negative likelihood ratio, 0.05).

• In the right clinical setting, a combination of positive markers increases the likelihood of an accurate diagnosis of appendicitis.

• Rule out pelvic pathology and pregnancy in women (usually part of the differential).

Imaging

Imaging and Diagnosis of Acute Appendicitis

Modality	Sensitivity & Specificity	Advantages	Disadvantages	Notes
US	71%,97%

• Low cost

• No radiation

• Can rule out pelvic pathology

|

• Operator dependent

• Can cause pain

| Diagnosis is equivocal if appendix is not identified | | CT | 83%,98% |

• Accessible in most EDs

• Does not cause pain

• Can identify other abdominopelvic pathology

|

• High cost

• Radiation risk

• Operator dependent

| | | MRI | 99%,100% |

• No radiation

• Does not cause pain

• Can rule out other abdominopelvic pathology

|

• High cost

• Limited access

| Usually not used unless patient is pregnant with an equivocal US and high clinical suspicion |

Treatment

• Give nothing by mouth (NPO).

• Provide analgesia (does not decrease sensitivity of exam).

• Treat nausea.

• Seek early surgical consultation if high suspicion.

• Antibiotics can be used as a safe primary treatment in uncomplicated appendicitis. See The Use of Pre- or Postoperative Antibiotics in Surgery for Appendicitis (Table 4) for a list of antibiotics that can be used for the treatment of appendicitis.

Nephrolithiasis/Urolithiasis

Renal calculi (nephrolithiasis) and ureteral calculi (ureterolithiasis) are often discussed together.

Clinical Presentation

• costovertebral angle tenderness

• pain can move with migration of ureteral stone

• in men, may manifest as normal-appearing painful testicle

• constant body positional movements (e.g., colicky pain with writhing, pacing)

• abdominal exam is not impressive, pain may not be elicited with palpation

• other symptoms include tachycardia, hypertension, nausea (with or without emesis)

Workup

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone. Confirmatory tests are usually performed to determine the presence of stones, evaluate for complications, and estimate the likelihood of stone passage. Consider checking creatinine level and urinalysis to adjust your clinical suspicion and consider pyelonephritis behind an obstructing stone. The usefulness of hematuria testing in patients with acute flank pain is limited. Therefore, the presence or absence of hematuria should not determine whether to perform a more definitive evaluation.

Imaging

• Noncontrast abdominopelvic CT: The imaging study of choice, it yields an accurate diagnosis and rules out other abdominal pathologies (sensitivity, 95%–100%).

• Renal ultrasonography: This determines the presence of a renal stone and hydronephrosis or ureteral dilation (used in children and in patients when radiation exposure is a concern); it is less accurate than CT in diagnosis of ureteral stones, especially those in the distal ureter; it is not reliable for stones <5 mm. However, in one study, ultrasound diagnosis was not associated with significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations than diagnosis by CT.

• Plain abdominal radiograph: This can show some but not all stones; some studies suggest the flat plate has relatively low sensitivity (40%–50%) and specificity.

Management

• Supportive care includes parenteral hydration, analgesia, antiemetic, and antibiotics, if needed.

• Stones ≥7 mm are unlikely to pass spontaneously and will require some type of surgical procedure; stones 4–6 mm have a 50% likelihood of requiring intervention.

• Consult urology for solitary or transplanted kidney, concurrent infection, stones unlikely to pass, or renal insufficiency; admit patients with intractable pain and vomiting.

• Patients without the described criteria can be discharged with urology follow-up, analgesia, tamsulosin, antiemetics, and a strainer.

Ectopic Pregnancy

Ectopic pregnancy is a condition in which the conceptus implants and matures outside the endometrial cavity. This can result in life-threatening hemorrhage, infertility, and death. Adequate testing to rule out ectopic pregnancy should be obtained for any woman of childbearing age with concerning abdominal pain.   

Signs and Symptoms

The classic clinical triad:

• abdominal pain

• amenorrhea

• vaginal bleeding

Patients may present with a range of symptoms, from those common to early pregnancy (e.g., nausea, breast fullness) to the presence of a surgical abdomen (abdominal rigidity, involuntary guarding, or severe tenderness). Patients can also present with or develop hypovolemia (syncope, near-syncope, orthostatic blood-pressure changes, tachycardia, hypotension).

Diagnosis

• Serum human chorionic gonadotropin (β-hCG) level

  • Serial levels 2 days apart provide insight on the viability or resolution of the pregnancy.

  • The β-hCG level above which an imaging scan should reliably visualize a gestational sac within the uterus in a normal intrauterine pregnancy is as follows:

  • • 1500–1800 mIU/mL with transvaginal ultrasonography

    • 6000–6500 mIU/mL with abdominal ultrasonography

Change in the hCG Level in Intrauterine Pregnancy, Ectopic Pregnancy, and Spontaneous Abortion

• Ultrasonography

• • FAST (Focused Assessment with Sonography for Trauma) can rapidly identify significant hemorrhage. Fluid in Morison pouch in setting of clinical concern for ectopic pregnancy warrants rapid gynecologic consultation in parallel with any confirmatory testing. 

  • Visualization of an intrauterine sac, with or without fetal cardiac activity, is often adequate to exclude ectopic pregnancy.

  • Absence of an intrauterine pregnancy on a scan when the β-hCG level is above the discriminatory zone represents an ectopic pregnancy or a recent abortion.

• Laparoscopy

• • Laparoscopy remains the criterion standard for diagnosis.

  • However, it is mainly used for patients who are in pain or hemodynamically unstable.

Management

• expectant management: for asymptomatic patients with objective evidence of resolution (e.g., declining β-hCG levels)

• methotrexate: the standard medical treatment for unruptured ectopic pregnancy; a single-dose intramuscular (IM) injection is the most commonly used regimen

  • intrauterine pregnancy

  • immunodeficiency

  • moderate-to-severe anemia, leukopenia, or thrombocytopenia

  • sensitivity to methotrexate

  • active pulmonary or peptic ulcer disease

  • clinically important hepatic or renal dysfunction

  • breastfeeding

  • evidence of tubal rupture

  • inability to follow up

• • contraindications to methotrexate therapy include the following:

• laparotomy: usually reserved for hemodynamically unstable patients with cornual ectopic pregnancies

Ovarian Torsion

Ovarian torsion is a significant cause of acute lower abdominal pain in women. The blood flow to the ovary is compromised, resulting in infarction of the ovary and adnexal structures that can lead to infertility.

Presentation

• nausea and vomiting

• acute-onset pelvic pain

• history of multiple ovarian cysts increases likelihood of diagnosis

• history of prior episodes of same pain, where torsion is presumed to have spontaneously resolved

• advanced presentations could include fever and peritoneal signs

Workup

• Perform ultrasonography with duplex color to assess blood flow.

• Ovarian enlargement secondary to impaired venous and lymphatic drainage is the most common sonographic finding.

Treatment

• Seek emergent gynecologic consultation and subsequent laparoscopy regardless of normal laboratory results.

• The likelihood of preserving viable ovarian tissue with conservative surgery (detorsion) decreases over time, with some evidence that pain for >48 hours is associated with a significant decrease in successful outcome.

Preeclampsia/Eclampsia/HELLP Syndrome

Preeclampsia/eclampsia/HELLP syndrome refers to a spectrum of peripartum diseases that have been recognized and described for years despite a general lack of understanding of the diseases and how best to define them. Preeclampsia is generally defined as new hypertension (diastolic blood pressure, ≥90 mm Hg) and substantial proteinuria (≥300 mg in 24 hours) at or after 20 weeks’ gestation. However, complications include disseminated intravascular coagulation (DIC), acute renal failure, pulmonary edema, intracranial hemorrhage, and cardiac arrest. See Pre-eclampsia (Table 1) for a summary table and comparison of different classification frameworks for preeclampsia.

Preeclampsia/Eclampsia

Diagnosis

The following table describes the American College of Obstetricians and Gynecologists’ diagnostic criteria for preeclampsia:

Diagnostic Criteria for Preeclampsia
Blood pressure
• ≥160 mm Hg systolic or ≥110 mm Hg diastolic, hypertension can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy
and
Proteinuria

or

• Protein/creatinine ratio ≥0.3 mg/dL
• Dipstick reading of 1+ (used only if other quantitative methods not available) | | Or in the absence of proteinuria, new-onset hypertension with the new onset of any of the following: | | Thrombocytopenia

Renal insufficiency

Impaired liver function

Pulmonary edema

Cerebral or visual symptom | • Platelet count less than 100,000/microliter

• Serum creatinine concentrations >1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease

• Elevated blood concentrations of liver transaminases to twice normal concentration |

(Reference: Hypertension in Pregnancy, Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013.)

Evaluation

Patients may present with:

• hypertension

• lower-extremity edema

• headache

• focal neurological complaints

• visual changes (scotomas or blurred vision)

• hyperreflexia

• altered mental status or agitation

• abdominal pain

• nausea and vomiting

• shortness of breath

Workup

• fingerstick glucose, complete blood count (CBC), and comprehensive metabolic panel (CMP), including liver function tests

• consider coagulation panel and urine protein panel

• other workup (head CT, toxicology, etc.) as indicated if trauma or other causes of seizure/altered mental state are suspected

Management

• Fetal well-being depends on maternal well-being. Focus on the mother; aggressive monitoring of the fetus is not necessary.

• Request early obstetrics consult.

• The definitive treatment is delivery; if patient is postpartum, aggressive treatment is warranted and will likely require intensive care unit (ICU) stay.

Seizure Control

• First treat with magnesium (4–6 g IV over 15 min, then 1–2 g/hr) and not with benzodiazepines.

• Administer diazepam or phenytoin as needed.

• Monitor for magnesium toxicity:

  • Toxicity presents with diminished deep-tendon reflexes, somnolence, dilated pupils, increased respiratory rate, hypotension, and bradycardia.

  • If identified early, stopping magnesium administration will result in steady improvement.

  • The antidote is calcium gluconate (10 mL of 10% solution over 10 minutes) if reversal is necessary.

Blood-Pressure Control

• Blood-pressure (BP) goal is 140–155/90–105 in several hours; be careful not to correct over 25% in the first 30 minutes.

• Administer labetalol (10–20 mg up to 200 mg) and double the dose every 10 minutes or hydralazine (5–10 mg) every 20 minutes.

Thrombocytopenia Control

• Administer platelets if the patient is thrombocytopenic and bleeding.

• Consult with obstetrics if the patient is thrombocytopenic and not bleeding.

The following table summarizes antepartum management options for women with preeclampsia:

Antepartum Management Options for Women with Pre-eclampsia by Gestational Age at Diagnosis

HELLP Syndrome

The acronym HELLP stands for hemolysis, elevated liver enzymes, and low platelet counts. The syndrome is a serious life-threatening complication of pregnancy of uncertain etiology and might be a variant of preeclampsia. Early diagnosis is critical. Platelet counts are the most reliable indicator of the presence of HELLP syndrome. The mainstay of therapy is similar to that of eclampsia: supportive management, including seizure prophylaxis with magnesium sulphate, blood pressure control, and transfusion of blood products for some patients. Most women with HELLP syndrome benefit from corticosteroid therapy.

Priapism

Priapism is defined as a persistent, painful erection lasting more than 4 hours, independent of sexual arousal. If untreated, the patient may develop penile fibrosis, dysfunction, and urinary retention.

Clinical Manifestations

Patients with low-flow priapism (ischemic) may present with:

• rigid erection

• ischemic corpora (indicated by dark blood upon corporeal aspiration)

• no evidence of trauma

Patients with high-flow priapism (nonischemic) may present with:

• penis not fully erect, generally not painful, and may manifest as episodic

• adequate arterial flow

• well-oxygenated corpora

• evidence of trauma to the penis or perineum (e.g., straddle injury)

• • raises concern for spinal cord injury in a trauma patient

Etiologies

The following table lists some etiologies of priapism:

Workup

• no need for workup if presentation is a recurrence or if due to recent use of vasoactive erectile agents, including after use of injection drug(s)

• workup for new priapism may include:

• CBC

• sickle cell labs

• toxicology screen

• corpus cavernosa blood gas

Typical Arterial Blood Gas Values

Management

• pain control

• treatment of vaso-occlusive crisis (if indicated)

• early urology consult

Suggested Algorithm for the Management of Acute Priapism

In ischemic priapism, treatment should begin by considering oral terbutaline administration, especially if urology consultation will be required and delayed. Systemic agents are not recommended by the American Urological Society; however, those guidelines are intended for urologists. First-line therapy is otherwise therapeutic aspiration or intracavernous injection of an alpha-adrenergic sympathomimetic agent (e.g., phenylephrine, etilefrine, ephedrine, norepinephrine, and metaraminol).  Note, there is anecdotal evidence for “arterial steal” as an intervention. (The editor of this rotation guide has had success with having a patient jog up and down multiple flights of stairs when urologic intervention was delayed and no oral agents were available.)

If the priapism is controlled, most patients can be discharged with wrap and pseudoephedrine (to prevent recurrence) and referral for urgent urology appointment.

Phimosis/Paraphimosis

Phimosis

• inability to retract the foreskin over glans of penis

• typically due to poor hygiene

• not emergent if urine outflow is not obstructed

• prescribe topical steroids for 4–6 weeks

• outpatient urology referral

Paraphimosis

• inability to pull proximal skin over the glans of the penis

• typically due to chronic catheters or vigorous sexual act

• a medical emergency because it can lead to gangrene and autoamputation

• consider urology consultation (if available) or if reduction methods are not successful

Management

Management goal is to reduce the foreskin using the following methods:

Reduction of Paraphimosis

• wrap the glans with elastic bandage

• place penis in ice

• use thumb to push glans back through the prepuce

• if persistent, perform a dorsal slit (1–2 cm incision at 12 o’clock on the foreskin)

• last resort is emergent circumcision by urologist

Testicular Torsion

Testicular torsion an ischemic emergency that includes risk of testicular infarction and infertility. After the neonatal period, torsion most often occurs in adolescents and young adults, with another node of increased frequency at ages 40–50 years. Involve urology early if there is high suspicion. Keep in mind differential diagnosis includes testicular appendagitis, epididymitis, epididymo-orchitis, orchitis, inguinal hernia, abscess, necrotizing fasciitis of the perineum (Fournier gangrene) involving the scrotum, cellulitis, testicular cancer, hydrocele, varicocele, and trauma. However, no test should ever delay progression to the operating room if torsion is suspected.

Signs and Symptoms

• acute unilateral testicular pain

• scrotal swelling

• sometimes associated abdominal pain, nausea, and vomiting

• history that is suggestive of intermittent torsion

• high-riding and/or abnormal lie of the testicle

• absence of nonspecific signs such as cremasteric reflex and Prehn sign (relief of pain with the elevation of the testicle)

Management

Surgery: Immediate surgical exploration is indicated for patients with testicular torsion.

Timing: The time elapsed between onset of pain and performance of detorsion and the corresponding salvage rate is as follows:

• <6 hours: 90%–100% salvage

• 12–24 hours: 20%–50%

• 24 hours: 0%–10%

Manual detorsion: Improves rates of surgical salvage; can protect testicular viability in cases of surgical delay and provides significant pain relief. Can be difficult because of acute pain during manipulation and is not a substitute for surgical exploration.

Most torsions are in medial direction; therefore, perform detorsion of testes from the medial to the lateral side (“open book” rotation). Color Doppler ultrasonography can be used to determine the direction of testicular torsion and guide manual detorsion.

Manual Testicular Detorsion

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