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fever and Abdominal Pain
Authors:
Christopher J Grace, M.D., FACP,
Thomas L. Husted, M.D.,
Joseph S. Solomkin, M.D.
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Approach to the Adult Patient with Fever of Unknown Origin
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Table 1: Diagnosis of patients with diffuse abdominal pain
|
Risk Factors |
Presentation |
Evaluation |
| Primary Peritonitis |
· Ascites due to cirrhosis, severe hypoalbuminemia from nephrotic syndrome, CHF, malignancy
· CAPD catheter
· VP shunts |
· Diffuse abdominal pain, fever, nausea, vomiting1
· Leukocytosis3
· Other signs and symptoms of hepatic failure5 |
· Blood cultures4
· AAS
· Abdominal CT scan
· Paracentesis2
· Liver enzymes7
· Amylase, lipase |
| Secondary Peritonitis |
· Appendicitis
· Cholecystitis
· Diverticulitis
· Peptic ulcer disease
· Abdominal injury
· GI neoplasm
· Bowel obstruction
· Mesenteric ischemia
· Surgical anastomotic leak
· GU infections6 |
· Acute onset of diffuse abdominal pain, fever, nausea, vomiting
· Abdomen rigid, hypoactive or absent bowel sounds, guarding and rebound tenderness
· Leukocytosis3 |
· Blood cultures4
· AAS
· Abdominal CT scan
· Liver enzymes7
· Amylase, lipase
· Exploratory laparotomy |
| Lower Lobe Pneumonia |
· Aspiration
· Smoking
· COPD |
· Upper abdominal pain
· Cough, hypoxia may be present
· Localized rales on chest examination |
· Blood cultures
· Chest x-ray |
CT, computerized tomography; CHF, congestive heart
failure; COPD, chronic obstructive lung disease; GI, gastrointestinal;
GU, genitourinary; CAPD, continuous peritoneal dialysis catheter; VP,
ventriculoperitoneal; AAS, acute abdominal series
1 Patients with cirrhosis and primary
peritonitis may occasionally present without fever or abdominal pain.
Consideration should be given to perform paracentesis inpatients with
ascites.
2 Ascitic fluid should be sent for white blood
cell count and differential, protein, Gram stain and culture, lactate
level and pH. Fluid may also be inserted into a blood culture bottle for
culture. The yield of ascitic fluid Gram stain and culture is poor. A
negative test result does not exclude spontaneous bacterial peritonitis
(SBP). A fluid white blood cell count > 250 cells/mm3 is diagnostic
of SBP.
3 Patients with overwhelming infections may have
leukopenia and marked bandemia
4 Two sets should be obtained prior to the
start of antibiotics. The yield of blood cultures in secondary
peritonitis approaches 75%, while it is substantially poorer in patients
with SBP.
5 Encephalopathy, variceal bleeding
6 septic abortion, salpingitis, post partum endometritis
7 Liver enzymes; aspartate amino transferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin
.
Table 2: Diagnosis of patients with localized abdominal pain
|
Risk Factors |
Presentation |
Evaluation |
| Hepatitis |
· Alcohol ingestion · IDU · Ingestion of contaminated food |
· RUQ pain · Fever, nausea, vomiting · Jaundice |
· Liver enzymes7 · Serologic tests for viral hepatitis3 · Serologic tests for less common causes as indicated4 |
| Hepatic abscess |
· Appendicitis
· Diverticulitis
· Cholecystitis · Bacteremia |
· RUQ and epigastric pain · Fever, nausea, vomiting · Leukocytosis |
· Blood cultures · Liver enzymes7 · RUQ ultrasound · CT scan |
| Cholecystitis1 |
· Gallstones · Trauma, burns |
· Postprandial RUQ
and epigastric pain · Fever, nausea, vomiting
· (+) Murphy’s sign2 · Leukocytosis |
· Blood cultures · RUQ ultrasound5 · Liver enzymes7 · Amylase, lipase |
| Cholangitis |
· Obstruction of the biliary tree from gallstones, malignancy, surgery |
· RUQ pain6
· Fever, nausea, vomiting
· Jaundice · Leukocytosis |
· Blood cultures · RUQ ultrasound · Liver enzymes7 · Amylase, lipase |
| Appendicitis |
· Generally none
· Foreign bodies
· Tumor · Strictures
· Parasitic infection8 |
· Periumbilical
pain migrating to RLQ · Fever, nausea,
vomiting · Leukocytosis |
· CT scan |
| Diverticulitis |
· Diverticulosis |
· LLQ pain9 · Fever, nausea, vomiting · Leukocytosis |
· Blood cultures · CT scan |
| Splenic abscess |
· Bacteremia
· Endocarditis · Sickle
cell disease · IVDA |
· LUQ pain
referred to left shoulder · Fever, nausea,
vomiting · Leukocytosis |
· CT scan · CXR11 |
| Colitis10 |
· Contaminated food and water · Antibiotics · Recent hospitalization |
· Diarrhea,
hematochezia · RLQ, LLQ pain
· Fever · Leukocytosis |
· Stool culture10 · Fecal leukocytes · Clostridium difficiletoxin assay |
| Pelvic Inflammatory Disease |
· Young age and sexual active12 · New sexual partner · Bacterial vaginosis · IUD |
· RLQ, LLQ pain · Fever · Leukocytosis |
· Bimanual pelvic examination · Pelvic ultrasound · CT scan |
| Endometritis |
· Pregnancy13 |
· Suprapubic pain · Fever · Leukocytosis |
· Bimanual pelvic examination |
| Pancreatic abscess |
· Pancreatitis |
· Periumbilical and back pain · Fever · Leukocytosis |
· Blood cultures · Liver enzymes7 · Amylase, lipase · CT scan |
| Renal abscess |
· Kidney stones
· Ureteral obstruction
· DM · Bacteremia |
· Flank and back pain · Fever · Leukocytosis |
· Blood cultures
· Urine culture
· Renal ultrasound · CT scan |
| Pyelonephritis |
· Kidney stones · Ureteral obstruction · DM |
· Flank and back pain · Fever, nausea, vomiting · Leukocytosis |
· Blood cultures · Urine culture · Renal ultrasound |
IDU, injection drug use; RUQ, right upper quadrant; RLQ,
right lower quadrant; LLQ, Left lower quadrant; LUQ, left upper
quadrant; CT, computerized tomography; DM, diabetes mellitus; CXR, chest
x-ray; IUD, Intrauterine contraceptive devices
1 95% due to gallstones. Acalculous cholecystitis can be seen after trauma, surgery, burns and in those with
HIV infection, immune suppression and DM
2 Murphy’s sign: inspiratory arrest during
palpation of the RUQ. Named after John B. Murphy (1857- 1918), a
Chicago, Illinois surgeon.
3 Hepatitis A virus IgG and IgM antibody,
Hepatitis B surface antigen (HBsAg), Hepatitis B surface antibody (HBsAb), Hepatitis B core antibody (HBcAb),
Hepatitis C virus antibody.
4 IgM, IgG antibody for
cytomegalovirus (CMV), monospot for
Epstein Barr Virus (EBV) infection, antibody for human immunodeficiency virus (
HIV) infection
5 Thickened gallbladder wall, pericholecystic fluid, (+) sonographic Murphy’s Sign
6 The classic Charcot’s triad of RUQ pain, fever and jaundice is seen in less than 20% of patients.
7 Liver enzymes: aspartate amino transferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin
8 Enterobius vermicularis, Ascaris lumbricoides, Strongyloides stercoralis
9 Pain may be RLQ or suprapubic depending on the position of the colon and location of the inflamed diverticula.
10 Including food borne bacterial colitis from
Campylobacter, Salmonella, Shigella,
Escherichia. Coli 015H7 and antibiotic related
Clostridium difficile.
11 May reveal left lower lobe atelectasis, effusion, elevated left hemidiaphragm
12 Pelvic inflammatory Diseases (PID) are often due to sexually transmitted pathogens such as
Neisseria gonorrhoeae or
Chlamydia trachomatis.
13 Seen more often with cesarian section,
ruptured membranes for > 6 hours, multiple cervical examinations and
chorioamnionitis.
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Table 3: Microbiology of diffuse peritonitis
| Clinical Diagnosis |
Community acquired |
Hospital acquired |
| Primary Peritonitis1 |
· E. coli, Klebsiella pneumoniae,Proteus spp, Enterobacter spp
OR
· S. pneumoniae
OR
· Streptococci, enterococci |
· Resistant E. coli, Klebsiella spp, Proteus spp, Enterobacter spp
OR
· P. aeruginosa |
| Secondary Peritonitis2 |
· E. coli, Klebsiella spp, Proteus spp, Enterobacter spp
AND
· Enterococci
AND
· Anaerobes including Bacteroides,Clostridium, Prevotella |
· Resistant E. coli, Klebsiella spp, Proteus spp, Enterobacter spp, P. aeruginosa, Serratia, Acinetobacter
AND
· Enterococci including VRE
AND
· Anaerobes including Bacteroides, Clostridium, Prevotella
AND
· Candida spp. |
1Primary peritonitis is most often
monomicrobial. One third of patients have negative cultures from
paracentesis. Anaerobic bacteria are uncommon and isolation should raise
the concern of secondary peritonitis.
2 Secondary peritonitis is polymicrobic involving aerobic gram negative rods (GNR), enterococci and anaerobes.
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