Periumbilical pain

Specialty: Gastrointestinal.

• Mesogastric pain
• colicky periumbilical pain
• pain in the center of the abdomen

Why it occurs

• Acute appendicitis in the initial phase (visceral phase mediated by type C painful sympathetic afferent fibers that converge at T10, before migrating and irritating the parietal peritoneum of the right iliac fossa)
• Acute mesenteric ischemia due to embolism or thrombosis of the superior mesenteric artery (characterized by pain disproportionate to the findings of the physical examination)
• Initial obstruction of the small intestine (due to post-surgical flanges, strangulated hernias or jejuno-ileal volvulus)
• Diffuse infectious gastroenteritis with predominant involvement of the jejunum and ileum
• Symptomatic abdominal aortic aneurysm that is not ruptured or in the active dissection phase.

Initial workup

Emergency CT angiography of the abdomen and pelvis with multiplanar reconstruction (priority study in case of suspicion of mesenteric ischemia or aortic pathology) | Complete emergency analysis with arterial blood gas to measure pH, bicarbonate and lactate, as well as serum amylase, D-dimer (high sensitivity although low specificity), blood count and CRP | Standing abdominal x-ray (air-fluid levels on ladder or sentinel loop) | Rapid scanning abdominal ultrasound in emergencies (abdominal FAST to rule out free fluid or aneurysmal masses).

Standard management

• Aggressive fluid resuscitation therapy with crystalloids — in case of obstructive shock, ischemia or septic shock of intestinal origin
• Empirical intravenous broad-spectrum antibiotic therapy that protects the intestinal barrier — piperacillin/tazobactam 4.5 g IV every 6 hours
• Continuous infusion of nitroglycerin or vasodilators in selected cases of non-occlusive mesenteric ischemia under strict monitoring
• Major intravenous analgesia (fentanyl 50-100 mcg IV or morphine, administered in a controlled manner after surgical management decisions have been made).