Article #2

CE
An In-Depth Look:
ACUTE ABDOMEN

Acute Abdomen: Diagnosis*

Valissitie Heeren, DVM†
Lisa Edwards, DVM‡
Elisa M. Mazzaferro, MS, DVM, PhD, DACVECC
Wheat Ridge Animal Hospital, Wheat Ridge, Colorado

ABSTRACT:

The term acute abdomen is defined as the sudden onset of abdominal dis-
comfort or pain. Clinical signs that usually accompany this condition in-
clude abdominal distention, anorexia, lethargy, generalized gastrointestinal
signs (e.g., vomiting, diarrhea), and various stages of shock. Clinical pathol-
ogy, radiology, ultrasonography, and methods of collecting free abdominal
effusion are often necessary to promptly diagnose and treat the disease
processes that lead to visceral pain. If the underlying cause is left un-
treated, death could result.

A
cute abdomen (i.e., sudden onset of abdominal pain) is commonly seen in vet-
erinary medicine. Because acute abdomen can be a clinical manifestation of
myriad conditions, cases of acute abdomen can often be diagnostic challenges.
The goals of this article are to review patient signalment, history, and physical exami-
nation as well as the diagnostic steps required to accurately assess and treat patients
with acute abdomen. Specific attention has been given to the processes of radiographic
and ultrasonographic imaging, clinical pathology, and diagnostic peritoneal lavage.

PATHOPHYSIOLOGY OF PAIN
Abdominal pain originates via stimulation of type C and A nerve fibers located in
the capsules of abdominal viscera, parietal peritoneum, and mesentery. The terminal
ends of these fibers receive activating stimuli when they are stretched. Stretching can
*A companion article on occur during food bloat, gastric dilatation–volvulus (GDV), obstructive ileus, and
treatment appears on swelling or hemorrhage of solid organs. Nociceptive stimulation also occurs with
p. 366. ischemic insults such as thromboembolic episodes or significant trauma. Inflamma-
tory mediators (e.g., substance P, histamine, serotonin) released during such events
Email comments/questions to can cause irritation and pain.1
[email protected], †Dr. Heerenis now affiliated with Seattle Veterinary Associates, Seattle, Washington.
fax 800-556-3288, or log on to ‡Dr. Edwards is now affiliated with Animal Emergency and Referral Center, Lynwood, Wash-
www.VetLearn.com ington.

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 Acute Abdomen: Diagnosis CE 351

Differential Diagnosis of Acute Abdomen

Gastrointestinal Splenic
• Infectious enteritis • Splenic torsion
—Parvovirus • Splenic neoplasia
—Panleukopenia • Splenic trauma
—Parasites
• Hemorrhagic gastroenteritis Urogenital
• Obstruction • Trauma
—Neoplasia
• Nephritis
—Foreign body
• Pyelonephritis
—Intussusception
—Bowel incarceration • Ureteral (obstruction or rupture)
• GDV • Urethral (obstruction or rupture)
• Gastric ulcer • Bladder rupture
• Gastric perforation • Bladder neoplasia
• Mesenteric volvulus • Prostatitis
• Obstipation • Prostatic abscess
• Pyometra
Hepatobiliary • Metritis
• Hepatitis (infectious, toxic) • Torsion (uterine or testicular)
• Hepatic neoplasia
• Hepatic abscess Peritoneal
• Cholangiohepatitis
• Peritonitis
• Biliary tree rupture
• Biliary obstruction —Chemical
—Septic
Pancreatic
• Pancreatic neoplasia Miscellaneous
• Pancreatic abscess • Abdominal wall hernia
• Pancreatitis • Spinal pain

Abdominal pain can be separated into two categories—visceral and

somatic. Splanchnic fibers of solid organs are responsible for carrying affer-
ent impulses toward the sympathetic chain and up the spinal cord.2 The
resultant sensation is dull, generalized pain. The parietal peritoneum con-
tains somatic pain fibers that are sensitized via inflammatory cytokines,
thereby generating localized, piercing pain. Pain sensations are sent to tho-
racolumbar spinal cord segments that directly correlate to areas within the
abdominal cavity.2 Understanding somatosensory pathways can help explain
why patients with severe inflammatory disease, such as pancreatitis or peri-
tonitis, clinically appear more uncomfortable than do animals with obstruc-
tive gastrointestinal (GI) problems or organ enlargement.

INITIAL ASSESSMENT
Patients with acute abdomen often present with significant cardiovascular
abnormalities. A quick assessment for shock is mandatory. Clinical signs of
shock depend on the cause and time frame. For example, clinical signs of
early compensatory shock include tachycardia, normal mucous membrane
color, rapid capillary refill time (CRT), and bounding pulses. Early in septic
shock, clinical signs may be hyperdynamic, with rapid CRT and brick-red
mucous membranes; as decompensation occurs, signs may include pale
mucous membranes, prolonged CRT, weak peripheral pulses, and depres-

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352 CE An In-Depth Look: Acute Abdomen

sion. This type of shock can be seen in patients with female that had a heat cycle 2 months ago and now
pyometra. However, septic cats present very differently presents with acute abdominal disease is a strong candi-
and are often bradycardic and hypothermic, with pale date for developing pyometra or other uterine abnor-
mucous membranes and prolonged CRTs.3 malities. Cases of dietary indiscretion or toxicities are
Asking owners appropriate questions regarding pa- often not related to age, breed, or gender.
tient history can be one of the most valuable diagnostic
tools available when presented with a case of acute PHYSICAL EXAMINATION
abdomen. First and foremost: What made the client Initial Assessment
bring in the pet? It is important to find out what clinical Because of the complex nature of acute abdomen, it is
signs, if any, the animal has been exhibiting and obtain a important to perform a detailed and systematic physical
general idea of the patient’s activities. Inquiries should examination. An abbreviated physical examination may
be made regarding the animal’s everyday habits, includ- be required, depending on the patient’s stability or need
ing urination, defecation, appetite, and thirst. Has the for immediate medical intervention. Following an initial
animal been in contact with other animals? Are any assessment, periodic reevaluations are necessary. The
other animals in the household sick? Has the animal animal’s posture and gait should be visually inspected
had a full series of vaccinations? Abnormalities, such as because abnormalities may be suggestive of abdominal
vomiting, diarrhea, difficulty breathing, and coughing, pain. Animals that stand with an arched posture or that

Abdominal evaluation of animals that present with clinical

signs of acute abdomen should include visual inspection,
auscultation, percussion, rectal examination, and palpation.

should be described in detail by the owner. Specific assume a “praying” position are often attempting to
questions should be asked pertaining to the color, the relieve discomfort.4–7 A patient with overall weakness or
texture, and even the smell of vomitus or abnormal spinal injury may present in lateral recumbency.8 Some
feces. Has there been blood in the vomitus/feces? How patients with nonspecific visceral pain may pace or
long has the animal been acting sick? The answers to appear restless.3 In addition, abdominal pain may mani-
these questions could prompt clinicians to highly sus- fest simply as a reluctance to move, a stilted gait, tensing
pect a more specific cause of illness (see the box on page when the affected area is palpated, vocalization, tachy-
351). For example, if projectile vomiting begins sud- pnea, or ptyalism due to nausea.4
denly, upper GI obstruction might be high on the list of Dehydration can be subjectively estimated by eval-
diagnostic differentials. Dark, tarry feces should prompt uating the patient’s skin turgor and mucous membrane
clinicians to suspect GI bleeding. It is also important to dryness. Skin turgor can be assessed by tenting the skin
ask whether the animal has had previous episodes of over the midlumbar area. Dry oral mucous membranes
similar clinical signs. Has there been exposure to toxic and eyes that appear dry and retracted into their sockets
substances? Does the pet chew on toys or other indicate severe dehydration. These tests are subjective
objects/substances? A systematic list of questions should and can be difficult to assess if a patient has lost weight
be posed in every case of acute abdomen so that critical and body fat. The mouth should be thoroughly exam-
pieces of information are not missed. ined for abnormalities such as linear foreign bodies,
Knowing the age, sex, and breed of the animal is ben- icteric mucous membranes, petechial hemorrhage, and
eficial when deciphering possible causes of acute evidence of ingestion of caustic substances.2
abdomen. For example, large, deep-chested dogs are
predisposed to developing GDV or splenic torsion.1 Abdominal Examination
However, puppies may be more likely to have parvoviral Abdominal evaluation is the most important aspect of
enteritis, intussusception, or a foreign body. An intact the physical examination. The abdomen should ideally

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 Acute Abdomen: Diagnosis CE 353

be palpated last to avoid inadvertently neglecting serious particular organ or organ system. For example, pain
extraabdominal abnormalities.4 In addition, abdominal elicited in the right cranial quadrant may indicate pan-
palpation may elicit pain, thus preventing further exam- creatitis, whereas midabdominal pain may be suggestive
ination. A complete abdominal examination consists of of pathology involving the kidneys, bowel, or spleen.6 A
visual inspection, auscultation, percussion, rectal exami- diagnosis of lower urinary tract obstruction can often be
nation, and palpation. made based on caudal abdominal palpation and presence
of a firm, distended urinary bladder. Deep palpation can
Visual Inspection identify other abnormalities such as organomegaly, organ
The abdomen should be visually inspected for signs of displacement, masses (e.g., intussusception, tumor, for-
distention. Abdominal trauma should be suspected if eign body), or the presence of fluid. A fluid “wave” can
there is blood on surrounding fur. Shaving the area may often be elicited with abdominal ballottement.
uncover evidence of petechial hemorrhage, icterus, pen-
etrating wounds, or swelling. These findings may reveal DIAGNOSTICS
clues about the underlying condition. For example, a Abdominal radiography is a standard tool used to
reddened umbilical region may indicate hemoabdomen. evaluate most patients with acute abdomen. Other valu-
The inguinal and perineal regions should be visually able imaging modalities include contrast radiography
inspected for irritation and discoloration, which can be and ultrasonography. Because of the critical status of
signs of urinary tract compromise.6 many patients with acute abdomen, survey radiographs
are important to obtain for quick diagnostic informa-
Auscultation, Percussion, and Rectal tion. Radiographs can give valuable information about
Examination whether surgical intervention is warranted. Conditions
The abdomen should be auscultated for evidence of readily diagnosed on sur vey films include GDV,
bowel sounds. Absent bowel sounds may be suggestive organomegaly, masses, obstruction, foreign body, free
of ileus, peritonitis, chronic obstruction, or abdominal gas, effusion, calculi (i.e., renal, ureteral, or cystic), and
fluid. Increased borborygmi may indicate acute enteritis body wall or diaphragmatic herniation.
or acute obstruction. Percussion involves gently “ping- Because of the rapid breathing pattern of many
ing” the abdominal wall between the thumb and forefin- patients with acute abdomen, a short x-ray exposure
ger while auscultating with a stethoscope. Dull sounds time is recommended.8 Two views (i.e., lateral and ven-
can be heard when the thumb and forefinger tap over a trodorsal) are preferred; however, a patient’s clinical sta-
solid organ, whereas high-pitched sounds can be heard tus may dictate positioning and the number of radio-
with gas-filled, hollow organs. Rectal examination is graphs taken. The ventrodorsal view is favored because

Survey abdominal radiography is extremely important, but

ultrasonography and contrast radiography are also valuable.

important to evaluate the prostate, urethra, pelvic inlet, patients are usually stretched out, resulting in less tissue
and sublumbar lymph nodes as well as fecal character.4 to penetrate.8 Positioning becomes more important with
certain conditions, such as GDV, in which a right lateral
Palpation radiograph is the view of choice. Hanging lateral and
Superficial palpation can be a very valuable diagnostic horizontal beam views become beneficial when looking
tool in patients with acute abdomen and should be per- for free fluid or gas.
formed before attempting deep palpation. Gentle palpa- On survey, extraabdominal structures should be evalu-
tion can help identify pain and compromise in the ated first. Spinal pain may often present like abdominal
abdominal wall. Deep palpation can be used to differen- pain; therefore, it is important to look for evidence of
tiate localized and generalized pain. Localizing pain to a intervertebral disk disease, diskospondylitis, and other
particular region can help focus the examination on a skeletal conditions. The abdominal wall and retroperi-

May 2004 COMPENDIUM

354 CE An In-Depth Look: Acute Abdomen

toneal space should be evaluated next. Loss of retroperitoneal detail may be

suggestive of hemorrhage or urine leakage, whereas the presence of
retroperitoneal gas can be secondary to pneumomediastinum or the result of
a punctured or ruptured viscus or emphysematous cystitis.9 Radiographic
signs consistent with blunt trauma include herniation of organs into the
thoracic cavity. Fluid of any type, including intraabdominal hemorrhage
from blunt trauma, urine, and septic and nonseptic effusion, is characterized
by decreased abdominal detail. Small pockets of fluid can occasionally be
visualized on survey radiographs; however, ultrasound is much more sensi-
tive, allowing detection of quantities as small as 4 ml/kg.10
Free abdominal gas is significant. The most common causes of pneu-
moperitoneum are penetration of the abdominal cavity (as a result of trauma
or recent laparotomy), GI perforation, emphysematous cystitis, and rup-
tured hepatobiliary abscess or urinary bladder.9 A thorough history allows
differentiation of the cause. Free abdominal gas rises to the highest point;
thus an animal can be positioned to enhance identification of small gas
pockets. Placing an animal in dorsal recumbency and taking a horizontally
directed view is a very sensitive technique. This positioning allows accumu-
lation of gas between the liver, diaphragm, and ventral abdominal wall.9
The abdomen should also be evaluated for organomegaly or mass effects,
which displace normal structures. Hepatomegaly is characterized by caudal
deviation of the stomach axis. A large tubular structure located between the
urinary bladder and colon in a female patient may be suggestive of pyome-
tra. Prostatic enlargement causes cranial displacement of the urinary bladder
and dorsal displacement of the colon. Splenomegaly and renomegaly may
also be found on survey radiographs. Differentials for splenomegaly include
neoplasia, hematoma, and torsion.7 The medical history should be consid-
ered because administering certain drugs such as thiobarbiturates may also
result in splenic enlargement. Kidneys that exceed 2.5 to 3.5 times (in dogs)
or 2.4 to 3 times (in cats) the length of the second lumbar vertebra on a
ventrodorsal view are considered enlarged. Diagnostic differentials for
renomegaly include neoplasia, abscesses, cysts, edema, inflammation,
hydronephrosis, and intracapsular hemorrhage.
Survey radiography is often used to diagnose other common causes of acute
abdomen, such as GI obstruction and linear foreign bodies (Figure 1). Radio-
graphic changes visible with obstruction include segmental dilation of bowel
loops and stacking of distended loops with characteristic hairpin turns. Lin-
ear foreign bodies are often diagnosed based on evidence of intestinal plica-
tion and C-shaped gas patterns on survey films. As a general rule, the small
bowel diameter in dogs should not exceed the height of the central portion of
the body of a lumbar vertebra or twice the width of a rib, whereas, in cats, the
diameter should not exceed twice the height of the central part of the fourth
lumbar vertebra.9 When the entire length of bowel is dilated and appears
enlarged, a diagnosis of mesenteric torsion or volvulus must be considered.
Other conditions such as pancreatitis have more subtle radiographic
changes; thus additional diagnostic testing is often required for definitive
diagnosis. Several changes that can be associated with pancreatitis include
localized loss of detail in the right cranial quadrant of the abdomen, persist-
ent gas in the descending duodenum, calcification due to fat saponification,

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356 CE An In-Depth Look: Acute Abdomen

Figure 1. Radiograph showing a distended colon and

large amount of foreign material that is impacting the
stomach. During surgery, the foreign material was revealed to
be 5 lb (2.3 kg) of ivy.

and a widened gastroduodenal angle. However, it is not

recommended to diagnose pancreatitis based on these
radiographic findings alone. Figure 2. Radiograph of a barium series in which
Various contrast studies may be helpful in diagnosing barium abruptly stops because of a nylon bone wedged
conditions that are equivocal on survey films (Figure 2). in the intestine.
Such studies are particularly valuable in outlining
abnormalities of the GI and urogenital systems. For an
upper GI study, a barium dose of approximately 10 to Care should be taken to ensure that an adequate volume
15 ml/kg is recommended. Rapid administration via a of barium is administered because this can greatly influ-
stomach tube can be beneficial because it can help ence transit time through the GI tract.
determine transit time more accurately.8 If GI perfora- Diaphragmatic hernia is always a concern with ab-
tion is suspected, using an organic iodide contrast dominal trauma. Positive-contrast peritoneography can
medium is recommended because it is less irritating be used to identify loss of diaphragmatic integrity. To
than barium should leakage into the peritoneal space use this technique, 1 ml/kg of a triiodinated contrast

Ideally, a complete blood cell count, chemistry screen,

urinalysis, and coagulation panel should be submitted
after stabilization and before volume replacement.
occur. GI contrast studies can help determine whether medium should be injected into the peritoneal space to
transit time is prolonged or accelerated; however, there help visualize the outline of the diaphragm.9 Presence of
is a wide range of normal values. In general, barium contrast material in the pleural space and irregularity of
should be cleared from the small bowel in 5 hours in the margin of the diaphragm are often diagnostic for
dogs and 3 hours in cats.9 Hypermotility can be second- diaphragmatic hernia.9
ary to increased intestinal contents (as with diarrhea) Contrast studies can also be used to assess the kid-
and conditions such as acute enteritis and peritonitis.11 neys, ureters, and urinary bladder (Figure 3). These

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 Acute Abdomen: Diagnosis CE 357

tures. When looking at the liver and other abdominal

organs, it is important to note their relative echogenicity
and homogenicity. A difference in echogenicity may be
suggestive of tissue pathology. Discussing the ultrasono-
graphic findings of all potential causes of acute abdomen
is beyond the scope of this article; however, several condi-
tions are relatively common and readily diagnosed with
ultrasonography. For example, presence of a dilated gall-
bladder and common bile duct may be suggestive of bil-
iary tract obstruction.13–15 Ultrasonic findings consistent
with pancreatitis include an enlarged and hypoechoic
pancreas as well as free fluid within the abdomen. In
addition, there may be evidence of hyperechoic peripan-
creatic tissue and extrahepatic biliary obstruction.13,16–17
Figure 3. Radiograph of a contrast study in which Ultrasonography is useful when looking for evidence of
iodinated material leaks into the peritoneal cavity from nephritis as well as radiolucent and radiopaque calculi
a tear in the bladder neck. The dog had been hit by a car 2 associated with the urinary system.18–20 Conditions associ-
days earlier. ated with the reproductive tract that should also be con-
sidered include pyometra and prostatitis.21–25

studies are particularly valuable when looking for rup- CLINICAL PATHOLOGY
tures or tears within the urinary system. Positive-con- Once a patient with acute abdomen has been initially
trast cystography is the procedure of choice to demon- stabilized, laboratory tests should be submitted as soon
strate bladder tears or ruptures. 9 To conduct this as possible. Ideally, a full chemistry panel, including
contrast study, the bladder should be evacuated and a obtaining pancreatic amylase and lipase levels (if pan-
20% organic iodide compound injected through a ure- creatitis is suspected); a complete blood cell count; elec-

When indicated, abdominocentesis and diagnostic

peritoneal lavage may be the most specific and helpful
tests in making a diagnosis.
thral catheter.9 Mucosal abnormalities and filling defects trolyte analysis; urinalysis; and a coagulation panel
such as calculi may be better visualized by using double- should be evaluated before volume replacement.
contrast cystography. Urethral integrity can be assessed Although not 100% sensitive or specific, elevations in
using contrast urethrography. It is recommended to use amylase and lipase can assist in diagnosing pancreatitis
a balloon-tipped catheter (to prevent reflux of the in some cases. This collection of tests can help deter-
medium) to inject 10 to 15 ml (in dogs) or 5 to 10 ml mine whether underlying disease processes are present,
(in cats) of an organic iodide contrast medium.9,12 including renal failure, coagulopathy, biliary dysfunc-
Ultrasonography can be very valuable in cases of acute tion, and urinary tract trauma. The leukogram, complete
abdomen and often leads to a definitive diagnosis. Ultra- with a manual differential count and morphologic
sonography is noninvasive; can help to specifically charac- description of the cells, can help determine whether
terize abdominal organs; and can be particularly useful inflammatory or infectious diseases are present.1 Pres-
when looking at the hepatobiliary system, pancreas, uri- ence of toxic changes or a left shift can also help deter-
nary tract, GI tract, reproductive system, and retroperi- mine the severity of inflammation or infection. The
toneal space. It can facilitate collection of abdominal fluid hematocrit can be used to determine whether anemia is
and help guide fine-needle aspiration of abdominal struc- present, keeping in mind that the erythrocyte volume

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358 CE An In-Depth Look: Acute Abdomen

can appear artifactually elevated or normal despite anemia when splenic

contraction occurs. Evidence of regeneration may be present in cases of
chronic anemia, whereas acute blood loss or anemia in chronic disease does
not produce evidence of regeneration. Hypoproteinemia could warrant
investigation of sources of hemorrhage or other exterior protein losses.
Unless pyometra is suspected, a urine sample collected via cystocentesis
helps evaluate whether glucosuria, bacteruria, pyuria, or hematuria are pres-
ent. Urine specific gravity can also be used to evaluate renal function and
concentrating ability.6 Evidence of hypoglycemia may support the presence
of septicemia in some patients. Aggressive IV antibiotic therapy would
therefore be warranted after collecting blood and peritoneal fluid samples
for bacterial culture and susceptibility testing. Other considerations in cases
with low serum glucose values include pancreatic or hepatic neoplasia.
If a clinician does not have access to a full laboratory, several necessary values
can be obtained even with minimal diagnostic capabilities. A manually
obtained packed cell volume (PCV), total protein concentration, blood glucose
level, urine specific gravity, blood urea nitrogen level, and activated clotting
time as well as a peripheral blood smear to assess platelet count provide much-
needed information about the immediate status of a critically ill patient.
Abdominocentesis with fluid analysis and cytology can also be conducted and
provides helpful clues about the cause of intraabdominal pathology.
Investigation into the presence of or predisposition for disseminated
intravascular coagulopathy (DIC) is also essential in critical patients.
Thrombocytopenia may be secondary to sequestration of platelets in the
liver or spleen, DIC, increased platelet use resulting from hemorrhage, or
decreased platelet production. A coagulation panel that measures prothrom-
bin time, activated partial thromboplastin time, and fibrin degradation
products can help rule out development of DIC.1
Once baseline blood and urine samples have been submitted and the
patient has been triaged and stabilized, more in-depth diagnostics should be
conducted. Arterial blood gas should be analyzed to determine the oxygena-
tion and ventilatory status of the animal if respiratory compromise is sus-
pected. Blood gas measurements are also helpful in determining the origin
of tachypnea, if present. An elevated respiratory rate could be attributed to
pain if oxygen content, alveolar to arterial oxygen gradient, and carbon diox-
ide levels of an arterial blood sample are normal. If oxygenation is low, how-
ever, the probability of impaired oxygen exchange in the lungs is increased.
If respiratory status is normal, a jugular venous blood gas analysis can easily
be obtained with little stress to the patient and can be used to assess
acid–base status. Lactic acidosis can develop as a result of decreased tissue
perfusion secondary to hypovolemia, further compromising patient stability.
Metabolic alkalosis can also develop as a result of loss of hydrochloric acid
in cases of pyloric obstruction.
Following diagnostic imaging modalities, diagnostic peritoneal lavage
should be performed in cases of acute abdomen. Collecting cells within the
peritoneal cavity can help determine whether hemoabdomen, biliary rupture,
leakage of urine into the abdomen, pancreatic inflammation, and/or bacterial
peritonitis are present. The information collected via diagnostic peritoneal
lavage can help clinicians decide between medical and surgical treatment.1

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360 CE An In-Depth Look: Acute Abdomen

Figure 4. To increase the chance of retrieving fluid from an effusive abdominal cavity, four separate quadrants must
often be tapped.

ABDOMINOCENTESIS AND DIAGNOSTIC this time, a syringe can be used to apply negative pres-
PERITONEAL LAVAGE sure to draw out effusive material.10 It should be kept in
Abdominal fluid retrieval is a quick and highly spe- mind that radiographs taken after abdominocentesis may
cific diagnostic method used to determine the clinical show free air in the abdomen (i.e., pneumoperitoneum)
status of a patient. If the amount of fluid in the peri- that is not part of the underlying abdominal pathology.
toneal cavity is significant (5 to 25 ml/kg or more), Therefore, radiographs should always be obtained before
abdominocentesis usually results in adequate sample four-quadrant paracentesis. False-negative results occur
collection.7 If only small amounts of fluid are present, more than half of the time, making the sensitivity of an
however, diagnostic peritoneal lavage may be necessary abdominal tap fairly low.2 If a clinician still thinks that
to investigate the character of the effusion. Indications peritoneal fluid collection would be beneficial but using
for performing either procedure include decreased centesis is unsuccessful in obtaining a sample, diagnostic
radiographic detail of the abdomen, blunt or penetrating peritoneal lavage or ultrasound-guided centesis should be
trauma that may have entered the peritoneal cavity, clin- used. Although this technique is not as simple to use as
ical signs of shock without a diagnosed cause, and sus- four-quadrant paracentesis, it is more than 90% accurate.
pected dehisced, surgically repaired, hollow viscous.7 Diagnostic peritoneal lavage produces false-negative
To increase the chance of retrieving fluid from an effu- results less than 5% of the time. Cases that may produce
sive abdominal cavity, tapping four separate quadrants is false-negative results include trauma such as retroperi-
often required (Figure 4). The ventral abdomen should toneal injury and diaphragmatic hernia. 6 Peritoneal
be surgically scrubbed before a tap. Four 20-gauge nee- lavage is highly beneficial to clinicians when deciding
dles can be used to enter each quadrant of the peritoneal whether to pursue surgery or medical management in a
cavity. The four quadrants can be determined by visualiz- patient with acute abdomen. If diagnostic peritoneal
ing a line at the level of the umbilicus to divide the lavage produces a negative result but the clinician still
abdomen into cranial and caudal halves and by using the suspects infection or inflammation, it may be necessary
ventral midline to divide the two halves into left and to repeat diagnostic peritoneal lavage several hours later
right components. A needle should be inserted into the because results can change rapidly.
central portion of each of these four quadrants.7 As the To perform diagnostic peritoneal lavage, the patient
needles are inserted through the skin, loops of intestines should be dorsally recumbent. The urinary bladder
should tend to move away from the needle hub, thus should be emptied with either catheterization or manual
making the procedure relatively risk free.10 The needles expression. The ventral abdomen should be surgically
should be left in place with no attachments for a couple clipped and scrubbed. The ventral abdominal midline
of minutes to allow the capillary action of the needle to should be locally anesthetized using 2% lidocaine (2
draw out fluid. If no material collects in the hub during mg/kg). The local block should begin 1 to 2 cm caudal

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 Acute Abdomen: Diagnosis CE 361

to the umbilicus and extend a few centimeters. If neces- diaphragmatic hernia is suspected. Increased intraab-
sary, a 2% solution can be diluted to a 1% solution to dominal pressure can further compress the thoracic cav-
extend the volume. An incision should then be made to ity, causing increased respiratory difficulty. 2 Another
dissect the skin, subcutaneous tissues, and superficial option that has been described for hemorrhage control
abdominal fascia. 6 Care should be taken to prevent is instilling fluid into the peritoneal cavity. This proce-
iatrogenic hemorrhage into the peritoneal space, which dure can help control hemostasis by increasing pressure
would produce false results suggestive of hemoabdomen. around leaking vessels or organs.
A fenestrated catheter (Argyle Trocar Thoracic Catheter, Creatinine level should also be evaluated on fluid col-
Kendall, Tyco Healthcare, Mansfield, MA) should be lected by abdominal paracentesis. Peritoneal creatinine
placed into the abdominal incision and directed caudodor- and potassium levels may be elevated compared with sys-
sally until all the holes in the catheter are within the peri- temic creatinine levels in cases of urinary tract trauma
toneal cavity. If no fluid is collected by simple catheter not restricted to the retroperitoneal space. 28 Bilirubin
placement and rolling the patient, warm 0.9% saline or lac- level is another useful chemical marker in cases of biliary
tated Ringer’s solution (10 ml/lb26) should be infused into tract rupture. Pathognomonic signs of biliary tract leak-
the abdominal cavity. The animal should then be gently age include a peritoneal bilirubin concentration that is
rolled from side to side to distribute the saline throughout greater than that in serum and/or the presence of green
the peritoneal space. The fluid can then be collected by bilirubin crystals in peritoneal fluid. Presence of amylase
attaching an extension set to an empty fluid bag and allow- in abdominal fluid collected via paracentesis is also useful
ing gravity to retrieve the infused fluid. Aspiration can be in cases of suspected pancreatitis or bowel ischemia.
attempted if gravity alone does not collect a significant vol-
ume. If the fluid is red or pink, the extension set should be SUMMARY
detached, the catheter capped, and a sample taken to deter- When patients present with acute abdomen, clinicians
mine the PCV. A PCV above 2% to 5% warrants a second must promptly determine the cause and whether to pursue
retrieval approximately 30 minutes later to determine medical or surgical treatment. This article outlines a com-
whether ongoing hemorrhage is present. The PCV should
be determined again to compare it with that of the first
sample. The catheter can be left in place for up to 3 hours.6
The fluid should be analyzed promptly after collec-
tion. If degenerate neutrophils, organic fibers, bacteria,
or more than 2,000 leukocytes/µl are observed micro-
scopically, surgery is needed immediately.2 If bacteria are
not observed, but septic abdomen is still suspected, the
following test results would be suggestive of bacterial
colonization in the peritoneal cavity10,27:
• Glucose concentration: <50 mg/dl
• pH: <7.2
• Partial pressure of carbon dioxide: >55 mm Hg
• Partial pressure of oxygen: <50 mm Hg
• Lactate concentration: >5.5 mmol/L

The presence of erythrocytes in the fluid is consistent

with abdominal trauma. If the animal is in shock, ther-
apy should be initiated promptly. If necessary, a blood
transfusion should be administered. Only after these
attempts fail to stabilize the patient should surgery be
considered an immediate need. Placing pressure wraps
around the abdomen may help control intraabdominal
hemorrhage. However, caution must be taken when

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362 CE An In-Depth Look: Acute Abdomen

plete series of diagnostics that can guide clinicians through 24. Matton JS, Nyland TG: Ovaries and uterus, in Nyland TG, Matoon JS (eds):
Small Animal Diagnostic Ultrasound, ed 2. Philadelphia, WB Saunders, 2002,
a thorough examination, including laboratory evaluation pp 231–249.
and more in-depth procedures such as diagnostic imaging, 25. Finn ST, Wrigley RH: Ultrasonography and ultrasound-guided biopsy of the
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26. Crowe DT: Diagnostic and abdominoparacentesis techniques: Clinical evalu-
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This article qualifies for 1.5 contact hours of continuing CE
(eds): Veterinary Emergency and Critical Care Medicine, ed 1. St. Louis, Mosby, education credit from the Auburn University College of
1992, pp 153–162. Veterinary Medicine. Subscribers who wish to apply this
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I. The Compendium Collection. Yardley, PA, Veterinary Learning Systems,
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189:90–95, 1986. b. prothrombin time

COMPENDIUM May 2004

 Acute Abdomen: Diagnosis CE 363

c. blood urea nitrogen level b. rodenticide intoxication.

d. amylase concentration c. Staphylococcus spp pyoderma.
e. PCV d. abdominal hemorrhage.
e. none of the above
6. The most appropriate therapy for a patient with
uroabdomen, azotemia, and metabolic acidosis
9. When looking for free fluid in the abdomen,
would be
which radiographic view is favored?
a. inserting a urinary catheter.
b. peritoneal drainage and observation. a. lateral
c. immediate surgical repair. b. ventrodorsal
d. medical therapy until stabilization and then surgery. c. dorsoventral
e. applying an abdominal pressure bandage. d. horizontal or hanging lateral
e. orthogonal
7. Which of the following conditions should be con-
sidered an immediate surgical emergency? 10. A dog presents 1 week after being treated at
a. pneumoperitoneum another facility for being hit by a car. The patient
b. lower intestinal obstruction/foreign body has signs of severe abdominal pain. Abdomino-
c. pancreatitis
centesis reveals green crystals in the neutrophils.
d. open pyometra
The most likely diagnosis would be
e. acute intraabdominal hemorrhage secondary to blunt
trauma a. traumatic pancreatitis.
b. digested hemoglobin from intraabdominal hemor-
8. Clinical signs of acute abdomen and a reddened rhage.
area around a patient’s umbilicus would be sug- c. biliary tract damage.
gestive of d. ingesta from ruptured stomach.
a. petechial hemorrhage. e. uroabdomen.