ACUTE ABDOMEN MANAGEMENT APPROACH

DR.M.HAZEM EL-FOLL FRCS-(UK) Consultant General and Laparoscopic Surgery

Definition And Epidemiology

Undiagnosed Abdominal Pain of less than 710 days duration. Abdomino-thoracic Trauma is excluded from this definition. It accounts for 5-10% of ER visits It accounts for 1% of all hospital admission. Most Patients-(70-75%) Discharged after ER Evaluation. Only 7-10% of Patients will Require Urgent Surgery for Life-Threatening Conditions.

Acute Abdomen

Acute Abdominal pain

SURGICAL CAUSESSURGICAL ABDOMEN MEDICAL CAUSES---NON-SURGICAL

ABDOMEN

Etio-Pathological Classification:-

Inflammatory/Infective
Acute Cholecystitis Acute Pancreatitis Inflammatory Bowel Disease Acute Appendicitis Acute Diverticulitis Meckle's Diverticulitis PID-(Salpingitis)/Tuboovarian abscess. UTI-Acute Pyelonephritis/Acute Cystitis

Perforation
Perforated Peptic Ulcer Disease

Perforated Appendicitis/Cholecystit is
Perforated Small Bowel

Esophageal Perforation
Perforated Colon Aortic Dissection

Etio-Pathological Classification Obstruction

Intestinal Obstruction

Infarction
Thrombo-embolic diseases Acute Intestinal Ischemia Renal Infarction Splenic Infarction GIT-Volvulus Omental Torsion Intussusception Torsion ovarian cyst/sub-serous fibroid

Biliary Colic
Renal Colic

Spontaneous intra-peritoneal bleeding

Etio-Pathological Classification

Rupture AAA. Rupture visceral A.Aneurysms in mesenteric; hepatic and renal arteries. Rupture pathologically enlarged spleen Rupture Hepatic Tumor. Gynecological causes: Ruptured Ectopic pregnancy Ruptured Ovarian Cyst Ruptured Graffian's follicles( mid-cycle) Ruptured Endometriosis.

Medial Causes of Acute Abdominal Pain

Non-Surgical Abdomen

Intra-Abdominal Conditions
Gastro-Enteritis. Infective Colitis Mesenteric Adenitis Typhoid Fever UTI

Intra-Thoracic Conditions MI Basal Lobar Pneumonia and Lung Abscess Pericarditis. Spontaneous Pneumothorax.

Liver Abscess
Acute Viral Hepatitis Congestive Hepatomegaly Liver Tumors

Non-Surgical Abdomen
Metabolic Causes Haematological Diseases

D-Ketoacidosis Uremia Adreno-cortical Insufficiency Hypercalcemia Acute Intermittent Porphyria. Heavy Metals Poisoning

Haemolytic Crisis of Chronic Haemolytic Anaemia. Polycythemia. Henoch- Schonelein Purpura. Lymphoma. Leukemia.

Non-Surgical Abdomen
Neurological Causes
Herpes Zostercommonly involving spinal nerves T3-L1. Spinal cord Compression: Degenerative-Disc Prolapse. Metastases. Nerve Entrapment: 2-3 localised areas just medial to linea semilunaris of rectus muscle.

Collagen Diseases
SLE.

Polyarteritis Nodosa.

Abdominal Pain caused by thrombosis of visceral arteries lead to Visceral infarction.

Management Approach
(I)-Clinical Evaluation: Accurate History and Complete Physical Examination are Essential for Diagnosis

(II)-Resuscitation and Immediate Diagnostic

Tools.

(III)-Other Investigations-according to clinical

progress of the patient.

History taking

Abdominal pain
Site of pain: at onset, at present, radiation Severity Progression of pain

Duration
Type: intermittent, steady, colicky. Radiation of Pain Aggravating factors: movement, coughing, food Relieving factors: position, drug, food

Physiology of Pain-Visceral Pain

Elicited by distention ; inflammation of the serous coat of hollow viscera and in the capsules of solid organs. Mediated by afferent autonomic nerve fibres. Diffuse; felt in the midline in regions related to the embryological development.

Somatic(Parietal)Pain
Elicited by direct irritation/inflammation of the somatically innervated parietal peritoneum. Mediated by afferent somatic nerve fibres. localised in the dermatomes supplied by segmental nerve roots innervating the parietal peritoneum.

Referred Pain
Pain Sensations perceived at a site distant from that of a strong primary stimulus.

Due to Confluence of
afferent nerve fibers from widely disparate areas within the posterior horn of the spinal cord. This may cause distorted central perception of the site of pain.

In Most causes of Surgical Abdominal pain There is insidious onset of pain started diffuse;

dull ach/or gripping pain. In hollow viscus

obstruction and in Strangulation; the pain is sever associated with nausea; vomiting; and

sweating; causing the patient to move around in

bed and inability to lie still. There is no aggravating of relieving factors. Visceral pain.

Progression of pain-In Inflammatory and Obstructed Causes

There is progression of pain over several hours; and change character of pain into sharp localised stabbing pain. The pain is aggevated by moving; coughing and relieved by lying still. Somatic Pain There will be associated Abdominal localised tenderness; rebound; and involuntary muscle guarding. Localised Peritonitis.

In perforation; Strangulation(Infarction);and Spontaneous Bleeding

The pain is more sudden in onset with progression over 1-2 hours; into sharp localised stabbing pain. There will be Generalised/or Localised Abdominal tenderness; rebound and rigidity. Shoulder tip and infra-scapular pain; is common

due to blood/or pus in sub-phrenic space.

In Most of Non-Surgical causes of Abdominal Pain

There will be Diffuse mild dull-ach/or vague discomfort. Vomiting usually precedes the onset of pain; especially in metabolic causes. There will be Diffuse; non-specific abdominal tenderness. However there will

be NO Rebound tenderness and NO Muscle

Guarding.

Associated symptoms Nausea and vomiting Indigestion Anorexia and weight loss

Bowel habit
Urinary Symptoms Gynecological Symptoms

Menstrual History-in women in Reproductive age

Sexual Activity and IUD Amenorrhea(Missed period) Vaginal Bleeding

Vaginal Discharge
Mid-Cycle

Medical History Medical Diseases; HTN ; CAD ; AF ; Vascular Diseases ;Pulmonary Diseases. Previous Surgery

Current Medications-(Iron ; Erythromycin)

Alcohol and Smoking

Physical examination

General Examination

Vital Signs: Pulse ; Temp.; BP. Pallor ; Jaundice ; Cyanosis. Tongue:-Dry ; Coated ; acetone smell.

Examination of Cervical LNs.

Examination of Chest and Heart.

Abdominal Examination General Inspection

Patient is agitated; the patient moves around in bed and inability to lie still.= visceral pain. In hollow viscus obstruction and Strangulation

Patient is lying motionless in bed=Parietal pain

In Localised/Generalised Peritonitis. Patient is Drowsy with decrease responsiveness . Haemodynamic Collapse/Sepsis.

Abdominal Examination
Inspection
Patient should be exposed from nipple to midthigh. Abdominal Distension.

Obvious Abdominal Swelling

Scar ; Fistula ; Sinus. Distended Superficial Veins Ecchymosis,Cullens and Gray-Turners Signs

 Cullen sign

Grey-Turner sign

Palpation and Percussion Light and deep palpation. Start gently and away from reported area of pain.

Palpation/Percussion
Rebound tenderness = Peritoneal irritation can be elicited by:Cough tenderness = Percussion tenderness. Involuntary Muscle guarding=Peritonitis. Areas of maximum tenderness. Detect Organomegaly. Tympanatic Abdomen.= gas in bowel loops. Shifting dullness in Ascites.

Auscultation
High-pitch tinkling sound = mechanical bowel obstruction. No sound within 1-2 min = absent bowel sounds.

Do Not Forget
Examination of: Hernial Orifices. External Genitalia-Testis and Scrotum.

Examination of the Back of the patient.

PR and PV Examination. Dip-stick testing of urine for sugar ; ketone ; blood ; proteins and pus cells.

Resuscitation and Immediate Investigations

Resuscitation
NPO NG-Tube in intestinal obstruction and if there is persistent vomiting. IV-Line and Start IV Fluids. Analgesia after initial assessment should be given for pain relief. Important:-Narcotic analgesia don't mask physical signs or obscure the diagnosis. Start broad spectrum IV Antibiotics if Inflammatory Conditions suspected. Correction of dehydration and electrolyte imbalance. Urinary catheter and monitor the urine output

Resuscitation-In Critically Ill-Patients

Air Way and Oxygen Supplement. Oxygen Saturation Monitoring ABG

CV-Line ; Volume Replacement.

Laboratory studies
CBC Electrolytes Blood urea nitrogen/creatinine Amylase / lipase Serum lactate levels Liver function test Pregnancy Test-In all Women in childbearing age. Sickling Test Blood Group and save the serum. ECG.

Plain X-Ray film

Film acute abdomen (upright CXR and supine abdomen) Lateral decubitus ( Pt. who can not stand). Gas-distended bowel loops in-- intestinal obstruction. Free Air under diaphragm inPerforated Viscus. Radio-opaque shadow in RIF and gas in biliary tree in---gall stone ileus. Calculi-- Renal and Biliary. Calcified wall of AAA.

Obliteration of psoas shadow in Free intraperitoneal fluid/blood.

Emergency Abdominal Ultrasonography:--

Detection of acute Cholecystitis; pancreatitis; pancreatic pseudo-cysts; liver abscess Detection of appendicitis/ appendicular abscess; diverticular abscess; mesenteric cysts; Tubo-ovarian abscess; PID and pelvic abscess. Useful in pregnant and young female patient (detect pelvic pathology);ovarian cysts ; sub-serous fibroid ;PID. Diagnosis of suspected AAA. Diagnosis of free intra-peritoneal blood/fluid.

Contrast-enhanced CT-Scan (oral and IV Contrast)

It is the secondary imaging modality of choice in the patient with an acute abdomen, following plain abdominal radiography; as images not masked by bowel gas and most surgeons can interpret the findings more than US.

CT-Scan establishes the diagnosis of acute

abdominal pain in over 95% of cases.

After the initial assessment the patients with acute abdominal pain should be categorized into:
(I)Patients with immediately and Rapidly Life Threatening conditions :(A)-Surgical causes: Rupture AAA. Intra-abdominal Haemorrhage Acute intestinal ischemia. Perforated viscus and Peritonitis Strangulated intestinal obstruction-volvulus Intussusception; strangulated hernia. (B)--Medical life threatening conditions: Myocardial infarction. Spontaneous tensionPneumothora D-Ketoacidosis Acute AD.Cortical Failure

Abdominal crises
These are sub-group of patients who require immediate laparotomy without delay to perform confirmatory images.

(1)-Patients with intra-peritoneal Bleeding;(Rupture AAA.; ruptured ectopic pregnancies, and spontaneous hepatic or splenic ruptures.) (2)-Advanced; intra-abdominal sepsis; (due to perforated viscus/or strangulation); with high fever; tachypnea; sweating; profound hypotension; deterioration of mental state(agitation, disorientation); indicating impending septic shock.

(II)-Serious conditions:-that need early planned surgery/or need early supportive treatment and close monitoring (1)-Appendicitis/appendicular abscess; acute Cholecystitis/peri-cholecystic abscess; acute pancreatitis. (2)-Diverticulitis/Diverticular abscess; PID /Tuboovarian abscess; intra-abdominal abscess. (3)-Small bowel obstruction. (4)-Large bowel obstruction due to: diverticular abscess/ carcinoma

(III)-Less serious conditions which require conservative treatment

Biliary colic; renal colic; Inflammatory bowel disease. Non-specific abdominal pain. Gastro-enteritis and infective colitis. UTI. Un-complicated ovarian cyst and fibroid; and endometriosis. Mid-ovulatory pain. Un-complicated Diverticulitis Most of Medical causes.

Differential Diagnosis

Differential Diagnosis of patients with Acute Abdominal Pain

Each List Represents > 90-95% of Causes in each Group)

Infants less than one year old

Infantile Colic. Gastro-enteritis. Constipation. UT-Infection.

Children 1-5 years old

Appendicitis. Non-specific abdominal pain Gastro-enteritis. UT-Infection Intussusception. Incarcerated congenital hernia. Constipation.

Intussusception.
Incarcerated congenital hernia.

Hirschsprung disease.

.Sickle cell crisis

Henoch scheneloin Purpura

Differential Diagnosis of patients with Acute Abdominal Pain

Young and middle age Adult
Appendicitis. Active/Perforated PU. Acute Cholecystitis. Acute Pancreatitis. UTI. Non-specific abdominal pain. Intestinal obstruction. Diverticulitis. Renal colic

Young and middle age Women

Salpingitis-PID. Appendicitis. UTI. Rupture ectopic pregnancy Rupture/Torsion Ovarian cyst. Mid-ovulatory Pain. Acute Cholecystitis. Acute Pancreatitis.

Differential Diagnosis of patients with Acute Abdominal Pain Old-age >60-65 years old

Colo-rectal Cancer. Diverticulitis. Present with subacute Colonic Obstruction/OR Perforation and Peritonitis. Acute Intestinal Ischemia. History of recent MI ; AF; Or Atherosclerosis

Rupture AAA.
Medical Causes

Acute Abdominal Pain in Elderly Patients

In Elderly patients >60 years old; after exclusion of the commonest causes of Acute Abdominal Pain; as: Acute Cholecystitis ' Acute Pancreatitis; Acute Appendicitis; Active/Perforated PU; and UTI; the patients should be investigated and may have colonic obstruction/ perforation due to Colo-rectal carcinoma; diverticular abscess In patients >70 years old; 10% of patients with Acute Abdominal Pain will have Vascular Accident; Acute Intestinal Ischemia; or MI.

Messages

 Accurate History and complete clinical Examination are

essential to put provisional diagnosis/or short list of DD; and to institute diagnostic tests and to decide if the patient will need urgent surgery.

It is NOT Important to make specific diagnosis but to detect

Urgent and immediate Life-Threatening conditions. The diagnosis of acute abdominal pain; particularly in early stage of presentation is often difficult and is accurate only in 45-65% of patients. So the patient should be re-examined by the same physician after resuscitation. Define Surgical from non-surgical Abdomen. The term Acute

Abdomen should never equate with the invariable need for

surgery.

 Special Attention should be made for the extreme of agethe children and old age. Analgesia-Make the patient pain-free.

Opioids as (Morphine and Pethidine) don't mask the

physical signs or prevent accurate diagnosis. Indications of Surgical Consultation:-

(A.)-Severe Progressive Abdominal Pain.

(B.)-Involuntary Abdominal Muscles Guarding/Rigidity. (C.)-Bile-stained or Faeculent Vomiting. (D.)-Haemodynamically Instability(Fluid/Blood Loss)-Signs of hypoperfusion as un-explained acidosis.