Acute Abdomen

ACUTE ABDOMEN
Dr. S Uma Sankar

PGDFM No 17PGDFM096
INTRODUCTION
• Definition:
• Acute abdomen means the patient complains of an acute
attack of abdominal pain that may occur suddenly or
gradually over a period of several hours and presents a
symptom complex which suggests a disease that possibly
threatens life and demands an immediate or urgent diagnosis
for early treatment.
• Many diseases, some of which are not surgical or even
intraabdominal, can produce acute abdominal pain and
tenderness.
• Because of the potential surgical nature of the acute
abdomen, an expeditious workup is necessary . The workup
proceeds in the usual order of history, physical examination,
and laboratory and imaging studies.
• Despite improvements in laboratory and imaging studies,
history and physical examination remain the mainstays of
determining the correct diagnosis and initiating proper and
timely therapy.
• The diagnoses associated with an acute abdomen vary
according to age and gender. Both surgical and non surgical
conditions cause acute abdomen .
• Nonsurgical Causes of the Acute Abdomen :
• Endocrine and Metabolic Causes
• Uremia
• Diabetic crisis
• Addisonian crisis
• Acute intermittent porphyria
• Hereditary Mediterranean fever
• Hematologic Causes
• Sickle cell crisis
• Acute leukemia
• Other blood dyscrasias
• Toxins and Drugs
• Lead poisoning
• Other heavy metal poisoning
• Narcotic withdrawal
• Black widow spider poisoning
Surgical Acute Abdominal Conditions:
• Hemorrhage
• Solid organ trauma
• Leaking or ruptured arterial aneurysm
• Ruptured ectopic pregnancy
• Bleeding gastrointestinal diverticulum
• Arteriovenous malformation of gastrointestinal tract
• Intestinal ulceration
• Aortoduodenal fistula after aortic vascular graft
• Hemorrhagic pancreatitis
• Mallory-Weiss syndrome
• Spontaneous rupture of spleen
• Infection
• Appendicitis
• Cholecystitis
• Meckel’s diverticulitis
• Hepatic abscess
• Diverticular abscess
• Psoas abscess
• Perforation
• Perforated gastrointestinal ulcer
• Perforated gastrointestinal cancer
• Boerhaave syndrome
• Perforated diverticulum
• Blockage
• Adhesion induction small or large bowel obstruction
• Sigmoid volvulus
• Cecal volvulus
• Incarcerated hernias
• Inflammatory bowel disease
• Gastrointestinal malignant neoplasm
• Intussusception
• Ischemia
• Buerger disease
• Mesenteric thrombosis or embolism
• Ovarian torsion
• Ischemic colitis
• Testicular torsion
• Strangulated hernias
History and Complaints
• A detailed and organized history is essential to formulating an
accurate differential diagnosis and subsequent treatment
regimen.
• Abdominal pain
• 1) visceral pain: vague and poorly localized. It is usually the
result of distention of a hollow viscus.
• 2) Parietal pain corresponds to the segmental nerve roots
innervating the peritoneum and tends to be sharper and
better localized.
• 3) Referred pain is pain perceived at a site distant from the
source of stimulus.
• Nature of pain:
• Sudden onset of excruciating pain suggests conditions such as
intestinal perforation, colic, torsion and arterial embolization.
• Pain that develops and worsens during several hours is typical
of cholecystitis, colitis, and bowel obstruction.
• Site of pain usually coincides with the position of the affected
organ. Flank pain suggest renal origin , right upper quadrant
pain suggests liver or gallbladder diseases, epigastic region
suggests peptic ulcer perforation ,acute pancreatitis,
periumbilical pain in case of small bowel pain, colon pain is
centered between the umbilicus and the pubic symphysis.
• Shifting of pain seen in acute appendicitis.
• Referred pain
• Right Shoulder
• Liver ,Gallbladder, Right hemidiaphragm
• Left Shoulder
• Heart,Tail of pancreas,Spleen,Left hemidiaphragm
• Scrotum and Testicles
• Ureter
• Activities that exacerbate or relieve the pain are also
important. Eating will often worsen the pain of bowel
obstruction, biliary colic, pancreatitis, diverticulitis, or bowel
perforation.
• Food can provide relief from the pain of nonperforated peptic
ulcer disease or gastritis.
• Patients with peritoneal inflammation will avoid any activity
that stretches or jostles the abdomen.
• Vomiting:
• Vomiting may occur because of severe abdominal pain of any
cause or as a result of mechanical bowel obstruction or ileus.
• In intestinal obstruction at first stomach contents, next
duodenal contents( bilious) and lastly the intestinal contents
are voided.
• In case of biliary colic the vomiting is usually bilious.
• Pain precedes vomiting in acute appendicitis, acute
pancreatitis, peptic ulcer, biliary and renal colic.
• Bowel habit:
• Absolute constipation i,e arrest of both faeces and flatus is the
usual accompaniment of intestinal obstruction and peritonitis.
• In pelvic appendicitis irritation of the rectum may lead to
tenesmus.
• Diarrheoa occurs in acute ulcerative colitis, regional ileitis and
acute enteritis. Bloody diarrhoea is seen in colonic ischemia.
• Micturition :
• Painful micturition is often seen in ureteric stone and stone in
bladder.
• Menstrual history: it is useful in the diagnosis of ectopic
pregnancy, ruptured leuteal cyst, PID.
• Past surgical history:
• Drug history: narcotics, NSAIDS, steroids, anticoagulants,
recreational drugs.
PHYSICAL EXAMINATION
• The physical examination should always begin with a general

inspection of the patient to be followed by inspection of the
abdomen itself.
• General examination : anemia , cyanosis, jaundice, cervical
lymphadenopathy.
• Vital signs: pulse rate, blood pressure. Respiratory rate,
temperature
• Cardiopulmonary examination: MI, pneumonia, pleural
effusion.
• In peritonitis the patient will typically lie very still in the bed
during the evaluation and often maintain flexion of their
knees and hips to reduce tension on the anterior abdominal
wall.
• Disease states that cause pain without peritoneal irritation,
such as ischemic bowel or ureteral or biliary colic, typically
cause patients to continually shift and fidget in bed while
trying to find a position that lessens their discomfort
• Inspect hernial orifices:
• Contour of abdomen: distended or scaphoid?
• Respiratory movement : sluggish in case of peritonitis.
• Peristaltic movements: ladder pattern in small intestinal
obstruction.
• Pulsatile swelling : aneurysm
• Skin: discolouration of left flank ( grey turner’s sign) and
bluish hue around umbilicus( cullen’s sign) in hemorrhagic
pancreatitis.
• Look for any scars:
• Auscultation:
• Bowel sounds are typically evaluated for their quantity and
quality. A quiet abdomen suggests an ileus, whereas
hyperactive bowel sounds are found in enteritis and early
ischemic intestine.
• Mechanical bowel obstruction is characterized by high-
pitched tinkling sounds.
• ? Abdominal bruits listen over aortic, iliac and renal arteries.
• Percussion: It is used to assess for gaseous distention of the
bowel,
free intra-abdominal air, degree of ascites, or presence of
peritoneal inflammation.
• Palpation:
• Palpation should always begin gently and away from the
reported area of pain. palpation can confirm the presence of
peritonitis as well as identify organomegaly or an abnormal
mass lesion.
• Involuntary guarding, or abdominal wall muscle spasm, is a
sign of peritonitis and must be distinguished from voluntary
guarding.
• Murphy sign – acute cholecystitis
• Rovsing sign- Acute appendicitis
• Digital rectal examination
• Pelvic examination should be included in all women In
evaluating pain located below the umbilicus.
LABORATORY STUDIES
• Hemoglobin
• White blood cell count with differential( infection and
inflammation)
• Electrolyte, blood urea nitrogen, and creatinine concentrations
• Urinalysis
• Urine human chorionic gonadotropin
• Amylase and lipase levels ( pancreatitis)
• Total and direct bilirubin concentration
• Alkaline phosphatase
• Serum aminotransferase
• Serum lactate levels and ABG( intestinal ischemia)
• Stool for ova and parasites
• C. difficile culture and toxin assay
• Pregnancy test
• Imaging studies:
• CXRPA
• plain x ray abdomen for pneumoperitoneum , calcification,
stones.
• Abdominal ultrasonography
• CT abdomen.
• Intraabdominal pressure monitoring: Normal intra-abdominal
pressure is considered to be 5 to 7 mm Hg for a relaxed
individual of average body build lying in a supine position.
• Abnormally elevated pressures are those above 11 mm Hg
and are graded 1 to 4 by severity.
• Diagnostic laproscopy:
• The purported advantages include high sensitivity and
specificity, ability to treat a number of the conditions causing
an acute abdomen laparoscopically, decreased morbidity and
mortality, decreased length of stay, and decreased overall
hospital costs.
• Management:
• Immediate insertion of IV cannula and fluid resusciation( for
fluid and electrolyte correction). A common electrolyte
abnormality requiring correction is hypokalemia.
• Preoperative acidosis may respond to fluid repletion and
intravenous bicarbonate infusion.
• Infusion of antibiotics
• Nasogastric tube placement
• Foley catheter bladder drainage to assess urine output, a
measure of adequacy of fluid resuscitation, is indicated in
most patients.
Indications for surgical exploration
• Involuntary guarding or rigidity ,especially if spreading

• Tense and progressive distension .
• Increasing or severe localized abdominal tenderness.
• Generalized peritonitis.
• Shock with bleeding or sepsis.
• Pneumoperitonium.
• Bile ,pus, blood in paracentesis.
• Mesenteric occlusion on angiography.
Thank you

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ACUTE ABDOMEN

Dr. S Uma Sankar

• The physical examination should always begin with a general

• Involuntary guarding or rigidity ,especially if spreading

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