ACUTE ABDOMEN

BY DR.NAJAM-UL-HAQ
ASSOCIATE PROFESSOR OF SURGERY
[email protected]
 ACUTE ABDOMEN
 ANATOMY
 PHYSIOLOGY
 AETIOLOGY
 INVESTIGATIONS
INTRODUCTION

 Spectrum of surgical, medical and gynecological conditions,

ranging from the trivial to the life-threatening, which require
hospital admission, investigation and treatment.
 Acute abdominal pain is defined as severe pain of more than 6
hours’ duration in a previously healthy person that requires timely
diagnosis and aggressive treatment, frequently surgical.
 Intra-abdominal process causing severe pain requiring admission
to hospital, and which has not been previously investigated or
treated and may need surgical intervention.
 ANATOMY ABDOMEN
Lies between the diaphragm and pelvis bounded by the margin of the lower
ribs, abdominal muscles and vertebral column
 MUSCLES
 Rectus abdominis, internal and external obliques and transverse
abdominis collectively produce trunk flexion and rotation

 More importantly these muscles protect the underlying abdominal

viscera.
 Abdominal Topography
 RUQ LUQ
 RLQ LLQ

 UPPER ABDOMEN
 LOWER ABDOMEN
 CENTRAL

 GENERALIZED
 TOPOGRAPHY
 Nine regions
 Four quadrants
8 ANATOMY
 LUQ;
 Spleen
 Pancreas (retroperitoneal)
 Stomach
 Left kidney (retroperitoneal)
 Splenic flexure of colon
9 Anatomy

 RUQ
 Liver
 Gall bladder
 Head of pancreas
 Duodenum
 Right kidney (retroperitoneal)
 Hepatic flexure of colon
 ANATOMY
10
 RLQ
 Appendix (supposed to be here)
 Ascending colon,
 Small intestine
 Right ovary, Fallopian tube
 LLQ
 Small intestine
 Descending colon,
 Left ovary, Fallopian tube
11
 Flank;
lateral abdomen
 Peritoneal; membrane lining the abdomen
 Most organs within peritoneum
 Retroperitoneal;
 kidneys, part of duodenum, part of
pancreas.
 CIRCULATORY SYSTEM
12 (ABDOMINAL CAVITY)

 Descending aorta
 Superior mesenteric and
inferior mesenteric arteries
 Aorta divides

 Iliac arteries
 Inferior vena cava
 Portal system
13 Genitourinary System
 Kidneys
 Ureters
 Urinary bladder
 Urethra
14
Male reproductive system
Testes
Epididymis
Prostate
Vas deferens
Urethra
Penis
Female reproductive system
Ovaries
Fallopian tubes
Uterus
Vagina
Vulva
DERMATOMES
PHYSIOLOGY
 RELATION OF PAIN TO EMBRYOLOGY
 Intestine and its outgrowths
(the liver, biliary system and pancreas)-> midline.

 FOREGUT STRUCTURES
(oesophagus to the second part of the duodenum)
->EPIGASTRIC AREA.

 MIDGUT STRUCTURES
(the second part of the duodenum to the splenic
flexure) ->UMBILICUS.

 HINDGUT STRUCTURES
(the splenic flexure to the rectum)->
HYPOGASTRIUM.
 SOMATIC PAIN
 SHARP, INTENSE, LOCALISED
VISCERAL PAIN

 DIFFUSE,DIFFICULT TO LOCALISE, AND REFER TO

CUTANEOUS DERMATOME
REFERRED PAIN
 PAIN REFERRED TO STRUCTURE WITH
SAME EMBRYONIC SEGMENT
REFERRED PAIN
 BILIARY COLIC
 REFERRED PAIN(BOAS SIGN)
RENAL COLIC
 CAUSES

A. Gastrointestinal-
1-Gut 2-Liver and biliary tract
Acute appendicitis cholecystitis
Intestinal obstruction cholangitis
Perforated peptic ulcer Hepatitis
Diverticulitis biliary colic
Inflammatory bowel disease
3-Pancreas
Acute exacerbation of peptic ulcer
Acute pancreatitis
Gastroenteritis
Mesensteric adenitis 4-Spleen
Meckel’s diverticulitis Splenic infarct and
spontaneous rupture
 CAUSES
B. Urinary tract D. Abdominal wall conditions
Cystitis Rectus sheath haematoma
Acute pyelonephritis
Ureteric colic
Acute retention E. Peritoneum
Primary peritonitis
Secondary peritonitis
C. Vascular
Ruptured aortic aneurysm
Mesenteric embolus
Mesenteric venous
thrombosis
Ischemic colitis
Acute aortic dissection
 CAUSES
F. Retroperitoneal
Hemorrhage e.g anticoagulants

G. Gynecological
Torsion of ovarian cyst
Ruptured ovarian cyst
Fibroid denegeration
Ovarian infarction
Salpingitis
Pelvic endometriosis
Severe dysmenorrhea
Endometriosis
 CAUSES
H. Extra-abdominal causes
Lobar pneumonia
Pleurisy
MI
Sickle cell crisis
Uremia
Hypercalcemia
DKA
Addison’s disease
Acute intermitent porphyria
TORSION OF TESTIS
INTESTINAL OBSTRUCTION
OBSTRUCTED INGUINAL HERNIA
INTUSSUSCEPTION
ACUTE APPENDICITIS
 MANAGEMENT
 History
 Physical examination
 Management

 History-
 Biodata
Age:
 Mesenteric adenitis in children
 Diverticulitis in elderly

Gender
CHARACTERISTICS OF ABDOMINAL PAIN
 Site
 Time and mode of onset
 Severity
 Nature/Character
 Progression
 Radiation
 Duration
 Cessation
 Exacerbating/relieving factors
 Associated symptoms
 SYMPTOMS--PAIN
Onset
sudden: perforation of bowel, smooth muscle colic
slow insidious onset: inflammation of visceral
peritoneum

Severity
Patient asked to rate pain from 1-10
Ureteric colic is one of worst pains

Character
Aching-dull pain poorly localised
Burning- peptic ulcer symptoms
Stabbing-ureteric colic
Gripping-smooth muscle spasm e.g. intestinal
obstruction worse by movement ; wringing of cloth
SYMPTOMS--PAIN
Progression
-Constant e.g. peptic ulcer
-Colicky e.g. seconds(bowel), minutes(ureteric colic)
or tens of minutes (gallbladder)
-may change character completely from dull poorly
localized pain to sharp pain indicates involvement of
parietal peritoneum e.g. appendicitis

Radiation of the pain

Back: duodenal ulcer, pancreatitis, aortic aneurysm
Scapula: gall bladder
Sacroiliac region: ovary
Loin to groin: ureteric colic
Groin: testicular torsion
PAIN
Cessation-
abrupt ending- colicky pains
resolving slowly-inflammatory pain,
biliary pain

Exacerbating/relieving factors-
Movement/Rest-inflammatory conditions
Food- peptic ulcers
 HISTORY
PAST HISTORY
previous surgery
trauma
any medical diseases
DRUG HISTORY
corticosteroid: mask pain
anti-coagulant: intra-mural hematoma
NSAIDS: gastritis, peptic ulcer
FAMILY HISTORY
colon cancer
IBD
 PHYSICAL EXAMINATION
General appearance
-Patient is lying motionless
acute appendicitis, peritonitis

-Rolling in bed
ureteric colic, intestinal colic

-Bending forward
chronic pancreatitis
Physical Examination
VITAL SIGNS
Temp.
low grade: appendicitis, acute cholycystitis
high grade: abscess
Pulse, BP, Resp.rate

GENERAL EXAMINATION-
Conjunctival pallor
cyanosis
jaundice
Signs of dehydration
Cervical lymphadenopathy
-mesenteric adenitis
 Physical Examination
CARDIO-PULMONARY EXAMINATION

-MI
-basal pneumonia
-pleural effusion
 PHYSICAL EXAMINATION
Abdomen
*Inspection
*Palpation
*Percussion
*Auscultation

Inspection
-movement with respiration
-distension, peristalsis, mass, scars and any
obvious cough impulse at hernia site
 PHYSICAL EXAMINATION
PALPATION
*superficial palpation
-tenderness,rebound tenderness, guarding,
rigidity, masses, hernial orifices
*deep palpation
-organomegaly
PERCUSSION
-tympanic note: intestinal obstruction
-dullness over bladder: acute retention
 PHYSICAL EXAMINATION
Auscultation
-silent abdomen: peritonitis
-increase bowel sound: intestinal obstruction
**Don’t forget to examine rectum for tenderness, mass,
blood and vaginal examination for discharge,
tenderness( PID).
CLINICAL DIAGNOSIS
CLASSIFICATION WITH AGE
Children Adult female
Gastroenteritis Salpingitis
Mesentric adenitis Pyelonephritis
Meckel’s diverticulitis Ectopic pregnancy
Intussusception
Henoch-schonlein Elderly
purpura Diverticulitis
Intestinal obstruction
Adult Colonic carcinoma
Regional enteritis Mesentric infarction
Ureteric colic Aortic aneurysm
Perforated ulcer
Testicular torsion
Pancreatitis
 INVESTIGATION
 Urea, electrolyte, creatinine, glucose (DKA)
 LFT(LIVER FUNCTION TEST)
 Amylase ( high in acute pancreatitis)
 urinalysis
 CXR ( basal pneumonia, free gas under diaphragm)
 CBC with differential (infection and inflammation)
 X-Rays plain abdomen erect and supine
-distended bowel with air fluid level
-stones
-calcified aorta
-air in biliary tree
 INVESTIGATION
U/S (ovarian cyst, ectopic pregnancy)
IVU for stones
Angiography (mesentric embolus or thrombosis)
Sickling test
Pregnancy test
 RADIOGRAPHS
 X-RAYS CHEST PA VIEW ERECT
 LATERAL DECUBITUS RADIOGRAPH
 SUPINE PLAIN RADIOGRAPH OF THE ABDOMEN
INTESTINAL OBSTRUCTION

Can determine the level of obstruction

large/small bowel. Ileum jejunum or colon
LATERAL DECUBITUS FILM FOR FREE GAS IN
ABDOMEN
IN CRITICAL PATIENTS NOT ABLE TO STAND/SHIFT
BED SIDE
 IMAGING

Free gas under both domes of diaphragm

FAECOLITH RIF
one of the causes of appendicitis
ERCP-THERAPEUTIC
STONE IN CBD
ACUTE CHOLECYSTITIS
 ULTRASONOGRAPHY

LIVER,GALLBLADDER,BILE
DUCT,SPLEEN,PANCREAS, KIDNEYS, OVARIES,
UTERUS, ADNEXA, INTRA-ABDOMINAL
COLLECTION
PERISTALSIS,
 ULTRASONONGRAPHY

 COLOR DOPPLER
 CONVENTIONAL
 CT-SCAN
 OVERCOME THE LIMITATIONS OF
ULTRASOUND
 INDENTIFY THE UNFORESEEN CONDITIONS
 REDUCE HOSPITAL STAY
 REDUCE MORTALITY
 CORRECT DIAGNOSIS
 EXCLUDE ALTERNATE DIAGNOSIS
 WATER SOLUBLE CONTRAST
STUDIES

DIFFERENTIATE PSEUDO OBSTRUCTION FROM ORGANIC

OBSTRUCTION OF LARGE BOWEL
 ENDOSCOPY
 UPPER AND LOWER GASTROINTESTINAL TRACT
 RIGID AND FLEXIBLE SIGMOIDOSCOPY
 ERCP
 VISCERAL ANGIOGRAPHY

 INTESTINAL ISCHEMIA
 ANGIOEMBOLISATION
 LAPAROSCOPY
 UNCERTAIN ACUTE ABDOMINAL PAIN
 LAPAROTOMY

 AS ULTIMATE DIAGNOSTIC INVESTIGATION

 TREATMENT
1. Resuscitation
2. Relieve the pain
3. IV fluids and nasogastric suction
4. Antibiotics in case of peritonitis or sepsis
5. Surgery if indicated

*Indication for surgery:

If patient has guarding or rigidity with peritoneal irritation
spreading tenderness
Progressive distension or generalized peritonitis
Shock with bleeding or sepsis
Free gas on x-ray
Mesentric occlusion on angiography
Blood, pus or bile on paracentesis