‫‪Lecture 35‬‬

‫‪Surgery‬‬

‫‪The Acute Abdomen‬‬

‫© כל הזכויות שמורות לחברת שילוב ‪ -‬קורס הכנה לבחינות‬

‫הרישוי לרפואה בישראל בע"מ ‪ .2013‬אין להעתיק או להפיץ את‬
‫המצגות ואין לעשות כל שימוש במצגות שאינו פרטי ואישי‪.‬‬
 Definition

The term acute abdomen refers to

signs and symptoms of abdominal
pain and tenderness, a clinical
presentation that often requires
emergency surgical therapy.
 Introduction
> 1000 causes exist
Non Specific Abdominal Pain (34%)
Acute appendicitis (28%)
Acute cholecystitis (10%)
SBO (4%)
Perforated PU (3%)
Pancreatitis (3%)
Diverticular disease (2%)
Others (13%)
20-40% admission rates
50-65% inaccurate initial diagnosis
 Pathophysiology
Visceral pain
Distention, inflammation or ischemia in hollow viscous
& solid organs
Localisation depends on the embryologic origin of the
organ:
 Forgut to epigastrium
 Midgut to umbilicus
 Hindgut to the hypogastric region
Parietal pain
Is localized to the dermatome above the site of the
stimulus.
Referred pain
Produces symptoms, not signs
 The Physical Examination

An organized and thoughtful

physical examination is critical to
the development of an accurate
differential diagnosis and the
subsequent treatment algorithm.
 General Abdominal Pain
Perforation
AAA
Acute pancreatitis
DM
Bilateral pleurisy
 Central Abdominal Pain
Early appendicitis
SBO
Acute gastritis
Acute pancreatitis
Ruptured AAA
Mesenteric thrombosis
 Epigastric Abdominal Pain
Duodenal/Gastric Ulcer
Esophagitis
Acute pancreatitis
AAA
 RUQ Abdominal Pain
Gallbladder disease
Duodenal Ulcer
Acute pancreatitis
Pneumonia
Subphrenic abscess
Algorithm for the treatment of right upper quadrant abdominal pain
 LUQ Abdominal Pain
Gastric Ulcer
Pneumonia
Acute pancreatitis
Splenic rupture
Acute perinephritis
Subphrenic abscess
Algorithm for the treatment of left upper quadrant abdominal pain
 Suprapubic Abdominal Pain
Urinary retention
UTIs
Cystitis
PID
Ectopic pregnancy
Diverticulitis
 RLQ Abdominal Pain
Acute appendicitis
Mesenteric adenitis
Diverticulitis
PID
Salpingitis
Ureteric colic
Meckel’s diverticulum
Ectopic pregnancy
Crohn’s disease
Biliary colic
Algorithm for the treatment of right lower quadrant abdominal pain
 Loin Pain
Muscle strain
UTIs
Renal stones
Pyelonephritis
 LLQ Abdominal Pain
Peritonitis
Diverticulitis
Constipation
IBS
PID
Rectal Carcinoma
Ulceritive Colitis
Ectopic pregnancy
Algorithm for the treatment of left lower quadrant abdominal pain
Specific Diagnoses
 Abdominal Aortic Aneurysm
Localized weakness of
blood vessel wall with
dilation
Pulsating mass in abdomen
Can cause lower back pain
Rupture , shock,
exsanguinations
 Appendecitis
Usually due to
obstruction with
fecalith
Appendix
becomes swollen,
inflamed
gangrene, possible
perforation
 Appendecitis
Pain begins periumbilical  moves to
RLQ
Nausea, vomiting, anorexia, fever
Patient lies on side, right hip, knee flexed
Pain may not localize to RLQ if appendix
in odd location
Sudden relief of pain = possible
perforation
 Bowel Obstruction
Blockage of inside of intestine
Interrupts normal flow of contents
Causes include adhesions, hernias,
fecal impactions, tumors
Cramping abdominal pain, nausea,
vomiting (often of fecal matter),
abdominal distension
 Cholecystitis
Inflammation of gall
bladder
Commonly associated
with gall stones
More common in 30 to
50 year old females
Nausea, vomiting,
RUQ pain, tenderness,
fever
Attacks triggered by
ingestion of fatty foods
 Diverticulitis
Pouches
become blocked
and infected
with fecal
matter causing
inflammation.
Pain,
perforation,
severe
peritonitis.
 Peptic Ulcer Disease
Steady, well-localized
epigastric or LUQ pain
Described as a “burning”,
“gnawing”, “aching”
Increased by coffee,
stress, spicy food,
smoking
Decreased by alkaline
food, antacids
 Peptic Ulcer Disease
Erosion of the lining of
the stomach, duodenum,
or esophagus
May cause massive GI
bleed
Patient lies very still with
complaint of intense,
steady pain, rigid
abdomen with exam,
suspect perforation
 Ectopic Pregnancy
Fertilized egg is
implanted outside the
uterus.
Growth causes
rupture and can lead
to massive bleeding.
Patient complains of
severe RLQ or LLQ
pain with radiation.
 Esophageal Varices
Dilated veins in
lower part of
esophagus
Common in EtOH
abusers, patients
with liver disease
Produce massive
upper GI bleeds
 Gastroesophageal Reflux
Signs and
symptoms can
mimic cardiac
pain.
Usually onset
after eating.
Typically
resolved with
medication.
 Inguinal Hernia
Protrusion of the
intestine through a
tear in the inguinal
canal.
Usually identified
by abnormal mass
in lower quadrant,
with or without
pain.
Strangulation can
lead to necrosis.
 Pancreatitis
Inflammation of
pancreas
Triggered by ingestion of
EtOH, triglycerides,
gallstones etc.
Nausea, vomiting;
abdominal tenderness;
pain radiating from
upper abdomen straight
through to back
Signs, symptoms of
hypovolemic shock
 Pelvic Inflammatory Disease
Inflammation of
the fallopian tubes
and tissues of the
pelvis
Typically lower
abdominal or
pelvic pain,
nausea, vomiting
 Splenic Trauma
Blunt force
trauma is typical.
Signs and
symptoms may not
developed until 24
hours later.
Pain usually LUQ
but may present
atypical to other
quadrants.
 Limitations
Limitations based on the
relationship between
Overlying tenderness
Underlying surgical disease
35% of intra-operative diagnoses
are considered to have had atypical
presentations
 Essential History
 Site
 Nature & character
 Duration
 Intensity
 Precipitating & relieving factors
 Associated symptoms
 Classification
Colicky Nagging Burning
pain Biliary colic PUD
Baseline of Cholecystit Esophagitis
no pain in is
true colic PID
IBS UTI
Bowel
obstruction Gnawing
Pancreatic
Stabbing cancer
AAA Pancreatiti
s
 Systemic Examination
Abdomen
Inspection
Scaphoid or flat in peptic ulcer
Distended in ascites or intestinal
obstruction
Visible peristalsis in a thin or
malnourished patient (with obstruction)
 Systemic Examination
Palpation
Check for Hernia sites
Tenderness
Rebound tenderness
Guarding- involuntary spasm of muscles
during palpation
Rigidity- when abdominal muscles are
tense & board-like. Indicates peritonitis.
 Systemic Examination
Local Right Iliac Fossa tenderness
Acute appendicitis
Acute Salpingitis in females
Low grade, poorly localized tenderness
Intestinal Obstruction
Tenderness out of proportion to examination
Mesenteric Ischemia
Acute Pancreatitis
Flank Tenderness
Perinephric Abscess
Retrocaecal Appendicitis
 Important Signs
Sign Finding Association

Cullen's sign Bluish periumbilical Retroperitoneal

discoloration haemorrhage

Kehr's sign Severe left shoulder pain Splenic rupture

Ectopic pregnancy
rupture
McBurney's sign Tenderness located 2/3 distance
from Appendicitis
anterior iliac spine to umbilicus
on right side
Murphy's sign Abrupt interruption of Acute cholecystitis
inspiration on palpation
of right upper quadrant
Sign Finding Association

Iliopsoas sign Hyperextension of right hip Appendicitis

causing abdominal pain

Obturator's sign Internal rotation of flexed right Appendicitis

hip causing
abdominal pain
Grey-Turner's Discoloration of the flank Retroperitoneal
sign haemorrhage

Chandelier sign Manipulation of cervix causes Pelvic inflammatory

patient to lift disease
buttocks off table
Rovsing's sign Right lower quadrant pain with Appendicitis
palpation of
the left lower quadrant
 Per Rectum Examination
 Tenderness
 Induration
 Mass
 Frank blood
 Per Vagina Examination
Bleeding
Discharge
Cervical motion tenderness
Adnexal masses or tenderness
Uterine Size or Contour

Gynecologist’s job, not the surgeon’s!

 Surgical Myths
Rebound tenderness, considered the clinical
indicator of peritonitis, has a high (25%) false
negative rate
Rigidity, referred tenderness & cough pain are
sufficient evidence for peritonitis
Except for detection of blood, routine PR exams
add little to clinical assessment
Administration of analgesics prior to surgical
consultation does not obscure the diagnosis, but
improves accuracy
 Initial Management
ABCDE
Resuscitation & analgesia (opioid IV)
Full monitoring (including urine)
Low threshold in seeking senior help
 Investigations
CBC (Hb & WCC)
Amylase (Pancreatitis)
U&Es, LFTs
Clotting (acute pancreatitis, sepsis, DIC, liver disease)
Glucose
Type + Screen of Blood
ABG
ECG
Cardiac enzymes (if appropriate)
 Radiography
Erect CXR
Supine AXR
Abdominal US
IVU (renal/ureteric colic)

Plain X-rays have limited utility in the evaluation of AAP

Low diagnostic yield, High incidence of misleading
incidental findings, Lack of impact on management,
Exception: Bowel obstruction or perforation
 Laparoscopy
Early diagnostic laparoscopy may result in
management which is:
Accurate
Prompt
Efficient
Reduces the rate of unnecessary laparotomy
Increases the diagnostic accuracy
May be a key to solving the diagnostic dilemma of
non specific abdominal pain
Algorithm for the treatment of acute severe, generalized abdominal pain
Algorithm for the treatment of gradual, generalized abdominal pain