ACUTE ABDOMEN.

PRESENTED BY -
DR PRIYANKA BORUDE.
 Definition

 The term acute abdomen refers to a sudden,

severe abdominal pain of unclear etiology
that is less than 24 hours in duration.
 • It is in many cases a medical / surgical (non
trauma)
 emergency, requiring urgent and specific
diagnosis.
 •Several causes need surgical treatment.
Epidemiology

 Can be trivial or life threatening

 •About 10-15% of Casualty visit
 Gastroenteritis is the most common cause of abdominal
pain not requiring surgery
 • In patients age 60 and older, biliary disease and
intestinal obstruction are the most common cause of
acute abdomen that is surgically correctable
 • Appendicitis is the most common cause
 of abdominal pain requiring surgery in patients < age 60
 • Appendicitis is the leading cause of
acute abdominal pain in children (32%)
The Physiology Of Abdominal Pain

 There are three types of Abdominal pain :

 Visceral Pain,
 Somatic (Parietal) Pain
 Referred Pain
Visceral pain•
 originates in abdominal organs covered
by peritoneum

Deep, Dull, Aching or Cramping and poorly

localised Stimulated by Stretching,
Distension or Contractions of the gut or
other hollow abdominal organ .
 Traction on the bowel mesentry
Inflammation or Ischemia Usually felt in the
midline, unaccompanied by tenderness.
Parietal (Somatic) Pain

 •Sharper and better localised and easily

described Aggravated by Stimulation or
Irritation of the parietal peritoneum with
movement, coughing or walking.
 • Cardinal signs : Pain, Guarding, Rebound
and Absent bowel sounds
 • A true parietal pain is the Surgical cause of
abdominal pain
Referred Pain

 Pain felt over the site other than that of the

primary noxious stimulus Occurs in an area supplied
by the same neuro segment as the involved organ
 Most visceral pain is of this type
 Its usually intense and most often secondary to an
inflammatory lesion
Eg: Sub diaphragm – shoulder pain
Biliary tract – right shoulder pain
Small bowel – back pain /
Appendicitis – Umbilical region
Abdominal Cavity

• Superior border =
diaphragm
• Inferior border =
pelvis
• Posterior border =
lumbar spine
• Anterior border =
musculara l adominal
wall
Differential Diagnosis By
Location
 Epigastrium

 Acid / Peptic Disease (Ulcer, GERD, Gastritis)

 Angina / Myocardial Infarction
 Aortic Aneurism, Cholelithiasis,
Choledocholithiasis
 Diaphragmatic Defect (Acquired / Congenital) &
Hernias
 Para esophageal Hernia, Gastric Volvulus,
Perforated Esophagus
 Gastroenteritis, Pancreatitis
 Carcinoma ( Gastric / Pancreatic / etc…)
 Right Upper Quadrant

 Cholelithiasis, Choledocholithiasis
 Liver Related ( Hepatitis / Hepatomegaly /
Abscess / Malignancy)
 Renal Related ( Pyelonephritis
Nephrolithiasis /Ureterolithiasis )
 Sub-diaphragmatic Abscess
 Appendicitis ( Reterocecal / Malrotated)
 Right side Pneumonia
Left Upper Quadrant

 Pancreas Related ( Pancreatitis / Malignancy)

 Gastric Ulcer / Intestinal Obstruction /
Mesenteric Thrombosis Colonic Ischemia /
Perforation Spleen Related (Infarct/ Rupture/
Abscess)
 Renal Related (Pyelonephritis/
Nephrolithiasis/ Ureterolithiasis)
 Sub diaphragmatic Abscess
 Left side Pneumonia
Peri-Umbilical / Mid-Abdomen

 Aortic Aneurysm
 Appendicitis
 Small Bowel Obstruction
 Ischemia (Intestinal Angina)
 Gangrene
Right / Left Lower Quadrant

 Appendicitis ( only for right lower quadrant)

 Colon Related - Colitis (Ulcerative / Pseudo
Membranous) / Diverticulitis (Meckler's) /
Carcinoma / Perforated Caecum / Colonic
Ischemia Sigmoid Volvulus / Diverticulitis
( only for left lower quadrant)
 Crohn’s Disease
 Hernia ( Inguinal / Femoral / Incarcerated)
 Psoas Abscess
RLQ & LLQ Continued

 Renal Related - Pyelonephritis / Nephrolithiasis

/ Ureterolithiasis
 • Gynecological :
Ruptured Ectopic (Tubal) Pregnancy /
Ovarian Torsion / Cyst / PID / Tubo ovarian
pathologies / Infections / Abcess Endometriosis
/ Salpingites / Malignancies / etc…
 Typhilitis
 Rectus / Retroperitoneal Hematomas
Supra – Pubic Region

 Urinary Tract Infection

 Diverticulitis
 Gynecological - Endometriosis, Endometritis,
 Pelvic Inflammatory Disease
 Prostitis
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 localized
Burning- peptic ulcer symptoms
Stabbing-ureteric colic
Gripping-smooth muscle spasm e.g. intestinal
obstruction worse by movement
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
Symptoms--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

 Vital signs
Temp.
 low grade: appendicitis, ac.
 Cholycystitis ; high grade: abscess Pulse, BP, Resp.rate
General examination-
Conjuctival pallor,cyanosis, jaundice Signs of dehydation
 Cervical lymphadenopathy - mesentric
 adenitis

Cardio-pulmonary examination – MI, basal

 pneumonia, pleural effusion
Physical Examination of the
Abdomen
 Inspection
 Auscultation
 Percussion
 Palpation
Inspection
 General observation
 Look at abdominal
contour,note location of
any scars, rashes or lesions
Other parts of the body – ex
– eyes scleral icterus – may
indicate hepatobiliary
disease
Inspection

 Patient twisting/ bending in agony - likely

has colicky abdominal pain caused by
ureteral lithiasis
 Patient lying very still – more likely to have
peritonitis
 Patient leaning forward to relieve pain -
may have pancreatitis
Auscultation

 Useful in assessing peristalsis

 • Bowel sounds are widely transmitted
through the abdomen therefore, necessary
to listen in all 4 quadrants
 • Auscultation should last at least 1 minute
 • Bowel sounds typically highly pitched so
the diaphragm of the stethoscope should
be used
 ? Bowel sounds normal/
hyperactive/hypoactive
 • Auscultation should
precede percussion and
palpation
 • ? Abdominal bruits -listen
over aortic,iliac and
renal arteries
History Of Presenting Illness

 Pain : When? Where? How?

 Onset : Abrupt / Gradual / How often / How
Long?
 Character : Dull / Sharp / Burning / Steady /
Intermittent Radiation / Quality / Severity /
Timing
 Previous Occurrence
 Accompanied by: Vomiting, Nausea, Anorexia
 Aggravating and Relieving factors
Physical Examination
 Overall appearance : Facial expression, diaphoresis, pallor,
mental status and degree of agitation
 Position: Sitting, recumbent or constantly moving around
 Vitals : Temperature (< 97F or >101F – consider abdominal
sepsis),
 Tachycardia, Hypotension
 Inspection : Scars, hernias, distention, discoloration or visible
masses
 Auscultation: Hyper active or hypo active bowel sounds, silent
BS or pulsatile
 bruit, borborygmi (stomach rumble)
 Percussion: Dull (fluid filled) / shifting dullness / liver or spleen
dullness
Continued….

 Palpation:
 •Tenderness
 Rigidity and guarding
 Board like abdomen
 Rebounding pain
 Rectal digital examination
 Per vaginal examination
 Careful examination of Heart, Lung and Sk
Lab Investigations

 Complete blood count (including differentials, ESR,

CRP, platelet count,peripheral smear) & Blood
Culture, BUN, Creatinine, Serum electrolytes
( sodium, potassium, bicarbonate)
 Complete urinalysis (with culture)
 Beta HCG – woman of child bearing age
 LFT – Bilirubin, ALP, ALT, AST, GGT – for RUQ pain &
jaundice
 Amylase, Lipase – for epigastralgia
 PT, APTT, bleeding time, clotting time
 ECG, CK – epigastralgia with aged patient
Diagnostic Imaging
 X-Ray – Standing CXR, upright and supine Abdominal X-ray ( helpful
for obstruction – free air visible)
 X-ray KUB – for Calcifications, air fluid levels, reactive bowel
patterns.
 Foreign bodies
 Ultrasound : rapid, safe & low cost, shows fluid, inflammation, air in
walls, masses, better for specific injuries( appendix, spleen, liver, gall
bladder, CBD,
pancreas, kidney, aneurysm, prostate, ovaries, uterus and other
pathologies)
 CT Scan: useful for diagnosis of bowel obstruction, diverticulitis,
colitis,
sepsis, abscess, free air, vessels, malignancies and ischemic bowel
(gold standard for acute pancreatitis/ appendicitis) and other fishing
expeditions as its better for a more generalised abdominal survey …
 •Radiographic:
Nuclear medicine ( for malignancies),
Angiography (for ischemic bowel/aneurysms),
etc…
 •Endoscopy : used judiciously
 •Laparoscopy : Diagnostic and Treatment
 •Exploratory Laparotomy
Peritonitis

 Primary : caused by spontaneous bacterial

seeding from states such as cirrhosis. No GI
leak.
 Secondary: caused by GI / GU leak ( PID,
ulcer rupture, etc..)
 Tertiary: Secondary turning into chronic
infection after closure of the leak.
Immediate Management
 Immediate insertion of a large bore IV and start with rather Saline
or Ringer Lactate solution (for fluid and electrolyte correction)
 IV / IM pain medication / Analgesics (Pro: can get more accurate
history and do examination / Con: Surgeons don’t suggest it and
prefer consultation immediately)
 Nasogastric tube if vomiting or concerned about obstruction
 Foley’s catheter to follow hydration status and to obtain
urinalysis
 Antibiotic administration if suspicious of inflammation or
perforation
 Definitive treatment or procedure (varies with diagnosis)
 Reassess patient on a regular basis and Refer to concerned
surgeon when indicted
When to Operate – Surgical consult

 Peritonitis : Excluding primary peritonitis

 Abdominal pain + Tenderness + Sepsis +
Shock
 Acute Intestinal Ischemia
 Pneumoperitoneum / Hemoperitoneum
 Exclude Pancreatitis
 Operable Tumor / Malignancies
When not to operate….
•
 Cholangitis
 • Appendicial abscess
 • Acute diverticulitis + abscess
 • Acute pancreatitis / hepatitis
 • Ruptured ovarian cyst
 • Long standing perforated
 ulcer
 • Diabetic ketoacidosis
 • Myocardial infarction, acute
 pericarditis
 • Pulmonary infarction, pneumonia
 • GE reflux, adrenal insufficiency
 • Acute porphyria
 • Rectus muscle hematoma
 • Pyelonephritis, sickle cell crisis
THANK YOU.