The

Acute Abdomen

Jason Smith MD DMI FRCS(Gen.Surg)

Consultant Surgeon

Mr Jason Smith - Consultant Surgeon

 Acute Abdomen

General name for presence of signs,

symptoms of inamma4on of peritoneum

Mr Jason Smith - Consultant Surgeon

The problems of a surgeon
If I operate and the problem is not surgical, pa4ent
exposed to unnecessary risk, anesthe4c, etc.
Risks greater with concomitant illness, older age

If I do not operate and problem is surgical, pa4ent at

risk because of wrong therapy.
Again the older pa4ent is under greater burden.

Risk-Predic4on Algorithms

Mr Jason Smith - Consultant Surgeon

Probably needs an operation
Acute pain
Sep4c & toxic
Board-like abdomen
Absent bowel sounds
WBC 25,000
Free air under diaphragm

Mr Jason Smith - Consultant Surgeon

Probably doesnt need an operation
Trivial pain
Robust appearance
SoM abdomen with no guarding
Normal bowel sounds
Normal WBC/CRP

Mr Jason Smith - Consultant Surgeon

Abdominal Anatomy
Organs can be classied as:
Hollow
Solid
Major vascular

Mr Jason Smith - Consultant Surgeon

Solid Organs
Liver
Spleen
Kidney
Pancreas

When solid organs are

injured, they bleed heavily
and cause shock

Mr Jason Smith - Consultant Surgeon

Patient Assessment Initial Views
Does the pa4ent look ill, sep4c or shocked?
Call for help!
Are they lying s4ll
(peritoni4s, shock),
or rolling around in agony
(colic)?
Assess and manage Airway, Breathing and Circula4on as a
priority (as per ALS/ATLS).

Mr Jason Smith - Consultant Surgeon

Patient Assessment Initial Views
As per ATLS, Mx occurs at the same 4me as assessment &
diagnosis
Large bore venon large vein
Oxygen
Analgesia (limited)
Am I out of my depth?
Do I have enough help?
Documenta4on!!
Safety - you

Mr Jason Smith - Consultant Surgeon

Patient Assessment - History
Where do you hurt?
Know loca4ons of major organs
But realize abdominal pain
loca4ons do not correlate well
with source

Mr Jason Smith - Consultant Surgeon

Patient Assessment - History
What does pain feel like?
Steady pain - inammatory
process
Crampy pain - obstruc4ve process
Sharp peritoneal irrita4on
Dull peritoneal stretching

Mr Jason Smith - Consultant Surgeon

Patient Assessment - History
Was onset of pain gradual
or sudden?
Sudden = perfora4on,
hemorrhage, infarct
Gradual = peritoneal
irriga4on, hollow organ
distension

Mr Jason Smith - Consultant Surgeon

Patient Assessment - History
Does pain radiate (travel) anywhere?
Right shoulder, angle of right scapula = gall bladder
Around ank to groin = kidney, ureter
Into middle of back = pancreas, duodenum

Mr Jason Smith - Consultant Surgeon

Patient Assessment - History
Dura4on?
<6 hour dura4on = ? surgical signicance
Nausea, vomi4ng? Bloody? Coee Grounds?

Any blood in GI tract =

Emergency until proven otherwise

Mr Jason Smith - Consultant Surgeon

Patient Assessment - History
Change in urinary habits? Urine appearance?
Change in bowel habits? Appearance of bowel
movements? Melena?

Mr Jason Smith - Consultant Surgeon

Patient Assessment - History
Regardless of underlying cause vomi4ng or diarrhea can
be a problem because of associated volume loss

Everybody has pancreatitis until proven

otherwise

Mr Jason Smith - Consultant Surgeon

Patient Assessment - History
Females
Last menstrual period?
Abnormal bleeding?

In females, abdominal pain =

Gynaeproblemuntil proven otherwise

In females, abdominal pain = Pregnant

until proven otherwise

Mr Jason Smith - Consultant Surgeon

Physical Exam
General Appearance
Lies perfectly s4ll inamma4on, peritoni4s
Restless, writhing obstruc4on
Abdominal distension?
Ecchymosis around umbilicus, anks?

Mr Jason Smith - Consultant Surgeon

Physical Exam

Vital signs
Tachycardia ? Early shock (more important than BP)
Rapid shallow breathing peritoni4s

Young / Old patients have different

responses to fluid loss

Mr Jason Smith - Consultant Surgeon

Physical Exam
Palpate each quadrant
Work toward area of pain
Warmhands, gentle approach!
Pa4ent on back, knee bent (helps relax)
Use childs own hand
Note tenderness, rigidity, involuntary guarding, voluntary
guarding (steth-test), masses

Mr Jason Smith - Consultant Surgeon

Physical Exam
Bowel Sounds
Listen 1 minute in each quadrant
Listen before feeling
Absent bowel sounds ileus, peritoni4s, shock

Auscultating bowel sounds has no value in

trauma patients

Auscultating bowel sounds in reality is a

waste of time in the acute phase

Mr Jason Smith - Consultant Surgeon

Management
Airway
High ow O2
An4cipate vomi4ng, appropriate clothing, bowel
An4cipate hypovolemia hence large bore cannulae
Nothing by mouth, un4l DDx established
Limited analgesics

Mr Jason Smith - Consultant Surgeon

Management
In adults > 30, consider possibility of referred cardiac
pain.
In females, consider possible gynaeproblem,
especially tubal ectopic pregnancy

Mr Jason Smith - Consultant Surgeon

Acute Abdomen - Investigations
Urinalysis
FBC, U&E
Plain AXR
(CT)

Mr Jason Smith - Consultant Surgeon

The WCC in 570 patients
Diagnosis Sensi+vity % Specicity %
Appendici4s () 91 21
Cholecys44s () 78 11
Obstruc4on () 56 8
Gastroenteri4s (N) 49 11
Other Non-surgical (N) 62 82

Predic4ve value of WCC for surgical condi4on 29%

Predic4ve value of WCC for non-surgical cond 93%

Mr Jason Smith - Consultant Surgeon

Sensitivity of plain AXR- 249 Patients
% Abnormal
Appendici4s 48
Cholecys44s 64
Pancrea44s 60
Intes4nal Obstruc4on 98
Perforated Ulcer 60

Mr Jason Smith - Consultant Surgeon

Frequency of Diagnoses in 1000 Patients

Unknown 41% Cholecys4s 4%

Urinary Tract 9% Intes4nal Obst 2.5%
Gastroenteri4s 7% Cons4pa4on 2%
PID 7% Misc 7%

80%!!

Mr Jason Smith - Consultant Surgeon

Appendiscitis
Age Young > old
Dx correct in 50%
Several episodes
Sx Central dull to RIF sharp
N&V
Off food
Si Pain, foetor
WCC, CRP waste of time

Ix Exclude gynae problems

Mx Fluid balance
Antibiotics
Laparoscopy or open

Mr Jason Smith - Consultant Surgeon

Stomach/duodenum Perforation
Age Young men & alcohol
Older anyone & drugs

Sx Pain, generalised, sharp, upper

Rigidity

Si Peritonism
Shock +/- sepsis

Ix Air under diaphragm

CT better

Mx Fluid resus most important

Laparotomy & oversew / patch
Conservative?

Mr Jason Smith - Consultant Surgeon

Age Young men & alcohol
Older anyone & drugs

Sx Haematemesis +/- Melena

Si Shock
Rockall score
Wilson Index
Ix OGD
(mesenteric angiogram)

Mx Fluid resus most important

OGD inject
Laparotomy & underun

Mr Jason Smith - Consultant Surgeon

Age Fat, female, forty, fertile
Common in Asians

Sx Colicky upper abdo pain

(stools/urine), Courvoisier's sign
N&V
Si Palpable GB
Jaundice

Ix USS +/- CT
(Must exclude Ca Pancreas)

Mx Conservative
Lifestyle adjustment / lipids
Lap Chole

Mr Jason Smith - Consultant Surgeon

Age Overweight, women > men
Hx Gallstones

Sx Acute sharp RUQ pain rad to back,

shoulder
N&V
Si Pyrexia +/- Rigors, tachcardia
Jaundice

Ix Bloods
USS +/- CT

Mx Antibiotics (met) 20% are infected

Analgesia
Lap Chole (acutely)

Mr Jason Smith - Consultant Surgeon

Cholangitis
Age As for previous

Sx Acute sharp RUQ pain rad to back,

shoulder
N&V
Si Pyrexia +/- Rigors
Jaundice
(Charcots Triad)
Ix Bloods
USS +/- CT
(medical emergency)
Mx Antibiotics (inc met)
ERCP / PTC
Lap Chole

Mr Jason Smith - Consultant Surgeon

Acute Pancreatitis
Age Any age, predom younger with alcohol
& older with gallstones

Sx Constant pain, N&V++

Shock

Si Pyrexia
(Peritonism)
(Jaundice)
Ix Bloods (amylase & CRP)
USS +/- CT
(medical emergency)
Mx Supportive & complex
(surgery)

Mr Jason Smith - Consultant Surgeon

Meckels Diverticulum
Age Rare, often found incidently

Sx Rectal bleeding
Sx similar to appendiscitis

Si

Ix Radioisotope scan

Mx Remove only if symptomatic

Mr Jason Smith - Consultant Surgeon

Small bowel obstruction
Age All ages, depends on underlying cause
5-10% of all admissions

Sx Colicky general pain

Vomiting early/late
constipation
Si Distended resonant abdomen
tinkling bowel sounds
shock
Ix CT

Mx Fluid balance
Conservative vs Operative

Mr Jason Smith - Consultant Surgeon

Mesenteric Ischaemia
Age 50% embolic, 25% atheroma,
10% venous
90% mortality
Sx Incredibly difficult to diagnose
Severe central pain
Pain out of proportion to findings
Si WCC, acidosis, lactate

Ix Laparotomy

Mx Embolectomy, grafting, resection

Open & close

Mr Jason Smith - Consultant Surgeon

Acute Diverticulitis
Age 10% at 40yrs
60% by 80yrs
Sx common in middle age/elderly
Sx Usually LIF pain
+/- constipation +/- rectal bleeding

Si Tenderness
Fever, tachycardia
Raised WCC & CRP
Ix Ba enema / flexi
CT

Mx Antibiotics, lifestyle
2 strikes and its out!

Mr Jason Smith - Consultant Surgeon

Lower GI Bleed
Age Age determines likely cause

Sx BR / DR rectal bleeding

Si Shock
Wilson Index

Ix Flexi / colonoscopy / angiogram

Mx Fluid balance & Mx of shock then

underlying cause

Mr Jason Smith - Consultant Surgeon

Perforated colon
Age Age determines likely cause
Dont overlook iatrogenic & self
induced causes
Sx Peritonism
Tachycardia

Si Shock
Generalised tenderness, boardlike

Ix WCC, CRP
CT

Mx Resuscitate
Laparotomy +/- stoma

Mr Jason Smith - Consultant Surgeon

Acute Severe Colitis
Age Young 20-35, women > men

Sx Bloody diarrhoea , mucus urgency ++

Generalised abdo pain

Si Shock
Anaemic, WCC up

Ix Flexi / colonoscopy
Plain films

Mx Fluid balance & Mx of shock

Steroids, cyclosporin
Joint Mx with physicians

Mr Jason Smith - Consultant Surgeon

Acute Abdominal Pain
Non-surgical Emergencies
Mesenteric Adeni4s
Acute Enteric Infec4ons
Acute Enteric Poisonings
Inammatory Bowel Disease
Pancrea44s (usually)

11/98 44 medslides.com
Mr Jason Smith - Consultant Surgeon
Acute Abdominal Pain
Metabolic Causes
Diabe4c Ketoacidosis
Heavy Metal Poisoning
Acute Porphyria
Sickle Cell Crisis

11/98 45 medslides.com
Mr Jason Smith - Consultant Surgeon