MODULE 2 Diseases and

Malfunctions
MINICOURSE 4 THE ACUTE
ABDOMEN

INTRODUCTION
Therearefewsituationsinclinicalmedicinewhichdemandprompt
anddecisiveactionasfrequentlyasdoesacuteabdominalpain.Acute
conditions of the abdomen are produced by inflammatory,
obstructive,orvascular
 mechanismsandaremanifestedbysuddenonsetofabdominalpain,
gastrointestinalsymptomsandvaryingdegreesoflocalandsystemic
reaction.Theyrequireurgenttreatment,oftenincludingemergency
operation. Their urgency usually precludes prolonged investigation
andtherearefewspecifictestsorexaminationswhichmayberelied
upon to give clearcut answers as to the exact cause of the acute
condition.
Ifsurgerycarriednoriskanddidnotadverselyaffectthecourseof
some diseases, it would be safe to say "if in doubt, operate."
Unfortunately,laparotomyitselfcarriesrisksandthecourseofsome
disorderssuchasacutepancreatitisandparalyticileusisadversely
influencedbyanesthesiaandsurgery.
Thediagnosisofacuteconditions,therefore,frequentlyresolvesitself
into arriving at a fairly immediate judgement derived from an
accurateanddetailedhistory,acarefulphysicalexaminationanda
fewselectedlabtestsandxraystudies.Whilegatheringtheevidence,
changesshouldbeevaluatedintermsofpathophysiologicalterations
ratherthanspecificdiagnoses,andattentionmustbegiventotheneed
forsupportivemeasureswhileinvestigationisunderway.
AnApproachtotheAcuteAbdomen
Oncompletionofthisminicourseyouwillbeableto:
1 Definetheacuteabdomen.
2 Describe the cause and pathophysiology of the following acute
abdominaldiseases:
a.acuteappendicitisinflammatory
b.acutesmallbowelobstructionmechanical
c.mesentericvascularocclusionvascular
d.perforatedduodenalulcerperforatedviscus
e.peritonitis
3 Identify and describe the symptoms, signs, clinical course and
laboratoryandxrayfindingsfortheacuteabdominaldiseaseslisted
underObjective2.
4 Identifytheclinicalfeaturesthathelptodistinguishthesurgicalfrom
thenonsurgicalacuteabdomen.
5 Construct anapproachtoevaluation andmanagementof theacute
 abdomen.

MINICOURSE2.4SECTION1
OBJ.1.Definetheacuteabdomen.
DefinitionoftheAcuteAbdomen
Theacuteabdomenmaybedefinedgenerallyasanintraabdominal
processcausingseverepainandoftenrequiringsurgicalintervention.
Itisaconditionthatrequiresafairlyimmediatejudgementordecision
as to management. General causes of the acute abdomen may be
dividedintosixlargecategories:
a.inflammatory
b.mechanical
c.neoplastic
d.vascular
e.congenitaldefects
f.traumatic
Eachofthesecategorieshasmanytypicalexamples,ofwhichonlya
few of the more common conditions will be discussed in this
minicourse.
The inflammatory category of causes may be divided into two
subgroups:1)bacterial,and2)chemical.Somecommonexamplesof
thebacterialcauseswouldincludeacuteappendicitis,diverticulitis,
and some cases of pelvic inflammatory disease. An example of a
chemical cause would be a perforation of a peptic ulcer, where
spillageofacidgastriccontentscausesanintenseperitonealreaction.
Mechanical causes of an acute abdomen include such obstructive
conditions as incarcerated hernia, postoperative adhesions,
intussusception, malrotation of the gut with volvulus, congenital
atresiaorstenosisofthegut.Themostcommoncauseoflargebowel
mechanicalobstructioniscarcinomaofthecolon.
Vascular entities producing an acute abdomen include mesenteric
arterialthrombosisorembolism.Whenthebloodsupplyiscutoff,
necrosisoftissueresults,withgangreneofthebowel.
 Congenital defects can produce an acute abdominal surgical
emergencyanytimefromtheminuteofbirth(withconditionssuchas
duodenal atresia, omphalocele or diaphragmatic hernia) to years
afterwardinconditionssuchaschronicmalrotationoftheintestine.
Traumaticcausesofanacuteabdomenrangefromstabandgunshot
wounds to blunt abdominal injuries producing such conditions as
splenic rupture. History or evidence of trauma should make this
diagnosisfairlyobvious.

EXERCISE1OBJECTIVE1Questions
1.Whatismeantbytheterm"acuteabdomen?"
2.Giveanexampleofanacuteabdomenduetoeachofthefollowing
mechanisms:
a.Inflammation
b.Mechanicalobstruction
c.Vascularentities
EXERCISE1DISCUSSION
OBJECTIVE1Answers
1. The term refers to acute conditions arising within the abdomen
associated with severe abdominal pain, requiring fairly immediate
managementandoftenrequiringsurgery.
2.Oneexampleofeachis:
a.Acuteappendicitis
b.Incarceratedhernia
c.Mesentericarterialthrombosis.Ofcourse,therearemanyothers.

MINICOURSE2.4SECTION2
OBJ. 2. Describe the cause and pathophysiology of the following
acuteabdominaldiseases:
a.Acuteappendicitisinflammatory
b.Acutesmallbowelobstructionmechanical
c.Mesentericvascularocclusionvascular
d.Perforatedduodenalulcerperforatedviscus
e.Peritonitis
CauseandPathophysiologyofAcuteAbdomen

a.AcuteAppendicitis
Inflammationintheappendixhasthesamefeaturesandfollowsthe
samecourseasinflammationelsewhereinthegut.Itsimportanceisa
function of its frequency as a serious surgical condition with
significantcomplications.
Obstructionoftheappendiceallumenbyfecalithswithinterferenceof
thevascularsupplyareimportantfeaturesinitspathogenesis.The
essentialelementcausinginflammationofthewalloftheappendixis
invasionbybacteria.Theusualorganismsintheinflamedappendix
arecolonbacilliandstreptococci,organismscommonlyfoundinthe
intestinal tract. Obstruction of the lumen and vascular occlusion
probablycontributebybreakingdowntheresistanceofthewallofthe
appendixtoinvasionbypotentialpathogensinthegut.
Theearliestlesionisasuperficialulcerationofthemucosa.Spread
thenoccursfromthemucosatothemusclelayersandtheserosaand
thelumenmaybecomefilledwithpus.Interferencewithcirculation
leadstoareasofnecrosisandperforationoftheappendix,withspread
ofinfectiontotheperitonealcavity.Iftheinfectionbecomeswalled
offaroundtheappendixalocalizedabscessmayresult.Otherwisea
generalizedperitonitisresults.
The same sort of inflammatory process may occur in acute
diverticulitis which usually involves the descending and sigmoid
colon. This is promoted by the lodging of fecal material in a
diverticulumwithspreadofinflammationtosurroundingtissue,and
isaccompaniedbyleftlowerquadrantpain.
In acute cholecystis there is inflammation of the wall of the gall
bladderduesochemicaldamagefromtheactionofconcentratedbile,
promoted by an obstruction of the cystic duct, usually by stones.
Bacterialinfectionwithstreptococciorcolonbacillimaysupervene.
In acute cholecystis the gall bladder is large and has a thick
edematouswall.Themucosashowsareasofulcerationandnecrosis
andleukocytesarepresentinthewall.Pusmayfillthecavity,withan
empyemaofthegallbladder.Necrosisandrupturemayoccur.

b.AcuteSmallBowelObstruction
Completeobstructiontothepassageofintestinalcontentiscaused
eitherbymechanicalobstructionofthelumenorbyparalysisofthe
intestinalmuscles(paralyticileus)andmaycausedeathinarelatively
shortperiodoftimeunlessrelieved.Acutemechanicalobstructionof
the small bowel is caused most commonly either by strangulated
herniaorbyadhesionsandbands,usuallypostoperative,withthe
peritonealcavity.
Age has a significant influence on the cause of small bowel
obstruction.Innewborns,congenitalproblemssuchasatresiaofthe
gut are important causes of obstruction and in small children
intussusceptionisencounteredwithfrequency.Theobstructionmay
beanentirelymechanicalocclusionofthelumen,whichisthecase
withanincarceratedhernia,congenitalatresiaofthelumenofthegut,
and kinking and external compression of the gut by peritoneal
adhesions,usuallypostoperativeinorigin.
Theremay,however,beanassociatedinterferencewiththebloodand
nervesupplyfortheintestines,inwhichcasethebowelissaidtobe
strangulated. Obstruction such as an incarcerated hernia, if not
promptly reduced, causes increasing edema of the gut with
impairment of the blood supply. Volvulus with twisting of the
mesenteryandintussusception(whereonesegmentofthesmallbowel
invaginatesintoanother)alsocauseinterferencewithnerveandblood
supply. Ischemic necrosis or infarction of the bowel wall occurs
unlessthebloodsupplyispromptlyrestored.Theinvolvedportionof
the intestine becomes in turn congested, edematous, necrotic and
finallygangrenous.Ingeneral,thehigherthesiteofanobstruction
within the intestinal tract, the more severe are the associated
symptoms of excessive vomiting with dehydration and chemical
disturbances occurring because of a great loss of water and
electrolytes.
Themostcommoncauseoflowerintestinalobstructioniscarcinoma
ofthedistalportionofthecolon.Thedevelopmentoftheclinical
pictureisslowerthaninsmallbowelobstructionandpatientsdonot
appearasillincomparablestages.Usuallytheacuteepisodeoflarge
bowelobstructionissuperimposedonprogressivechangeofbowel
habits, with decreasing caliber of the stools and increasing
constipation.
Functional intestinal obstruction due to neurogenic factors which
causeparalysisoftheintestinalmuscleandfailureofperistalsisis
fairlycommon.Itistermedadynamicorparalyticileusanditoccurs
to some extent in most patients who have undergone abdominal
surgery,andmaybeassociatedwithshockoranyseveretrauma,such
ashipfracture.Ischemiaoftheintestinealsorapidlyinhibitsmotility
andparalyticileusresults.Paralyticileusiscommonlyaconcomitant
ofgeneralizedperitonitis.Paralyticileusistreatednonoperativelyby
suctionanddecompressionoftheintestine,andisadverselyaffected
byanesthesiaandsurgery.Itisimportanttodifferentiateafunctional
fromamechanicalobstruction,wheresurgeryisimperative.
Paralyticileusistheendresultinamechanicalobstruction,unlessthe
compromisedbloodsupplyispromptlyrestored.Otherwisetheremay
beinexorableprogression,terminatingingangrene.

c.MesentericVascularOcclusion
Interferencewiththebloodsupplytoasegmentoftheintestine,asin
thrombosisorembolismofthesuperiormesentericvessels,resultsin
a paralytic obstruction without any mechanical blockage. The
majorityofpatientswithembolisminvolvingthesuperiormesenteric
arteryhaveacardiaclesionthatiscapableofthrombusformationand
emboli.Recentmyocardialinfarctionandatrialfibrillationarethetwo
cardiacproblemsthatgiverisemostoftentomesentericemboli.The
segmentofintestinewhichisdeprivedofitsbloodsupplyrapidly
becomescongested,edematousandfinallynecrotic.

d.PerforatedDuodenalUlcer
Whileallthefactorsresponsibleforthedevelopmentandpersistence
ofchronicpepticulcersarenotthoroughlyunderstood,theonefactor
ofestablishedimportanceistheactionofacidpepsingastriccontent
ontheduodenalmucosawithulcerformation.Insomeindividuals
thereseemstobetoomuchgastricacidsecretionwithrespecttothe
degree of protection provided for the mucosa. Peptic ulcers are
constantinlocation,beingfoundinthepyloricportionofthestomach
near the lesser curvature and the first portion of the duodenum
proximal to the ampulla. These chronic ulcers appear as deep,
punchedout, funnelshaped craters whose base is covered with
grayish necrotic material. The base of the ulcer is composed of
fibrousscartissuewhichmaycausedeformityoftheduodenalbulb,
demonstrablebyxray.
Hemorrhagemayresultfromerosionoflargevesselsinthebaseof
theulcer.Perforationmayresultwhentheulcercontinuestopenetrate
deeply and erodes through the wall of the duodenum into a
remarkableseriesofdramaticchanges.Spillageofacidpepticgastric
juice, bile, and pancreatic juice causes a marked chemical
inflammation of the peritoneum comparable to a burn. Bacterial
invasionmaysoonfollow.Withinashorttimemassiveamountsof
extracellular fluid may be extravasated into the area of peritoneal
injuryandthislossoffluidmaybringabouthypovolemicshock.
Acutepancreatitismaycloselysimulateaperforatedduodenalulcer.
Theeffectsarecausedbytheescapeoflyticpancreaticenzymesinto
the gland itself. These act on the parenchyma of the gland, blood
vessels and fatty tissue causing edema, necrosis, hemorrhage, and
suppuration of varying degree. It appears to be due to increased
pancreaticsecretionwithpartialorcompleteobstructionofoutflow
andraisedintraductalpressure.Itmayoccursuddenlywithsevere
abdominalpain,peripheralvascularcollapseorshock,andmaybe
fatal.

e.Peritonitis
Theperitonealcavity,linedbyserousperitonealmembraneswhich
coverthevisceraandtheparietalwalls,isaclosedsacexceptforthe
openingsofthefallopiantubesinthefemale.Generalinflammationof
theperitonealcavityisusuallycausedbybacterialinvasion,which
mayresultbyspread:1)fromarupturedviscussuchasaperforated
peptic ulcer or gangrenous appendix; 2) through an ischemic and
necrotic but unruptured bowel wall, as in strangulated hernia,
mesentericocclusion,orvolvulus;or3)asaresultofextensionof
infectionfromabdominalorganssuchasoccurswithaliverabscess
orapelvicinflammatorydisease.
Themajorityofcasesofperitonitisinvolveorganismsfoundinthe
normal flora of the gastrointestinal tract. Perforation of a hollow
viscusismostfrequentlythesourceofentryoftheseorganisms.The
peritonealinfectionmaybecomewalledoffandlimitedtoalocalized
area as in an appendiceal abscess, or there may be generalized
peritonitis, which may be a serious complication of any of the
diseasesdescribedaboveinad.

EXERCISE2OBJECTIVE2Questions
1. Outline the sequence of events in the pathogenesis of acute
perforatedappendicitis.
2.Thetwomostcommoncausesofacutemechanicalsmallbowel
obstructioninadultsare:
3.Whatisthesequenceofchangeswhichoccurwhenaloopofbowel
becomesstrangulated?
4.Whatistheunderlyingmechanismoftherapiddevelopmentof
generalizedperitonitis,hypovolemicshockandperforatedduodenal
ulcer?
5.Howdonecrosisandgangrenediffer?

EXERCISE2DISCUSSIONOBJECTIVE2Answers
1. Obstruction of appendiceal lumen by a fecalith is followed by
edemaandinterferencewithbloodsupply,ulcerationofmucosaand
bacterialinvasionoftheappendicealwall.Extensionofinfectionto
muscle layers and serosa (viscera] peritoneum) is followed by
increasing impairment of blood supply, ischemia, necrosis and
 perforation. Spillage of infected materials results in localized or
generalizedperitonitis.
2.Incarceratedhernia.Postoperativeadhesions.
3. Mechanical obstruction, as in an incarcerated hernia, causes
increasing distention of the bowel, edema of the gut wall and
interferencewithnerveandbloodsupply.Thesegmentofgutwhich
hasanimpairedbloodsupplyissaidtobestrangulated.Unlessthe
obstruction is relieved and blood supply promptly restored, the
involvedportionrapidlybecomesinturnmorecongested,edematous,
ischemic, necrotic, and finally gangrenous. The nonviable wall is
friable and perforated easily or may allow passage of infected
materialintotheperitonealcavitywithoutgrossperforation.
4. With acute perforation of duodenal ulcer, there is immediate
spillage of highly irritating acidpepsin gastric contents into the
peritoneal cavity, causing an intense peritoneal reaction with a
generalizedchemicalperitonitis.Theperitonealinjuryiscomparable
to an extensive chemical burn, and large amounts of extracellular
fluidmaybeextravasatedintotheareaofperitonealinjury,causing
hypovolemicshock.
5.
Necrosismeansthedeathofagroupofcellsoroftissueusuallyina
localizedarea.
Gangrene iscellandtissuedeathonawidespreadbasis,resulting
fromlossofnutritivesupplyandbybacterialinfection.

MINICOURSE 2.4 SECTION 3: Clinical

presentationofacuteabdomen
OBJ.3. Identifyanddescribethesymptoms,signs,clinicalcourse,
andlaboratoryandxrayfindingsfortheacuteabdominaldiseases
listedunderObjective2.

ClinicalCharacteristicsoftheAcuteAbdomen
Sincepainisthemostprominentpresentingcomplaintinapatient
withanacuteabdomen,itisimportanttoknowtheorigin,location,
radiationandcharacterofabdominalpaininordertounderstandits
significance.
Theperceptionofabdominalpainisfirstvisceralandthenbecomes
somatic.Theabdominalvisceraandthevisceralperitoneumreceive
sensoryfibersviathesympatheticchainfromT5throughL3.The
sensorysupplytothevisceraissparseandvisceralpainisvagueand
poorlylocalized.Thealimentarytractfromtheesophagustotheanal
canalisinsensitivetomanystimuliwhichproduceintensepainin
other structures. The gut can be biopsied, crushed or cauterized
withoutpain.
Iftheboweloranyotherhollowviscusisdistendedorifitsmuscle
coatgoesintospasm,however,painisfelt.Thecauseofvisceralpain
istensioninthemusclefibersproducedbystretchingofthewall,
spasmofthemuscleorstretchingofthecapsuleoftheorgan.Violent
peristalticcontractionsoccurinanattempttoforceluminalcontents
throughanobstruction.Painassociatedwithobstructionissevereand
crampinginnature,butintermittent,withpainfreeintervalsandis
calledcolic.Ischemiaofvisceralmusclegivesrisetopainbecausethe
gutlosesmotilityandbecomesdistended.Visceralpainofischemic
originiscausedmostoftenbystrangulationofthebowelinherniaor
volvulus.Alessfrequentcauseisacutemesentericthrombosis.
The parietal peritoneum which lines the abdominal cavity and the
interior surfaces of the diaphragm derives sensory fibers from the
somatic nerves T6 through L1. When the parietal peritoneum is
irritated, somatic pain results. Somatic pain is with localized
tenderness and spasm of the muscle groups supplied by the
dermatome of origin of the pain stimulus. For example, the right
lowerquadrant(RLQ)pain,tendernessandmusclespasmassociated
withappendicitisiscausedbyinflammationofthecontiguousRLQ
parietalperitoneum.Theabdominalsignsinperforatedpepticulcer,
ontheotherhand,aregeneralizedbecausediffusionofhighlyacid
fluidthroughouttheperitonealcavitycausesintenseirritationofall
theparietalperitonealsurfaces.
Painexperiencedatasiteotherthanthatstimulatedbutinsomatic
zonessuppliedbythesameoradjacentsegmentsofthespinalcordis
calledreferredpain.Visceralpainisreferredtothreezoneslocated
inthemidlineoftheabdomen.Thelocalizationofabdominalpain
indicates which organs may be involved. Epigastric pain is
associated with structures innervated by T6T8, the stomach,
duodenum, pancreas, liver, biliary tree and associated parietal
peritoneum. Periumbilicalpain isrelatedtoinnervationfromT9to
T10 and includes the small intestine, appendix, and upper ureters.
Hypogastricpain hasitsorigininstructuresinnervatedbyTlland
T12,thecolon,bladder,loweruretersanduterus.
Thepatternofradiationofpainmayprovideimportantcluesastoits
origin. For example, pain which initially is located in the
periumbilical area and then moves to the RLQ occurs with
appendicitis,whereaspainintheepigastriumwhichradiatestothetip
oftherightscapulaisfrequentlyfoundwithacutecholecystitis.Such
shiftingorradiationofpaintoalocalizedsitewithlocaltenderness
and muscle spasm denotes local inflammation of the parietal
peritoneumandsuggestsacircumscribedinflammatoryprocess.The
painofrenalcolicusuallyisfeltintheflankandradiatestowardsthe
groinonthesameside.
Painthatinvolvestheentireabdomenalmostimmediatelyafteronset
isusuallyduetofloodingoftheperitonealcavitywithanirritating
fluidfromaperforatedulcer,orfrombloodandchorionictissueina
rupturedectopicpregnancy.
Ageneralruletofollowisthatthemajorityofsevereabdominalpain
occursinpatientswhohaveenjoyedfairlygoodhealthandwhich
persistsaslongassixhoursiscausedbydiseasesrequiringsurgical
intervention.Obviously,therearealwaysexceptionstoanyrule.
 Other features of pain and associated GI symptoms which may
provideimportantcluesastocausearelistedbelowintabularform
withsomeexamplesofeach.

Typeofonset
suddenruptureofviscus,mesentericthrombosisgradual
cholecystitis,appendicitis
Quality
dullinitialepigastricpainofappendicitis
sharprenalorbiliarycolicorobstructionofgut
achingpelvicinflammatorydisease
pleuriticintensifiedbybreathing
lancinatingacutepancreatitis
tearingdissectinganeurysm
Intensity
severeruptureofviscusorbloodintheperitonealcavity
moderateRLQappendiceal
 mildpepticulcer,withoutperforation
Temporalfeatures
continuousacutepancreatitis
pulsatileabdominalaneurysm
colickylumenobstruction,intermittentseverepainwithpainfree
intervals
frequency&durationtransientpainofshortdurationwhichdoesnot
recurisusuallyinsignificant.Thelongerthedurationthemorelikely
asurgicalcondition.
Factorswhichintensifyorrelievepain
relationtomealspepticulcerpainrelievedbyfood,cholecystitis
painaggravatedbyfattymeal
posturejackknifinglegdrawnuptodecreaseperitonealirritationin
suppurativeappendicitis
motionanymovementcausesintensepainingeneralizedperitonitis
andthepatientliesmotionless
Associated nausea and vomiting nausea & vomiting reflex, or
irritativenonspecificvomitingoccursinmanyconditions.Insurgical
disease such as acute appendicitis, anorexia always occurs and
vomiting, if it occurs, usually follows abdominal pain rather than
precedingit,asingastroenteritis.Repeatedvomitingoflargeamounts
occursingutobstruction,isoftenbilestainedandmaybecomefecal.
Protractedvomiting
timeearlyinhighGIobstruction;lateinlowGIobstruction
characterofvomitusbloodbleedingulcerbilestainedobstruction
belowampullaofVaterfecalintestinalobstruction,mechanicalor
withparalyticileus;copiousamount
Diarrheamostcommonwithacutegastroenteritisorfoodpoisoning,
butitmayoccurwithappendicitisorotherfocalinflammatorylesions
ofthegut
ConstipationorobstipationWithcompletesmallbowelobstruction
unrelenting constipation (obstipation) after fecal material below
obstructionhasbeenpassed.Progressiveconstipationwithcarcinoma
ofthelargebowel.
Gasstoppagewithdecreasedorabsentbowelsoundsparalyticileus
All of the patient's symptoms must be carefully considered and
 analyzed,especiallywithregardtoorgansmostlikelytogiveriseto
acuteconditions.Extraabdominalconditionswhichsimulatetheacute
abdomenarisemostoftenintheheart,lungs,urinarytractandfemale
reproductiveorgans.
Theageandsexofthepatientwillprovidehelpfulleadsastowhich
conditions responsible for a "hot belly" are most likely, outlined
below:
Agenewborncongenitalanomalies,gutatresia,imperforateanus,
malrota2ion,diaphragmatichernia
Neonatalhypertrophicpyloricstenosis(males),megacolon,hernia
Laterinfancyintussusception
Childhoodandyoungadultshernia,appendicitismostcommonbut
canoccuratanyage
Young adolescent females "mittelschmerz" rupture of graafian
folliclewithLLQorRLQabdominalpainoccurringinthemiddleof
themenstrualcycle.
Females gallbladder female, fair, fat, forty ectopic pregnancy
pelvicinflammatorydisease
Malespepticulcer
Advancing age mesenteric thrombosis or embolus often after
myocardialinfarction,largebowelneoplasms,diverticulitis
Past history of disease or abdominal operation abdominal scars,
adhesionsintestinalobstructionpepticulcerpossibleperforation
chroniccholecystitisorbiliarycolicacutecholecystitis
PhysicalExamination
Carefulandcompletedatacollectionbyhistoryandphysicalexamis
theprimediagnosticaidtoavoiderrorsofomissionandtoseparate
thoseconditionswhichrequireimmediatesurgeryfromthosewhich
requirewatchfulexpectancy,orthosewhichrequiremedicalrather
thansurgicalmanagement.Oftenthepatient'sconditionissuchthat
extensive laboratory investigation requiring many hours would
compromisethepatient'slifeandthustheoutcomeoftendependsona
preciseanddetailedhistoryandphysicalexamination.
Acompletegeneralphysicalexaminationprovidesessentialdatafor
making the diagnosis, determining the urgency of the condition,
assessing the patient as an operative risk, and making a sound
managementplan.
First, the patient is surveyed rapidly for fever and/or evidence of
shock,hemorrhage,anemia,dehydrationorcardiacdecompensation.
When necessary, if the patient is severely ill and/ or shocked,
resuscitativetreatmentshouldbestartedimmediatelyandadetailed
historyandexaminationdeferredtemporarily.Onobservationofthe
patient, the severity and character of the pain may be apparent.
Temperature, pulse, respiration and blood pressure are recorded,
providingabaselineforlaterobservation.Completeandsystemic
examination of all organ systems is done next, usually deferring
abdominalrectalandpelvicexaminationuntillast.Itisimportantthat
theheartandlungsbecarefullyexamined,notonlytodetermineifan
extraabdominalcauseforabdominalpainispresent,buttodetermine
whetherthepatientisinsatisfactoryconditionforsurgeryifthisis
indicated.
The abdominal examination, including pelvic and rectal, provides
informationwhichindicatesthetypeanddegreeoftheintraabdominal
processonwhichthediagnosiscanbebasedandtherecommendation
fororagainstsurgicalinterventiondetermined.Theabdomenmustbe
exposed completely for examination. The patient should be in a
comfortablesupinepositionwiththekneesslightlyflexedtorelaxthe
abdominalmusculature,andtheexaminershandshouldbewarm.A
calmsympatheticapproachandgentlenessinexaminationonthepart
ofthepractitionerareveryhelpful.Thepatientisaskedtopointwith
onefingertotheareaofgreatestpain,andtheexaminershouldbe
especially gentle when studying these areas. Inspection of the
abdomenmayrevealsignificantsurgicalscars.
Auscultationoftheabdomenisperformednext.Theintestineisquite
sensitivetotouch,andperistalticbowelsoundscanbebestevaluated
bylisteningtotheabdomenbeforepalpatingit.Auscultationismost
helpful in determining functional activity of the bowel. When
alterationsinbowelsoundsoccurinassociationwithotherchanges,
theyhaveclinicalsignificance.Decreaseingastrointestinalmotility
andfunctionispartofthereactiontolocalandgeneralstress.For
example,anacutefractureofthefemurwillcauseaparalyticileus
andasilentabdomen,aswillgeneralizedperitonitis.Theinhibition
generallydoesnotpersistand,afterseveralhoursordays,soundswill
be heard again as bowel function resumes following appropriate
treatment.
Bowelsoundsinestablishedmechanicalobstructionmaybestriking.
The sounds are loud, booming, rhythmical, and synchronous with
colickypain.Asthebowelbecomesdistended,thesoundsbecome
morehighpitchedandtakeonatinklingquality.Borborygmiisthe
termappliedtotheveryhyperactivebowelsoundsassociatedwith
mechanicalobstruction.Earlyinbowelobstructionperistalticactivity
canbeveryvigorous.Intime,however,theobstructedbowelfatigues
andbowelmotilitydecreases,resultinginhypoactiveorabsentbowel
sounds as distentioninhibition and vascular impairment of the
intestinedevelop.
The next step is systematic palpation of the abdomen with light
pressure(toadepthofabout1cm)beginningatadistancefromthe
area of maximal tenderness and alternately testing and comparing
eachsidewiththeoppositeside,whileobservingthepatientclosely
forwincingorotherevidenceofpain.Theentireabdomenispalpated
systematicallyforareasoftenderness,musclespasm,orpresenceof
masses.Anyspecificareaswhichmayappearabnormalshouldbe
retestedandreevaluated.Deeppalpation,againdonegently,gives
more information about deep tenderness or the nature, size, and
consistencyofanylesionormass.Ondeeperpalpationtheexaminer
advancestheprobingfingersdeeperintothepatient'sabdomenwhen
thepatientinspires,asthismaneuvertendstorelaxthemusculatureof
the abdominal wall. When muscle spasm and tenderness are very
marked, deep palpation is quite painful, uninformative and
unnecessary.
Persistent localized tenderness, point tenderness , is the most
important sign of peritoneal inflammation. In acute appendicitis,
when point tenderness is definite, it is an indication for surgery.
Reboundtendernessmaybedemonstratedwhenpainisexperienced
on sudden release of deep pressure. Information concerning a
localizedareaofperitonealirritationmayalsobeobtainedbyhaving
thepatientriseonhistoesandcomedownsuddenlyonhisheels,
identifyingwherepainisfelt.Thisisthesocalled"jarringtest"andit
issaidtobemoreobjectivethanthereboundtest.
Percussionoftheabdomenishelpfulindemonstratinggasorfluidin
holloworgansorinthefreeperitonealcavity.Whentheabdomenis
enlarged and hyperresonant, intestinal distention or pneumo
peritoneum should be considered. Free fluid within the peritoneal
spaces is demonstrated by testing for a fluid wave and shifting
dullness.Inascites,bulgingintheflanksmaybeobserved.Dullness
topercussioncanbehelpfulindeterminingthesizeofanenlarged
spleenorliverorasolidtumormass.
Thephysicalexaminationmustincluderectalpalpationinthemale
and pelvic and rectal examination in the female. Fecal impaction,
pelvic abscess, and neoplasms may produce signs of intestinal
obstruction.Whenaninflamedappendixlieslowinthepelvis,there
mayberectaltendernessorapalpablepelvicmassintheabsenceof
abdominalsigns.Diseaseofthefemalepelvicorgansmayproduce
acuteabdominalconditions.Bimanualpelvicexaminationmayreveal
a tubal or ovarian mass, exquisite tenderness on movement of the
cervix,orbloodyorpurulentcervicaldischarge,suggestiveofacute
pelviccomplications.
Ifphysicalfindingsareequivocal,thepatientshouldbereexaminedat
frequent intervals until a diagnosis can be made and/or proper
managementofthepatientdetermined.
LaboratoryTests
Urgencyofacuteabdominalconditionsusuallyprecludesprolonged
investigation. There are only a few specific tests or examinations
whichmaybereliedupontogiveclearcutanswerstotheexactcause
oftheacutecondition.
Urineandbloodshouldbeexaminedroutinely.Pusorbloodinthe
urinesuggestdiseaseoftheurinarytractandcanalsoresultfroman
inflamed appendix lying in proximity to the ureter or bladder. In
dehydrationthespecificgravityoftheurinemaybeincreased,andthe
red cell and hemoglobin values increased as a result of
hemoconcentration. The total leukocyte count and percentage of
polymorphonuclearcellsareusuallyelevatedinacuteinflammatory
conditions,whereasearlyinthecourseofintestinalobstructionthere
maybenosignificantalterations.Conditionsinwhichtissuenecrosis
occurs, as in a strangulated intestinal obstruction, are generally
associatedwithamarkedpolymononuclearleukocytosis.Withacute
appendicitis,theleukocytosisisn'tgreatunlessyoualreadyhavea
perforatedappendix.
The serum amylase test is essential when the possibility of acute
pancreatitis exists. This possibility should be kept in mind in all
patients with acute severe upper abdominal pain. Serum amylase
valuesinexcessof500unitsaresignificantandlevelsof15002000
units or more are not unusual in the early stages of severe acute
pancreatitis.
Certain tests are indicated when extraabdominal conditions are
suspectedasthecauseofanacuteabdomen.Theseincludebloodand
urine sugar determinations in diabetic keto acidosis, hemoglobin
electrophoresisinpossiblesicklecellcrisis,chestxrayinpneumonia,
EKGincoronaryarterydisease,andleadlevelsinchildrenwithpica
andanemiawithaneyetochronicleadpoisoning.
Serum electrolytes to determine the degree of dehydration and
electrolyte imbalance should be done when fluid loss has been
significant.

XrayExamination
Plainxrayfilmsoftheabdomeninthesupineanduprightpositions
canoftenprovideimmediateinformationwhichhelpstoconfirma
diagnosisorexcludecertaindiagnoseswhichhavebeenconsidered.
Gasbelowthediaphragmintheuprightfilmisalmostpathognomonic
orperforationofahollowviscus,usuallyarupturedpepticulcerora
traumaticperforation.
In mechanical small bowel obstruction, plain films in the upright
positionrevealdilateddistendedloopsofgutwithfluidlevelsabove
the obstruction, and absence of gas below the obstruction, i.e.,
terminalileumandcolon.Generalizeddistentionoflargeandsmall
boweloccursinparalyticileus.
Plain films may reveal the presence of radiopaque gall stones or
 kidneystones.
UsuallyupperGIbariumstudiesarecontraindicatedbecauseofthe
possibility of barium leakage into the peritoneal cavity when
perforationisimpendingorperforationexists.Bariumenemaisan
importantdiagnosticaidinintussusceptionofinfantsandchildren,
andsometimesisusedtherapeuticallyunderlowpressuretoreduce
the intussusception. Barium enema may also be helpful in
diverticulosis of the colon and in large bowel neoplasms, where
sigmoidoscopyandbiopsymaybehelpful.
Whenacutecholecystitisissuspected,intravenouscholangiographyis
useful for differential diagnosis. When the patient is acutely ill,
investigationandsupportivetreatmentshouldproceedconcurrently,if
aspecificdiagnosisisnotimmediatelyapparent.Supportivetreatment
includesnasogastricsuctiontorelievedistention,intravenousfluidsto
correctfluidandelectrolyteimbalanceandtoprovidemaintenance
duringperiodsofnooralintake,andtypingandcrossmatchingof
bloodforpossibletransfusion.
Exceptinacaseofsevereprostratingpain,narcoticsshouldnotbe
useduntildiagnosisisestablishedbecausetheymaymaskimportant
clinicalfeaturesofthepain.Inacuteinfectiousconditionsantibiotics
areusuallybegunaftercultureshavebeenobtainedandadiagnosis
fairly well established because they may alter early characteristic
clinical features which may be important in diagnosis. Choice of
antibioticswillbedeterminedbysensitivityresultsoncultures.
NowforbriefclinicalpicturesofthediseaseslistedinObjective2,a
throughe.TableIandIIsummarizesalientclinicalfeaturesofthe
morecommonconditionswhichcauseormimictheacuteabdomen.
a.AcuteAppendicitisInacuteappendicitispainistypicallythefirst
symptom.Theinitialpainisdiffuseandnotwelllocalized,withadull
painintheepigastriumorperiumbilicalregion.Afteraperiodofa
fewhours,thepainshiftstotherightlowerquadrant(RLQ)ofthe
abdomen and becomes more localized and severe. Anorexia is an
important symptom in patients with appendicitis. Nausea and
vomitingarevariableinfrequencyandintensity,andwhentheydo
occur,theyusuallyfollowtheabdominalpain.However,themajority
ofpatientslosethedesiretoeatordrinkandmayactuallyhavean
aversiontofood.Temperature,pulse,andrespiratoryratearewithin
normal limits early in the disease. Later the temperature may be
elevated, but seldom exceeds 101 degrees unless perforation has
occurred.Attheonset,thepatientwithcolickypain(duetoafecalith
in the lumen) may be somewhat restless. However when the pain
becomeslocalizedintheRLQ,thepatientusuallypreferstolieonthe
rightsidewiththethighflexed.LocalizedtendernessintheRLQis
thesinglemostimportantfindinginacuteappendicitis.Thedegreeof
muscleguardingvariesconsiderablyandreboundtendernessmaybe
demonstrable.Rectalexaminationisessentialintheexaminationof
patientssuspectedofhavingappendicitis.Whentheappendicitisisin
theretrocecalposition,rectalexaminationelicitsmarkedtenderness
which may be minimal or absent on abdominal examination.
Laboratorydeterminationsareoflimitedvalue.Thewhitecellcount
maybenormalorslightlyelevatedintherangeof1012,000with
someincreaseinthenumberofneutrophils.Withperforationofthe
appendix, the white count and percentage of neutrophils increase
markedly.Thechiefcomplicationofacuteappendicitisisperforation
withabscessformationordiffuseperitonitis. Oftenthesevereright
lowerquadrantpainsubsidespromptlyatthetimeofperforationand
thepatientisrelievedofacutesymptomsforabriefperiod.Steady
pain, however, then develops that may spread to involve the
remainder of the abdomen as the clinical picture associated with
diffuseperitonitisdevelops.Whentheclinicalpictureofappendicitis
isequivocal,ashortperiodofobservationoftwotofourhoursmay
be helpful as the patient is carefully observed for progression of
symptoms.Nonarcoticsshouldbegiven.Repeatedexaminationand
determinationoftemperature,pulse,respiratoryrateandwhitecell
anddifferentialcountsshouldbedoneatfrequentintervals,untilthe
diagnosisisestablishedordisproven.Awidevarietyofproblemsmay
mimicacuteappendicitis.Ruptureofagraafianfollicleintheright
ovary(mittelschmerz)maysimulateappendicitis.Thisisacommon
causeoflowerquadrantpainofovarianoriginandtypicallyoccursin
themidportionofthemenstrualcycle.Otherconditionswhichmay
simulate acute appendicitis include pelvic inflammatory disease,
mesentericadenitisinyoungchildren,anddiverticulitis. Obviously
 thespecifictreatmentofappendicitisisappendectomy.Theprognosis
is excellent when the operation is performed before perforation
occurs. Perforation of the acutely inflamed appendix is a serious
complicationwhichstillresultsinsignificantmorbidityandmortality.
b. Acute Small Intestinal Obstruction Acute obstruction of the
smallbowelinadultsiscausedmostcommonlyeitherbyincarcerated
herniaorbypostoperativeadhesionswithintheperitonealcavities.
Age has a significant influence upon the cause of small bowel
obstruction. In newborns, congenital problems such as atresia and
meconium ileus are important causes of obstruction. In young
children,intussusceptionisencounteredwithfrequency. Ingeneral,
thehigherthesiteoftheobstructionwithintheintestinaltract,the
moreseverethesymptoms.Painisusuallysuddeninonset,severe,
andspasmodicinnaturebecauseitresultsfromvigorousperistaltic
activityofthebowelasitattemptstopropeltheintestinalcontents
throughthesiteofobstruction.Thepatientwilloftendoubleupwith
painduringcrampingdistressandthenhaveabriefperiodoffreedom
fromdistress.Vomitingoccursearlyinhighintestinalobstructionand
iscopiousinamount.Initiallythevomituscontainsgastriccontents,
followed by small intestinal contents later, usually bile colored. If
persistentvomitingoccurs,andiftheobstructionisinthelowerpart
ofthesmallbowel,thevomitusbecomesfecalincharacter.Usually
withestablishedintestinalobstructionthepatientisunabletopass
flatusorstoolsspontaneously.Bowelcontentsbeyondtheobstruction
maybepassed,however,andinchildrenwithintussusception,this
material contains bloody mucus which gives it the characteristic
"currantjelly"appearance.Intheearlystages,temperature,pulserate
and respiratory rate are normal, as is the white count. Increased
temperature with elevated white count suggest that strangulation
obstructionisdeveloping.Onexamination,inspectionwillrevealthe
presence or absence of surgical scars or evidence of inguinal or
femoral hernia. Palpation is usually not revealing but with
intussusception, a sausageshaped mass may be felt in the right
abdomen.Thismassistheinvaginatedsegmentofthesmallintestine.
Progressivedistentionoccurs.Tendernessandmusclerigidityinthe
presence of intestinal obstruction are suggestive of peritoneal
 inflammationandstrangulationobstruction.Auscultationwillreveal
increasedbowelsounds.Duringepisodesofpain,loudhighpitched
peristalticrushesoccur.Asdistentionprogresses, interferencewith
neurogenicandvascularelementsoftheboweldevelops,motilityis
reduced and bowel sounds are decreased. Vomiting with high
intestinalobstructionisassociatedwithsignificantlossoffluidand
electrolytes,anddehydrationandelectrolyteimbalanceensuerapidly
unless the obstruction is relieved. Circulatory impairment leads to
ischemiaandnecrosisofthegutwallandprogressivereductioninall
bowelfunctions. Plainxrayfilmsareoftendiagnostic.Thebowel
loops above the obstruction are distended with gas and fluid with
absenceofgasseenbelowthelevelofobstruction.Intheuprightfilm
fluidlevelsarefoundinthedilatedloops.Theconditionsmostlikely
tobeconfusedwithbowelobstructionarethoseinwhichcolickypain
inasmoothmuscleorganistheoutstandingsymptom;thusdiseases
ofthegallbladder,theurinarytract,andthefemalepelvicorgansmay
resemble an intestinal obstruction. Paralytic ileus or functional
intestinal obstruction must also be considered. Surgery is not
indicated for paralytic ileus and may adversely affect its course.
Examination of the abdomen with a stethoscope is most helpful.
Bowelsoundsinparalyticileusarehypoactivetoabsent,incontrast
tothehyperactivesoundsassociatedwithmechanicalobstruction.
Treatment of mechanical obstruction consists in relieving the
obstructionsurgicallyattheearliesttimeconsistentwithsafetyofthe
patient.Thedistentionmustbecorrectedbysuctiondecompression
andfluidelectrolyteblooddeficitsrepaired,buttheoperationshould
be done as soon as possible when the patient is in satisfactory
conditionandbeforeischemicnecrosisdevelops.Strangulationofthe
bowelisadangerouscomplicationwhichisthecauseofmostdeaths
fromobstruction.Whenbloodsupplyiscompromised,theinvolved
segmentsbecomenecrotic,perforateeasilywithdiffusesoilingofthe
peritoneal cavity, and resection of the gangrenous bowel will be
required.
c. Acute Mesenteric Vascular Occlusions Mesenteric artery
occlusion can result from thrombosis or embolism which usually
arisesfromarecentmyocardialinfarctionoratrialfibrillation.Thisis
 ararebutseriouscauseofanacuteabdomen,characterizedbysudden
onset of severe diffuse abdominal pain associated with nausea,
vomiting, progressive distention, and sometimes bloody diarrhea.
Typically,thepainisoutofproportiontothephysicalfindingswhich
are minimal at the onset. Initially peristalsis is hyperactive, then
graduallydiminishes.Whenperistalsisisabsent,thebowelwallis
usuallynotviable.Signsofperitonitisdeveloprapidlywithdistinctly
elevatedwhitecellcountandelevatedtemperature.Xrayfilmsofthe
abdomenmayrevealwidespreadgasandfluidfilledloopsofbowel
butnegativexrayfindingsdonotexcludethisdiagnosis.Itcanbe
suspected in a patient who has a cardiac lesion capable of
embolizationandsuddenonsetofdiffuseseverepain,bloodinthe
stoolsandtherapiddevelopmentofsignsofperitonitis.
d.PerforatedDuodenalUlcerPerforationofaduodenalulcerisone
of the important causes of the development of sudden severe
abdominalpain.Typicalhistoryinvolvesamaleusuallybetween20
and 40 years of age who has a history of episodes of epigastric
distressrelievedbymilkandantacids.Theepisodeofperforationis
usually dramatic, with sudden, severe, midepigastric pain which
spreadsrapidlytoinvolvetheentireabdomen.Thepatientliesvery
still and resists any movement, which is very painful. After the
appearanceofpain,thepatientmayvomitonceortwicebutvomiting
isnotacommonfeatureofperforatedulcer.Thepainissosevereand
prostrating that the patient may faint. On examination, the patient
appearsveryill,ingreatdistress,withmoderatetachycardia.Blood
pressure is usually normal for the first several hours. Palpation
demonstratesdiffuseabdominaltendernessandrigidityofthemuscle
wall which has been described appropriately as "board like."
Auscultation reveals the bowel sounds to be absent or markedly
diminished.Thewhitebloodcellcountincreasesquicklyandmayrise
to 15,000 within a few hours. An upright film of the chest and
abdomen will reveal air under the diaphragm in about 85Z of the
cases. Thisispathognomonic ofaperforatedulcer, inconjunction
withthecharacteristichistoryandphysicalfindingsalreadydescribed.
Acutepancreatitismaybedifficulttodistinguishfromaperforated
ulcer. Many patients with pancreatitis have either a history of
 alcoholism or gallstone disease. The onset of pancreatitis is more
gradualandisoftenassociatedwithprodromalepisodesofepigastric
distress 23 weeks before the onset of the severe pain which is
constant, epigastric in location and radiates through to the back.
Muscletendernessandspasmmaybelimitedtoormoremarkedin
the upper abdomen and the rigidity is less marked than with a
perforated ulcer. The serum amylase level is markedly elevated in
inflammatory disease of the pancreas and free air under the
diaphragm is not found on xray examination. Lobar pneumonia
involvingtherightlowerlobemayleadtoamistakendiagnosisof
subdiaphragmaticdisease.Acarefulhistoryandexaminationofthe
patient should provide a clue to the pulmonary disease. Rapid
respiration,cyanosis,dyspnea,cough,andfeverarehelpfulsigns.X
raywillconfirmtheRLLconsolidationandabsenceoffreeairunder
the diaphragm. Rupture of the abdominal aneurysm may produce
suddensevereprostratingpain,butthepictureofbloodlossandshock
predominatesquickly,suggestingthetruenatureofthecatastrophe
whichmayberapidlyfatal.
e.PeritonitisCausesofperitonitishavealreadybeendiscussed.Itis
obviousthattheonsetofperitonitisvarieswidelydependinginlarge
partupontheorganinvolvedandthenatureoftheprimaryprocess.
Perforationofaduodenalulceroccurssuddenlyanddramaticallyand
theinitialinsultisprimarilyachemicalperitonitisduetotheacid
gastricjuice.Bacterialinvasionoccurslater.Perforationoftheacutely
inflamedgallbladderismoreinsidiousandmayoccurwithfew,if
any, changes in the clinical picture in a patient with acute
cholecystitis.Whentheoriginoftheperitonitisliesinthepelvis,as
withpelvicinflammatorydisease,thepatientmayreportthatthepain
beganinthehypogastriumandspreadupward.Physicalfindingsmay
varywidely.Temperatureandpulserateareelevatedinmostpatients.
Painisthemostimportantsymptomandisusuallyverysevereand
mostpronouncedintheareaoforiginoftheperitonealcontamination.
Atfirstitisoftenalocalizedperitonitisintherightupperabdomen
when the gall bladder perforates, or in the left lower quadrant
followingperforationofsigmoiddiverticulitis.Spreadingofthepain
toinvolvemoreoftheabdomenisastrongevidencethatgeneralized
peritonitisisdeveloping.Painintheshouldersindicatesinvolvement
ofthediaphragmaticsurfacesbytheinflammatoryprocessbutdoes
not assist materiallyin localizing thesite ororigin.Vomiting isa
commonlyassociatedsymptomwhichisusuallyreflexatfirst,but
becomes more pronounced as paralytic ileus develops with
progressionofperitonealinflammation. Onexamination,thepatient
appearspale,ingreatpain,withbeadsofsweatontheforehead.Any
motionispainfulandthepatientusuallyliesverystillwiththighs
flexedtorelaxabdominalmusculature.Respirationsaresplintedand
shallow.Auscultationrevealsdecreasedtoabsentbowelsounds.On
palpationthereisgeneralizedtendernessandrigidityoftheabdominal
walls. Rectal examination and pelvic examinations in women are
importantfordiagnosisofrectocecalappendix,PID,tubalpregnancy
and neoplasm. The diagnosis of acute peritonitis is usually not
difficult.Itisofgreatimportance,however,todeterminethecauseof
the peritonitis in order to institute appropriate treatment promptly.
The most commonly encountered diseases that lead to peritonitis
whennottreatedareacuteappendicitis,acutecholecystitis,perforated
pepticulcer,andacutediverticulitis.Earlyremovalorclosureofthe
sourceofperitonealcontaminationisafundamentalruleoftreatment
whenpossible.Forexample,aperforatedappendixmustberemoved,
arupturedulcermustbeclosed,andanecroticsegmentofgutmust
be resected. An exception to this rule would be the nonsurgical
antibiotictreatmentofacutepelvicinflammatorydiseasewhichhas
causedleakageintotheabdominalcavity.Carefulattentionmustbe
giventothepatient'spreoperativestateandallnecessarymeasures
takentoimprovehiscondition.Thisusuallyrequiresthecorrectionof
fluidandelectrolyteimbalance,blooddeficits,suctiondecompression
of the gastrointestinal tract and institution of vigorous antibiotic
therapy.Earlyoperationisindicatedassoonasthepatient'scondition
permits.
 EXERCISE3OBJECTIVE3Questions
1.Whatarethedifferencesbetweenvisceralandsomaticpain?
2.Visceralpainfromtheseorganswouldbeexperiencedinwhatzone
oftheabdomen?
1 pancreas
2 smallintestine
3 colon
4 uterus
3.Identify theusualpatternof radiationof painwhichsuggestsa
diagnosisof:
1 a.acuteappendicitis
2 b.acutecholecystitis
3 c.renalcolic
4. a. Describe the pain which occurs with acute small bowel
obstruction.
b.Describetheearlybowelsoundsinacutesmallbowelobstruction.
5. On physical examination, what is the most important and
dependableearlysignsofperitonealinflammation?
6. On an upright film of the abdomen, demonstration of free air
beneaththediaphragmispracticallypathognomonicof?
7.Whatisthemostlikelydiagnosiswiththefollowingdata?
a.Peristalticpaincolickyinnature.Copiousvomitingofbilestained
material. Failure to pass stool, previous abdominal operation or
presenceofhernia.
b.Historyofalcoholismorgallstones.Diffuseepigastrictenderness
 and severe pain which radiates to the back. Elevation of serum
amylaselevels.

EXERCISE3DISCUSSIONOBJECTIVE3Answers
1.Visceralpainresultsfromgutdistentionandstretchingorspasmof
themusclefibers.Itiscarriedbysympatheticnervefibers,andis
experiencedasdull,vague,poorlylocalizedpaininthemidzonesof
theabdomen.
Somatic pain results when the parietal peritoneum is inflamed or
irritated.Itiscarriedbysensoryfibersinsomaticnerves.Itisbetter
defined,morelocalized,greaterinintensity,andisassociatedwith
localizedtendernessandspasmofthemusclegroupssuppliedbythe
samedermatomeofthecord.
2. a. epigastrium b. periumbilical area c. hypogastrium d.
hypogastrium
3.
a.epigastric>RLQ
b.epigastric>RUQ>rightscapulararea
c.flank>groinonsameside
4. a. intermittent severe, cramping, colicky pain, with painfree
intervals b. the bowel sounds are loud, booming, rhythmical and
synchronouswiththecolickypain
5.localizedpointtenderness
6.rupturedhollowviscus
7. a. mechanical small bowel obstruction, due to postoperative
adhesionsoranincarceratedhernia
b.acutepancreatitis

MINICOURSE2.4
SECTION4
OBJ. 4. Identify the clinical features that help to distinguish the
surgicalfromthenonsurgicalacuteabdomen.
 Surgicalvs.NonsurgicalAcuteAbdomen
In Tables I and II are summarized characteristic features for
differentialdiagnosisofcommonconditionswhichmayeithercause
or mimic an acute abdomen. Table IV divides these diseases into
surgicalandnonsurgicalgroups.Althoughitisnotalwayspossibleto
make an exact diagnosis preoperatively, it is obvious that certain
clinicalfeaturesofintraabdominaldiseasearehighlysuggestiveor
practicallypathognomonicofanacuteabdomenwhichmayrequire
promptsurgicalintervention.Thesefeatureswhichmayoccursingly
orincombinationarelistedbelow:
1 Severe abdominal pain in patients who have been fairly well, and
whichpersistsaslongassixhours.
2 Persistent localized tenderness with muscle spasm, indicative of
localized peritoneal inflammation. The tenderness may be best
determinedbyrectalorpelvicexam.
3 Characteristic, severe, intermittent cramping, colicky pain, with
obstructionofahollowviscus.
4 Markedlyhyperactivebowelsoundswithsmallintestinalobstruction,
ordecreasedtoabsentbowelsoundswithparalyticileus.Paralytic
ileus not secondary to other abdominal pathology is treated
nonsurgically. Paralytic ileus as an endresult of mechanical small
bowel obstruction or perforated duodenal ulcer requires surgical
interventiontorelievetheunderlyingpathology.
5 Repeated vomiting of copious amounts of bilestained or fecal
materialinsmallbowelobstruction.
6 Palpationofamass.InRLQorRUQwithintussusception.Adnexal
mass by pelvic exam ectopic pregnancy. Tender and thickened
adnexaebypelvicinPID.Anirreducibleincarceratedinguinalhernia.
A tender RLQ mass by abdominal palpation or rectal exam
appendicealabscess.
7 Certaintestswhenassociatedwithcharacteristicclinicalfeatures:
1 markedlyelevatedserumamylaselevelsacutepancreatitis
2 freeairunderdiaphragminanuprightxrayfilmperforationofa
hollowviscususuallyaduodenalulcer
3 distendedloopsofsmallbowelabovethelevelofobstructioninsmall
bowelobstructionwithabsenceofgasbelowbyxray;generalized
distentionoflargeandsmallbowelparalyticileus
The character, location and radiation of the pain along with other
associatedsymptomsandsignsassummarizedinTablesIandIIwill
behelpfulinestablishingadiagnosisanddecidingwhethersurgeryis
indicated.
When significant abdominal pain occurs in association with
extraabdominaldisease,diagnosiscanfairlyreadilybeestablishedby
careful history, physical exam and appropriate laboratory or xray
studies. For example, chest xray will confirm RLL pneumonia
suggested by the respiratory symptoms and signs associated with
RUQ pain and tenderness. Similarly, in acutely ill patients with
coronaryocclusionwithseverepain,radiatingtoneck,shoulderand
leftarm,theEKGisveryhelpful.
Inaddition,thereisamiscellaneousgroupofdiseaseswhichhave
beenmentionedearlierwheresevereabdominalpainisaprominent
symptom.Thediagnosismaybemissedandthepatientsubjectedto
needless and hazardous surgery if these are not considered and
diagnosed or excluded by careful evaluation and appropriate tests,
whensuspected.Theseinclude:"Mittelschmerz,"mesentericadenitis,
biteofablackwidowspider(baybefollowedbyabdominalcramps
and boardlike rigidity of the abdomen which are relieved by
intravenousinjectionofcalciumgluconate).
TABLE I Differential Diagnosis of Diseases Causing
UpperAbdominalPain

*Acute*Acute*Perforated
AcutePleurisyCoronary
AppendicitisCholecystitisPepticUlcer
Pancreatitis andOcclusion

Pneumonia

Age Usually under 40 Over 40 3050

3050AnyAgeOver40

Sex Both Female,fat Rarein

femalesFemalespreBothMale

dominate

Pain Epigastric; Severe;radiates Historyof

ulcerSuddenonsetInupperabLancinating;
shiftstoRLQ;tobackandin6075%;
sudafterlargedomen,notloradiatesto
constantwithshoulder;redenonset,
inmeal;severecalized;relievedleft
exacerbations quires morphine; tense,
constantconstant;rabysplintingshoulderand
relievedbyantipain;
requiresdiatestobackrespiratoryarm
spasmodicmorphine
requiresmuscles

morphine

Vomiting Exception, but Reflex; may be Not

prominentAlwaysExceptionReflex
alwaysanorexiamuchretching

AppearNotacutelyillWornbecauseofAcutelyill;
Acutelyill;Restless;mayDyspneic;
ance untilperiton pain keeps
abdomenshocklikeifhavegruntingcyanotic;
itisimmobile;
shocknecrosisrespirationsveryrest
like
less;sweat

ing;BPsub

normal

Temp. 991OOF;higher 99102F Subnormal

Subnormalat100103FNormalto
after perfora
onset;latersubnormal
tion
variable

Tender Localized RLQ Localized in RUQ Diffuse,

moreinEpigastric;reEpigastric;inUpperabdo
ness rebound upper
abdomen;bound;bowelconsistent;men,but
boardlike
risoundsdenorestrictionchangeable
gidity;
absentcreasedofabdominalandincon
bowelsounds
respiratorysistent

movement

LaboraLeukocytosisLeukocytosisLeukocytosis
SerumamylaseHighleukocyLeukocytosis
tory
elevatedtosisECGvery

helpful

XrayNohelpMayshowstonesFreeairin
85%"Sentinelloop"ChestxrayNohelp
ornonvisualiza4hr.after
onsetofsmallboweldiagnostic
tionofgallbladder

TABLE II Differential Diagnosis of Diseases Causing

LowerAbdominalPain

*AcuteUreteralAcute
*Ectopic
Appendicitis Obstruction
SalpingitisPregnancyDiverticulitis

AgeUsuallyunder40Under40Under40
Under40Over40

SexBothBothFemale
FemaleMale

Pain Epigastric; shifts Severe, knife Dull,

constantSharp,knifeDullcramping;
toRLQ;constantlike;beginsinbothLQ;
recurrentlike(usuallynotLLPpain;diarrhea
withexacerbationslumbararea;raattacks;
jarringdiagnosableuntil
diatestogroin, is
painful;backruptureoccurs)
scrotum,thigh,ache;
dysuria
dysuria;frequency

MensesNochange
ormenMissedorscanty
orhagia
period;1525%have

noirregularity
Temp.90100FbeforeNormal99102F
Normal99101F
perforation

TendernessLocalizedRlQ;Costovertebral;Bilateral
LQ;UnilateralLQ;LLQ;rebound,mass+
rebound none in abdomen
suprapubic;rereboundmilddistention+
bound

*Surgical

TABLEII(continued)

*AcuteUreteralAcute
*Ectopic
Appendicitis Obstruction
SalpingitisPregnancyDiverticulitis

PelvicTendernesshighExquisite
tenderCervixmoderately
Examonrightnesson
movementtendertomovement;
Rectal of
cervix;profusebloodydischarge
purulent
discharge(dirtybrown)

LabsNormalsed.Hematuria;noVaginal
orcerviAschheimZondekLeukocytosis
rate; leukocytosis leukocytosis cal
culturepos.mayormaynotbe
for
 gonococcus;positive;culde
sedimenta
tionsacpunctureblood
rate
elevated

XrayNohelpSeestoneonNohelp
NohelpNohelpunless
flat 85%; IV
bariumxraypre
pyelogram helps
viouslyshowed

diverticulosis

*Surgical

EXERCISE4OBJECTIVE4Questions
1.Justforfun,asanindexofthecomplexityoftheproblem,seeif
youcancomeupwithadozencausesofrightlowerquadrantpainin
ateenagegirl.
2.Identify2or3clinicalfeaturesofeachoftheaboveonwhicha
reasonablepresumptivediagnosiscanbebased.
3.Whichoftheaboverequireimmediateorfairlyimmediatesurgery?
Explaintheclinicalfeatureswhichledyoutodecidethatsurgeryis
indicatedineachoftheconditionsyouselected.

EXERCISE4DISCUSSION
OBJECTIVE4Answers
1.
1)Mittelschmerz
2)acuteappendicitis
3)acutemesentericadenitis
4)acutepelvicinflammatorydisease(PID)
5)regionalenteritis
6)rupturedectopicpregnancy
7)cecalgassyndrome
8)irritablecolonsyndrome
 9)constipationsyndrome
l0)emotionalupset
ll)acutepyelonephritis
12)twistedovariancyst
2.
1)painoccursmidwayinmenstrualperiod,shortduration
2)lowgradefever,radiationfromepigastriumtoRLQ,RLQpoint
tenderness
3)highfever,highWBC,associatedoftenwithacutepharyngitis
4)purulentvaginalandcervicaldischargewithculturepositivefor
GC.Onpelvicexamthickeningandmarkedtendernessofadnexae.
5)chroniccoursewithweightloss,fever,intermittentboutsofpain
anddiarrhea
6)missedmenstrualperiod;rightadnexaltendermass,signsofblood
lossandshock
7)increasedtympanyovercecalarea;reliefwithpassageofflatus
8) alternating diarrhea and constipation, small caliber stools,
associatedwithemotionaltension
9)historyofinfrequent,hard,largecaliberstools;rectalexamination
rectumfulloffeces
10)history,observationofpatientforevidenceoftension,anxiety,
depression
ll)fever,dysuria,frequency,positiveurineculture
12)historyordemonstrationbypelvicexamofacysticovarianmass;
suddenonset,severepain,developmentofshock
3.Acuteappendicitis,obviously.RLQpointtendernessisindicative
oflocalizedinflammationofcontiguousparietalperitoneum,resulting
fromextensionoftheappendicealinfectionthroughtheserosa.
Ruptureofanectopicpregnancy.Thesuddensevereonsetofpain
suggests a ruptured viscus and the rapid development of shock
suggestsmassivehemorrhagewhichmayfloodtheperitonealcavity
andcausegeneralizedperitonealirritation.
Twistedovariancyst.Althoughthishasnotbeendiscussed,when
torsionofthepedicleoccurs,thereissuddeninterferencewithblood
supply(asinthecauseofvolvulusofthemesentery).Thiscauses
suddenonsetofseverepainandthepatientappearsillandshocky.
Unlessbloodsupplyispromptlyrestored,ischemicnecrosisofthe
cystwallandperforationwithspillagewillensue.

MINICOURSE2.4
SECTION5
OBJ.5.Constructanapproachtoevaluationandmanagementofthe
acuteabdomen.

EvaluationandManagementoftheAcuteAbdomen

Table III categorizes conditions which cause or simulate an acute

abdomen according to the type of onset, the pathogenesis, the
presentingclinicalpicture,andtheurgencyofneedformedicaland/or
surgical treatment. Table IV divides the disease into surgical or
nonsurgicalgroups.Thesetablesprovidetheschemaforevaluation
andmanagementofacuteabdominalconditions.
Priority I indicates catastrophic events, such as perforation of a
viscus,massivehemorrhage,suddenarterialocclusionwithextensive
tissue necrosis, all of which are characterized by sudden onset of
severe prostating continuous pain, moderate to extreme abdominal
tendernessandmusclespasm,andrapiddevelopmentofshock.There
ismarkedtissuedamageandfluidlossfromtraumaticchemicalor
vascularinsult.Immediateinstitutionofsupportiveandresuscitative
measures (i.e., intravenous correction of fluid and electrolyte
imbalance, blood replacement, gastric suction, vasopressor agents,
oxygen,narcotics)isimperative.Emergencyoperationassoonasthe
patient'sconditionpermitsmustbedonetorepairaperforatedviscus,
torestorebloodsupplybyreliefofstrangulationobstruction,orto
controlhemorrhageinarupturedectopicpregnancy,rupturedspleen
and(hopefullywhenconditionspermit)adissectinganeurysm.
Acutepancreatitis,whichmayhaveasuddencatastrophiconset,is
treatednonoperativelywithsupportiveandresuscitativemeasures,as
outlined above, with nasogastric suction to control or prevent
paralyticileus,andwithantibioticstocontrolorpreventinfection.
The pathophysiology of acute pancreatitis involves intrapancreatic
activation of digestive enzymes and autodigestion of the pancreas
withedema,hemorrhageandnecrosisofthegland.Surgicaltreatment
foracutepancreatitisisnolongerstrictlytabooduetobetterfluidand
electrolytemanagement.
It may be difficult to differentiate acute pancreatitis from other
catastrophicconditions.Theclinicalpictureandmarkedlyelevated
serumamylasewillbehelpful.Differentiationofanacutemyocardial
infarctionisordinarilynotadifficultdiagnosticproblemandtheEKG
willbehelpful.Anacutedissectinganeurysmmayprogresswithsuch
rapiditythattheremaybelittleornotimefordiagnosisorsurgical
treatment.
In this catastrophic group, emergency treatment is imperative.
Withouttreatment,rapidandprogressivedeteriorationofthepatient
occurs,andtheprognosisisveryguarded.
Priority II includes conditions associated with vigorous smooth
musclecontractionsinanattempttopropelluminalcontentspastan
obstruction.Thisisthesocalledcolicgroup,whichischaracterized
by severe intermittent recurrent cramping pain and serious
disturbanceingastrointestinalfunctionwhentheobstructionisinthe
smallbowel.
Markedsystemicreactionsarenotgenerallyencounteredintheearly
stagesofgutobstruction,butbecomesevereastheprocessadvances.
In bowel obstruction the need for surgical treatment is urgent to
prevent ischemic necrosis of the gut, but not as critical as in the
catastrophecategory.Thereismoretimeforstudiesandpreparation
ofthepatient.Diagnosiscanusuallybeestablishedbycarefulclinical
evaluationofthepatient,characteristichyperactivebowelsounds,and
demonstrationbyxrayofdistendedloopsofgutabovethelevelof
obstruction.Fluidandelectrolyteimbalancemustbecorrectedand
distention relieved by nasogastric suction before operation. The
prognosisisgoodincasesseenearlybutmuchmoreseriouswhen
ischemicnecrosisofgutoccursandresectionofgangrenousbowelis
required.
Biliary and renal colic are treated conservatively with use of
meperidine (Demerol) for relief of pain and relaxation of smooth
muscle spasm tofacilitate passageof thecalculus.Both renaland
biliarycolicaretreatedmedicallywithdiet,fluidsandnarcotics,and
surgeryisusuallynotrequired,atleastfortheacuteepisodeofcolic.
At times a marked gastroenteritis or a fecal impaction may cause
severecolickypain,buthistory,physicalexam,andthebenigncourse
willobviateanyseriousconsiderationofilladvisedsurgery.
PriorityIII,thelowestcategoryofurgency,includes inflammatory
conditions associated with abdominal pain and a possible acute
abdomen. The progression of inflammatory changes occurs over a
period of several hours to a few days. Initially the systemic and
abdominal manifestations are not severe and there is considerably
moretimetoobserveandevaluatethepatient.Withprogressionof
inflammation and infection, pain and tenderness increase, become
more localized, and fever and leukocytosis increase. Without
treatment, there is further tissue damage, and perforation and
peritonitismayensue.Clinicaldiagnosisisusuallypossibleonthe
basisofclinicalfeatureandtests(seeTablesIandII).
Untiladiagnosisoradecisiontooperateismade,narcoticanalgesics
shouldnotbeusedlesttheymaskthepainwhichissuchanimportant
diagnosticfeatureofthedisease.Similarly,antibioticsmayalterthe
course and they should be deferred until diagnosis is established.
Operativeandnonoperativemeasuresshouldbeinstituted,according
to the diagnosis and indications, and the prognosis is generally
favorable.
Acute appendicitis is prototypic of the acute inflammatory group.
Diagnosis is clinical and early operation is indicated before
suppurationandperforationoccur.
Diverticulitisisaninflammatoryprocessoccurringindiverticulosisof
the colon in older adults. It is usually treated medically with
antispasmodics, intestinal antibiotics and diet. Colostomy or
colectomymaybecomenecessaryforpatientswithrepeatedattacks
who fail to respond to medical therapy. When the lumen of a
diverticulum becomes obstructed, inflammation occurs within the
diverticulumandspreadstoadjacentbowelwall.Themostcommon
complication is perforation with localized peritoneal inflammation.
This causes the socalled LLQ appendicitis for which surgery is
required.
Acute cholecystitis is generally a complication of chronic
cholecystitisandoccurswhenthegallbladderoutletissuddenlyand
completelyoccluded,usuallybyastone.Plainfilmoftheabdomen
mayrevealradiopaquestonesandgallbladderstudieswithcontrast
media show a nonfunctioning gall bladder. When the patient is in
good condition and the acute attack is of short duration,
cholescystectomy is the treatment of choice. In more seriously ill
patients with more chronic infection, operation may be deferred 6
weeks,untiltheacuteprocesshassubsidedduetomedicaltreatment.
The important nonoperative measures include gastrointestinal
decompression,parenteralfluids,antibioticsandcloseobservationof
the patient for evidence of progression of disease or impending
rupture.
Nonsurgicaldiseases inthe inflammatory category(listedin Table
IV)includethefollowing:
Achildwhohasmoderatelyhighfever102ormore,withabdominal
pain,andRLQtenderness(althoughitmaybeLLQorbilateral)will
have acute mesenteric adenitis 80% of the time, rather than
appendicitis. Mesenteric adenitis is associated with an acute
pharyngitis, often with a leukocytosis of 1520,000 and surgical
interventionisnotrequired.Sometimesthediagnosiscannotbemade
withcertaintyexceptatoperation.Whenthedangeroflaparotomyis
considerably less than that of a possible perforated appendix,
operationisjustified,and4outof5isaprettygoodbattingaverage.
Regionalenteritis isachronicgranulomatousinflammationofthe
terminalileum,characterizedbychronicity,weightlossandboutsof
infection,diarrhea,andcrampingabdominalpain.Occasionallyacute
exacerbations may mimic an acute abdomen. Barium study of the
small intestine gives a characteristic "string" appearance in the
involvedsegment.Medicaltreatmentissymptomaticandsupportive.
Acutepelvicinflammatorydisease canbereadilydiagnosedbyits
clinicalfeaturesandbycultureofcervicaldischarge.Treatmentis
medical and includes vigorous appropriate antibiotic therapy along
withgeneralsupportivemeasures.
Finally,thereisamiscellaneousgroupofconditions(seeTableIV)
inwhichabdominalpainisaprominentfeature.Toavoidmistakesin
diagnosisandunnecessaryandharmfulsurgery,itisimportantthat
theseconditionsbekeptinmindandtestedforwhenindicated,as
discussedinSection4.
TABLEIIIManagementofAcuteConditionsof
theAbdomen
AccordingtoUrgencyandClinicalPatterns

PRIORITY PATTERN MECHANISM

CLINICALPICTUREMANAGEMENT

I Pain, collapse, shock Perforation, hemor

Suddenseverepain;shockImmediateresuscitative
(catastrophic), e.g., rhage, thrombosis,
orshocklikestate;abdoandsupportivemeasures;
perforated ulcer, rup necrosis
minaltenderness;rigidity;diagnosticstudies;early
tured ectopic pregnancy,
silentabdomen;severeoperationifindicated
acute pancreatitis,
systemicreaction
mesentericthrombosis,
rupturedaneurysm,etc.

II Pain (intermittent), Obstruction of hol

Recurrentcrampingpains;Establishdiagnosisif
colic, e.g., acute intes low muscular organ
vomiting;distention;noisypossible;correctsystemic

tinal obstruction, biliary (smooth muscle);

abdomen;systemicreactionimbalances;earlyoperation
colic,ureteralcolic strangulationmaybe
slighttomoderate;xrayifindicated
impendingorexistent
maybediagnostic

III Pain,tenderness,inflamIrritationduetobac
Painvariable,usuallyinClinicaliagnosisusually
matron, e.g., acute ap terial, chemical,
creasing,tendernesslocalpossible;earlyoperation
pedicitis, acute chole ischemic factors
ized,thendiffusewithinappendicitis,proper
cystitis, acute diver
rupture;musclespasm,timingofalltherapy
ticulitis, acute salpin
oftenamass;systemic(fluids,antibiotics,
gitis
reactionmoderatetooperation)
s
evere

TABLEIVSpecificDiseasesCausingorSimulating
anAcuteAbdomen
AccordingtoCategoriesofUrgencyandNeed

Surgical
Nonsurgical

Catastrophe Ruptureofaholloworgan Acute

pancreatitis
(PriorityI)spontaneousortraumaticCoronary
thrombosis
(peptic ulcer, ectopic preg
Dissectinganeurysm
nancy)withmassivehemorrhage (with
immediatediagnosis
Ruptureofasolidorgan and
appropriatecondi
usuallytraumatic(spleen,tions
surgical).
liver,kidney)
Acutevascularocclusion
(mesentericaccident,
strangulatingobstruction)
Massivehemorrhage,peptic
ulcer,esophagealvarices.

ColicAcuteintestinalobstructionBiliary
colic,renal
(PriorityII)smallandlargebowelcolic,
gastroenteritis,
 Acuteappendicitis(colicfecal
impaction
fromfecalithinlumen)

Inflammation Acute appendicitis

Mesentericadenitis
(PriorityIII) Acute cholecystitis
Regionalenteritis
AcutediverticulitisPelvic
inflammatory
disease
Ruptured
ovarian
follicle
(Mittels
chmerz)
Urinary
tractinfection
Pneumoni
aandpleuritis

MiscellaneousDiabetic
acidosis
Lead
poisoning
Sickle
cellcrisis
Black
widowspiderbite

EXERCISE5
OBJECTIVE5Questions
1.
a.Whatclinicalfeaturescharacterizetheacutecatastrophicabdominal
conditionswhichdemandthemostimmediateandurgenttreatment?
b.Howshouldthesecatastrophicconditionsbechanged?
2. In acute inflammatory conditions of the abdomen with a more
gradual onset and less rapidly progressive course, what clinical
featuresandtestsaremosthelpfulinarrivingatadiagnosisand/or
managementplan?
3.
 a. What findings are highly suggestive of acute mechanical small
bowel obstruction where surgical correction of the obstruction is
imperative?
b.Ifoperationisdelayed2436hours,bowelsoundsmaybecome
decreasedtoabsentwithincreasedT.WBC,Zneutrophils,localized
orgeneralizedabdominaltendernessandrigidity.Whathashappened
andwhatisnowyourpresumptiveworkingdiagnosis?
4.A6yearoldmalechildentersyourofficewithpainintheright
lowerquadrant.Helooksflushedandfeverishandhistemperatureis
102.8.Hehasenlargedtenderanteriorcervicallymphnodesandhis
pharynxisbeefyredincolor.HisWBCanddifferentialis18,000
with80Xpolys.Hehastendernessinhisabdomen,somewhatmore
markedintherightlowerquadrant.Hehasbeenanorexicforthelast
two meals and has vomited twice. How would you manage this
patient?
5.Ifindoubt,whynotalwaysoperate?
6.A40yearoldpatienthasathreeyearhistoryofepigastricdistress
relievedbymildandantacids.Duringthepast3months,shehashada
severe,cramping,colickyepigastricpain,radiatingtoRUQandright
scapulaandrequiringDemerolforrelief.Shehasalsonoticedthatfor
severalmonthsfattyfoodscauseindigestionandepigastricdistress,
which is not relieved by mild and antacids. ROS reveals that the
patienthasconsumedabut1/2pintgindailyforthepasttwoyears.
Sheisseenbecauseofsuddenonsetofsevereprostatingepigastric
pain 2 hours earlier which has now become very severe and
generalized, with diffuse abdominal tenderness and rigidity. She
appearsacutelyillandshocked.Sheisobviouslyinseverepainwhich
isaggravatedbyanymovement.
a.Whatisyourfirsthypothesis?Why?
b.Whatfurtherinformationwouldbemostimmediatelyhelpfulin
yourdifferentialdiagnosis?
c.Inthisurgentcatastrophicsituationwherepromptsupportiveand
resuscitative measures are imperative, why bother with further
investigationtoestablishadefinitivediagnosis?
 EXERCISE5DISCUSSION
OBJECTIVE5Answers
1.
a.Suddenseverepain,shockorshocklikestate,markedabdominal
tenderness and rigidity, localized or generalized, silent abdomen,
severesystemicreaction.
b. With immediate resuscitative and supportive measures, i.e.,
narcoticsforpain,intravenousfluidsforrepairofwaterelectrolyte
deficits,plasmaexpandersorbloodreplacement,vasopressoragents
ifnecessary,oxygen,nasogastricsuction/decompression.Ifindicated,
surgeryisperformedassoonasthepatient'sconditionsafelypermits.
2.1)completehistoryandphysicaltoexcludeextraabdominalcauses
of abdominal pain; 2) location and radiation of pain; 3) localized
tendernessandmusclespasm;4)baselinerecordingofT.R.P.WBC,
anddifferential;5)repeatdeterminationsforincreasingevidenceof
infection increased temperature, increased WBC, increased %
neutrophils; 6) frequent reevaluation of patient for progression of
physicalsigns.
3.
a.Severecrampingintermittentcolickypain.Repeatedvomitingof
copiousamounts.Vomitus,usuallybilestained,maybecomefecal.
Abdominaldistention.Borborygmi,xraydilatedloopsofsmallgut
withfluidlevels.
b.Withincreasingdistentionofthegutimpairmentofnerveand
blood supply has caused necrosis of the gut wall, perforation and
peritonitiswithparalyticileus.Diagnosisisstrangulation/obstruction,
withgangrene,peritonitisandparalyticileus.
4. This is a common problem in children. It may be difficult or
impossible to distinguish between acute appendicitis and acute
mesentericadenitiswithoutoperating.Mostsurgeonsareconsidered
correctinthisdecisionwithabattingaverageof80%thatistosay,
operating on at least 20% of children who ultimately do not have
appendicitis but in fact do have mesenteric adenitis. If the body
temperatureissignificantlyelevated,102orabove,80%ofthetime
the abdominal pain is not due to acute appendicitis. This patient
 should be treated with antipyretics and clear liquids and a throat
culturetaken,withreexaminationofthepatient23hourslaterfor
pointtendernessifthepainpersists.Antibioticsshouldbewithheld
untilamoredefinitivediagnosisismadee.g.,throatculturepositive
forGroupAbetahemolyticstreptococci.Onreexaminationseveral
hourslater,ifmorelocalizedRLQtendernessispresent,thereisno
choiceexcepttooperate.Themesentericnodesmaybefoundtobe
inflamed and enlarged and the appendix normal. The appendix is
removed,however,topreventasimilarprobleminthefuture.Ifon
theotherhand,afteranintervalofseveralhours,painandtenderness
have decreased, syptomatic treatment is continued until culture
reportsareback.Ifpositiveforbetastrep,penicillinisgivenforten
days.
5.Surgeryandanesthesiacreatetraumaandadditionalstressinan
already ill patient. Two conditions especially which cannot be
relieved by surgery, seem to be definitely adversely affected by
anesthesiaandlaparotomy,i.e.,acutepancreatitisandparalyticileus.
Paralytic ileus often occurs temporarily following any type of
abdominal surgery, apparently from disturbed gut function from
handling.Postoperativeadhesionsmayresultfromsurgeryandcause
obstruction later. Sound judgement is required. Any time the
possibilityofseriouscomplicationssuchasperforationorgangreneis
present,thedangerofnotoperatingoutweighsthatofsurgery.
6.
a. While peptic ulcer is more common in males, it can occur in
women.Obviouslythehistoryofepigastricdistressrelievedbymild
andantacidssuggestspepticulcerdiseaseandthesuddenonsetof
severe epigastric pain which quickly becomes generalized, with
diffuseabdominaltendernessandboardlikerigidityistypicalofa
perforatedduodenalulcer.TherecentepisodesofRUQcolickypain
with radiation to the right scapular area severe enough to require
Demerol for relief are typical of biliary colic. Gallstones and
indigestionaggravatedbyfattyfoodsadduptocholecystitis,which
canbecomeacutewhenobstructiontotheflowofbileoccurs.Onset
ofacutecholecystitisisusuallynotsosuddenorprostratingasthat
described,althoughitcanbesuperimposedonbiliarycolic.Thepain,
 tendernessandmuscleguardingremainlocalizedintheRUQ,with
pain radiating to back and right shoulder, rather than quickly
becominggeneralized,asitdoeswhenspillageofacidpepsingastric
contentsoccurs.Acutepancreatitismayhaveasuddenonsetofsevere
prostrating epigastric pain as described. It is often associated with
alcoholismandgallstones,andismorecommoninwomen.Thepain,
tenderness,andmusclespasmusuallyislimitedtotheupperabdomen
withradiationtotheback,andtherigidityislessdiffuseandmarked
thanwithperforatedulcer.So,whilethehistoryandfindingsaremost
suggestiveofaperforatedduodenalulcer,bothacutepancreatitisand
acutecholecystitishavetobeconsideredveryseriously.Therapid
development of generalized pain, tenderness and rigidity are not
typicalofeither.Acutecholecystitisusuallyhasamoregradualonset,
but the clinical manifestations and course of acute abdominal
conditionsdonotalwaysaccommodateusbybeingentirelytypical.
b.Themosthelpfuldeterminationswillbe:
1 demonstrationoffreeairunderthediaphragminanuprightplainfilm
oftheabdomen.Thiswillconfirmruptureofahollowviscus.With
theassociatedclinicalsymptomsandsigns,adefinitediagnosisofa
perforatedduodenalulcerisestablished.
2 Amarkedlyelevatedserumamylaselevelwillmakeadiagnosisof
acutepancreatitisalmostcertain,inconjunctionwithabsenceoffree
airunderthediaphragm.
3 It is possible with the history of biliary colic that radiopaque
gallstonesmaybedemonstratedontheflatplateoftheabdomen.This
does not establishadiagnosisofacutecholecystitis,forthestones
maynotbeoccludingtheflowofbile.Intravenouscholangiography
wouldbenecessarytodemonstrateanonfunctioninggallbladder.The
diagnosis then would be: 1) acute perforated duodenal ulcer, 2)
cholelithiasis(gallstones).
c.Itisimportanttoestablishthisdiagnosisquickly.Whilesupportive
and resuscitative measures must be instituted promptly, it is
imperative that surgical repair of the ulcer perforation be
accomplishedassoonasthepatient'sconditionpermits.Otherwisethe
coursewillbeoneofprogressivedeteriorationanddeath.Ifacute
cholecystitishadbeenmostlikelyonthebasisofdemonstrationof
gall stones and a nonfunctioning gallbladder by cholangiography,
withnofreeairinperitonealcavityandnormalserumamylase,more
timeforevaluationandpreparationofthepatientwouldhavebeen
available, and for a considered judgement as to whether surgery
shouldbedonenoworaftertheacuteprocesshassubsided.If,onthe
otherhand,acutepancreatitishadseemedmostlikelyonthebasisof
no free air under the diaphragm and a markedly elevated serum
amylase, surgery is not only not indicated, but is definitely
contraindicated because it has an adverse effect on an already
critically ill patient. Resuscitative and supportive measures are
indicatedinallurgentandcatastrophicacuteabdominalconditions.
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