Acute Abdomen

Zarifah Adilah Abdul Rahman

Definition
an acute intra-abdominal condition
of abrupt onset, usually associated
with pain due to inflammation,
perforation, obstruction, infarction,
rupture of abdominal organ, &
usually requiring emergency
surgical intervention

Dorland Dictionary

Acute abdominal pain in 9

regions

Common Causes of Acute

Abdomen
Gastrointestinal tract
disorders
Nonspecific abdominal pain
Appendicitis
Small and large bowel obstruction
Perforated peptic ulcer
Incarcerated hernia
Bowel perforation
Meckels diverticulitis
Diverticulitis
Inflammatory bowel disorders
Mallory-Weiss syndrome
Gastroenteritis
Acute gastritis
Mesenteric adenitis
Parasitic infections

Liver, spleen, and biliary

tract disorders
Acute cholecystitis
Acute cholangitis
Hepatic abscess
Ruptured hepatic tumor
Spontaneous rupture of the
spleen
Splenic infarct
Biliary colic
Acute hepatitis
Pancreatic disorders
Acute pancreatitis

Urinary tract disorders

Vascular disorders

Ureteral or renal colic

Acute pyelonephritis
Acute cystitis
Renal infarct

Ruptured aortic and visceral

aneurysms
Acute ischemic colitis
Mesenteric thrombosis

Gynecologic disorders

Peritoneal disorders

Ruptured ectopic pregnancy

Twisted ovarian tumor
Ruptured ovarian follicle cyst
Acute salpingitis
Dysmenorrhea
Endometrios

Intra-abdominal abscesses
Primary peritonitis
Tuberculous peritonitis

Retroperitoneal disorders
Retroperitoneal hemorrhage

History
Location of Pain
visceral pain :is elicited by distension, by inflammation or
ischemia stimulating the receptor neurons, or by direct involvement
of sensory nerves. The centrally perceived sensation is generally
slow in onset, dull, poorly localized, and protracted
parietal pain : is mediated by both C and A delta nerve fibers,
the latter being responsible for the transmission of more acute,
sharper, better-localized pain sensation. Direct irritation of the
somatically innervated parietal leads to more precisely localized pain
Referred pain :denotes noxious (usually cutaneous) sensations
perceived at a site distant from that of a strong primary stimulus.
Distorted central perception of the site of pain is due to the
confluence of afferent nerve fibers from widely disparate areas
within the posterior horn of the spinal cord


Spreading or shifting pain
parallels the course of the underlying condition. The site of
pain at onset should be distinguished from the site at
presentation

Mode of Onset and Progression of Pain

The mode of onset of pain reflects the nature and severity of
the inciting process. Onset may be sudden (within seconds),
rapidly progressive (within 12 hours), or gradual (over
several hours).
factors that aggravate or relieve pain
Pain caused by localized peritonitis, especially when it affects
upper abdominal organs, tends to be exacerbated by
movement or deep breathing.

 Character of Pain :
Sharp superfcial constant pain severe peritoneal
irritation i.e. perforated ulcer/ruptured appendix, ovarian
cyst/ ectopic pregnancy
intermittent, vague, deep-seated, and crescendo small
bowel obstruction
colic if there are pain-free intervals that reflect
intermittent smooth muscle contractions, as in ureteral
colic
aching discomfort pain peptic ulcer
stabbing, breathtaking pain acute pancreatitis and
mesenteric infarction
searing pain ruptured aortic aneurysm

Other Symptoms Associated with

Abdominal Pain

Other Relevant Aspects of the

History

Physical Examination
General observation:

The writhing of patients with visceral pain

(e.g., intestinal or ureteral colic) contrasts
with the rigidly motionless bearing of those
with parietal pain (e.g., acute appendicitis,
generalized peritonitis).
Diminished responsiveness or an altered
sensorium often precedes imminent
cardiopulmonary collapse.

 Systemic signs:

usually accompany rapidly progressive

or advanced disorders associated with
an acute abdomen. Extreme pallor,
hypothermia, tachycardia, tachypnea,
and sweating suggest major intraabdominal hemorrhage (e.g., ruptured
aortic aneurysm or tubal pregnancy).

 Fever:

Constant low-grade fever :common

in inflammatory conditions
Disorientation or extreme lethargy +
high fever :impending septic shock.
mild or absent :in elderly, chronically
ill, or immunosuppressed patients
with a serious acute abdomen.

Examination of the acute abdomen

:
Inspection:

A tensely distended abdomen with an old

surgical scar suggests both the presence and
the cause (adhesions) of small bowel
obstruction.
A scaphoid contracted abdomen is seen with
perforated ulcer. visible peristalsis occurs in
thin patients with advanced bowel obstruction.

 Palpation:
Guarding

Voluntary
Involuntary
Reflex spasm of abdominal muscles
Suggests peritoneal irritation

 Tenderness
Tenderness is usually well demarcated in
acute cholecystitis -RHC
Appendicitis-RIF
Diverticulitis-LIF

If there is poorly localized tenderness

unaccompanied by guarding, one should suspect
gastroenteritis or some other inflammatory
intestinal process without peritonitis.

 Abdominal masses
Are usually detected by deep palpation.
Superficial lesions such as a distended
gallbladder or appendiceal abscess are often
tender and have discrete borders.

Percussion:

Tenderness on percussion rebound tenderness

Tympany near the midline in a distended
abdomen air trapped within distended bowel
loops.
Shifting dullness free peritoneal fluid
With a perforated viscus, free air accumulating
under the diaphragm may efface normal liver
dullness.

 Auscultation:

 Inguinal and femoral rings; male

genitalia
Rectal examination

tenderness
rectal tumor
blood-stained stool, or occult blood

Pelvic examination

A pelvic examination is vital in women

with a vaginal discharge, dysmenorrhea,
menorrhagia, or left lower quadrant pain.

Investigations
Labs
Hematological: Hemoglobin, hematocrit, and
white blood cell and differential counts
Biochemistries: Serum electrolytes, urea
nitrogen, and creatinine
Liver function tests, Amylase
Arterial blood gas
Coagulation studies
Urine Test: Urinalysis, urine culture, UPT
Stools: stool smear, occult blood, stool culture
Blood culture

Imaging Studies
Abdominal x-ray
3 views: upright chest, flat view of abdomen,
upright view of abdomen
Limited utility: restrict use to patients with
suspected obstruction or free air
Ultrasound
Good for diagnosing AAA but not ruptured
AAA
Good for pelvic pathology

 CT abdomen/pelvis
helpful in identifying small amounts of free
intraperitoneal gas and sites of inflammatory
diseases that may prompt or postpone operation.

MRI
Most often used when unable to obtain CT due to
contrast issue

Endoscopy
OGDS
ERCP
Colonoscopy

Preoperative Management
Analgesia
Resuscitation
Medications
Particular care should be given to use of
cardiac drugs and corticosteroids and to
control of diabetes.
diabetes
Antibiotics are indicated for some
infectious conditions or as prophylaxis
during the perioperative period.

 A nasogastric tube should be inserted in

patients likely to undergo surgery and for those
with hematemesis or copious vomiting,
vomiting suspected
bowel obstruction,
obstruction or severe paralytic ileus.
ileus
A urinary catheter should be placed in
patients with systemic hypoperfusion.
hypoperfusion In some
elderly patients,
patients it eliminates the cause of pain
(acute bladder distention) or unmasks relevant
abdominal signs.
Informed consent for surgery may be difficult
to obtain when the diagnosis is uncertain. It is
prudent to discuss with the patient and family the
possibility of multiple-staged operations,
temporary or permanent stomal openings.

References
Baileys and Love Short Practice of Surgery-26th
Edition
http://www.medscape.org/viewarticle/573206
https://www.merckmanuals.com/professional/gast
rointestinal-disorders/acute-abdomen-andsurgical-gastroenterology/acute-abdominal-pain