The Acute Abdomen

by :
Andreas Andrianto
Airlangga School of Medicine/Dr Sutomo Hospital
Definition
Acute abdomen describes clinical
condition as result of emergency situations
intra abdominal with pain as main
symptom
Table 1. Sensory innervations of intra abdominal
structures

Structure Nerve Level

Middle part of Phrenicus C 3-5
Diaphragm
Edge of diaphragm, Plexus celiac Th 6-9
stomach, pancreas,
gall bladder, intestine
Appendix,proximal Plexus mesentericus Th 10-11
colon
Distal colon, rectum, Splanchnic caudal Th 11-L 1
kidney, urethra &
testis
Vesica urinary, recto S 2-4
sigmoid
Figure 1. Innervations of diaphragm and shoulder
 Referred Pain

Shifting Pain

Figure 2.Referred pain and shifting pain in the acute

abdomen
 Abrupt, excruciating pain Rapid onset of severe, constant pain

IMA Acute pancreatitis

Colic billier Perforated

ulcer Mesenteric thrombosis,
strangulated bowel
Colic ureter Ruptured
aneurysm
Ectopic pregnancy

Gradual, steady pain Intermittent, colicky pain with free interval

Early
Acute cholecystitis, pancreatitis
acute cholangitis, (rare)
acute hepatitis
Small bowel
obstruction
IBD
Appendicitis,
salpingitis
Colic billier

Figure 3. The location and character of the pain are useful in the differential
diagnosis of the acute abdomen
Extra abdominal conditions that causes
abdominal pain

These may rarely present as referred

abdominal pain. The most important to
remember : pneumonia (especially lower
lobe), Myocardial Infarction. Those
diseases tend to be Medical diseases and
surgery is not generally indicated
Table 2. Physical findings with various causes of acute
abdomen
Conditions Helpful sign
Perforated viscous Scaphoid (early), tense abdomen, diminished
bowel sound (late), loss of liver dullness,
guarding or rigidity
Peritonitis Motionless, absent bowel sound (late), rebound
tenderness, guarding
Inflamed mass or abscess Tender mass, special sign (Murphy's, obturator or
psoas)
Intestinal obstruction Distention, visible peristaltis (late),
hyperperistaltis (early) or quiet abdomen (late),
diffuse pain, hernia (some)
Paralytic ileus Distention, minimal bowel sound

Ischemic or strangulated Not distended (until late), severe pain, rectal

bowel bleeding (some)
Bleeding Pallor, shock, distention, pulsatile (aneurysm)
Figure 3. Causes of shock in patients with acute abdomen
Consideration of Surgery
Intervention
Decision of surgery intervention on
acute abdomen depends on correct
diagnosis. If we got difficulties to
make decision, we should observe
patient closely.
Meanwhile patient must fasting, apply
naso gastric tube and IV line
Table 3. Indications for urgent operations in patients
with acute abdomen

Physical findings
Involuntary guarding or rigidity, especially if spreading
Increasing or severe localized tenderness
Tense or progressive distention
Tender or abdominal or rectal mass with high fever or hypotension
Rectal bleeding with shock or acidosis
Radiologic findings
Pneumoperitoneum
Gross or progressive bowel distention
Free extravasations of contrast material
Space occupying lesion on scan, with fever
Mesenteric occlusion on angiography
 Summary
Acute abdomen is serious surgical
emergency requiring the surgeon to
combine the result of the history and
physical examination with properly
selected laboratory and radiographic
studies
Correct preoperative diagnosis will usually
lead to a successful operation