IMAGING IN ACUTE ABDOMEN

BALRAM SINGH

Acute abdomen
Defined as clinical syndrome characterized by acute pain abdomen of sudden onset often requiring emergency medical or surgical treatment diseases involving ;
Biliary tree Solid viscera intestine, genitourinary system Pelvic organs in females

Clinical Diagnosis
Characterizing the pain is the key
Onset, duration, location, character

Visceral pain dull & poorly localized

i.e. distension, inflammation or ischemia

Parietal pain sharper, better localized

Sharp RUQ pain(choly), LLQ pain(divertic)

Kidney / ureter flank pain

Clinical Diagnosis Pain contd

Location Upper abdomen PUD, choly, pancreatitis Lower abdomen Divertic, ovary cyst, TOA Mid abdomen early appy, SBO Migratory pattern Epigastric Peri-umbil RLQ = Acute appy Localized pain Diffuse = Diffuse peritonitis

Other history
GI symptoms Nausea, emesis (? bilious or bloody) Constipation, obstipation (last BM or flatus) Diarrhea (? bloody) Both Nausea/Diarrhea present usu. medical Change in sx w eating? NSAID use (perf DU) Jaundice, acholic stools, dark urine

Drinking history (pancreas) Prior surgeries (adhesions SBO, ?still have gallbladder & appendix) History of hernias Urine output (dehydrated) Constituational Sx Fevers/chills Sexual history

Clinical Diagnosis
Location of pain by organ RUQ Gallbladder Epigastrum Stomach Pancreas Mid abdomen Small intestine Lower abdomen Colon, GYN pathology

Clinical Diagnosis

Common Causes of Acute Abdominal Pain by Age Groups

Infancy GI
Acute gastroenteritis Appendicitis Intussusception Volvulus Meckel's diverticula

Adolescence/childhood GI
Acute gastroenteritis Appendicitis Constipation IBD Peptic ulcer disease Cholecystitis Pancreatitis Neoplasm

Other
Colic Trauma

Common Causes of Acute Abdominal Pain by Age Groups

Adolescence/childhood

Other
Functional abdominal pain
Pelvic inflammatory disease Pregnancy

Sickle cell crisis

Trauma
Diabetic ketoacidosis Heavy metal poisoning

Pyelonephritis
Pneumonia

Renal stone

Common Causes of Acute Abdominal Pain by Age Groups

Adult
IBS non-ulcer dyspepsia mesenteric ischemia malignancy abscess chronic intractable abdominal pain

GI
esophagitis esophageal spasm esophageal rupture intestinal obstruction
hernia, intussusception, adhesions, volvulus

gallstones ampullary stenosis IBD pancreatitis

Cardiac
ischemia/MI myocarditis/endocarditis CHF

Common Causes of Acute Abdominal Pain by Age Groups

Thoracic
pneumonitis pleurodynia PE/infarct PTX empyema

Metabolic
uremia DM porphyria acute adrenal insufficiency hyperPTH

Neurologic
radiculopathy abdominal epilepsy tabes dorsalis

Common Causes of Acute Abdominal Pain by Age Groups

Toxins
hypersensitivity: insect or venom lead poisoning

Miscellaneous
muscle contusion, hematoma, tumor

narcotic withdrawal
FMF psychiatric depression heat stroke Mittelschmerz

Infections
zoster osteomyelitis typhoid

Think Broad categories for DDx

Inflammation Obstruction Ischemia Perforation (any of above can end here) Offended organ becomes distended Lymphatic/venous obstrux due to pressure Arterial pressure exceeded ischemia Prolonged ischemia perforation

Investigations in acute abdomen

: 1. Abdominal X-Ray/Chest X-Ray erect Look for bowel obstruction calcification, free air and lower lobe pneumonia. Also soft tissue mass may be seen 2. Ultrasound of both pelvis and upper abdomen For hepatobiliary, renal and gynaecological pathology. 3. Complete blood count Increased in case of necrosis, bacterial infection, abscess 4. Peripheral smear for HUS, Sickle cell. 5. Urine examination for UTI, porphyria

Available modalities
Plain x-ray Barium meal follow through Small bowel enema Large bowel enema Ultrasound CT scan

 Additional investigations ; Serum Amylase/lipase for pancreatitis Blood cultures Beta HCG CT scan for abdomen Stool examination for worm infestation

The Abdominal Series

For all acute abdominal complaints where plain film imaging is indicated, get a COMPLETE abdominal series Exceptions: Suspected renal calculus or foreign body, where a single view is OK CT and ultrasound are often performed after plain films

Abdominal Series Indications:

Highest yield: Presentations suggestive of free air or obstruction Not very good for masses, ascites, organomegaly, biliary tract disease, GI bleeding and vague abdominal complaints

The Abdominal Series

Erect chest, AP supine and erect abdomen Or, if patient unable to sit/stand: supine chest, supine and left lateral decubitus abdomen For calculus or foreign body: AP supine abdomen

The Erect Chest

Best for free air
To evaluate for intrathoracic abnormalities presenting with abdominal complaints, especially pneumonia (more common in kids)

The Normal Abdominal Series

Chest Supine abdomen Erect abdomen Left lateral decubitus abdomen

Supine Abdomen
Best for abdominal detail: Organs, bones and joints, calcifications, fat and gas pattern

Erect Abdomen
For air-fluid levels and little else

Left Lateral Decubitus Abdomen

Substitute for erect chest (free air) and erect abdomen (air-fluid levels) in a patient unable to sit or stand

The Check List

Bones and joints Calcifications Organs Fat Gas: In bowel and outside of bowel

A memory aid
First organs, bones, and stones, Then masses, fat, and gas. Dont forget the corner zones, And youll always cover yoursubject

Chest

Supine Abdomen

Erect Abdomen

Left Lateral Decubitus Abdomen

Dont forget to look for pneumonia

GAS
In the gut, and elsewhere

The Gas Pattern

Can be specific for obstruction Often, nonspecific: General ileus, focal ileus, ischemia, or obstruction A paucity of gas may be due to vomiting or fluid-filled bowel

Pneumoperitoneum

Signs
Right upper quadrant gas Peri hepatic Sub hepatic Morrisons pouch Fissure for lig teres Riglers (double wall sign) Ligament visualization

Falciform
Umblical inverted V sign Urachus Triangular air The cupola sign Football or air dome Scrotal air in children

Causes of pneumoperitoneum without peritonitis

Sealed of perforation Post operative Peritoneal dialysis Post chromo insufflation in fallopian tubes

Perforated cyst in pneumatosis intestinalis

MASSIVE PNEUMOPERITONEUM FOOTBALL SIGN

FALCIFORM LIGAMENT GAS BUBBLE OVER LIVER

FALCIFORM LIGAMENT

PNEUMOPERITONEUM SUBHEPATIC GAS BUBBLE

Triangle Sign

Ligaments

Pneumo-left decubitus

Air in Biliary System

Usually secondary to surgery on bile ducts Can be due to biliary-bowel fistula from infection or neoplasm emphysematous cholycystitis

Air in Bile Ducts

Air in Gall Bladder

Portal Venous Air

A sign of dead or dying bowel

Portal Venous Air

Mesenteric venous thrombosis Mesenteric arterial occlusion Pneumatosis is intestinalis Gastroenterocolitis Mucosal necrosis d/t chemical agents

Portal Venous Air

Plain film- -multiple tubular gas collections in PV and its side branches Portal gas forms a ramifying pattern that radiates periphrry of liver owing to centrifugal blood flow Best seen in lt lateral film USG-canilicular gas filled structure in periportal field with acoustic shadoweing and reverberation

Conditions mimicking pneumoperitoneum

Subphrenic abscess
Chilaiditi syndrome Supra diaphragmatic pulmonary collapse Diaphragmatic irregularity Subdiaphragmatic fat Cysts in pneumatosis intestinalis

Subphrenic abscess

Chilaiditi

OBSTRUCTION
Small bowel Colon

Goals of imaging in a suspected case of intestinal obstruction

To confirm that it is true obstruction To differentiate it from ileus To determine level of obstruction To determine cause of obstruction To look for findings of strangulation To allow a good management medically/ surgically

Available modalities
Plain x-ray Barium meal follow through Small bowel enema Large bowel enema Ultrasound CT scan

Gastric dilatation
Mechanical GOO DU ulcer ,antral ca, extrinsic compression
Paralytic ileus Air swallowing

Gastric volvolus

Gastric valvulus
Laxity of gastro hepatic ,gastro colic and gastrolineal ligament predispose to valvulus Seen in elderly with diaphragmatic hernia 3 types Organoaxial-m/c Mesentroaxial Combination

Gastric valvulus

Gastric valvulus
Dilated stomach contain both air and fluid seen as spherical viscus, displaced upward and left ,a/w elevation of lt hemidiaphragm Small bowel collapsed d/d- caecal volvolus UGI

OBSTRUCTION
Small bowel obstruction much more common than colon

Small Bowel Obstruction: Causes

Adhesions 80% Hernia 15% Tumors, intussusception, midgut volvulus, etc.

Small Bowel Obstruction: Findings

Step-ladder dilated bowel loops on supine view Step-ladder air-fluid levels on erect/decubitus views Stretch sign on supine view String-of-pearls sign on erect/decubitus views

Normal lumen diameter

BMFT
Proximal jejunum Mid small bowel Distal ileum 3cm 2.5cm 2cm

Enteroclysis
4cm 3.5cm 3cm

Small vs large bowel

Small bowel
Valvulae conniventes Number of loops
Distribution of loops Haustra Diameter Radius of curvature Solid faeces

Large bowel

Present in jejunum Absent

Many Central Absent 3-5cm Small Absent Few Peripheral Present >5cm Large Present

Small bowel vs Large bowel dilatation

Radiological Findings
Haustra Valvulae conniventes Number of loops Distribution of loops Radius of curvature of loop Diameter of loop

Small bowel
Absent Present in jejunum many Central Small 30-50mm

Large bowel
Present Absent Few Peripheral Large 50mm+

Solid faeces

Absent

May be present

Bowel wall diameter

Normal Small Intestine
SI Fluid levels Large Intestine LI Fluid levels
2.5 cms <2 5.5 cms < 5 or < 2.5 cms length

Abnormal
> 2.5 cms >2 > 5.5 cms 5 & > 2.5cms length

Caecum

9 cms

> 9 cm

How Big is Big?

In an adult, any visible small bowel is abnormal, but small amounts often not significant. Kids normally have small amounts. Jejunum over 3 cm and ileum over 2 cm diameter is very abnormal, but not specific for obstruction

Air, Fluid or Both?

Small bowel can be distended by either air or fluid or both Fluid-filled bowel may be more significant than air-filled bowel, but often the significance is the same

Air Filled Small Bowel

Fluid Filled Small Bowel

Air-Fluid Levels
Always abnormal in small bowel, but not specific; often normal in colon The height of the fluid levels, same or different, is NOT helpful in distinguishing ileus from obstruction

Small Bowel Air-Fluid Levels

What is Dilated?
If small bowel and colon dilated equally, probably not small bowel obstruction: nonspecific ILEUS If small bowel significantly more dilated than colon, suggests SBO Some gas in colon does NOT exclude SBO

Ileus

Small Bowel Obstruction,

Supine

Erect

Stretch Sign: Supine

String-of-Pearls Sign: Erect

SBO: Hernia

SMALL BOWEL OBSTRUCTION - ADHESION

CT FINDINGS Transition from dilated to collapsed loop

SMALL BOWEL OBSTRUCTION HERNIA

STRANGULATIONING OBSTRUCTION
Machinical obstruction when 2 limbs of a loop incarcerated by a band or in hernias compromising blood supply CT sensitive >plain Closed loop usually fluid filled and v shaped or radial with mesenteric vessels converging towards point of obstruction

STRANGULATION

bowel wall enhancement with contrast is poor serrated beak sign

Incarcerated ventral hernia

MIDGUT VOLVOLUS
Whirl pattern-The superior mesenteric vein (SMV) and its tributaries wrap around the superior mesenteric artery (SMA) as a result of volvulus of the midgut. Small bowel loops & fat converging to the point of torsion SMV left of SMA Caecum- high position or on left DJ flexure inferior to bulb

Sensitivity, specificity, and positive predictive value of the clockwise whirlpool sign for midgut volvulus were 92%, 100%, and 100%, respectively

 malrotaion

volvulus

MIDGUT VOLVOLUS

Intussusception
Ileocolic, ileoileal, colocolic or jejunojejunal Soft tissue mass surrounded by crescent of air Target sign due to peritoneal fat Barium enema diagnostic (claw sign) Sausage shaped or target mass on CT

Intussusception
Plain - Supine Enema

INTUSSUSCEPTION
Concentric rings due to bowel wall & mesenteric fat Sometimes tumour identified

INTUSSUSCEPTION

Gall stone ileus

Impaction of gall stones in intestine terminal ileum m/c 2% of small bowel obstruction Signs Gas in bile duct centrally (c.f.PV) Complete /incomplete small bowel obstruction Abnormal location of gall stone Change in position of gall stone

Gallstone ileus

COLON Obstruction
Causes Carcinoma of the colon Volvulus Diverticulitis Fecal impaction Radiological features depend upon- i.c valve competency Type1- i.c valve competent-dilated colon and caecum but not small bowel Type 11- i.c valve incompetent. No distention of caecum asc.colon but distention of small bowel

Colon Obstruction: Carcinoma

Colon Obstruction: Volvulus

80% sigmoid
20% cecum The cecum is the most distensible part of the colon A cecum of 9 cm diameter is cause for concern A cecum of 11 cm is impending perforation

Sigmoid volvulus
Ahaustral margin Left flank overlap sign Apex above T10 Apex under left hemidiaphragm Inferior convergence on left Liver overlap sign Air fluid ratio >2:1 Bird of prey sign Screw pattern of mucosal folds

Caecal volvulus
Caecum with mesentery Associated malrotation Marked caecal distension Attached appendix Moderate small bowel obstruction Collapsed left colon
90 80 70 60 50 40 30 20 10 0 1st 2nd 3rd 4th Qtr Qtr Qtr Qtr East

Distended Cecum

DIVERTICULITIS
Pain, LIF pain & elevated WBC Colonic wall thickening Pericolonic fat stranding Phlegmon Air pockets Abscess Dependant fluid collection

COLON-Diverticulitis
Increased density of pericolic fat Diverticula Focal wall thickening Stranding Phlegmon Abscess Localised perforation Fistula

COLON-Diverticulitis

Other Emergency Conditions of the Gut

Toxic megacolon: Crohn, UC; 5cm transverse colon is impending perforation Enterocolitis: C. diff. and other microbes Ischemia

Toxic Megacolon

Acute intestine ischemia

Causes-;
Arterial embolism(25%)-90% originate from left heart Arterial thrombosis(40%)- arising from atherosclerosisin SMA Venous thrombosis (15%) Non occlusive ischemia (15%) External compression trauma

Acute intestine ischemia

Radiology Plain film early stage
gasless abdomen with increasing grond glass haziness from hyper peristalsis with diarrhea

Latent stage
isolated distention of affected loops of sb with fluid level Rigid loop sign-decreased mobility of sb loops on repositioning Bowel wall thickening by edema and transmural bleeding

End stage
paralytic ileus( combined small and large bowel) Gas accumulation in bowel wall Gas in pv and mesenteric vein

 intestine ischemia`1
USG-most important adjuvent to plain film in early and latent stage
Bowel wall edema Thropmbus in SMV/SMA Excludes other cause of sb loops sepration(e.gascites ,pseudomyxoma)

CT ambolus/ thrombus in SMA/SMV Thickend and edematous wall of affected bowel Intramural gas Gas in PV

A word on Thumbprinting
It means thickened bowel wall It can occur acutely in C. diff. or ischemia or hemorrhage Chronically, it can be seen in inflammatory bowel disease and neoplasm and a few other less common diseases

C. diff. Enterocolitis

Ischemia: Findings
Normal gas pattern Non-specific ileus Thumbprinting Gas in bowel wall Gas in portal vein system Free air

Ischemia: Thumbprinting

Ischemia: CT

Inflammatory conditions

ACUTE APPENDICITIS
Right iliac fossa pain Nausea & vomiting Fever Elevated WBC

 USG (90% sensitivity)

blind tubular structure at point of tenderness Non compressible d/m =7>7 No peristalsis Apendicolith- acoustic shadowing (30%) Highly echogenic, non compressible surrounding fat Surrounding fluid or abscess Edema of caecal pole

CT
dilated fluid filled appendix > 7 mm peri appendicular fat stranding wall enhancement appendicolith Surrounding inflammatory changes;
Incresased fat attunation Fliud,caecal thiking Abcess,extraluminal gas,lap

Arrow head sign

Focal Ileus

Appendicolith

Acute Appendicitis: CT

Acute Appendicitis: CT

Diseases mimicking appendicitis

Ectopic pregnancy Ovarian cyst /torsion Salpingitis Diverticulitis Infectious ileocaecitis Crohns disease Intussusception Meckel Diverticulitis Urolithiasis Mesenteric adenitis

Gall Bladder Disease

Cholelithiasis

Cholelithiasis: Ultrasound

13-YEAR-OLD GIRL WITH CROHNS DISEASE

HAS SUBACUTE FEVER AND ABD PAIN

RETROPERITONEAL GAS
EXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT

ABDOMINAL PAIN 4 HOURS AFTER COLONOSCOPY AND BIOPSY

EXTENSIVE RETROPERITONEAL GAS

BAROTRAUMA
MEDIASTINUM RETROPERITONEUM FREE AIR

RETROPERITONEAL GAS
CAUSES
IATROGENIC
SURGERY DIAGNOSTIC PROCEDURE

TRAUMA
PENETRATING RUPTURED VISCUS
RETROPERITONEAL DUODENUM, COLON, RECTUM

PERFORATED BOWEL
SECONDARY TO TUMOR, INFECTION, OBSTRUCTION, NECROSIS

CAUDAL EXTENSION OF PNEUMOMEDIASTINUM GAS WITHIN ABSCESS

ISCHEMIC BOWEL

ISCHEMIC BOWEL
IMAGING SIGNS
DILATION
PSEUDOOBSTRUCTION

BOWEL WALL
THICKENED PNEUMATOSIS UNENHANCING

GAS IN VESSELS
MESENTERIC, SMV, PORTAL VEINS

OBSTRUCTED VESSELS
SMA, SMV
HIGH DENSITY CLOT ON UNENHANCED CT FILLING DEFECTS ON CT WITH IV CONTRAST

ASCITES, FREE AIR AFTER PERFORATION

ACUTE ONSET OF ABDOMINAL PAIN

SMA EMBOLIS

ISCHEMIC COLITIS IN TWO PATIENTS

ISCHEMIC SB AND COLON

THICKENED MUCOSAL FOLDS

SBO ISCHEMIC BOWEL

AT SURGERY: SB TWISTED UNDER ADHESION WITH OBSTRUCTI0N & SEGMENT OF DEAD BOWEL

61-YEAR-OLD MAN WITH PROSTHETIC AORTIC VALVE HAS ACUTE GI BLEEDING

ISCHEMIC COLITIS

ISCHEMIC SMALL BOWEL ETIOLOGY ?

SMV CLOT

47-YEAR-OLD WOMAN 2 WEEKS AFTER MI ACUTE ABDOMINAL PAIN OCCULT BLOOD + STOOL

SMA EMBOLIS FROM MURAL THROMBUS

Small bowel folds during enteroclysis

Jejunum
Number of folds per inch 4-7

Ileum
2-4 1-1.5mm 1-3mm

Fold thickness 1-2mm Fold height 3-7mm

Signs of Gallstone ileus

Small bowel obstruction
Gas within GB / Bile duct Abnormal location of gall stone Change in position of gall stone Relatively large fluid : Gas ratio in distended loops

Acute ulcerative colitis

Descending colon

Irregular outline
Loss of haustra No faecal residue

Paralytic ileus
Peritonitis Surgery

Trauma
Inflammation Renal colic/failure Low K+ Leaking abdominal aortic aneurysm Drugs morphine General debility or infection

Non obstructive ileus

Functional obstruction
Obstruction due to cessation of peristalsis Dilated loops filled with gas Fluid levels at late stage Both small and large bowel involved Difficult to distinguish from distal large bowel obstruction Barium and CT confirms diagnosis

Causes of functional obstruction

Postoperative Peritonitis Inflammation Trauma Congestive cardiac failure Vascular occlusion Pneumonia Renal failure Renal colic Leaking aortic aneurysm Hypokalemia Drugs

ACUTE APPENDICITIS

SMALL BOWEL OBSTRUCTION

Common cause of acute abdomen Etiology : Adhesion 64 79% Hernia 15 25% Tumor 10 15% High grade obstruction 95% accuracy Low grade obstruction 66% accuracy.so needs BMFT corelation

ISCHEMIC BOWEL
SYMPTOMS : Minor discomfort to Ac Abd pain CAUSE : Arterial/venous occlusion/thrombosis

ISCHEMIC BOWEL

PNEUMATOSIS INTESTINALIS

MESENTRIC AIR

CT FINDINGS Bowel wall thickening Pneumatosis intestinalis Air in mesentry Air in portal venous system Grave prognosis

INTUSSUSCEPTION

Stomach & Bowel

Dilated bowel loop can be due to

Focal bowel ileus

Small bowel obstruction

Large bowel obstruction Paralytic ileus

Causes of a massively dilated stomach

Mechanical gastric outlet obstruction
Duodenal or pyloric canal ulceration Carcinoma or pyloric antrum Paralytic ileus Surgery Trauma Peritonitis Pancreatitis Cholecystitis Diabetes Drugs Gastric volvulus Intubation Air swallowing - Acute gastric dilatation.

Gastric volvulus

Small Bowel Obstruction

Supine Erect

Small Bowel Obstruction

String of beads sign

Small Bowel Obstruction

Mechanical bowel obstruction periappendiceal adhesions

Large Bowel Obstruction

Abdominal Calcification

Approach to radioopaque shadow

Site Anterior or overlapping spine

Texture, central lucency

Movement with respiration

Movement in serial films

Ca++ associated with acute. abdomen

Calcification
Gallstones Calcified GB wall Limey bile Appendix calculus Calculus in: Meckels diverticulum Jejunal diverticulum Colonic diverticulum Pancreatic calculi Ureteric calculus Calcified aneurysms aortic, splenic, hepatic Teeth in ovarian dermoid

Acute condition
Cholecystitis Biliary colic (stone may be close to spine) Empyema of gallbladder Gallstone ileus (stone in abnormal location) Appendicitis Acute inflammation or perforation

Pancreatitis chronic and acute (rate) Renal colic Rupture Torison

Gall Bladder and Cystic duct

Mercedes Benz

Emphysematous cholecystitis

Liver abscess

Splenic artery

Coproliths - Appendix

Coproliths Retrocecal Appendix

Calcified mesenteric lymphnodes

Calcified mesenteric lymphnodes

Pancreatitis - Calcification

ACUTE CHOLECYSTITIS
Right upper quadrant pain - Nausea, vomiting Fever Almost all a/w gall stone and caused by cystic duct obstruction Plain x ray Gall stone in 20% Duodenal ileus,ileus of hepatic flexor of colon Rt hypochondrial mass d/t enlarged gb Gas in the Biliary tree USG thickend echogenic gb wall with hypoechoic margin50-70 % Gall bladder distension, stones/sludge Pericholecystic fluid +ve sonographic murphy sign HIDA scan Non functioning gall bladder

with focal ileus

ACUTE CHOLECYSTITIS

CT FINDINGS Inflammation Distended GB Wall enhancement Wall thickening Haziness of pericholic fat Pericholic fluid collection

COMPLICATIONS Abscess Emphysematous Perforation Inf.cholangitis

Emphysematous cholecystitis
Gas in wall/lumen of gb Gas in bile duct (20%) Cystic duct obstruction ischeamia gas forming organism proliferation Clostridium welchi m/c In diabetics(30%),m>n Plain film-lines of gas bubbles parallel to wall/ oval collection of gas in gb lumen (d/d-gall stone ileus, enteric fistula) Gb usually enlarged USG/CT-air in wall/lumen

Organ Stomach

Inflammation versus Obstruction Lesion Location

Gastric Ulcer Duodenal Ulcer

Lesion
Adhesions Bulges Cancer Crohns disease Gallstone ileus Intussusception Volvulus

Small Bowel Obstruction

Biliary Tract
Pancreas

Acute choly +/choledocholithiasis

Acute, recurrent, or chronic pancreatitis Crohns disease Meckels diverticulum Appendicitis Diverticulitis

Small Intestine Large Intestine

Large Bowel Obstruction

Malignancy Volvulus: cecal or sigmoid Diverticulitis

Take Home Points

Careful history (pain, other GI symptoms) Remember DDx in broad categories Narrow DDx based on hx, exam, labs, imaging Always perform ABC, Resuscitate before Dx If patients sick or toxic, get to OR (surgical emergency) Ideally, resuscitate patients before going to the OR Dont forget GYN/medical causes, special situations For acute abdomen, think of these commonly (below) Perf DU Cholecystitis Appendicitis +/- perforation Ischemic or perf bowel Diverticulitis +/- perforation Ruptured aneurysm Bowel obstruction Acute pancreatitis