THE ACUTE ABDOME

an overviewBy

Hamdy Sedky.MD,MRCSLecturer Of GI Surgery

Definition Etiology

Presenting symptoms

Physical examination

Investigations

Treatment

Any unexpected spontaneous (non-

traumatic) disorder whose chief

manifestations are in the abdominal area

and for which urgent operation may be

necessary.

Definition

Etiology Presenting symptoms

Physical examination

Investigations

Treatment

Surgical causes

Gastrointestinal tract disorders

Appendicitis

Small and large bowel obstruction

Perforated peptic ulcer

Incarcerated hernia

Bowel perforation

Meckel's diverticulitis

Boerhaave's syndrome

Diverticulitis

Inflammatory bowel disorders

 Mallory-Weiss syndrome

Gastroenteritis

Acute gastritis

 Mesenteric adenitis

Parasitic infections

Pancreatic disorders

Acute pancreatitis

Liver, spleen, and biliary tract disorders

Acute cholecystitis

Acute cholangitis

Hepatic abscess

Ruptured hepatic tumor

Spontaneous rupture of the spleen

Splenic infarct

Biliary pain

Acute hepatitis

Urinary tract disorders

Ureteral or renal colic

Acute pyelonephritis

Acute cystitis

Renal infarct

Gynecologic disorders

Ruptured ectopic pregnancy

Twisted ovarian tumor

Ruptured ovarian follicle cyst

Acute salpingitis

Dysmenorrhea

Endometriosis

Vascular disorders

Ruptured aortic and visceral aneurysms

Acute ischemic colitis

Mesenteric ischaemia

Peritoneal disorders

Intra-abdominal abscesses

Peritonitis

Tuberculous peritonitis

Retroperitoneal disorders

Retroperitoneal hemorrhage

MEDICAL CAUSES Endocrine and metabolic disorders

Uremia

Diabetic crisis

Addisonian crisis

Acute intermittent porphyria

Acute hyperlipoproteinemia

Hereditary Mediterranean fever

Hematologic disorders

 Sickle cell crisis

Acute leukemia

Other dyscrasias

Toxins and drugs

Lead and other heavy metal poisoning

Narcotic withdrawal

Black widow spider poisoning

Infections and inflammatory disorders

Tabes dorsalis

Herpes zoster

Acute rheumatic fever

Henoch-Schonlein purpura

Systemic lupus erythematosus

Polyarteritis nodosa

Referred pain Thoracic region

Myocardial infarction

Acute pericarditis

Pneumonia

Pleurisy

Pulmonary embolus

Pneumothorax

Empyema

Hip and back

Definition

Etiology

Presenting symptoms Physical examination

Investigations

Treatment

Abdominal pain

The most common,

The most predominant and

The most important

symptom of an acute abdomen.

(1) Location of Pain

The abdominal region has a dual

nerve supply; visceral and somatic,

abdominal pain may be visceral or

parietal

Visceral pain

Stimuli: Stretching of peritoneum or organ capsules

Traction on the bowel mesentery

Inflammation

Ischemia

Sensation: Diffuse and poorly localized, deep seated, slow in onset, dull in character,

and protracted.

May be perceived at remote locations related to organ’s sensory innervation

that corresponds to its embryologic origin (foregut, midgut, hindgut)

Example:

Visceral pain sites.

Somatic pain

Stimuli

› Irritation of parietal peritoneum

Sensation

› Well-localized pain

› Of acute onset

› Sharp pain

› More superficial

› Easily described

Example:

Change in pain location

› Referred pain

› Radiating pain

› Shifting pain

› Spreading pain

Change in pain location

(2) Mode of Onset and Progression of Pain

May be

Explosive (within seconds),

Rapidly progressive (within 1-2 hours), or

Gradual (over several hours).

Sudden, excruciating generalized pain

suggests an intra-abdominal catastrophe

Examples: perforated viscus or

rupture of an aneurysm,

ectopic pregnancy.

A less dramatic onset of a mild pain that

increases gradually over 1-2 hours

Examples:

acute cholecystitis,

acute pancreatitis,

strangulated bowel,

mesenteric infarction,

high small bowel obstruction.

(3) Character of Pain

The sharp superficial constant pain is typical of perforated ulcer

or a ruptured appendix.

The gripping pain of small bowel obstruction is usually

intermittent, vague, deep-seated, and crescendo decrescendo

Pain associated with bowel obstruction is severe but bearable,

while pain caused obstruction of smaller conduits (bile ducts and

ureters) rapidly becomes unbearably intense.

The aching discomfort of ulcer pain,

The stabbing pain of acute pancreatitis and mesenteric infarction,

The tearing pain of ruptured AAA.

Location and character of pain

Definition

Etiology

Presenting symptoms

Physical examination Investigations

Treatment

General condition

Disturbed conscious level

Facies

Gait

Decubitus:

The rolling patients

The rigidly motionless patient

The bent sitting patient

The patient with a flexed Rt. hip

Fever Constant low-grade fever:

diverticulitis,

acute cholecystitis, and

appendicitis.

High fever (> 39 °C), disorientation, and rigors indicate

impending septic shock:

advanced peritonitis,

acute cholangitis, or

pyelonephritis.

Pitfall:

elderly,

chronically ill, or

immunosuppressed patients.

Systemic signs extreme pallor,

Cyanosis

Jaundice

Hypo hyperthermia,

hypotension

tachycardia,

tachypnea

Sweating

Foeter hepaticus, fruity odour

Inspection

Your eyes are always first

A distended abdomen with a scar or a hernia

A scaphoid contracted abdomen

Visible peristalsis

Diminished respiratory abdominal wall movements

Pulsations

A visible swelling

Skin abnormalities

Palpation Guarding and rigidity

Tenderness:

is the most important finding in acute abdomen.

Types:

Localized

Rebound

Cross

Cough

Percussion

Palpation

Murphy's sign

Iliopsoas sign

Obturator sign

Costovertebral angle tenderness

Palpation

Swellings:

Inflammatory mass

Tumours

Intussusception

Ischaemic bowel

The tense tympanic balloon

Palpation

Hyperaesthesia:

Sherren’s triangle

Boas’s sign

In renal inflammatory lesions

In salpingitis

Hernial orifices

The scrotum

Percussion

Percussion tenderness

Liver dullness.

Free peritoneal fluid

The diffusely dull abdomen

Auscultation

Loud peristalsis synchronous with colic are heard in mid

small bowel obstruction

The high-pitched hyperperistaltic sounds unrelated to the

crampy pain in enteritis.

A silent abdomen except for infrequent tinkling sounds in

late bowel obstruction or diffuse peritonitis.

Pelvic examination

Rectal examination

Pelvic examination:

Definition

Etiology

Presenting symptoms

Physical examination

Investigations

Treatment

The abdominal series

Advantages

Readily available

Mobile

Don’t need radiologist

Disadvantages

2D image

Radiation dose (40x effective dose of CXR)

Relatively low sensitivity

The abdominal series

It includes: PA erect chest,

AP supine and

AP erect abdomen

If patient unable to sit/stand: supine and

left lateral decubitus abdomen

The abdominal series

What to look for: Bowel distension

Bowel wall thickening/oedema (>3mm)

Intramural gas

Free intraperitoneal gas

Calcification

Stones

Pancreatic

Vascular

Psoas shadows

Free intraperitoneal gas

Ultrasonography

Ultrasonography is helpful in evaluating: Acute cholecystitis, cholangitis

Acute appendicitis

Complicated external hernias

Renal and ureteric lesions

Intra-abdominal free and localized fluid collections

Transanal and transvaginal probes for evaluating

pelvic pathology specially in females

Young/pregnant patients with abdominal symptoms

Ultrasonography Advantages

No radiation

Mobile

Allows real time visualisation, eg peristalsis

Excellent contrast between fluid and soft tissue, eg

gallbladder

Disadvantages

Operator dependent

Poor images in larger patients

Bowel gas

CT scan

Advantages

Very high resolution images (esp. multislice CT)

Higher diagnostic accuracy

No problems with obese patients/bowel gas

Disadvantages

High radiation dose (approximately 200x CXR)

Side effects of IV contrast (nephrotoxicity, allergy, etc)

Not portable (cf AXR and ultrasound)

CT Scan

CT is helpful in:

Examining retroperitoneal organs (Acute pancreatitis)

Detecting sites of inflammatory diseases that may prompt

(appendicitis, tubo-ovarian abscess) or postpone (diverticulitis,

pancreatitis, hepatic abscess) operation.

Identifying small amounts of free intraperitoneal gas

Free localized intraperitoneal and retroperitoneal fluid

Bowel ischaemia/perforation/obstruction

Vascular pathology, eg intraabdominal aneurysm, MVO

Obese patients

Unresolved diagnosis following AXR/US

angiography

Selective visceral angiography is useful

in:

mesenteric infarction,

ruptured liver adenoma or carcinoma or

ruptured abdominal aneurysm

Endoscopy

Proctosigmoidoscopy is indicated in any patient

with acute abdomen and suspected segmoid

volvulous

Paracentesis In patients with free peritoneal fluid, aspiration of

blood, bile, or bowel contents is an indication for

urgent laparotomy.

Infected ascitic fluid may establish a diagnosis in

spontaneous bacterial peritonitis, tuberculous

peritonitis, or chylous ascites which rarely

require surgery.

Culdocentesis may be useful for suspected

ruptured corpus luteum cyst.

Laparoscopy

In female patients in the child bearing period

presenting with lower abdominal pain.

In obtunded, elderly, or critically ill patients.

In adhesive bowel obstruction

Definition

Etiology

Presenting symptoms

Physical examination

Investigations

Treatment

Indications for surgery in acute abdomen

Physical findings

Involuntary guarding or rigidity, especially if spreading

Increasing or severe localized tenderness

Tense or progressive distention

Tender abdominal or rectal mass with high fever or

hypotension

Equivocal abdominal findings along with Sepsis

Suspected ischemia (acidosis, fever, tachycardia)

Deterioration on conservative treatment

Indications for surgery in acute abdomen

Radiologic findings

Pneumoperitoneum

Gross or progressive bowel distention

Free extravasation of contrast material

Space-occupying lesion on scan, with fever

Mesenteric occlusion on angiography

Endoscopic findings

Perforated or uncontrollably bleeding lesion

Paracentesis findings

Blood, bile, pus, bowel contents, or urine

Treatment of the Acute Abdomen

ABCDE

large bore IV lines with either saline or lactated Ringer’s

solution

IV pain medication

Nasogastric tube if vomiting or concerned about

obstruction

Foley catheter to follow hydration status and to obtain

urinalysis

Antibiotic administration if suspicious of inflammation or

perforation

Definitive therapy or procedure will vary with diagnosis

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