ACUTE ACUTE ABDOMENABDOMEN

DEFINITIONDEFINITION

Any sudden non-traumatic disorder whose chief Any sudden non-traumatic disorder whose chief manifestations are in the abdomen , which manifestations are in the abdomen , which definitely or possibly threatens life and for which definitely or possibly threatens life and for which

urgent surgical interference may be necessary.urgent surgical interference may be necessary. Frequently there is a progressive underlying Frequently there is a progressive underlying

disorder.disorder. So undue delay in diagnosis and treatment may So undue delay in diagnosis and treatment may

adversely affect the outcome.adversely affect the outcome. The surgeon may often have to perform a The surgeon may often have to perform a

calculated gamble – either to “wait & see” or calculated gamble – either to “wait & see” or “look & see”“look & see”

In 20% cases the decision to operate may be In 20% cases the decision to operate may be uncertain uncertain

Many a times “wait & see” policy may be Many a times “wait & see” policy may be disastrous and disastrous and

“ “look & see” policy ( even if incorrect ) look & see” policy ( even if incorrect ) is rewarding is rewarding

of no loss , examples-of no loss , examples-• ““wait & see”- in ruptured ectopic wait & see”- in ruptured ectopic

pregnancy, dissecting aortic aneurysm pregnancy, dissecting aortic aneurysm etcetc

• ““look & see”- in suspected appendicitis, look & see”- in suspected appendicitis, acute exacerbation of ch. PUD.acute exacerbation of ch. PUD.

Frederick H. Marsh (1839-1915) a Frederick H. Marsh (1839-1915) a British surgeonBritish surgeon said “ said “ Happy is he Happy is he who has no serious consequence of who has no serious consequence of his erroneous diagnosis to regret”.his erroneous diagnosis to regret”.

Common causes Common causes A.A. Intra-peritonealIntra-peritonealI.I. GIT- GIT- *Appendicitis*Appendicitis *Gut obstruction*Gut obstruction *Incarcerated hernia*Incarcerated hernia * Small/Large gut perforation in--- typhoid * Small/Large gut perforation in--- typhoid

ulcer, intestinal TB ,Crohn’s diseases, round ulcer, intestinal TB ,Crohn’s diseases, round worm- ulcer, Burst appendix, Colonic worm- ulcer, Burst appendix, Colonic diverticulitis, CA-colon, Meckel’s diverticulitis.diverticulitis, CA-colon, Meckel’s diverticulitis.

* Boerhaave’s syndrome* Boerhaave’s syndrome * Acute GE* Acute GE * Mesenteric adenitis* Mesenteric adenitisII.II. HBS & PancreasHBS & Pancreas *Acute cholecystitis *Acute *Acute cholecystitis *Acute

cholangitis cholangitis

* Biliary colic- due to stone in biliary tree* Biliary colic- due to stone in biliary tree round worms, clots.round worms, clots. * Hepatic abscesses* Hepatic abscesses * Hepatic tumor necrosis* Hepatic tumor necrosis * Haemorrhage in hepatic cysts * Haemorrhage in hepatic cysts * Splenic infarcts * Splenic infarcts * Acute hepatitis * Acute * Acute hepatitis * Acute

pancreatitispancreatitisIII.III. Urinary tract Urinary tract * Acute pyelonephritis * Acute cystitis* Acute pyelonephritis * Acute cystitis * Renal infarcts * Acute * Renal infarcts * Acute

haemorrhage in haemorrhage in renal tumors.renal tumors.

IV.IV. Gynaecological disordersGynaecological disorders * Ruptured ectopic pregnancy* Ruptured ectopic pregnancy * Twisted ovarian cyst or tumor* Twisted ovarian cyst or tumor * Ruptured ovarian follicular cyst* Ruptured ovarian follicular cyst * Acute sulphingo-oophoritis* Acute sulphingo-oophoritis * Dysmenorrhoea * Endometriosis* Dysmenorrhoea * EndometriosisV.V. Vascular disordersVascular disorders * Ruptured aortic or major vessels aneurysm* Ruptured aortic or major vessels aneurysm * Acute ischemic colitis * Acute ischemic colitis * Mesenteric vascular thrombosis* Mesenteric vascular thrombosisVI.VI. Peritoneal disordersPeritoneal disorders * Intra-abdominal abscesses* Intra-abdominal abscesses * Peritonitis * Peritonitis a. Pyogenic b. Tuberculous c. Chemicala. Pyogenic b. Tuberculous c. ChemicalVII.VII. Retro-peritoneal disordersRetro-peritoneal disorders * Haemorrhage. * Haemorrhage.

B.B. Extra peritoneal causesExtra peritoneal causesI.I. CardiopulmonaryCardiopulmonary * Pneumonia * Empyema thoracis* Pneumonia * Empyema thoracis * Acute MI * Acute RHD* Acute MI * Acute RHDII.II. GenitourinaryGenitourinary * Nephritis * Pyelitis * Perinephric * Nephritis * Pyelitis * Perinephric

abscessabscess * Ureteric colic * Epididymitis *Prostatitis* Ureteric colic * Epididymitis *Prostatitis * Cystitis* CystitisIII.III. VascularVascular * Dissecting aortic aneurysm * Periarteritis* Dissecting aortic aneurysm * PeriarteritisIV.IV. NeurogenicNeurogenic * Spinal cord tumor * Osteomyelitis of * Spinal cord tumor * Osteomyelitis of

spine spine * Tabes Dorsalis * Herpes Zoster* Tabes Dorsalis * Herpes Zoster * Abdominal epilepsy * Abdominal epilepsy

V.V. MetabolicMetabolic

* Uremia * Acidosis* Uremia * Acidosis

* Poryphyria * Addisonian crisis* Poryphyria * Addisonian crisis

VI.VI. ToxinsToxins

* Bacterial (eg: tetanus) * Insects bites* Bacterial (eg: tetanus) * Insects bites

* Venoms *Drugs* Venoms *Drugs

* Lead poisioning* Lead poisioning

VII.VII. Abdominal wall – intramuscular Abdominal wall – intramuscular haematomahaematoma

VIII.VIII. PsychogenicPsychogenic

AssessmentAssessment Approach- must be orderly & thoroughly.Approach- must be orderly & thoroughly. History & clinical exam should suggest the History & clinical exam should suggest the

probable cause and guide the choice of lab. studies.probable cause and guide the choice of lab. studies. The clinician must then decide correctly whether The clinician must then decide correctly whether

hospitalization is needed & non-operative hospitalization is needed & non-operative treatment is needed.treatment is needed.

Harmful inaccurate diagnosis should not be >1% Harmful inaccurate diagnosis should not be >1% and harmless inaccurate diagnosis not >20%and harmless inaccurate diagnosis not >20%

HistoryHistory

a.a. PainPain- points to note –- points to note –

* time and mode of onset* time and mode of onset

* duration* duration

* site* site

* shifting* shifting

* radiation * radiation

* referred pain * referred pain

* character of pain, change of the * character of pain, change of the character.character.

* effect of pressure* effect of pressure

* relation to food, movements, * relation to food, movements, respiration, respiration,

micturation, defecationmicturation, defecation

* what makes the pain better or worse * what makes the pain better or worse

Just the mode of onset of pain may Just the mode of onset of pain may dictate the diagnosisdictate the diagnosis

Sudden onset Sudden onset Gradual Gradual

onsetonset• Perforated viscus AppendicitisPerforated viscus Appendicitis• Volvulus Cholecystitis Volvulus Cholecystitis • Mesenteric vascular thrombosis PancreatitisMesenteric vascular thrombosis Pancreatitis• Ruptured aortic aneurysm PyelonephritisRuptured aortic aneurysm Pyelonephritis• Ruptured ectopic pregnancy Low intestinal Ruptured ectopic pregnancy Low intestinal

obstructionobstruction• Twisted ovarian cyst Leaking aortic Twisted ovarian cyst Leaking aortic

aneurism aneurism • Mittelschmers Splenic vein Mittelschmers Splenic vein

thrombosisthrombosis• Intra-peritoneal haemorrhage EndometriosisIntra-peritoneal haemorrhage Endometriosis

Intermittent painIntermittent pain Constant pain with Constant pain with acute exacerbationacute exacerbation

• PUD PancreatitisPUD Pancreatitis• Reflux oesophagitis Alkaline reflux Reflux oesophagitis Alkaline reflux

gastritisgastritis• CholelithiasisCholelithiasis• DiverticulitisDiverticulitis• Ch. PancreatitisCh. Pancreatitis• Crohn’s diseases Crohn’s diseases • EndometriosisEndometriosisb. Vomitingb. Vomiting CharacterCharacter FrequencyFrequency QualityQuality VomitusVomitus Relation with painRelation with pain

c. Bowel movementsc. Bowel movements Absolute constipationAbsolute constipation Loose motionLoose motion Spurious diarrhoeaSpurious diarrhoea Passage of red currant jelly (in Passage of red currant jelly (in

intussusceptions)intussusceptions)

d. Micturitiond. Micturition Strangury (in ureteric or vesicle calculi)Strangury (in ureteric or vesicle calculi) Increase frequency with dysuriaIncrease frequency with dysuria

e. In womene. In women Menstrual historyMenstrual history H/O missed periodH/O missed period

f. Past historyf. Past history H/O PUD, Haematemesis, MelaenaH/O PUD, Haematemesis, Melaena H/O similar attack in the pastH/O similar attack in the past

g. Drug historyg. Drug history

Anticoagulants, NSAIDS, Steroids, AspirinAnticoagulants, NSAIDS, Steroids, Aspirin

h. Family historyh. Family history : Any other member having : Any other member having similar prblems.similar prblems.

i. Traveling history i. Traveling history :: related to related to Amoebic liver abscessAmoebic liver abscess Hydatid cystHydatid cyst Malarial spleenMalarial spleen Typhoid ulcer in ileumTyphoid ulcer in ileum Worm infestationWorm infestation

Physical examinationPhysical examination Do notDo not jump into exam. the abdomenjump into exam. the abdomen Methodical & complete general examination must Methodical & complete general examination must

precede abdominal examination.precede abdominal examination. Extreme pallor Extreme pallor

HypothermiaHypothermia

Tachycardia May suggest Tachycardia May suggest intraintra

Tachypnoea abdominal Tachypnoea abdominal haemorrhage haemorrhage

Sweating (provided exta Sweating (provided exta

Cold & clammy extrimities abdominal Cold & clammy extrimities abdominal bleedingbleeding

excluded) excluded)

FeverFever• Low grade: Low grade: AppendicitisAppendicitis CholecystitisCholecystitis DiverticulitisDiverticulitis• High grade: High grade: Empyema GBEmpyema GB Appendicular abscessAppendicular abscess Burst appendix with peritonitisBurst appendix with peritonitis Acute salphingo-oophoritisAcute salphingo-oophoritis PyonephrosisPyonephrosis• High fever with disorientation , lethargy, chills High fever with disorientation , lethargy, chills

& rigor- impending septic shock.& rigor- impending septic shock.

Examination of abdomen Examination of abdomen

1.1. Inspection :Inspection : Scaphoid abdomen – unlikely to have acute Scaphoid abdomen – unlikely to have acute

pathology.pathology. Tensely distended abdomen with old scar- Tensely distended abdomen with old scar-

suggest intestinal obstructionsuggest intestinal obstruction Central distention- suggest small gut obstructionCentral distention- suggest small gut obstruction In volvulus of sigmoid colon distention mostly in In volvulus of sigmoid colon distention mostly in

left side & part of central abdomen.left side & part of central abdomen. Visible peristalsis indicates gut obstruction- Visible peristalsis indicates gut obstruction-

direction & site is pathognomic .direction & site is pathognomic . Ladder pattern gut loops distention with Ladder pattern gut loops distention with

peristalsis- in central abdomen also indicates peristalsis- in central abdomen also indicates small gut obstruction.small gut obstruction.

Hernial orifices must be inspected for obstructed Hernial orifices must be inspected for obstructed hernias.hernias.

Movement with respiration Movement with respiration * Sluggish or no movement indicates diffuse * Sluggish or no movement indicates diffuse

peritonitis –due to visceral perforation, intra-peritonitis –due to visceral perforation, intra-peritoneal haemorrhage.peritoneal haemorrhage.

* Localized limitation in respiratory movement – * Localized limitation in respiratory movement – occurs in acute appendicitis , acute cholecystitis etc.occurs in acute appendicitis , acute cholecystitis etc.

Localized swelling – Localized swelling – moving with breathing inmoving with breathing in * Empyema GB* Empyema GB * Mucocele GB* Mucocele GB * Ca- stomach* Ca- stomach * Enlarged liver* Enlarged liver - - not moving with breathing innot moving with breathing in * Retro-peritoneal tumor* Retro-peritoneal tumor * Mesenteric cyst* Mesenteric cyst * Ca- colon * Ca- colon

Pulsatile swelling—Pulsatile swelling—

* Abdominal aortic aneurysm * Abdominal aortic aneurysm

* Tumor lying over the aorta* Tumor lying over the aorta

II.II. Palpation : Palpation : assessassess * * Local rise of temperatureLocal rise of temperature

* Muscle guard (exclude voluntary contraction * Muscle guard (exclude voluntary contraction by deep breathing with mouth open.)by deep breathing with mouth open.)

* Hyperesthesia* Hyperesthesia

ImportanceImportance : :

1. Hyperesthesia + Muscle guard in Sherrer’s 1. Hyperesthesia + Muscle guard in Sherrer’s triangle triangle

Gangrenous appendicitisGangrenous appendicitis

In burst appendix hyperesthesia In burst appendix hyperesthesia disappears disappears

2.2. Boas’ sign --- hyperesthesia Boas’ sign --- hyperesthesia between 9between 9thth &11 &11thth ribs in right infrascapular ribs in right infrascapular region indicates acute cholecystitisregion indicates acute cholecystitis

3. 3. Hyperesthesia with extra Hyperesthesia with extra abdominal causeabdominal cause

* Herpes Zoster* Herpes Zoster * Spinal root compression* Spinal root compression * other neuromuscular problems * other neuromuscular problems

TendernessTenderness * Always constant over inflamed organ.* Always constant over inflamed organ. * Tenderness + muscle guard ---- most important * Tenderness + muscle guard ---- most important

finding in acute abdomenfinding in acute abdomen Tenderness with out muscle guardTenderness with out muscle guard : :

GGastroenteritis, astroenteritis, IIntestinal inflammation with out ntestinal inflammation with out peritonitis peritonitis

Minimum tenderness but severe painMinimum tenderness but severe pain * * Uncomplicated hollow viscera obstructionUncomplicated hollow viscera obstruction

Specific point tendernessSpecific point tenderness 1. Murphy’s sign --- Acute cholecystitis1. Murphy’s sign --- Acute cholecystitis 2. McBurney’s point --- Acute appendicitis2. McBurney’s point --- Acute appendicitis 3. Rovsing’s sign --- Acute appendicitis3. Rovsing’s sign --- Acute appendicitis 4. Duodenal point --- Duodenal ulcer4. Duodenal point --- Duodenal ulcer 5. Renal angle --- Pyelonephritis, Renal calculi, 5. Renal angle --- Pyelonephritis, Renal calculi,

Perinephric abscessPerinephric abscess Rebound tenderness --- Sign of peritonitis Rebound tenderness --- Sign of peritonitis

with inflamed organ underneath. Eg. Acute with inflamed organ underneath. Eg. Acute Appendicitis Appendicitis

Rebound Tenderness –Bloomberg’s Sign Rebound Tenderness –Bloomberg’s Sign ––rebound tenderness in Acute Intestinal rebound tenderness in Acute Intestinal

Obstruction –suggests strangulationObstruction –suggests strangulation Bed shaking test (of Bapat) +ve in early Bed shaking test (of Bapat) +ve in early

peritonitis (helpful test –when early peritonitis (helpful test –when early peritonitis is in doubt)peritonitis is in doubt)

Spread of tenderness –indicates spreading Spread of tenderness –indicates spreading peritonitis –eg. Perforation of PUD, burst peritonitis –eg. Perforation of PUD, burst appendix.appendix.

Pointing test –if the point of pain shown by Pointing test –if the point of pain shown by the patient is the point of tenderness –it is the patient is the point of tenderness –it is certainly the site of the diseased viscus.certainly the site of the diseased viscus.

Cough test –pain in the abdomen with cough Cough test –pain in the abdomen with cough indicates the site of the diseased viscusindicates the site of the diseased viscus

Appendicular tenderness –best elicited in left Appendicular tenderness –best elicited in left lateral positionlateral position

PatiencePatience ususally gives the ususally gives the clinicalclinical

ExperienceExperience diagnosis in >90% of diagnosis in >90% of casescases

Repeated Exam.Repeated Exam. If still in doubt –pt. must be hospitalizedIf still in doubt –pt. must be hospitalized Rising pulse over hours is very significantRising pulse over hours is very significant 4 signs of maxm. Importance in acute 4 signs of maxm. Importance in acute

abdomenabdomen Pointing testPointing test Cough testCough test Rebound tendernessRebound tenderness Bed-shaking testBed-shaking test

Trigger pt. sensitivityTrigger pt. sensitivity signify parietalsignify parietal Lateral costal rib tip tendernessLateral costal rib tip tenderness

abdominal wallabdominal wall Pain exacerbated by spinal motionPain exacerbated by spinal motion

pathologies.pathologies.

Referred pain:Referred pain: -to shoulder tip (C -to shoulder tip (C44), ), subscapular area (Tsubscapular area (T6-86-8) without local ) without local tenderness –may indicate thoracic pathologytenderness –may indicate thoracic pathology

Specific signs-Specific signs- Murphy’s Sign –Ac. CholecystitisMurphy’s Sign –Ac. Cholecystitis McBurney;s Sign –Ac. AppendicitisMcBurney;s Sign –Ac. Appendicitis Cope’s Psoas –Ac. Appendicitis (Retrocaecal appendix), Cope’s Psoas –Ac. Appendicitis (Retrocaecal appendix),

Psoas Psoas abscess, Perinephric abscess abscess, Perinephric abscess Cope’s obturator –Ac. Appendicitis (Pelvic abcess)Cope’s obturator –Ac. Appendicitis (Pelvic abcess)

-obstructed obturator hernia-obstructed obturator hernia

Masses in Ac. Abd. –Empyema GBMasses in Ac. Abd. –Empyema GB

-Pancreatic abscess-Pancreatic abscess

-Liver abscess-Liver abscess

-appendicular lump-appendicular lump

-appendicular abscess-appendicular abscess

-Haemorrhage in -Haemorrhage in splenomegalysplenomegaly

-Renal/perinephric abscess-Renal/perinephric abscess Hernial orificesHernial orifices

InguinalInguinal UmbilicalUmbilical may reveal obstructed herniasmay reveal obstructed hernias FemoralFemoral

DREDRE –without it, no abdominal exam is complete. –without it, no abdominal exam is complete.

Ant. Wall tenderness Ant. Wall tenderness In Ac. Appendicitis (pelvic app.)In Ac. Appendicitis (pelvic app.) Ac. Salphingo-oophoritisAc. Salphingo-oophoritis Twisted ovarian cystTwisted ovarian cyst Ruptured ectopic pregnancyRuptured ectopic pregnancy Pelvic abscessPelvic abscess

Other findingsOther findings Rectal tumoursRectal tumours IntussusceptionIntussusception Thrombosed haemorrhoidsThrombosed haemorrhoids Ischiorectal abscessIschiorectal abscess

PercussionPercussion:: Less important in acute abdomenLess important in acute abdomen Because it may be painfulBecause it may be painful If done, it differentiates fluid or gaseous If done, it differentiates fluid or gaseous

distensiondistension Shifting dullness –in ascitesShifting dullness –in ascites

AuscultationAuscultation: BS –not heard within 1 min. : BS –not heard within 1 min. over several quadrants means –absent.over several quadrants means –absent.

Absent BS –means Absent BS –means Profound ileusProfound ileus HypokalaemiaHypokalaemia HypomagnesemiaHypomagnesemia Narcotic overdosageNarcotic overdosage PeritonitisPeritonitis Mesenteric thrombosis Mesenteric thrombosis

Hypoactive BS (<3/min)Hypoactive BS (<3/min) HypokalaemiaHypokalaemia PeritonitisPeritonitis Bowel ischaemiaBowel ischaemia

Hyperactive BS (>10/min)Hyperactive BS (>10/min) Early gut obstructionEarly gut obstruction Early diverticulitisEarly diverticulitis Early mesenteric artery thrombosis/embolismEarly mesenteric artery thrombosis/embolism Early GEEarly GE

General survey in Acute abdomenGeneral survey in Acute abdomen::AppearanceAppearance: : Peculiar ‘Abdominal facies’Peculiar ‘Abdominal facies’ –it can –it can

discriminate abdominal from extra-abd. causediscriminate abdominal from extra-abd. cause

Facies HippocrativaFacies Hippocrativa Terminal stage of peritonitisTerminal stage of peritonitis Anxious look, bright eyes, pinched face with Anxious look, bright eyes, pinched face with

cold sweating foreheadcold sweating forehead Once seen, will never be forgottenOnce seen, will never be forgotten..

Facies of dehydrationFacies of dehydration Sunken eyes, drawn cheeks & dry tongue.Sunken eyes, drawn cheeks & dry tongue.

AttitudeAttitude:: In colics –pt. tossing on bed, doubled-up or rolls In colics –pt. tossing on bed, doubled-up or rolls

in agonyin agony In peritonitis (early) –calm & quiet.In peritonitis (early) –calm & quiet. In terminal peritonitis & post-op. peritonitis –In terminal peritonitis & post-op. peritonitis –

highly excitable, throwing out bed clothes, highly excitable, throwing out bed clothes, tossing head, grumbling, ineffective movement tossing head, grumbling, ineffective movement of limbsof limbs

PulsePulse: Normal –in early stage Ac. Abdomen, : Normal –in early stage Ac. Abdomen, eg. Acute eg. Acute intestinal obstruction, intestinal obstruction, haemorrhagic pancreatitis, haemorrhagic pancreatitis, perforation of perforation of PUD.PUD.

Increased –in Ac, appendicitis, Increased –in Ac, appendicitis, internal internal haemorrhage, spreading peritonitis, haemorrhage, spreading peritonitis, advancing advancing intestinal obstruction, intestinal obstruction, dehydration.dehydration.

Respiration:Respiration: -seldom increased, except in – -seldom increased, except in –internal haemorrhage & late peritonitis.internal haemorrhage & late peritonitis.Resp. rate, proportionately increases with Resp. rate, proportionately increases with increasing fever.increasing fever. RR with movements of alae nasi- indicates RR with movements of alae nasi- indicates thoracic pathology, eg. Lobar pneumonia, thoracic pathology, eg. Lobar pneumonia, basal pleurisy etc.basal pleurisy etc.

TemperatureTemperature: -increases in any infective & : -increases in any infective & inflammatory condition but the range variesinflammatory condition but the range varies

Low grade ↑ -early Ac. Appendicitis, Low grade ↑ -early Ac. Appendicitis, pancreatitispancreatitis

Moderate grade –Ac. CholecystitisModerate grade –Ac. Cholecystitis The temp. rise is never an early sign in Ac. The temp. rise is never an early sign in Ac.

Abdomen.Abdomen. High temp (with fluctuations)High temp (with fluctuations)

Empyema GBEmpyema GB App. AbscessApp. Abscess Pancreatic abscessPancreatic abscess Residual intraperitoneal abscessResidual intraperitoneal abscess Pyogenic liver abscess etc.Pyogenic liver abscess etc.

TongueTongue: the mirror of the GIT & many : the mirror of the GIT & many general conditions.general conditions.

• Dry tongue –dehydrationDry tongue –dehydration• Dry, brown tongue –toxaemiaDry, brown tongue –toxaemia• Dry, thinly coated –early appendicitisDry, thinly coated –early appendicitis

AnaemiaAnaemia: Any haemorrhagic condition, : Any haemorrhagic condition, chronic illness.chronic illness.

JaundiceJaundice: often in: often ino Biliary colicBiliary colico Biliary pancreatitisBiliary pancreatitiso CholangitisCholangitiso Round worm in CBDRound worm in CBD CyanosisCyanosis: in haemorrhagic pancreatitis, massive : in haemorrhagic pancreatitis, massive

lobar pneumonia etc.lobar pneumonia etc.