Afr. J. Integ. Health Vol 1: No1; 2013 Correspondence to: Dr E.P. Weledji PO Box 126, Limbe, S.W. Region, Cameroon Tel 00237, 99922144; E-mail: elroypat@yahoo.co.uk

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WELEDJI and NGOWE NGOWE: The Acute Abdomen- Revisited: AJIH 2013, 01:01-05 Review Articles

The Acute Abdomen- Revisited

Elroy Patrick WELEDJI1 and Marcelin NGOWE NGOWE1 1Department of Surgery, Obstetrics and Gynaecology. Faculty of Health Sciences, University of Buea, South West Region,

Cameroon

Keywords Acute abdomen, differential diagnosis, surgical peritonitis, acute

appendicitis, intestinal obstruction

Abstract Introduction: The aim of this paper was to review the differen-

tial diagnosis of the acute abdomen and emphasise the greater

importance of history and examination over investigations in

early diagnosis. After resuscitation, an accurate history will fre-

quently point to the diagnosis, and, the ability to identify the

presence of peritoneal inflammation probably has the greatest

influence on the final surgical decision. Method: Electronic

searches of the medline (PubMed) database, Cochrane library,

and science citation index were performed to identify original

published studies on the acute abdomen. Relevant articles were

searched from relevant chapters in specialized texts and all in-

cluded. Result: A precise history of the acute abdomen may

indicate the pathology and physical examination may indicate

where the pathology is. However, the ability to identify the pres-

ence of peritoneal inflammation probably has the greatest influ-

ence on the final surgical decision. Conclusion: Regular re-

assessment of patients and making use of the investigative op-

tions available will meet the standard of care expected by pa-

tients with acute abdominal pain. Early recognition, prompt

resuscitation and early surgical intervention will abort the evolv-

ing process of sepsis.

Introduction An acute abdomen is a non-traumatic, catastrophic event that

affects any of the intra-abdominal organs and, acute severe ab-

dominal pain is usually the hallmark [1,2]. Surgical peritonitis

and intestinal obstruction are the two important causes of the

acute abdomen. Surgical peritonitis may emanate from perfora-

tion, ischaemia (mesenteric or strangulation) pancreatitis and

anastomotic leakage [3]. Peritonitis can occur with or without

infection. Peritonitis without infection (chemical) occurs with

urine, bile or blood in the peritoneal cavity. When sepsis (bacte-

ria) is present, pathogenic organisms reach the peritoneal cavity

by either (a) perforation of the gastrointestinal or biliary tract,

(b) via the female genital tract (e.g. ascending infection, septic

abortion), (c) by penetration of the abdominal parietes (pene-

trating or blunt trauma), (d) by haematogenous spread (immuno-

compromised patients, osteomyelitis in children) [1,2,4-9].

The attitude of a patient with advanced peritonitis is best de-

scribed by Hippocrates (460-370 B.C.) as one with a ‘sharp

nose, hollow eyes, collapsed temples, the ears cold’ now known

as the Hippocratic facies. The patient is usually ill and clammy

with a rapid thready pulse. The patient will lie perfectly still to

minimize discomfort, the abdomen held totally rigid as the pa-

tient takes rapid shallow breaths using chest movements only

[1]. Acute appendicitis is one of a relatively dwindling number

of conditions in which a decision to operate may be based solely

on clinical findings. It is interesting to know that surgery for the

acute abdomen caused by appendicitis for example, only

evolved when the mortality associated with perforated appendi-

citis was found to be high. Conservative treatment with later

drainage of any abscess had been the standard and diffuse peri-

tonitis was usually fatal. Although only few patients progressed

to the potentially lethal complications, early surgery for all pa-

tients with suspected appendicitis became the definitive method

of preventing severe peritoneal sepsis [2]. Although a study

demonstrated that simple appendicitis may be treated with anti-

biotics only, there is a risk of recurrent attacks [3]. Recent ad-

vances in interventional radiological techniques for peritonitis

have significantly reduced the morbidity and mortality of physi-

ologically severe complicated abdominal infection [5,9-11].

However, when there is clinical suspicion of the acute abdomen

the best policy is early surgery if diagnostic tools are not readily

available. The mortality of perforated viscus increases with de-

lay in diagnosis and management [12,13]. It is greatest in the

elderly and those ill from intercurrent disease (poor ASA

score)[9,10]It is not possible to practice fully the ideal manage-

ment of early diagnosis and surgery for the acute abdomen, thus

reducing morbidity and mortality to zero, because patients and

the disease are variable. However, because infection, inadequate

tissue perfusion and a persistent inflammatory state are the most

important risk factors for development of multiple organ failure

it seems logical that initial therapeutic efforts should be directed

at their early treatment or prevention (early goal-directed thera-

py) [14-17]. It is thus important to recognize the features of the

acute abdomen which would indicate the need for high depend-

ency or intensive care unit support.

Differential diagnosis of the acute abdomen

There are undoubtedly specific features associated with all acute

abdominal conditions which are well established. The aim of

both the history and examination is to determine a diagnosis and

clinical decision [4].The patient’s abdominal pain should be

characterized precisely in terms of its onset (sudden or gradual),

initial and subsequent location, radiation, exacerbating and alle-

viating factors, associated symptoms of nausea, vomiting,

change in bowel habit, fever, or chills. Conditions that start sud-

denly and produce signs of peritonitis are perforation of viscus,

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Review Articles

infarction (embolus or volvulus) and intraperitoneal haemor-

rhage. Abdominal tenderness, due to intraperitoneal blood, has a

different character and is less pronounced than that of peritoneal

inflammation due to sepsis[4,7,18]. Acute pancreatitis should

always be considered in the differential diagnosis of a perforated

peptic ulcer because of their similar mode of onset of abdominal

pain and epigastric location. The serum amylase concentration

should be determined, remembering that moderate elevation

may occur in a perforation. Free subdiaphragmatic gas on erect

chest x-ray is seen in about 70% of patients with perforation [4].

It is vital to consider acute mesenteric ischaemia in every patient

with an acute abdomen, especially if they have co-existing pe-

ripheral vascular disease or if they are diabetic. Too often these

patients present with established disease which is beyond sal-

vage [4].

Conditions that produce peritonitis of gradual onset usually arise

from a progressively inflammed viscus such as acute appendici-

tis, cholecystitis or diverticulitis. However, it remains the ability

to identify the presence or absence of peritoneal inflammation

which probably has the greatest influence on the final surgical

decision. Being somatic abdominal pain resulting from stimula-

tion of pain receptors in the parietal peritoneum or abdominal

wall, the patient may exhibit rebound tenderness (pain localized

to the inflamed viscus on gentle percussion or on coughing)

[2,18-20]. Acute appendicitis is the most common cause of the

acute abdomen requiring surgery with a life time risk of ~7%

which is maximal in childhood and declines steadily with age as

the lymphoid tissue and vascularity atrophy[2,4]. The natural

history of acute appendicitis left untreated is that it will either

resolve spontaneously by host defenses, or progress to a fatal

suppurative necrosis (gangrene) with perforation. The appendic-

ular artery is a single end artery closely applied to the wall dis-

tally, and secondary thrombosis is common giving rise to gan-

grene which explains the short progressive history (3-5 days) of

appendicitis and the poorer prognosis with the artherosclerosis

of the aged. The typical presentation is referred, dull, poorly

localized, colicky periumbilical pain (visceral) from the luminal

obstruction (mid-gut origin) for 12-24 hrs that shifts and localiz-

es to the right iliac fossa as peritoneal irritation by the inflamed

appendix occurs (somatic pain). There is nausea, vomiting more

than twice is rare, a low grade pyrexia and constipation is usual

[2]. An alternative outcome is that the appendix becomes sur-

rounded by a mass of omentum or adjacent viscera which walls

off the inflammatory process and prevents inflammation spread-

ing to the abdominal cavity yet resolution of the condition is

delayed (appendix mass). Such a patient usually presents with a

longer history (a week or more) of right lower quadrant ab-

dominal pain, appears systemically well and has a tender palpa-

ble mass in the right iliac fossa. Conservative management risks

a 30% recurrence of acute inflammation [4,15]. However, a

mass is often detected only after the patient has been anaesthe-

sized and paralysed. Thus, the differentiation of a phlegmonous

mass from an abscess is not a practical problem because surgery

is the correct management for both. Such a policy renders any

debate on interval appendicectomy redundant. Operation during

the first admission is expeditious and safe, provided steps are

taken to minimize postoperative sepsis [4]. The serious conse-

quences of missing a carcinoma in the elderly patient are abol-

ished.

Clinical assessment

Just as appendicitis should be considered in any patient with

abdominal pain, virtually every other abdominal emergency can

be considered in the differential diagnosis of suspected appendi-

citis. In acute appendicitis the point of maximum tenderness

(McBurney’s point) usually lies one third along a line from the

anterior superior iliac spine to the umbilicus which denotes the

surface anatomy of the appendix. This is associated with guard-

ing of the inflamed area from being prodded further [2]. Occa-

sionally; patients with appendicitis have signs of widespread

peritonitis, which obscure the area of maximal tenderness. Re-

examination, after resuscitation and adequate analgesia, permits

more reliable localization of signs [2,16]. Although not of diag-

nostic value as being non-specific, pressure in the left iliac fossa

produces pain in the right iliac fossa (Rovsing’s sign) [4].In

acute appendicitis, the position of the appendix (retrocaecal or

pelvic) is important in determining the subsequent symptoms

and signs. A retrocaecal appendix can give rise to tenderness in

the right upper quadrant whereas a pelvic appendix may be as-

sociated with central abdominal discomfort. Passive extension or

hyperextension of the hip increases the abdominal pain due to an

inflamed appendix lying on the psoas muscle (Psoas stretch

test). The obturator sign is positive when passive internal rota-

tion of the hip aggravates the pain of an inflamed appendix lying

on the obturator internus, but, an ovarian pathology may do

same[2,4,16]. When rebound tenderness is detected in the lower

abdomen further examination by rectal examination has been

shown to provide no new information. Rectal examination is

reserved for those patients without rebound tenderness or where

specific pelvic disease needs to be excluded. It is of little value

in the diagnosis of acute appendicitis even when the organ lies in

the pelvis [20].

With regard to acute appendicitis the demonstration and inter-

pretation of these physical signs are skills which fade without

practice. The age, sex and personality of the patient are im-

portant modifiers of clinical signs; the most typical cases occur

in older children (5-15yrs) of either sex and in young males. In

other individuals, the features are more obscure, and the poten-

tial for alternative pathology is greater [4,9,21]. A typical sign

of acute cholecystitis is the pain produced by inspiration during

deep palpation under the midpoint of the right subcostal margin

where the fundus of the gallbladder is located (Murphy’s

sign)[4]. In acute diverticulitis where infection of one or more

diverticulae (mucosal out-pouchings between the taenia coli

because of a high intraluminal pressure resulting from constipa-

tion) and inflammation of the adjacent colon especially the sig-

moid colon (60%), patients present with left iliac fossa pain of

variable severity, systemic signs of sepsis and an altered bowel

habit (diarrhoea or constipation). There may be tenderness in the

left iliac fossa or signs of local peritonitis (‘l-sided appendicitis’)

or an abdominal mass. It is a clinical diagnosis and once the

patient’s condition has responded to medical management (in-

travenous antibiotic therapy, bowel rest and analgesia) the diag-

nosis is confirmed by flexible sigmoidoscopy, barium enema

examination or CT scan which may also exclude a co-existent

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colonic carcinoma [5]. Those who develop complications such

as pericolic abscess, perforation (purulent or faecal peritonitis),

major haemorrhage, diverticular stricture or fistula

formation, require resection of the diseased segment of bowel

[6].

Any role for special investigations in appendicitis?

There are no special investigations to confirm appendicitis. As

no test is accurate, the diagnosis has to rely on clinical symp-

toms and signs [2-5]. Tests should serve as adjuncts to clinical

diagnosis and may help to exclude alternative diagnoses. A

white cell count is usually elevated but a normal white cell count

does not exclude appendicitis [2,4]. Ultrasonography in expert

hands is perhaps the most useful investigation[4]. Laparoscopy

is essentially an operation rather than an investigation. Howev-

er, the continuing development of ultrasound techniques and

laparoscopic surgery have both prompted the view that the pro-

portion of normal appendices removed (20%) is unacceptably

high[24]. Although it is clearly advantageous to spare patients

unnecessary surgery, the morbidity and mortality of failing to

diagnose appendicitis until perforation has occurred is greater

than that associated with removal of normal appendix [4].

If diagnostic tools not readily available

The best policy is early surgery when there is clinical suspicion

of acute appendicitis. If the appendix is macroscopically normal,

the terminal 60cm of ileum must be delivered to exclude a

Meckel’s diverticulum, terminal ileitis and mesenteric adenitis.

If the base of the appendix and caecum are healthy, the appendix

must be removed when ileitis is present [2]. Biopsy and culture

of inflamed nodes aids a diagnosis of Yersinia infection. The

right ovary and tube must be visualized. Extension of the inci-

sion, a head down tilt and adequate retraction may be required.

Occasionally, fluid leaking from a perforated peptic ulcer down

the right paracolic gutter produces clinical findings resembling

those of acute appendicitis. A classical appendicectomy incision

would reveal bile-staining free peritoneal fluid and a second

upper abdominal incision is usually required. Purulent fluid

tracking down the right paracolic gutter may also suggest acute

cholecystitis. If clinical diagnosis is equivocal despite investiga-

tions, it is best to begin with a low midline incision which could

be extended if there is evidence of a perforated peptic ulcer

[2,21].

Diagnostic dilemma of the acute abdomen

The young woman

It is not surprising that women have the highest appendicecto-

my rate with 30% revealing normal appendices [22]. In young

women, various gynaecological conditions present with lower

abdominal pain, and the history gives important clues. Vaginal

discharge, a longer history (often more than 72hrs) and absence

of gastrointestinal upset raise the possibility of pelvic inflamma-

tory disease. A bilateral, low distribution of pain aggravated by

cervical movement support the diagnosis. Abrupt onset of pain

suggests rupture of a follicle, cyst or ectopic gestation. The con-

dition of Curtis- Fitz- Hugh syndrome, when transperitoneal

spread of pelvic inflammatory disease produces right upper

quadrant pain due to perihepatic adhesions is now well recog-

nized and care must be taken to distinguish this from acute bili-

ary conditions [23]. Early recognition with diagnostic laparos-

copy and appropriate treatment of pelvic inflammatory disease

may help to avoid potentially serious longer term sequelae and

must be encouraged. Many studies have now demonstrated that

laparoscopy significantly improves surgical decision- making in

patients with acute abdominal pain [24].

Chronic appendicitis or “the grumbling appendix”

Patients with true relapsing or chronic appendicitis are rare and

often difficult to diagnose as the symptoms may be atypical and

short-lived. In genuine cases the macroscopic appearance of the

appendix is abnormal and, thus the diagnosis is best established

by laparoscopy, following which the appendix can be removed

[24]. Minor frequent episodes of right iliac fossa pain “the

grumbling appendix” can be caused by thread worms in the ap-

pendix or by some conditions other than the appendix [2,20].

The pregnant woman

Difficulty in diagnosis, reluctance to operate on pregnant women

and avoidable delay account for the high risks of appendicitis in

pregnancy. In pregnancy, the enlarging uterus progressively

displaces the appendix up into the right hypochondrium. Delay

is so harmful to mother and unborn child that provided urinary

tract infection has been excluded, one should operate early. Ma-

ternal and fetal deaths do not result from appendicectomy but

from peritonitis following perforation. The risk of maternal mor-

tality increases as pregnancy progresses [25].

The elderly and the infant

Appendicitis has a more rapid course in the elderly as due to

artherosclerosis, gangrene and perforation are common. Its

atypical presentation adds to the delay in diagnosis [9]. A diag-

nosis of carcinoma of the caecum or lymphoma, which has ob-

structed the appendix must be considered and excluded by bari-

um enema or colonoscopy. Diagnosis of acute appendicitis may

be difficult in infants. Delay in diagnosis is common because the

classical signs and symptoms may be absent or unobtainable,

and perforation is common as host defenses including the omen-

tum are not fully developed. The development of fever associat-

ed with any abdominal tenderness should always raise the suspi-

cion of acute appendicitis [2,4]. ‘Active observation’ is safe and

effective in early appendicitis and in patients where the diagno-

sis is in doubt. It permits differentiation between patients with

persistent or progressive signs requiring surgery and those with

non-specific pain or alternative pathology [4,26]. Deliberate

delay allows time for the results of appropriate investigations to

be reviewed and it is extremely rare for such an appendix to rup-

ture during observation and the diagnosis will usually become

apparent within 12-24 hours [4].

The AIDS patient

Abdominal pain is common in patients with AIDS, but less than

1% of patients with AIDS will need an emergency laparotomy

[27]. Some patients (and their families) refuse surgery in desper-

ate situations (such as bowel perforation) as they want an end to

4

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WELEDJI and NGOWE NGOWE: The Acute Abdomen- Revisited: AJIH 2013, 01:01-05

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the suffering. The commonest presentation requiring laparotomy

are megacolon, small bowel obstruction and localized peritonitis

[28]. Clearly, this is a very different case mix from the acute

abdomen that the general surgeon sees in the non-HIV popula-

tion. Again the commonest disease processes, Cytomegalovirus

(CMV) colitis, B-cell lymphoma, acute appendicitis (CMV-

associated) and atypical mycobacterial infection are quite differ-

ent from those in the non-HIV population. Appendicectomy and

colectomy are the commonest abdominal operations in AIDS

patients. A platelet count is mandatory prior to any surgery since

thrombocytopenia is common. With careful patient selection,

emergency laparotomy confers worthwhile palliation [27,28].

Acute intestinal obstruction may occur as a closed -loop ob-

struction with a volvulus or an obstructed hernia. The cardinal

clinical features of intestinal obstruction are colicky abdominal

pain whose frequency increases and later becomes constant as

peritonitis ensues, vomiting, constipation and abdominal disten-

sion. Gangrene which occurs rapidly in a closed-loop obstruc-

tion and perforation are disastrous complications.Intestinal adhe-

sions are the commonest cause of small bowel obstruction in the

western world due to the greater number of operations per-

formed. Meanwhile, inguinal hernias are the commonest cause

of obstruction in the developing world where the uptake of mod-

ern medicine is low with the consequent delay in surgical inter-

ventions. The overall operative mortality for strangulated hernia

is 10% and so adequate preoperative resuscitation is crucial.

Spontaneous resolution will occur in up to 70% of patients with

obstruction secondary to adhesions [4]. Surgical intervention is

necessary when conservative treatment with nasogastric decom-

pression and intravenous fluid resuscitation fails after 48hrs as

patient should not remain obstructed for more than that length of

time, or with evidence of peritonitis from strangulation obstruc-

tion [4].

Primary small bowel volvulus is a life-threatening surgical

emergency requiring immediate laparotomy following resuscita-

tion. It occurs in the ‘virgin’ abdomen with no anatomic abnor-

malities nor predisposing factors. It is often seen in Africa and

Asia, and seems to be associated with special dietary habits. The

main problem is to differentiate it from other causes of obstruc-

tion that can be treated conservatively. Central abdominal pain

resistant to narcotic analgesia should heighten the suspicion of

the diagnosis [29]. Sigmoid volvulus is the commonest form of

volvulus in the gastrointestinal tract. The anatomic defect is the

narrow attachment of the root of the mesentery to the posterior

abdominal wall and a long mesenteric axis. Predisposed by the

very high fibre diet and long redundant sigmoid colon in Afri-

cans, chronic constipation and laxative abuse, psychiatric and

senile disorders, the sigmoid colon rotates around its mesenteric

pedicle usually more than 1800 counterclockwise resulting in

partial or complete large bowel obstruction. There is a palpable

tympanic mass and with the risk of ischaemia from venous ob-

struction sigmoid colectomy is indicated [30].

A closed loop obstruction may also follow an acute on chronic

large bowel obstruction from a distally obstructing colonic le-

sion. Right iliac fossa tenderness in a patient with large bowel

obstruction may indicate caecal distension possibly leading to

necrosis of the wall. Strangulation obstruction is not a problem

here but a similar problem to look out for is ischaemia of the

caecum due to stretching. According to the law of Laplace, the

caecum which has the widest diameter of the colon, takes the

brunt of the distension with an imminent perforation [30]. When

the ileocaecal valve is incompetent (10%) both small and large

bowel become distended. The patient will start to vomit, but

ischaemia or perforation of the bowel is unlikely.

Fig. 3 Laplace’s law-obstruction from a transverse colon carcinoma (a) ileocaecal valve remains open, (b) valve stopping reflux into the ileum

resulting in closed loop obstruction.30 (with permission)

Conclusion

A precise history of the acute abdomen may indicate the pathol-

ogy and physical examination may indicate where the pathology

is. However, the ability to identify the presence of peritoneal

inflammation probably has the greatest influence on the final

surgical decision. The best policy is early surgery when there is

clinical suspicion of the acute abdomen if diagnostic tools are

not readily available, but ‘active observation’ is effective and

safe in early appendicitis. Regular re-assessment of patients and

making use of the investigative options available will meet the

standard of care expected by patients with acute abdominal pain.

Early recognition, prompt resuscitation and early surgical inter-

vention will abort the evolving process of sepsis.

Conflict of Interests None

Afr. J. Integ. Health Vol 1: No1; 2013 The Acute Abdomen- Revisited 5

WELEDJI and NGOWE NGOWE: The Acute Abdomen- Revisited: AJIH 2013, 01:01-05

Review Articles

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