Acute Abdomen: Medical or Surgical

Introduction:

The term “Acute Abdomen” denotes any sudden, disorder whose chief manifestation is in the abdominal area.

Evaluation of acute abdomen must be efficient and should lead to an accurate diagnosis early in the presentation.

So that the treatment of patients who are seriously ill is not delayed and patients with self limited disorder are not over treated.

The Epidemiology of Acute Abdominal Pain

5-10% of all patients comes to hospital with acute abdomen.

Among them 14-40% patients need surgical intervention.

So prompt diagnosis is important to prevent morbidity and mortality.

Medical causes:

Metabolic/Haematologic :

1)Familial metabolic : Acute intermittent porphyria, Haemochromatosis.

2)Endocrine: Diabetic ketoacidosis, Addisonian crisis. 3)Haematologic: Sickle cell crisis, Leukaemia, Acute

haemolytic state.

Inflammatory condition:

Infections : Enteric infections, spontaneous bacterial peritonitis, Hepatitis, AIDS related disorders, Mumps.

Non infectious: Acute rheumatic fever, SLE ,Henoch Schoenlein purpura , Inflammatory bowel disease, Pancreatitis.

Drugs: Heavy metal poisoning (lead ,mercury ,Arsenic , Copper) NSAIDS, Anticoagulants, narcotic , steroid withdrawal, snake bite , black widow spider bite.

Referred : Extraperitoneal causes:

Pulmonary: Pnemonia ,Pulmonary embolism

Pleurisy.

Cardiac: Acute MI, Pericarditis.

Urologic: Pyelonephritis , Renal infarct, Cystitis,

Prostatis.

Neurological / spinal : Multiple sclerosis, Tabes dorsalis, Herpes zoster ,Abdominal migraine.

Surgical causes: Hemorrhage: Solid organ trauma ,Leaking or ruptured arterial

aneurysm, Ruptured ectopic Pregnancy ,Intestinal ulcers, Hemorrhagic Pancreatitis, Spontaneous rupture of spleen.

Infection: Appendicitis, Cholecystitis, Meckel’s diverticulitis, Hepatic abscess, Psoas abscess.

Perforation: Perforated gastrointestinal ulcer, Perforated gastrointestinal cancer.

Blockage: Adhesion induction small, large bowel obstruction, Sigmoid volvulus, Cecal volvulus, Gastrointestinal malignancy , Intussusception.

Ischemia: Mesentric thrombosis/embolism, testicular torsion, Ischemic colitis, Ovarian torsion, Strangulated hernia.

Approach:

Approach to a patient with an Acute abdomen must be orderly.

An Acute Abdomen must be suspected even if the patient has only or atypical complaints.

The history and physical examination should suggest the probable causes and guide the choice of initial diagnostic studies.

The History

An accurate history is the essential foundation for the diagnosis of abdominal pain. This requires time, patience, and skill.

The way patients tell their story is as important as the story itself.

Any additional questions should be short, specific, and direct and must be in language the patient understands.

Negative findings are always as useful as positive ones.

Unnecessary or irrelevant facts can be misleading and will always add to the difficulties in analysis.

Pain is the most comman and predominant presenting feature of an acute abdomen ,careful consideration of the location , mode of onset and progression and character of pain .

Pain When? Where? How? Abrupt, gradual Character Sharp, burning, steady, intermittent Referral? Previous occurrence?

Three Types of Abdominal Pain

Visceral Pain

Somatic (Parietal) Pain

Referred Pain

Visceral Pain Within the muscular walls

of hollow organs and the capsules of solid organs.

Stimulated primarily by stretching, distension, and excessive contractions.

Characteristically deep, dull, aching or cramping, and poorly localized.

Usually felt in the midline, unaccompanied by tenderness.

Somatic (Parietal) Pain

Characteristically sharper, aggravated by stimulation of the parietal peritoneum with movement, coughing, or walking.

True parietal pain indicates surgical cause of abdominal pain.

Referred Pain Pain felt a site other than

that of the primary noxious stimulus.

Occurs in an area supplied by the same neurosegment as the involved organ.

Most visceral pain is of this type.

Usually intense and most often secondary to an inflammatory lesion.

Other Symptoms Associated : Vomiting. Distension of abdomen.

Fever : High grade with or without chills. Loss of appetite

Jaundice

Hematochezia or Hematemesis

Frequency and urgency of urine

Diarrhea.

Constipation

Obstipation

Relevant aspects : Gynecological history.

Drug history.

Family history.

Travel history.

Psycho social history.

Personal history.

Occupational exposure

Operation history

PHYSICAL EXAMINATION The patient’s general appearance and vital

signs can help narrow

the differential diagnosis.

Overall appearance: ( Facial expression, pallor, and degree of agitation, Detail examination of heart , lungs and skin)

Walking and recumbent.

Vital signs Temperature Tachycardia Hypotension

General Observation:

Fairly reliable indicator of the severity of the clinical situation.

The writhing of the patients with visceral pain ,contrasts with the rigidly motionless bearing of those with parietal pain.

Diminished responsiveness or altered sensorium often precedes imminent cardiopulmonary collapse.

Differential Diagnosis :RUQ Pain:

Investigations: Xray:

Upright chest

Upright and supine abdominal.

Ultrasound.

ECG

Complete Blood count.

Urinalysis.

Amylase, Creatinine, BUN, Electrolytes.

RLQ

Investigations Urinalysis (to exclude

obvious urinary causes)

Pregnancy test( female of childbearing age)

Ultrasound

Complete blood count

Stool test.

Gynecologic causes of LQ Pain:

DD of LUQ and Epigastric:

Investigations Upright chest XR Upright and

supine abdominal XR

Ultrasound. ECG. Complete blood

counts Amylase and

lipase .

Periumblical:

Investigations CBC.

Ultrasound.

Amylase and lipase.

Erect and supine abdominal XR

Stool tests

LLQ:

Pregnancy test(female of childbearing age)

Urinalysis Ultrasound Complete blood

count Upright and supine

abdominal XR CT scan( if

diverticular disease is suspected)

Rectal examination :

The right wall may be tender in pelvic type appendicitis, and often tenderness is elicited in the rectovesical pouch in perforated peptic ulcer.

In intussusception the gloved finger to be smeared with mucus and blood.

The bulging of the anterior wall of the rectum with tenderness is significant of a pelvic abscess.

Vaginal examination:

Purulent discharge and tenderness in both fornices are suggestive of Acute Salpingitis.

In Ruptured Ectopic Gestataion the cervix feels softer and any movement of cervix will initiate pain.

Special signs:

sign Description condition

Aaron Pain or pressure in epigastrium or anterior chest with persistent firm pressure applied to Mc Burney point

Acute appendicitis

Blumberg Transient abdominal wall rebound tenderness

Peritoneal inflammation

Carnett Loss of abdominal tenderness when abdominal wall muscles are contracted

Intra abdominal source of a abdominal pain

Charcot Intermittent Right upper abdominal pain ,Jaundice , Fever.

choledocholithiasis

Special signs:

Claybrook Accentuation of breath and cardiac sounds through abdominal wall .

Ruptured abdominal viscus

Courvoisier Palpable gall bladder in presence of jaundice

Periampullary tumor

Cullen Periumbilical bruising Haemo peritoneum

Fothergill Abdominal wall mass that does not cross midline and remains palpable when rectus contracted

Rectus muscle hematomas

Grey Turner Local area of discoloration around umbilicus and flanks

Acute hemorrhagic pancreatitis

Special Signs

Kehr Left shoulder pain when supine and pressure placed on left upper abdomen

Hemoperitoneum (especially from splenic origin)

Murphy Pain caused by inspiration while applying pressure to right upper abdomen

Acute cholecystitis

Obturator Flexion and external rotation of Right thigh while supine creates hypogastric pain

Pelvic abscess or inflammatory mass in pelvis

Rovsing Pain in Mc Burney’s point when compressing the left lower abdomen

Acute appendicitis

Approach TO Acute Care: Airway: Is the patient able to

maintain an airway? Risk for aspiration of vomit or oral

secretions.

Breathing : how effectively is the patient breathing? Rapid and shallow , use of accessory muscles.

Circulation: Is the patient is in shock?, is there any evidence of active bleeding.

Immediate Treatment of the Acute Abdomen

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

Solution.

Provide pain relief by IV Analgesics NSAIDS,Opioids,H2 receptor blocker and PPI.

Provide other symptomatic relief (e.g., antiemetics, antispasmodics).

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.

Careful follow-up with frequent re examination (by the same examiner, when possible)

Definitive therapy or procedure will vary with diagnosis