Consultant General and
Definition And Epidemiology
Undiagnosed Abdominal Pain of less than 7-10 days
Abdomino-thoracic Trauma is excluded from this
It accounts for 5-10% of ER visits
It accounts for 1% of all hospital admission.
Most Patients-(70-75%) Discharged after ER
Only 7-10% of Patients will Require Urgent Surgery
for Life-Threatening Conditions.
SURGICAL CAUSES—SURGICAL ABDOMEN
Acute Abdominal pain
spinal nerves T3-L1.
• 2-3 localised areas just
medial to linea
semilunaris of rectus
• Abdominal Pain caused
by thrombosis of
visceral arteries lead to
• (I)-Clinical Evaluation:
• Accurate History and Complete Physical
Examination are Essential for Diagnosis
• (II)-Resuscitation and Immediate Diagnostic
• (III)-Other Investigations-according to clinical
progress of the patient.
Onset; Progression of pain
Site of pain: at onset, at present.
• Type: intermittent colicky, sharp persistent
Radiation of Pain
Aggravating factors: movement, coughing, food
Relieving factors: position, drug, food
Physiology of Pain-Visceral Pain
• Elicited by distention ;
inflammation of the serous
coat of hollow viscera and
in the capsules of solid
• Mediated by afferent
autonomic nerve fibres.
• Diffuse; felt in the midline
in regions related to the
• Elicited by direct
the somatically innervated
• Mediated by afferent
somatic nerve fibres.
• localised in the
dermatomes supplied by
segmental nerve roots
innervating the parietal
• Pain Sensations perceived
at a site distant from that
of a strong primary
• Due to Confluence of
afferent nerve fibers from
widely disparate areas
within the posterior horn of
the spinal cord. This may
cause distorted central
perception of the site of
In Most causes of Surgical Abdominal pain
• There is insidious onset of pain started diffuse;
dull ach/or gripping pain. In hollow viscus
obstruction; the pain is sever gripping associated
with nausea; vomiting; and sweating; causing the
patient to move around in bed and inability to lie
still. There is no aggravating of relieving factors.
• In Early Inflammatory Processes of Solid Viscera;
there is diffuse dull ache pain
Progression of pain-In Inflammatory and
• There is progression of pain over several hours;
and change character of pain into sharp localised
stabbing pain. The pain is aggevated by moving;
coughing and relieved by lying still.
• There will be associated Abdominal localised
tenderness; rebound; and involuntary muscle
guarding. (Localised Peritonitis.)
In perforation; Strangulation(Infarction);and
• The pain is sudden in onset with progression over
minutes to 1-2 hours; into sharp localised
stabbing pain. There will be Localised (Early) / or
Generalised Abdominal tenderness; rebound and
• Shoulder tip and sub-scapular pain; is common
due to blood/or pus in sub-phrenic space.
In Most of Non-Surgical causes of Abdominal
• There will be Diffuse mild dull-ach/or vague
• Vomiting usually precedes the onset of pain;
especially in metabolic causes.
• There will be Diffuse; non-specific
abdominal tenderness. However there will
be NO Rebound tenderness and NO Muscle
• Nausea and vomiting
• Anorexia and weight loss
• Bowel habit
• Urinary Symptoms
• Gynecological Symptoms
Menstrual History-in women in Reproductive
• Sexual Activity and IUD
• Amenorrhea(Missed period)
• Vaginal Bleeding
• Vaginal Discharge
• Medical Diseases; HTN ; CAD ; AF ; Vascular
Diseases ;Pulmonary Diseases.
• Previous Surgery.
• Current Medications.
• Alcohol and Smoking.
• Vital Signs: Pulse ; Temp.; BP.
• Pallor ; Jaundice ; Cyanosis.
• Tongue:-Dry ; Coated ; acetone smell.
• Examination of Cervical LNs.
• Examination of Chest and Heart.
• Patient is agitated; the patient moves around in
bed and inability to lie still.= visceral pain.
In hollow viscus obstruction and Strangulation
• Patient is lying motionless in bed=Parietal pain
In Localised/Generalised Peritonitis.
• Patient is Drowsy with decrease responsiveness .
• Patient should be exposed from nipple to mid-
• Abdominal Distension.
• Obvious Abdominal Swelling
• Scar ; Fistula ; Sinus.
• Distended Superficial Veins
• Ecchymosis,Cullen”s and Gray-Turner”s Signs
Palpation and Percussion
Light and deep palpation.
Start gently and away from reported area of
pain. Palpation with pulp of fingers NOT Tips
Rebound tenderness = “Peritoneal irritation can
be elicited by:-
Cough tenderness = Percussion tenderness.
Involuntary Muscle guarding=Peritonitis.
Areas of maximum tenderness.
Tympanatic Abdomen.= gas in bowel loops.
Shifting dullness in Ascites.
• High-pitch “tinkling” sound = mechanical
• Hyperactive bowel sounds = Enteritis and
early intestinal ischemia
• No sound within 1-2 min = absent bowel
Do Not Forget
• Hernial Orifices.
• External Genitalia-Testis and Scrotum.
• Examination of the Back of the patient.
PR and PV Examination.
Dip-stick testing of urine for sugar ; ketone ;
blood ; proteins and pus cells.
• NG-Tube in intestinal obstruction and if there is
• IV-Line and Start IV Fluids.
• Analgesia after initial assessment should be
given for pain relief.
• Important:-Narcotic analgesia don't mask
physical signs or obscure the diagnosis.
• Start broad spectrum IV Antibiotics if
Inflammatory Conditions suspected.
• Correction of dehydration and electrolyte
• Urinary catheter and monitor the urine output.
Resuscitation-In Critically Ill-Patients
• Air Way and Oxygen Supplement.
• Oxygen Saturation Monitoring
• CV-Line ; Volume Replacement.
• Blood urea nitrogen/creatinine
• Amylase / lipase
• Serum lactate levels
• Liver function test
• Pregnancy Test-In all Women in child-
• Sickling Test
• Blood Group and save the serum.
Emergency Abdominal Ultrasonography:--
Detection of acute Cholecystitis; pancreatitis; pancreatic
pseudo-cysts; liver abscess
Detection of appendicitis/ appendicular abscess; diverticular
abscess; mesenteric cysts; Tubo-ovarian abscess; PID and
Useful in pregnant and young female patient (detect pelvic
pathology);ovarian cysts ; sub-serous fibroid ;PID.
Diagnosis of suspected AAA.
Diagnosis of free intra-peritoneal blood/fluid.
Contrast-enhanced CT-Scan (oral and IV
• It is the secondary imaging modality of
choice in the patient with an acute
abdomen, following plain abdominal
radiography; as images not masked by
bowel gas and most surgeons can interpret
the findings more than US.
• CT-Scan establishes the diagnosis of acute
abdominal pain in over 95% of cases.
fluid-filled appendix with surrounding inflammation
CT-IV Contrast-Small Bowel Ischemia due to
After the initial assessment the patients with acute abdominal
pain should be categorized into:
(I)Patients with immediately Life Threatening conditions :-
Patients who need immediate Laparotomy
( Abdominal Crises )
(1)—Massive intra-abdominal bleeding; (Ruptured AAA. or visceral
aneurysms, ruptured ectopic pregnancies, and spontaneous hepatic
or splenic ruptures).
(2)—Acute Intestinal Ischemia with hypovolemia and resistant
(3)-Intra-abdominal sepsis; (due to perforated viscus/or
strangulation; volvulus; Intussusception; strangulated hernia ) ; with
high fever; tachypnea; sweating; frank hypotension; deterioration of
mental state(agitation, disorientation); indicating impending septic
Medical life threatening conditions:-
Spontaneous tension Pneumothorax.
Acute AD.Cortical Failure.
(II)– Patients with Rapidly Life Threatening conditions.
Patients who need; Urgent laparotomy;(with in 4-6H.)
Perforated hollow viscera.
Intra-abdominal Abscesses; (Appendicular; and Diverticular);
with free intra-peritoneal perforation and diffuse peritonitis.
Clinical; Laboratory; and Radiological indicators for Urgent
Increasing severe localized tenderness.
Progressive tense abdominal distention.
Spreading Involuntary muscle Rigidity.
High fever, tachycardia, confusion.
Marked Leukocytosis with left shift.
(III)-Serious conditions:-that need early
planned surgery/or need early supportive
treatment and close monitoring
Appendicitis/appendicular abscess; acute
Cholecystitis/peri-cholecystic abscess; acute
Diverticulitis/Diverticular abscess; PID /Tubo-
ovarian abscess; Localised intra-abdominal or
Small bowel obstruction.
Large bowel obstruction due to: diverticular
(IV)-Less serious conditions which require
Biliary colic; renal colic.
Inflammatory bowel disease.
Non-specific abdominal pain.
Gastro-enteritis and infective colitis.
Un-complicated ovarian cyst and fibroid; and
endometriosis. Mid-ovulatory pain.
Most of Medical causes.
Differential Diagnosis of patients with Acute
Each List Represents > 90-95% of Causes in each Group)
Infants less than one year old
• Infantile Colic.
• Incarcerated congenital
• Hirschsprung disease.
• Volvulus neonatorum
Children 1-5 years old
Non-specific abdominal pain
Sickle cell crisis
Henoch scheneloin Purpura
Differential Diagnosis of patients with
Acute Abdominal Pain
Young and middle age Adult
• Acute Cholecystitis.
• Acute Pancreatitis.
• Non-specific abdominal
• Intestinal obstruction.
• Active/Perforated PU.
• Renal colic
Young and middle age Women
• Acute Cholecystitis.
• Acute Pancreatitis.
• Rupture ectopic pregnancy
• Rupture/Torsion Ovarian
• Mid-ovulatory Pain.
Acute Abdominal Pain in Elderly Patients
In Elderly patients >60 years old; after exclusion of
the commonest causes of Acute Abdominal Pain; as:-
Acute Cholecystitis ' Acute Pancreatitis; Acute
Appendicitis; the patients should be investigated as;
they may have colonic obstruction/ perforation due
to Colo-rectal carcinoma; diverticular abscess
In patients >70 years old; 10% of patients with
Acute Abdominal Pain will have Vascular Accident;
Acute Intestinal Ischemia; or MI.
Accurate History and complete clinical Examination are
essential to put provisional diagnosis/or short list of DD; and
to institute diagnostic tests and to decide if the patient will
need urgent surgery.
It is NOT Important to make specific diagnosis but to detect
Urgent and immediate Life-Threatening conditions.
The diagnosis of acute abdominal pain; particularly in early
stage of presentation is often difficult and is accurate only in
45-65% of patients. So the patient should be re-examined by
the same physician after resuscitation.
Define Surgical from non-surgical Abdomen. The term Acute
Abdomen should never equate with the invariable need for
Analgesia-Make the patient pain-free.
Opioids as (Morphine and Pethidine) don't mask the
physical signs or prevent accurate diagnosis.
The most common surgical diagnosis: -- acute appendicitis,
followed by acute Cholecystitis, small bowel obstruction,
and gynecologic disorders.
A useful rule is never to place appendicitis lower than
second in the differential diagnosis of acute abdominal pain
in a previously healthy person.
Indications of Surgical Consultation:-
(A.)-Severe Progressive Abdominal Pain.
(B.)-Involuntary Abdominal Muscles Guarding/Rigidity.
(C.)-Bile-stained or Faeculent Vomiting.
(D.)-Haemodynamically Instability(Fluid/Blood Loss)-
Signs of hypoperfusion as un-explained acidosis.