3. Introduction
• Abdominal pain is a common ED presentation and can be the cause of
a wide variety of GI problems.
• Severity is not a reliable indicator of the seriousness of the condition.
• Site and characteristics of the pain can often indicate the cause.
• Pain usually arises from an organ within the abdominal cavity that is
• Inflamed
• Distended
• Perforated
• Ischeamic
• Pain can also be referred from an organ outside the abdominal cavity
4. Acute Abdomen
• The acute abdomen is a term given to sudden severe pain in the
abdomen.
• This requires swift diagnosis, and treatment usually involves
emergency surgery.
6. Assessment of abdominal pain
• Where is the pain (site)?
• Helps to localize an area/quadrant.
• What is the pain like (quality)?
• Colicky
• Spasmodic
• Sharp
• Dull
7. Assessment of abdominal pain
• Where is the pain (site)?
• Helps to localize an area/quadrant.
• What is the pain like (quality)?
• Colicky pain comes and goes.
• Spasmodic pain can be ‘squeezing’ in nature and suggests
obstruction of a hollow structure.
• Sharp pain is localized and suggests peritoneal irritation.
• Dull pain is less localized and suggests an organ disorder.
8. • When did the pain start (time)?
• Sudden onset suggests acute
perforation or rupture.
• How long does the pain last
(time)?
• Is it intermittent or persistent?
• Where does the pain go
(radiation)
9. • What makes the pain better or worse (relief and provocation)?
• Eating can relieve pain in peptic ulcer disease (PUD), or make pain from
pancreatitis or small bowel obstruction worse.
• Breathing can aggravate pain if the disordered organ lies next to the
diaphragm.
• Movement that makes pain worse suggests peritonitis.
• Position. Flexing the legs may relieve pain from peritonitis. Lying flat can ↑
pain from pancreatitis.
• What else is going on (other symptoms)?
• Nausea, vomiting, fever, diarrhoea, GU symptoms, LMP.
10. Physical assessment
Inspection
• Observe for abdominal distension, which can be caused by fat, flatus,
faeces, fetus, or fluid.
• Ascites.
• Scars from previous surgery.
• Surface trauma to the abdomen or lower ribs: wounds; bruising;
abrasions; impaled objects.
• Evisceration.
• Jaundice. Cholestatic jaundice is either directly related to a problem within
the liver, e.g. cirrhosis, or due to extrahepatic causes, e.g. bile duct stone,
pancreatitis, or carcinoma.
11. • Palpation
• Palpation of the abdomen by the assessing clinician can identify the
specific
• site of pain
• pain patterns on examination
• the presence of any masses.
• In health, abdominal organs are not usually palpable, except in the
very thin.
13. Pain patterns
• Tenderness. Pain may be localized to an abdominal organ or a
quadrant on palpation.
• Guarding is the normal tendency to contract the abdominal muscles
on examination. Guarding (↑ abdominal muscle tone), despite
relaxing/reassuring the patient, accompanies intra-abdominal
disease.
• Rebound tenderness reveals deep-seated inflammation and is
elicited on abrupt withdrawal of the palpating hand.
• Rigidity. Generalized ‘board-like’ rigidity implies peritonitis; the
abdomen does not move on respiration.
14. Auscultation
• All four quadrants should be auscultated for bowel sounds.
• Absent bowel sounds are highly suggestive of intra-abdominal pathology.
• Tinkling bowel sounds suggest obstruction.
Percussion
• Dullness indicates fluid or an enlarged organ;
• hyper-resonance suggests air in the abdominal cavity.
• Percussion can be extremely painful, especially in the acute abdomen.
15. Investigations
• Assessment of the patient with abdominal pain can be complex.
• Even those apparently well and triaged into a low-priority
category should have a full set of vital signs.
• Even slight abnormalities, e.g. tachycardia, should not be dismissed.
• The elderly, critically ill, and immunocompromised may not develop a fever,
even in the presence of overwhelming infection.
• Pulse.
• Temperature.
• RR.
• BP.
• Pain assessment and score.
• Urinalysis.
• ECG if pain is epigastric.
16. Investigations
• Assessment and examination by the assessing clinician may be required
to identify what, if any, investigations are indicated.
• FBC, U&E, β-HCG, amylase/lipase.
• Lactate in sepsis, and it is useful in helping to diagnose bowel ischaemia,
especially in the elderly.
• CBG (DKA can present as an acute abdomen).
• Abdominal X-ray (AXR); erect CXR.
• ABG if the patient is shocked.
• USS, conducted by an experienced clinician, can be very useful in establishing a
diagnosis or the detection of free fluid.
• CT: often provides the clinician with a definitive diagnosis, as is becoming the
investigation of choice for most GI emergencies.
17. evaluation and management of acute surgical
abdomen
•e.g. ruptured abdominal aortic
aneurysm.
Immediate operation
– these patients will
die unless taken to
theatre immediately
• may present with an acute abdomen and require urgent
operation;e.g. Peritonitis due to Perforated Duodenal
Ulcer or perforated appendix; however,
• preoperative dehydration and electrolyte abnormalities
need to be corrected before going to theatre.
Preoperative preparation
and operation urgently
within 6 h – elderly
patients
• May be dealt with on a routine emergency list, e.g. acute
appendicitis, small bowel obstruction with no adverse
symptoms (e.g. no fever, no leukocytosis, no peritonism).
Urgent operation
(within 24 h) –
certain conditions,
particularly in young
patients
18. evaluation and management of acute
surgical abdomen
• Numerous causes of an acute
abdomen only require conservative
treatment, i.e. nil by mouth,
antibiotics (e.g. acute cholecystitis).
Conservative
treatment
• Many patients may have equivocal
clinical signs but be in the early
stages of a condition. Time is a great
diagnostic tool and frequent re-
examination may reveal evolving
signs.
Observation
Discharge.
20. Gastrointestinal bleeding
Bleeding can occur from any part of the GI system.
• Acute upper GI bleeding can present as haematemesis ±
melaena.
• It is commonly caused by
• PUD (50%),
• oesophageal varices (10–20%),
• gastric erosions (15–20%),
• Mallory–Weiss syndrome (5–10%).
21. Acute Lower GI bleeding
• Massive acute lower GI bleeding is rare and most commonly seen in
the elderly.
• A small amount of bleeding from haemorrhoids is much commoner
and a frequent cause of anxiety that prompts an ED attendance.
• Massive lower GI bleeding is usually due to diverticular disease,
inflammatory bowel disease (IBD), tumour, or ischaemic colitis.
• Patients require the same rapid assessment and resuscitation as
those with upper GI bleeding.
22. Acute GI Bleed presentations
Haematemesis
• Vomiting fresh blood or darker blood (sometimes called ‘coffee grounds’)
occurs after bleeding in the oesophagus, stomach, or duodenum.
• Darker/coffee-ground vomit occurs, as blood is altered in the stomach over
time by gastric acid.
Melaena
• is abnormally black, tarry stools with a distinctive offensive odour.
• The stools contain digested blood that has usually originated from an
upper GI bleed that may be acute or chronic.
Hematochezia
• Refers to fresh, red blood in the stool. This blood might be mixed in with
the stool or come out separately.
23.
24. Chronic GI bleeding
• Chronic GI bleeding usually presents as anaemia.
• Iron deficiency anaemia in men and post-menopausal women is
usually of GI origin
• investigations of the upper and lower GI tract may be necessary to
identify the cause if it is not apparent from history and examination.
26. Massive gastrointestinal bleeding
• Bleeding from PUD or oesophageal varices accounts for up to 70% of
upper GI haemorrhages.
• Urgent resuscitation is required prior to any in-depth assessment as
to the cause.
• Bleeding from ruptured varices can be phenomenal—like a hosepipe!
Loss of >40% of blood volume is immediately life-threatening, and
blood loss is often underestimated.
27. Early management of massive GI bleeding
• Airway protection.
• In patients with massive haemorrhage and a reduced level of
consciousness, urgent intubation may be required to protect the airway.
• O2 administration may be difficult if there is continued vomiting.
• Nasal prongs may be a useful way of administering low-flow O2
• IV access. × 2 large-bore cannulae into large veins will allow rapid infusion
of warmed fluids, blood, platelets, and FFP.
• Immediate central access may be indicated if the bleeding is significant.
• Bloods sent for FBC, U&E, LFTs, cross-match, coagulation.
28. • ABGs.
• IV fluids.
• Give warmed crystalloid or colloid, followed by blood.
• Blood transfusion is indicated when 30% of circulating volume is lost.
• O-negative blood can be given almost immediately, followed by type-
specific, then fully cross-matched, blood.
• Replacement platelets/clotting factors.
• Platelets, FFP, and cryoprecipitate may need to be given in massive blood
loss (usually when >100% blood volume has been lost).
• These replace essential clotting factors and can help prevent the
development of DIC.
29. Cont…
• Tranexamic acid may be indicated.
• CVP monitoring.
• Arterial line to enable continuous invasive monitoring.
• Urinary catheter. Aim for a urine output >30mL/h.
• NG tube.
• Keep the patient warm. Hypothermia ↑ the risk of serious
complications
30. Management
Upper GI bleeding
• Urgent endoscopy, performed
within 24 hours of presentation.
• Proton pump inhibitors should be
initiated upon presentation with
upper GI bleeding.
• Guidelines recommend high-dose
proton pump inhibitor treatment
for the first 72 hours post-
endoscopy because this is when
rebleeding risk is highest.
Lower GI bleeding
• Most patients should undergo
colonoscopy.
• abdominal computed
tomographic angiography .
• Surgical intervention should be
considered only for patients with
uncontrolled severe bleeding or
multiple ineffective nonsurgical
treatment attempts.
31. A 41-year-old male with a history of chronic alcoholism has
massive hematemesis following a bout of prolonged vomiting.
This is most typical for:
A. Hiatal hernia
B. Mallory-Weiss tear
C. Esophageal variceal bleeding
D. Boerhaaeve’s syndrome
32. Case 2
• A 15 year old male, presents with severe abdominal pain, and vomiting.
There is no history of fever, weightloss, diarrhea, jaundice and joint pain.
• Based on above information what additional history, physical findings, labs
and/or radio imaging are needed to make a diagnosis of
• Pancreatitis
• Appendicitis
• Malrotation with volvulus
• Intusseception
• Testicular tortion
• Renal calculi
• DKA
