Acute Abdomen

1. PRESENTER:
DR. FAHAD AKHTAR
HISTORY AND EXAMINATION OF
ACUTE ABDOMEN

3. What Is Acute Abdomen?
 Synonym: Acute abdominal pain
 Defination: A condition of severe abdominal pain
caused by an acute disease or injury to internal
organ(s) usually requiring emergency surgery.
OR
Previously undiagnosed pain that arises suddenly
less than 7 days (usually less than 48 hours),
needs urgent surgical intervention .
OR
Abdominal pain of a non traumatic origin with
maximum duration of 5 days.

4. Common Causes:
 SURGICAL:
1) Inflammation/Infection ( Acute appendicitis,
acute cholecystitis, acute pancreatitis, meckels
diverticulitis, acute diverticulitis, acute
cholangitis, urinary tract infection)
2) Obstruction ( Intestinal obstruction, biliary colic,
ureteric colic, acute retention of urine)
3) Ischemia ( Mesenteric ischemia, torsion of a
viscus)
4) Perforation ( Perforated peptic ulcer, perforated
appendix, toxic mega colon with perforaton, gall
bladder perforation, ruptured abdominal aortic
aneurysm)

5. MEDICAL Causes:
1) Cardiovascular ( Myocardial infarction)
2) Gastrointestinal (Gastritis, gastroenteritis,
mesenteric adenitis, hepatitis, hepatic abscess)
3) Metabolic ( Diabetes mellitus(DKA), porphyria,
uremia, hypercalcemia)

6. Gynecological Causes:
 1) Ectopic pregnancy
 2) Ovarian cyst ( torsion, rupture, haemorrhage,
infarction)
 3) Pelvic inflammatory disease
 4) Fibroid degeneration
 5)Endometriosis
 6) Mittelschmerz

7. HISTORY:
 1) PARTICULARS : Age, gender, marital status,
occupation, address .
 2) PRESENTING COMPLAINTS: Symptoms
which made patient to come to doctor, for
example: abdominal pain.
 3) HISTORY OF PRESENTING ILLNESS:
Describe the presenting complaints in detail one
by one.

8. PAIN CHARACTERISTICS:
 Site – Where is the pain? Or the maximal site of
the pain.
 Onset – When did the pain start, and was it
sudden or gradual? Include also whether it is
progressive or regressive.
 Character – What is the pain like? An ache?
Stabbing?
 Radiation – Does the pain radiate anywhere?
 Associations – Any other signs
or symptoms associated with the pain?
 Time course – Does the pain follow any pattern?
 Exacerbating/relieving factors – Does anything
change the pain?

11. ASSOCIATED FEATURES:
 VOMITING :
 Billous (green): Intestinal obstruction
 Coffee ground: Gastitis, gastric ulcer, esophagitis
 Fresh blood: Esophagitis, gastritis,
gastric/duodenal ulcer, mallory weiss tear
 Feculent: Late intestinal content

12. Other Symptoms Associated With
Abdominal Pain
 Constipation: Suggests mechanical bowel
obstruction
 Diarrhea: Suggests pelvic abscess, blood stained
suggests ischemic colitis, IBD
 Fever: Marker of inflammation
 Hematochezia or malena: Lower GI bleed or
colonic ischemia
 Hematuria: Cystitis, ureteric colic

13. Past Medical History
 Ask about: Diabetes mellitus, hypertension, IHD,
tuberculosis, hepatitis, blood transfusion
Past Surgical History
 Ask about: Previous abdominal surgery, mode of
operation (laparoscopic or open), operative notes
and pathology reports should be obtained and
reviewed

14. Medication History
 Ask about: NSAIDS, anticoagulants, antiplatelets,
OCPs, corticosteroids, chemotherapeutics or
immunosuppresents
Family History: Often provides the best
information about medical causes of acute
abdomen
Gynecological History:
 Ask about: Menstruation history is crutial to
diagnosis of ectopic pregnancy, mittelschmerz,
endometriosis, History of vaginal discharge or
dysmenorrhea to rule out pelvic inflammatory

15. Personal And Social History
 Ask about: Any habit or addiction, dietary details,
sleep disturbance, patient economic status, home
surroundings
Occupational History
 Ask about: Exact nature of job, details of job in
past, exposure to chemicals or radiations
Travel History
 May raise the posibility of amebic liver abscess,
hydatid cyst, tuberculosis, dysentery

16. EXAMINATION
 Three types of abdominal pain (visceral, parietal,
referred)
 1) Visceral pain: Due to stretching of fibers
innervating the walls of hollow or solid organs,
occurs early and poorly localized, can be due to
early ischemia or inflammation
 2) Parietal pain: Caused by irritation of parietal
peritoneum fibers, occurs late and better
localized, can be localized to a dermatome
superficial to site of painful stimulus
 3) Referred pain: Pain is felt at site away from
pathological organ, pain is usually ipsilateral to

17. Abdominal Exam
 Although we will focus on abdominal exam, but a
thorough physical exam (head to toes) is very
important in arriving at comprehensive differential
diagnosis list.
 Examples:
 Presence of jaundice may indicate biliary or
hepatic etiology
 Irregularly irregular heart rate atrial fibrillation:
mesenteric ischemia
 Skin lesions (pyoderma gangrenosum): IBD

18. ABDOMINAL EXAM
 The exam should be performed in this specific
order:
 1) General appearance
 2) Vital signs
 3) Inspection
 4) Auscultation
 5) Percussion
 6) Palpation
It should include: examination of inguinal area (
including external genitalia in males), Rectal
exam, Pelvic exam in females.

19. GENERAL APPEARANCE
 Pallor – Malabsorption, acute or chronic blood
loss
 Icterus – Heaptobiliary disease
 Cyanosis – Cirrhosis with portal HTN
 Clubbing – Ulcerative colitis, crohn’s diease
 Lymphadenopathy – Localized or generalized

20. Continued
 Inflammation, peritonitis ( lies perfectly still or in
bed with thighs and knees flexed)
 Obstruction/Colic ( restless, writhing, abdominal
distension)
 Shock ( pallor, cyanosis, diaphoresis, decreased
mental status)

21. VITAL SIGNS
 Tachycardia (early shock)
 Rapid shallow breathing (peritonitis)
 Hypotension (may be a late finding, infectious
etiology or perforation)

22. INSPECTION
 Abdominal contour : Distended vs scaphoid,
irregular (mass, volvulus, obstruction, hernias)
 Skin : Ecchymossis around umblicus, flanks (
pancreatitis, trauma)
 Scars
 Prominent veins on the abdominal wall (portal
hypertension)

23. AUSCULTATION
 Bowel sounds
 Auscultate all regions
 Listen in each region
 Listen before feeling
 Absent bowl sounds (ileus, peritonitis, shock)
 Hyperactive (enteritis, obstruction)
 Bruits ( AAA, reno-vascular disease)

24. PERCUSSION
 Hyperresonance : Bowel distension with air
(obstruction)
loss of liver dullness in RUQ (liver dullness) - free
air
• Fluid thrill and shifting dullness: Ascites

25. PALPATION
 Palpate each region
 Warm hands
 Communicate with patient (let the patient know
what you are about to do)
 Place patient supine
 Note tenderness (localize vs diffuse)
 Rebound tenderness (press on abdomen and
release, positive if pain is worse upon release
 Involuntary and voluntary guarding (distract the
patient)
 Rigidity
 Feel for masses

26. Findings that suggest specific
etiology
 Courvoisier sign (palpable gall bladder in
presence of painless jaundice – periampullary
tumor)
 Caput medusa (varicose veins at umblicus –
cirrhosis with portal HTN)
 Murphy’s sign (pain during inspiration while
palpating RUQ – acute cholecystitis)
 Ransohoff sign (periumblical yellow discoloration
– ruptured CBD)

27. Hemoperitoneum
 Hemorrhagic pancreatitis (cullen sign –
periumblical bruising, grey turner sign –
disoloration around flanks )
 Danforth sign (shoulder pain on inspiration)
 Kehr’s sign (left shoulder pain when supine or
pressure applied to LUQ – splenic rupture

28. Appendicitis
 Rovsing sign (palpation on LLQ produces pain at RIF)
 Ten horn test (pain caused by gentle traction of right
testicle)
 Aaorn sign (persistent pressure applied at
McBurney’s point causes pressure in epigastrium and
upper chest wall)
 PELVIC INFLAMMATION/ABSCESS
 Illiopsoas sign (allow patient to lie on opposite side of
pain, extend the thigh on affected side, this cause
pain if there is irritation of iliopsoas muscle)
 Obturator sign (flexion and internal rotation of right
thigh produces hypogastric pain)
 Chandelier sign (extreme lower abd/pelvic pain with

29. Inguinal examination
 Palpate inguinal area with and without valsalva
maneuver
 Pay attention to femoral area to rule out femoral
hernia
 In males testis should be examined to rule out
testicular torsion
 NEVER MISS DRE (digital rectal examination )
AND PELVIC EXAMINATION.