This presentation is about the differential diagnosis of abdominal pain and how to manage the different diseases, presenting as acute abdominal pain.

1. ACUTE ABDOMINAL PAIN

2. ACUTE ABDOMEN
• Challenge to Surgeons & Physicians
• Most common cause of surgical emergency admission
• Clinical course can vary from minutes to hours to
weeks.
• It can be an acute exacerbation of a chronic problem
e.g. Chronic Pancreatitis, Vascular Insufficiency.

3. DEFINITION:
"An acute abdomen" denotes any sudden,
spontaneous, nontraumatic disorder whose
chief manifestation is in the abdominal area
and for which urgent operation may be
necessary.

4. PATHOPHYSIOLOGY
• Visceral Pain:
– vague, deep, dull and poorly localized.
– Distention, inflammation or ischemia in hollow viscous &
solid organs
• Parietal Pain:
– Sharpe, Severe and well localized
– Mediated by spinal somatic nerves
– is localized to the dermatome above the site of the
stimulus.

5. Sensory Levels Associated with Visceral
Structures
Structures Nervous System Pathways Sensory Level
Liver, spleen, and central part
of diaphragm
Phrenic nerve C3–5
Peripheral diaphragm,
stomach, pancreas,
gallbladder, and small bowel
Celiac plexus and greater
splanchnic nerve
T6–9
Appendix, colon, and pelvic
viscera
Mesenteric plexus and lesser
splanchnic nerve
T10–11
Sigmoid colon, rectum, kidney,
ureters, and testes
Lowest splanchnic nerve T11–L1
Bladder and rectosigmoid Hypogastric plexus S2–4

6. DIFFERENTIAL DIAGNOSIS
• Generalized Abdominal pain
– Perforation(Peritonitis)
– AAA
– Acute pancreatitis
– Acute Ishemia
– Bilateral pleurisy

8. EVALUATION OF ACUTE ABDOMINAL PAIN
• Well elicited history
• Proper physical examination
Diagnosis can be made most of the time by a good
history and a proper physical examination.
Investigations are usually carried out :
• only to support the diagnosis.
• or to narrow down the differential diagnoses.

9. HISTORY
Onset And Duration Of Pain:
– Sudden onset (with in seconds)
– Rapidly accelerating (with in minutes)
– Gradual onset (with in Hours)

10. Character of Pain:
– Colicky pain (waxes and wanes)
– Sharp, severe, Persistent, Steadily increasing.
Location And Radiation Of Pain:
Alleviating And Aggravating Factors:

11. Associated Symptoms:
– NAUSEA & VOMITING
– ANOREXIA
– CONSTIPATION-
– URINARY SYMPTOMS
– FEVER & CHILLS/RIGORS

12. PHYSICAL EXAMINATION
GENERAL APPEARANCE
a. Anxious Patient lying
motionless:
(i) Acute appendicitis
(ii) Peritonitis
b. Rolling in bed & restless:
(i) Ureteric Colic
(ii) Intestinal colic
c. Writhing in Pain:
Mesenteric Ischemia
d. Bending Forward:
Chronic Pancreatitis
e. Jaundiced:
CBD obstruction
f. Dehydrated
(i) Peritonitis
(ii) Small Bowel obstruction

13. VITAL CHARTING
• Temperature, Pulse, BP, Respiratory rate
• Ruptured AAA or ectopic pregnancy can lead to
- Pallor
- Hypotension
- Tachycardia
- Tachypnea

14. SYSTEMIC EXAMINATION
Cardiopulmonary examination
Check for:
- Possible MI
- Basal Pneumonia
- Pleural Effusion

15. Abdomen:
– Inspection
– Palpation
• Local Right Iliac Fossa tenderness:
• Low grade, poorly localized tenderness:
• Tenderness out of proportion to examination:
• Flank Tenderness:
– Percussion
– Auscultation

16. IMPORTANT SIGNS IN PATIENTS WITH ABDOMINAL PAIN
SIGN FINDING ASSOCIATION
Cullen's sign Bluish peri-umbilical discoloration Retroperitoneal haemorrhage
Kehr's sign Severe left shoulder pain Splenic rupture
Ectopic pregnancy rupture
Iliopsoas sign Hyperextension of right hip causing
abdominal pain
Appendicitis
McBurney's sign Tenderness located 2/3 distance from
umbilicus to anterior iliac spine on
right side
Appendicitis
Murphy's sign Abrupt interruption of inspiration on
palpation of right upper quadrant
Acute cholecystitis
Grey-Turner's sign Discoloration of the flank Retroperitoneal haemorrhage
Obturator's sign Internal rotation of flexed right hip
causing abdominal pain
Appendicitis
Chandelier sign Manipulation of cervix causes patient
to lift buttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with
palpation of the left lower quadrant
Appendicitis

17. Per Rectal Examination:
- tenderness
- induration
- mass (Blummer’s shelf)
- frank blood
Pelvic Examination Testicular and scrotal examination

18. INVESTIGATIONS
• FBC:
• LFTs:
• Amylase: serum level >1000 iu diagnostic of pancreatitis.
Serum level 500–1000 iu, ?pancreatitis, perforated ulcer,
bowel ischaemia, severe sepsis.
Serum level raised <500 iu, non-specific indicator of
pathology.
• β-HCG (serum): ectopic pregnancy.
• Arterial blood gases:
• ECG: myocardial infarction.

19. RADIOLOGICAL STUDIES
• Chest X-ray: perforated viscus (free gas), pneumonia.
• Abdominal X-ray:
• Ultrasound:
• CT scan:
• IVU:

22. A, CT scan of uncomplicated appendicitis.
A thick-walled, distended, retrocecal
appendix
B, CT scan of complicated appendicitis. A
retrocecal appendiceal abscess (A)
APPENDICITIS

23. A, thrombosed superior mesenteric vein
(solid arrow) and incidental gallstones
(open arrow).
B, Thickening of proximal small bowel wall
(arrow) coincided with several feet of
infarcting small bowel at time of operation.
SMALL BOWEL INFARCTION ASSOCIATED WITH MESENTERIC VENOUS THROMBOSIS.

24. PARTIAL SMALL BOWEL OBSTRUCTION

25. DIAGNOSTIC LAPAROSCOPY
• Early diagnostic laparoscopy may result in:
– accurate,
– prompt,
– efficient management of acute abdominal pain
• Reduces the rate of unnecessary laparotomy
• Increases the diagnostic accuracy
• May be a key to solving the diagnostic dilemma of
nonspecific abdominal pain.

26. Preoperative Management
• ABCDE
• Parenteral analgesics
• Resuscitation
• A nasogastric tube
• A urinary catheter
• Informed consent for surgery may be difficult to
obtain when the diagnosis is uncertain. It is prudent
to discuss with the patient and family the possibility
of multiple-staged operations, temporary or
permanent stomal openings.

27. THANK
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