3. Acute Abdomen
A serious condition within the abdomen characterized by
•sudden onset,
•pain,
•tenderness, and
•muscular rigidity, and
•usually requiring emergency surgery
4. Acute Abdomen
An acute intra-abdominal condition
•of abrupt onset,
•usually associated with pain due to
– inflammation, perforation, obstruction, infarction, or rupture of
abdominal organs, and
•usually requiring emergency surgical intervention.
•Its also called the surgical abdomen.
9. Major Common Causes
•This list is far from exhaustive but is a useful aide-
memoir for those conditions commonly seen in the
community
•Non-surgical disease, e.g. myocardial infarction,
pericarditis, pneumonia, sickle cell crisis, hepatitis,
inflammatory bowel disease, opiate withdrawal, typhoid,
acute intermittent porphyria
11. Diagnosis
•An acute abdomen requires immediate evaluation and
diagnosis because it may indicate a condition that calls
for surgical intervention.
•Diagnosis depends on
– a good history,
– examination and
– investigations
12. History
• This should cover the following points:
• Demographic details, occupation, recent travel, history of recent
abdominal trauma
• Pain: (SOCRATES)
– Site (ask patient to point), localised or diffuse
– Onset (including whether new pain or previously experienced)
– Nature (constant/intermittent/colicky)
– Radiation
– Severity
– Relieving/aggravating factors (e.g. if worsened by
movement/coughing suspect active peritonitis; pancreatitis is
relieved by sitting forward)
13. History (cont..)
• Associated symptoms: Vomiting and nature of vomitus (undigested food or bile
suggests upper GI pathology or obstruction; feculent vomiting suggests lower GI
obstruction)
• Haematemesis or melaena
• Stool/urine colour
• New lumps in abdominal region/groins
• Eating and drinking - including when was last meal?
• Bowels - including presence of diarrhoea, constipation and ability to pass flatus
• Fainting, dizziness or palpitations
• Fever/rigors
• Rash or itching
• Urinary symptoms
• Recent weight loss
14. History (Cont…)
•Past medical and surgical history/medication
•Gynaecological and obstetric history:
–Contraception (including IUCD use)
–LMP
–History of STIs/PID
–Previous gynaecological or tubal surgery
–Previous ectopic pregnancy
–Vaginal bleeding
–Drug history and allergies - including any complementary
medication
16. Examination
General Examination
– Pulse, temperature and blood pressure.
– Assess respiratory rate and pattern. Patients with peritonitis
may take shallow, rapid breaths to reduce pain.
– If altered consciousness check GCS
17. Inspection
Inspection:
• Look for evidence of anaemia/jaundice.
• Look for visible peristalsis or abdominal distension.
• Look for signs of bruising around the umbilicus (Cullen's sign -
can be present in haemorrhagic pancreatitis and ectopic
pregnancy) or flanks (Grey Turner's sign - can be present in
retroperitoneal haematoma).
• Assess whether patient is dehydrated (skin turgor/dry mucous
membranes).
18.
19.
20.
21.
22. Palpation
• Palpate the abdomen gently, then more deeply, starting away from the pain
and moving towards it.
• Feel for masses, tenderness, involuntary guarding and organomegaly
(including the bladder).
• Test for rebound tenderness.
• Examine the groins for evidence of herniae.
• Always examine the scrotum in men as pain may be referred from
unrecognised testicular pathology.
• Check supraclavicular and groin lymph nodes.
23. Percussion
• Percuss the abdomen to assess whether swelling/distension might
be due to bowel gas or ascites.
• Patients who display tenderness to percussion are likely to have
generalised peritonitis and this should act as a red flag for serious
pathology.
• Assess for shifting dullness and fluid thrill.
• Percussion can also be used to determine size of an abdominal
mass/extent of organomegaly.
24. Auscultation
Auscultate abdomen in all four quadrants.
• Absent bowel sounds suggest paralytic ileus, generalised
peritonitis or intestinal obstruction.
• High-pitched and tinkling bowel sounds suggest sub-acute
intestinal obstruction.
• Intestinal obstruction can also present with normal bowel sounds.
• If there is reason to suspect aortic aneurysm, listen carefully for
abdominal and iliac bruits.
25. Further examination
•DRE/VE - Perform rectal or pelvic examination as needed
with an appropriate chaperone.
•Check lower limb pulses if there could be an abdominal aortic
aneurysm.
•Dipstick urine and send for culture if appropriate.
•In a woman of child-bearing age, assume that she is pregnant
until proven otherwise - perform a pregnancy test.
•Examine any other system that might be relevant, e.g.
respiratory, cardiovascular.
26. Investigations
The following tests are often used but can be non-specific and must be
interpreted in the clinical context and with appropriate medical/surgical
expertise:
• Blood tests: FBC, U&E, LFT, amylase, glucose, clotting, and occasionally
amylase and lipase (pancreatitis), malaria slide
• Group and Save or crossmatch
• Blood cultures
• Pregnancy test in women of child bearing age
• Urinalysis
• Radiology - AXR (erect, supine), CXR (erect looking for gas under the
diaphragm), IVP, CT, ultrasound scan as appropriate
• Consider ECG and cardiac enzymes
• Peritoneal lavage if history of abdominal trauma
27. Red flags that raise suspicion of serious pathology
• Hypotension, Confusion/impaired consciousness - Signs of shock
• Systemically unwell/septic-looking
• Signs of dehydration
• Rigid abdomen
• Patient lying very still or writhing
• Absent or altered bowel sounds
• Associated testicular pathology
• Marked involuntary guarding/rebound tenderness
• Tenderness to percussion
• History of haematemesis/melaena or evidence of latter on PR
examination
• Suspicion of medical cause for abdominal pain
31. Introduction
•Intestinal obstruction happens when there is restriction to
the normal passage of intestinal contents
•It may be divided into two main groups as
Paralytic (adynamic)
Mechanical (dynamic)
32. Mechanical Obstruction
Further classified according to the following
•Speed of onset: acute, chronic, acute on chronic
•Site: High or low
•Nature: simple versus strangulating
•Aetiology – according to the cause
33. Speed of onset
•Acute obstruction – the onset is rapid with severe
symptoms
•Chronic obstruction – symptoms are insidious (gradual,
subtle) e.g. most cases of carcinoma of large bowel
•Acute on chronic – a chronic obstruction that suddenly
becomes complete
35. Accordung to the Nature of obstruction
•Simple obstruction – when bowel is occluded without
damage to its blood supply
•Strangulated – when the blood supply of the involved
segment of intestine is cut off e.g. strangulated hernia,
volvulus, intussusception or adhesive band. Gangrene
may occur if untreated
36. Aetiology
•Causes in the lumen – fecal impaction, gallstone ‘ileus’,
food bolus, parasites, intussusception, pedunculated
tumour
•Causes in the wall – congenital atresia, tumours,
diverticulitis, Crohn’s disease
•Causes outside the wall – strangulated hernia (external
or internal), volvulus, adhesions
37. Common causes by age groups
•Neonatal – Congenital atresia and stenosis, imperforate
anus, volvulus neonatorum, Hirschsprung’s disease,
meconium ileus
•Infants – intussusception, Hirschsprung’s disease,
strangulated hernia, Merkel’s diverticulum
38. Causes by age (Cont…)
•Young adults and middle age – strangulated hernia,
adhesion and bands, Crohn’s disease
•The elderly – strangulated hernia, Ca colon, colon
diverticulitis, impacted faeces
Hernia is an important cause from infants to old age an
must always be ruled out
50. •A Meckel's diverticulum, a true congenital diverticulum,
is a slight bulge in the small intestine present at birth and
a vestigial remnant of the vitelline duct or yolk stalk)
51.
52.
53.
54.
55.
56. Pathophysiology – Intestinal fluid
1.Fluid intake, ingests or drinks
2. Fluid made up of various digestive juices (8.5 l/day)
•Saliva 1000mls/day
•Gastric secretions -2000mls/day
•Bile - 1000mls/day
•pancreatic secretions- 1500mls/day
•Succus entericuss -3000mls/day)
57. Pathophysiology
•Bowel distal to the obstruction rapidly empties and
becomes collapsed
•Above the obstruction becomes dilated with gas
(swallowed air) and fluid poured from gastric, biliary and
pancreatic secretions
•Increased peristalsis to overcome obstruction causing
intestinal colic
58. Pathology of obstruction
•As bowel distends blood supply becomes impaired with
mucosal ulceration, perforation
•Perforation may occur due to pressure by a band causing
ischaemic necrosis or pressure from within the gut
59. Pathophysiology
•In strangulating obstruction the integrity of the mucosal
barrier is lost due to ischaemia
•Bacteria and toxins can no longer be contained within the
lumen
•Transudation of bacteria into peritoneal cavity takes place
with secondary peritonitis
60. Pathophysiology
Lethal effects of obstruction is due to
•Fluid and electrolyte depletion (shock) due to copious
vomiting and loss into the bowel lumen
•Protein loss into the gut
•Toxaemia due to migration of toxin and bacteria into the
peritoneal cavity
61. Clinical Features
Four cardinal symptoms of intestinal obstruction
•Colicky abdominal pain
•Distension
•Absolute constipation
•Vomiting
NB: Not all may be present
62. Clinical Features
Pain
•Usually the first symptom
•Small bowel obstruction - peri-umbilical
•Distal obstruction – suprapubic
•Post op obstruction - may be disguised by general
discomfort and by opiates given to the patient
64. Clinical features
Absolute constipation
•Failure to pass either flatus of faeces
•Its an early feature of large bowel obstruction but late
feature of small bowel obstruction
•Patient may pass one or two motions early after onset of
obstruction
•Partial or chronic obstruction may have passage of small
amounts of flatus
65. Clinical Features
Vomiting
•Early in high obstruction
•Late or absent in chronic or low obstruction
•Late stages - faeculent but not faecal
•Faeculent because of decomposing of stagnant contents
and altered blood transudating into the lumen
•True faecal vomiting only happens in gastrocolic fistula
66. Clinical Examination
•Dehydration
•In pain, may be rolling about with colic
•Tachycardia
•Afebrile, if fever may suggest strangulation
•Abdominal distention
•May have visible peristalsis
67. Clinical Features
During inspection look for
•Strangulated external hernia – inguinal or femoral (may
be difficult in fat people)
•Abdominal scar – previous operation may suggest
adhesions or bands
68. Clinical Features
•On palpation mass may be present (intussusception or
carcinoma)
•Bowel sounds may be accentuated or tinkling
•Rectal examination (DRE, ?PR) – should always be done.
It may reveal a mass in the Pouch of Douglas, the apex of
an intussusception or faecal impaction
69. Clinical Examination
•Digital vagina examination in a female patient is
mandatory.
•This is done before rectal examination with the same
gloved finger
•On auscultation - bowel sounds are increased in early
stages of obstruction but later on decrease and even stops.
70. Special Investigations
•Abdominal X-Rays (Erect and supine). Small bowel -
ladder pattern of dilated loops in central position and by
striations that pass completely across the width of dilated
bowel. Large bowel is peripheral and show haustration of
the taenia coli
•Computerised tomography (CT Scan)
•Water soluble contrast studies
74. Small bowel obstruction
- Diametre >3cm
- Distension central (“picture”)
- Valvaulae conniventes
- Many fluid levels
- Absent gas in large bowel
- “step-ladder”
Clinical Features
77. • Specific treatment is according to the cause
• Chronic large bowel obstruction, slowly progressing obstruction
can be investigated at some leisure with sigmoidoscopy,
colonoscopy and barium enema and treated electively
• Acute obstruction, of sudden onset, complete and with risk of
strangulation is an urgent problem requiring emergency surgical
intervention
Treatment – General Principles
78. Preoperative Preps in Acute Obstruction
•Gastric aspiration by nasogastric suction – this helps to
decompress the bowel and reduce risk of inhalation of
gastric content during induction of anaesthesia
•Intravenous venous fluid replacement – Hartmann’s
solution or Normal Saline with potassium of renal
function is okay
•Antibiotic therapy if strangulation is likely
80. Operative treatment
•Affected bowel should be carefully inspected for viability
•Doubtful bowel may recover after relief of obstruction
•If extensive areas of bowel are doubtful second look
laparotomy after 48 hrs
•Small bowel may be resected and primary anastomosis
done
81. Operative treatment
•Large bowel resection with ileocolic anastomosis may be
done
•A colonic primary (colo-colonic) anastomosis is very
liable to leak in the presence of an obstruction
•A defunctioning loop colostomy or ileostomy may be
performed to minimize the complications of anastomotic
leak
82. Conservative Treatment
Conservative treatment is by means of iv fluids and NG
aspiration (‘drip and suck’). This is indicated
•Post operative paralytic ileus
•Repeated episodes of obstruction due to massive intra-
abdominal adhesions
•Chronic large bowel obstruction, remove faeces by
enema, prepare bowel and do elective operation
83. Paralytic ileus
• Functional obstruction most commonly seen after abdominal
surgery
• Also associated with trauma, intestinal ischaemia, sepsis
• Small bowel is distended throughout its length
• Absorption of fluid, electrolytes and nutrients is impaired
• Significant amounts of fluid may be lost from the extracellular
compartment
84. Clinical Features
•Usually history of recent operation or trauma
•Abdominal distension is often apparent
•Pain is often not a prominent feature
•If no nasogastric tube in-situ vomiting may occur
85. Clinical Features
•Large volume aspirates my occur via nasogastric tube
•Flatus will not be passed until resolution of the ileus
occurs
•Auscultation will reveal absence of bowel sounds
86. Investigations
•Plain abdominal x-ray may show dilated loops of small
bowel
•Gas may be present in the colon
•If doubt as to whether there is a mechanical or functional
obstruction
•Water soluble contrast study may be helpful
87. •Prevention is better than cure
•Bowel should be handled as little as possible
•Fluid and electrolyte derangements should be corrected
•Sources of sepsis should be eradicated
Management
88. Management
For an established ileus the following will be required
•Nasogastric tube
•Fluid and electrolyte replacement
•No drugs are available to reverse the condition
•Usually resolves spontaneously after 4 or 5 days
91. Peritonitis
Acute peritonitis is the acute or chronic inflammation of the visceral
/parietal peritoneum of the abdominal cavity
• The peritoneal cavity is the potential space between the parietal
peritoneum and the visceral peritoneum i.e. the two membranes that
separate the organs in the abdominal cavity from the abdominal wall
• The peritoneal fluid is present in between the visceral and parietal
membrane
• There is normally about 50 ml of sterile peritoneal fluid, it has anti-
inflammatory properties - antibodies, immunoglobulins and the white
cells
• It lubricates the organs in the peritoneal cavity
92. •Intra-abdominal organs include the stomach, duodenum,
ileum, caecum, appendix, ascending colon, transverse
colon descending colon, sigmoid and the upper third of
the rectum.
•Other organs located in the abdomen are the liver, the
spleen and the tail of the pancreas
93. Aetiology
Bacteria may enter the peritoneum via four portals
1. From the exterior – penetrating wound, infection at laparotomy,
peritoneal dialysis
2. From intra-abdominal viscera:
• Gangrene of a viscus – acute appendicitis, acute cholecystitis,
diverticulitis or infarction of the intestine
• Perforation of a viscus –perforation of a viscus –perforated
duodenal ulcer, perforated appendix, rupture of intestine from
trauma
• Post operative leakage of intestinal suture line
94. Aetiology
3. Via the bloodstream – as part of a septicaemia
(pneumococcal, streptococcal or staphylococcal. This has
sometimes called primary peritonitis, but there is usually
some source
4. Via the female genital tract – acute salpingitis or
puerperal infection.
•Approximately 30% in adults result from post operative
complications, 20% from acute appendicitis ad 10% from
perforated peptic ulcers
95. Primary Peritonitis
Primary peritonitis occurs when disease causing organism
gain entry into the peritoneal cavity
•Blood borne organisms
•Genital tract organisms
•Cirrhosis with ascites
96. Primary Peritonitis
• Rare condition almost confined to females, below the age of 8.
• It is probably due to retrograde infection via the genital tract.
• The purulent exudate grows either streptococci or pneumococci
(rarely, E. coli) and these children are nearly always thought,
before operation, to have pelvic appendicitis.
• Primary peritonitis occasionally complicates the ascites of
nephrosis.
97. Secondary Peritonitis
Secondary causes are the most common causes of peritonitis
• Ruptured appendicitis
• Trauma to the abdominal organs
• Ruptured diverticulitis
• Pancreatitis
• Perforations
• Peritoneal dialysis
• Post operative complications
98.
99.
100. Pathology
• Intestinal and gastric contents irritate the normal sterile
peritoneum which produce an initial chemical peritonitis and
once bacteria gain entry it is followed by a bacterial peritonitis in
just a few hours
• The resulting inflammatory response causes vaso-dilatation,
increased capillary permeability allowing leucocytes and
subsequently phargocytosis of the offending organisms
• But if this fails it will result in widespread inflammation and
massive fluid shifts and oedema
• It also results in the formation of adhesions as the body tries to
wall off the infection
101. Pathology
• Peritonitis of bowel origin usually shows mixed feacl flora
(Escherichia coli, strep fecalis, psuedomonas, Klebsiella and Proteus,
together with the anaerobic Clostridium and Bacteroides)
• Gynaecological infections may be chlamydial, gonococcal or
streptococcal.
• Blood-borne peritonitis may be streptococcal, pneumococcal,
staphylococcal or tuberculous
• In young girls there may be a rare gynaecological infection due to
pneumococcus
102. Pathology
The pathological effects of peritonitis are as follows
1. widespread absorption of toxins from the large inflamed
surface
2. The associated paralytic ileus with the following
•Loss of fluids
•Loss of electrolytes
•Loss of protein
3. Gross abdominal distention with elevation of the
diaphragm, which produces liability to lung collapse and
pneumonia
103. Clinical manifestations
• Abdominal pain – quite severe, patients tend to lie still, take
shallow breaths because even the slightest movements can cause
pain
• Irritation of the diaphragm may cause referred pain to the
shoulder tip
• Rigid board like abdomen
• Rebound tenderness
• Decreased peristalsis, abdominal distension, constipation
• Anorexia, nausea and vomiting
• High fever tachycardia and tachypneoa
• Possible poor respiration
104. Investigations
• X-ray of the abdomen – shows dilated loops if there is paralytic
ileus, free air if perforation has occurred, air-fluid levels if there is
a bowel obstruction
• Ultrasound and CT scan may identify the abscesses and ascites
• Peritoneal aspiration – analysis of peritoneal fluid may help
identify blood, bile, pus, bacteria and amylase contents if the
pancreas is involved
• Lab - leucocytosis
• Blood culture
105. Complications
• Dehydration
• Oliguria and possible renal failure
• Hypovolemic shock
• Sepsis – when bacteria enter the blood stream, causing septicaemia and
septic shock
• Intraabdominal abscess formation
• Paralytic ileus
• Bowel obstruction
• ARDS – acute respiratory distress syndrome due to increased
abdominal pressure against the diaphragm from intestinal distention
and fluid shift to the peritoneal cavity
106. Management
•The impulse to rush the patient, who is so obviously
gravely ill, to the operating theatre must be resisted:
•Time wisely spent on preoperative treatment may be life-
saving.
107. Treatment
Non surgical
• Nil by mouth (nil orally, NPO)
• NG tube to suction to decompress the stomach
• Iv fluids – isotonic fluids to replace the fluid lost from the
extracellular compartment
• Antibiotics – broad spectrum, penicillin, gentamicin, or
cephalosporin together with metronidazole
• Analgesics – with opiates, intravenous morphine, pethidine etc
• Oxygen – according to patient’s respiratory status
108. Surgery is indicated for identifying the cause
•Exploratory laparotomy – to remove/repair the inflamed
perforated organ
•Surgery focusses on controlling the contamination or
infection, removing the foreign material from the
peritoneal cavity and draining the pus which may have
collected
•Before abdominal closure irrigation of the peritoneal
cavity with antibiotic solution is done
109. Conservative management
Conservative treatment (‘drip, suck, antibiotics’) is
indicated at least initially,
•when infection has been localised e.g. appendix mass, or
•when the primary focus is irremovable as in pancreatitis
or post-partum infection.
•When the patient is moribund
•Lack of surgical facilities e.g. on board a ship
