acute abdomen and differential diagnosis

4. Epidemiology
• Gastroenteritis is the most common
cause of abdominal pain not requiring
surgery
• In patients age 60 and older, biliary
disease and intestinal obstruction are
the most common cause of acute
abdomen that is surgically correctable
• Appendicitis is the most common cause
of abdominal pain requiring surgery in
patients < age 60
• Appendicitis is the leading cause of
acute abdominal pain in children (32%)

5. ACUTE ABDOMEN
• “Acute Abdomen” implies
the sudden onset of
abdominal pain for which
a surgically correctable
cause is likely

6. Early Diagnosis
• Diagnose early
• No narcotics until diagnosis is made
• Examination ,re-examination ,testing by
experienced hands leads to diagnosis
and early pain relief
• A correct diagnosis essential to correct
treatment
• Spot diagnosis is magnificent but not
sound, is impressive but unsafe.
• Deduction and induction from observed
facts – less chances of fallacies

7. Abdominal Cavity
• Superior border = diaphragm
• Inferior border = pelvis
• Posterior border = lumbar
spine
• Anterior border = muscular
abdominal wall

8. Peritoneum
• Abdominal cavity lining
• Double-walled structure
• Visceral peritoneum
• Parietal peritoneum
• Separates abdominal cavity into
two parts
• Peritoneal cavity
• Retroperitoneal space

9. Primary GI Structures
• Esophagus
• Portion of digestive
tract between
pharynx and
stomach
• Stomach
• Hollow digestive
organ
• Receives food from
esophagus

10. Primary GI Structures
• Small intestine
• Between stomach and cecum
• Composed of duodenum,
jejunum and ileum
• Site of nutrient absorption
into body
• Large intestine
• From ileocecal valve to anus
• Composed of cecum, colon,
rectum
• Recovers water from GI tract
secretions

11. Accessory GI Structures
• Liver
• Large solid organ in right
upper quadrant
• Produces, secretes bile
• Produces essential proteins
• Produces clotting factors
• Detoxifies many substances
• Stores glycogen
• Gallbladder
• Sac located beneath liver
• Stores and concentrates bile

12. Accessory GI Structures
• Pancreas
• Endocrine pancreas secretes insulin
into bloodstream
• Exocrine pancreas secretes
digestive enzymes, bicarbonate into
gut
• Vermiform appendix
• Hollow appendage
• Attached to large intestine
• No physiologic function

13. Major Blood Vessels
• Aorta
• Inferior vena cava

14. Solid Organs
• Liver
• Spleen
• Pancreas
• Kidneys
• Ovaries (female)

15. Hollow Organs
• Stomach
• Intestines
• Gallbladder and bile ducts
• Ureters
• Urinary bladder
• Uterus and Fallopian tubes
(female)

16. Right Upper Quadrant
• Liver
• Gallbladder
• Duodenum
• Transverse colon (part)
• Ascending colon (part)

17. Left Upper Quadrant:
• Stomach
• Liver (part)
• Pancreas
• Spleen
• Transverse colon (part)
• Descending colon (part)

18. Right Lower Quadrant
• Ascending colon
• Vermiform appendix
• Ovary (female)
• Fallopian tube (female)

19. Left Lower Quadrant
• Descending colon
• Sigmoid colon
• Ovary (female)
• Fallopian tube (female)

22. Abdominal Pain
 Visceral– originates in
abdominal organs covered by
peritoneum
Colic – crampy pain
Parietal – from irritation of
parietal peritoneum
Movement of pain – produced
by pathology in one location
felt at another location

23. Abdominal Pain
• Visceral pain
• Stretching of peritoneum or
organ capsules by distension or
edema
• Diffuse
• Poorly localized
• May be perceived at remote
locations related to organ’s
sensory innervation

24. Abdominal Pain
• Somatic pain
• Inflammation of parietal
peritoneum or diaphragm
• Sharp
• Well-localized

25. Abdominal Pain
Colic – crampy pain
produced by hollow organs
or tubular organs, due to
obstruction in the lumen
Rediated, reffered or shifted –
produced by pathology in
one location felt at another
location

26. Causes
A. Gastrointestinal-
1-Gut
Acute appendicitis
Intestinal obstruction
Perforated peptic ulcer
Diverticulitis
Inflammatory bowel disease
Acute exacerbation of peptic
ulcer
Gastroenteritis
Mesensteric adenitis
Meckel’s diverticulitis

27. 2-Liver and biliary tract
cholecystitis
cholangitis
Hepatitis
biliary colic
3-Pancreas
Acute pancreatitis
4-Spleen
Splenic infarct and spontaneous
rupture
Causes

28. B. Urinary tract
Cystitis
Acute pyelonephritis
Ureteric colic
Acute retention
C. Vascular
Ruptured aortic aneurysm
Mesenteric embolus
Mesenteric venous
thrombosis
Ischemic colitis
Acute aortic dissection
Causes

29. Causes
D. Abdominal wall
conditions
Rectus sheath
haematoma
E. Peritoneum
Primary peritonitis
Secondary peritonitis

30. Causes
F. Retroperitoneal
Hemorrhage.
G. Gynecological
Torsion of ovarian cyst
Ruptured ovarian cyst
Fibroid denegeration
Ovarian infarction
Salpingitis
Pelvic endometriosis
Severe dysmenorrhea
Endometriosis

31. Causes
H. Extra-abdominal causes
Lobar pneumonia
Pleurisy
MI
Sickle cell crisis
Uremia
Hypercalcemia

32. AGE
• Differential diagnosis of abdominal pain in
children - differs from dx in elderly patient
• Abdominal pain in most age groups - acute
appendicitis, intestinal obstruction,
strangulated hernias
• Intussusception is most likely the cause of
intestinal obstruction in children
• Adhesions are most likely the cause of
intestinal obstruction in adults
• In older patients, pain from a MI can be referred
to the upper abdomen
• Intussusception in infants rare <2, Cancerous
stricture rare below30, A/c pancreatitis rare
below 20, Perforated GU rare below 15

33. Classification with age
Children
Gastroenteritis
Mesentric adenitis
Meckel’s diverticulitis
Intussusception
Adult
Regional enteritis
Ureteric colic
Perforated ulcer
Testicular torsion
Pancreatitis

34. Classification with age
Adult female
Salpingitis
Pyelonephritis
Ectopic pregnancy
Elderly
Diverticulitis
Intestinal obstruction
Colonic carcinoma
Mesentric infarction
Aortic aneurysm

35. Characteristics of abdominal pain
• Site
• Time and mode of onset
• Severity
• Nature/Character
• Progression
• Radiation
• Duration
• Cessation
• Exacerbating/relieving factors
• Associated symptoms

36. Location / site
• Abdomen divided into 4
quadrants, which are further
divided (with some overlap)
into the epigastric,
periumbilical, and suprapubic
regions

37. Location of Abdominal Pain
• Four quadrants:
• Right Upper Quadrant
• Right Lower Quadrant
• Left Upper Quadrant
• Left Lower Quadrant
• Three central areas:
• Epigastric
• Periumbilical
• Suprapubic

38. Location
• RUQ pain -
• duodenal ulcers, acute pancreatitis, acute
cholecystitis, and acute hepatitis
• LUQ pain -
• gastritis, gastric ulcer, acute pancreatitis,
and splenic infarct or rupture
• RLQ pain -
• acute appendicitis,
• LLQ pain -
• diverticulitis
• GYN and urologic causes of acute abdominal
pain can also present with lower quadrant
abdominal pain

42. Symptoms--Pain
Onset
sudden: perforation of bowel, smooth muscle
colic
slow insidious onset: inflammation of visceral
peritoneum
Severity
Patient asked to rate pain from 1-10
Ureteric colic is one of worst pains
Character
Aching-dull pain poorly localised
Burning- peptic ulcer symptoms
Stabbing-ureteric colic
Gripping-smooth muscle spasm e.g. intestinal
obstruction worse by movement.

43. Symptoms--Pain
Progression
-Constant e.g. peptic ulcer
-Colicky e.g. seconds(bowel), minutes(ureteric
colic) or tens of minutes (gallbladder
-may change character completely from dull
poorly localized pain to sharp pain indicates
involvement of parietal peritoneum
e.g.appendicitis
Radiation of the pain
Back: duodenal ulcer, pancreatitis, aortic
aneurysm
Scapula: gall bladder
Sacroiliac region: ovary
Loin to groin: ureteric colic
Groin: testicular torsion

44. Cessation-
abrupt ending- colicky pains
resolving slowly-inflammatory pain,
biliary pain
Exacerbating/relieving factors-
Movement/Rest-inflammatory
conditions
Food- peptic ulcers
Symptoms--Pain

46. History
Past history
previous surgery
trauma
any medical diseases
Drug history
corticosteroid: mask pain
anti-coagulant: intra-mural hematoma
NSAIDS: gastritis, peptic ulcer
Family history
colon cancer
IBD

47. Physical Examination
General appearance
-Patient is lying motionless
acute appendicitis, peritonitis
-Rolling in bed
ureteric colic, intestinal colic
-Bending forward
chronic pancreatitis

48. Physical Examination
Vital signs
Temp.
low grade: appendicitis, ac.
Cholycystitis ; high grade: abscess
Pulse, BP, Resp.rate
General examination-Conjuctival pallor,
cyanosis, jaundice
Signs of dehydation
Cervical lymphadenopathy - mesentric
adenitis
Cardio-pulmonary examination – MI, basal
pneumonia, pleural effusion

49. Inspection
Auscultation
Percussion
Palpation
Physical Examination of the Abdomen

50. Inspection
• General observation
• Look at
• abdominal contour,
• note location of any
scars,
• rashes or lesions
• Other parts of the
body – ex – eyes
scleral icterus - may
indicate hepatobiliary
disease

51. Inspection
• Patient twisting/ bending in
agony - likely has colicky
abdominal pain caused by
ureteral lithiasis
• Patient lying very still - more
likely to have peritonitis
• Patient leaning forward to
relieve pain - may have
pancreatitis

52. Auscultation
• Useful in assessing peristalsis
• Bowel sounds are widely
transmitted through the abdomen
- therefore, necessary to listen in
all 4 quadrants
• Auscultation should last at least 1
minute
• Bowel sounds typically highly
pitched so the diaphragm of the
stethoscope should be used

53. Auscultation
• ? Bowel sounds-
normal/hyperactive/hypoac
tive
• Auscultation should
precede percussion and
palpation
• ? Abdominal bruits -
• listen over aortic,iliac
and
renal arteries

54. Auscultation
• Hypoactive bowel sounds -
associated with paralytic ileus,
intestinal obstruction, peritonitis
• Intestinal obstruction can
produce hyperactive bowel
sounds which are high pitched
tinkling sounds occurring at brief
intervals; very audible

55. Percussion
• Dull/resonant or
hyperresonant
• Tympany normally
present in
supine position
• ? Unusual dullness
• ? Clue to
underlying
abdominal mass

56. Percussion
• Gastric region -
• percussion over the gastric region will
generate a hyperresonant note
because of usual
presence of a gastric air bubble
• Liver -
• percussion over the liver will generate
a dull note
• A normal liver span is 6 to 12 cm in
the midclavicular line

57. Percussion
• Generalized percussion is a
useful method for detecting the
presence of ascites or intestinal
obstruction in a distended
abdomen
• In ascites - a dull percussion note
would be generalized
• In intestinal obstruction - a
hyperresonant note would be
heard

58. Percussion
• If ascites is suspected, then a test
for shifting dullness can be
performed
• Ascites typically sinks with
gravity, percussion of the flanks
generates a dull note and
percussion of the periumbilical
region generates a resonant note
in the supine patient

59. Shifting Dullness
• If dullness on percussion shifts
when the patient is rolled on the
side, peritoneal fluid (ascites)
may be present.

60. Percussion
• Splenic Enlargement
• A change from tympany to dullness
suggests splenic enlargement

61. Palpation
• Before palpating the abdomen the
examiner should ask the patient to
point directly to the area that hurts
most and avoid palpating that area until
absolutely necessary
• May be difficult in patient who has
guarding (voluntary or involuntary)

62. Palpation
• Voluntary guarding - conscious
elimination of muscle spasms
• Involuntary guarding - reported when
the spasm response cannot be
eliminated, which usually indicates
diffuse peritonits

63. Palpation
• Where is pain ? Begin with light
palpation
• Guarding - voluntary/involuntary
• Rebound tenderness

64. Palpation
• Rebound tenderness is elicited by
pressing on the abdominal wall
deeply with the fingers and then
suddenly releasing the pressure
• Pain on the abrupt release of steady
pressure indicates the presence of
peritonitis
• Asking the patient to cough is
another method of eliciting signs of
peritonitis

65. Rebound Tenderness
• This is a test for peritoneal irritation.
Palpate deeply and then quickly release
pressure. If it hurts more when you
release, the patient has rebound
tenderness

66. Deep Palpation
• ? Areas of deep tenderness/masses

67. Liver Palpation

68. Palpation of Aorta
• Easily palpable on most
• Pulsate with deep palpation of central
abdomen
• Enlarge aorta -
• ? Sign of aortic aneurysm

69. Palpation of Spleen
• Not normally palpable

70. Costovertebral Angle
Tenderness
• CVA tenderness is often associated
with renal disease. Use the heel of your
closed fist to strike the patient firmly
over the costovertebral angles

71. Vomiting
• Severe irritation of nerves of the
peritoneum or the mesentery eg. DU
perforation or torsion ovarian cyst.
• Obstruction of an involuntary muscle
tube.
• Absence of vomiting is sufficiently
common in many abdominal
catastrophes as rupture ectopic

72. • Vomiting is early, sudden and violent in
ureteric colic
• Early and copious in upper intestinal
obstruction
• No vomiting until late in large bowel
obstruction
• Frequent scanty in A/c pancreatitis
• Vomiting precedes pain in gastroenteritis
• In gastritis vomitus contains food particle
and some bile
• In duodenal atresia differentiated by
presence of bile
• In intestinal obstruction content varies from
gastric , bilious greenish yellow to orange
and brown indicating feculent vomitus.
• Patient vomits on doctor ZES
Character of Vomitus

73. Specific Disorders
• Upper abdominal pain - common
causes of acute abdominal pain in the
upper abdomen include: acute
cholecystitis, acute pancreatitis,
perforated ulcers
• Pain usually overlaps the left and right
upper quadrants

75. •Localized or diffuse RUQ pain
•Radiation to right scapula
•Vomiting and constipation
•Low grade fever
Classic Presentations
Acute Cholecystitis

76. Cholecystitis
• Positive Murphy’s sign
• Disease of adulthood
• More common in women
• Bacteria invasion can develop into ascending
cholangitis
• Charcot’s triad
• Right upper quadrant pain
• Fever
• Jaundice

77. Acute pancreatitis
• Retroperitoneal dissection of blood can result in
bluish discoloration of the flanks (Turner’s sign)
or of the periumbilical region (Cullen’s sign)
• Biliary pancreatitis secondary to cholelithiasis is most
common women > age 50 in community hospital setting
• Alcoholic pancreatitis is most common in men ages 30-
45 years in urban hospital sett
• Symptoms-epigastric pain,nausea,vomiting,pain
is constant & boring in nature
• Bowel sounds decrease - lack of rigidity or
rebound tenderness

78. Perforated Peptic Ulcer
• Sudden onset - severe epigastric pain
• Pain becomes generalized after a few hours to
involve the entire abdomen
• Perioperative mortality rate of 23%
• Patient usually lying quietly and breathing
shallow.
• Abdomen rigid,board-like, guarding - maximal
at site of perforation
• Upright chest x-ray - detection of free
intraperitoneal air

80. Specific Disorders
• Midabdominal pain - common
causes of midabdominal pain
include
• intestinal obstruction,
mesenteric ischemia and
early appendicitis
• dissecting aortic aneurysm
• myocardial infarction

81. Intestinal Obstruction
• Mechanical - results from
• gallstones, adhesions, hernias,
volvulus, intussuseption,
tumors
• Non-mechanical- results from
• intestinal infarction or occurs
after surgery as a paralytic
ileus, pain medication

82. Intestinal Obstruction
• Obstruction high in small intestine
• results in severe abdominal pain in
epigastric or umbilical region with
bilious vomiting, distention of
abdomen not an early feature
• Obstruction located lower in small
intestine
• results in less severe pain
• Vomiting late feature and may be
feculent

83. Intestinal Obstruction
• Differential Diagnosis of obstruction
of small intestine
• strangulated hernia
• volvulus
• mesenteric thrombus
• gallstone ileus
• Abdominal x-ray of distal
obstruction of small intestine will
show a dilated loop

84. Large Intestine Obstruction
• Pain less severe than small intestine
obstruction
• Vomiting infrequent
• Distention of abdomen - common
• Main Causes of Large Intestine Obstruction
• Ca of colon (change bowel habits, wt
loss, rectal bleeding)
• diverticulitis (fixed,tender, LLQ mass)
• volvulus (sigmoid volvulus most
common)

85. Mesenteric Ischemia
• Presents with acute, diffuse,
midabdominal pain, vomiting,
decreased bowel sounds and distention
resulting from intestinal obstruction
• Abdominal pain is out of proportion to
physical examination findings
• Abdominal distention is a late sign
indicative of gangrene - signs of
peritoneal irritation also indicative of
gangrene

86. Specific Disorders
• Lower abdominal pain - common
causes of lower abdominal pain
include
• Acute appendicitis (typically
RLQ pain)
• Sigmoid diverticulitis (typically
LLQ pain)
• Gynecologic causes
• Urologic causes

87. Diverticulitis
• Lower Left Quadrant Pain
• Cramping sensation
• Possible fever

88. Appendicitis
• Peak incidence in 2nd decade of
life
• Differential diagnosis is broad
and errors in diagnosis are
common
• Diagnostic error rate
• Men 23%
• Women 42%

89. Appendicitis
• Patients seen in first few hours -
report poorly defined constant pain
in periumbilical region
• As disease progresses - pain shifts
to RLQ in a region known as
McBurney’s point (located 2/3 of the
distance along a line drawn from the
umbilicus to the right anterior
superior iliac spine)

90. Appendicitis
• Pain relieved somewhat when
patient assumes a right
lateral decubitus position
with slight hip flexion
• Abdominal tenderness - most
likely physical finding
• Voluntary guarding in RLQ is
common

91. Appendicitis
• Rovsing’s sign can be elicited by
palpating deeply in the left iliac
area and observing for referred
pain in the right iliac fossa
• When present, the psoas and
obturator signs are also helpful in
establishing a diagnosis of
appendicitis

92. Appendicitis
• Psoas sign - the psoas sign is
pain elicited by extending the
right hip while the patient is in the
left lateral decubitus position -
• alternatively, while in the supine
position, the patient can lift the
right thigh against the examiners
hand, which is placed above the
knee

93. Psoas Sign
• The psoas sign. Pain on passive
extension of the right thigh.
Patient lies on left side.
Examiner extends patient's right
thigh while applying counter
resistance to the right hip.

94. Appendicitis
• Obturator sign - the obturator
sign is pain elicited by flexing the
patient’s right thigh at the hip
with the knee flexed and then
internally rotating the hip
• Right sided rectal tenderness may
also be elicited on rectal exam of
patients with acute appendicitis

95. Obturator Sign
• The obturator sign. Pain on passive
internal rotation of the flexed thigh.
Examiner moves lower leg laterally
while applying resistance to the
lateral side of the knee resulting in
internal rotation of the femur.

96. •Diffuse periumbilical pain and
anorexia early
•Pain localizes to RLQ as
peritonitis develops
•Low grade fever, nausea and
vomiting may not be present
•Xrays and other tests are often
negative
Remember that the position of the appendix is highly variable!
Classic Presentations
Acute Appendicitis

97. Other Causes of Abdominal
Pain
• Abdominal aortic aneurysm
• abdominal pain/backache
• hypotension
• 71% perioperative mortality rate
• Physical exam of abdomen - detect
pulsatile mass
• unequal femoral pulses

98. Abdominal Aortic Aneurysm

99. Other Causes of Abdominal
Pain
• Nephrolithiasis
• ureteral colic 4% of patients w/acute
abdominal pain
• Colicky pain - Upper lumbar region
radiates laterally to inguinal region
• Patient writhing in pain

100. Classic Presentations
Acute Renal Colic
•Severe flank pain
•Radiation to groin
•Vomiting and urinary
symptoms
•Blood in the urine

101. Other Causes of Abdominal Pain
• Cardiac Origin
• Gastritis
• GERD
• Esophageal disease
• Hiatal hernia
• Liver abscess/subdiaphragmatic abscess
• Pulmonary origin
• Herpes Zoster
• Hernia

102. Other Causes of Abdominal Pain
• Gynecologic
• Ovarian cyst
• Ectopic pregnancy
• PID

103. Gynecologic Causes
• In the absence of a positive pregnancy
test result -
• fresh blood suggests a corpus
luteum hemorrhage
• old blood suggests a ruptured
endometrioma (chocolate cyst)
• purulent fluid suggests acute pelvic
inflammatory disease (PID)
• sebaceous fluid indicates a dermoid
cyst.

104. Ectopic Pregnancy
• Unruptured ectopic pregnancy -
localized pain due to dilatation of the
fallopian tube.
• Ruptured ectopic - pain tends to be
generalized due to peritoneal irritation
• Symptoms of rectal urgency due to a
mass in the pouch of Douglas may also
be present
• Syncope, dizziness, and orthostatic
changes in blood pressure are
sensitive signs of hypovolemia in these
patients

105. Ectopic Pregnancy
• Abdominal examination findings
include tenderness and guarding in the
lower quadrants.
• Once hemoperitoneum has occurred,
distension, rebound tenderness, and
sluggish bowel sounds may develop.

106. Corpus luteum hematoma
• Slow leakage produces minimal pain
• Frank hemorrhage can lead to
hemoperitoneum and hypovolemic
shock
• Generalized abdominal pain and
syncope are features of such a
presentation.

107. Ruptured Ovarian Cyst
• The most common causes are dermoid
cyst, cystadenoma, and endometrioma
• Blood loss is minimal, hypovolemia does
not supervene
• Peritoneal irritation due to leakage of cyst
fluid can lead to significant tenderness,
rebound tenderness, abdominal
distension, and hypoperistalsis

108. Ovarian Torsion
• Frequently - resolves spontaneously - only
presenting symptom -lower abdominal pain
• Persistent torsion leads to congestion,
ovarian enlargement, thickening of the
ovarian capsule, and subsequent infarction.
• Pain becomes severe -accompanied by
nausea, vomiting, and restlessness
• Infarction also leads to fever and mild
leukocytosis

109. PID
• Acute salpingo-oophoritis is a
polymicrobial infection that is
transmitted sexually.
• Neisseria gonorrhoeae and Chlamydia
trachomatis are usually identified in
patients with PID, and both organisms
often coexist in the same patient.
• Gonococcal disease tends to have a
rapid onset, while chlamydial
infection has a more insidious onset

110. Diagnostic Criteria for PID
• Lower abdominal tenderness
• Cervical motion tenderness
• Adnexal tenderness
• Diagnosis may also be supported by
• Temperature greater than 101°F (38.3°C)
• Abnormal cervical or vaginal discharge
• Laboratory evidence of C trachomatis or N
gonorrhoeae
• Elevated erythrocyte sedimentation rate or
elevated C-reactive protein value

111. Tubo-ovarian abscess
• A ruptured abscess can lead to gram-
negative endotoxic shock; therefore, this
condition is a surgical emergency.
• The most common presentation is bilateral,
palpable, fixed, tender masses.
• Patients often present with generalized
abdominal pain and rebound tenderness
caused by peritoneal inflammation

112. Fibroids
• A pedunculated subserous fibroid may
twist and undergo necrosis, causing
acute abdominal pain
• A pedunculated submucous fibroid
may present with cramping pain and
vaginal bleeding

113. Endometriosis
• Pain associated with endometriosis
may worsen premenstrually or during
menses.
• Patients experience generalized lower
abdominal tenderness, and associated
complaints include dysmenorrhea,
dyschezia, and dyspareunia

114. Things to Remember
• Inguinal/rectal examination in males.
• Pelvic/rectal examination in females.
• Disorders in the chest will often
manifest with abdominal symptoms.
• It is always wise to examine the chest
and cardiovascular system when
evaluating an abdominal complaint
• Consider mesenteric ischemia in
diabetic patients and patients with
vascular disease and vasculitis

115. Investigation
CBC with differential (infection and inflammation)
Urea, electrolyte, creatinine, glucose
LFT
Amylase ( high in acute pancreatitis)
urinalysis
CXR ( basal pneumonia, gas under diaphragm)
AXR
-distended bowel with air fluid level
-stones
-calcified aorta
-air in biliary tree

116. Investigation
U/S (ovarian cyst, ectopic pregnancy)
IVU for stones
Angiography (mesentric embolus or
thrombosis)
Sickling test
Pregnancy test

117. Treatment
1. Relieve the pain
2. IV fluids and nasogastric
suction
3. Antibiotics in case of peritonitis
or sepsis
4. Surgery if indicated

118. • If patient has guarding or rigidity
with peritoneal irritation
• spreading tenderness
• Progressive distension or
generalized peritonitis
 Shock with bleeding or sepsis
 Free gas on x-ray
 Mesentric occlusion on
angiography
 Blood, pus or bile on
paracentesis
Indication for surgery: