basic approach to the patient with acute abdominal pain

1. THE ACUTE ABDOMEN
Dr Winston Makanga, M.B.Ch.B, M.MEd (Surg)
Consultant General and Laparoscopic Surgeon
Bachelor of Science in Clinical Medicine IV

2. “The abdomen is a jungle…"
- Author unknown

3. SCENARIO
70 y/o with DM, AS, LVH
Sudden onset LUQ pain
Nocturia, urgency and frequency
BP - 156/90, Lt renal angle tenderness
Urine dipstick-leucocytes, protein, blood and
glucose.
CBC, UEC – all normal
2 days later P/W – worsening and more
generalized pain, BP 140/80, Kehr sign +ve

5. Overview
• Definition
• Classification
• Etiology
• Clinical presentation
• Clinical work-up and care

6. Definition
• “Acute abdomen” - pain that is sudden and severe -
<6-24hrs that requires surgical attention
• Acute abdominal pain
– Pain of sudden onset, arising from the abdomen –
of less than 7 days duration
– 5 -10% present at casualty with abdominal pain
– Can range from benign to life threatening
– 33% are severe and require admission
Graff et al, Ann Emerg Med 1991

7. Classification by etiopathogenesis
• Inflammatory
• Ischaemic
• Obstructive
• Peritonitis*
• Others (neoplastic, congenital, gynecologic**)

8. Classification by Clinical pattern
• Abdominal pain and shock
• Generalized peritonitis
• Localized peritonitis
• Intestinal obstruction
• “Medical” illness

9. Aetiology
Inflammatory
• Appendicitis
• Cholecystitis
• Diverticulitis
• Gastritis
• Enteritis
• Colitis

10. Aetiology
Ischaemic/vascular
• Arterial
– Thrombosis
– Embolism
• Venous
– Thrombosis
• Ruptured (AAA) aneurysm*

11. Aetiology
Obstructive
• Obstructed hernia
• Post-operative adhesions
• Intussusception
• Volvulus
• Renal and biliary* colic

12. Aetiology
Peritonitis*
• Perforated viscus
– Appendix
– Colon/ileum
– Gall bladder
– Gastric/duodenal ulcer
• Gangrenous viscus
• Rupture of intra-abdominal abscess

14. Clinical presentation
Inflammatory
1. Sudden onset
2. Severity slowly builds up
3. Poorly localized initially (visceral)
4. Later localized with signs of peritoneal
irritation (somatic)
5. Clinical SIRS

15. Inflammatory pain

16. Clinical presentation
Ischaemic
1. Abrupt onset (usually after eating)
2. Constant, severe
3. Not in keeping with clinical exam picture
4. Minimal peritonism
5. Look for stigmata of vascular disease*
• Ruptured AAA – sudden, tearing pain with
associated shock

17. Clinical presentation
Obstructive
1. ‘Insidious’ onset (unless it has a vascular
component)
2. Pain is colicky, moderate (depends on level of
obstruction)
3. Associated with upstream/downstream
symptoms

18. Peritonitis
• Generalized, severe pain
• Marked signs of peritoneal irritation
• Pain is constant
• Clinical ileus is noted
Clinical presentation

19. Caveats
• Extremes of age
• Immunosuppresion
• Medications (antibiotics, steroids)
• Abdominal pain from medical causes
– DKA
– Inferior wall MI
– Lower lobe pneumonia
– Porphyria
• Pregnancy*

20. MANAGEMENT

22. Pathways
• Immediate surgery
• Work-up then surgery
• Observation/conservative care
• ? Home

23. Clinical work-up
• Laboratory
– CBC, amylase/lipase, lactate (met. acidosis)
– Urinalysis, mcs, uPDT
– UEC, LFT
• Radiology
– U/S
– AXR/CXR
– CT Scan*

24. Imaging strategy

25. Ancillary assessment
• Urine and RBS, urinary ketones
• Endoscopy
• Hb electrophoresis
• CXR
• ECG + cardiac enzymes
• BS for MPs, BC for enteric fever

26. Exploratory laparotomy
• Offers both diagnosis and therapy
• Careful patient selection risk/benefit analysis
• Midline incision if diagnosis is equivocal
• ? Cost of Negative exploration?
• Role of diagnostic laparoscopy…
• Must we always open and see?*

27. Review
• Definition √
• Classification √
• Aetiology √
• Clinical presentation √
• Clinical work-up √

28. Questions, comments