Acute abdomin ayman abdelmofeed

AcuteAcute
AbdomenAbdomen
By
Ayman M. Abdelmofeed
Lecturer of General &Plastic Surgery

 "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.
Because there is frequently a
progressive underlying intra-
abdominal disorder, undue delay in
diagnosis and treatment adversely
affects outcome
DefinitionDefinition

condition characterized by severe
abdominal pain which develops
over a period of 8 hrs. In pt who
have been previously well.
rapid and accurate diagnosis is
essential for morbidity and mortality
process.

 ‘‘severe’ abdominal painsevere’ abdominal pain
 acute onsetacute onset
 short durationshort duration
 urgent interventionurgent intervention
necessarynecessary
WWW.SMSO.CCWWW.SMSO.CC

EtiologyEtiology
> 1000 causes exi st 2

According to
System
Pathology
area

• Gastrointestinal tract disorders
*Nonspecific abdominal pain
*Appendicitis
*Small and large bowel obstruction
 *Perforated peptic ulcer
Incarcerated hernia
Bowel perforation
Meckel's diverticulitis
Boerhaave's syndrome
*Diverticulitis
 Inflammatory bowel disorders
 Mallory-Weiss syndrome
 Gastroenteritis
 Acute gastritis

• Liver, spleen, and biliary
tract disorders
*Acute cholecystitis
Acute cholangitis
 Hepatic abscess
Ruptured hepatic tumor
 Spontaneous rupture of the spleen
 Splenic infarct
 Biliary colic
 Acute hepatitis
 Pancreatic disorders
 *Acute pancreatitis

 Urinary tract disorders
 *Ureteral or renal colic
 Acute pyelonephritis
 Acute cystitis
 Renal infarct
 Gynecologic disorders
 Ruptured ectopic pregnancy
 Twisted ovarian tumor
 Ruptured ovarian follicle cyst
 *Acute salpingitis
 Dysmenorrhea
 Endometrios

Vascular disorders
 Ruptured aortic and visceral aneurysms
 Acute ischemic colitis

Mesenteric thrombosis
 Peritoneal disorders
 Intra-abdominal abscesses
 Primary peritonitis
 Tuberculous peritonitis
Retroperitoneal disorders
 Retroperitoneal hemorrhage

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

InflammatoInflammato
ryry
obstructioobstructio
nn
IschemicIschemic PerforationPerforation
InflammatoryInflammatory
BowelBowel
DiseaseDisease
AppendicitisAppendicitis
DiverticulitisDiverticulitis
PancreatitsPancreatits
cholecystitischolecystitis
CholangitisCholangitis
Meckel’sMeckel’s
diverticulum.diverticulum.
IntestinalIntestinal
ObstructionObstruction
Biliary colicBiliary colic
UretericUreteric
coliccolic
MesentericMesenteric
ischemiaischemia
Torsion ofTorsion of
viscusviscus
(organ)(organ)
PepticPeptic
UlcerativeUlcerative
DiseaseDisease
(PUD)(PUD)
DiverticularDiverticular
diseasedisease
AppendixAppendix
ToxicToxic
megacolonmegacolon
Hemorrhage
ruptured
arterial
aneurysm
Spontaneo
us rupture
of spleen
pathologypathology
 SurgicalSurgical

MedicalMedical gynecologicalgynecological
Myocardial InfarctionMyocardial Infarction
GastritisGastritis
GastroenteritisGastroenteritis
HepatitisHepatitis
Urinary Tract InfectionUrinary Tract Infection
Ectopic pregnancyEctopic pregnancy
Ovarian cyst torsionOvarian cyst torsion
EndometriosisEndometriosis (endometrial(endometrial
cells are deposited in areas outside thecells are deposited in areas outside the
uterine cavity )uterine cavity )

Endocrine and Metabolic Causes
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria
Hereditary Mediterranean fever
Hematologic Causes
Sickle cell crisis
Acute leukemia
Other blood dyscrasias
Toxins and Drugs
Lead poisoning
Other heavy metal poisoning
Narcotic withdrawal
Black widow spider poisoning
Nonsurgical Causes of Acute Abdomen

 Visceral painVisceral pain
– Distention, inflammation or ischaemiaDistention, inflammation or ischaemia
in hollow viscous & solid organsin hollow viscous & solid organs
– Localisation depends on theLocalisation depends on the
embryologic origin of the organ:embryologic origin of the organ:
 Forgut to epigastriumForgut to epigastrium
 Midgut to umbilicusMidgut to umbilicus
 Hindgut to the hypogastric regionHindgut to the hypogastric region
 Parietal painParietal pain
– is localised to the dermatome aboveis localised to the dermatome above
the site of the stimulus.the site of the stimulus.
 Referred painReferred pain
– produces symptoms, not signs e.g.produces symptoms, not signs e.g.
tendernesstenderness

Common causes of abdominal
pain

Abdominal Pain

 visceral pain :is elicited by distention, by
inflammation or ischemia stimulating the
receptor neurons, or by direct involvement (e.g.,
malignant infiltration) of sensory nerves. The
centrally perceived sensation is generally slow in
onset, dull, poorly localized, and protracted
 parietal pain : is mediated by both C and A
delta nerve fibers, the latter being responsible
for the transmission of more acute, sharper,
better-localized pain sensation. Direct irritation
of the somatically innervated parietal peritoneum
(especially the anterior and upper parts) by pus,
bile, urine, or gastrointestinal secretions leads to

Ref erred
Produces sympt oms not si gns
Based on devel opment al embryol ogy
- Uret eral obst ruct i on →
t est i cul ar pai n
- Subdi aphragmat i c i rri t at i on →
i psi l at eral shoul der or
supracl avi cul ar pai n
- Gynecol ogi c pat hol ogy back→
or proxi mal l ower ext remi t y
- Bi l i ary di sease ri ght→
i nf rascapul ar pai n
- MI epi gast ri c, neck, j aw or→
upper ext remi t y pai n

Generalized APGeneralized AP
 PerforationPerforation
 AAAAAA
 Acute pancreatitisAcute pancreatitis
 DMDM
 Bilateral pleurisyBilateral pleurisy

Central APCentral AP
 Early appendicitisEarly appendicitis
 SBOSBO
 Acute gastritisAcute gastritis
 Ruptured AAARuptured AAA
 MesentericMesenteric
thrombosisthrombosis

Epigastric painEpigastric pain
 DU / GUDU / GU
 OesophagitisOesophagitis
 AAAAAA

RUQ painRUQ pain
 Gallbladder diseaseGallbladder disease
 DUDU
 PneumoniaPneumonia
 Subphrenic abscessSubphrenic abscess

Suprapubic painSuprapubic pain
 Acute urinary retentionAcute urinary retention
 UTIsUTIs
 CystitisCystitis
 PIDPID
 Ectopic pregnancyEctopic pregnancy
 DiverticulitisDiverticulitis

RIF painRIF pain
 Acute appendicitisAcute appendicitis
 Mesenteric adenitis (young)Mesenteric adenitis (young)
 Perf DUPerf DU
 DiverticulitisDiverticulitis
 PIDPID
 SalpingitisSalpingitis
 Ureteric colicUreteric colic
 Meckel’s diverticulumMeckel’s diverticulum
 Crohn’s diseaseCrohn’s disease
 Biliary colic (low-lying gallBiliary colic (low-lying gall
bladder)bladder)

Loin painLoin pain
 Muscle strainMuscle strain
 UTIsUTIs
 Renal stonesRenal stones
 PyelonephritisPyelonephritis

 Acute appendicitis,
constant
,progressive more severe start per
umbilical move toward RIF.+
nausea, vomiting, low grade fever,
anorexia &/or constipation.

 Acute cholecytitis
Constant moderate pain in RUQ
radiated to Rt shoulder tip +
nausea, bilious vomitus, low grade
fever & jaundice

 Perforated peptic ulcer,
Sudden onset of pain in
midepigastrium that spreads and is
aggravated by movement; patient
appears acutely ill and is reluctant
to move; rigid abdomen; grunting
respiration; bowel sounds absent

 Ectopic pregnancy,
Pain sudden, severe,persistent,following
a missed or abnormal period, typically
epigastric; associated with hypotension
and tachycardia
 Ovarian cyst
Pain constant with sharp, sudden onset,
usually in ipsilateral hypogastrium; may
have nausea and vomiting following the
pain.

 Pelvic inflammatory disease.
Pain at end of or after normal
menstrual period, bilateral lower
quadrant pain aggravated by
cervical manipulation; anorexia,
nausea, and vomiting rare; possible
cervical discharge; fever

 Urinary stone,
Pain location changes with
movement of stone, may radiate to
testicle, groin of involved side, pain
very severe; patient cannot get
comfortable

Clinical evaluationClinical evaluation
HistoryHistory
 AgeAge
Certain conditions occur in certain age groupsCertain conditions occur in certain age groups
E.g.E.g. diverticulitis in elderlydiverticulitis in elderly
Mesenteric adenitisMesenteric adenitis (inflammation of mesenteric lymph(inflammation of mesenteric lymph
nodes)nodes) in childrenin children
 PainPain
– OnsetOnset
sudden perforationsudden perforation
gradual inflammatory causesgradual inflammatory causes

sitesite
 SiteSiteCholecystitis
cholangitis
Peptic Ulcerative
Disease (PUD)
Peptic
Ulcerative
disease
(PUD)
Pancreatitis
cholecystitis
Gastric ulcer
Perforated colon
Appendicitis
Salpingitis
Ruptured.
Ectopic
pregnancy
Diverticulitis
Salpingitis
Tubo-ovarian
abscess

History, cont…History, cont…
– NatureNature
colicky obstruction (cramping pain)colicky obstruction (cramping pain)
dull inflammation e.g. pancreatitisdull inflammation e.g. pancreatitis
(constant pain)(constant pain)
– RadiationRadiation
to tip of the right shoulder in acuteto tip of the right shoulder in acute
cholecystitis (boa’s sign)cholecystitis (boa’s sign)

– Aggravating factorsAggravating factors
breathingbreathing
coughing peritonitiscoughing peritonitis
changing positionchanging position
fatty meal cholecystitisfatty meal cholecystitis
– Relieving factorsRelieving factors
lying still peritonitislying still peritonitis
leaning forward pancreatitis (prayer’s signleaning forward pancreatitis (prayer’s sign
passing flatus Intestinal Obstructionpassing flatus Intestinal Obstruction

– Associated factorsAssociated factors
1.1. vomitingvomiting
 Precedes the pain medical conditionPrecedes the pain medical condition
 Follows the pain surgical conditionFollows the pain surgical condition
 ContentsContents
– Bilious Small Bowel ObstructionBilious Small Bowel Obstruction
– Nonbilious pyloric stenosisNonbilious pyloric stenosis

2.2. Change in bowel habitsChange in bowel habits
– constipationconstipation
– Obstipation (constipation +no flatus)Obstipation (constipation +no flatus)
– DiarrheaDiarrhea
3.3. Anorexia (poor appetite)Anorexia (poor appetite)
– e.g. appendicitise.g. appendicitis
4.4. feverfever
– Inflammatory causesInflammatory causes

ExaminationExamination
 Note: physical signs may be less obviousNote: physical signs may be less obvious
in elderly, obese patients, and those onin elderly, obese patients, and those on
steroidssteroids
 General examinationGeneral examination
– Motionless peritonitisMotionless peritonitis
– in agony colicin agony colic
– Jaundice- obstructive jaundiceJaundice- obstructive jaundice
– dehydrationdehydration

Examination, cont…Examination, cont…
 Vital signsVital signs
– PulsePulse
– Respiratory rateRespiratory rate
– Blood PressureBlood Pressure
High grade feverHigh grade fever Low grade feverLow grade fever
Acute cholangitisAcute cholangitis
(Fever,jaundice,abdominal pain due to(Fever,jaundice,abdominal pain due to
bacterial proliferation superimposed onbacterial proliferation superimposed on
obstruction of biliary tree due to gallobstruction of biliary tree due to gall
stones)stones)
PeritonitisPeritonitis
Acute cholecystitisAcute cholecystitis

Abdominal examinationAbdominal examination
 InspectionInspection
What you seeWhat you see What it meansWhat it means
DistensionDistension
RigidityRigidity
Decreased movementDecreased movement
ScarsScars
HerniaHernia
Visible peristalsisVisible peristalsis
Intestinal Obstruction , AscitisIntestinal Obstruction , Ascitis
AdhesionsAdhesions
Intestinal ObstructionIntestinal Obstruction

Abdominal examination,Abdominal examination,
cont…cont… Palpation-(to feel)Palpation-(to feel)
signsign significancesignificance
Tenderness,Tenderness,
guarding,guarding,
Rebound tendernessRebound tenderness
Rigidity (board like)Rigidity (board like)
Pulsatile massPulsatile mass
Succession splashSuccession splash
(splashing sound due to presence(splashing sound due to presence
Inflammation of parietalInflammation of parietal
peritoniumperitonium
peritonitisperitonitis
Aortic aneurysmAortic aneurysm
Gastric outlet obstructionGastric outlet obstruction

cont…cont…
 PercussionPercussion-(tapping on a surface)-(tapping on a surface)
ResonanceResonance
Loss of liver dullnessLoss of liver dullness
Shifting dullnessShifting dullness
PerforationPerforation
Ascitis, free fluidAscitis, free fluid

cont…cont…
 AuscultationAuscultation
Absent bowel soundsAbsent bowel sounds
Increased sound,Increased sound,
BorborygmiBorborygmi (rumbling(rumbling
sound caused by gas moving)sound caused by gas moving)
BruitBruit (Abnormal sound over(Abnormal sound over
blood vessel)blood vessel)
Paralytic ileusParalytic ileus etcetc
Mechanical obstructionMechanical obstruction
Vascular diseaseVascular disease

Specific signsSpecific signs
signsign indicationindication
Murphy’s signMurphy’s sign
Boa’s signBoa’s sign
Rovsing’s signRovsing’s sign
Obturator signObturator sign
Psoas signPsoas sign
Grey turner & cullen’sGrey turner & cullen’s
Acute cholecystitsAcute cholecystits
Retrocecal appendicitis,Retrocecal appendicitis,
HemorrhagicHemorrhagic

Murphy’s sign, Psoas sign –if positive where
is the appendix?
Retrocecal

cont…cont…
 Rectal examinationRectal examination
 Per vaginal examinationPer vaginal examination

Digital rectal examination,Per Vaginal
Examination

 Aaron sign
– Pain or pressure in epigastrium or anterior chest with persistent
firm pressure applied to McBurney's point for Acute appendicitis
 Bassler sign
– Sharp pain created by compressing appendix between abdominal
wall and iliacus for Chronic appendicitis
 Blumberg's sign
– Transient abdominal wall rebound tenderness Peritoneal
inflammation
 Carnett's sign
– Loss of abdominal tenderness when abdominal wall muscles are
contracted Intra-abdominal source of abdominal pain
 Chandelier sign
– Extreme lower abdominal and pelvic pain with movement of cervix
Pelvic inflammatory disease
 Charcot's sign
– Intermittent right upper abdominal pain, jaundice, and fever
Choledocholithiasis

 Claybrook sign
– Accentuation of breath and cardiac sounds through abdominal
wall Ruptured abdominal viscus
 Courvoisier's
– sign Palpable gallbladder in presence of painless jaundice
Periampullary tumor
 Cruveilhier sign
– Varicose veins at umbilicus (caput medusae) Portal hypertension
 Cullen's sign
– Periumbilical bruising Hemoperitoneum
 Danforth sign
– Shoulder pain on inspiration Hemoperitoneum
 Fothergill's sign
– Abdominal wall mass that does not cross midline and remains
palpable when rectus contracted Rectus muscle hematomas
 Grey Turner's sign
– Local areas of discoloration around umbilicus and flanks Acute
hemorrhagic pancreatitis

 Iliopsoas sign Elevation and extension of leg against resistance
creates pain = Appendicitis with retrocecal abscess
 Kehr's sign Left shoulder pain when supine and pressure placed
on left upper abdomen Hemoperitoneum (especially from splenic
origin)
 Mannkopf's sign Increased pulse when painful abdomen palpated
Absent if malingering
 Murphy's sign Pain caused by inspiration while applying pressure
to right upper abdomen Acute cholecystitis
 Obturator sign Flexion and external rotation of right thigh while
supine creates hypogastric pain Pelvic abscess or inflammatory
mass in pelvis
 Ransohoff sign Yellow discoloration of umbilical region Ruptured
common bile duct
 Rovsing's sign Pain at McBurney's point when compressing the
left lower abdomen Acute appendicitis
 Ten Horn sign Pain caused by gentle traction of right
testicle Acute appendicitis

InvestigationsInvestigations
 To assess patients condition in generalTo assess patients condition in general
1.1. Complete Blood Count (Blood Routine)Complete Blood Count (Blood Routine)
2.2. Electrolytes-Na ,K ,ClElectrolytes-Na ,K ,Cl
3.3. Blood Urea Nitrogen (BUN) & CreatinineBlood Urea Nitrogen (BUN) & Creatinine
4.4. Arterial Blood Gas (ABG)Arterial Blood Gas (ABG)
5.5. UrinalysisUrinalysis
6.6. Liver Function Test (LFT)Liver Function Test (LFT)
7.7. Prothrombin Time (PT)11 to 13.5 sec,PTT –25Prothrombin Time (PT)11 to 13.5 sec,PTT –25
to 35 secto 35 sec(Partial thromboplastin time)(blood test that tells how long it(Partial thromboplastin time)(blood test that tells how long it
takes for plasma to clot?)takes for plasma to clot?)
8.8. Blood grouping and cross matchingBlood grouping and cross matching

Investigations, cont…Investigations, cont…
2.2. Serum Beta HCGSerum Beta HCG (human chorionic(human chorionic
gonadotrophin hormone)gonadotrophin hormone)
– In female of child bearing ageIn female of child bearing age
– To rule out ectopic pregnancyTo rule out ectopic pregnancy

 Specific investigationsSpecific investigations
A. LabA. Lab
1.1. Amylase & lipaseAmylase & lipase
– Lipase elevation is specific for pancreatitisLipase elevation is specific for pancreatitis
– Amylase elevation confirms the diagnosisAmylase elevation confirms the diagnosis
of Pancreatitis, but also seen in:of Pancreatitis, but also seen in:
 Perforated viscus (Internal organs)Perforated viscus (Internal organs)
 Intestinal.ObstructionIntestinal.Obstruction
 Acute cholecystitisAcute cholecystitis

B. RadiologicalB. Radiological
1.1. Chest x-rayChest x-ray
 Air under theAir under the
diaphragm indiaphragm in
perforated viscusperforated viscus
(duodenal perforation)(duodenal perforation)
 Elevated diaphragm inElevated diaphragm in
abdominal distentionabdominal distention

2.2. Abdominal x-rayAbdominal x-ray
 air fluid levels in intestinal obstructionair fluid levels in intestinal obstruction
 Stones (90% of kidney stones can be seenStones (90% of kidney stones can be seen
in x-ray and 10% can’t be seen but 10% ofin x-ray and 10% can’t be seen but 10% of
gallstones can be seen in x-ray but 90%gallstones can be seen in x-ray but 90%
can’t be seen) why ? Calcium .can’t be seen) why ? Calcium .

3.3. USG-Ultra sound ScanUSG-Ultra sound Scan
 GallstonesGallstones
 AppendicitisAppendicitis
 Torsion of ovarian cystTorsion of ovarian cyst
 empyemaempyema
4.4. CT scanCT scan
 pancreatic pathologypancreatic pathology
 Acute aortic aneurysmAcute aortic aneurysm
 Severe diverticulitisSevere diverticulitis
 Abdominal abscessAbdominal abscess

CT scanCT scan
What i s t he di agnosi s?Acut e appendi ci t i s

5.5. Duplex scan or angiographyDuplex scan or angiography
for superior mesenteric embolus orfor superior mesenteric embolus or
thrombosisthrombosis
6.6. ERCP (Endoscopic retrogradeERCP (Endoscopic retrograde
cholangio-pancreatography)cholangio-pancreatography)

C. ParacentesisC. Paracentesis
– To assess Small Bowel Perforation inTo assess Small Bowel Perforation in
ascitisascitis
– Free blood, bile, bowel contents suggestFree blood, bile, bowel contents suggest
Bowel perforationBowel perforation
D. Endoscopy & laparoscopyD. Endoscopy & laparoscopy
E. Diagnostic peritoneal lavageE. Diagnostic peritoneal lavage

Peritoneal lavage, Paracentesis

ManagementManagement
 Initial managementInitial management
– Nil Per OralNil Per Oral
– Intravenous fluids, Bolus Ringer Lactate solutionIntravenous fluids, Bolus Ringer Lactate solution
– Monitor urine outputMonitor urine output
– Nasogastric tubeNasogastric tube
 DecompressionDecompression
 suctionsuction
– AnalgesiaAnalgesia
 PethidinePethidine

Management, cont…Management, cont…
– AntibioticsAntibiotics
 BroadspectrumBroadspectrum
 In case of sepsis or peritonititsIn case of sepsis or peritonitits

Management, cont…Management, cont…
 Surgical managementSurgical management
– IndicationsIndications
1.1. Physical findingsPhysical findings
 Localized peritoneal irritation with guardingLocalized peritoneal irritation with guarding
or rigidityor rigidity
 Spreading tendernessSpreading tenderness
 Tense or progressive distensionTense or progressive distension
 Tender abdominal or rectal mass with highTender abdominal or rectal mass with high
fever or hypotensionfever or hypotension

Indications for surgery,Indications for surgery,
cont…cont…
 Rectal bleeding with shock or acidosisRectal bleeding with shock or acidosis
 Equivocal (uncertain)abdominal findings withEquivocal (uncertain)abdominal findings with
– Septicemia: high fever, leukocytosis,Septicemia: high fever, leukocytosis,
mental status changesmental status changes
– Bleeding: shock, acidosis, fallingBleeding: shock, acidosis, falling
hematocrithematocrit
– Suspected ischemia: acidosis, fever,Suspected ischemia: acidosis, fever,
tachycardiatachycardia

cont…cont…
2.2. Radiological findingsRadiological findings
 Pneumoperitonium –bowel perforationPneumoperitonium –bowel perforation
 Gross or progressive bowel distension-bowelGross or progressive bowel distension-bowel
obstructionobstruction
 Free extravasation of contrast media-bowelFree extravasation of contrast media-bowel
perforationperforation
 Space occupying lesion –Mass or tumorSpace occupying lesion –Mass or tumor
 Mesenteric occlusion-IschemiaMesenteric occlusion-Ischemia

cont…cont…
3.3. Endoscopic findingsEndoscopic findings
 Perforated lesionPerforated lesion
 Uncontrolled bleeding lesionUncontrolled bleeding lesion
4. Paracentesis4. Paracentesis
 BloodBlood
 bilebile
 bowel contentsbowel contents
 urineurine

The Acute Abdomen: Management OptionsThe Acute Abdomen: Management Options
 Emergent (‘surgery now’)Emergent (‘surgery now’)
 Urgent (‘surgery today’)Urgent (‘surgery today’)
 Semi-urgent (‘surgery tomorrow’)Semi-urgent (‘surgery tomorrow’)
 Non operativeNon operative
- Act i ve observat i on
- Di scharge

Abdominal Pain ClinicalAbdominal Pain Clinical
PearlsPearls Significant abdominal tenderness should never be attributed toSignificant abdominal tenderness should never be attributed to
gastroenteritisgastroenteritis
 Incidence of gastroenteritis in the elderly is very lowIncidence of gastroenteritis in the elderly is very low
 Always perform genital examinations when lower abdominal painAlways perform genital examinations when lower abdominal pain
is present – in malesis present – in males andand females, infemales, in youngyoung andand oldold
 In older patients with renal colic symptoms, exclude AAAIn older patients with renal colic symptoms, exclude AAA
 Severe pain should be taken as an indicator of serious diseaseSevere pain should be taken as an indicator of serious disease
 Pain awakening the patient from sleep should always bePain awakening the patient from sleep should always be
considered signficantconsidered signficant
 Sudden, severe pain suggests serious diseaseSudden, severe pain suggests serious disease
 Pain almost always precedes vomiting in surgical causes;Pain almost always precedes vomiting in surgical causes;
converse is true for most gastroenteritis and NSAPconverse is true for most gastroenteritis and NSAP
 Acute cholecystitis is the most common surgical emergency inAcute cholecystitis is the most common surgical emergency in
the elderlythe elderly
 A lack of free air on a chest xray does NOT rule out perforationA lack of free air on a chest xray does NOT rule out perforation
 Signs and symptoms of PUD, gastritis, reflux and nonspecificSigns and symptoms of PUD, gastritis, reflux and nonspecific
dyspepsia have significant overlapdyspepsia have significant overlap
 If the pain of biliary colic lasts more than 6 hours, suspect earlyIf the pain of biliary colic lasts more than 6 hours, suspect early
cholecystitischolecystitis

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