Acute abdomen is an abdominal emergency that requires prompt evaluation and treatment. Patients often present in the evening with sudden onset abdominal pain within the last 24 hours. A thorough history and physical exam are important to determine the cause, which can include appendicitis, cholecystitis, pancreatitis, diverticulitis, perforated ulcer, bowel obstruction, mesenteric ischemia, or ruptured abdominal aortic aneurysm. Diagnostic testing may include bloodwork, imaging studies like ultrasound or CT scan, and surgery if indicated by the condition. Proper diagnosis and management are needed to prevent complications.

1. Acute abdomen
Dr. SUNDARPRAKASH SIVALINGAM

2. Acute abdomen is an abdominal emergency no
temporizing is ever justifiable.
Patients present more likely in the evening
hours.Never wait for your decision till the
next morning
1

3. Characteristics of acute
abdomen
has been present for less than 24 hours.
Sudden and unexpected onset of
abdominal pain.
associated symptoms:
nausea, vomiting, abdominal dystension,
diarrhea, constipations, anorexia
The pain may arise from intra-and extra-
abdominal structures.
2

4. Neural innervation of the gastrointestinal
tract
5

5. History
4
allow the patient to give his/her entire
current history before asking specific
questions.
the character and onset of pain are
essential.
–colicky pain: obstructive processes
–sustained pain :infectious processes
Referred pain patterns may give a clue.

6. 7

7. Abdominal pain onset patterns
I. sudden(seconds)
–A. perforation or rupture of a viscus:peptic
ulcer, abdominal aortic aneurysm,
esophagus, ectopic pregnancy
–B. infarction:gut, heart, lung

8. Abdominal pain onset patternsII. rapid(minutes)
–A. colic syndromes: biliary, ureteral, small
bowel obstruction(high)
–B. inflammatory processes:
pancreatitis, diverticulitis,
appendicitis, penetrating ulcer,
cholecystitis
–C. ischemic processes:
strangulation, torsion

9. Abdominal pain onset patterns
III. Gradual(hours)
A. inflammatory :appendicitis, cholec.,
pancreat., divertic., salpingitis, ¤
prostatitis, inflamm.bowel dis., intra-
abdominal abscess
B. obstruction:distal small bowel or
colon,ectopic pregnancy,urinary retention,
incarcerated hernia
C. neoplastic:perforating or penetrating
tumors (colon, stomach, small intestine)9

10. Physical examination
Observation of the patients body
habitus and facial expression
–peritonitis :unwillingness to change
posture, hip flexion with the knees
drawn up, shallow breathing
–colicky pain: intense movements to
alleviate
10

11. Physical examination
Inspection of the abdomen:localized or
generalized dystension, visible
peristaltsis, hernial bulges, erythema
Auscultation of bowel sounds, if no
sounds are heard : paralytic ileus
 Percussion
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absence of hepatic
dullness (!!) : perforation

12. 13

13. Physical examinationPalpation : superficial, gentle of all
quadrants, first at the least painful areas,
after this deeper.
classic rebound tenderness (deep
palpation followed by rapid release) is not
specific.
have the patient laugh, cough, distend or
maximally reduce his/her abdominal girth.
A rectal digital examination is obligatory
13

14. 16
Characteristic
scars,
Now often laparoscopy

15. Laboratory evaluation
Complete blood count:WBC differential,
CRP, sed.rate
urinalysis:
serum amylase (urine)
beta human chorionic gonadotropin in
females
serum electrolytes,BUN,creatinine and
glucose
liver function test in upper abdominal pain
use only relevant laboratory
investigations
the results of which effect therapy !!
15

16. X-ray evaluation
upright PA and lateral film of the chest
supine and erect plain film of the
abdomen
–the upright film should include the
diaphragm
 to detect free intraperitoneal
air
 only horizontal beam films detect
fluid levels within the bowel
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17. X-ray evaluation
contrast study may be required (dangers!)
abdominal ultrasound mandatory
in some instances endoscopic
CT , MRI, nuclear (PET scan if
cost/benefit !! O K)
angiography
 may add to diagnostic accuracy
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18. 20

19. Causes of acute abdomen
Appendicitis
Acute cholecystitis
Acute pancreatitis
Diverticulitis
Perforated peptic ulcer
Bowel obstruction
Mesenteric ischemia
Ruptured abdominal aortic aneurysm
Gynecologic causes
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20. Appendicitis
History: tipically midabdomonal pain ¤
onset of nausea and vomiting
relocation of pain to the right
lower quadrant
elevation of temperature
20

21. 23ZETA (Sir Zachary Cope)

22. Appendicitis : bacterial infection with
contributory factors:intraluminal
obstruction -fecalith lymphoid
hyperplasia, parasites, carcinoid tu.
–typical symptoms:midabdominal
pain moving to the right lower
quadrant- elicited by coughing
laughing or bumping, nausea and
vomiting, anorexia,fever.
22

23. Differntial dg of appendicitis
Localization of the appendix
ascending:
cholec,perf
duodenal ulc
perinephr absc
hydronephr
Iliacal
penetrating duod ulc
Crohn diseas !!
Ileocecal cc.
Tbc
uretolith
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pyonephr
pyelitis
nephrolith
omental torsion
Meckel’s diverticulum
Psoas absc
hip !!
muscle rupture
typhlitis

24.  Appendicitis 2 :
abdominal X-ray rarely useful,
ultrasound(periappendicular
fluid,edema,abscess,visualization of
the lumen) increasing significance
Peak incidence 15-24 years
choice of treatment ,surgery:10-20%
negative appendectomy
Keep in mind the danger of perforation
in the elderly
24

25. Acute cholecystitis
obstruction of the bile duct by stone
1. bacterial in 50-85% of cases
2. Chemical agents : lysolecithin,
other tissue factors
3. Inflammation from
mechanical strech
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26. Acalculous cholecystitis with dilated
gallbladder and thickened gallbladder wall
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27. Diagnosis of stone disease by ultrasound
shadow
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28. Cholesterol stones gall bladder
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29. Appearance of gallstones
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30. Characteristic symptoms:
colic, localized to the right upper
quadrant
RUQ tenderness
patient suddenly stops inspiration
(Murphy‘sign)
irradiates to the right shoulder or
scapula
vomiting , exsiccosis
fever usually moderate, but also
chills
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31. The „convergence projection” :
in the lateral spinothalamic tract the fiber
number is less than the sensory fibers
somatic> visceralis
the brain “learns” that on the given tract
the somatic signals are transmitted
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32. 32

33. Acute pancreatitis
Increasing incidence: 36 to 44/100 000 adults
in California (1994-2001)
200 000 hospital admission/year in the USA
Bile reflux is the trigger (1856 Claude Bernard)
2 enzymes are released from acinar cells
amylase and lipase
33

34. Causes
gallstones 38%
alcohol abuse 36%
pancreas divisum ( congenital abnormality of
the pancreatic duct)
intraductal papillary tumors
ERCP (increase of serum amylase
after the procedure )
Serum triglyceride >11mmol/L
some drugs
infections
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35. Diagnosis
Symptoms of acute abdomen
•Constant acute pain in the epigastric area or the
right upper quadrant
•Nausea , vomiting
•Tenderness in the upper abdomen
•Cullen’s sign:
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36. 36

37. 20% severe (4% die)
Early development
sequential organ failure
increased capillary permeability
decreased intravascular volume
hypovolemia
renal dysfunction
pulmonary complication
Pancreatic necrosis a very severe complication
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38. Severity is assessed by CT and contrast enhanced CT
38

39. Treatment
Correct fluid losses
monitor respiratory, cardiovascular and
renal function. Multidisciplinary
Stop parenteral nutrition : a rule!??
Infection
antibiotic prophylaxis is debated in
proven infection: imipenem
39

40. Lancet 2008;371:143 ¤43

41. BMJ 2004;328:1407 41

42. 42

43. Causes of acute abdomen
Diverticulitis
 prevalence 5% , increases with age
 the sigmoid colon is most commonly involved
 in 50% the only segment, right sided 0,1-2,5%
 signs and symptoms protean
 left lower quadrant pain, low grade fever,
 leucocytosis,nausea, vomiting, distension
 Sigmoidoscopy not indicated(perforation!!),nor
 barium enema, not in acute phase ,only later
"elective "
 X-ray or CT scanning
43

44. Causes of acute abdomen
Mesenteric ischemia: 0,4% of abdominal surgery
vascular disorders-usually catastrophic illness
–embolic occlusion or thrombosis:intestinal infarction--
gangrenous bowel
–mortality 40-70%
abdominal pain,vomiting diarrhea, melena ,
distension,tenderness
bowel sounds from hypoactivity to absent
Bloody peritoneal transsudate,leucocytosis 20 t
hemoconcentration
history of abdominal angina,atrial fibrillation
rapid visceral angiography
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45. Causes of acute abdomen
Perforated peptic ulcer 10% ofhospital
admission for ulcer 7-10 pts/100000/year
undiagnosed pts die,duodenal 6-8x more often¤
sudden onset epigastric pain"hit with a knife"
– spreading to the entire abdomen:rigidity,diffuse
tenderness-hypovolemia, shock
upright or left lateral decubitus X-ray 55-85%
pneumoperitoneum:on physical disappearance of
hepatic dullness, X-ray
may heal spontaneously,dudenal anterior wall ¤
surgery,broad spect.antibiot,fluid
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46. 49
Succussion splash

47. Colonic perforation
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48. Causes of acute abdomen
Ruptured abdominal aortic aneurysm
51
pain,sudden onset ,midabdominal,paravertebral
pulsatile abdominal mass,hypotension "triad"
risk: atheroscler.diameter and rate of increase
– 5,5 cm threshold for electivesurgery
– Abdominal ultrasound
X-ray (contrast iv.deviation of the ureters,aortic
 wall,CT,angio time consuming
MR
emergency operation-high mortality

49. Classification of thoraco-abdominal aortic
aneurysms
49

50. Atherosclerotic abdominal aortic aneurysm after
fatal rupture
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51. Causes of acute abdomen
Bowel obstruction: ileus 20% of all acute
surgical hospital admissions
causes: mechanical
extrinsic: adhesions,hernias,volvulus,masses
intraluminal objects: fecal impaction,gallstone,
gastric bezoars,foreign bodies
intrinsic lesions:neoplasms,inflammation,
intussusception,hematoma
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52. 52

53. Causes of acute abdomen
Ileus 2 : adynamic(paralytic)
reflex inhibition:laparotomy,trauma
inflammation:peritonitis,toxic megacolon,
acute irradiation
infectious process:appendicitis,cholecystitis
ischemic processes:arterial insuff.
retroperitoneal :ureter,kidney
drug induced:opiates,anticholinergic drugs
metabolic:porphyria ,ketoacidosis
X-ray diagnosis: air-fluid levels -small or large bowel
53

54. Causes of acute abdomen
Gynecoligical:in reproductive age
 pelvic inflammatory, ectopic pregnancy, ovarian
cyst hemorrhage,adnexal or ovarian torsion
pain,delayed menstrual period,diffuse pelvic
 tenderness, acute rupture of blood filled
fallopian tube
SYNCOPE,pelvic examination,pregnancy test
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55. „A good eater must be a good man,
for a good eater must have good
digestion, and good digestion
depends upon good conscience”
Benjamin Disraeli
1804-1881
Prime minister of Great-Britain: 1868, 1874-80
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57. Some reminder of anatomy and
pathophysiology
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58. 58

59. .
The foregut,midgut and hindgut have and
retain their own innervation and blood
supply
forgut : oropharynx to the duodenum (bile
duct)
midgut: distal duodenum,jejunum,
ileum,appendix, ascending colon,
proximal 2/3 transverse colon
59

60. .
hindgut: distal1/3 of transverse colon to
anus
peritoneum: visceral autonomic
innervation dull,crampy or aching pain
:parietal somatic innervation
sharp, severe and persistent pain
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61. Acute abdomen
Abdominal pain :visceral, somatic or referred
abdominal wall: anterior and lateral spinal T7-L1
Two types of nociceptors
–A-delta fibers rapid : sharp well localized
–C-fibers slow:dull, poorly localized
 :posterior L2-L5
pain fibers enter spinal cord ipsilaterally
 visceral pain arises in the midline
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 fibers enter spinal cord bilaterally

62. “ To study the phenomenon of disease
without books is to sail an uncharted
sea,
while to study books without patients
is not to go sea atall”
William Osler
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63. A University should be
a place of light,
of liberty, and of learning.
Benjamin DISRAELI, 1873
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66. Diagnosis:
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