An overview of acute abdomen,a medical emergency,based on information provided in Sabiston textbook of medicine 20th edition and ACS surgery 7th edition,2 of the best textbooks in surgery. acute abdomen is a must know for every medical student and medical care practitioners,especially surgeons.

1. Navid Manafi
Medical student
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Navid Manafi
Iran University of medical sciences

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Iran University of medical sciences

3. Ronald A. Squires , MD
Professor,Department of
Surgery,University of Oklahoma
Health Sciences Center,Oklahoma
city,Oklahoma
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Iran University of medical sciences

4. Russell G. Postier, MD
John A. Schilling Professor and
Chairman,Department of Surgery,University of
Oklahoma Health sciences Center,Oklahoma
City,Oklahoma
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Iran University of medical sciences

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Iran University of medical sciences

6. Alex Nagle , MD, FACS
Northwestern University Feinberg School of
Medicine
Chicago,IL
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Iran University of medical sciences

7. Dr. Zachary Cope
English surgeon
1921 until 1971
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Iran University of medical sciences

8. HISTORY
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Iran University of medical sciences

9. DEFINITION
• Sabiston :
Signs & symptoms of abdominal pain &
tenderness,a clinical presentation that
often requires emergency surgical
therapy
• ACS Surgery :
Previously undiagnosed pain that arises
suddenly & is of less than 48 hour
duration
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Iran University of medical sciences

10. • younger : appendicitis
older :biliary disease , bowel obstruction
intestinal ischemia & Infarction ,
diverticulitis
• surgical dd. A/W acute abdomen :
1-Infection
2-Obstruction
3-Ischemia
4- Perforation
W/O : Hx , Ph/E , labs , Imaging
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Iran University of medical sciences

11. Surgical Acute Abdominal Conditions
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Iran University of medical sciences

12. Surgical Acute Abdominal Conditions
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Iran University of medical sciences

13. Abdominal Pain
1-Visceral (vague , mostly midline
(epigastrium ,periumbilical , hypogastrium)
usually from distention of a hollow viscus
2-Parietal (Sharper & better localized)
Sensory innervation of the viscera
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Iran University of medical sciences

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Iran University of medical sciences

15. Out pouching of
fluid
from peritoneal
membrane
Peritoneum:
Blood flow
permeability
formation of fibrinous exudate on
its surface
Bowel : local or generalized paralysis
Adherence between bowel & omentum
or abdominal wall
& help localize inflammation
Abscess :
sharply localized pain
+
normal bowel sounds & GI function
Diffuse process(perforated duodenal ulcer):
generalized abdominal pain
+
quiet abdomen
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Iran University of medical sciences

16. Entire abdominal cavity or part of visceral or parietal peritoneum
sever tenderness on palpation +/- rebound tenderness & guarding
causes infections e.g. Gram -ve bacteria or anaerobes
noninfectious e.g pancreatitis
Primary peritonitis in children (esp by Pneumococcus or Hemolytic Strep spp.)
Adults with ESRD on peritoneal dialysis Gram -ve cocci
adults with ascites & cirrhosis primary peritonitis esp E.Coli & klebsiella
PERITONITIS
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Iran University of medical sciences

17. Pain shown with finger (parietal innervation) peritoneal inflammation
……………….. palm of hand (visceral innervation) bowel or solid organ disease
sudden onset of excruciating pain intestinal perforation
arterial embolization with ischemia
biliary colic
Pain that develops & worsens over several hh. bowel obstruction
(progressive inflammation or infection) colitis
cholecystitis
Intermittent episodes of pain (colicky pain ) bowel obstruction
biliary colic from cystic duct obstruction
Genitourinary obstruction
HISTORY TAKING PEARLS
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Iran University of medical sciences

18. Small bowel pain periumbilical
colon pain between umbilicus & pubic symphysis
liver pain to shoulder is via C3 - C5 n. roots
Genitourinary pain commonly radiates
Flank (Splanchnic nn. of T11-L1)
Scrotum or Labia (Hypogastric plexus of S2-S4)
pain of Bowel obstruction , biliary colic,pancreatitis
, diverticulitis , bowel perforation
pain of non perforated PUD or gastritis
HISTORY TAKING PEARLS
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Iran University of medical sciences

19. Patients with peritoneal inflammation will avoid any
activity that stretches or jostles the abdomen
pain with sudden body movement
pain when knees flexed
Vomiting may occur because of severe abdominal pain of any
cause or as a result of mechanical bowel obstruction or ileum
HISTORY TAKING PEARLS
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20. Many conditions : Vomiting severe abdominal pain
Acute surgical abdomen : Severe pain Vomiting
(via medullary efferent fibers)
Complete obstruction subsequent bowel ischemia
or perforation caused by massive distention that can occur
Infectious enteritis
IBD
Parasitic contamination
Colonic ischemia
A/W
Bloody
diarrhea
Diarrhea in
acute abdomen
HISTORY TAKING PEARLS
Lower abdominal pain
in a young lady
EP ,
PID ,
Mittelschmerz ,
Severe endometriosis 20

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25. High dose Narcotic Obstipation & Obstruction (Interfer with bowel activity)
Spasm of sphincter of Oddi(exacerbate biliary or pancreatic pain)
Suppress pain sensation & alter mental status
NSAIDs risk of upper GI inflammation & perforation
Steroids block protective gastric mucous production by chief cells & the inflammatory reaction
to infection ( e.g. Advanced peritonitis)
DRUG HISTORY
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26. Coagulopathy & portal HTN from liver impairment
Intense vasospastic reaction Life threatening HTN
Cardiac & intestinal ischemia
DRUG HISTORY
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28. PHYSICAL
EXAMINATION
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Iran University of medical sciences

29. Patients with peritoneal irritation typically lie
very still in bed during evaluation & often maintain
flexion of knees & hips to tension on Anterior
abdominal wall
pain other than peritoneal irritation
( Ischemic bowel or ureteral or biliary colic)typically cause
the patient to shift & fidget in bed continually while trying
to
find a position that lessens their discomfort
Erythema or edema of skin cellulitis of
abdominal wall
ecchymosis sometimes observed with deeper
necrotizing infections of the fascia or
abdominal structures (e.g. pancreatitis)
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Iran University of medical sciences

30. Bowel sounds quantity & quality
Quiet abd. ileus
Hyperactive Enteritis & early ischemic intestine
Mechanical bowel obstruction high pitched tinkling sounds that tend to come in rushes & A/W pain
echoing sounds when significant luminal distention exists
Bruits in abd. turbulent blood flow in vascular system 70% - 95% : High grade arterial stenoses
also if AV fistula
Use stethoscope to check consistency of information with palpation
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Iran University of medical sciences

31. Percussion
Hyperresonance(tympany to percussion) gas-filled loops of bowel
peritonitis is also assessed by percussion
Firmly tapping the iliac crest,flank,or heel of an extended leg will jar the abdominal viscera & elicit
characteristic pain when peritonitis is present
Palpation
gives most of the information
always begin away from the reported area of pain
involuntary guarding sign of peritonitis(must distinguish from voluntary guarding)
abdominal wall muscle spasm
The examiner applies constant pressure to the abdominal wall,away from the point of maximal pain,while
asking the pt to take a slow deep breath
voluntary guarding abdominal wall muscles relax during inspiration
involuntary guarding spastic & tense
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Iran University of medical sciences

32. Abdominal examination signs
Sign Description Dx /condition
Aaron Pain or pressure in epigastrium or ant. chest with persistent firm pressure to
McBurney’s point
Acute appendicitis
Bassler sharp pain created by compressing appendix between abdominal wall & illiacus chronic appendicitis
Blumberg Transient abd. wall rebound tenderness peritoneal inflammation
Carnett Loss of abdominal tenderness when abd. wall muscles are contracted Intra-abdominal source of
abdominal pain
Chandelier Extreme lower abdominal & pelvic pain with movement of cervix PID
Charcot Intermittent RUQ pain,jaundice & fever choledocholithiasis
Claybrook accentuation of breath & cardiac sounds through abdominal wall ruptured abdominal viscus
Courvoisier Palpable gallbladder in presence of jaundice periampullary tumor
Cruveihier varicose vv. at umbilicus (caput medusa) Portal HTN
Cullen periumbilical bruising
Hemoperitoneum
Danforth shoulder pain on inspiration
Ballance presence of dull percussion note in both flanks,constant on L. side but but
shifting with change of position on R. side
ruptured spleen
Beevor Upward movement of umbilicus paralysis of lower portions
of rectus abdominis
muscles
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33. Abdominal examination signs
Sign Description Dx / condition
Fothergill abdominal wall mass that does not cross midline & remains palpable
when rectus contracted
rectus muscle hematomas
Grey turner local areas of discoloration around umbilicus & flanks acute hemorrhagic pancreatitis
Iliopsoas elevation & extension of leg against resistance creates pain appendicitis with retrocecal
abscess
Kehr L. shoulder pain when supine & pressure placed on left upper abd. hemoperitoneum(esp from splenic
origin)
Mannkopf increased pulse when painful abd. palpated Absent if malingering
Murphy pain caused by inspiration while applying pressure to RUQ. acute cholecystitis
Obturator flexion & ext. rotation of R. thigh while supine creates hypogastric
pain
pelvic abscess or inflammatory
mass in pelvis
Ransohoff Yellow discoloration of umbilical region ruptured common bile duct
Rovsing Pain at McBurney’s point when compressing the L. lower abd.
Acute appendicitis
Ten Horn Pain caused by gentle traction of R. testicle
Chaussier severe epigastric pain in gravid female prodrome of eclampsia
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34. Abdominal examination signs
Sign Description Dx / condition
Cutaneous
hyperesthesia
increased abdominal wall sensation to light touch parietal peritoneal inflammation
2nd to inflammatory intra-
abdominal pathology
Dance slight retraction in area of R. iliac fossa Intussusception
Kustner palpable mass ant. to uterus dermoid cyst of ovary
McClintock HR>100 in 1 hour postpartum postpartum hemorrhage
Puddle alteration in intensity of transmitted sound in intra-abdominal
cavity 2nd to percussion when patient is positioned on all fours &
stethoscope is gradually moved toward flank opposite percussion
free peritoneal fluid
Toma R. sided tympany & L.sided dullness in supine position as a result
of peritoneal inflammation & subsequent mesenteric contraction of
intestine to R. side of abdominal cavity
Inflammatory ascites
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Iran University of medical sciences

35. Carnett’s sign
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36. Charcot’s sign
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37. Cruveihier’s sign
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39. Grey turner’s sign
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41. Obturator’s sign
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42. Ransohoff’s sign
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43. Rovsing's sign
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44. Beevor’s sign
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45. Dance’s sign
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46. Puddle’s sign
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47. Signs helping to localize site Obturator , Psoas , Rovsing’s
of underlying peritonitis
Intra-abdominal VS abd. wall Fothergill & Carnett signs
A DRE needs to be performed in ALL patients with Acute abdominal pain.
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Iran University of medical sciences

48. Evaluation
&
Diagnosis
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Iran University of medical sciences

49. Test indication
Hemoglobin level
WBC count with differential Most pts with acute abd. will have a leukocytosis or bandemia
Electrolyte,BUN,Cr helpful in evaluating effect of vomiting or third space fluid losses
U/A bacterial cystitis,pyelonephritis,endocrine abnormalities (Diabetes or
renal parenchymal disease)
urine culture………UTI
Urine human chorionic gonadotropin level Pregnancy
Amylase,Lipase Pancreatitis (also increase in small bowel infarction or duodenal ulcer
perforation)
{if normal does not exclude pancreatitis}
Total & direct bilirubin levels
LFTs …….. for partial biliary tract causes of acute abdominal painAlkaline phosphatase
Serum aminotransferase
Serum Lactate level in intestinal ischemia or infarction
Stool for Ova & Parasites
C. difficile culture & toxin assay esp in patients with diarrhea
Laboratory studies
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Iran University of medical sciences

50. plain radiograph upright CXR…………………………1 mL air in peritoneum
lat. decubitus abd. radiograph ……….5-10 mL air in peritoneum
(Patients who can’t stand)
75% of patients with perforated duodenal ulcer have enough pneumoperitoneum to be visible with X-ray
Abnormal calcifications 5% of appendicoliths
10% of gallstones Radiopaque
90% of renal stones
Pancreatic calcifications in chronic pancreatitis
AAA calcifications
Visceral a. aneurysm……..splenic,renal,hepatic,mesenteric aa.
Atherosclerosis in visceral vessels
}
IMAGING STUDIES
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Iran University of medical sciences

51. Upright & supine abd. radiograph GOO
Obstruction of small bowel
Complete +ve gas in colon
Partial -ve gas in colon
Volvulus of cecum or sigmoid
IMAGING STUDIES
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Iran University of medical sciences

52. ULTRASOUND
Extremely accurate for gallstones & assessing gallbladder wall thickness & presence of fluid around gallbladder
Determining diameter of extra hepatic & intrahepatic bile ducts
(limited use in detecting common bile duct stones)
Abdominal & Transvaginal U/S………………..Ovaries,Adnexa,Uterus
intraperitoneal fluid
IMAGING STUDIES
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Iran University of medical sciences

53. Imaging modality of choice in acute abdomen 1-Abdominal radiography
2-CT
For appendicitis CT with oral,rectal & IV contrast (Perfect)
CT excellent for differentiating mechanical small bowel obstruction from paralytic ileus
Many patients suffering a blunt abdominal trauma will have altered mental states from coexisting closed
head injuries or from intoxicating substances.
small bowel injury Bowel wall thickening
following blunt trauma Any gas outside of lumen
Intraperitoneal fluid
IMAGING STUDIES
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Iran University of medical sciences

54. Appendicitis
CT scan of uncomplicated
appendicitis.A thick-walled,
distended,retrocecal
appendix
is seen with inflammatory
change
in the surrounding fat
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Iran University of medical sciences

55. Appendicitis
CT scan of complicated
appendicitis -a retrocecal
appendeceal abscess(A) with
an associated phlegmon
posteriorly found in a 3 W
postpartum, obese
woman.inflammatory change
extends through the flank
musculature into the
subcutaneous fat
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Iran University of medical sciences

56. Small bowel infarction
A/W mesenteric
venous thrombosis
Note the low density
thrombosed SMV (solid
arrow) & incidental
gallstones(open arrow)
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Iran University of medical sciences

57. Small bowel infarction
A/W mesenteric
venous thrombosis
Thickening of proximal
small bowel wall (arrow)
coincided with several feet
of infracting small bowel
at time of operation
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Iran University of medical sciences

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69. IAP Blood flow to organs
Venous return to heart
Upward press on diaphragm peak inspiratory pressure ventilatory efficiency
Risk of esophageal reflux & pulmonary aspiration
consider possibility of Abdominal HTN in any patient who presents with a rigid or significantly distended
abdomen.
Normal IAP = 5-7 mmHg ( in obesity & elevation of head of bed)
Morbid obesity……………………………… normal pressure by 4-8 mmHg
elevation of head of bed to 30 degrees……… normal pressure by 5 mmHg
INTRA-ABDOMINAL PRESSURE MONITORING
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Iran University of medical sciences

70. we measure pressure via bladder by a pressure transducer to a foley catheter
pressure recordings are obtained at end-expiration following instillation of 50 mL of saline into an
otherwise empty bladder
Pressure > 11 mmHg = abdominal HTN
Abdominal HTN=4 grades :
grade 1 medical intervention (maintaing euvolemia,gut decompression with NGT,laxatives & ,
enemas,withdrawing enteral feeding,catheter aspiration of ascitic fluid,abd. wall
relaxation,judicious use of hypotonic IV fluids
grade 2
grade 3
grade 4
}
}Laparotomy
INTRA-ABDOMINAL PRESSURE MONITORING
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Iran University of medical sciences

71. INTRA-ABDOMINAL PRESSURE MONITORING
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Iran University of medical sciences

72. DIFFERENTIAL
DIAGNOSIS
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Iran University of medical sciences

73. Peritoneal lavage………..1000 mL of saline
Preparation for emergency operation:
— IV access should be obtained & any fluid or electrolyte abnormalities corrected
— Almost all patients require antibiotic infusions Gram -ve enteric organism & anaerobes ( initiated
once a presumptive Dx has been made)
— NGT for patients with generalized paralytic ileus likelihood of vomiting & aspiration
— Foley………assess urinary output
prep urine output of 0.5 mL/kg/h
SBP > 100 Adequate IV volume
HR < 100
If significant hypokalemia Get CV line (administering potassium through a peripheral line is limited
by the potential of PHLEBITIS)
Preop acidosis fluid repletion & IV bicarbonate infusion
Acidosis caused by intestinal ischemia or infarction may be refractory preop therapy.
significant anemia is uncommon & preop blood transfusions are usually unnecessary
}
WHAT TO DO…
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Iran University of medical sciences

75. ATYPICAL
PATIENTS
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Iran University of medical sciences

76. ATYPICAL PATIENTS
-Greatest threat facing the pregnant patient with acute
abdominal pain is the potential for delayed diagnosis
-The appendix rises out of the pelvis to within a few
centimeters out of the right anterolateral costal margin
late in the 3rd. trimester.
-results of lab studies are altered in pregnancy(e.g.
WBC)
-periop risk is by maintaining physiologic O2 & CO2
levels during surgery, avoiding episodes of hypotension
& minimally manipulating the uterus
PREGNANCY
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Iran University of medical sciences

77. Appendicitis
-Most common non obstetric disease requiring
surgery(1/1500 pregnancies)
-50% - 60% ………..right lateral abdominal
pain,nausea,anorexia
-fever is uncommon unless appendix is perforated with
abdominal sepsis
-Leukocytosis as high as 16000 cells/mm3 is common
in pregnancy,& labor can the count to 21000.Many
authors have suggested that a neutrophil shift > 80%
is suspicious for an acute inflammatory process, e.g.
appendicitis
PREGNANCY
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Iran University of medical sciences

78. APPENDICITIS
1st
Most common non obstetric surgical
diseases in a pregnant woman
BILIARY TRACT
DISORDERS
2nd
BOWEL
OBSTRUCTIONS
3rd
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Iran University of medical sciences

79. Biliary tract disorders……..U/S & Alp(increased by estrogen)
If nuclear scan……foley (so that isotope cleared by the kidneys does not collect near the uterus)
Gallstone pancreatitis & acute cholecystitis should be managed more carefully( 60% fetal loss)
Bowel obstruction……..1-2/4000 deliveries
cause: 66%…..adhesion
25%…..volvulus
3 periods in gestation A/W
risk of obstruction with rapid
changes in uterine size
{
weeks 16-20 ……….uterus grows beyond the pelvis
weeks 32-36………..fetal head descends
early postpartum period
PREGNANCY
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Iran University of medical sciences

80. CPB mesenteric ischemia
paralytic ileus
ogilvie’s syndrome
stress peptic ulceration
acute calculus cholecystitis
acute pancreatitis
vasoactive
medications
ventilator
support
{
CRITICALLY ILL PATIENTS
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Iran University of medical sciences

81. mild-moderate compromise
(less abdominal pain &
delayed fever &
blunted leukocytosis)
Severely compromised Transplant recipients with immunosuppression for > 2months
Cancer patients on chemo ( esp those with neutropenia )
HIV patients with CD4 < 200/mm3
Older patients
diabetics
malnourished
Transplant patients on routine maintenance therapy
Cancer patients
Renal failure patients
HIV patients with CD4 > 200/mm3
{
{
IMMUNOCOMPROMISED PATIENTS
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Iran University of medical sciences

82. -also in lymphoma,leukemia,& AIDS
s&s……..diarrhea , dehydration , abdominal pain , fever , leukocytosis
CT Bowel wall thickening
pancolonic distribution
pericolonic standing
ascitis , generalized mucosal enhancement , diffuse bowel dilation,
double halo sign(IV contrast enhances the mucosa & muscular propria
while edema in submucosa creates an area of low attenuation in
between)
-14% normal CT
Atypical infections -peritoneal tuberculosis
-fungal infections……..aspergillus & endemic
mycoses
CMV,EBV
{
{
PSEUDOMEMBRANOUS COLLITIS
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83. Morbidly obese patients
Abdominal sepsis is a more subtle diagnosis & may
only be A/W malaise , shoulder pain , hiccups , SOB
Laparoscopy is a valuable tool here (esp designed
trochars & hand assist ports
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Iran University of medical sciences

84. ALGORITHMS
IN ACUTE ABDMEN
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Iran University of medical sciences

85. Navid manafi
medical student,Rasool Akram hospital,Tehran,Iran
acute-onset,severe ,
generalized abdominal pain
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Iran University of medical sciences

86. Navid manafi
medical student,Rasool Akram hospital,Tehran,Iran
Treatment of gradual-onset , severe ,
generalized abdominal pain
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Iran University of medical sciences

87. Navid manafi
medical student,Rasool Akram hospital,Tehran,Iran
Treatment of RUQ
abdominal pain
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Iran University of medical sciences

88. Navid manafi
medical student,Rasool Akram hospital,Tehran,Iran
Treatment of LUQ
abdominal pain
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Iran University of medical sciences

89. Navid manafi
medical student,Rasool Akram hospital,Tehran,Iran
Treatment of RLQ
abdominal pain
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Iran University of medical sciences

90. Navid manafi
medical student,Rasool Akram hospital,Tehran,Iran
Treatment of LLQ
abdominal pain
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Iran University of medical sciences

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92. Thank
you
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