ACUTE ABDOMEN IN SURGICAL PATIENTS PRESENTING IN ER

1. DR. NAMERAH NASIR| PGY-2
PAF HOSPITAL, ISLAMABAD

3. LEARNING OBJECTIVES
• Definition
• Etiology
• Assessment
• History
• Physical examination
• Laboratory Investigations
• Imaging Studies
• Management

4. DEFINITION
• “ACUTE ABDOMEN” is a general term used to describe
a variety of serious, non-traumatic intra-abdominal
pathologies that mandate emergency or urgent surgical
or major medical intervention.

5. ETIOLOGY

6. MEDICAL CAUSES

7. ASSESSMENT
• An acute abdomen must be suspected even though the
patient has only mild or atypical symptoms.
• History and Physical examinations should suggest the
probable cause and guide the clinical diagnosis.

8. HISTORY
OLD AGE ADULTS YOUNG
ADULTS
CHILDRE
N
INFANTS Newborn
Sigmoid
volvulus
Acute
Pancreatitis
Appendicitis Roundworm
infection,
Intussusceptio
n,
Anorectal
malformati-
ons
Carcinoma
of the colon
Acute
Cholecystitis
Appendicitis Midgut
volvulus,
Intestinal
atresia
Diverticulitis Perforation Acute non-
specific
mesenteric
lymphadenitis
Congenital
hypertrophic
pyloric
stenosis
Meconium
ileus
Age: Common disorders according to different age groups:

9. PAIN
• Pain is the cardinal symptom of acute abdomen
• It is important to be familiar of other sources of pain
arising from such sites as the abdominal wall (e.g.,
rectus sheath hematoma) or extra-abdominal organs
(e.g., testicular torsion).
• Irritation of the peritoneum is responsible for the origin of
pain arising from an intra-abdominal process.

10. ABDOMINAL PAIN CONTD.
• Abdominal pain may be :
1. Visceral pain
2. Parietal Pain
3. Referred pain and shifting pain

11. ABDOMINAL PAIN CONTD
• Visceral Pain:
 Vague, slow in onset, dull, poorly localized.
 Distention, inflammation, ischemia or malignant
infiltration of sensory nerves.
 Often indicates intra abdominal cause
 Most often felt in the midline because of the bilateral
sensory supply.

12. VISCERAL PAIN SITES
Visceral pain corresponds with
the embryological origin of
alimentary tract
Epigastric: Foregut-derived
structures (stomach
to second portion of duodenum, liver,
biliary tract, pancreas, spleen).
Periumbilical: Midgutderived
structures (second portion of
duodenum to proximal two-thirds of
transverse colon).
Suprapubic: Hindgut-derived
structures (distal transverse colon to
anal verge).

13. ABDOMINAL PAIN CONTD.
• Parietal Pain:
 Is in a distinct abdominal quadrant, causing sharp and
severe pain
 Well localized
 Occurs due to peritoneal irritation by localized
inflammation of an organ in contact with the parietal
peritoneum

14. PARIETAL PAIN SITES

15. ABDOMINAL PAIN CONTD.
• Referred pain:
 Pain felt away from
the original site of the
painful stimulus
Examples include
biliary tract pain which
refers to the right
scapular area
• Spreading or
shifting pain:
Origin of the pain is in
one site later pain
shifts to another site
where pain at the
initial site disappear.
Eg. Acute
appendicitis.

17. THE MODE OF ONSET OF PAIN
SUDDEN ONSET
(Within Seconds)
RAPID ACCELERATION
(within minutes)
GRADUAL
(over hours)
Perforated viscus Colic syndromes: biliary,
ureteric, bowel obstruction
Inflammatory:
appendicitis, cholecystitis;
Ruptured aneurysm Inflammatory:
Appendicitis, Pancreatitis,
Diverticulitis;
Obstructive:
Non strangulated bowel
obstruction, Urinary
retention
Other
Myocardial infarction Ischemic: Mesenteric
ischemia,
Bowel strangulation,
Volvulus
Mechanical: Ectopic
pregnancy, Tumors

18. CHARACTER OF PAIN
Continuous: perforation, torsion, haemorrhage,
inflammation
Colicky: spasm of hollow viscus eg. Intestinal, biliary,
ureteric
 Throbbing: cholecystitis
 Severe agonizing: Acute pancreatitis
Twisting: Torsion
Continuous and burning: acute peritonitis and
duodenal ulcer perforation

20. AGGRAVATING AND RELIEVING
FACTORS
• Colicky pain is relieved by local pressure
• Inflammatory pain gets aggravated by pressure
• Pain aggravates on movement in cholecystitis,
appendicitis, ureteric stone
• Coughing and deep breathing aggravates pain due to
diaphragmatic irritation
• Fatty meal aggravates pain of gastric ulcer.
• In acute pancreatitis leaning forward relieves the pain

21. VOMITING
• Character: it may be of two types
1. Projectile: involuntary forceful ejection of upper intestinal
contents
2. Non-projectile: regurgitation of mouthful contents seen in
general peritonitis.
• Contents: whether partly digested food particles or fluid,
bilious or not, haematemesis, or intestinal contents
(faeculent).
• Relationship with pain: pain preceeds vomiting in acute
appendicitis, acute pancreatitis, peptic ulcer and biliary and
renal colics; in high intestinal obstruction vomiting and pain
appear almost simultaneously and later in distal GI
obstruction. In PUD vomiting relieves pain.

22. ASSOCIATED FEATURES:
1. Diarrhoea: copious in gastroenteritis; blood stained in ulcerative
colitis, Crohn’s disease and bacterial or amoebic dysentery
2. Constipation: may be absolute or relative (Intestinal Obstruction)
3. Bowel habits: quantity, nature, frequency, odor, color, tenesmus
(painful, futile straining on defecation with passage of mucus and
blood)
4. Abdominal distention
5. Urinary symptoms: burning sensation, frequency, strangury
(frequent attempts of micturition, urological form of tenesmus) as
seen in case of impacted calculi or irritation of the bladder by an
inflamed appendix or in pelvic peritonitis.
6. History of fever, chills and rigor, jaundice, melena etc.

23. • Past Medical History:
1. Pulmonary TB
2. Cardiac Disease: AF
3. PUD
4. Biliary colic &
Pancreatitis
5. IBD
6. Abdominal trauma i.e
Delayed splenic
bledding. etc
• Past Surgical History:
1. Previous abdominal
surgery.
2. Mode of operation
(laparoscopic, open,
endovascular)
3. Operative notes and
pathology reports
should be obtained
and reviewed.

24. OTHER RELEVANT ASPECTS OF THE
HISTORY
• Gynaecological History:
The menstrual history*
 A history of vaginal
discharge or dysmenorrhea
may denote pelvic
inflammatory disease.
• Medication History:
NSAIDS or aspirin,
Anticoagulants or
antiplatelet drug. OCP,
Corticosteroid or
chemotherapeutic or
immunosuppressive drugs.
• Family history: Hereditary
pancreatitis
• Travel History : amebic
liver abscess or hydatid
cyst, malarial spleen,
tuberculosis, Salmonella
typhi infection of the
ileocecal area, or dysentery

25. PHYSICAL EXAMINATION
• Appearance:
 Hippocratic facies
Facies of dehydration
• Attitude
• Vitals
a. Fever suggests inflammatory or infectious process;
marked fevers >39 C suggests the presence of abscess,
cholangitis, or pneumonia.
b. Hypotension and/or tachycardia signal hypovolemia or
sepsis

26. ABDOMINAL EXAMINATION
• 3. Abdominal examination should be done
systematically. Analgesia administered prior to
examination may alter findings, but does not decrease
diagnostic accuracy.
A. Inspection should be carried out for distention, scars,
masses, or skin changes.
B. Palpation should be performed with the patient
supine.*

29. • Percussion:
Tympanic sounds - bowel distention
Shifting dullness – presence of free fluid
Obliteration of liver dullness – pneumoperitoneum
• Auscultaion :
High-pitched bowel sounds – obstruction
Absence of sounds - ileus or diffuse peritonitis.
• Rectal examination
(1) Rectal mass may be an obstructing cancer; note fraction
of circumference involved, mobility, and distance from anal
verge.
(2) Occult blood in stool specimen indicates GI bleeding
• Vaginal examination

30. LABORATORY INVESTIGATION
• Blood Studies:
 Neutrophilic leucocytosis
 CRP raised
 Electrolyte imbalance
 Creatinine & BUN (deranged with dehydration)
 ABG
 Serum Lactate (Raised in ischemic bowel)
 Serum amylase,lipase
 Liver function tests if suspect hepato-biliary disease
 'Group and save' or crossmatch
 Beta HCG (women of childbearing age.)
 Urine Tests: RE to see hematuria, pyuria
 Dipstick Test - for albumin, bilirubin, glucose and ketones, Pregnancy
test

31. IMAGING STUDIES
• Chest Xray
Free intraperitoneal air is best visualized on upright
chest x-rays which include both hemi-diaphragms.
(1) If the patient is unable to assume an upright position, a
left lateral decubitus x-ray should be performed.
(2) Free air may not be detected in up to 50% of cases of
perforated viscus
 lower lobe pneumonia or ruptured esophagus
 An elevated hemidiaphragm or pleural effusion

32. • Pneumoperitoneum: usually suggests a perforated
viscous
1 ml air in peritoneum produce pneumoperitoneum in
upright CXR
 5-10 ml air in peritoneum produce pneumoperitoneum
in lateral decubitus position (after 10 minutes)
Pneumoperitoneum is usually not found in perforated
appendix

34. ABDOMINAL XRAY
• Upright abdominal - Multiple air fluid level or 3 , 6 , 9 rules or string of
Pearl sign to identify intestinal obstruction.
Bowel gas pattern
(1) In SBO, small bowel dilation and air-fluid levels proximal to the
obstruction can be seen, along with a paucity of gas in distal bowel.
Absence of air in the rectum suggests complete obstruction.
(2) A sentinel loop may be seen adjacent to an inflamed organ
representing localized ileus.
(3) The bent inner tube or omega signs are classic for sigmoid and cecal
volvulus respectively.
(4) 90% renal stone 10 % gall stone, 5% appendicolith, pancreatic
calcification, AAA calcification can be seen
(5) Pneumatosis (intramural gas in the GI tract) or pneumobilia (gas in
the biliary tree) in the absence of surgical anastomosis or sphincterotomy
suggests bowel ischemia.

36. ULTRASONOGRAPHY
• Important diagnostic adjunct - biliary tract and ovaries.
• Portable, inexpensive, and has little associated morbidity.
A.Up to 95% of gallstones are detectable by US.
Dilation of CBD (>8mm or >10 mm after cholecystectomy) indicates
biliary obstruction.
B. Pelvic or transvaginal US -in women in whom ovarian pathology
or ectopic pregnancy is suspected.
C. Testicular US -testicular torsion, epididymitis, or orchitis.
• Pitfall :
Obesity
 Ascites
 Gaseous distension of upper abdominal viscera

37. COMPUTED TOMOGRAPHY (CT)
• Thorough evaluation of the abdomen and pelvis
• Relatively quick.
• Oral and IV contrast should be administered unless
contraindicated by allergy, renal insufficiency, or
hemodynamic instability.
• Best study in patients with an unclear etiology for
abdominal pain

38. CONTRAST STUDIES
• Rarely indicated in the acute setting, but can be useful in
some situations.
a. Contrast enema differentiate an ileus from distal
colonic obstruction.
b. Water-soluble contrast agents such as Hypaque
should be used to avoid barium peritonitis if there is any
risk of bowel perforation.

39. ROLE OF LAPAROSCOPY IN ACUTE
ABDOMEN
• Laparoscopy - therapeutic as well as diagnostic modality
• In cases of unclear diagnosis, it guide surgical planning
and avoid unneeded laparotomies.
• In young women, it may distinguish a nonsurgical
problem (ruptured graffian follicle, pelvic inflammatory
disease, tubo-ovarian disease) from appendicitis.

40. CAREFUL ABOUT SPECIAL
POPULATION
• 1. Extremes of age (Children & Elderly)
• 2. Obese
• 3. Pregnant
• 4. Critically ill patient
• 5. Immunocompromised Pt

41. RED FLAGS THAT RAISE SUSPICION OF SERIOUS
PATHOLOGY
• Hypotension.
• Confusion/impaired consciousness.
• Signs of shock.
• Systemically unwell/septic-looking.
• Signs of dehydration.
• Rigid abdomen.
• Patient lying very still or writhing.
• Absent or altered bowel sounds.
• Associated testicular pathology.
• Marked involuntary guarding/rebound tenderness.
• Tenderness to percussion.
• History of haematemesis/melaena or evidence of latter on
examination per rectum (PR).
• Suspicion of a medical cause for abdominal pain.

42. MANAGEMENT
• Identify and treat life threatening conditions
• Airway
Profound shock or protracted emesis may compromise
airway and require intubation
• Breathing
Provide supplemental O2
O2 saturation monitoring

43. • Circulation:
IV access (2 large bore IV catheters)
Cardiac rhythm monitoring
Volume repletion with an isotonic crystalloid solution
May require several liters of fluid
Titrate volume to hemodynamic status and urine output
Extreme conditions e.g. ruptured AAA, massive GI hemorrhage,
ruptured spleen, and hemorrhagic pancreatitis may require
blood replacement
12-lead EKG
Nasogastric tube (for bowel obstruction)
Urinary catheter for critically ill patients (to monitor urine output)

44. WHAT NEXT?
• After the initial assessment the patients with acute abdominal
pain should be categorized into
(A) Patients with immediately Life Threatening conditions :
Patients who need immediate Laparotomy ( Abdominal
Crises)
(1) Massive intra-abdominal bleeding; (Ruptured AAA. or
visceral aneurysms, ruptured ectopic pregnancies, and
spontaneous hepatic or splenic ruptures).
(2) Acute Intestinal Ischemia with hypovolemia and resistant
acidosis.
(3) Intra-abdominal sepsis;

45. WHAT NEXT? CONTD.
(B) Patients with Rapidly Life Threatening conditions.
Patients who need; Urgent laparotomy;(with in 4-6H.)
1. Perforated hollow viscera.
2. Strangulated Bowel.
3. Intra-abdominal Abscesses; (Appendicular; and
Diverticular); with free intra-peritoneal perforation and
diffuse peritonitis.

46. WHAT NEXT? CONTD.
(C)-Serious conditions: that need early planned
surgery or need early supportive treatment and close
monitoring
(1) Appendicitis/appendicular abscess; acute
Cholecystitis/peri-cholecystic abscess; acute
pancreatitis.
(2) Diverticulitis/Diverticular abscess; PID /Tuboovarian
abscess; Localised intra-abdominal or Pelvic abscess.
(3) Small bowel obstruction.
(4) Large bowel obstruction due to: diverticular abscess/
carcinoma

47. WHAT NEXT? CONTD.
(D)-Less serious conditions which require
conservative treatment
(1) Biliary colic; renal colic.
(2) Inflammatory bowel disease.
(3) Non-specific abdominal pain.
(4) Gastro-enteritis and infective colitis.
(5) UTI.
(6) Un-complicated ovarian cyst and fibroid; and
endometriosis. Mid-ovulatory pain.
(7) Un-complicated Diverticulitis.
(8) Most of Medical causes.

48. MEDICO LEGAL PITFALLS AND TIPS
• Careful documentation of the clinical situation and decision-making process is essential.
• Failure to appreciate the severity of illness through not assessing vital signs/taking
heed of general condition.
• Failure to examine adequately or to document findings.
• Failure to examine for an enlarged bladder, for herniae or to check the scrotum.
• Failure to carry out rectal or vaginal examination when it is indicated.
• Treating children as little adults and not considering paediatric-specific diagnoses.
• Failing to make concrete follow-up arrangements or advising a patient of when they should
seek further assessment, when managing patients in the community.
• Delayed transfer of acutely unwell patients to hospital.
• Steroids or other forms of immunocompromised may mask symptoms and signs.
• When pain outstrips signs, consider gut infarction or AAA.
• Don't rely on a normal test result to discount pathology if the clinical condition suggests
otherwise.
• Failing to consider pregnancy or conduct a pregnancy test.
• Be ready to reassess your initial diagnosis, or a colleague's diagnosis, where the clinical
situation has changed.

49. THANK YOU!