2. ACUTE ABDOMEN
-denotes any sudden, spontaneous, non-traumatic disorder whose
chief manifestation is in the abdominal area and for which urgent
surgery is necessary.
The primary symptom of the "acute abdomen" is –
Abdominal Pain
3. QUADRANTS OF THE ABDOMEN
Right Upper
Quadrant
Right Lower
Quadrant
Left Upper
Quadrant
Left Lower
Quadrant
6. Types of Abdominal Pain:
1. Visceral
• Due to stretching of fibers innervating the walls of hollow or solid organs. It occurs
early and poorly localized. It can be due to early ischemia or inflammation.
2. Parietal
• Caused by irritation of parietal peritoneum fibers. It occurs late and better
localized. Can be localized to a dermatome superficial to site of the painful
stimulus.
3. Referred
• Pain is felt at a site away from the pathological organ. Pain is usually ipsilateral to
the involved organ and is felt midline if pathology is midline. Pattern based on
developmental embryology.
7. Clinical Presentation of Abdominal
Problems
◦ 1. Pain
-Most common abdominal symptom, may be due to inflammatory, infective or obstructive pathology. This can arise
from the abdomen or as a referred pain outside the abdomen like pneumonia from the lungs and angina from the heart.
Organ Radiation of Pain
Gallbladder To the back and tip of scapula
Posterior wall of
stomach or duodenal
ulcer
To the back
Pancreatic pain Left and back
Kidneys Pain in the loin, radiate to groin
Pelvic structures Lower back or perineum
8. History
• Duration?
• Nausea, vomiting? Bloody? (Coffee grounds
emesis?)
• Change in urinary habits? Urine appearance?
• Change in bowel habits? Melena (Dark, tarry
stools?)
• Regular food/water intake?
• Females
–Last menstrual period?
–Abnormal bleeding? In females, abdominal
pain = GYN problem until proven otherwise
9. History
• Location, quality, severity, onset, and duration
of pain, aggravating and alleviating factors
• GI symptoms (N/V/D)
• GU symptoms
• Vascular symptoms (A. fib / AMI / AAA)
• Can overlap i.e. Nausea seen in both GI / GU
pathologies.
10. History
• PMH
– Recent / current medications
– Past hospitalizations
– Past surgery
– Chronic disease
– Social history
– Occupation / Toxic exposure (CO / lead)
14. 1. Acute gastritis/duodenitis/peptic
ulceration
◦ Disease: Mucosal infection by Helicobacter pylori is a major contribution
History
-Symptoms: Acute epigastric
discomfort or pain of short duration,
related to meals.
i) Gastric ulcers: Aggravated by
meals, relieved by vomiting
ii) Duodenal ulcers: Relieved by
meals
+ hematemesis and melena are
complications
+History of similar symptoms
+History of NSAIDs abuse, smoking
and periods of stress
Physical Examination
-Epigastric tenderness, with guarding if
pain is severe
May be anaemic
Investigation
-Endoscopy
15. MANAGEMENT
◦ MEDICAL
‘Triple therapy’
-NICE guideline
:PPI, with amoxicillin or
clarithromycin
◦ SURGICAL
Necessity in
: Perforation
: Bleeding
: Obstruction
◦ CONSERVATIVE
-Avoidance of NSAIDs
-Reduction of smoking and
alcohol control
16. 2. Perforated peptic ulcer
◦ Disease: Acid gastric will enter the peritoneal cavity if a peptic ulcer erodes the wall of the stomach or
duodenum at a point where it is only covered by visceral peritoneum. This causes a chemical peritonitis, which
later becomes infected with bacteria.
History
-Most common between age 50-60
-Symptom:
Sudden severe and constant pain,
begins in epigastrium and reaches
peak quickly and remains for many
hours
Gradually extends to whole
abdomen
Worsen with movement, including
respiration
+ previous history of dyspepsia
+ history of NSAIDs
Physical Examination
General: Looks ill, in pain, not moving
Tachycardia, shallow respiration,
usually afebrile
Specific: Tenderness and guarding
confined to epigastrium initially,
eventually whole abdomen becomes very
tender with severe guarding-
’board-like ridgidity’
Bowel sounds disappear in established
peritonitis
Investigation
Endoscopy
i) Diagnostic-Localization of ulcer –
Biopsy to rule out malignancy
ii) Therapeutic-Injection of adrenaline
Erect chest XRAY
#WARNING
Develop
-Increasing tachycardia
-Absent bowel sounds
-Increasing abdominal distension
-Sunken eyes
Developing hypovolemia when the acid
becomes dilutes and pain and guarding
reduces—actually developing peritonitis
17. MANAGEMENT
INITIAL MANAGEMENT
-Resuscitation, oxygen therapy, IV
fluids, broad spectrum antibiotics,
and NG tube as necessary
-Analgesia and PPI given
appropriately
◦ SURGICAL
-Following resuscitation
1. Duodenal ulcer
-Simple closure, whereby ulcer is
plugged using pedicle omental
patch, coupled with thorough
peritoneal lavage
2. Gastric ulcer
-Biopsy, followed by simple
closure or local excision of the
ulcer
18. 3. Acute Cholecystitis
◦ Disease: Acute inflammation of the gallbladder is commonly caused by obstruction of the cystic duct by a small stone
causing gallbladder distension, inflammation of its wall and eventually secondary inflammation.
History
-30-60 years, more common in women
-Symptom: Severe pain at right
hypochondrium, radiating to the tip
of scapula, continuous, exacerbated by
moving and breathing
+nausea and vomiting
+obstructed jaundice-dark urine,
pale stool and itchy skin
Physical Examination
-Distressed, in pain, not moving
-Tachycardia, febrile, jaundices, patient
may be sweating
-Fullness in right hypochondrium
(Zackary Cope’s sign)
-Sharp pain on palpation and release of
right hypochondrium causing cessation
of breathing
(Murphy’s sign)
-Guarding, gallbladder may be palpable
-Hyperaesthetic when drawing a pin
down the back of chest
(Boas sign)
Investigation
FBC-neutrophilia
Elevated bilirubin or ALP: Common
bile duct stone
Plain abdominal x-ray: Shadowing of
stone
Abdominal ultrasound-To visualize
gallbladder
Cholangiography: ERCP/MRCP
19. 4. Cholelithiasis
◦ Disease: Asymptomatic in 80% of the cases, divided into 3 main types, cholesterol, pigment ( brown/black) and
mixed. Usually detected incidentally on imaging.
History
Symptoms: Severe right upper
quadrant or epigastric colicky pain,
radiating to the back
-May have dyspepsia, flatulence, food
intolerance especially to fats
-Typically starts at night
+history of similar symptoms, relieved
by strong analgesics
Physical Examination
Mild tachycardia, afebrile and may be
jaundiced (Indicating obstruction)
Tenderness at upper quadrant with
severe guarding
Investigation
Similar as above
20. 5. Ascending Cholangitis
◦ Disease: Results from obstruction to the biliary system with infection of stagnant bile. Most common cause is
choledocholithiasis.
History
-Charcot’s Triad: RHC pain, fever,
jaundice
-symptoms of obstructive jaundice: tea
coloured urine, pale stool with colicky
pain
Physical Examination
Tenderness at right hypochondrium
Palpable gallbladder indicating
inflammation
Investigation
Full Blood Count: Raised TWC
suggesting infection
Bilirubin level: For obstructive jaundice
Blood CNS: Pathogen
Abdominal US: To look for stones
Complications: Sepsis, electrolyte
abnormality, coagulopathy
21. 6. Acute Pancreatitis
◦ Disease: Acute pancreatitis is a condition in which activated pancreatic enzymes autodigest the pancreatic gland. It
may be caused by obstruction of the pancreatic duct, usually by a small gallstone obstructing the ampulla of Vater or,
a peri-ampullary carcinoma or alcohol abuse.
History
Symptom: Sudden pain, at
epigastrium, and steadily increases
causing the patient to lie still and
breathe steadily
Usually radiates to the back
Exacerbated by movement
+frequent vomiting and retching
+persistent nausea in between bouts of
vomiting
+ate unusually large meal or drank
alcohol before pain
+history of gallstones
Social hx: alcoholic
Physical Examination
In severe pain, pale, ill, sweating-
hypovolemic
When respiration impaired-grey,
apprehensive, dyspnoeic, cyanosed
Sclerae tinge of jaundice
Tachycardia
Hypotensive
Severe pain but with minimal
abdominal signs-Pancreatitis
Severe pain causes increased abdominal
tone-abdomen will not move with
respiration, abdominal distension when
paralytic ileus develops
Investigations
Serum amylase- raised 4x
Serum lipase-raised in first 8H
Abdominal US- Sentinal loop sign (
dilated proximal jejenul loop near
pancreas) and colon cut off sign
Chest XRAY- For pleural effusion and
air under diaphragm
ERCP
#WARNING
Bruising and discolouration in left flank
(Grey Turner’s sign)
Around umbilicus
(Cullen’s sign)
In haemorrhagic pancreatitis
22.
23. MANAGEMENT
◦ SURGICAL
Necessity in
-Alternative diagnosis is suspected
by CT scan
-Gallstones is the most likely
cause-cholecystectomy is carried
out after acute attack
-When complications develop
◦ CONSERVATIVE
-Pain relief with analgesia
-Fluid resuscitation to maintain
adequate tissue perfusion
-Nutritional support: Enteral
feeding
24. 7. Abdominal aortic aneurysm
◦ Pathology – aneurysm is localised
abnormal dilatation od blood vessel
◦ True aneurysm - bound by all layer of
blood vessel
◦ False aneurysm –breach in blood vessel
wall leading to extravascular haematoma
that freely communicates with
intravascular space
25. Aetiologies Congenital:
proximal of coarcatation of aorta
Berry aneurysm
Acquired :
Traumatic
Degenerative ( atherosclerosis in abdominal aorta and popliteal artery)
Effects on
aneurysm
Pressure on neighbouring structure :
1) Veins – edema of distal limb ( abdominal, femoral and popliteal aneurysm)
2) Nerves – altered sensation ( pain, numbness)
3) Bones – erosion of bone ( in vertebrae in case of aortic aneurysm )
Thrombosis – laminated thrombus cause limited blood flow to extremities causing ischemia
Emboli formation
History taking 1) Abdominal pain – at chest or back , can occur with an expanding aneurysm, back pain localized, severe and
possible worse at night
Dissection pain – ripping sensation and become more severe at onset and before rupture.
Impending rupture cause extreme, severe pain of abrupt onset in the chest or mid-back and followed by shock if
unattended
2) Pressure symptoms , aetiologies factors , hypertension
26. Physical
examination
Aneurysm test
• Expansile pulsation – finger separation test
• Thrill and bruits are present
• Distal pulses are weak
• Grey Turner’s sign and Cullen’s sign ( bruising around the umbilicus ) late indicators for long-
standing rupture.
Complication TIPS
Thrombosis – cause embolization
Ischemia – to the distal organs
Pressure – on surrounding
Skin changes – inflammation
Others – rupture (pressure necrosis ) and can cause hemorrhage/ shock
Investigation CT – for patient with suspected ruptured
Chest x ray – for patient complained of chest discomfort, hypoxia or hypertension
MRI – accurate details about aortic root and aortic valve
Echocardiogram, transthoracic and transeosophageal – patients with aneurysm of ascending or
descending thoracic aorta
28. Sub-acute Strangulated Dynamic Paralytic
Nature of
obstruction
Intestinal colic No complete
remission of pain in
between colic
Pain continues in
nature
Abdominal colicky
pain, vomiting
Early post- operative
period ( up to 4 days)
after abdominal
operation
No colicky pain
Bowel sound absent
Unaffected vital sign Pulse rapid, high
temperature
Tachypnea, BP falls
Vital sign depend on
duration and severity
Poor vital sign
No muscle rigidity ,
rebound tenderness
with normal passing
of flatus
Muscle rigidity,
rebound tenderness
Cardinal signs of
peritonitis present
along with intestinal
obstruction
Distended abdomen
/ tenderness /
increased bowel
sound / visible
peristalsis
Gradual distension of
abdomen without
visible peristalsis
Silent abdomen on
auscultation
29. Site of obstruction High in ileum Terminal part of ileum Large bowel obstruction
Presentation Early and profuse vomiting –
content are gastric fluid in
beginning, later bile
Dehydration
No marked distension
Sudden onset
Pain at umbilical region
Neither early or profuse vomiting –
vomitus- early stage is gastric
contents àbile àfeculent
Marked abdominal distension (
central )
Visible peristalsis
Elderly
Gradual onset
Pain not prominent
Constipation
Caecum distended
Features on x-ray Air fluid conspicuous,
straight
Segment generally central
and lie transverse
No gas in colon
To small bowel air fluid level
Jejunum- valvulae conniventes (
stack of coins)
Ileum – distal ileum described as
featureless
Caecum- distended and showed as
rounded gas shadow in right iliac
fossa
Large bowel – except
caecum showed haustra fold
Sigmoid volvulus- coffee
bean sign
30.
31. Management
STRANGULATED
• External hernia , when loop of bowel become trapped within abdominal cavity or when there is mass
rotation of bowel, twisting and compressing the mesentery
àEmergency laparotomy, resection of the gangrenous bowel
NON-STRANGULATED
• Supportive
- Nasogastric decompression and fluid replacement with Hartman’s solution or normal saline.
- Antibiotics ( mandatory for all patient undergoing small or large bowel resection)
- Large bowel obstruction due to faecal impaction can be relieved by enemas or manual removal of faeces
• Surgery
- Identify the caecum first, if dilated, it is large bowel obstruction. If collapsed, lesion is in small bowel.
- Operative decompression may be required if severe dilatation of bowel loop
- Treat underlying obstruction
32. 9. Acute mesenteric ischemia (AMI)
• Definition :
• Acute mesenteric ischemia refers to the sudden onset of small
intestinal hypoperfusion, which can be due to reduction or cessation
of arterial inflow.
• Ischemia due to acute mesenteric arterial occlusion can be caused by
embolic obstruction of the intestinal blood supply, most commonly
to the superior mesenteric artery (SMA).
• Acute ischemia can also occur due to acute thrombotic obstruction,
often in the setting of an already diseased mesenteric vessel (eg,
atherosclerosis).
33. Risk factors
Occlusive Non-occlusive (
due to vasospasm
and constriction)
1) Emboli
Recent MI
Dysarrhymia (AF)
Valvular heart
disease
2) Thrombosis
Age > 50
Hypovolaemia
1) Poor perfusion
Hypotension
Hypovolaemia
MI
2) Compression
from external
sources (
intraabdominal
tumour )
3) Vasculitis
4) Radiotherapy
Hyperactive phase – primary symptoms
very severe and passage of bloody stool
Paralytic phase – if ischemia continues,
abdominal pain become widespread, belly
more tender, bowel motility decreases à
abdominal bloating, no bowel sound
Shock phase – fluid starts leakage through
damaged colon lining à result in shock and
metabolic acidosis with dehydration,
hypotension, tachycardia and confusion
Progressive phase
34. Classical triad
- Acute severe abdominal pain
- No physical signs
- Rapid hypovolaemia à shock
History
Severe abdominal pain – out of proportion
Persistent vomiting and defaecation occur early, with the
subsequent passage of altered blood.
Blood in stool
Paralytic ileus
Physical examination
◦ abdominal distension
◦ -abdominal tenderness
◦ -sign of peritonitis(guarding, rigidity)
◦ -hypotension
35. Investigation
• FBC : high HB/HCT ( due to plasma
loss/ haemoconcentration) , high TW >
15 in 75%
• ABG : metabolic acidosis, lactate
• Urea / creatinine ration : renal failure,
hypovolemia
• Pt/apt : hypercoagulable states
• Raised amylase or LDH
• AXR : submucosal hemorrhage and
edema in colon produce characteristics of
thumb printing
• CT arteriogram- presence of bowel
abnormalities and pathology of
mesenteric vessels
• CTAP : exclude other cause
• Colonoscopy if diagnosis remains unclear
36. Management
Acute
1) ABC – maintain airways and give high flow O2, establish large bore IV line and infuse fluids at
maintenance rate ( unless patient in shock )
2) Monitoring ( patient prone to get extensive peritonitis, shock )
3) Consider NGT
4) Antibiotic
Papaverine infusion , surgical embolectomy ( if it is caused by embolus) or bypass grafting ( if it is caused
by thrombosis ) and intra-arterial thrombolysis.
If bowel gangrene take place with sign of peritonitis, emergency resection of bowel is done.
39. History
◦ Can occur at any age, but most often affects teenagers and young adults of either sex
◦ Periumbilical pain which radiates to the RIF
◦ Loss of appetite- usually precedes onset of pain by few hours
◦ Nausea and vomiting- almost always occurs after pain
◦ Fever, may have diarrhea or constipation
◦ Inflammed appendix near bladder/ureter may cause irritative voiding symptoms
40. Causes pain in lateral part
of RIF and flank
Can p/w
bladder or large
bowel symptoms
Can p/w intestinal
obstruction sx – colic and
abdominal distension
41. ◦ RIF tenderness on palpation, rigidity and guarding, +ve rebound tenderness
◦ LIF tenderness in pt with situs inversus or lengthy appendix extending to LIF
◦ Cough sign: RIF pain on coughing
◦ Rovsing sign: RIF pain with palpation of the LIF (while this maneuver stretches the entire
peritoneal lining, it only causes pain in any location where peritoneum is irritating the muscle)
◦ Obturator sign: RIF pain with internal rotation of a flexed right hip
◦ Psoas sign: RIF pain with hyperextension of the right hip
Physical Examination
42.
43. Causes
◦ Obstruction of appendiceal lumen;
◦ Faecaliths: hard fecal mass
◦ Lymphoid hyperplasia: a/w inflammatory (Crohn’s) & infective dx (GE,
measles)
◦ Less common causes: parasites, TB, tumor, FB
Diagnosis
◦ Clinical diagnosis
◦ Predictive score: Alvarado score, Ripasa score
Causes and Diagnosis
44. Score 1-4: unlikely appendicitis, can be discharged without imaging
Score 5-6: possible appendicitis, consider imaging (US/CT)
Score >7: strongly predictive of acute appendicitis, surgical consultation
45. ◦ Blood;
◦ FBC: to look for leukocytosis
◦ CRP: look for evidence of active inflammation
◦ BUSE: to look for evidence of electrolyte imbalance
◦ Blood culture: if sepsis suspected
◦ Coagulation profile, GSH: to prepare pt for surgery
◦ Urine;
◦ UFEME: to rule out UTI, UPT to rule out ectopic
◦ Imaging (Abdominal Xray/USG/CT scan)
◦ If there is clinical suspicion, to confirm diagnosis and to rule out differential diagnosis
Investigations
46. ◦ Imaging (Abdominal Xray/USG/CT scan) (con’t)
◦ Abdominal US- more useful in children and thin adults and if gynecological pathology
is suspected
◦ CT is highly sensitive (94-98%) and specific (up to 97%) for the diagnosis of acute
appendicitis
◦ CT- most useful if there is diagnostic uncertainty, particularly older pt in whom acute
diverticulitis, IO and neoplasm are likely differential diagnosis
Investigations
47. ◦ NBM, IV drip
◦ Symptomatic relief: anti-emetics, analgesia
◦ IV abx , correct electrolyte imbalance
◦ Definitive tx: appendicectomy (open or laparoscopic)
◦ If peforated appendicitis → emergency appendicectomy
◦ Conservative tx for appendiceal mass: Oschner Sherren regime
Management
