2. Acute abdomen
Acute abdomen refers to a sudden, severe abdominal
pain
It is in many cases a emergency, requiring urgent and
specific diagnosis
Most can be diagnosed clinically
•Require accurate and focused history taking
•Need meticulous & rationale physical examination
Several causes need immediate surgical treatment
Importance:
Need immediate diagnosis & treatment
Prevent morbidity & mortality
3. The
Diagnostic
Process
HISTORY
Patient perception of symptoms
Patient description of symptoms
Physician perception
Physician interpretation of symptoms
LABORATORY SYNTHESIS PHYSICAL
FINDINGS RECORDING EXAMINATION
DECISION
4. History Taking
• 60 - 80% of accurate diagnosis arises from
good & meticulous history taking
• 10 - 15% of accurate diagnosis arise from
laboratory & radiological examinations
• May confirm :
– Suspected diagnosis
– Possible etiology
– Disease stages/ complications
– Differential diagnosis
Kauffman GL. Acute Abdomen In: Corson JD, Williamsons RC eds. Surgery. 1 ed. Spain: Mosby st International Limited, 2001:1-14
5. Chief complaint:
PAIN Site at present
Onset
Radiation
Type
Aggravating /relieving factors
Severity
Duration
Site at onset
Progression
10. • Does pain radiate (travel) anywhere?
– Right shoulder, angle of right scapula = gall
bladder, liver, spleen
– Around flank to groin = kidney, ureter
12. • Was onset of pain gradual or sudden?
– Gradual = peritoneal irritation or hollow organ
distension
– Sudden = perforation, hemorrhage, infarct
• What does pain feel like?
– Steady pain - inflammatory process
– Crampy pain - obstructive process
13. Type and severity of pain
Progressive & Continous colicky pain due to strangulated bowel obstruction
(ischemic stage)
14. Type and severity of pain
• A. Toothache
• C. Colicky pain of calculi
A
C
15. Other related symptoms:
Ask the patient concerning related/concomitant symptoms of
• Gastro-intestinal function:
– Nausea
– Vomiting
– Loss of appetite
• Jaundice
• Bowel habit:
– Constipation?
– Diarrhoea?
– Colour of the stool?
– Presence or absence of blood and mucus
16. Other related symptoms:
• Urinary function:
– Micturition: amount of urine, lower abdominal
discomfort, colour of urine
• Gynaecological function ( female)
– Menstrual function
– Delayed or missed period
– Abnormal bleeding or discharge (colour, quantity)
18. Implementation:
• Examine the vital signs:
– Temperature
– Pulse rate
– Blood Pressure
– Respiratory rate
• Vital signs
– Tachycardia ? Early shock (more important
than BP)
– Rapid shallow breathing peritonitis
19. Implementation:
• Perform other systems examination, including
cardio-pulmonary system.
• Ask the patient politely to expose his/her
abdomen.
20. Abdominal Examination:
Inspection
– Inspect the movement:
• Respiratory movement
• Visible bowel peristaltics
– Is there any scars on the skin of the abdomen?
– Is there any abdominal distention?
• Flatus ? , Fluid ? , Fetus?
21. Abdominal Examination:
Inspection
• Is there any rashes and discolouration?
– Cullen’s sign
– Gray Turner’s sign
– Ecchymosis of the abdominal wall
• Is there any masses:
– Tumors?
– Hernial sites?
– Masses with pulsation?
23. Abdominal Examination:
Palpation
• Ask the patient to locate the site of maximum pain
with the tip of a finger.
• Using the palmar surface of your fingers, gently
palpate the abdomen, starting from a site farthest
from the area of maximum pain, move gradually
towards it.
24. While palpating look for any signs of :
• Tenderness
• Rebound tenderness
• Muscle guarding
• Rigidity
• Murphy’s sign
•Swelling or masses
•Rovsing’s sign
•Expansile pulsation
•Hernial orifices
•Scrotum in male
27. Digital Rectal Examination
• Gently insert your right index finger
into the anus, move toward the anal
canal slowly, and evaluate the
followings:
– Anal margin: Hemmorhoids?
– Sites of any pain elicited
– Masses or swelling: consistency,
location, surface, fixity to the
surroundings.
– Bowel contents: consistency of
faeces? Mucus? Blood?
– Ballooning – S/0 Obstruction
29. Appendicitis
• Usually due to
obstruction with
fecalith
• Appendix becomes
swollen, inflammed,
gangreous, possible
perforation
30. Appendicitis
• Pain begins periumbilical; moves to RLQ
• Nausea, vomiting, anorexia, fever
• Patient lies on side; right hip, knee flexed
• Pain may not localize to RLQ if appendix
in odd location
• Sudden relief of pain = possible
perforation
• Appendicitis is a clinical diagnosis rather
than a radiological one
• MANTRELS scoring
• Treatment:
Appendicectomy/Conservative
31. Acute Cholecystitis
• Inflammation of gall bladder
• Commonly associated with
gall stones
• More common in 30 to 50
year old females
• Nausea, vomiting; RUQ pain,
tenderness; fever
• Attacks triggered by
ingestion of fatty foods
• Management: Conservative/
lap cholecystectomy/
Interval Cholecystectomy
32.
33. Bowel Obstruction
• Blockage of inside of intestine
• Interrupts normal flow of
contents
• Causes include adhesions,
hernias, fecal impactions, tumors
• Cramping abdominal pain,
nausea, vomiting (often of fecal
matter), abdominal distension
• DRE: Ballooning
• Pt stable: CECT- f/B intervention
• Unstable: Stabilize- F/b
Exploratory laparotomy
34. Inguinal Hernia
• Protrusion of the
intestine through a tear
in the inguinal canal.
• Usually identified by
abnormal mass in lower
quadrant, with or
without pain.
• Strangulation can lead
to necrosis.
• Often missed as a cause
of acute abdomen
35. Renal Stone
• Mineral deposits form in
kidney, move to ureter
• Often associated with
history of recent UTI
• Severe flank pain
radiates to groin, scrotum
• Nausea, vomiting,
hematuria
• Extreme restlessness
36. Pancreatitis
• Inflammation of pancreas
• Triggered by ingestion of
EtOH; large amounts of
fatty foods
• Nausea, vomiting;
abdominal tenderness;
pain radiating from upper
abdomen straight through
to back
37.
38.
39. Some other commonly encountered
cases in casualty
• Aneurysm
• BTA
• Intussusception
• Sigmoid volvulus
• Diverticulitis
• Peptic Ulcer
• GERD
