This document provides guidance on evaluating patients presenting with acute abdomen pain. It outlines the importance of a thorough history and physical exam in making a diagnosis. Key aspects of the history include characteristics of the pain, associated symptoms, past medical history, and medications. The physical exam focuses on vital signs, inspection, palpation, and specific tests to locate the source of pain. Recommended basic tests include blood tests, urine analysis, chest x-ray, and ultrasound. Further imaging like CT scans may be needed in some cases. A systematic approach combining history, exam and selective tests usually leads to the correct diagnosis.

1. Evaluation of Acute Abdomen By Dr. Conrad D’Costa, MS, DNB (Senior House Officer) Mr.Sudhir Jain,MS,FRCS,FACS, (Specialist Registrar Surgery) North Middlesex University Hospital,London

2. Acute Abdomen Challenge to Surgeons & Physicians Most common cause of surgical emergency admission Clinical course can vary from from minutes to hours to weeks. It can be an acute exacerbation of a chronic problem e.g. Chronic Pancreatitis,Vascular Insufficiency.

3. DEFINITION Acute Abdomen is a term used synonymously for a condition that needs immediate surgical intervention

4. ASSESMENT Well elicited history Proper physical examination Diagnosis can be made most of the time by a good history and a proper physical examination.

5. Assesment(cont.) Investigations are usually carried out : only to support the diagnosis. or to narrow down the differential diagnoses.

6. History History of Present illness Family History Past Medical history History of drugs taken or Medication eg. ingestion of certain toxic drugs or Alcohol intake

7. PAIN The Most Important Symptom History of pain should include: 1. Onset 2. Severity 3. Type of pain 4. Radiation of Pain 5. Change in nature of Pain 6. Associated bowel or urinary symptoms 7. Aggravating or relieving factors

8. (i) Onset of Pain Sudden onset pain which wakes the patient from sleep eg. perforation or strangulation of bowel Slow insidious Onset a. Inflammation of visceral peritoneum. b. Contained process such as evolving abscess. Crampy or colicky pain Biliary colic , Ureteric colic or Intestinal colic

9. (ii) Progression of Pain Progression from: Dull, aching, poorly localized character To: Sharp, constant & better localized pain indicates involvement of Parietal peritoneum

10. (iii) Associated Bowel Symptoms CONSTIPATION a. Progressive intestinal obstruction from a neoplasm or inflammatory bowel disease b. Paralytic Ileus c. Post Operative d. Obstructed groin hernia

11. (iv) Associated Bowel Symptoms DIARRHOEA Diarrhoea with pain is mainly medical. The following are the exceptions: a. Obstructed Richter's Hernia b. Gall Stone ileus c. Superior mesenteric vascular occlusion d. Intestinal Obstruction associated with pelvic abscess e. Spurious diarrhea in chronic faecal impaction

12. DRUG HISTORY Corticosteroids – mask pain Anticoagulants – can lead to an intramural haematoma of the gut causing obstruction Oral Contraceptives - rupture of hepatic adenomas NSAIDs - erosive gastritis & peptic ulcers

13. NAUSEA & VOMITING Frequency of vomiting (ii) Character of vomiting: projectile, non-projectile or self-induced (iii) Nature of vomiting: a. Bilious vomiting of small bowel obstruction b. Non-bilious vomiting in obstruction proximal to ampulla of vater c. Faeculent vomiting in distal small gut obstruction, large bowel obstruction , strangulation

14. NAUSEA & VOMITING Pain first, followed by Vomiting is usually surgical. The vomiting is due to ‘reflex pylorospasm’ Nausea & vomiting first , followed by pain is usually due to a medical condition

15. Vomiting (cont.) Vomiting is very prominent in a. Mallory-Weiss syndrome. b. Boerhaave syndrome(trans- mural esophageal tear) c. Acute gastritis d. Acute pancreatitis

16. ANOREXIA Anorexia or decreased appetite with pain is usually seen in Acute appendicitis

17. Urinary Symptoms with Pain Ureteric colic Cystitis

18. FEVER & CHILLS/RIGORS Amoebic Liver Abscess Pygenic Liver Abscess Perinephric Abscess Intra-abdominal pus collection

19. OTHER HISTORY Past Surgical history: previous operations- leading to adhesions Past Medical history: Sickle cell disease, Diabetes or Cancer or Renal failure Menstrual History in females (i) Missed period- ectopic pregnancy (ii) Mid of period-ovulation pain (Mittel- schmerz) (iii) With heavy periods- endometriosis Family history of colon cancer, any other malignancy or inflammatory bowel disease

20. Physical Examination General Appearance a. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitis b. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colic c. Writhing in Pain: Mesenteric Ischemia

21. Physical Examination (contd.) d. Bending Forward: Chronic Pancreatitis e. Jaundiced: CBD obstruction f. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

22. Physical Examination (contd.) Vital Charting Temperature, Pulse, BP, Respiratory rate Ruptured AAA or ectopic pregnancy can lead to -Pallor -Hypotension -Tachycardia -Tachypnea

23. Physical Examination (contd.) Low grade temp. is seen with - Appendicitis - Acute cholecystitis High grade temp. is seen with - Salpingitis - Abscess Very High Grade Temp.with increasing lethargy seen in imminent septic shock - Peritonitis - Acute cholangitis - Pyonephrosis

24. Systemic Examination Cardiopulmonary examination Check for: - Possible MI - Basal Pneumonia - Pleural Effusion

25. Systemic Examination Per Abdomen: Inspection - Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

26. Systemic Examination Erythema or discolouration a. Peri-umbilical - Cullen sign b. Inguinal – Fox sign c. Flanks - Grey Turner sign Seen in Hemorrhagic pancreatitis or any other cause of haemoperitoneum Any Visible masses Any visible cough impulse at hernia site

27. Systemic Examination Per abdomen: Palpation Be gentle Start away from site of pathology then towards Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis.

28. Systemic Examination Local Right Iliac Fossa tenderness: a. Acute appendicitis b. Acute Salpingitis in females c. Amoebiasis of Caecum Low grade, poorly localized tenderness: Intestinal Obstruction Tenderness out of proportion to examination: a. Mesenteric Ischemia b. Acute Pancreatitis Flank Tenderness: a. Perinephric Abscess b. Retrocaecal Appendicitis

29. Systemic Examination Rovsing’s Sign in Acute Appendicitis Obturator Sign in Pelvic Appendicitis Psoas Sign - Retrocaecal appendicitis - Crohn’s Disease - Perinephric Abscess

30. Systemic Examination Murphy's sign in Acute Cholecystitis Thumping tenderness over lower ribs in inflammation of -Diaphragm - liver or spleen

31. Systemic Examination Pulsatile Abdominal Mass with Hypotension Leaking AAA Cutaneous Hyperaesthesia indicates involvement of Parietal Peritoneum

32. Systemic Examination Per Rectal Examination: - tenderness - induration - mass (Blummer’s shelf) - frank blood

33. Systemic Examination Per Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

34. INVESTIGATIONS Complete Blood Count with differential C-reactive protein estimation Electrolyte ,Blood Urea , Creatinine Urine dipstick Amylase or Lipase Liver Function Test

35. Radiology Upright X ray chest for - Basal Pneumonia - Ruptured Oesophagus - Elevated Hemi diaphragm - Free Gas under diaphragm

36. Radiology Abdominal X ray film Air-Fluid Levels Stones Ascites Eggshell calcification in AAA Air in Biliary tree. Obliteration of Psoas Shadow in retro- peritoneal disease Right lower quadrant sentinel loop in acute appendicitis

37. INVESTIGATIONS Other Investigations - USG - CT abdomen for AAA, Pancreatic disease, or ureteric colic (non- Contrast) - IVU - Mesenteric Angiography for Ischaemia, Haemorrhage

38. THANK YOU