This document discusses the approach to acute abdominal pain, emphasizing the distinction between benign and serious conditions, and the need for urgent surgical intervention in life-threatening cases. It highlights the significant number of emergency admissions for abdominal pain and stresses the importance of experienced surgeons in triaging cases effectively. The document also outlines key symptoms, signs, diagnostic investigations, and pre-operative optimization strategies to improve patient outcomes.

1. Approach to the
Acute Abdomen
DR. Mohamad Al-Gailani ‫الكيالني‬ ‫محمد‬ ‫الدكتور‬
Chief of Surgery ‫الجراحة‬ ‫قسم‬ ‫رئيس‬
Al Hammadi Hospital, Nuzha ‫الحمادي‬ ‫مستشفى‬
,
‫النزهة‬
Riyadh ‫الرياض‬
KSA ‫السعود‬ ‫العربية‬ ‫المملكة‬
‫ية‬

2. ABDOMINAL PAIN
Overview
• 5 to 10% of ER visits.
• Can be a challenging complaint because it is
frequently a benign complaint, but it can also herald
serious acute pathology.
• AIM: To determine which patients can be safely
observed or treated symptomatically and which
require further investigation or specialist referral.
• 80% of patients discharged with undifferentiated
abdominal pain improve or become pain-free within
two weeks of presentation.
“UpToDate 2022”
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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3. THE ACUTE ABDOMEN
• The rapid onset of severe symptoms of abdominal
pathology
• May indicate a potentially life-threatening condition
• Usually requires urgent surgical intervention
• Linear relationship between delay in treatment and
mortality!
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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4. THE BURDEN & SCALE OF ACUTE ABDOMEN
Commissioning Guide, Emergency General Surgery
ASGBI & RCSE 2014
• Annually 600,000 Emergency Admissions under the care of
General Surgeons in England.
• Over half present with Abdominal Pain.
• Data from the Emergency Laparotomy Network confirm
that Emergency Laparotomy still carries a mortality of
15% overall with even higher risks in the elderly and
comorbid.
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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5. • Access to an experienced Surgeon reduces unnecessary
admissions.
• At the other end of the spectrum, around 90,000 patients
annually are admitted with non-specific abdominal pain,
where no further diagnosis is forthcoming.
ASGBI & RCSE 2014
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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THE BURDEN & SCALE OF ACUTE ABDOMEN
Commissioning Guide, Emergency General Surgery
ASGBI & RCSE 2014

6. ACUTE ABDOMEN
THE IMMEDIATE ASSESSMENT
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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7. ACUTE ABDOMEN
THE IMMEDIATE ASSESSMENT
• Triage: Distinguishing patients with True Acute
Abdomen that requires urgent surgical intervention
from patients who can initially be managed
conservatively.
Silen W. Cope's early diagnosis of the acute abdomen. 22nd ed. New
York, NY: Oxford University Press; 2010
• Experienced Surgeons are pivotal in making the right
distinction!
ASGBI & RCSE 2014
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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8. ACUTE ABDOMEN
SYMPTOMS: Salient Pain Features
1. Any Pain of Over 6 hours is likely Surgical!
2. Pain first, then Vomiting is likely Surgical!
3. Vomiting first, then Pain is likely Medical!
4. Shifting Pain e.g. Central > RIF
5. Worsening Pain!
6. Anorexia associated with pain, is likely Surgical!
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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9. ACUTE ABDOMEN
SIGNS: Salient Features
• Resistance to move, bed bound!
• Clammy, Sweaty, Fever, Tachycardia (Beware! Patients on
Beta Blockers)
• Tenderness, Rebound, Guarding & Board Like Rigidity
• Beware! Minimal abdominal signs in retrocaecal
appendicitis or patients on immunosuppressants!
• Silent Abdomen (absent bowel sounds)
• PR essential! (blood, tenderness, mass)
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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10. ACUTE ABDOMEN
INVESTIGATIONS: BLOOD
• CBC, ESR, CRP, PROCALCITONIN (Anaemia, Leucocytosis, Inflammatory
Markers)
• U & E (Renal Impairment, Electrolyte Imbalance)
• LFT, AMYLASE, LIPASE (Pancreatitis!)
• Blood Glucose (DKA, Undiagnosed DM)
• Clotting studies (Bleeding Tendency & Diseases)
• Pregnancy test (Ectopic!)
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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11. ACUTE ABDOMEN
INVESTIGATIONS: IMAGING
• ERECT CXR…Essential!
• PLAIN AXR…Essential!
• ULTRASOUND…Routine
• C/T…Likely
• OTHERS: Angiography, Radionuclide, MRI. (According to Need)
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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12. PRE-OPERATIVE
OPTIMIZATION BEFORE SURGERY
• ICU Admission
• Resuscitation
• Pain relief
• Fluid replacement
• Antibiotics
• Nasogastric tube
• Foley’s catheter
• Central & Arterial Lines
• Speak to Next of Kin!
• Consent!
• High Risk Consent!
• Prepare Blood!
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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13. INDICATIONS
LAPAROTOMY / LAPAROSCOPY
1. When the diagnosis is certain e.g. Perforated Viscous
2. Generalized peritonitis.
3. Pneumoperitoneum!
4. Equivocal Abdominal Findings PLUS+:
Septicaemia.
Suspected ischaemia.
Deterioration on conservative treatment.
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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14. CLINICAL SCENARIOS
Q & A
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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15. DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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Case 1
Patient presented to ER in shock
with several hours worsening
abdominal and back pain. He had
had mild back pain for some
weeks.
Q: What does the plain abdominal
film show?

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Answer 1
Abdominal Aortic Aneurysm
(AAA)
Dx:
Leaking AAA
Dx suspected on Plain AXR, Proven on CT

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Case 2
75 year old man presented to ER
with acute abdominal pain and
bloody diarrhoea.
Q: What does the plain abdominal
film show?

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Answer 2
Colitis with Toxic
Megacolon
Dx suspected on Plain AXR, Proven on CT
Over 12 cm

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Case 3
Acute epigastric pain of sudden
onset.
Q: What is the diagnosis?

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Answer 3
Pneumoperitoneum.
Perforated Viscous
Dx suspected on Plain AXR, Proven on CT

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Case 4
62 year old woman presented to ER
with one week history of increasing
abdominal pain and distension. She
gave a long history of chronic
constipation.
Q: What does the X-ray show?

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Answer 4
Sigmoid Volvulus
Dx suspected on Plain AXR
Proven on CT Inverted-U sign
Bent Inner Tube sign
Coffee Bean sign

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Case 5
A 55 year old admitted
with a one day history of
epigastric pain and an
acute abdomen.
Q: What is the
Diagnosis?

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Answer 5:
Severe Necrotizing
Pancreatitis
Routine Amylase & Lipase High
Diagnosis Suspected on Plain AXR
Proven on CT
CT Plain AXR

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Case 6
24 Year-Old Female
Right Iliac Fossa Pain.
CT scan.
What are the Findings?
Q: What is the Diagnosis?

26. DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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Routine Beta HCG- HIGH
US suggested possible Right Adnexal Mass
CT reported Right Adnexal Mass, possible
Ectopic
Rx: Diagnostic Laparoscopy
Answer 6:
Right Ectopic Pregnancy

27. NON-SURGICAL
(MEDICAL) ABDOMINAL PAIN
• ACUTE MESENTERIC ADENITIS, YERSINIA
PSEUDOTUBERCULOSIS.
• DIABETIC KETOACIDOSIS, ADDISONIAN CRISIS
• ACUTE INTERMITTENT PORPHYRIA, SYSTEMIC LUPUS
ERYTHEMATOSIS, HENOCH-SHONLEIN PURPURA.
• BLOOD DISORDERS: SICKLE CELL CRISIS, ACUTE LEUKAEMIA.
DR. Mohamad Al-Gailani FRCS Approach to the Acute Abdomen AHH Riyadh, KSA
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28. CONCLUSION
THE ACUTE ADOMEN IS A POTENTIALLY LIFE
THREATENING CONDITION
EARLY AND ENERGETIC INTERVENTION IS CRUCIAL
ERECT CXR & PLAIN AXR MUST BE ROUTINE ER
INVESTIGATIONS
ACCESS TO AN EXPERIENCED SURGEON REDUCES
UNNECESSARY ADMISSIONS AND EXPEDITES THE
MANAGEMENT OF TRUE SURGICAL EMERGENCIES.
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