Acute abdomen

1. Modulator: Dr.Shitahun A.(G. Surgeon)
DEBRE BIRHAN UNIVERSITY
COLLEGE OF MEDICINE
ACUTE ABDOMEN
By Zelalem Mekonnen (C-I)
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2. OUTLINE
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 Introduction & anatomic land mark
 Causes of acute abdomen
 Clinical evaluation
 History & physical examination
 Patient evaluation

3. REGION OF ABDOMEN
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5. Acute abdomen
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Previously undiagnosed pain that arises suddenly and is of
less than 7 days' (usually less than 48 hours') duration
Severe, sudden onset of abdominal pain which persists for 6
or more hours and likely needs emergency surgical operation
The acute abdomen does not always signify the need for
surgical intervention; however, surgical evaluation is
warranted
Other symptoms depends on individual disease entities,
duration & other variables

6. Pathologic classification
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1. Obstruction:- small & large bowel
2. Inflammation:- peritonitis, appendicitis, cholecystitis
3. Hemorrhage:- rupture of aneurysms and ectopic
pregnancy
4. Infarction:- mesenteric ischemia
5. Perforation:- peptic ulcer or bowel perforation
6. Strangulation:- gangrenous volvulus, hernias

7. Clinical features
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Abdominal pain
It is the main symptom of acute abdomen
Characterize pain and needs detail information
about abdominal pain and other associated
symptoms

8. Parietal pain
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Parietal peritoneum is innervated unilaterally via
the spinal somatic nerves that also supply the
abdominal wall.
Unilateral innervation causes parietal pain to
localize to one or more abdominal quadrants
Parietal pain is sharp, severe, and well localized

9. Visceral pain
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Visceral peritoneum is innervated bilaterally by the
autonomic nervous system
The bilateral innervation causes visceral pain to be
midline, vague, deep, dull, and poorly localized
Visceral pain signifies intra-abdominal disease but
not necessarily the need for surgical intervention

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Embryologic origin of the affected organ determines the
location of visceral pain in the abdominal midline.
Foregut- from stomach to the second portion of the
duodenum, liver and biliary tract, pancreas, spleen)
present with epigastric pain.

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Midgut – 2nd duodenum to the proximal two thirds of the
transverse colon present with periumbilical pain
Hindgut- from distal transverse colon to the anal verge
present with suprapubic pain

12. Types of visceral pain
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13. Referred pain
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Referred pain arises from a deep visceral structure but is
superficial at the presenting site.
It results from central neural pathways that are common to
the somatic nerves and visceral organs.

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 Biliary tract pain referred to the right inferior scapular area
 Diaphragmatic irritation referred to the ipsilateral
shoulder
 Pain from pleurisy or inferior wall myocardial infarction
may be referred to the epigastric area

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 Quality, severity, and periodicity of the pain may provide
clues to the diagnosis
 Steady, sharp pain accompanies perforated duodenal ulcer
or perforated appendix
 Dull pain which progress to colicky pain is of small bowel
obstruction

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 Pain due to ureteric stone obstruction appear
restless, agitated, or hyperactive and tend to move
about
 Peritoneal inflammation, patient prefer to lie quietly
and remain undisturbed

18. Evaluation of a patient
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 Evaluation influenced by patient history and
physical exam.
 Supportive imaging & lab tests can help to complete the
diagnosis and guide treatment decisions.

19. History
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Onset of Pain
Sudden onset of pain (within seconds) suggests
perforation or rupture
Perforated peptic ulcer or ruptured abdominal aortic
aneurysm.
Infarction, such as myocardial infarction or acute
mesenteric occlusion

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Rapidly accelerating pain (within minutes) may
result from
 Colic syndrome - biliary colic, ureteral colic, and small-
bowel obstruction.
 Inflammatory processes - acute appendicitis, pancreatitis,
and diverticulitis.
 Ischemic processes - mesenteric ischemia, strangulated
obstruction

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Gradual onset of pain (over several hours) increasing
in intensity
 Obstructive processes – non strangulated bowel
obstruction and urinary retention.
 Other mechanical processes - ectopic pregnancy and
penetrating or perforating tumors

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Character of pain
Colicky pain waxes and wanes - Hyperperistalsis of smooth
muscle against a mechanical site of obstruction
 exception is biliary colic, in which pain tends to be
constant.
Pain that is sharp, severe, persistent, and steadily
increases in intensity over time - infectious or
inflammatory process (e.g., appendicitis

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Alleviating & aggravating factors
 What makes the pain worse?
 What makes the pain better?
Peritonitis
 Worsening of pain with movement
 Ameliorated by lying still.

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Pancreatitis
 Aggravating factors - lying supine
 Relieving factors - leaning forward
Duodenal ulcer
 Aggravating factors - hunger
 Relieving factors - food
Gastric ulcer
 Aggravating factors - food
 Relieving factors – hunger, vomiting

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Acute cholecystitis
 Aggravating factors - fatty meal & deep breathing
Appendicitis
 Aggravating factors – movement & cough
 Relieving factors - lying quietly

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Pattern of pain
Constant Vs intermittent
Radiation of pain
Site
 Where is your pain?
Severity
 On a scale of 0-10, how bad is your pain?
 Mild/moderate/severe/very severe/worst possible
pain.

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Associated symptoms
 Vomiting after the onset of pain – appendicitis
 Vomiting before the onset of pain - diagnosis of
gastroenteritis or food poisoning.

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Bilious emesis - distal to the duodenum.
Hemetemesis - a peptic ulcer or gastritis.
Fever or chills - an inflammatory or an infectious
process, or both

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Past medical/surgical history
 Peripheral vascular disease (PAD) or coronary artery
disease (CAD) - AAA or mesenteric ischemia.
 Cancer - bowel obstruction

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Exclude extra-abdominal causes of abdominal pain.
 Diabetic / PAD / CAD - vague epigastric symptoms may
have myocardial ischemia
 Right lower lobe pneumonia - RUQ pain in association
with cough and fever

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Menstrual & sexual history must be obtained in
women
 PID
 Ectopic pregnancy
 Ovarian cyst
 Endometriosis

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Previous abdominal surgeries
 Bowel obstruction
 Incisional hernias
Drugs

33. Physical examination
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General appearance
 Still patients (Peritonitis)
 Restless patients (Ureteric colic)
 Toxic & Weak (septic)
 Jaundices (obstructive jaundice)
Vital sign
 Fever
 Low BP , tachycardia
HEENT
 Dehydration, pallor, Icterus sclera

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Abdominal examination
Inspection: flat/distended/scaphoid, movement with
respiration, scars, bulging mass, hernia sites, erythema,
bruising
Auscultation: bowel sounds, bruits
Palpation:
 Start from areas distant to the site of pain
 Tenderness / rebound tenderness / guarding / mass

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Percussion- resonance and signs of fluid collection,
hyper tympanic
DRE - colonic Ca, intussesception, stool
PV examinations R/o gynecologic cause
Testicular examination

36. Special physical examinations
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Murphy’s sign
Obturator sign
Iliopsoas sign
Rovsing's sign

37. Common Differentials
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Surgical - intestinal obstruction, appendicitis,
cholecystitis, peritonitis, perforated PUD
Gynecologic - pelvic inflammatory disease, ruptured
ectopic pregnancy, ovarian torsion
Medical - to be ruled out- basal pneumonia,
pyelonephritis, enteritis

38. Investigations
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Stool exam
U/A
CBC, Hct
Electrolytes
AST, ALT, Bilirubin
Pancreatic Lipase & amylase
Beta HCG

39. Imaging
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Radiologic test
 Air-fluid level
 Calcifications (stones, fecalith)
 Free gas
Chest X-ray
Ultrasound
Endoscopy
Laparoscopy
Contrast studies

40. Management
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IV fluid administration- saline and ringers solution
Catheterize- U/O and pain relief
Analgesics (IV/IM after diagnosis
Antibiotics
Nasogastric tube- if vomiting or obstruction
Blood transfusion
Oxygen

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Surgery is the main stay of management except for
medical problems

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Decision to operate
 Definite signs of peritonitis - tenderness, guarding, and
rebound tenderness support the decision to operate
 Severe or increasing localized abdominal tenderness
should prompt an operation
 Patients with abdominal pain and signs of sepsis
 Signs of acute intestinal ischemia

43. References
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1. Sabiston Textbook of Surgery, 18th edition
2. Schwartz's principle of surgery , 11th edition
3. Up to date 21.2

44. Thank you
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