THE ACUTE ABDOME
an overviewBy
Hamdy Sedky.MD,MRCSLecturer Of GI Surgery
Definition Etiology
Presenting symptoms
Physical examination
Investigations
Treatment
Any unexpected spontaneous (non-
traumatic) disorder whose chief
manifestations are in the abdominal area
and for which urgent operation may be
necessary.
Definition
Etiology Presenting symptoms
Physical examination
Investigations
Treatment
Surgical causes
Gastrointestinal tract disorders
Appendicitis
Small and large bowel obstruction
Perforated peptic ulcer
Incarcerated hernia
Bowel perforation
Meckel's diverticulitis
Boerhaave's syndrome
Diverticulitis
Inflammatory bowel disorders
Mallory-Weiss syndrome
Gastroenteritis
Acute gastritis
Mesenteric adenitis
Parasitic infections
Pancreatic disorders
Acute pancreatitis
Liver, spleen, and biliary tract disorders
Acute cholecystitis
Acute cholangitis
Hepatic abscess
Ruptured hepatic tumor
Spontaneous rupture of the spleen
Splenic infarct
Biliary pain
Acute hepatitis
Urinary tract disorders
Ureteral or renal colic
Acute pyelonephritis
Acute cystitis
Renal infarct
Gynecologic disorders
Ruptured ectopic pregnancy
Twisted ovarian tumor
Ruptured ovarian follicle cyst
Acute salpingitis
Dysmenorrhea
Endometriosis
Vascular disorders
Ruptured aortic and visceral aneurysms
Acute ischemic colitis
Mesenteric ischaemia
Peritoneal disorders
Intra-abdominal abscesses
Peritonitis
Tuberculous peritonitis
Retroperitoneal disorders
Retroperitoneal hemorrhage
MEDICAL CAUSES Endocrine and metabolic disorders
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria
Acute hyperlipoproteinemia
Hereditary Mediterranean fever
Hematologic disorders
Sickle cell crisis
Acute leukemia
Other dyscrasias
Toxins and drugs
Lead and other heavy metal poisoning
Narcotic withdrawal
Black widow spider poisoning
Infections and inflammatory disorders
Tabes dorsalis
Herpes zoster
Acute rheumatic fever
Henoch-Schonlein purpura
Systemic lupus erythematosus
Polyarteritis nodosa
Referred pain Thoracic region
Myocardial infarction
Acute pericarditis
Pneumonia
Pleurisy
Pulmonary embolus
Pneumothorax
Empyema
Hip and back
Definition
Etiology
Presenting symptoms Physical examination
Investigations
Treatment
Abdominal pain
The most common,
The most predominant and
The most important
symptom of an acute abdomen.
(1) Location of Pain
The abdominal region has a dual
nerve supply; visceral and somatic,
abdominal pain may be visceral or
parietal
Visceral pain
Stimuli: Stretching of peritoneum or organ capsules
Traction on the bowel mesentery
Inflammation
Ischemia
Sensation: Diffuse and poorly localized, deep seated, slow in onset, dull in character,
and protracted.
May be perceived at remote locations related to organ’s sensory innervation
that corresponds to its embryologic origin (foregut, midgut, hindgut)
Example:
Visceral pain sites.
Somatic pain
Stimuli
› Irritation of parietal peritoneum
Sensation
› Well-localized pain
› Of acute onset
› Sharp pain
› More superficial
› Easily described
Example:
Change in pain location
› Referred pain
› Radiating pain
› Shifting pain
› Spreading pain
Change in pain location
(2) Mode of Onset and Progression of Pain
May be
Explosive (within seconds),
Rapidly progressive (within 1-2 hours), or
Gradual (over several hours).
Sudden, excruciating generalized pain
suggests an intra-abdominal catastrophe
Examples: perforated viscus or
rupture of an aneurysm,
ectopic pregnancy.
A less dramatic onset of a mild pain that
increases gradually over 1-2 hours
Examples:
acute cholecystitis,
acute pancreatitis,
strangulated bowel,
mesenteric infarction,
high small bowel obstruction.
(3) Character of Pain
The sharp superficial constant pain is typical of perforated ulcer
or a ruptured appendix.
The gripping pain of small bowel obstruction is usually
intermittent, vague, deep-seated, and crescendo decrescendo
Pain associated with bowel obstruction is severe but bearable,
while pain caused obstruction of smaller conduits (bile ducts and
ureters) rapidly becomes unbearably intense.
The aching discomfort of ulcer pain,
The stabbing pain of acute pancreatitis and mesenteric infarction,
The tearing pain of ruptured AAA.
Location and character of pain
Definition
Etiology
Presenting symptoms
Physical examination Investigations
Treatment
General condition
Disturbed conscious level
Facies
Gait
Decubitus:
The rolling patients
The rigidly motionless patient
The bent sitting patient
The patient with a flexed Rt. hip
Fever Constant low-grade fever:
diverticulitis,
acute cholecystitis, and
appendicitis.
High fever (> 39 °C), disorientation, and rigors indicate
impending septic shock:
advanced peritonitis,
acute cholangitis, or
pyelonephritis.
Pitfall:
elderly,
chronically ill, or
immunosuppressed patients.
Systemic signs extreme pallor,
Cyanosis
Jaundice
Hypo hyperthermia,
hypotension
tachycardia,
tachypnea
Sweating
Foeter hepaticus, fruity odour
Inspection
Your eyes are always first
A distended abdomen with a scar or a hernia
A scaphoid contracted abdomen
Visible peristalsis
Diminished respiratory abdominal wall movements
Pulsations
A visible swelling
Skin abnormalities
Palpation Guarding and rigidity
Tenderness:
is the most important finding in acute abdomen.
Types:
Localized
Rebound
Cross
Cough
Percussion
Palpation
Murphy's sign
Iliopsoas sign
Obturator sign
Costovertebral angle tenderness
Palpation
Swellings:
Inflammatory mass
Tumours
Intussusception
Ischaemic bowel
The tense tympanic balloon
Palpation
Hyperaesthesia:
Sherren’s triangle
Boas’s sign
In renal inflammatory lesions
In salpingitis
Hernial orifices
The scrotum
Percussion
Percussion tenderness
Liver dullness.
Free peritoneal fluid
The diffusely dull abdomen
Auscultation
Loud peristalsis synchronous with colic are heard in mid
small bowel obstruction
The high-pitched hyperperistaltic sounds unrelated to the
crampy pain in enteritis.
A silent abdomen except for infrequent tinkling sounds in
late bowel obstruction or diffuse peritonitis.
Pelvic examination
Rectal examination
Pelvic examination:
Definition
Etiology
Presenting symptoms
Physical examination
Investigations
Treatment
The abdominal series
Advantages
Readily available
Mobile
Don’t need radiologist
Disadvantages
2D image
Radiation dose (40x effective dose of CXR)
Relatively low sensitivity
The abdominal series
It includes: PA erect chest,
AP supine and
AP erect abdomen
If patient unable to sit/stand: supine and
left lateral decubitus abdomen
The abdominal series
What to look for: Bowel distension
Bowel wall thickening/oedema (>3mm)
Intramural gas
Free intraperitoneal gas
Calcification
Stones
Pancreatic
Vascular
Psoas shadows
Free intraperitoneal gas
Ultrasonography
Ultrasonography is helpful in evaluating: Acute cholecystitis, cholangitis
Acute appendicitis
Complicated external hernias
Renal and ureteric lesions
Intra-abdominal free and localized fluid collections
Transanal and transvaginal probes for evaluating
pelvic pathology specially in females
Young/pregnant patients with abdominal symptoms
Ultrasonography Advantages
No radiation
Mobile
Allows real time visualisation, eg peristalsis
Excellent contrast between fluid and soft tissue, eg
gallbladder
Disadvantages
Operator dependent
Poor images in larger patients
Bowel gas
CT scan
Advantages
Very high resolution images (esp. multislice CT)
Higher diagnostic accuracy
No problems with obese patients/bowel gas
Disadvantages
High radiation dose (approximately 200x CXR)
Side effects of IV contrast (nephrotoxicity, allergy, etc)
Not portable (cf AXR and ultrasound)
CT Scan
CT is helpful in:
Examining retroperitoneal organs (Acute pancreatitis)
Detecting sites of inflammatory diseases that may prompt
(appendicitis, tubo-ovarian abscess) or postpone (diverticulitis,
pancreatitis, hepatic abscess) operation.
Identifying small amounts of free intraperitoneal gas
Free localized intraperitoneal and retroperitoneal fluid
Bowel ischaemia/perforation/obstruction
Vascular pathology, eg intraabdominal aneurysm, MVO
Obese patients
Unresolved diagnosis following AXR/US
angiography
Selective visceral angiography is useful
in:
mesenteric infarction,
ruptured liver adenoma or carcinoma or
ruptured abdominal aneurysm
Endoscopy
Proctosigmoidoscopy is indicated in any patient
with acute abdomen and suspected segmoid
volvulous
Paracentesis In patients with free peritoneal fluid, aspiration of
blood, bile, or bowel contents is an indication for
urgent laparotomy.
Infected ascitic fluid may establish a diagnosis in
spontaneous bacterial peritonitis, tuberculous
peritonitis, or chylous ascites which rarely
require surgery.
Culdocentesis may be useful for suspected
ruptured corpus luteum cyst.
Laparoscopy
In female patients in the child bearing period
presenting with lower abdominal pain.
In obtunded, elderly, or critically ill patients.
In adhesive bowel obstruction
Definition
Etiology
Presenting symptoms
Physical examination
Investigations
Treatment
Indications for surgery in acute abdomen
Physical findings
Involuntary guarding or rigidity, especially if spreading
Increasing or severe localized tenderness
Tense or progressive distention
Tender abdominal or rectal mass with high fever or
hypotension
Equivocal abdominal findings along with Sepsis
Suspected ischemia (acidosis, fever, tachycardia)
Deterioration on conservative treatment
Indications for surgery in acute abdomen
Radiologic findings
Pneumoperitoneum
Gross or progressive bowel distention
Free extravasation of contrast material
Space-occupying lesion on scan, with fever
Mesenteric occlusion on angiography
Endoscopic findings
Perforated or uncontrollably bleeding lesion
Paracentesis findings
Blood, bile, pus, bowel contents, or urine
Treatment of the Acute Abdomen
ABCDE
large bore IV lines with either saline or lactated Ringer’s
solution
IV pain medication
Nasogastric tube if vomiting or concerned about
obstruction
Foley catheter to follow hydration status and to obtain
urinalysis
Antibiotic administration if suspicious of inflammation or
perforation
Definitive therapy or procedure will vary with diagnosis
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