Acute Abdomen

Mr. Adam Mohamed Ibrahim

September 2015
Definition
It is an intraabdominal process causing severe
pain and often requiring surgical
intervention. It is a condition that requires a
fairly immediate judgment or decision as to
.management
Definition
Aspect of surgical, medical & gynecological
conditions that ranging from trivial to live
threatening which required hospital admition,
. investigations & treatment
Definition
Acute Abdomen is a term used synonymously
for a condition that needs immediate surgical
intervention
Epidemiology
General causes of the acute abdomen may be
:divided into six large categories
a. inflammatory
b. mechanical
c. neoplastic
d. vascular
e. congenital defects
f. traumatic
Epidemiology
:The most common causes
Non-specific abdominal pain -1
Acute appendicitis -2
Acute biliary disease-3
Bowel obstruction-4
.Diverticulitits in elderly patients-5

Acute appendicitis represents the cause of

surgical intervention in two-thirds of the
.children with acute abdomen
Inflammatory causes
The inflammatory category of causes may be
:divided into two subgroups
bacterial, and 2) chemical. Some common )1
examples of the bacterial causes would
include acute appendicitis, diverticulitis, and
some cases of pelvic inflammatory disease.
An example of a chemical cause would be a
perforation of a peptic ulcer, where spillage
of acid gastric contents causes an intense
.peritoneal reaction
Mechanical causes
Mechanical causes of an acute abdomen
include such obstructive conditions as
incarcerated hernia
post-operative adhesions
intussusception
malrotation of the gut with volvulus
.congenital atresia or stenosis of the gut
The most common cause of large bowel
mechanical obstruction is carcinoma of the
.colon
Vascular
Vascular entities producing an acute abdomen
include mesenteric arterial thrombosis or
embolism. When the blood supply is cut off,
necrosis of tissue results, with gangrene of
.the bowel
Congenital
Congenital defects can produce an acute
abdominal surgical emergency any time from
the minute of birth (with conditions such as
duodenal atresia, omphalocele or
diaphragmatic hernia) to years afterward in
conditions such as chronic malrotation of the
.intestine
Traumatic causes
Traumatic causes of an acute abdomen range
from stab and gunshot wounds to blunt
abdominal injuries producing such conditions
as splenic rupture. History or evidence of
trauma should make this diagnosis fairly
.obvious
Diagnosis
Well elicited history
Proper physical examination
Diagnosis can be made most of the time by a
good history and a proper physical
.examination
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
Abdominal Pain
The Most Important Symptom
:History of pain should include
Onset .1
Severity .2
Type of pain .3
Radiation of Pain .4
Change in nature of Pain .5
Associated bowel or urinary symptoms .6
Aggravating or relieving factors .7
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
Progression of pain
:Progression from
Dull, aching, poorly localized character

:To
Sharp, constant & better localized pain
indicates involvement of Parietal
peritoneum
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
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
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
NAUSEA & VOMITING
Frequency of vomiting )i(

:Character of vomiting )ii(

projectile, non-projectile or self-induced

:Nature of vomiting )iii(

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
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
Vomiting (cont.)
Vomiting is very prominent in
.a. Mallory-Weiss syndrome
b. Boerhaave syndrome(trans- mural
esophageal tear)
c. Acute gastritis
d. Acute pancreatitis
Anorexia
Anorexia or decreased appetite with pain is
usually seen in Acute appendicitis
Urinary Symptoms
with Paincolic
Ureteric
Cystitis
FEVER & CHILLS/RIGORS
Amoebic Liver Abscess
Pygenic Liver Abscess
Perinephric Abscess
Intra-abdominal pus collection
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

Missed period- ectopic pregnancy )i(
Mid of period-ovulation pain (Mittel- schmerz) )ii(
With heavy periods- endometriosis )iii(

Family history of colon cancer, any other

malignancy or inflammatory bowel disease
Physical Examination
General Appearance
:a. Anxious Patient lying motionless
Acute appendicitis )i(
Peritonitis )ii(
:b. Rolling in bed & restless
Ureteric Colic )i(
Intestinal colic )ii(
:c. Writhing in Pain
Mesenteric Ischemia
Physical Examination
(contd.)
:d. Bending Forward
Acute Pancreatitis
:e. Jaundiced
CBD obstruction
f. Dehydrated
Peritonitis )i(
Small Bowel obstruction )ii(
Physical Examination
(contd.)
Vital Charting
Temperature, Pulse, BP, Respiratory rate
Ruptured AAA or ectopic pregnancy can
lead to
Pallor-
Hypotension-
Tachycardia-
Tachypnea-
Physical Examination
(contd.)
Low grade fever is seen with
Appendicitis -
Acute cholecystitis -
High grade fever is seen with -
Salpingitis -
Abscess -
Very High Grade fever with increasing lethargy
seen in imminent septic shock
-Peritonitis -
Acute cholangitis -
Pyonepheritis - -
Systemic Examination
Cardiopulmonary examination
:Check for
Possible MI -
Basal Pneumonia -
Pleural Effusion -
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)
Systemic Examination
Erythema or discolouration
a. Peri-umbilical - Cullen sign
b. Inguinal – Fox sign
c. Flanks - Grey Turner sign
Seen in Hemorrhagic pancreatitis

Any Visible masses

Any visible cough impulse at hernia site
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
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
Systemic Examination
Rovsing’s Sign in Acute Appendicitis
Obturator Sign in Pelvic Appendicitis
Psoas Sign
Retrocaecal appendicitis -
Crohn’s Disease -
Perinephric Abscess -
Systemic Examination
Murphy's sign in Acute Cholecystitis
Thumping tenderness over lower ribs in
inflammation of
Diaphragm-
liver or spleen -
Systemic Examination
Pulsatile Abdominal Mass with
Hypotension
Leaking AAA
Cutaneous Hyperaesthesia
indicates involvement of
Parietal Peritoneum
Systemic Examination
:Per Rectal Examination
tenderness -
induration -
mass (Blummer’s shelf) -
frank blood -
Systemic Examination
Per Vaginal Examination
Bleeding -
Discharge -
Cervical motion tenderness -
Adnexal masses or tenderness -
Uterine Size or Contour -
INVESTIGATIONS
Complete Blood Count with differential
C-reactive protein estimation
Electrolyte ,Blood Urea , Creatinine
Urine dipstick
Amylase or Lipase
Liver Function Test
Radiology
Upright X ray chest for
Basal Pneumonia -
Ruptured Oesophagus -
Elevated Hemi diaphragm -
Free Gas under diaphragm -
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
INVESTIGATIONS
Other Investigations
USG -
CT abdomen for AAA, Pancreatic disease, or -
ureteric colic (non- Contrast)
IVU -
Mesenteric Angiography for -
Ischaemia, Haemorrhage
THANK
YOU