Acute Abdomen

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Definition
Include a group of conditions that
present with acute onset of
abdominal pain.
Acute abdomen is characterized
by any sudden, spontaneous,
nontraumatic, severe abdominal
pain of less than 24hours
duration, and for which urgent
operation may be necessary.
Evaluation of abdominal pain
- history
Location
Quality
Severity
Onset
Duration
Modifyingfactors
Change over time
Origin of pain
Visceral pain
◦Originating from hollow or solid organs;
midline pain due to stretching of fibres
innervating the walls of hollow and solid
organs
◦Present as Steady ache or vague
discomfort to excruciating or colicky pain
◦Poorly localized
◦Epigastric region: stomach, duodenum,
biliary tract
◦Periumbilical: small bowel, appendix,
cecum
◦Suprapubic: colon, sigmoid, GU tract
Origin of pain
Parietal pain
◦Due to irritation of parietal
peritoneum
◦Localized pain
◦Causes tenderness and
guarding which progress to
rigidity and rebound as
peritonitis develops
 Origin of pain
Referred pain
◦ Pain is felt at a site away from
pathological organ.
◦ Produces symptoms not signs
◦ It is Based on developmental embryology
 Ureteral obstruction → testicular pain
 Subdiaphragmatic irritation → ipsilateral
shoulder or supraclavicular pain
 Gynecologic pathology → back or
proximal lower extremity
 Biliary disease → right intrascapular pain
 MI → epigastric, neck, jaw or upper
extremity pain
Which systems to review
GI symptoms
◦ Nausea, vomiting, hematemesis,
anorexia, diarrhea, constipation,
bloody stools, melena stools
GU symptoms
◦ Dysuria, frequency, urgency,
hematuria, incontinence
Gyn symptoms
◦ Vaginal discharge, vaginal bleeding
General
◦ Fever, lightheadedness
Past Medical history
GI
◦Past abdominal surgeries, h/o Gall
Bladder disease, ulcers; FamHx
Irritable Bowel Disease
GU
◦Past surgeries, h/o kidney stones,
pyelonephritis, UTI
Gyn
◦Last menses, sexual activity,
contraception, h/o Pelvic
Inflammatory Disease or STDs, h/o
ovarian cysts, past gynecological
surgeries, pregnancies
 Past medical history
Vascular
◦h/o Myocardial Infarction, heart
disease, atrial-fibrillation,
anticoagulation, Congestive Heart
Failure, Peripheral Vascular Disease,
Fam Hx of Abdominal Aortic
Aneurysm
Other medical history
◦DM, organ transplant, HIV/AIDS,
cancer
Social
◦Tobacco, drugs – Especially cocaine,
alcohol
Medications
◦NSAIDs, H2 blockers, PPIs,
 Physical Examination
General
◦Pallor, diaphoresis, general
appearance, level of distress or
discomfort, is the patient lying still
or moving around in the bed
Vital Signs
◦Orthostatic VS when volume
depletion is suspected
Cardiac
◦Arrhythmias
Lungs
◦Pneumonia
 Physical exam
Abdomen
◦ Look for distention, scars, masses
◦ Auscultate – hyperactive or obstructive
BS increase likelihood of SBO fivefold –
otherwise not very helpful
◦ Palpate for tenderness, masses, aortic
aneurysm, organomegaly, rebound,
guarding, rigidity
◦ Percuss for tympany
◦ Look for hernias!
◦ rectal exam
Back
◦ Costovertebral Angle tenderness
Physical exam
Pelvic exam
◦ Cervical Motion Tenderness
◦ Vaginal discharge – Culture
◦ Adnexal mass or fullness
 Abdominal Findings
Guarding
◦Voluntary
 Contraction of abdominal
musculature in anticipation of
palpation
 Diminish by having patient flex
knees
◦Involuntary
 Reflex spasm of abdominal muscles
 aka: rigidity
 Suggests peritoneal irritation
 Abdominal findings
Rebound
◦Present in 1 of 4 patients without
peritonitis
Pain referred to the point of
maximum tenderness when palpating
an adjacent quadrant is suggestive of
peritonitis
◦Rovsing’s sign in appendicitis
Rectal exam
◦Little evidence that tenderness adds
any useful information beyond
abdominal examination
◦Gross blood or melena indicates a GI
Bleebing.
 Differential Diagnosis
Gastritis, ileitis, Abdominal wall
colitis, syndromes:
esophagitis muscle strain,
Ulcers: gastric,
hematomas,
peptic, trauma,
esophageal Bowel
Biliary disease:
cholelithiasis, obstruction,
cholecystitis volvulus
Hepatitis, Diverticulitis
pancreatitis, Appendicitis
Cholangitis Ovarian torsion
Splenic infarct, Hernias:
Splenic rupture incarcerated,
Pancreatic strangulated
pseudocyst Kidney stones
Hollow viscous
perforation
Differential dx
Pyelonephritis Testicular torsion
Hydronephrosis Epididymitis,
Inflammatory bowel
prostatitis,
disease: crohns, orchitis, cystitis
Gastroenteritis,
Constipation
enterocolitis
pseudomembranous Abdominal aortic
colitis, ischemia aneurysm,
colitis ruptures
Tumors: aneurysm
carcinomas, lipomas Aortic dissection
Meckel's
Mesenteric
diverticulum
ischemia
Differential dx
Mercury salts Sickle cell crisis
Acute inorganic Vasculitis
lead poisoning Irritable bowel
Electrical injury
syndrome
Opioid withdrawal Ectopic
Mushroom toxicity pregnancy
Diabetic Pelvic
ketoacidosis Inflammatory
Adrenal crisis Disease.
Thyroid storm Urinary retention
Hypo- and Ileus, Ogilvie
hypercalcemia syndrome
Differential dx
Myocardial
infarction
Acute pericarditis
Pneumonia
Pulmonary
embolism
Pneumothorax
Conditions of the
hip and back.
All these causes
referred pain
Most Common Causes of
Acute Bdomen in the ED
 Non-specific abd pain34%
 Appendicitis 28%
 Biliary tract dz 10%
 Small Bowel Obstruction 4%
 Gyn disease 4%
 Pancreatitis 3%
 Renal colic 3%
 Perforated ulcer 3%
 Cancer 2%
 Diverticular dz 2%
 Other 6%
Investigations
Depends what you are looking
for!
Labs
◦CBC: “What’s the white count?”
◦Chemistries
 UEC
 Liver function tests, Lipase
◦Coagulation studies
◦Urinalysis, urine culture
◦Lactate
 Investigations
Abdominal series  CT abdomen/pelvis
◦ Erect abdominal ◦ Noncontract for
xray free air, renal
◦ Lateral decubitus colic, ruptured
xray AAA, (bowel
Ultrasound obstruction)
◦ Contrast study for
◦ Good for diagnosing abscess, infection,
Abd Aortic inflammation,
Aneurysm but not unknown cause
ruptured AAA  MRI
◦ Good for pelvic ◦ Most often used
pathology when unable to
obtain CT due to
contrast issue
 Indication for surgical

exploration
Surgery is sometimes necessary
without precise diagnosis.
Physical findings that indicate
laparotomy.
Involuntary guarding and rigidity.
Increasing or severe localized
tenderness
Tense or progressive distension of the
abdomen
Tense abdomen or rectal mass with
high fever..
Rectal bleeding with shock or acidosis.
Indication for surgical
exploration
Endoscopic findings:
◦ Perforated or uncontrollable bleeding
lesion.
Radiological finding:
◦ Pneumoperitoneum
◦ Gross or progressive bowel
distension (obstruction)
◦ Free extravasation of contrast
(perforation)
◦ Mesenteric occlusion
Indication for surgical
exploration
Paracentesis aspirates:
◦ Blood
◦ Bile
◦ Pus
◦ Bowel content
◦ Urine
APPENDICITIS
Appendicitis
Isan inflammation of the
vermiform appendix that develop
most common in adolescents and
young adults
Incidence
Appendicitis is the most common
acute surgical condition of the
abdomen.
Approximately 7% of the
population will have appendicitis
in their life time, with peak of
incidence occurring between the
ages of 10-30 years.
Pathophysiology
 Pathophysiology
Obstruction of the appendiceal lumen By
food matter, adhesions, or lymphoid
hyperplasia, fecalith.
Mucous secretion in the appendix continue
to increase intraluminal pressure.
Eventually the pressure exceeds capillary
perfusion pressure and venous and
lymphatic drainage are obstructed.
With vascular compromise, epithelial
mucosa breaks down and bacterial
invasion by bowel flora occurs.
Pathophysiology
Increased pressure also leads to
arterial stasis and tissue
infarction due to reduced oxygen
supply.
End result is perforation and
spillage of infected appendiceal
contents into the peritoneum
causing peritonitis.
 Symptoms
Primary symptom: abdominal pain
Pain beginning in epigastrium or periumbilical area
that is vague and hard to localize.
As the illness progresses RLQ localization typically
occurs.
Associated symptoms:
◦indigestion,
◦discomfort,
◦flatus,
◦need to defecate,
◦anorexia, nausea, vomiting
Signs
Tenderness to deep palpation
over McBurney’s point (just below
the middle of a line connecting
the umbilicus and the ASIS)
Rebound tenderness,
Voluntary guarding,
Muscular rigidity,
Tenderness on rectal- pelvic
appendix
Fever: late finding.
Physical Exam
Rovsing’s sign: pain in RLQ with
palpation to LLQ
Psoas sign: place patient in Left
lateral decubitus and extend Right leg
at the hip. If there is pain with this
movement, then the sign is positive.
Obturator sign: passively flex the R
hip and knee and internally rotate the
hip. If there is increased pain then
the sign is positive
Diagnosis
Acute appendicitis should be
suspected in anyone with
epigastric, periumbilical, right
flank, or right sided abd pain who
has not had an appendectomy.
Investigations
Women of child bearing age:
Pelvic exam
Pregnancy test.
Everybody:
CBC, - elevated WBC
UA, - R/o UTI
imaging studies
Diagnosis
Imaging studies:
1.Xrays of abdomen
Abnormal findings include:
fecalith, appendiceal gas, localized
paralytic ileu, and free air
Abdominal xrays have limited use
b/c the findings are seen in
multiple other processes
Diagnosis
2. Graded Compression US:
Basis of this technique is that
normal bowel and appendix can be
compressed whereas an inflamed
appendix can not be compressed.
Limitations of US: retrocecal
appendix may not be visualized,
perforations may be missed due to
return to normal diameter
Diagnosis
CT scan abdomen: best choice
based on availability and
alternative diagnoses.
More sensitive, accurate, -
predictive value
(ALVARADO Scoring
system
(MANTRELS): DIAGNOSIS
Symptom Score
1
Migratory abdominal
pain
1
Anorexia
1
Nausea
signs
2
Tenderness
1
Rebound tenderness
1
Symptom score
a

Lab findings
2
Leukocytosis
1
Shift to the left
10
Maximum

Score of >/= 7 is strongly

predictive of acute
appendicitis
Treatment
Appendectomy.
Patients should be NPO, given
IVF, and preoperative antibiotics
Antibiotics are most effective
when given preoperatively and
they decrease post-op infections
and abscess formation
Types of incision
Gridiron: centered on McBurney's
point
Lanz incision (Transverse or skin
crease incision)
Rutherford Morison's incision
Possible complications
Wound infection
Intra-abdominal abscess
Fecal fistula
Intestinal obstruction
Incisional hernia
Peritonitis
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