PRESENTED BY:NIXON OMULIMI

Definition:
Encompasses a spectrum of surgical, medical and
gynaecological conditions, ranging from trivial to
life-threatening, which require hospital admission,
investigation and treatment. The primary
symptom of the condition is abdominal pain.
‘Abdominal pain of less than 1 week’s duration
requiring admission to hospital, which has not
been previously investigated or treated’
It has been estimated that at least 50% of general
surgical
admissions are emergencies, and of these 50%
present with
acute abdominal pain.
30-day mortality of 4% among patients admitted with
acute
abdominal pain, rising to 8% in those who undergo
operative
treatment.
Affect all age groups, either sex & all socio-economic
groups.
Careful methodical approach required to arrive at
NEUROLOGIC BASIS OF ABDOMINAL PAIN
Pain receptors in the abdomen respond to
mechanical and chemical stimuli.
 Stretch - principal mechanical stimulus involved
in visceral nociception,
Others:distention, contraction, traction,
compression, and torsion.
Visceral receptors responsible for these
sensations are located on serosal surfaces, within
the mesentery, and within the walls of hollow
viscera, in which they exist between the
muscularis mucosa and submucosa.
• Mucosal receptors respond primarily to chemical
stimuli, in contrast to other visceral nociceptors
that respond to chemical or mechanical stimuli.
• Triggers: substance P, bradykinin, serotonin,
histamine, and prostaglandins, released in
response to inflammation or ischemia
Visceral pain
Dull, deep and aching in character, although it
can be colicky; often poorly localized.
Associated with symptoms like nausea,
vomiting.
Due to distention or spasm of a hollow organ.
E.g. in I.O or cholecystitis.
• Parietal pain
Sharp and very well localized. It arises from
peritoneal irritation.
The parietal peritoneum - develops from the
somatopleural layer of the lateral plate
mesoderm.
Nerve supply:- somatic nerves supplying the
abdominal wall musculature and the skin (T5–L2).
Parietal peritoneum is sensitive to mechanical,
thermal or chemical stimulation
Referred pain is aching and perceived to be
near the surface of the body.
Localization of pain
• Most digestive tract pain is perceived in the
midline because of bilaterally symmetric
innervation
• Visceral pain is perceived in the spinal segment at
which the visceral afferent nerves enter the spinal
cord
• E.g afferent nerves mediating pain arising from
the small intestine enter the spinal cord between
T8 to L1. Thus, distension of the small intestine is
usually perceived in the periumbilical region.
Foregut- pain referred to the epigastrium
Midgut- pain referred to the periumbilical
region
Hindgut- pain referred to the hypogastrium
Aetiology
Right upper quadrant Epigastric
• Peptic ulcer disease
• Acute Hepatitis
• Gastroesophageal reflux disease
• Acute Cholecystitis
•
• Gastritis
Cholangitis –
• Pancreatitis
• Pancreatitis
• Myocardial infarction
• Budd-Chiari syndrome
• Pericarditis
• Pneumonia/empyema pleurisy
• Ruptured aortic aneurysm
• Subdiaphragmatic abscess
• Perforated oesophagus
• Liver abscess
• Congestive cardiac failure Periumbilical
• Hepatic infarction • Early appendicitis
• Gastroenteritis
Right lower quadrant
•
• Bowel obstruction
Appendicitis
• Ruptured aortic aneurysm
• Inguinal hernia –strangulated, incarcerated
• Diverticulitis
• Nephrolithiasis
• Mesenteric thrombosis
• Inflammatory bowel disease (UC ,Crohn’s )
• Mesenteric adenitis (yersina)
• Psoas abscess
• Meckel’s diverticulitis
• Salpingitis
• Ectopic pregnancy
• Tubo ovarian abscess
• Ovarian cyst- torsion, rupture, bleeding
• Mittelschmerz
Left upper quadrant Diffuse
• Splenic abscess • Gastroenteritis
• Splenic infarct • Mesenteric ischemia
• Ruptured spleen • Metabolic (eg, DKA, porphyria)
• Pyelonephritis • Malaria
• Pneumonia • Familial Mediterranean fever
• Gastritis • Bowel obstruction
• Gastric ulcer • Peritonitis
• Pancreatitis • Irritable bowel syndrome
• Aortic aneurysm • Sickle cell crisis
Left lower quadrant
• Diverticulitis
• Inguinal hernia
• Nephrolithiasis
• Irritable bowel syndrome
• Inflammatory bowel disease
• Salpingitis
• Ectopic pregnancy
• Tubo ovarian abscess
• Ovarian cyst- torsion, rupture,
bleeding
• Mittelschmerz
Pathogenesis

Two main underlying pathological processes

involved:
2.Inflammation
3.Obstruction.
Inflammation >reactive hyperaemia of the injured
tissue as a result of capillary and arteriolar
dilatation > exudation of fluid into the tissues as a
result of an increase in the permeability of the
vascular endothelium > increase in filtration
pressure. Finally, there is emigration of leukocytes
from the vessels into the inflamed tissues.
 Obstruction
The smooth muscle in the wall of the obstructed
viscus will contract reflexly in an effort to
overcome the impedance.
This reflex contraction produces colicky
abdominal pain. The exception to this rule is
‘biliary colic’. The gallbladder and biliary system
has little smooth muscle in its wall and attempts
at contraction tend to be more continuous than
‘colicky’.
If the obstruction is not overcome, there will be an
increase in intraluminal presure and proximal
dilatation.
 Management

Careful, methodical approach – necessary for

proper management of acute abdomen
Classify the patient:
-Operation necessary
-Operation not immediately necessary
-Operation not necessary
Acute abdominal pain frequently requires urgent
investigation and management.
Initial management = resuscitate before
investigating! Do the ABC.
acute care facility where more appropriate
nursing care and laboratory and radiology
facilities are available.
Patient Evaluation
Detailed clinical Hx:
Pain:- remember SOCRATES
 Site
 Time and mode of onset
 Severity
 Nature -colicky, continous
 Progression
 Duration
 Exacerbating/relieving factors
 Radiation
 Associated symptoms: including fevers, chills, weight loss or gain,
nausea, vomiting, diarrhea, constipation, hematochezia, melena,
jaundice, change in the color of urine or stool.
 Past medical and surgical history, including risk factors for
cardiovascular disease and details of previous abdominal
surgeries.
 Family history of bowel disorders. Alcohol intake. Intake of
medications including over the counter medications such as
 Physical examination. Need a thorough P/E
 Vital signs- really vital
 General examination: The general appearance and level
of comfort or discomfort should be noted, clinical evidence
of anaemia, jaundice, cyanosis and dehydration
 Abdominal exam
 Inspection
- abdominal contour
- movement with respiration
-Does the patient lie still or writhe
-Scars – relevant previous illness, adhesions causing I.O
-Hernia – intestinal obstruction, strangulated
-Visible peristalsis – intestinal obstruction
-Visible masses
Palpation
Is there tenderness, guarding or rigidity?
Are there abnormal masses/palpable organs?
Rebound tenderness – peritonitis
Percussion
 Is the percussion note abnormal? Resonance – intestinal
obstruction
 Loss of liver dullness – gastrointestinal perforation
 Dullness – free fluid, full bladder
 Shifting dullness – free fluid
Auscultation
Are bowel sounds present/abnormal?
Absent sounds – paralytic ileus
Hyperactive sounds – mechanical obstruction, gastroenteritis
Bruit – vascular disease
Specific signs
Murphy’s sign and Boas’s sign-acute cholecystitis
Grey-Turner’s and Cullen’s signs- acute pancreatitis
Rovsing’s sign, Mcburney’s point tenderness-acute
appendicitis
Blumberg’s sign-peritoneal irritation
Do not forget to:
Examine the groin- check for hernias
Do a digital rectal examination
Do a vaginal examination when appropriate
Examine the chest- lungs need to be
examined for signs of consolidation and the
heart for murmurs and rubs.
Resuscitation or emergency surgery may be
needed, so:
- Keep the patient Nill by mouth.
- Intravenous access – large-bore
cannulae.
- Naso-gastric tube.
- Urinary catheter to monitor I/O
- Appropriate analgesia.
- IV Fluids
-Broad spectrum antibiotics
 Investigations
Laboratory investigations
 Complete blood count with differential
 Electrolytes, BUN, creatinine, and glucose
 Aminotransferases, alkaline phosphatase, and bilirubin
 Serum amylase
 Lipase
 Serum calcium
 Urinalysis
 Pregnancy test
 blood and urine cultures
 Arterial BGA.
 G & Save or cross-match.
Radiological investigations
 Plain X-rays
- Erect CXR.-pneumonia, air under the diaphragm
- Supine AXR: Multiple fluid levels, calcification (renal
stones, chronic pancreatitis)
- Left lateral decubitus AXR.
- Ultrasound.
-water soluble contrast studies -LGIT
- CT Scan.
- MRI
 Other investigations:
- Endoscopy – diagnostic & therapeutic.
- Rigid or flexible sigmoidoscopy for sigmoid
volvulus.
- ERCP for acute biliary obstruction.
- Visceral angiography – intestinal ischaemia, angi-
embolization for GI bleeding.
- Laparoscopy.
Diagnostic Peritoneal lavage: in patients
whom you can’t elicit clear signs or with
altered consciouness
Laparotomy – may be the ultimate
diagnostic procedure. Needed for
peritonitis or ruptured viscus
Definitive management – dependent on
specific aetiology.
Prognosis: depends on aetiology