Acute Abdomen

YIN Detao MD
Department of General Surgery,
the First Affiliated Hospital of
ZhengZhou University
Term

The term acute abdomen denotes any

sudden nontraumatic disorder whose
chief manifestation is in the abdominal
area and for which urgent operation
may be necessary.
The approach to a patient with acute
abdomen must be orderly and thorough.
Acute abdomen must be suspected even if
the patient has only mild or atypical
complaints.
The history and physical examination should
suggest the probable causes and guide the
choice of diagnostic studies.
一 . HISTORY

 ( 一 ). Abdominal Pain
 Pain is usually the predominant and
presenting feature of acute abdomen.
1. Location of Pain:
 Visceral pain is elicited either by distention,
inflammation, or ischemia stimulating the receptor
neurons or by direct involvement of sensory nerves.
 The centrally perceived sensation is generally slow in
onset, dull, poorly localized, and protracted. Parietal
pain is responsible for the transmission of more
acute, sharper, better-localized pain sensation.
 So parietal pain is more easily localized than visceral
pain.
Abdomen pain may be referred or may
shift to sites far removed from the
primarily affected organs.
The term referred pain denotes
noxious sensations perceived at a site
distant from the site of a strong primary
stimulus.
Pain may be referred to the shoulder
from lesions such as pleurisy or basal
pneumonia, especially in young
patients.
Although more often perceived in the
right scapular region, referred biliary
pain may mimic angina pectoris if it is
felt in the epigastric or left shoulder
areas.
Spreading or shifting pain parallels the
course of the underlying condition.
Beginning classically in the epigastric
or periumbilical region, the incipient
visceral pain of acute appendicitis later
shift to become sharper parietal pain in
the right lower quadrant.
The location of pain serves only as
rough guide to the diagnosis and
typical descriptions are reported in only
two-thirds of cases.
2.Mode of onset and progression of
pain:

The mode of onset of pain reflects the

nature and severity of the inciting
process. Onset may be explosive
(within seconds), rapidly progressive
(within1-2 hours), or gradual (over
several hours).
A less dramatic clinical picture is
steady mild pain becoming intensely
centered in a well-defined area within
1-2 hours, especially in acute
cholecystitis, acute pancreatitis,
strangulated bowel, renal or ureteral
colic, etc.
3. Character of pain:

The nature, severity, and periodicity of

pain provide useful clues to the
underlying cause.
Steady pain is most common.
 Agonizing pain denotes serious or advanced
disease. Colicky pain is usually promptly
alleviated by analgesics.
 Nonspecific abdominal pain is usually mild,
but mild pain may also be found with
perforated ulcers or mild acute pancreatitis.
 Past episodes of pain and factors that
aggravate or relieve pain should be noted.
 ( 二 ). Other symptoms
associated with abdominal
pain
 1. Vomiting:

Pain in acute surgical abdomen usually

precedes vomiting;in medical conditions,
the reverse is true.
Severe incontrollable retching provides
temporary pain relief a moderate attacks
of pancreatitis. The absence of bile in the
vomitus is a feature of pyloric stenosis.
 2. Constipation:

Constipation itself is hardly an absolute

indicator of intestinal obstruction.
However, obstipation strongly suggests
mechanical bowel obstruction if there is
progressive painful abdominal distention
or repeated vomiting.
3. Diarrhea:

Blood-stained diarrhea suggests

ulcerative colitis, crohn’s disease, or
bacillary or amebic dysentery.
4. Specific gastrointestinal symptoms:

These are extremely helpful if present.

Jaundice suggests hepatobiliary
disorders; hematuria, ureteral colic or
cysititis.
 ( 三 ). Other relevant
aspects of history
1. Menstrual history:

The menstrual history is crucial to the

diagnosis of ectopic pregnancy and
endometriosis.
2. Drug history:

The drug history is important not only

in perioperative management but also
because it may offer a diagnostic clue.
3. Family history:

The family history often provides the

best information about medical causes
of acute abdomen.
4. Travel history:

 A travel history may raise the

possibility of amebic liver abscess,
malarial spleen, tuberculosis, etc.
二 . Physical examination
1. General observation:

General observation affords a fairly

reliable indication of the severity of the
clinical situation.
2. Systemic signs:

Systemic signs usually accompany

rapidly progressive or advanced
disorders associated with acute
abdomen.
Extreme pallor, tachycardia,
tachypnea, and sweating suggest
major intra-abdominal hemorrhage.
3. Fever:

Low-grade fever is common in

inflammatory conditions such as acute
cholecystitis, and appendicitis.
High fever with lower abdominal
tenderness in a young woman without
signs of systemic illness suggests
acute salpingitis.
4. Examination of abdomen

Inspection of abdomen:

The abdomen should be carefully

inspected before palpation.
Auscultation of abdomen:

Auscultation of the abdomen should

also precede palpation. An abdomen
that is silent except for infrequent tinkly
or squeaky sounds marks late bowel
obstruction or diffuse peritonitis.
Percussion of abdomen:

With a perforated viscus, free air

accumulating under the diaphragm
may efface normal liver dullness.
Palpation of abdomen:

Palpation is performed with the patient

resting in a comfortable supine position.
If there is voluntary spasm, the muscle
will be felt to relax when the patient
inhales deeply through the mouth.
Tenderness that connotes localized peritoneal
inflammation is perhaps the most important
finding in patients with acute abdomen.
Compared with the degree of pain,
unexpectedly little and only poorly localized
tenderness is elicited in uncomplicated hollow
viscus obstruction.
5. Abdominal masses

 Abdominal masses are usually

detected by deep palpation.
Superficial lesions such as a distended
gallbladder or appendiceal abscess are
often tender and have discrete borders.
Deeper masses may be adherent to the
posterior or lateral abdominal wall.
As a result, their borders are ill-defined,
and only dull pain may be elicited by
palpation.
三 . Diagnostic imaging
The role of the radiologist in the
evaluation of the patient with an acute
abdomen has evolved greatly in the
past decade.
Moreover, CT and ultrasonography
play an increasing role in the
evaluation of this complex, emergent
clinical problem.
四 . Treatment
1. Nonoperative treatment:

General supportive therapy;

Antibiotics.
2. Operative treatment:

 If the nonoperative treatment is

inefficient, then we need operation.