The Acute Abdomen

Andik Kusbiantoro
SMF Ilmu Bedah RSUD Dr.R.Soedjono Selong

Definition
Acute
abdomen
describes
clinical
condition as result of emergency situations
intra abdominal condition that needs
immediate surgical intervention
with pain as main symptom

Introduction
Challenge to Surgeons & Physicians
Most common cause of surgical emergency
admission
Clinical course can vary from from minutes to
hours to weeks.
It can be an acute exacerbation of a chronic
problem.

Assesment
Well elicited history
Proper physical examination
Diagnosis can be made most of the time by
a good history and a proper physical
examination.

Assesment (cont)
Investigations are usually carried out :
only to support the diagnosis.
or to narrow down the differential
diagnoses.

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

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

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
Mid of period-ovulation pain (Mittel- schmerz)
With heavy periods- endometriosis
Family history of colon cancer, any other
malignancy or inflammatory bowel disease

Pain

The Most Important Symptom

History of pain should include:
1. Onset
2. Severity
3. Type of pain
4. Radiation of Pain
5. Change in nature of Pain
6. Associated bowel or urinary symptoms
7. Aggravating or relieving factors

Onset of Pain (cont)

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 (cont)

Progression from :
Dull, aching, poorly localized character
To:
Sharp, constant & better localized pain
indicates involvement of Parietal peritoneum

Table 1. Sensory innervations of intra abdominal

structures

Structure

Nerve

Level

Middle part of
Diaphragm

Phrenicus

C 3-5

Edge of diaphragm,
stomach, pancreas,
gall bladder, intestine

Plexus celiac

Th 6-9

Appendix,proximal
colon

Plexus mesentericus

Th 10-11

Distal colon, rectum,

kidney, urethra &
testis

Splanchnic caudal

Th 11-L 1

Vesica urinary, recto

sigmoid

S 2-4

Figure 1. Innervations of diaphragm and shoulder

Referred Pain

Shifting Pain

Figure 2.Referred pain and shifting pain in the acute

abdomen

Abrupt, excruciating pain

Rapid onset of severe, constant pain

IMA

Perforated
ulcer

Colic billier

Ruptured
aneurysm

Colic ureter

Acute pancreatitis

Mesenteric thrombosis,
strangulated bowel

Ectopic pregnancy

Gradual, steady pain

Acute cholecystitis,
acute cholangitis,
acute hepatitis

Intermittent, colicky pain with free interval

Early
pancreatitis
(rare)
Small bowel
obstruction

Appendicitis,
salpingitis

IBD

Colic billier

Figure 3. The location and character of the pain are useful in the differential
diagnosis of the acute abdomen

Nausea & Vomiting

Frequency of vomiting
Character of vomiting:
projectile, non-projectile or self-induced
Nature of vomiting:
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

Urinary Symptoms
with Pain
Ureteric colic
Cystitis

Table 2. Physical findings with various causes of acute

abdomen

Conditions

Helpful sign

Perforated viscous

Scaphoid (early), tense abdomen, diminished

bowel sound (late), loss of liver dullness,
guarding or rigidity

Peritonitis

Motionless, absent bowel sound (late), rebound

tenderness, guarding

Inflamed mass or abscess

Tender mass, special sign (Murphy's, obturator or

psoas)

Intestinal obstruction

Distention, visible peristaltis (late),

hyperperistaltis (early) or quiet abdomen (late),
diffuse pain, hernia (some)

Paralytic ileus

Distention, minimal bowel sound

Ischemic or strangulated
bowel

Not distended (until late), severe pain, rectal

bleeding (some)

Bleeding

Pallor, shock, distention, pulsatile (aneurysm)

Figure 3. Causes of shock in patients with acute abdomen

Consideration of Surgery Intervention

Decision of surgery intervention on acute
abdomen depends on correct diagnosis. If
we got difficulties to make decision, we
should observe patient closely.
Meanwhile patient must fasting, apply
naso gastric tube and IV line

Table 3. Indications for urgent operations in patients

with acute abdomen
Physical findings
Involuntary guarding or rigidity, especially if spreading
Increasing or severe localized tenderness
Tense or progressive distention
Tender or abdominal or rectal mass with high fever or hypotension
Rectal bleeding with shock or acidosis
Radiologic findings
Pneumoperitoneum
Gross or progressive bowel distention
Free extravasations of contrast material
Space occupying lesion on scan, with fever
Mesenteric occlusion on angiography

Summary
Acute abdomen is serious surgical
emergency requiring the surgeon to
combine the result of the history and
physical examination with properly
selected laboratory and radiographic
studies
Correct preoperative diagnosis will usually
lead to a successful operation

Physical Examination
General Appearance
a. Anxious Patient lying motionless:
(i) Acute appendicitis
(ii) Peritonitis
b. Rolling in bed & restless:
(i) Ureteric Colic
(ii) Intestinal colic
c. Writhing in Pain:
Mesenteric Ischemia

Physical Examination (cont...)

d. Bending Forward:
Chronic Pancreatitis
e. Jaundiced:
CBD obstruction
f. Dehydrated
(i) Peritonitis
(ii) Small Bowel obstruction

Physical Examination (cont...)

Vital Charting
Temperature, Pulse, BP, Respiratory rate
Ruptured AAA or ectopic pregnancy can lead to
-Pallor
-Hypotension
-Tachycardia
-Tachypnea

Physical Examination (cont...)

Low grade temp. is seen with
- Appendicitis
- Acute cholecystitis
High grade temp. is seen with
- Salpingitis
- Abscess
Very High Grade Temp.with increasing lethargy
seen in imminent septic shock
- Peritonitis
- Acute cholangitis
- Pyonephrosis

Extra abdominal conditions that causes

abdominal pain
These may rarely present as referred
abdominal pain.
The most important to remember :
Pneumonia (especially lower lobe)
Myocardial Infarction.

Those diseases tend to be Medical

diseases and surgery is not generally
indicated

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
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 & boardlike. 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
Rovsings Sign in Acute Appendicitis
Obturator Sign in Pelvic Appendicitis
Psoas Sign
Retrocaecal appendicitis
Crohns Disease
Perinephric Abscess

Murphy's sign in Acute Cholecystitis

Systemic Examination
Per Rectal Examination:
- tenderness
- induration
- mass
- frank blood

Investigations

Complete Blood Count with differential

C-reactive protein estimation
Electrolyte, Blood Urea, Creatinine
Urine dipstick
Amylase or Lipase
Liver Function Test

Radiology
Chest x ray
Abdominal x ray

Investigations
Other Investigations
- USG
- CT abdomen for AAA, Pancreatic disease,
or ureteric colic (non- Contrast)
- IVU
- Mesenteric Angiography for
Ischaemia, Haemorrhage

THANK YOU