Approach to a patient with acute abdomen

Sapna Philip Sr. Vinaya, Sr. Benit

Acute abdomen: Definition

Severe abdominal pain with duration of onset less than eight hours

Approach
History
Clinical examination Laboratory data Extra-abdominal causes Special circumstances

Approach
History
Clinical examination Laboratory data Extra-abdominal causes Special circumstances

History: Chronology
Onset

Rapidity of onset is a measure of severity

Sudden-onset, severe, well localized pain: intraabdominal catastrophe (perforated viscus, mesenteric
infarction, ruptured aneurysm)

Duration Longer duration before consultation suggests less severe disease

Onset of common causes

Onset
Sudden

Condition
Perforated peptic ulcer, mesenteric ischemia / infarction, ruptured aneurysm, ruptured ectopic pregnancy
Cholecystitis, pancreatitis

Rapid

Gradual

Appendicitis, diverticulitis, small bowel obstruction, gastroenteritis, pelvic inflammatory disease

History: Chronology
Progression Self-limited (e.g., gastroenteritis) Progressive (e.g., appendicitis)

Colicky crescendo-decrescendo (e.g., ureteric)

Patterns of pain

Self-limited

Colic

Progressive

Catastrophic

History: Location
A stimulus may cause confusion by resulting in visceral, somatoparietal and referred pain Knowledge of neuroanatomic pathways therefore essential Change in location may represent progression from visceral to parietal irritation, or development of diffuse peritoneal irritation

Location of common causes

Location
Periumbilical

Conditions
Appendicitis (later, RLQ), small bowel obstruction, mesenteric ischemia / infarction, gastroenteritis Cholecystitis Pancreatitis Diverticulitis (left), pelvic inflammatory disease, ruptured ectopic pregnancy Pancreatitis, ruptured aortic aneurysm

Right upper quadrant Epigastric, left upper quadrant Lower quadrants Back

History: Intensity and character

Intensity difficult to characterize

Depends on individual, setting, past experiences, personality, cultural differences Generally, severity of pain reflects magnitude of stimulus

Intensity of common causes

Intensity
Mild Moderate

Condition
Gastroenteritis, diverticulitis Appendicitis, cholecystitis, pancreatitis (or severe), small bowel obstruction, pelvic inflammatory disease, ruptured ectopic pregnancy Perforated peptic ulcer, mesenteric ischemia / infarction, ruptured aneurysm

Severe

Character of common causes

Character
Localized

Condition
Cholecystitis, pancreatitis, diverticulitis, perforated peptic ulcer (later, diffuse), pelvic inflammatory disease, ruptured ectopic pregnancy Gastroenteritis, appendicitis (later, localized), small bowel obstruction, mesenteric ischemia / infarct, ruptured aneurysm

Diffuse

History: Aggravating and alleviating factors

Position (motionless in peritonitis, writhing in colic) Meal type (fatty food and biliary colic) Meal time (aggravated by meal in gastric ulcer and mesenteric
ischemia, relieved by meal in duodenal ulcer)

Bowel movements Medication (antacid in ulcer disease) Stress

History: Associated symptoms

Constitutional symptoms (fever, weight loss, myalgia) Digestive disturbances (anorexia, nausea / vomiting,
flatulence, diarrhea / constipation)

Jaundice Dysuria Menstrual disturbances

History: Past, family and social history

Similar previous history Systemic illness (scleroderma, lupus, porphyria, sickle cell) Medication Substance abuse Occupation

Travel

Physical examination
Systemic
Appearance, breathing, position, discomfort, facial expression

Vital signs
Lungs (pneumonia), extremities (perfusion)

Physical examination
Abdomen

Inspection: Distension, scars, hernia, rigidity,

ecchymoses, visible peristalsis Palpation: Degree and location of tenderness; mass Light percussion Auscultation: Hyperperistalsis, bruits Genitals, rectum, pelvis

Extra-abdominal causes
Cardiac Myocardial infarction, myocarditis, endocarditis
Pneumonia, pleurodynia, pulmonary infarction, pneumothorax, esophageal rupture Radiculitis, abdominal epilepsy, tabes Uremia, diabetes [DKA], porphyria, Addisons, hyperparathyroidism, hyperlipidemia

Thoracic

Neurologic Metabolic

Extra-abdominal causes
Hematologic Sickle cell, hemolysis, acute leukemia, Henoch-Schnlein purpura Hypersensitivity reactions, lead Herpes zoster, typhoid, osteomyelitis Muscular lesions, narcotic withdrawal, familial Mediterranean fever, psychiatric disorders, heat stroke

Toxins Infections Miscellaneous

Special circumstances
Extremes of age

Pregnancy
Immunocompromised host

If symptoms disproportionate to abdominal signs,

consider
Metabolic causes Extra-abdominal causes Ischemic events

Laboratory data
Tailor to individual need Complete blood count, urinalysis, metabolic parameters in all Renal and liver profile as indicated, but essential preoperatively

Amylase, pregnancy test where indicated

Radiology
Plain abdominal series in all (supine, and upright or left lateral decubitus): 10% diagnostic for pathology Chest radiograph in all (pneumoperitoneum, pneumonia)

Ultrasonography
Doppler studies as indicated CT abdomen and pelvis: most versatile (gas, calcifications,
mass lesions, trauma, vascular lesions, hemorrhage)

Specialist diagnostic tests

Peritoneal lavage (hemoperitoneum, purulent or feculent
material)

Laparoscopy (may also be therapeutic)

Exploratory laparotomy (where diagnosis is obvious or where

delay in therapy is life-threatening)

Management in ER
Emergency management
Supportive Symptomatic

Specific measures

Management in ER
Airway, Breathing, Circulation
Ensure
IV access (large bore)

Oxygenation
Monitoring vitals (oxymetry, BP, urine output)

Send labs (counts, sugar, creatinine, electrolytes,

ABG, amylase, grouping, ECG, blood culture [if

indicated])

Management in ER
NPO / NG tube IV fluids (crystalloids / colloids) Analgesics as indicated

Empiric antibiotic if indicated

Imaging as appropriate (X-ray abdomen / chest, USG / CT)

Inform specialist