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Acute abdomen
Prof. M K Alam M S ; F R C S
Learning objectives
 Definition of acute abdomen
 Anatomy and physiology of abdominal pain.
 Pathophysiology of common causes of acute abdomen.
 Symptoms and signs of acute abdomen in relation to
the underlying pathology
 Laboratory and imaging investigations
 Initial and definitive management
Definition
Acute abdomen: a clinical presentation
of
abdominal pain and tenderness,
that often requires emergency
surgical therapy.
• Some non-surgical or non intra-abdominal
diseases, can present with acute abdominal
pain.
• Every attempt should be made to make a
correct diagnosis so that an appropriate
therapy is given
Types of abdominal pain
• Visceral
• Parietal
Visceral pain
• Vague, poorly localized
• Splanchnic nerves
• Usually the result of distention of a hollow viscus
• Depending on the origin of the affected organ from the
primitive foregut, midgut, or hindgut, the pain is localized to
epigastrium, periumbilical , or hypogastrium respectively
Parietal pain
-Corresponds to the segmental nerve roots
(somatic nervous system) innervating the
peritoneum.
-Sharper and better localized.
Referred pain
Definition:
Pain perceived at a site distant from
the source of stimulus.
Common examples of referred pain:
Right shoulder- Gall bladder
Left shoulder- Heart, tail of pancreas, spleen (Kehr's sign)
Scrotum and testis- ureter
Pain locations (Great degree of overlap)
• Right hypochondrium.- gallbladder
• Left hypochondrium.- pancreas
• Epigastrium.- Stomach and duodenum
• Lumber- kidney
• Umbilical- small bowel, caecum, retroperitoneal
• Right iliac fossa- Appendix, caecum
• Left iliac fossa- Sigmoid colon
• Hypogastrium- Colon, urinary bladder, adenexae
Pathophysiology
Surgical Acute Abdominal Conditions
• Infection- Appendicitis, cholecystitis
• Perforation- Perforated duodenal ulcer
• Obstruction- Small bowel adhesions, obstructed hernia,
sigmoid volvulus
• Ischemia- Mesenteric ischemia (thrombosis/ embolism)
strangulated hernia
• Hemorrhage- Ruptured ectopic pregnancy, ruptured
aneurysm, solid organ trauma
Nonsurgical Causes of Acute
Abdomen
• Diabetic crisis
• Uremia
• Hereditary Mediterranean fever
• Sickle cell crisis
• Acute leukemia
Pathophysiology: Acute appendicitis
• Most common general surgical emergency
• Derived from the midgut
• Obstruction of the lumen (fecalith, lymphoid hyperplasia,
vegetable matter or seeds, parasites) is
the major cause of
acute appendicitis.
• Obstruction contributes to bacterial overgrowth,
Pathophysiology: Acute appendicitis
• Continued secretion of mucus leads to intraluminal distention.
• Distention produces the visceral pain sensation as
periumbilical pain.
• Promote a localized inflammatory process
• May progress to gangrene and perforation.
• Inflammation of the adjacent peritoneum- localized pain in the
right lower quadrant.
• Perforation usually occurs after 48 hours from the onset of
symptoms
Pathophysiology- peritonitis
• Introduction of bacteria or irritating chemicals
into the peritoneal cavity cause peritoneal
inflammation
• A localized inflammation (appendicitis) produce
sharply localized pain and normal bowel sounds
• A diffuse process (perforated viscus) produces
generalized peritonitis causing generalized
abdominal pain with a quiet abdomen
Types of peritonitis
• Secondary peritonitis: more common, secondary to an
inflammatory insult from within abdomen, most often gramnegative infections with enteric organisms or anaerobes. Exampleappendicitis
• Primary peritonitis: uncommon.
Children: Pneumococcus or hemolytic Streptococcus.
Adults: peritoneal dialysis for end-stage renal dis.(gram+ve cocci),
ascites and cirrhosis(Escherichia coli and Klebsiella)
• Noninfectious inflammation- pancreatitis (chemical peritonitis)
Pathophysiology: Small bowel obstruction
• Post-operative adhesion- most common
• Hernia, tumour, Crohn’s disease- other causes
• Early- the intestinal contraction increases to propel contents past
the obstructing point (colicky pain)
• Later- the intestine becomes fatigued and dilates, contractions
becoming less intense.
• Bowel dilates, water and electrolytes accumulate in lumen and in
the bowel wall.
• Massive third-space fluid loss: dehydration and hypovolemia.
• Intraluminal pressure increases in the bowel, a decrease in mucosal
blood flow occurs.
Pathophysiology: Mesenteric Ischemia
• Arterial: embolism, thrombosis
• Venous: thrombosis
• Superior mesenteric vessel distribution
• Intestinal mucosal sloughing within 3 hours of
onset and
• Full-thickness intestinal infarction by 6 hours
Symptoms & Signs
in
Acute abdomen
Main symptom- Abdominal pain
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Location: finger vs hand
Severity:
Onset: sudden in perforation, ischemia, biliary colic
Progress: develops and worsens over several hours is
typical of progressive inflammation or infection such as
appendicitis, cholecystitis
Spasmodic: Biliary colic, or genitourinary obstruction
Radiation and shift: cholecystitis, appendicitis
Exacerbating factors: food worsen pain of bowel
obstruction
Relieving factors: food relieves pain of non-perforated
peptic ulcer disease or gastritis.
Associated symptoms
• Vomiting likely to precede significant abdominal pain in medical
conditions whereas pain presents first in acute surgical abdomen.
• Constipation or obstipation can be a result of either mechanical
obstruction or decreased peristalsis (ileus).
• Diarrhea is associated with several medical causes of acute
abdomen, including infectious enteritis, inflammatory bowel
disease (IBD), and parasitic contamination
• Bloody diarrhea- IBD, Colonic ischemia
PHYSICAL EXAMINATION
(Inspection)
• Inspection of the patient:
• Ischemic bowel and ureteral and biliary colic, typically cause
patients to continually shift and fidget in bed while trying to find a
position that lessens their discomfort.
• Patients with peritonitis lie very still in the bed during the
evaluation and often maintain flexion of their knees and hips to
reduce tension on the anterior abdominal wall.
Inspection of the abdomen
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Distension
Restricted mobility- ?peritonitis
Scars of previous surgery
Hernias
Mass effect
Ecchymosis ? Acute pancreatitis (Cullen’s, Grey
Turner’s sign)
Palpation of the abdomen
• Start gently, away from the area of pain.
• Severity and exact location of tendernesslocalized/ generalized
• Involuntary guarding
• Organomegaly, mass
• Murphy’s sign, Rovsing’s sign,
• Rebound tenderness (Blumberg’s sign)
Percussion of the abdomen
• Hyperresonance :distended bowel loops
• Dullness due to organomegaly or mass
• Liver dullness lost- free intra-abdominal air is suspected.
• Shifting dullness
• Tenderness
Auscultation of the abdomen
• Quiet abdomen- ileus
• Hyperactive bowel sounds- enteritis, ischemic
intestine
• Mechanical bowel obstruction- high-pitched
“tinkling” sounds that come in rushes and are
associated with pain
• Bruits- high-grade arterial stenosis
Digital rectal examination
• Performed in all patients with acute
abdominal pain
• Checking for mass, pelvic pain, or intraluminal
blood
• Pelvic examination in female
Investigations
Routine laboratory investigations
• Hematology: WBC count, differential count, hemoglobin,
platelets, red blood cells
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Electrolytes, urea, creatinine
Amylase, lipase
LFTs: Bilirubin (T & D), alkaline phosphatase, aminotransferase,
Serum lactate & arterial blood gas
Urine analysis
Urine human chorionic gonadotropin
Stool for parasites
• WBC count: confirm infection
• Electrolytes, blood urea nitrogen, and creatinine:
the effect of vomiting or third-space fluid losses
• Serum amylase and lipase- acute pancreatitis, small
bowel infarction or duodenal ulcer perforation
• Liver function tests: biliary tract
disease.
• Lactate levels and arterial blood gas:
intestinal
ischemia or infarction.
• Urinalysis: bacterial cystitis, pyelonephritis, diabetes.
• Urinary human chorionic gonadotropin: suggest
pregnancy as a factor in the patient's presentation or aid in
decision making regarding therapy.
• Stool: occult blood, parasite, Cl. Difficile (toxin & culture).
Plain radiographs
• Upright chest radiographs – free gas under
the dome of diaphragm
Perforated duodenal ulcer-75%
• Lateral decubitus abdominal radiographspneumoperitoneum in patients who cannot
stand
Plain x-ray abdomen
• Calcifications: renal stones 90%, chronic
pancreatic, aortic aneurysms, fecalith
• Supine and upright films: distension, fluid levels,
gas distribution (small vs large bowel), volvulus
of sigmoid colon/ cecum
Abdominal ultrasonography
• Gallbladder: stone, wall thickness, fluid around
gallbladder, diameter of bile ducts
• Liver: abscess, other masses
• Pelvis: Ovarian, adnexal & uterine pathologies
• Free fluid in peritoneum
• Limited evaluation of pancreas
• Limitations: bowel gas, person dependent, difficult
to interpret for most surgeons
CT abdomen
• Widely available
• Easier to interpret by surgeons
• Imaging modality of choice in acute abdomen,
following plain abdominal radiographs.
• Accuracy and utility of CT abdomen and pelvis
in acute abdominal pain is well established.
• Most common causes of acute abdomen are
readily identified by CT
• Highly accurate in acute appendicitis,
mechanical bowel obstruction, intestinal
ischemia
DIAGNOSTIC LAPAROSCOPY
• Ability to diagnose and treat a number of the
conditions causing an acute abdomen
• High sensitivity and specificity
• Decreased morbidity and mortality, decreased
length of stay, and decreased overall hospital costs
• Advances in equipment and greater availability
DIFFERENTIAL DIAGNOSIS
• Differential diagnosis of acute abdominal pain is extensive.
• Comprehensive knowledge of the medical and surgical
conditions that create acute abdominal pain
• Mild, self-limited illness to the rapidly progressive and fatal
• Evaluated immediately upon presentation and reassessed at
frequent intervals.
• Many acute abdomen require surgical intervention but some
abdominal pain are medical in aetiology.
Management
Preoperative preparation
• Fluid and electrolyte abnormalities corrected
• Antibiotic infusions for the bacteria common in acute
abdominal emergencies (gram-negative enteric organisms and
anaerobes)
• Nasogastric tube to decrease the likelihood of vomiting
and aspiration
• Foley catheter- to assess urine output -0.5 mL/kg/hour
• Blood typed and cross matched for operation
Preoperative preparation
• Frequent evaluation of the patient
• Stabilization of co-morbid conditions
• Surgical vs non- surgical management
• Consent for surgery
Surgical intervention
• Excision: Appendectomy, cholecystectomy, tumors.
• Resection and anastomosis: Bowel tumors, gangrenous
bowel,
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Relieve obstruction: Hernia, division of adhesion.
Repair of perforation: Perforated DU, stomach, ileum
Drainage: Appendicular abscess.
Bowel diversion: Colostomy.
Non-surgical intervention
• Conservative management: NPO, IV fluid, antibiotics
• Radiological intervention: PCD, placing stents in obstructed
bowel.
• Endoscopic intervention: Bile duct decompression.
Thank you!