MANAGEMENT OF ACUTE

ABDOMEN BY SURGICAL SIDE

CURRENT PRYMARY APPROACH, DIAGNOSTIC, MANAGEMENT AND
REFERRAL

Tomy Lesmana

Acute Abdomen

Abdominal pain of short duration that

requires a decision regarding whether an
urgent intervention is necessary (Moshe
Schein 2005)

Doc, which of them has an

acute abdomen?

Why Acute Abdomen is Special?

Abdominal pain is one of the most

frequent reasons to visit physician
offices and ERs
Early diagnosis is the key to improving
outcomes
An accurate history and complete
physical examination are more
important than any diagnostic test

avoid further morbidity and

Appproach to Abdominal
Pain

Take Pain to Elicit Pain History

Location and character

Onset
Intensity
Patterns of radiation and refferal of pain
Duration and progression
Profocative and palliating factors
Previous episodes
Mc Namara. Emerg Med Clin N Am
2011
Macaluso. Int J Gen Med 2012

Take Pain to Elicit Pain History

Location and character

Onset Site of pain gives you some idea
about site of pathology
Intensity

PatternsSomatic?
of radiation and refferal of pain
Visceral?
Duration and progression
Profocative and palliating factors
Previous episodes

Take Pain to Elicit Pain History

Location and character

Sudden (several second/minutes)
Onset
Ruptured AAA, perforated ulcer,
Intensity torsion, ectopic pregnancy

(1-2 hour)
Patterns Acute
of radiation
and refferal of pain
Acute cholecystitis, pancreatitis,
Duration and
progression
strangulation,
mesenterial infark,
obstruction
Profocativesmall
and bowel
palliating
factors
Gradual (several hours)
Previous episodes
Appendicitis, inacarcerated hernia,
large bowel obstruction, peptic ulcer

Take Pain to Elicit Pain History

Location and character

Onset
Intensity
Patterns of radiation and refferal of pain
Duration and progression
Profocative and palliating factors
Previous episodes

Take Pain to Elicit Pain History

Location and character

Onset
Intensity
Patterns of radiation and refferal of pain
Duration and progression
Profocative and palliating factors
Previous episodes

Take Pain to Elicit Pain History

Location and character

Onset
Intensity
Patterns of radiation and refferal of pain
Duration and progression
Profocative
and palliating factors
Acute appendicitis
Perforated
duodenal ulcer
Previous
episodes
Intestinal obstruction: colicky
constant
somatic pain
(perforated)

Take Pain to Elicit Pain History

Location and character

Onset
Intensity
Peptic ulcer
Cholelithiasis
Patterns of radiation
and refferal of pain
irritation
Duration and Peritoneal
progression
(cough/walk)
Profocative and palliating factors
Previous episodes

Take Pain to Elicit Pain History

Location and character

Onset
Intensity
Cholelithiasis
Patterns of radiation
and refferal of pain
Ureterolithiasis
Diverticulitis
Duration and progression
Partial bowel
Profocative and palliating factors
obstruction
Previous episodes

PQRST mnemonic

P
Q
R3

3 : positional, palliating, and provoking factors

S
T

: quality
: region, radiation, referral
: severity
: temporal factors (time and mode of onset,
progression, previous episodes).
Mc Namara. Emerg Med Clin N Am
2011

Assessment of the Associated Symptoms

Anorexia
Vomiting
Constipation
Diarrhea
Other symptoms:

Jaundice
Hematocezia
Hematemesis
Hematuria

Past Medical/Surgical
History

Medications
Allergies
Past Surgical History

Previous abdominal or pelvic operations

Prior work up for abdominal pain

Past Medical History

Diabetes
Cardiovascular disease
Gastrointestinal disease

Phisical Examination

General Appearance

Lies perfectly still

Restless, writhing

Obstruction colic

Bending forward

Chronic pancreatitis
Facial expression
Vital Sign

Inflammation, peritonitis

Abdominal Examination

Art of Bed Side

Test for Peritoneal Irritation

Often innacurate
Rebound tenderness

Muscle guarding and rigidity

Voluntary VS involuntary
Localized VS generalized
Knees and hips flexed
Work toward area of pain
Warm hands
Abdominal wall tension troughout the respiratory cycle

Abdominal Pain Exam Dont Forget

Cardiopulmonary examination

MI, basal pneumonia, pleural effusion

Rectal exam for tenderness, mass, blood

Vaginal/pelvic exam for discharge,
tenderness (PID)

Differential Diagnosis

the Clinical Patterns of Acute Abdomen

Abdominal pain and shock

Generalized peritonitis

Appendicitis/cholecystitis

Intestinal obstruction

Hollow organ perforation

Localized peritonitis

Ruptured Aneurisma/Ectopic/Hemorrhagic Pancreatitis

Mechanical/functional

Medical illness

Inferior wall AMI/diabetic ketoacidosis

Scheins Common Sense Emergency Abdominal

Abdominal Pain and Shock

Ruptured abdominal aortic aneurism
Ruptured ectopic pregnancy
Surgical rescuscitation

3rd space fluid loss

Intestinal obstruction
Acute mesenteric ischemia
Severe acute pancreatitis

Generalized Peritonitis

diffuse severe abdominal pain

looks sick and toxic
lies motionless
extremely tender abdomen
with peritoneal signs

Perforated ulcer
Colonic perforation
Perforated
appendicitis

Generalized Peritonitis

Management: pre-operative preparation

and operation (surgery tonight).
The patient should be taken to the
operating room only after adequate preoperative preparation
Pitfall: acute pancreatitis

Localized Peritonitis

Localized Peritonitis

Often not an indication for a surgery

tonight policy
Uncertain diagnosis initially be treated
conservatively

admitted to the surgical floor

intravenous antibiotics
Hydration
actively observed (serial physical exams)

Intestinal Obstruction

Simptoms

Central, colicky abdominal pain

Distension
Constipation
Vomiting.

Sign

Distention
Increased bowel sound

Intestinal obstruction

Useful Tips:
1.
Small bowel Vs Large bowel
2.
Scarred abdomen Vs Virgin abdomen
3.
Never forget to look for Femoral hernia
4.
Mechanical Vs Functional bowel
obstruction

True/Pseudo obstruction

Small vs Large bowel

Symptoms

Small Bowel
Obstruction

Large Bowel
Obstruction

Colicky Pain

+++

Vomiting

+++

Distension

++

++++

Constipation

+++

Virgin Abdomen Vs Scarred

Abdomen

Strangulated Hernia
Crohns/TB
Intussusception
Cancer

In cases of Acute abdomen

Never forget to look for Femoral Hernia

Intestinal Obstruction

Management

Intravenous fluid
NGt decompression
Antibiotics
Conservative / Operative

Important Medical Causes

Acute myocard infark

Diabetic ketoacidosis
Porphyria
Basal pneumonia

Know the Value & Limitation of Laboratory

Test
Value

Causes

HB/HCT

Low

Ruptured Ectopic

White
cells

>10000
>20000
<4000/>10000

Acute abdomen
Ischemic bowel
Severe Sepsis

Platelets

Low

Dengue fever

Serum
amylase

> 1000 units

Acute Pancreatitis

Urine

Pus cells

UTI

pregnancy test

Ectopic Pregnancy

mal White cell count will not rule out Appendic

Role of Imaging in Acute

Abdomen

X ray Chest
Abdomen Erect , Supine, KUB
US abdomen
CT abdomen
MRI
Visceral Angiogram
Etc

Role of Xrays
X ray abdomen Supine
X ray Chest

Pneumoperitoneum

Dilated loops

X ray abdomen Erect

Multiple Fluid Levels

Role of US in Acute
Abdomen

Appendicitis

Gall
Stones

Normal US abdomen will no

Exclude acute appendicitis

CT Abdomen

Free gas
Fluid in the abdomen
Solid viscera
Liver/Spleen
Kidney
Hollow viscus
Retroperitoneum
AAA
Pancreatitis

When to Call the Surgeon ?

Unstable vital sign (hypotension, sepsis)

Obvious peritonitis
Work up complete in stable patient, but
still without a definitive diagnosis

When the diagnosis is in question

Serial examination in an observation

unit/ED

When the patient is discharged home

Instruction to return if:

Pain

worsen
New vomiting occurs
Fever
Pain persist beyond 8-12h

Conclusion
Clinical Decision Making is
an Art
Knowledge, Experience &
Rely
on your expertise and
Instinct

instinct
rather than Scans and tests!

THANKYOU