Clinical aPPROACH TO

ACUTE ABDOMEN

DR. J. S. LAMBA
MBBS, MS, FICS
SR CONSULTANT
DEPT. OF SURGERY,
PUSHPANJALI CROSSLAY HOSPITAL,
VAISHALI, GHAZIABAD
 ACUTE ABDOMEN
“the general rule can be laid down that the majority of
severe abdomonal pain which ensue in patients who
have been previously fairly well, and which last as
long as six hours, are caused by conditions of
surgical import.”
[zachary cope, 1881-1974]

Acute abdomen refers to severe abdominal pain of

short duration that requires fairly immediate
management and decision regarding an urgent
surgical intervention.
 ACUTE ABDOMEN
 Frequent causes of acute abdomen
 Clinical features
 How to perform physical examination
 D/d upper abdominal pain
 D/d lower abdominal pain
 Clinical patterns
 Natural history of frequent causes
 Conclusion
 Frequent causes of acute abdomen
LONG LIST—DIAGNOSIS FROM A LIMITED MENU

1.Inflammatory
a) Bacterial --appendicitis, diverticulitis, PID
b) Chemical– peptic perforation, ac. pancreatitis

2.Mechanical
Obstruction—incarcerated hernia, adhesions, intussusception,
large bowel obstruction -- CA or volvulus

3.Vascular
Ac mesenteric arterial thrombosis/embolism
Mesenteric venous thrombosis
ABDOMINAL PAIN

Visceral
Somatic
Referred
VISCERAL
 stretching of peritoneum or organ capsule by
distension or oedema
 diffuse
 Poorly localised
 May be perceived at remote locations related
to organ’s sensory innervation
SOMATIC
 Inflammation of peritoneum or diaphragm
 Sharp
 Well localised

REFERRED
 Perceived at distance from diseased organ
 Pneumonia
 Acute MI
 Male GU problem
 C/F OF ACUTE ABDOMEN

PAIN

1) Origin & location

 Epigastric - stomach, duodenum, pancreas, liver,
biliary tree, associated parietal peritoneum, HEART
 Periumbilical - small intestine, appendix, upper ureter
 Hypogastric - colon, bladder, lower ureter, uterus
2) Radiation
appendicitis, cholecystitis, renalcolic, pancreatitis,
peptic perf.,ruptured ectopic pregnancy, spleen. Pain
of abd aortic aneurysm radiates from lower back to
one or both legs

3) Type of onset & Intensity

sudden & severe -- rupture of viscus,mesenteric
thrombosis,infarct,haemorrhage
gradual & moderate-- cholecystitis,appendicitis,
peritoneal irritation,hollow organ
distension
4) Quality
dull-- epig pain of appendicitis
sharp/colicky-- renal,biliary,int obst
aching-- PID
pleuritic-- intensified by breathing
lancinating--pancreatitis

5) Special features
continuous-ac pancreatitis
pulsatile-abdominal aneurysm
colicky-int obst,gall /renal colic
6) Factors which intensify/relieve pain
relation to meals—peptic ulcer, cholecystitis
postural-appendicitis, pancreatitis
movement-peritonitis

7) Associated symptoms
nausea/ vomiting/ diarrhoea/ obstipation
haematochesia/ malaena/ change in urinary
habits /fever

MURPHY’S SYNDROME

8) EXTRA ABDOMINAL CONDITIONS WHICH

SIMULATE THE ACUTE ABDOMEN ARISE MOST
OFTEN IN HEART,LUNGS,URINARY TRACT AND
FEMALE REPRODUCTIVE ORGANS
 Complete physical examination
 vitals
 Anaemia, shock, haemorrhage, dehydration
 Palpation– must expose abdomen fully
pt on back&knees bent
warm hands
work towards area of pain
tenderness, rigidity, guarding, masses
Percussion hyper resonant,liver dullness
 Auscultation-- listen for 1 minute in each quadrant
MUST EXAMINE HEART & LUNGS
 P/R
 Bimanual pelvic exam
EQUIVOCAL FINDINGS—RE EXAMINE AT
 D/d of diseases causing upper
abdominal pain
 Ac oesophagitis
 Ac appendicitis
 Ac cholecystitis
 Perforated peptic ulcer
 Ac pancreatitis
 Pleurisy / pneumonia
 Ac coronary occlusion - consider possible MI with
pain referred to abdomen in patient >30 years old
 D/d of diseases causing lower
abdominal pain

 Ac appendicitis
 Ureteral obstruction
 Ac diverticulitis
 Ac salpingitis
 Ectopic pregnancy
 Twisted ovarian cyst
OESOPHAGITIS

 Inflammation of distal oesophagus

 Usually from gastric reflux,hiatal hernia
 Substernal burning pain
 Worsened by supine position
PANCREATITIS

 Sudden, severe,constant mid epigastric pain

radiating to back
 Often worsened by food
 Profuse vomiting
 Less guarding than peptic perf
 Bluish flank discoloration[Grey Turner sign]
 Bluish periumbilical discoloration[Cullen sign]
 Absent bowel sounds
CHOLECYSTITIS

 Sudden pain, often severe in RUQ

 Radiating to right shoulder
 Nausea,vomiting
 Often associated with fatty food intake
 Point tenderness under R costal margin [Murphy’s
sign]
APPENDICITIS

 Periumbilical pain—RLQ
 Nausea, vomiting, anorexia
 Low grade fever
 Mc burney’s sign
 Aaron’s sign epig pain on palpation of RLQ
 Rovsing’s sign pain in LLQ on palpation of RLQ
 Psoas sign pain when patient extends R leg while
lying on left side
PERFORATED PEPTIC ULCER

 Sudden, intense & constant pain

 Patient keeps abdomen immobile
 Rapid shallow breathing
 Tenderness, guarding alover abd
 Liver dullness masked
 Absent bowel sounds
ULCERATIVE COLITIS

 Crampy abdominal pain,nausea, vomiting

 Bloody diarrhoea or stool containing mucus
 Ischaemic damage with perforation may occur

DIVERTICULITIS
 Older patient, Inadequate fibre in diet
 Bright red blood in stools,alt consti/diarrhoea
 Tenderness in LLQ
 Rupture may cause peritonitis and sepsis
ECTOPIC PREGNANCY

 In females of child bearing age abd pain or

unexplained shock
 ECTOPIC PREGNANCY DOES NOT
NECESSARILY CAUSE MISSED PERIOD

TWISTED OVARIAN CYST

 Sudden severe pain
 sick looking,shock
 Ischaemic necrosis-perf & spillage
 clinical patterns
1) Abdominal pain & shock [apoplexy] catastrophic event
a. ruptured aortic aneurysm
b. ruptured ectopic pregnancy
c. fluid loss into ‘third space’ eg: ac mesenteric
ischaemia, severe ac pancreatitis, int obst

2) Generalised peritonitis
a. ruptured viscus perf ulcer, colonic perf,
perforated appendicitis
b. ischaemic unruptured bowel strangulated hernia
mesenteric occlusion,volvulus
c. extension of infection liver abscess, PID
 Clinical pattern contd
3) Localised peritonitis
RUQ,RLQ,LLQ,SILENT ZONE

POINT TENDERNESS

TIME IS SUPERB DIAGNOSTICIAN

4) intestinal obstruction
Making diagnosis is not a big issue but important is
deciding appropriate course of action

5) medical illness
Inf wall MI, basal pneumonia, porphyria,diabetic
ketoacidosis,HIV positive suffering from AIDS
 Clinical pattern contd.

6) gynaecological
ectopic preg, twisted ovarian cyst,PID

7) mixed pattern[obstruction & inflammation]

Int. distension & obstruction/inflammation
eg; enteritis,colitis
MIMICS PERITONITIS
 Natural history of frequent causes

Life Threatening Self Limiting

Aortic Aneurysm Appendicitis Gastroenteritis

rupture cholecysitis mesenteric
pancreatitis signoid lymphadenitis
Bowel ischaemia diverticulitis epiploic
Perforated peptic salpingitis appendigitis
ulcer omental infarction
Perforated caecal diverticulitis
diverticulitis
 Conclusion

‘It is as much an intellectual exercise

to tackle the problems of belly ache
as to work on the human genome’
[Hugh dudley]