9.

Acute Abdomen
Definition

 Acute abdomen is a condition where the patient experiences moderate to severe

abdominal pain of less than 24h duration
 Has many causes and only after a thorough history taking and complete PE aided by
laboratory and radiologic examination, can a physician differentiate those conditions
needing surgical vs medical management

Pathogenesis

 Depends on the particular disease entity but abdominal pain is divided into
neuroanatomic categories: visceral, somatic , and referred.

VISCERAL PAIN SOMATIC PAIN REFERRED PAIN

PAIN TRANSMISSION Unmyelinated C fibers
CHARACTER Dull, crampy, gnawing,
midline, difficult to localize
MECHANISM Obstruction, ischemia, or
inflammation can cause
stretching of unmyelinated
fibers that innervate the walls
or capsules of organs.
Visceral afferent nerves
follow a segmental
distribution and is therefore
localized by the sensory
cortex to an approximate
spinal cord level.
Intraperitoneal organs are
innervated bilaterally and the
stimuli are sent to both sides
of the spinal cord causing
intraperitoneal visceral to be
felt midline
Myelinated A-δ fibers Interplay b/w 2 fibers
Sharp, sudden, well Felt in areas distant
localized pain from the diseased organ
Irritation of Visceral and somatic
myelinated fibers that afferent neurons from a
innervate the parietal different anatomic
peritoneum. region converge on 2nd
order neurons on the
The pain can be spinal cord at the same
localized to the spinal segment.
dermatome
superficial to the site For example, ureteral
of the pain stimulus. obstruction presents
with ipsilateral testicular
pain. Pain is always
perceived on the same
side as the involved
organ because it is not
mediated fibers that
provide bilateral
innervation of the cord
Probable etiologies depending on the Location of Pain

DIFFUSE PAIN: (DEGGSA) DKA, Early appendicitis, Gastroenteritis, Generalized peritonitis, Small
bowel obstruction, abdominal aortic aneurysm dissected or ruptured
RUQ pain (gallbladder, bileduct, liver) Biliary LUQ pain (Stomach, Heart, pancreas)
colic, Cholangitis, Cholecystitis, Hepatits, Peptic ulcer disease complicated, Gastritis,
Hepatic congestion Hepatic abscess, MI MI, Pancreatitis, Splenic rupture
RLQ pain (appendix, cecum, small LLQ pain
instestines, ascending colon, adnexa, Same + sigmoid CA, colorectal CA except
testicles, ureter) Appendicitis, Cecal without acute AP and meckel’s diverticulum
diverticulitis/carcinoma, Incarcerated,
strangulated hernia, meckel’s diverticulum,
colon CA, diverticultis, acute mesenteric
ischemia ureteral calculi, ectopic pregnancy,
PID, testicular torsion, ovarian torsion,
endometriosis

DISCUSS ACUTE CHOLANGITIS, ACUTE APPENDICITIS or MECHANICAL INTESTINAL

OBSTRUCTION

Additional DDX:

Acute cholecystitis
 Definition: Is the inflammation of the gallbladder secondary to gallstone disease.
Less often, acute cholecystitis develop without gallstones( acalculous
cholecystitis)
 Clinical manifestation: Characterized by a triad of RUQ PAIN, FEVER AND
LEUKOCYTOSIS accompanied by gallbladder inflammation
 RUQ pain described as - “biliary colic”- steady, severe, prolonged (greater than 4
to 6 hours) radiating to the right shoulder, scapula or back precipitated by fatty
food ingestion 1 hour before
 Associated symptoms fever, nausea, vomiting and anorexia
 Physical examination:+ RUQ tenderness and + Murphy’s sign ( hook fingers
deeply beneath the right costal margin while the patient takes a deep breath,
+mid inspiratory arrest
 Laboratory findings: leukocytosis shift to the left
 Imaging: Ultrasound- + sonographic murphy’s sign, edema(double wall sign,
gallstone, gallbladder thickening >3mm, distented GB lumen > 4mm,
Pericholecystic fluid collection, Impacted stone in cystic duct
 If diagnosis is uncertain after utz the Gold standard test is : Cholescintigraphy
(Hepatobiliary IminoDiAcetic scan)- radioactive chemical technecium 99m
given via IV removed from blood via liver and secreted into bile goes to
gallbladder and bile ducts and a gamma camera sense the radioactivity. If no
 cystic blockage it will go to gall bladder. + result non visualization of the
gallbladder
 CT SCAN- to rule out complications
 Management- Admit to hospital give supportive care:
 IV hydration
 Correction of electrolyte imbalance
 Pain control- NSAID Ketorolac 30mg/tab for biliary colic
and inflammation– watch out for renal insufficiency or
Opiods Morphine, Meperidine – leads to sphincter of Oddi
contraction 
 IV antibiotics- important since cholecytitis is commonly
accompanied with secondary infections of gallbladder.
Guidelines suggest routinely administering antibiotics to
all patients diagnosed with acute cholecystitis until
gallbladder is removed. Cover for klebsiella,
ecoli,enterococci, pseudomonas, bacteroides, clostridium
(keep bc)
o Ampicillin/Sulbactam
o Piperacillin/tazobactam
o Ertapenem
o Ciprofloxacin + Metronidazole
o Cefepime
 Mainstay of treatment: Cholecystectomy unless poor surgical candidate
perofrom non operative management first with antibiotics
o EMERGENCY CHOLECYSTECTOMY- for complicated acute
cholecystitis since it may be fatal!!!
 Complications: gangrenous cholecystitis (gangrene of the bldder wall) leading to
sepsis , gallbladder perforation leading to peritonitis, emphysematous
cholecystitis (cause by gas forming organism) leading to abdominal crepitus, and
gallstone ileus leading to bowel obstruction
 Prognosis: Uncomplicated acutecholecystitis has an excellent prognosis. Most
have complete remission within 1-4 days however 25-30 % will require surgery.
Once with complications- less favorable
 Mortality rate of calculous cholecystitis- 4%, Acalculous
cholecystitis- 10 to 50%. In acalculous cholecystitis plus
perforation 50 to 60%