Practical Approach to

Acute Abdomen
FRA N SI SCUS A RI FI N
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Surgeons are
internists who
operate...
Acute Abdomen :
Abdominal pain of short duration
that requires a decision regarding
whether an urgent intervention is
necessary.
…the majority of severe abdominal pains
that ensue in patients who have been
previously fairly well, and that last as
long as 6 h, are caused by conditions of
surgical import
C ope ’s Ear ly Diagn osis Of T he A c u t e A b d om e n ,22 e d
Key to Diagnosis: Clinical
Pattern
K EY TO CLI N I CA L PAT T ERN ? → H I STORY A N D PH YSI C A L
EXA MI N AT I ON
“God gave you ears, eyes, and hands; use them
on the patient in that order.”

William Kelsey Fry

Good Diagnosis (in Acute Abdomen)= History (and
History, and History…) + Physical Exam + (Adjunct)
Physical Exam
• General appearance
• Vital signs : Pulse, BP, RR,
temperature, pain
• Abominal :
• Inspection : skin, contour, bowel contour
• Auscultation : bowel sounds
• Palpation : mass, tenderness, guarding,
liver, spleen, kidney
• Percussion: liver dullness, bowel
distension, free fluid
Clinical Patterns in Acute Abdomen
• Abdominal pain and shock
• Generalized/Localized peritonitis
• Intestinal obstruction
• Gynecological
• Trauma
• Waste basket (‘non-specific’ abdominal pain or due to ‘medical
causes’)
 Simplified Algorithm

Exception for
Generalized
Laparotomy
Peritonitis
Check For
Localized
Quadrants

Male Bowel
Obstruction
Distension
Trauma No Sudden
Shock
Abdominal Pain No Bowel
Others
No Peritonitis Distension
Non Trauma

Non Sudden Shock AAA

Gynecologic
Female
Rupt. Ect.
Gynecologic Preg.Cyst
Torsion,PID
Generalized Peritonitis→Surgery, except:
• Intestinal distension associated with
obstruction
• Acute pancreatitis
• Enterocolitis (severe)
The key for the ‘best’ outcome of the acute
abdomen is:
Operate only when necessary, and do the
minimum possible, BUT
Do not delay a necessary operation, and do the
maximum when indicated.

Schein’s Common Sense Emergency

Abdominal Surgery, 4th ed
Generalized Peritonitis, Common DD :
• Almost always due to
perforation of hollow organ :
• Peptic ulcer perforation free
air
• Bowel perforation free air
• Perforated Appendicitis no
free air
Localized Peritonitis
Referral Pain
Bowel Obstruction

• Clinical pattern : Pain (colicky), distention,

vomiting, constipation

• DD :
• Functional (Ogilvie Syndrome)
• Mechanical :
• Scibala obstruction
• Volvulus
• Intussuseption
• Adhesion
• Hernia
• Tumors
• Mesenteric Ischaemia (rare)
Small vs Large Bowel
Role of Ultrasound
• Mainly to identify free fluid
• Mass/intusseption
• Abscesses
On Too Many Diagnostic Tools…

Schein’s
Common Sense
Emergency
Believe nobody — question everything... the more the noise — the less the fact. Abdominal
Surgery, 4th ed
Key to successful surgery

“Biology is the king, case selection is the queen, and the technical
maneuvers undertaken are the princes and princesses of the
realm.’’
Blake Cady
Patient Optimization
• Balance the time for optimization and the acuity of surgery
• Extremes :
• Intraabdominal hemorrhage → straight to OR (door to OR time < 30 minutes)
• Uncomplicated bowel obstruction → 72 hours

• For any infection (sepsis) that requires source control : As soon as

logistically and medically possible, in 6-12 hours
SSC Hour-1 Bundle of Care Elements:

• Measure lactate level (remeasure if >2 mmol/L, after resuscitation)

• Obtain blood cultures before administering antibiotics
• Administer broad-spectrum antibiotics
• Begin rapid administration of 30mL/kg crystalloid for hypotension or
lactate level ≥ 4 mmol/L.
• Apply vasopressors if hypotensive during or after fluid resuscitation
to maintain MAP ≥ 65 mm Hg.
(Lactate,Culture,Antibiotics,Volume,Vasopressor)
Surviving Sepsis Campaign Guidelines
 Antibiotics
• For prophylaxis or treatment ?
• Treatment :
• Broad spectrum, guided by possible
source and sensitivity map
• As soon as possible in sepsis (after
diagnosis and blood culture sample)
• Deescalation is the strategy of choice
Optimize oxygen transport
• Abdominal distension → decompression (NGT and
catheter)
• Hypotension → fluid and vasopressor
• Anemia → transfusion
• Supplemental oxygen (canule, mask, NIV, or
ventilator)
Fluid and electrolytes
• Correction of
hypovolemia →
measure urine
production
• Correction of
electrolyte imbalance
• Do not overrescucitate !
“Never operate on a patient who is getting rapidly
better or rapidly worse.”
Francis D Moore

Reevaluate ! (even if you have made a decision)

Disclaimer : This will NOT cover all acute
abdomen cases, but at least the majority of cases
can be identified

#If-possible
Thank You !

• farifin@gmail.com
• 0811375636 (WhatsApp)