Acute Abdomen

2210040 Tan Tze Xuan

2211031 Arissa Zulaikha
2210020 Aisya Adnan
2210001 Alia Maisarah
Acute Abdomen
Definition : presence of abdominal pathology
which is left untreated [<72 hours] that will
result in patient morbidity and mortality

The hallmark of the acute abdomen is sudden

onset of severe abdominal pain

Abdominal pain arising from intra-abdominal

pathology originates in the peritoneum
(visceral & parietal layer)
Anatomy of the Abdomen
It arises anteriorly from
the abdominal aorta at the
level of the L1 vertebrae,
immediately inferior to the
origin of the coeliac trunk
supplies the organs of the
midgut – from the major
duodenal papilla (of the
duodenum) to the
proximal 2/3 of the
transverse colon.

arises at L3, near the inferior border of the

origin: 2nd branch of abdominal aorta[ at T12 level]
duodenum, 3-4 cm above where the aorta
bifurcates into the common iliac arteries
supply the hindgut. distal 1/3 of the
transverse colon, splenic flexure, descending
colon, sigmoid colon and rectum
 NERVES INNERVATION
The majority of thoracic and abdominal visceral organs are dually innervated by
parasympathetic and sympathetic outflows [autonomic nervous system]
visceral peritoneum : supplied by parasympathetic and sympathetic nervous
systems
parietal peritoneum and abdominal wall : receives somatic innervation from
spinal nerves

Afferent pain fibres from the abdominal organs and visceral peritoneum travel
with sympathetic nerves
Skin, muscles and parietal peritoneum are supplied by iliohypogastric and
ilioinguinal nerves and the lower six intercostal
nerves
 Types of Pain
Duration : acute vs chronic
Source : tissue damage [nociceptive] vs nerve damage [neuropathic] vs nociplastic
Types of Pain
DIFFERENTIAL DIAGNOSIS
 Classical Signs
Acute pancreatitits

Grey turner sign: Cullen sign:

Fox sign
bilateral flank bruising due to bleeding into Irregular hemorrhagic patches at periumbilical area
parietoneum due to bleeding into peritoneum

Acute appendicitis

Obturator sign: Psoas sign:

pain on passive internal rotation of flexed hip pain on passive extension of the right hip/flexion of
right hip against resistance
 Classical Signs

Acute cholecystitis

Boas sign: Murphy sign:

patient is asked to take in and hold a deep breath
an area of hyperaesthesia between 9th and while palpating the right subcostal area
11th ribs posteriorly on the right side If pain occurs on inspiration, when the inflamed
gallbladder comes into contact with the
examiner’s hand,: Murphy’s sign is positive
 Acute Pancreatitis
Aetiology Classical Symptoms
I-GET-SMASHED Acute severe abd pain
a) Idiopathic (15-25%) - epigastric/RHC
b) Gallstones (40-70%) - dull and constant
c) Ethanol (25-35%) - radiates to the back
d) Trauma - increased.alcohol/fatty food
e) Steroids - reduce by leaning forward
f) Mumps and other infections Nausea and vomiting
(ie. mycoplasma, Hepatitis B) Pale colour stool/dark coloured urine - OJ
g) Autoimmune Pathophysiology
h) Scorpion toxin
unregulated activation of trypsin within pancreatic acinar cells --> activating pro-
I) Hypertriglyceridemia, enzymes leading to auto-digestion + inflammatory cascade --> amplifies local
hypercalcemia inflammatory response --> SIRS
gallstones --> obstruction of the pancreatic duct --> increased pressure -->
j) ERCP (2-5%) extravasation of pancreatic juice --> interstitial edema that impairs blood flow to
k) Drugs (1-2%) the pancreatic cells --> ischemic cells injury
l) others : Neoplasm Alcohol --> direct toxic effect

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

 Physical Examination

Low-grade pyrexia, jaundice

inspection; abdominal distension (paralytic ileus)
palpation;
- Focal epigastric tenderness
- Signs of peritonism;
rebound tenderness, guarding, board-like rigidity
- Any palpable mass (ie. pseudocysts, pancreatic phlegmon)
- Signs of hemorrhagic pancreatitis;
1. Grey-Turner sign (Flank)
2. Cullens sign (periumbilical)
3. Foxs sign (inguinal)
Aucultation
- Diminished/Absent (paralytic ileus)
Repiratory examination
- TRO pleural effusion, ARDS

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

Investigations
(Diagnostic)
Serum Amylase: (30-100U/L)
- level >3 times the normal upper limit
- within the first 24 hours of clinical features
Serum Lipase: (10-140U/L)
- level >3 times the normal upper limit
- has longer half-life than serum amylase
- Useful for patient with delayed presentation
(Asess severity)
Full Blood Count; leukocytosis
Renal Profile;
- degree of renal impairment
Serum calcium; hypocalcemia
RBS; hyperglycemia
LFT; high AST, high LDH, hypoalbumenia
(Radiological)
CXR; pleural effusion
AXR; sentinel loop sign, colon-cut off sign,
pancreatic calcification
CTTAP; confirm diagnosis
Reference: Bailey & Love’s Short Practice of Surgery 28th Edition
Diagnosis the diagnosis of acute pancreatitis requires 2 of the following 3 features

Abdominal pain
Serum lipase/amylase at least 3x greater than normal upper limit
Characteristics findingsof acute pancreatitis
Management
(Supportive treatment)
Fluid resuscitation
Monitoring vital signs
Pain control with analgesics; do not give NSAIDS
Nutrition
Antibiotic;
- IV rocephin (ceftriaxone) / Flagyl (amoxycilin)

Complications
Acute pancreatic fluid accumulation
Acute necrotic collection
Pancreatic pseudocyst
Pleural effusion
Acute kidney injury
Reference: Bailey & Love’s Short Practice of Surgery 28th Edition
 PEPTIC ULCER DISEASE
Disruption of mucosal integrity of stomach or duodenum or both --> ulcer

Aetiology Clinical presentation

increased stimulation/irritation Symptoms of Dyspepsia
- increase HCL stimulated by gastrin or vagus a) ulcer-like dyspepsia; burning, intermittent epigastric pain
- NSAIDs - duodenal ulcer; pain 2-3hrs after meal and at night
- Mucosal irritants; alcohol, smoking, spicy foods - gastric ulcer; pain exacerbated with food intake
- Stress b) Dysmotility-like ulcer; non-painful discomfort
- H. Pylori infection - gram negative spiral bacilli c) unspecific dyspepsia
reduced protection Bleed
- mucus secretion - Mild and chronic; IDA
- bicarbonate secretion into the mucus - Severe and acute; haematemesis or melena
Perforation
Location 1. (3 phases)
Duodenum - proximal (75%) - <2 hours - epigastric pain, tachycardia cool extremities
Stomach - lesser curvature, antrum (20%), greater - 2-12 hrs - generalized and pain, and rigidity, inv. guarding,
curvature - >12 hrs - and distention, fever, hypotension
Esophagus 2. Sudden onset of epigastric pain
Meckel’s diverticulum 3. No relieving factors
*Giant ulcers (.3cm) along the greater curvature - malignancy
obstruction (uncommon for gastric ulcer)

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

 Investigations
Endoscopy - view the ulcer and take biopsy
H. Pylori test
- Culture and sensitivity
- Urea breath test
- Campylobacter like organism test = rapid test
- done during OGDS using CLO kit
- result within 3 hrs
- Change from yellow to pink
- Antibody in blood
- Antibody in stool
Erect CXR (left lateral decubitus view) - for perforation
FBC - to detect anemia or infectious causes

Complications
Penetration PUD
Obstructed PUD
Perforated PUD
Bleeding/Haemorrhage PUD

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

 Management
(Medical therapy)
Eradication of H. Pylori
- Omeprazole (PPI)
- Metronidazole + Amoxicilin
Decrease acid secretion
- Ranitidine (H2 receptor agonist)
- Omeprazole (PPI)
Forrest 1a-b, 2a - Management under OGDS
1. Thermal coagulation; heater prob (disadvantage is
perforation)
2. injection-surround the ulcers;
- Adrenaline - vasoconstriction effects
3. Mechanical; haemostatic clipping
Principle dual modality is better
(usually adrenaline injection + clip/heater probe
Forrest 2b,2c,3 - management by triple regime

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

 Acute Appendicitis
Aetiology Classical Symptoms
Decreased dietary fibre & Increased refined carbohydrates Migratory pain (from
Obstruction of appendiceal lumen: periumbilical region to RIF)
a) Fecaliths / Appendicolith: - Visceral discomfort: poorly
Inspissated faecal material, calcium phosphates, localized, colicky pain.
bacteria, epithelial debris. - Somatic: intense, constant,
b) Lymphoid hyperplasia. localized pain.
c) Parasite: Enterobius vermicularis (pinworm) (less common). Nausea & vomiting (occur
d) Foreign body (rare). after pain).
Low grade fever.
Pathophysiology Anorexia.
Luminal obstruction → continuous mucus secretion & inflammatory exudates →
increased intraluminal pressure → obstruct lymph drainage → oedema & bacterial
translocation to submucosal layer → mucosal ulceration → progression further distend
appendix → venous obstruction & ischemia of appendix wall → bacteria invades
muscularis propria & submucosal → acute appendicitis

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

Physical Examination
Low-grade pyrexia.
(Inspection): Limitation of respiratory movements in
lower abdomen.
(Palpation):
- RIF tenderness (McBurney’s point: 1/3 of
distance from right ASIS to umbilicus).
- Muscle guarding over McBurney’s point (point of
maximum tenderness in RIF).
- Rebound tenderness over McBurney’s point.
(Percussion): Tenderness over RIF.

Rovsing’s sign: RIF pain with deep palpation of LIF.

Obturator sign: RIF pain with internal rotation of a
flexed right hip (spasm of obturator internus).
Psoas sign: RIF pain on passive extension of right
thigh while patient lies on left side (inflamed
appendix lying on psoas muscle).

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

 Investigations
(Routine):
Full blood count: Leukocytosis (normal WCC does not rule
out appendicitis).
Urine FEME: may have pyuria, haematuria.

(Selective / To rule out other causes / To assess complications):

≤ 4: unlikely appendicitis.
5-6: recommend contrast-enhanced CT
scan / abdominal ultrasonography to
reduce rate of negative appendicectomy.
≥ 7: strongly predictive of acute
appendicitis.
Urine pregnancy test: to rule out ectopic pregnancy.
Renal profile: identify any electrolytes imbalance.
C-reactive protein: raised inflammatory markers.
Blood culture: if there is high grade fever (gangrenous &
perforated appendicitis).
Contrast-enhanced CT abdomen & pelvis (CTAP): high
specificity & sensitivity to diagnose appendicitis.
Erect CXR: to exclude any free gas under diaphragm as a
result of perforation.

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

Management
Conservative management for uncomplicated appendicitis: Bowel rest (nil by mouth), IV drip, IV
antibiotics (Metronidazole, 3rd generation Cephalosporin).
Conservative management for appendix mass: Ochsner Sherren regime.
- Inadvertent surgery is difficult and hard to find the appendix.
- Careful monitoring of vital signs, extent of mass, spread of abdominal pain.
- Symptomatic treatment & give antibiotics.
Correct electrolyte imbalances.
Symptomatic relief: Anti-emetics, Analgesia.

Definitive Treatment: Appendectomy (open / laparoscopic).

Complications
Gangrenous appendicitis.
Peritonitis.
Phlegmonous mass / Paracaecal abscess: greater omentum and loops of small bowel wrap
around inflamed appendix, result in localized inflammatory process.

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

 Acute Calculous Cholecystitis
Initiated by obstruction of cystic duct by an Physical Examination
impacted gallstone → obstruct biliary flow → Positive Murphy’s sign.
distend the gallbladder. Boas’s sign: hyperaesthesia below right scapula.
Persistent gallstone impaction → Right hypochondrium tenderness with guarding.
inflammation of gallbladder. Palpable gallbladder: if omentum wrap around
gallbladder.
Mild jaundice: due to obstructed cystic duct.
Clinical Presentation
Constant, unremitting, severe right
hypochondrium pain: due to inflammation
spread to parietal peritoneum.
- Exacerbated by moving & breathing.
Radiate to inferior angle of scapula,
interscapula.
Nausea, vomiting, anorexia.
Low grade fever.

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition,

Browse ssx of Surgical Diseases

Complications
Empyema: gallbladder filled with pus.
Gangrene & perforation.
Cholecystoenteric fistula: common in
duodenum, colon, stomach; after repeated
attack of cholecystitis.
Investigations
Ultrasound Hepatobiliary System:
- Thickened gallbladder wall.
- Sonographic Murphy’s positive.
- Pericholecystic fluid (oedema of gallbladder wall).
- Presence of gallstones in biliary system.
- Contracted gallbladder (chronic gallstone disease).
CT Abdomen: to rule out complications (empyema,
perforation).
Full blood count: Leukocytosis.
- If severely elevated: consider complications
(gangrene, perforation, cholangitis).
C-reactive protein: elevated inflammatory marker.
Liver function test: Mild transaminitis.
Renal profile: look for electrolytes imbalance.
Amylase: mildly raised.
Reference: Bailey & Love’s Short Practice of Surgery 28th Edition
 Management
Monitor & assess vital signs, resuscitate if needed: IV
fluid resuscitation.
Empirical intravenous antibiotics: IV Ceftriaxone,
Metronidazole.
Nil by mouth for bowel rest.
Analgesia: strong opioid agonist.
Careful monitoring of signs of complications: non-
resolving fever / pain.

Definitive Treatment: Cholecystectomy (open /

laparoscopic).

Alternative Treatment: Percutaneous Cholecystostomy.

Drain the gallbladder and alleviates the inflammation
(resolve acute episode).
Indicated for patients who did not fit for surgery or
when early surgery is difficult due to extensive
inflammation.

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

 Diverticular Disease
Acquired pseudo-diverticular outpouching of colonic mucosa and submucosa

Risk Factors Classical Symptoms

Diet : Low fiber diet and High in red meat / fat Mild Symptoms
Lack of physical activity Abdominal distension
Obesity Flatulence
Genetic : Asian --> RDD , Causasian --> LDD Heavy sensation (Lower abdomen)
Old Age : Diverticulitis
Persistent lower abdominal pain
5% - 40 y/o Diarrhea / Constipation
30% - 60 y/o
Palpation : Tender
65% - 80 y/o
Rectal Exam. : Tender mass
Generalised Peritonitis
Pathophysiology Palpation : Generalised tenderness +
Altered collagen structure with ageing, motility disorder and Guarding
increased intraluminal pressure --> Herniation of mucosa and Bleeding
submucosa athrough the circular muscle at point where the
blood vessels penetrate the bowel wall
Painless and Profuse

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

 Diverticular Disease
Acquired pseudo-diverticular outpouching of colonic mucosa and submucosa

Classification Investigation
CT Abdominal
Excellent sensitivity & specificity
Bowel wall thickening (>4mm)
Abscess formation
Assess complication (Abscess,Diverticulitis,)
Aids in intervention management
Endoscopy
Avoided for 6 weeks after acute attack as it
Investigation (Biochemical) may cause perforation
Full Blood Count : To look for TWC To exclude coexisting carcinoma
C-Reactive Protein : Raised (>50) To assess extent of diverticular diseases
Arterial Blood Gas : Suspect Sepsis/Dehydration Colonoscopy
Coagulation Profile : If require intervention Only done if endoscopy to narrowed area may
cause perforation
Biopsy may be taken (If possible)
Reference: Bailey & Love’s Short Practice of Surgery 28th Edition
 Diverticular Disease
Acquired pseudo-diverticular outpouching of colonic mucosa and submucosa

Management
Uncomplicated (Conservative therapy)
NBM : Clear liquid diet and consume high
fibre low residue diet
Analgesic
Antibiotic (10-14 days) : IV Ceftriaxone &
Metranidazole
Lifestyle Modification

Complicated (Surgical)
Same as Uncomplicated
Perforation : Stage 2 surgery
Obstruction : Stage 1 / 2 surgery
Abscess : CT guide drainage +/- Stage 1 surgery
Fistula : Elective stage 1 surgery

Reference: Bailey & Love’s Short Practice of Surgery 28th Edition

Thank You