The Acute Abdomen

Melvin D. Schursky MD
Morristown Memorial Hospital

July 16, 2006

 The Acute Abdomen

• Challenge to Surgeons & Physicians

• Most common cause of surgical emergency
admission
• Clinical course can vary from from minutes
to hours to weeks.
• It can be an acute exacerbation of a chronic
problem i.e. Chronic Pancreatitis,Vascular
Insufficiency.
 Definition

A serious condition within the abdomen

characterized by sudden onset, pain,
tenderness, and muscular rigidity, and usually
requiring emergency surgery.
 Definition

The abrupt (acute) onset of abdominal pain. A potential

medical emergency, an acute abdomen may reflect a major
problem with one of the organs in the abdomen such as the
appendix (being inflamed = appendicitis), the gallbladder
(inflamed = cholecystitis), the intestine (an ulcer that has
perforated), the spleen (that has ruptured), etc.
 Question:

Which of the following statements is true regarding

normal embryologic development?
a. The normal rotation of the gut along the superior
mesenteric axis is 270 degrees clockwise.
b. The superior mesenteric artery supplies blood to
the hindgut.
c. The foregut includes the stomach, duodenum, and
the rest of the small bowel.
d. The hindgut is composed of the distal colon and
rectum.
 Question:

Which of the following statements is true regarding

normal embryologic development?
a. The normal rotation of the gut along the superior
mesenteric axis is 270 degrees clockwise.
b. The superior mesenteric artery supplies blood to
the hindgut.
c. The foregut includes the stomach, duodenum, and
the rest of the small bowel.
d. The hindgut is composed of the distal colon and
rectum.
 Answer Explanation:

• The normal rotation of the gut is 270

degrees counterclockwise and the superior
mesenteric artery supplies blood to the
midgut, which is composed of the distal
duodenum to the distal colon.
 Anatomy and Physiology

• Developmental Anatomy
• Foregut
• Midgut
• Hindgut
• Visceral Peritoneum
• Parietal Peritoneum
 Question:

Stimuli to the diaphragm cause referred shoulder pain because:

a. The phrenic nerve and afferent fibers in C1, C2, and C3
dermatomes innervate the diaphragmatic musculature and the
peritoneum on its undersurface.
b. The greater, lesser, and least splanchnic nerves innervate the
diaphragmatic musculature and the peritoneum on its
undersurface.
c. The phrenic nerve and afferent fibers in C3, C4, and C5
dermatomes innervate the diaphragmatic musculature and the
peritoneum on its undersurface.
d. The transhiatal vagal nerve branches innervate the
diaphragmatic musculature and the peritoneum on its
undersurface.
 Question:

Stimuli to the diaphragm cause referred shoulder pain because:

a. The phrenic nerve and afferent fibers in C1, C2, and C3
dermatomes innervate the diaphragmatic musculature and the
peritoneum on its undersurface.
b. The greater, lesser, and least splanchnic nerves innervate the
diaphragmatic musculature and the peritoneum on its
undersurface.
c. The phrenic nerve and afferent fibers in C3, C4, and C5
dermatomes innervate the diaphragmatic musculature and the
peritoneum on its undersurface.
d. The transhiatal vagal nerve branches innervate the
diaphragmatic musculature and the peritoneum on its
undersurface.
 Answer Explanation:

• Pain referred to the shoulder can be an

important symptom of subphrenic
inflammation or subphrenic blood.
 Assessment

• Well elicited history

• Proper physical examination
• Diagnosis can be made most of the time by a
good history and a proper physical examination.
• Investigations are usually carried out :
• only to support the diagnosis.
• or to narrow down the differential diagnoses.
Causes of Acute Abdominal Pain
 Abscess Splenic
infarct/rupture
Acute Cholecystitis
Mesenteric
Peptic Ulcer Lymphadenitis

Obstruction Ulcerative
Colitis

Meckel’s
Diverticulum Volvulus

Traumatic
Perforation Diverticulitis

Intussusception

Appendicitis
Gynecological
 History

• History of Present illness

• Family History
• Past Medical history
• History of drugs taken or Medication eg.
ingestion of certain toxic drugs or Alcohol
intake
 Drug History

• Corticosteroids – mask pain

• Anticoagulants – can lead to an intramural
hematoma of the gut causing obstruction
• Oral Contraceptives - rupture of hepatic
adenomas
• NSAIDs - erosive gastritis & peptic ulcers
 Other History

• Past Surgical history: previous operations- leading to

adhesions
• Past Medical history: Sickle cell disease, Diabetes or
Cancer or Renal failure
• Menstrual History in females
• Missed period- ectopic pregnancy
• Mid of period-ovulation pain (Mittelschmerz)
• With heavy periods- endometriosis
• Family history of colon cancer, any other malignancy
or inflammatory bowel disease
Pain : The Most Important Symptom

History of pain should include:

• Onset
• Severity
• Type of pain
• Radiation of Pain
• Change in nature of Pain
• Associated bowel or urinary symptoms
• Aggravating or relieving factors
 Question:

Primary or spontaneous peritonitis can occur as a diffuse bacterial

infection without an obvious intraabdominal source contamination.
Which of the following statements about primary peritonitis is
FALSE?
a. Pneumococcal primary peritonitis occurs more commonly in
children than adults.
b. Hemolytic streptococcal primary peritonitis occurs more
commonly in children than adults.
c. Toxemia of pregnancy increases the risk of primary
peritonitis in the perinatal period.
d. Adults with Ascites and cirrhosis are susceptible to primary
peritonitis due to Escherichia coli or Klebsiella.
 Question:

Primary or spontaneous peritonitis can occur as a diffuse bacterial

infection without an obvious intraabdominal source contamination.
Which of the following statements about primary peritonitis is
FALSE?
a. Pneumococcal primary peritonitis occurs more commonly in
children than adults.
b. Hemolytic streptococcal primary peritonitis occurs more
commonly in children than adults.
c. Toxemia of pregnancy increases the risk of primary
peritonitis in the perinatal period.
d. Adults with Ascites and cirrhosis are susceptible to primary
peritonitis due to Escherichia coli or Klebsiella.
 Answer Explanation:

• Primary or spontaneous peritonitis can occur as a

diffuse bacterial infection without an obvious
intrabdominal source of contamination. Primary
peritonitis, most commonly caused by
Pneumococcus or hemolytic Streptococcus occurs
more commonly in children than in adults.
However, adults with ascites and cirrhosis are
susceptible to spontaneous peritonitis resulting
from Escherichia coli and Klebsiella
 Question:

Which of the following statements is true?

a. Nausea is the focal issue in the evaluation of the
patient suspected of having an acute abdomen.
b. Anorexia is the focal issue in the evaluation of the
patient suspected of having an acute abdomen.
c. Pain is the focal issue in the evaluation of the patient
suspected of having an acute abdomen.
d. Vomiting is the focal issue in the evaluation of the
patient suspected of having an acute abdomen.
 Question:

Which of the following statements is true?

a. Nausea is the focal issue in the evaluation of the
patient suspected of having an acute abdomen.
b. Anorexia is the focal issue in the evaluation of the
patient suspected of having an acute abdomen.
c. Pain is the focal issue in the evaluation of the patient
suspected of having an acute abdomen.
d. Vomiting is the focal issue in the evaluation of the
patient suspected of having an acute abdomen.
 Answer Explanation:

• As many as 30% of patients seeking

medical attention for abdominal pain have
nonspecific abdominal pain that abates
spontaneously. Persisting pain is the focal
issue in the diagnosis of the acute abdomen
 Physical Exam:
General Appearance

• Anxious Patient lying motionless

• Acute appendicitis
• Peritonitis
• Rolling in bed & restless
• Renal Colic
• Intestinal colic
• Bending Forward
• Chronic Pancreatitis
 Physical Exam:
General Appearance

• Jaundiced:
• CBD obstruction
• Dehydrated
• Peritonitis
• Small Bowel obstruction
 Physical Exam:
Vitals

• Temperature
• Pulse
• BP
• Respiratory rate
• Ruptured AAA or ectopic pregnancy can lead to
• Pallor
• Hypotension
• Tachycardia
• Tachypnea
 Physical Exam:
Vitals

• Low grade temp

• Appendicitis
• Acute cholecystitis
• High grade temp
• Salpingitis
• Abscess
• Very High Grade Temp
• Peritonitis
• Acute cholangitis
• Pylonephrosis
 Physical Exam:
Systemic

• Cardiopulmonary examination
• Check for:
• Possible MI
• Basal Pneumonia
• Pleural Effusion
 Physical Exam:
Systemic

• Abdominal Examination
• Scaphoid or flat in peptic ulcer
• Distended with ascites or intestinal obstruction
• Visible peristalsis in a thin or malnourished
patient (with obstruction)
 Physical Exam:
Signs

• Erythema or discoloration
• Cullen sign
• Peri-umbilical
• Fox sign
• Inguinal
• Grey Turner Sign
• Flanks
• Seen in Hemorrhagic pancreatitis or any other cause
of hemoperitoneum
• Any Visible/Palpable masses
 Physical Exam:
More Signs

• Rovsing’s Sign
• Obturator Sign
• Psoas Sign
• Retro-cecal appendicitis
• Crohn’s Disease
• Perinephric Abscess
• Ovarian Cyst
• Murphy’s Sign
 Physical Exam:
Palpation

• Be gentle
• Start away from site of complaints then towards
• Check for Hernia sites
• Tenderness
• Rebound tenderness
• Guarding - INVOLUNTARY spasm of muscles
during palpation
• Rigidity- when abdominal muscles are tense &
board-like
• Indicates peritonitis.
 Physical Exam:
Palpation

• Local RLQ tenderness:

• Acute appendicitis
• Acute Salpingitis in females
• Low grade, poorly localized tenderness
• Intestinal Obstruction
• Tenderness out of proportion to examination
• Mesenteric Ischemia
• Acute Pancreatitis
• Flank Tenderness
• Perinephric Abscess
• Retrocecal Appendicitis
 Physical Exam:
The Rectal

• tenderness
• induration
• mass (Blummer’s shelf)
• frank blood
• mucous
 Physical Exam:
Gynecologic Exam

• Vaginal Examination
• Bleeding
• Discharge
• Cervical motion tenderness
• Adnexal masses or tenderness
• Uterine Size or Contour
 Laboratory Values

• CBC c diff
• Electrolytes
• BUN/Creatinine
• Urinalysis
• Amylase or Lipase
• Liver Function Test
• Lactate
• Coags
 Radiologic Studies

• Upright Chest X ray

• Basal Pneumonia
• Ruptured Esophagus
• Free Air under diaphragm
 Radiologic Studies

• Abdominal X ray film

• Air-Fluid Levels
• Stones
• Ascites
• Eggshell calcification in AAA
• Air in Biliary tree.
• Obliteration of Psoas Shadow in retro-peritoneal disease
• Right lower quadrant sentinel loop in acute appendicitis
 Radiologic Studies

• Other Investigations
• CT scan of Abdomen
• US
• Mesenteric Angiography
• HIDA
• MRCP
• ERCP
 Question:

When evaluating radiographs of patients with abdominal pain

which of the following statements is true?
a. An upright chest radiograph is a very sensitive test fro
evaluating free abdominal air.
b. The majority of patients with a perforated duodenal
ulcer will not have free air on plain films.
c. The majority of gallstones are radiopaque.
d. A cross-table lateral radiograph with the patient in the
left lateral position is a more sensitive method of
detecting free air than an upright chest radiograph.
 Question:

When evaluating radiographs of patients with abdominal pain

which of the following statements is true?
a. An upright chest radiograph is a very sensitive test fro
evaluating free abdominal air.
b. The majority of patients with a perforated duodenal
ulcer will not have free air on plain films.
c. The majority of gallstones are radiopaque.
d. A cross-table lateral radiograph with the patient in the
left lateral position is a more sensitive method of
detecting free air than an upright chest radiograph.
 Answer Explanation:

• An upright chest radiograph is a very

sensitive way to evaluate free air, but is less
sensitive than a decubitus film.
 Question:

The accuracy of CT scanning in the diagnosis

of acute appendicitis is:
a. 56%
b. 27%
c. 98%
d. 77%
 Question:

The accuracy of CT scanning in the diagnosis

of acute appendicitis is:
a. 56%
b. 27%
c. 98%
d. 77%
 Answer Explanation:

• Although CT scans can provide excellent

accuracy in the diagnosis of acute
appendicitis we must remember that the
data cited were obtained in a specialty
center. These results may not yet apply in
many hospitals.
RADIOLOGY QUIZ
Few More Questions…
 Question:

The safest time for abdominal surgery during

pregnancy is:
a. First Trimester
b. Second Trimester
c. Third Trimester
d. Abdominal surgery is never safe during
pregnancy.
 Question:

The safest time for abdominal surgery during

pregnancy is:
a. First Trimester
b. Second Trimester
c. Third Trimester
d. Abdominal surgery is never safe during
pregnancy.
 Answer Explanation:

• Abdominal operations have been done throughout

pregnancy with good outcomes. However, for
elective or semi-elective procedures on should
avoid operations during the first trimester to
minimize fetal damage during the period of
organogenesis and to minimize the risk of
abortion. Also, elective or semi-elective
procedures should be done before the third
trimester to avoid inducing premature labor.
 Question:

The diagnostic accuracy of laparoscopy in

patients with acute abdominal pain is:
a. 24% to 30%
b. 66% to 72%
c. 93% to 100%
d. 86% to 90%
 Question:

The diagnostic accuracy of laparoscopy in

patients with acute abdominal pain is:
a. 24% to 30%
b. 66% to 72%
c. 93% to 100%
d. 86% to 90%
 Answer Explanation:

• Laparoscopy can accurately reveal the

cause of abdominal pain.
 Question:

A 60-year-old man suddenly developed severe

abdominal pain. In the emergency department 2
hours later his abdomen was soft and nontender,
his WBC was 18,300/mm3, and his arterial blood
pH was 7.32. The probable diagnosis is:
a. Acute Appendicitis
b. Acute pancreatitis
c. Superior mesenteric artery embolism
d. Perforated duodenal ulcer.
 Question:

A 60-year-old man suddenly developed severe

abdominal pain. In the emergency department 2
hours later his abdomen was soft and nontender,
his WBC was 18,300/mm3, and his arterial blood
pH was 7.32. The probable diagnosis is:
a. Acute Appendicitis
b. Acute pancreatitis
c. Superior mesenteric artery embolism
d. Perforated duodenal ulcer.
 Answer Explanation:

• Severe abdominal pain with minimal

abdominal physical findings plus
leukocytosis and acidosis characterize acute
visceral ischemia.
 Question:

Which of the following is not a

contraindication to laparoscopy in a
patient with acute abdominal pain?
a. Hemodynamic instability
b. Pregnancy
c. Extensive abdominal distention
d. History of multiple laparotomies
 Question:

Which of the following is not a

contraindication to laparoscopy in a
patient with acute abdominal pain?
a. Hemodynamic instability
b. Pregnancy
c. Extensive abdominal distention
d. History of multiple laparotomies
 Answer Explanation:

• Pregnancy was previously a

contraindication to laparoscopy. However,
clinical reports suggest that laparoscopy can
be performed safely in pregnant patients.
 Question:

A 20-year-old man presents to the emergency department with an

8-hour history of vague lower abdominal pain, anorexia, and
some nausea. He is now complaining of right lower quadrant
abdominal pain and tenderness. The explanation for the
patient’s pain can be best explained by which of the following:
a. Acute cholecystitis is the most likely diagnosis in this patient.
b. The main reason for the patient’s localizing the pain in the
right lower quadrant is secondary to irritation of his parietal
peritoneum.
c. The vague lower abdominal pain is caused by stimulation of
the somatic innervations to the appendix.
d. This history of presentation and pain is very atypical for acute
appendicitis.
 Question:

A 20-year-old man presents to the emergency department with an

8-hour history of vague lower abdominal pain, anorexia, and
some nausea. He is now complaining of right lower quadrant
abdominal pain and tenderness. The explanation for the
patient’s pain can be best explained by which of the following:
a. Acute cholecystitis is the most likely diagnosis in this patient.
b. The main reason for the patient’s localizing the pain in the
right lower quadrant is secondary to irritation of his parietal
peritoneum.
c. The vague lower abdominal pain is caused by stimulation of
the somatic innervations to the appendix.
d. This history of presentation and pain is very atypical for acute
appendicitis.
 Answer Explanation:

• This is a fairly classic history of appendicitis in

which the pain later localizes to the right lower
quadrant secondary to peritoneal irritation. The
initial vague pain is secondary to visceral
peritoneal irritation or distention of the
appendix.