The Acute Abdomen

dr. Dwicha Rahmawansa, SpB-KBD

Surgery Department, Subdivision of Digestive Saiful Anwar General

Hospital Malang / Brawijaya University.
 Introduction

• Abdominal pain is the

presenting complaint in as many
as 5 to 10% of emergency
departament patients.

Karmin RA, Nowiciki TA. Courtney DS, Powers RD. Pearls and Pitfall in the Emergency Department Evaluation of Abdominal Pain, Emrg Med Clin North Am.2003;21:61-72[PubMed]
 Introduction
• Etiologies :
– Non Specific Abdominal Pain (34%)
– Acute appendicitis (28%)
– Acute chlecystitis (10%)
– Small Bowel Obstriction (4%)
– Perforated Peptic Ulcer (3%)
– Pancreatitis (3%)
– Diverticular disease (2%)
– Others (13%)

De Dombal FT, Margulies M. Acute abdominal pain. Surgery1996;

 Pathophysiology
• Visceral abdominal pain :
– Elicited by distention, inflammation or ischaemia in
hollow viscous & solid organs  stimulating the
receptor neurons, or by direct involvement (eg,
malignant infiltration) of sensory nerves.
– Localisation depends on the embryologic origin of
the organ:
• Forgut to epigastrium
• Midgut to umbilicus
• Hind gut to the hypogastric region

Visceral pain sites

Glasgow RE, Mulvhill SJ. Abdominal pain, including the acute abdomen. In: Feldman M, Friedman LS, Sleisenger MH, edi- tors. Gastrointestinal and liver disease: pathophysiology/
diagnosis/management. Philadelphia: WB Saunders; 2002. p. 71–83.
 Pathophysiology
Visceral abdominal pain :

(A). Visceral Abdominal Pain is usually caused (B) Less commonly, it si caused by isquemia or inflammation.
by distention of hollow organs or capsular The tissue congestion sensitizes nerve endings of visceral
stretching of solid organs. pain fibers and lowers the threshold for stimulus.
 Pathophysiology

Visceral Abdominal Pain

If the involved organ is affected by peristalsis,

the pain is often described as intermittent,
crampy, or colicky in nature.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Pathophysiology
Visceral Abdominal Pain

• The visceral pain fibers are bilateral,

unmyelinated, and enter the spinal
cord at multiple levels.
• The visecral abdominal pain is usually
dull, poorly localized and experienced
in the midline.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Visceral Abdominal Pain

Sensory levels associated with visceral structures

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Differential Diagnosis of Acute Abdominal Pain by Located

Mahadevan SV. Abdominal pain. In: Mahadevan SV, Garmel GM, eds. An Introduction to Clinical Emergency Medicine. 2nd ed. Cambridge: Cambridge University Press; 2012:139-152.
doi:10.1017/CBO9780511852091.016.
 Pathophysiology
• Parietal abdominal pain :
– Pain is localised to the
dermatome above the site of
the stimulus  Direct
irritation of the somatically
innervated parietal
peritoneum by pus, bile,
urine, or gastrointestinal
secretions leads to a more
precisely localized pain.

Abdomen-Omental bursa
Schematic tranvers section-Level of T12

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Pathophysiology
Parietal (Somatic) Abdominal Pain

Myelinated afferent fibers transmit the

painful stimulus to specific dorsal root
ganglia on the same side and dermatomal
level as the origin of the pain.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Parietal (Somatic) Abdominal Pain

• The parietal pain, in contrast to

visceral pain, often can be localized
to the region of the painful
stimulus.

This pain is typically sharp, knife-

like and constant; coughing and
moving are likely to aggravate it.
 The classic presentation of
appendicitis involves both
visceral and parietal pain.

The pain of early presentation is often periumbilical

(visceral ) but localizes to the right lower quadrant
(RLQ) when the inflammation extends to the
peritoneum (parietal).
 Pathophysiology

• Referred pain :
– Is defined as pain felt at a
distance from the diseased
organ. It results from shared
central pathways for afferent
neurons from diferent locations.

Surface Areas of Referred Pain from Different Visceral Organs

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
Referred Pain

Referred pain and shifting pain in the acute abdomen. Solid circles indicate
the site of maximum pain, dashed circles indicate sites of lesser pain
 Mode of Onset and Progression of Pain

The mode of onset of pain

reflects the nature and severity
of the underlying process.

Onset may be explosive (within seconds),

rapidly progressive (within 1-2 hours), or
gradual (over several hours).

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Character of Pain
Sharp superficial constant
pain is typical of perforated
ulcer or a ruptured
appendix, ovarian cyst, or
ectopic pregnancy

Steady pain indicates

a process that will Intermittent, crampy
lead to peritoneal pain (colic) is
inflammation. characteristic of
obstruction of a
hollow viscus.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Prominent symptom in upper gastrointestinal diseases such as
Boerhaave syndrome, Mallory–Weiss syndrome, acute gastritis
Vomiting and acute pancreatitis

Obstipation suggest mechanical bowel

Constipation obstruction if there is progressive painful
Diarrhea abdominal distention or repeated vomiting.
Watery diarrhea  Gastroenteritis
Blood Stained  Ulcerative Colitis, Crohn Fever
Disease, or amebic dysentery

Other
Weight Loss
Hematochezia

Other Symptoms Associated

with Abdominal Pain

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Other Relevant Aspects of the History
Past Medical History

Operation History

Gynecologic History

Medication History

Family History

Travel History

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Gynecologic Malignant and
disorders vascular diseases

In children, appendicitis
accounts for one-third of
Mesenteric all abdominal pain and
nonspecific abdominal
adenitis pain for much of the
DIFFERENTIAL remainder
DIAGNOSIS

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 PHYSICAL EXAMINATION
• Examination should begin with an initial assessment of the patient’s
vital signs.
• The abdominal examination should be done with the patient in the
supine position.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Steps in Physical Examination of the Acute
Abdomen
1. Global assessment, vital signs • Deep tenderness
2. Inspection • Bump tenderness
3. Auscultation • Masses
4. Cough tenderness 7. Special signs
5. Percussion 8. External hernias and male genitalia
6. Palpation 9. Rectal examination
• Guarding or rigidity 10. Pelvic examination
• Local palpation
• Rebound tenderness

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Condition Helpful Signs
Perforated Scaphoid, tense abdomen; diminished bowel sounds
Physical findings viscus (late); loss of liver dullness; guarding or rigidity.
in various causes Peritonitis Motionless; absent bowel sounds (late); cough and
of acute rebound tenderness; guarding or rigidity.

abdomen. Inflamed mass Tender mass (abdominal, rectal, or pelvic); bump

or tenderness; special signs (Murphy, psoas, or
abscess obturator).
Intestinal Distention; visible peristalsis (late); hyperperistalsis
obstruction (early) or quiet abdomen (late); diffuse pain without
rebound tenderness; hernia or rectal mass (some).

Paralytic ileus Distention; minimal bowel sounds; no localized

tenderness.
Ischemic or Not distended (until late); bowel sounds variable; severe
strangulated pain but little tenderness; rectal bleeding (some).
bowel
Bleeding Pallor, shock; distention; pulsatile (aneurysm) or tender
(eg, ectopic pregnancy) mass; rectal bleeding (some).

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Laboratory Investigations
Blood Studies Urine Tests Stool Tests

• Hemoglobin • Dark urine or a raised specific
• Hematocrit gravity  mild dehydration in
• white blood cell and patients with normal renal
• Differential counts function.
• Hyperbilirubinemia  rise to
tea-colored urine
• Stool samples for culture 
• Dipstick testing (for albumin,
bilirubin, glucose and ketones)
 medical cause of an acute
abdomen.
• Pregnancy tests  All women of
childbearing age.
• A positive Occult fecal blood test
 mucosal lesion that may be
responsible for
• large bowel obstruction
• chronic anemia
• unsuspected carcinoma.
patients with suspected
gastroenteritis, dysentery, or
cholera. Clostridium difficile
should be on the differential of
anyone with a recent course of
antibiotic therapy.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Imaging Studies
Plain Abdominal X-Ray Studies
• Bowel obstructions are usually accompanied with findings of gaseous distention,
air-fluid levels, distended cecum and a paucity of air in the rectum.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Imaging Studies
Plain Abdominal X-Ray Studies.
• Free air under the hemidiaphragm
suggests a perforated viscous.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
Imaging Studies
Ultrasonography
• Ultrasonography  diagnostic sensitivity of about 80% for acute appendicitis and
is most useful in pregnant patients due to its safe modality and lower cost.
• Color Doppler studies can distinguish avascular cysts and twisted masses from
inflammatory and infectious processes.

Color Doppler US image shows prominent blood flows (arrows)

Sign perforation of appendix in abdominal US
at the periphery of the mass

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Imaging Studies
Abdominal CT
• CT provides excellent diagnostic
accuracy.
• CT can identify small amounts of free
intraperitoneal gas and sites of
inflammatory diseases that may
prompt (appendicitis, tuboovarian
abscess) or postpone (noncomplicated
diverticulitis, pancreatitis, hepatic
abscess) operation.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Imaging Studies
CT angiography (CTA)
• Percutaneous invasive angiographic studies
• Selective visceral angiography is a reliable
method of diagnosing mesenteric infarction.
• Emergency angiography may confirm a
ruptured liver adenoma or carcinoma or an
aneurysm of the splenic artery or other
visceral artery.
• Additionally it can be therapeutic for coiling
or embolizing aneurysmal disease.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 Imaging Studies
Endoscopy
• Proctosigmoidoscopy, indicated :
• Large bowel obstruction, grossly bloody stools, or a rectal mass.
• Reducing a sigmoid volvulus.
• colonoscopy  the source of bleeding in cases of lower gastrointestinal hemorrhage
that has subsided.
Gastroduodenoscopy and endoscopic retrograde
cholangiopancreatography (ERCP) are usually done
electively to evaluate less urgent inflammatory
conditions (eg, gastritis, peptic disease) in
patientswithout alarming abdominal signs.
However, urgent ERCP indicated suspected
cholangitis.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
Paracentesis
• Paracentesis is becoming increasingly rare, patients with
• free peritoneal fluid
• aspiration of blood
strong indication for
• Bile laparotomy.
• or bowel contents

• On the other hand, infected ascitic fluid may establish a diagnosis in

• spontaneous bacterial peritonitis
• tuberculous peritonitis rarely require surgery.
• or chylous ascites

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
Laparoscopy
• Therapeutic as well as diagnostic modality.
• Useful modality in the treatment of abdominal
emergencies (decreased pain and faster recovery time)
• Dependent on surgeon experience and hospital and OR
equipment and staffing.
• In cases of unclear diagnosis helps guide surgical
planning and avoid unneeded laparotomies.
• Standard of care for operative treatment of
appendicitis and cholecystitis.
• Acute cholecystitis, laparoscopy performed within 48 hours
of symptom onset significantly reduces the risk of
conversion to an open procedure, reinforcing the
importance of early diagnosis.
• May also be used in treating small bowel obstructions
(result in lower morbidity and a faster return to normal
diet)

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
INDICATIONS FOR SURGICAL EXPLORATION

• The need for

operation is apparent
when the diagnosis is
certain, but surgery
sometimes must be
undertaken before a
precise diagnosis is
reached.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 PREOPERATIVE MANAGEMENT
• After initial assessment, parenteral analgesics for pain relief should
not be withheld. In moderate doses, analgesics neither obscure
useful physical findings nor mask their subsequent development.
• Abdominal masses may become obvious once rectus spasm is
relieved.
• Pain that persists in spite of adequate doses of narcotics suggests a
serious condition  requiring operative correction.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 PREOPERATIVE MANAGEMENT
• Resuscitation  proceed based on their intravascular fluid deficits and
systemic diseases.
• Medications should be restricted to essential requirements.
• Antibiotics are indicated for some infectious conditions or as prophylaxis
in the perioperative period.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 PREOPERATIVE MANAGEMENT
• Nasogastric tube should be inserted :
• Hematemesis or copious vomiting.
• Suspected bowel obstruction, or severe paralytic ileus.
• This precaution may prevent aspiration in patients suffering from drug
overdose or alcohol intoxication, patients who are comatose or debilitated, or
elderly patients with impaired cough reflexes.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 PREOPERATIVE MANAGEMENT
• Urinary catheter should be placed :
• Systemic hypoperfusion.
• In some elderly patients  eliminates the cause of pain (acute bladder
distention) or unmasks relevant abdominal signs.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
 PREOPERATIVE MANAGEMENT
• Informed consent for surgery  may be difficult
to obtain when the diagnosis is uncertain.
• Discuss with the patient and family the possibility of
multiple-staged operations, temporary or
permanent stomal openings, impotence or sterility
and postoperative mechanical ventilation.
• Whenever the exact diagnosis is uncertain
especially in young or frail or severely ill
patients a frank preoperative discussion of the
diagnostic dilemma and reasons for laparotomy
or laparoscopy will reduce postoperative
anxieties and misunderstanding.

Brownson EG, Mandell K. The Acute Abdomen. In: Doherty GM, ed. Current Diagnosis & Treatment : Surgery. 14th ed. Lange, Mc Graw Hill Education; 2015:483-497.
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