ACUTE ABDOMEN

ACUTE ABDOMEN
Definition
Abrupt onset of abdominal pain usually accompanied by
one or more peritoneal signs (i.e., rigidity, tenderness
(with or without rebound), involuntary guarding).
 Most causes of acute abdomen are surgical.
History
Pain is the most common presenting feature of an acute
abdomen.
Special attention to the characteristics of the pain will
aid in reaching the diagnosis.
LOCATION
Visceral pain: Poorly localized, usually dull, achy pain arising
from distention or spasm in hollow organs. Example: Crampy
pain felt during early intestinal obstruction.
Mid-epigastrium: Stomach, duodenum, hepatobiliary
system, pancreas.
Mid-abdomen: jejunum, ileum.
Lower abdomen: colon, internal reproductive organs.
Parietal pain: Sharp, well-localized, somatic pain arising from
irritation (usually by pus, bile, urine, or gastrointestinal
secretions) of the parietal peritoneum.
Example: Inflamed appendix causing sharp right lower
quadrant (RLQ) pain due to irritation of nearby peritoneum.
Assessment of pain should Kehr’s sign is pain
include PQRST: referred to the left
Precipitating or shoulder due to
palliative factors irritation of the left
Quality of pain: hemidiaphragm.
Stabbing, shooting, Often seen
boring, dull with splenic rupture.
Radiation
Severity
Timing
QUALITY OF PAIN
Steady pain is most common, but differentiating
character of pain is helpful:
Gradual, steady pain , Intermittent, colicky pain
Acute cholecysitis , Small bowel obstruction
Acute cholangitis , Inflammatory bowel disease
Hepatic abscess ,Biliary colic ,Diverticulitis.
Abrupt, excruciating pain , Rapid-onset, severe
constant pain
Perforated ulcer , Acute pancreatitis
Ruptured aneurysm , Ectopic pregnancy
Ureteral colic , Mesenteric ischemia
Strangulated bowel , Acute appendicitis
PRECIPITATING OR PALLIATIVE FACTORS
May include:
 Change in position.
 Association with food (better, worse).
 Pain that wakes one from sleep (significant).
RADIATION
 Biliary tract pain may radiate to the right shoulder or
right scapula (due to right hemidiaphragmatic
irritation).
 Splenic rupture pain may radiate to left shoulder.
 Kidney pain may radiate from flank to groin and
genitalia (loin to groin).
 Pancreas pain may radiate to back.
ASSOCIATED SYMPTOMS
 Vomitting: Pain relieved by vomiting is supportive of
small bowel obstruction (SBO), afferent loop
syndrome.
 Bilious vomiting is a clue for proximal SBO.
 Bowel habits: Constipation or obstipation (no stool or
flatus) is suggestive of bowel obstruction.
 Mucoid diarrhea with blood (red currant jelly stool) is
seen in intussusception.
 Anorexia: Very nonspecific symptom; however, most
patients with acute appendicitis will have anorexia.
Fever: seen in appendicitis, acute cholecystitis, acute
pancreatitis.
MEDICAL AND SURGICAL HISTORY
 Past abdominal surgery? Any abdominal surgery
increases the chance of SBO secondary to adhesions
(even years later).
 Atrial fibrillation: Increased risk for mesenteric
ischemia (embolism) because of emboli to mesenteric
arteries.
 Menstrual and sexual history (acute salpingits vs.
pelvic inflammatory disease vs. ruptured ectopic).
Serial abdominal
exams and observation
may be necessary in
cases in which the
etiology of abdominal
pain is initially unclear
Pain of perforated ulcer is
severe and of sudden
onset.
Murphy’s sign is seen in
cholecystitis.
Most common cause by far
(90%) of free air under
diaphragm is perforated
peptic ulcer. Other causes
include hollow viscus injury
secondary to trauma,
mesenteric ischemia
(usually under left
hemidiaphragm), and large
bowel perforation.
PHYSICAL EXAM
Things to look for:
 Vital signs: Most patients with a surgical abdomen
will have vital sign abnormalities secondary to pain,
inflammation, fluid and electrolyte derangements, and
anxiety.
 General: Hydration status, mentation, nutritional
status.
 Chest: Auscultation.
 Abdomen: See Tables.
Steps in Physical Examination of the Acute Abdomen
1. Inspection
2. Auscultation
3. Cough tenderness
4. Percussion
5. Guarding or rigidity
6. Palpation
One-finger
Rebound tenderness
Deep
7. Punch tenderness
Costal area
Costovertebral area
8. Special signs
9. External hernias and male genitalia
10. Rectal and pelvic examination
 Physical Findings in Various Causes of Acute Abdomen
CONDITION HELPFUL SIGNS

Perforated viscus Scaphoid, tense abdomen; diminished

bowel sounds (late); loss of liver dullness;
guarding or rigidity.

Peritonitis Motionless; absent bowel sounds (late);

cough and rebound tenderness; guarding
or rigidity.

Inflamed mass or abscess Tender mass (abdominal, rectal, or pelvic);

punch tenderness;
special signs (Murphy’s, psoas, or
obturator).
CONDITION HELPFUL SIGNS

Intestinal Distention; visible peristalsis (late); hyperperistalsis (early) or

obstruction 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 pain
strangulated bowel but little tenderness; rectal bleeding (some).

Bleeding Pallor, shock; distention; pulsatile (aneurysm) or tender (e.g.,

ectopic pregnancy) mass; rectal bleeding (some).
DIAGNOSIS
Initial laboratory evaluation should include:
 CBC.
 Electrolytes.
 Amylase, lipase.
 Electrocardiogram (ECG) to rule out myocardial infarction (MI) and
also as a preoperative baseline cardiac assessment.
 Liver function tests (LFTs) for right upper quadrant (RUQ) pain.
 β-hCG (human chorionic gonadotropin) for all women of childbearing
age.
 Chest x-ray (CXR) and abdominal x-ray (AXR) to look for free air (can detect
as little as 1–2 mL); easier to see under right hemidiaphragm. Presence of
stomach bubble obscures it on the left .
 Abdominal CT should be used after the above assessment is complete and
the diagnosis remains elusive (e.g., young male with clinical signs and
symptoms of appendicitis should not undergo CT) .
Contrast for abdominal CT:
For the most optimal imaging, both oral and IV
contrast is used. In some cases (such as impaired renal
function or allergy to IV contrast) this is not feasible.
Noncontrast CT, although suboptimal for most cases
(except nephrolithiasis), still provides lots of
information.
Upright CXR demonstrating free air under both hemidiaphragms
(arrows).
MANAGEMENT
 Early diagnosis improves outcome.
 Key is deciding whether surgical intervention is needed .

SURGICAL CAUSES OF ABDOMINAL PAIN

Right Upper Quadrant (RUQ)
Perforated duodenal ulcer
Acute cholecystitis
Hepatic abscess
Retrocecal appendicitis
Appendicitis in a pregnant woman
Right Lower Quadrant (RLQ)
Appendicitis
Cecal diverticulitis
Meckel’s diverticulitis , intussusception
Left Lower Quadrant (LLQ)
Sigmoid diverticulitis
Volvulus
Left Upper Quadrant (LUQ)
Splenic rupture
Splenic abscess
Diffuse
Bowel obstruction
Leaking aneurysm
Mesenteric ischemia
Periumbilical
Early appendicitis
Pain from small bowel obstruction
Suprapubic
Ectopic pregnancy
Ovarian torsion
Tubo-ovarian abscess
Psoas abscess
Incarcerated groin hernia
 Appendicitis is still the
most common surgical
The pain of appendicitis emergency in the
localizes to McBurney’s pregnant woman
point.
Physical exam signs in
appendicitis: Rovsing’s, Patients with splenic
obturator, psoas . rupture will have an
elevated white count in
the setting of trauma.
Normal abdominopelvic CT scan of a 26-year-old man. Both
oral and intravenous contrast was administered.
A. Liver(right and left lobes), stomach, and spleen B. Liver,
gallbladder, kidneys, and pancreas
C. Kidneys, pancreas, and intestines.
D. Small bowel, cecum, ascending colon, and normal
appendix.
 E. Intestines and ureters at level of iliac wings.
F. Bladder, distal ureters, and rectum at the level of the
acetabular domes.
Abdominal CT anatomy.
Indications for Urgent Operation in Patients with Acute
Abdomen
Physical findings
Involuntary guarding or rigidity, especially if spreading.
Increasing or severe localized tenderness.
Tense or progressive distention.
Tender abdominal or rectal mass with high fever or hypotension.
Rectal bleeding with shock or acidosis.
Equivocal abdominal findings along with—
Septicemia (high fever, marked or rising leukocytosis, mental
changes, or increasing glucose intolerance in a diabetic patient).
Bleeding (unexplained shock or acidosis, falling hematocrit).
Suspected ischemia (acidosis, fever, tachycardia).
Deterioration on conservative treatment.
Radiologic findings
Pneumoperitoneum.
Gross or progressive bowel distention.
Free extravasation of contrast material.
Space-occupying lesion on scan, with fever.
Mesenteric occlusion on angiography.
Endoscopic findings
Perforated or uncontrollably bleeding lesion.
Paracentesis findings
Blood, bile, pus, bowel contents, or urine
 Abdominal aortic aneurysm
(AAA):
Pulsatile mass on physical exam.
Patients with bowel
obstruction will
initially be able to
take in fluids by Fitz-Hugh–Curtis syndrome
mouth, and vomit a is perihepatitis associated
short time afterward. with chlamydial infection of
cervix.
IMPORTANT NONSURGICAL CAUSES OF
ABDOMINAL PAIN
Myocardial infarction
Mittelschmerz
Poisoning (lead, black widow spider)
Herpes zoster
Lower lobe (RLL) pneumonia
Endocrine (Addisonian crisis, diabetic ketoacidosis)
Sickle cell crisis
Porphyrias
Psychological (hysteria)
MI: Do an ECG on all
patients presenting with
midepigastric pain

Pain of pancreatitis is
described as boring, radiating
straight to the back.
Plain xray abdomen in errect posture