acute abdomen

dharma prakasa
 definition
• acute abdomen—> tremendous severe pain arising the
abdominal area and requires immediate care.

• an abdominal emergency situation —> caused by

surgical or non-surgical problems.

• as clinicians (provide primary health care) must be

able to identify the case as either surgical or non-
surgical case.
 patophisiology
• visceral pain
• Distention, inflammation or ischemia in hollow viscous
& solid organs
• Localization depends on the embryologic origin of the
organ:
• Foregut to epigastrium
• Midgut to umbilicus
• Hindgut to the hypogastric region
• Parietal pain :

• localized to the dermatome above the site of the

stimulus.

• Referred pain: produces symptoms, not signs e.g.

tenderness
• The most common causes of acute abdomen
• appendicitis, biliary colic, cholecystitis,
diverticulitis,
• bowel obstruction, visceral perforation,
pancreatitis,
• peritonitis, salpingitis, mesenteric adenitis,
renal colic.
 Key points on history
• Site of pain

• Nature & character

• Duration

• Intensity

• Precipitating & relieving factors

• Associated symptoms
 Associated symptoms
• Fever

• Nausea/vomiting

• Genitourinary

• Gynaecological

• Vascular
 Management Acute Abdoment
1. Recognition & resuscitation for life-threatening
causes of abd. Pain

2. Physical exam features

3. Choosing diagnostic tests

4. Initial treatment

5. Differential diagnosis

6. Key points about the most common specific

causes
Diagnostic & Treatment Priorities
First : recognize presence of shock or intraabdominal bleeding

Second : start resuscitative measures for shock or bleeding (if

these are present)

Third : determine if the abdomen is the source of the shock or

bleeding

Fourth : determine if emergency laparotomy is needed

Fifth : complete the secondary survey (head to toe exam) ;

obtain needed lab or radiographic studies

Sixth : Conduct frequent reassessments of the patient

 General Approach to the Patient
Evaluate & treat the ABC's (Airway, Breathing,
Circulation) first in same sequence as for any other
emergency patient

Determine if an immediate life-threatening cause of abd.

pain may be present & if there is any history of
possible abd. Trauma

Start resuscitation and emergently consult a surgeon if

an emergent laparotomy is needed

Complete the secondary survey, treat pain, and decide

what other diagnostic tests will be needed
 Immediate Life-Threatening
Causes of Acute Abdominal

These must be recognized from the primary survey

:
1. Ruptured abdominal aortic aneurism (AAA)
2. Rupture of the spleen or liver
3. Ruptured ectopic pregnancy
4. Bowel infarction
5. Perforated organ
 Exam of the Abdomen
1. Inspection : Look for :
- Scars from prior surgeries
- Distension
- Localized swelling or mass
- Eccymoses or erythema
- Visible peristalsis
2. Auscultation
Listen for bowel sounds & bruits
3. Palpation & percussion
 LABORATORY TESTS
• a complete peripheral blood count (including
differential count of leukocytes), determination of
serum electrolyte, ureum, creatinine, blood glucose
and urinalysis.
• Pregnancy testing should be performed in all
women of reproductive age with abdominal pain.
• Liver function tests and determination of serum
amylase level should be ordered in patients with
abdominal pain of upper right quadrant, either with
or without clinical jaundice.
 other diagnostic tests
• Three-position plain abdominal radiographs should be
done to determine the presence of perforation signs, ileus
and bowel obstruction.
• Plain abdominal radiographs may be helpful in evaluating
pancreatic calcification, vertebral fracture and radioluscent
stone of renal contour.
• Another routine test is abdominal ultrasonography
(abdominal USG), which may reveal disrupted
hepatobiliary system, urinary tract and gynecologic tract
as well as the acute appendicitis.
• Nowadays, other imaging tests such as colon in loop,
gastrointestinal endoscopy, abdominal CT-scan, MRI CT
arteriography have been increasingly used.
• However, those tests should be ordered appropriately and
consistent with the indication considering that the cost is
still relatively high.
 Treatment
• Hypotension and tachycardia suggest blood loss,
hypovolemia, or sepsis and require prompt
aggressive fluid resuscitation with adequate large
bore IV access.
• Broad-spectrum antibiotics covering gram-negative
enteric organisms should be administered in a timely
fashion when infection, peritoneal soilage, or sepsis
is in the differential.
• Patients should be monitored with ongoing vital sign
resuscitation.
• Adequate pain relief with opioids is a standard of
care. The use of anti-emetics is likewise important.
• If a surgical emergency is suspected based on
presentation or physical findings, a surgeon should
be consulted in an emergent fashion.
• The surgeon must be contacted before potentially
time-consuming testing is performed.
Acute Abdominal Summary
1. Assess the ABC's & provide emergent Rx if life-
threatening cause suspected

2. Complete exam prior to deciding on other Dx

tests

3. Focus on the most likely Dx's initially

4. Decide early if surgical consult or hospital

admission needed

5. Don’t forget "secondary" treatments

•

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Sep;35(9):579-580. [PubMed] References
1.Elhardello OA, MacFie J. Digital rectal examination in patients with acute abdominal pain. Emerg Med J. 2018

2.Maleki Verki M, Motamed H. Rectus Muscle Hematoma as a Rare Differential Diagnosis of Acute Abdomen; a Case
Report. Emerg (Tehran). 2018;6(1):e28. [PMC free article] [PubMed]
• 3.Kaushal-Deep SM, Anees A, Khan S, Khan MA, Lodhi M. Primary cecal pathologies presenting as acute abdomen
and critical appraisal of their current management strategies in emergency settings with review of literature. Int J Crit
Illn Inj Sci. 2018 Apr-Jun;8(2):90-99. [PMC free article] [PubMed]
• 4.Li PH, Tee YS, Fu CY, Liao CH, Wang SY, Hsu YP, Yeh CN, Wu EH. The Role of Noncontrast CT in the Evaluation
of Surgical Abdomen Patients. Am Surg. 2018 Jun 01;84(6):1015-1021. [PubMed]
• 5.de Burlet K, Lam A, Larsen P, Dennett E. Acute abdominal pain-changes in the way we assess it over a decade. N Z
Med J. 2017 Oct 06;130(1463):39-44. [PubMed]
• 6.Geng WZM, Fuller M, Osborne B, Thoirs K. The value of the erect abdominal radiograph for the diagnosis of
mechanical bowel obstruction and paralytic ileus in adults presenting with acute abdominal pain. J Med Radiat Sci.
2018 Dec;65(4):259-266. [PMC free article] [PubMed]
• 7.Mohammed MF, Elbanna KY, Mohammed AME, Murray N, Azzumea F, Almazied G, Nicolaou S. Practical
Applications of Dual-Energy Computed Tomography in the Acute Abdomen. Radiol Clin North Am. 2018
Jul;56(4):549-563. [PubMed]
• 8.Nakashima T, Miyamoto K, Shimokawa T, Kato S, Hayakawa M. The Association Between Sequential Organ
Failure Assessment Scores and Mortality in Patients With Sepsis During the First Week: The JSEPTIC DIC Study. J
Intensive Care Med. 2020 Jul;35(7):656-662. [PubMed]
• 9.Pucher PH, Carter NC, Knight BC, Toh S, Tucker V, Mercer SJ. Impact of laparoscopic approach in emergency
major abdominal surgery: single-centre analysis of 748 consecutive cases. Ann R Coll Surg Engl. 2018
Apr;100(4):279-284. [PMC free article] [PubMed]
• 10.Bhosale PR, Javitt MC, Atri M, Harris RD, Kang SK, Meyer BJ, Pandharipande PV, Reinhold C, Salazar GM,