THE ACUTE ABDOMEN

• DR. E. NKHATA
DEFINITION OF ACUTE
ABDOMEN

• Abdomen anterior region of the trunk between thoracic

diaphragm superiorly and pelvic brim inferiorly.
• Condition of the sudden onset usually associated with
abdominal pain, perforation, obstruction, infarction or
rupture of intra abdominal organs (Anderson, Novak,
Keith and Elliot, 2012).
• Synonym – Surgical abdomen
• Its a surgical emergency.
PATHOPHYSIOLOGY OF
ACUTE ABDOMEN
• There maybe:
• inflammation secondary to infection (acute appendicitis and
diverticulitis)
• Obstruction (small and large bowel obstruction)
• Malrotation of the gut
• Mechanical distention, inflammation, ischaemia and intense
contraction of smooth muscles as in colic pain i.e. visceral
innervation visceral pain secondary to embryonic foregut,
midgut and hindgut and somatic pain.
HISTORY: Abdominal Pain

• Thorough history is essential to

come up with accurate diagnosis
and rule out unlikely conditions.
• The most common and chief
presenting feature of an acute
abdomen is pain.
• Special attention should be paid to
the location, the mode of onset
and progression as well the
character of the pain to come up
with possible differential
diagnoses
A. Location of Pain

• The dual visceral and parietal

sensory innervation of the abdominal
region is complex and thus pain is
vaguely localized.
• However general patterns provide
clues to diagnosis.
 Visceral pain

• Is elicited by:
1. distention
2. inflammation or ischemia that
stimulate the receptor neurons
3. direct involvement (by malignant
infiltration) of sensory nerves
 Parietal pain

• Mediation of parietal pain is via both

C and A delta nerve fibers.
• Accurate and exact location of pain
results from direct irritation of the
somatically innervated parietal
peritoneum by pus, bile, urine or
gastrointestinal secretions.
The referred pain

• Noxious (usually cutaneous) sensation at a site distant

from strong primary stimulus.
• The distortion in central perception of the site of pain
results from the confluence of afferent nerve fibers
within the posterior horn of the spinal cord.
• Pain due to subdiaphragmatic irritation by air,
peritoneal fluid, blood, or a mass lesion is referred to
the shoulder via the C4-mediated (phrenic) nerve.
Spreading or shifting pain

• The site of pain at onset should be differentiated

from the site at presentation.
• The initial typical pain in the epigastric or
periumbilical region, the incipient visceral pain of
acute appendicitis (as a result of distention of the
appendix) later shifts to become sharper parietal
pain localized in the right lower quadrant due to
direct inflammation of the overlying peritoneum.
Common causes of the acute
abdomen
• Gastrointestinal tract disorders
   *Nonspecific abdominal pain
   *Appendicitis
   *Small and large bowel obstruction
   *Perforated peptic ulcer  
Incarcerated hernia
    Bowel perforation
   
 Meckel's diverticulitis
   Boerhaave's syndrome
   *Diverticulitis
   Inflammatory bowel disorders
   Mallory-Weiss syndrome
   Gastroenteritis
   Acute gastritis
   Mesenteric adenitis
   Parasitic infections
Liver, spleen, and biliary tract
disorders
•

*Acute cholecystitis
   

   Acute cholangitis
   Hepatic abscess
   Ruptured hepatic tumour
   Spontaneous rupture of the spleen
   Splenic infarct
   Biliary colic
   Acute hepatitis
 Pancreatic disorders

•    *Acute pancreatitis
Urinary tract disorders
   *Ureteral or renal colic
   Acute pyelonephritis
   Acute cystitis
   Renal infarct
Peritoneal disorders

•    Intra-abdominal abscesses
   Primary peritonitis
   Tuberculous peritonitis
• Gynecologic disorders
   Ruptured ectopic pregnancy
   Twisted ovarian tumour
   Ruptured ovarian follicle cyst
   *Acute salpingitis
   Dysmenorrhea
   Endometriosis
• Vascular disorders
   Ruptured aortic and visceral aneurysms
   Acute ischaemic colitis
   Mesenteric thrombosis

Retroperitoneal disorders
   Retroperitoneal hemorrhage
 Gastrointestinal disturbances

Vomiting could be an indication of:

1. gastrointestinal obstruction
2. pyloric stenosis
3. the reflex effect biliary or renal colic.
Mode of Onset and Progression
of Pain
• Depict the nature and severity of the
precipitating factor.
• Onset may be explosive, rapidly progressive
or gradual.
• Unknown, excruciating generalized pain
suggests perforated viscus or rupture of an
abdominal aortic aneurysm, ectopic
pregnancy or abdominal abscess
Character of Pain

• The nature, severity and periodicity of pain

points to the underlying cause
• Steady pain is most common.
• Sharp superficial constant pain from severe
peritoneal irritation occurs in perforated
peptic ulcer or a ruptured appendix, ovarian
cyst or ectopic pregnancy.
• The gripping, mounting pain of small bowel obstruction and
early pancreatitis is usually intermittent, vague, deep-seated,
and crescendo initially then becomes sharp, unremitting and
better localized.
• The disquieting bearable pain associated with bowel
obstruction, pain due to lesions that occlude smaller conduits
(bile ducts, uterine tubes and ureters) rapidly becomes
unbearably intense.
• Colic Pain is pain with pain-free intervals that entails
intermittent smooth muscle contractions, as in ureteral colic.
Symptoms Associated with Abdominal Pain

• Anorexia,
• nausea
• vomiting,
• constipation,
• diarrhoea
A. Vomiting

• Sufficient stimulation by secondary visceral

afferent fibers of the medullary vomiting
centers, activates efferent fibers to induce
reflex vomiting.
• Pain in the acute surgical abdomen usually
occurs before vomiting, However vomiting
precedes pain in medical conditions.
B. Constipation

• Reflex ileus is frequently induced by visceral

afferent fibers which stimulate efferent fibers of
the sympathetic autonomic nervous system
(splanchnic nerves) to minimize intestinal
peristalsis.
• Therefore paralytic ileus undermines the value
of constipation in the differential diagnosis of
an acute abdomen
C. Diarrhoea

• Copious watery diarrhoea is typical

of gastroenteritis and other medical
causes of an acute abdomen.
• Blood-stained diarrhoea is suggestive
of ulcerative colitis, Crohn's disease,
or bacillary or amoebic dysentery
Relevant Aspects of the History

• A. Gynecologic History
• B. Drug History
• C. Family History
• D. Travel History
• E. Operation History
 PHYSICAL EXAMINATION

• A methodical and complete

general physical examination is
essential.
• Look for specific signs that
confirm or exclude differential
diagnoses.
General observation

• General observation suggest reliable indication of

the severity of the clinical situation.
• Though uncomfortable, most patients remain calm.
• The writhing of patients with visceral pain as in
intestinal or ureteral colic is in contrast with the
rigidly motionless bearing of patients with parietal
pain such as acute appendicitis or generalized
peritonitis.
Systemic signs

• Follow rapidly progressive or advanced

disorders associated with an acute abdomen.
• Extreme pallor, hypothermia, tachycardia,
tachypnea, and sweating suggest major intra-
abdominal hemorrhage such as ruptured
abdominal aortic aneurysm or tubal
pregnancy.
Fever

• Constant low-grade fever is common in

inflammatory conditions : diverticulitis, acute
cholecystitis and appendicitis.
• High fever with lower abdominal tenderness in a
young woman without signs of systemic illness is
typical acute salpingitis.
Steps in physical examination of
the acute abdomen
• Inspection
• Auscultation
• Cough tenderness
• Percussion
• Guarding or rigidity
• Palpation
• One-finger
• Rebound tenderness
• Deep
• Punch tenderness
• Costal area
• Costovertebral area
• Special signs
• External hernias and male
genitalia
• Rectal and pelvic examination
Physical findings in various
causes of acute abdomen.
• 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).
• Intestinal obstruction Distention;
visible peristalsis (late);
hyperperistalsis (early) or quiet
abdomen (late);
• Paralytic ileus Distention; minimal
bowel sounds; no localized tenderness.
• Ischemic or strangulated bowel: Not
distended (until late), bowel sounds
variable, severe pain but little
tenderness; rectal bleeding.
• Bleeding: Pallor, shock,
distention, pulsatile
(Abdominal aortic aneurysm)
or tender in ectopic
pregnancy) mass, rectal
bleeding.
INVESTIGATIVE STUDIES

• The history and physical examination

provide the diagnosis in two-thirds of
cases of an acute abdomen.
• Supplementary laboratory and
radiologic examinations are essential in
diagnosis of several surgical conditions.
LABORATORY
INVESTIGATIONS
• A. Blood Studies
Hemoglobin, hematocrit, and white blood cell and
differential counts should be taken on admission.
B. Urine Tests
Urinalysis. Dark urine or a raised specific gravity
indicates mild dehydration in patients with normal
renal function.
• C. Stool Tests
Gastrointestinal bleeding is not a
common feature of the acute
abdomen.
Testing for occult faecal blood should
be routinely performed.
Imaging Studies

• A. Plain Chest X-Ray Studies

• An erect chest x-ray is essential in all cases
of an acute abdomen.
• For preoperative assessment and
demonstration supradiaphragmatic conditions
that simulate an acute abdomen such as lower
lobe pneumonia or ruptured esophagus.
B. Plain Abdominal X-Ray Studies
Plain supine films of the abdomen should be
obtained only selectively.

• In general, erect (or lateral

decubitus) views contribute little
additional information except in
suspected intestinal obstruction.
• Radiologic abnormalities are
present in up to 40% of patients and
are diagnostic only half the time.
• C. Angiography: Percutaneous invasive angiographic
studies, or magnetic resonance angiography (MRA)
indication intra-abdominal intestinal ischemia or
suspicion of ongoing haemorrhage.
• D. Gastrointestinal Contrast X-Ray Studies
Gastrointestinal contrast studies should not be
requested routinely or be regarded as screening
studies.
• E. Ultrasonography: Ultrasonography is of value evaluation
in upper abdominal pain not related to ulcer pain or bowel
obstruction and in investigating abdominal masses
• F. CT Scan: Urgent or emergent CT scan of the abdomen is
now generally routinely and rapidly available

• Endoscopy: Proctosigmoidoscopy is indication in any

patient with suspected large bowel obstruction, grossly
bloody stools or a rectal mass.
• Paracentesis: In patients with free peritoneal fluid,
aspiration of blood, bile, or bowel contents is a strong
indication for urgent laparotomy - DPL.
• Laparoscopy: Laparoscopy is therapeutic and
diagnostic modality
• In young women, it may distinguish a nonsurgical
or gynaecological condition (ruptured graafian
follicle, pelvic inflammatory disease, tubo-ovarian
disease) from appendicitis.
In obtunded, elderly, or critically ill patients, who often
have deceptive manifestations of an acute abdomen,

• It may facilitate earlier

treatment in those with positive
findings while eliminating the
added morbidity of a
laparotomy in negative cases
 DIFFERENTIAL DIAGNOSIS

• The age and gender of the patient assist in the

differential diagnosis:
• Mesenteric adenitis mimics acute appendicitis in the
young.
• Gynecologic disorders complicate the evaluation of
lower abdominal pain in women of childbearing age;
• Malignant and vascular diseases are more common
in the elderly.
INDICATIONS FOR SURGICAL
EXPLORATION AND COMPLICATIONS

• The need for operation is apparent when the

diagnosis is certain,
• surgery sometimes must be undertaken before a
precise diagnosis is reached.
• Sepsis
• Necrosis and/or bowel gangrene
• Fistula and death.
BIBLIOGRAPHY

1. Anderson D. M, Novak P.D, Keith J and Elliot M. A

(2012) Dorland’s illustrated Medical Dictionary,
Elsevier Saunders Company Philadelphia United
States of America ISBN: 978-1-4160-6257-8
2. Mugala D. D (2012) The acute abdomen, the
Copperbelt University Lecture notes
3. Patterson J. W, Kashyap S and Dominique E (2020)
Acute abdomen
ncbi.nlm.nih.gov.books/NBK459328