Acute Abdomen

Introduction

 The acute abdominal pain continues to be common diagnostic

challenge to the surgeon and other medical specialties.
 Acute abdominal pain is a surgical emergency requiring the surgeon
to combine the results of the history & physical examination with
properly selected laboratory & radiographic studies.
 Abdominal pain is the common symptom of gastro-intestinal
pathology & most diseases of the abdominal organs are associated
with abdominal pain.
 Abdominal pain may be Acute or Chronic & three types of pain are
recognized:
a) Visceral pain
b) Somatic pain
c) Referred pain
A. Visceral is caused by stretching or contracting hollow organs & is
usually colicky in nature.
B. Somatic pain is produced by irritation of the parietal peritoneum &
is usually continuous.
C. Referred pain is the perception of pain in an area of the body
distant to the site of origin of the pain.
 History of present illness (H.P.I.):
 Careful & detailed history usually defines: the time of onset of pain, its
location and change in character.
Types of pain

A. Colicky pain:
 colicky pain usually indicates hyper peristalsis which may be caused by
an obstructive process e.g. intestinal obstruction, biliary colic, ureteric
colic, or an infective process e.g. acute Gastro-enteritis.
 Typically, colicky abdominal pain comes in waves mounts to crescendo
& then passes off for short period before the cycle start again.
 Colicky pain is often associated with nausea, vomiting or diarrhea & is
not relieved altering position.
 The character of pain initially & later is important in the differentiation
of small bowel obstruction and strangulation of the intestine (S.I.
obstruction: cramping, intermittent pain, whereas, S.I.
Strangulation :severe, constant pain.
B. Continuous pain:
 Continues pain usually indicates parietal peritoneum irritation &
described as burning, boring, sharp or stabbing by the patient. Nausea
& vomiting may occur and the pain is made worse by shifting position.
Onset of pain

 Perforated viscous will produce sudden onset of sharp, severe

continuous pain.
 Pancreatitis will produce continuous pain of gradual onset.
 Intestinal obstruction will produce gradual onset, colicky pain.
 Ureteric colic will produce sudden severe colicky pain.
Site of pain

 The site of onset of the pain often gives clue to the anatomical structure most likely
to be involved.
 In general, Foregut structures cause upper abdominal pain, Midgut structures
produce central abdominal pain, while Hindgut structures give rise to lower
abdominal pain.
 Epigastric region: lower esophagus, stomach, duodenum, biliary, pancreas. cardiac.
 R.U.Q.: B.T., liver, pancreas, lung.
 L.U.Q.: Spleen, pancreas, lung.
 RT. & LT. Loins: kidney, ureter.
 Central: small bowel. Appendix, ascending colon & proximal two third of T. Colon.
 R.I.F.: caecum, Appendix, kidney, ureter, ovary.
 L.I.F.: Sigmoid colon, kidney, ureter, ovary.
 Supra pubic region: Sigmoid colon, urinary bladder, uterus.
 N.B. often visceral pain precedes somatic pain, so that the site of
pain may change with the progress of the disease e.g. Diverticulitis
may initially present with lower abdominal pain which later become
localized to the L.I.F.
 Diffuse abdominal pain is not uncommon (the patient is unable to
localize the pain to any one area).
 There are several causes for diffuse abdominal pain e.g. peritonitis,
Mesenteric adenitis, Mesenteric ischemia, Diabetic keto-acidosis,
Non specific abdominal pain, sickle cell crisis, leukemia.
Radiation of pain

 Biliary pain radiate from R.U.Q. to right shoulder.

 Pain extending into the back, indicates retro-peritoneal pathology:
pancreatitis, cancer of the pancreas, penetrating posterior D.U.,
Leaking A.A.A.
 Renal or ureteric colic: loin pain radiate to groin & genitalia.
 Testicular pain e.g. torsion, Epididymo-orchitis may radiate to iliac
fossa.
 Pancreatitis: Epigastric pain radiates along both costal margins to
the back.
Duration of pain & periodicity

 Acute abdominal pain is defined as pain less than 6 hours, such pain
is usually severe & usually has obvious cause.
 P.U. pain, classically exhibit periodicity (pain for days or weeks
with long pain free spells, lasting months).
Relieving & Exacerbating factors

 3 factors usually involved: position, food & drugs.

1. Position has no effect on colicky pain, while, patient with somatic
tend to find the most comfortable position and remain in that position
e.g. patient with pancreatitis find that sitting forward gives the most
comfort.
2. Food:
 Food may exacerbate G.U. or relieve D.U.
 Fatty food may provoke an episode of biliary colic.
 Post prandial Epigastric pain (hours) may indicate mesenteric ischemia.
3. Drugs:
 NSAIDS will increase P.U. pain.
 Antacids & Proton pump inhibitor will relieve P.U. pain.
Associated symptoms

 Associated symptoms such as: nausea, vomiting, hematemesis, anorexia,

weight loss, change in bowel habit, rectal bleeding, melena, fever, rigors,
jaundice, symptoms of anemia, urinary symptoms, hematuria, should be
sought.
 N.B. the relationship of the abdominal pain & vomiting is important and
may provide valuable diagnostic clue to the underlying etiological factor.
 Vomiting or diarrhea usually precede abdominal pain in acute G.E.
 The character of vomiting include: frequency, amount, color, contents.
 Clear vomitus (no bile ): suggests pyloric obstruction, whereas bile
stained emesis indicates that the obstruction is distal to the entrance of
C.B.D. INTO THE DUODENUM.
 Anorexia is usually associated with acute abdominal pain & in patients
with acute Appendicitis.
 Systemic review
 Assessment of the abdominal pain in female patients:
 Menstrual history: L.M.P., frequency & duration.
 History of vaginal bleeding, vaginal discharge.
 Past history:
 Previous diagnosis of an abdominal pain (e.g. P.U. disease, gall stones
disease, inguinal hernia).
 Previous hospitalization & surgery e.g. appendectomy,
cholecystectomy, gastric or intestinal surgery.
 Drug history – Family history – Social history
 GENERAL PHYSICAL EXAMINATION.
 EXAMINATION OF THE ABDOMEN:
 Inspection:
 Contour, movement with respiration, Hernial orifices, scar or obvious
masses.
 Palpation:
A. Superficial palpation: tenderness, rigidity, rebound tenderness.
B. Deep palpation: Liver, Kidney, Spleen, Masses.
 Percussion
 Auscultation
 N.B. P/R or P/V examination, external gentalia, femoral pulses
 Laboratory studies:
 General: CBC, U&E, U,G
 Specific: LFT, Serum amylase, HCG
 Radiographic studies:
 CXR
 AXR (erect & supine)
 USS od the abdomen & pelvis
 CT scan of the abdomen
 KUB, IVU, CT scan
ETIOLOGY OF ACUTE
ABDOMEN

 The most common causes of acute abdominal pain in the G.I.T. relates to an
inflammatory or mechanical process of the stomach, small & large bowel, gall bladder
C.B.D. or pancreas.
 Perforated P.U.
 Acute cholecystitis
 Acute pancreatitis
 Acute Appendicitis
 Pelvic inflammatory disease
 Renal calculi
 Mackle's diverticulitis
 Acute diverticulitis
 Bowel obstruction
 Volvulus
 Intussusception
 Pseudo-obstruction of the colon
Perforated peptic ulcer

 PPU is more common in the D.U than G.U.

 The pain is sudden onset, severe & located first in the epigastrium,
later spreading over the entire abdomen ( diffuse peritonitis),
shoulder pain is common due to irritation of the diaphragm.
 The patient usually lies in supine position, looks ill with tachypnea
& tachycardia.
 Abdominal examination: distension, generalized tenderness, rigidity
(firm, board-like abdomen), rebound tenderness, bowel sounds:
sluggish or absent.
 Laboratory data: leukocytosis, serum amylase may be slightly
raised.
 CXR ( erect film): air under the diaphragm (75%).
Acute cholecystitis

 The attack is characterized by the onset of a constant dull pain in the right
hypochondrium, radiating to the right shoulder.
 Nausea & vomiting are common.
 The pain may subside after several hours, if so, the episode is considered to be
biliary colic. Otherwise the disease process may progress to Acute cholecystitis.
 History of fatty dyspepsia and may be past history of similar condition.
 Abdominal examination: mild distension and abdomen may show asymmetry in the
right U.Q. (a mass may be palpated along right costal margin (( distended G.B.))).
 Tenderness & rigidity in the right U.Q.
 Murphy's Sign : +ve.
 Laboratory data: leukocytosis - serum bilirubin (2 - 2.5 mg), if serum bilirubin is
increased more than 3 mg, this may suggest stone in C.B.D.
 USS of the abdomen: gall stones, dilatation of the C.B.D. secondary to stone.
Features of chronic cholecystitis.
Acute pancreatitis

 Etiology:
 Major: gall stones, alcohol, idiopathic.
 Minor: Hypercalcemia, Hyperlipidemia, Trauma including abdominal
Surgery & ERCP drugs e.g. thiazide. Lasix, sulpha, valproate, viruses
e.g. mumps, coxsackie B.. hereditary cystic fibrosis, carcinoma of the
pancreas, tropical pancreatitis.
 Clinical Features:
 Sudden onset of severe Epigastric pain, radiating along both costal
margins to the back.
 Anorexia, nausea & vomiting.
 Severe necrotizing hemorrhagic pancreatitis (25%): Hypovolemic
shock, acute renal failure, atelectasis, pleural effusion, A.R.D.S.,
M.Ö.S.F.
 Abdominal examination :
 Tenderness, most evident in the Epigastric region, paralytic ileus, bowel sounds:
sluggish or absent, ecchymosis of the anterior abdominal wall e.g. Cullen's & Grey
Turner signs.
 Fever, Tachycardia & Hypotension
 Laboratory Data:
 Increase serum amylase & lipase.
 Leukocytosis
 Imaging:
1. USS of the abdomen.
2. CT SCAN.
3. MRI.
4. MRCP (show pancreatic & bile ducts dilation, blockage or narrowing).
5. ERCP (diagnostic & therapeutic).
Acute appendicitis

 Acute Appendicitis is a common cause of abdominal pain and it is difficult

to diagnose in children (less 3 years ) & older patients (more than 70 years).
 Clinical pictures:
 The abdominal pain first begins in the epigastrium, then gradually shift to the
peri-umbilical region and finally to the right L.Q. ( R.I.F.).
 Anorexia, nausea & vomiting are common.
 Fever and change in bowel may occur.
 ABDOMINAL EXAMINATION:
 Tenderness, rigidity & rebound tenderness in the R.I.F. (N.B. Rovsing sign,
Psoas sign, Obturator sign).
 Per rectal examination may reveals tender boggy mass-pelvic abscess
 Laboratory data: leukocytosis.
 USS of the abdomen and pelvis.
PELVIC INFLAMMATORY
DISEASE

 P.I.D. with Salpingitis is encountered in patient before the menopause.

 CLINICAL FEATURES:
 Acute pelvic pain originating in the right & left lower quadrants, often
become symptomatic at the completion or just follow menstrual period.
 Fever, nausea, vomiting and may be anorexia.
 Tenderness, usually in both L.Qs.
 P.V. examination: Cervical irritation, bilateral adnexal masses, vaginal
discharge.
 LABORATORY DATA: CBC (leukocytosis) - vaginal swab for C&S.
 USS.
Renal calculi

 Renal or ureteric calculi: RENAL COLIC.

 CLINICAL FEATURES:
 Loin pain radiating to the groin, scrotum and perineum.
 Nausea, vomiting, hematuria.
 Laboratory data: CBC, U&E, RFT, U.G.
 IMAGINGS: K.U.B, USS, CT SCAN, MRI, IVU.
Meckel diverticulum

 Meckel diverticulum is the persistent remains of the vitelo-intestinal tract

and occurs on the anti-mesenteric border of the terminal ileum in
approximately 2% of individuals and usually 2 feet's of the ileo-cecal
valve.
 It is true diverticulum (composed of all intestinal coats).
 It may contains ectopic tissues e.g. gastric, pancreatic.
 In children below 2 years, ulceration of the ectopic mucosa in Meckel
diverticulum is the commonest cause of rectal bleeding.
 Other complications include:
 Inflammation, which clinically similar to acute appendicitis.
 Perforation (peritonitis)
 Intestinal obstruction (volvulus or intussusception).
 INVESTIGATIONS: CBC, U&E, USS.
Acute diverticulitis

 Diverticular disease (Diverticulosis ) is a condition in which many

sac- like mucosal projection (false diverticulosis) develop in the
large bowel , especially the sigmoid colon.
 Acute inflammation of the diverticulum causes Acute Diverticulitis.
 Etiology:
 Low fiber diet → constipation, cause increase in the intra-luminal
colonic pressure → herniation of the mucosa through the coats of the
colon, at the weak points where the blood vessels penetrate to sub-
mucosa & mucosa.
 Clinical Features:
1. Diverticulosis: pain in the left iliac fossa and change in bowel
habit.
2. Acute Diverticulosis: malaise, fever, L.I.F. pain - abdominal
distension, tenderness, rigidity and may be palpable mass.
 Complications Of Acute Diverticulitis:
1. Perforation causes localized or diffuse peritonitis.
2. Peri-colic abscess & Fistula.
3. Strictures & large bowel obstruction.
4. Lower G.I.T. bleed.
 Investigations:
1. General: CBC, U&E, RFT, U.G.
2. Specific:
 CXR, AXR
 Barium enema, Gastrografin or water soluble enema.
 Colonoscopy.
 USS, C.T. scan, MRI.
 Cystoscopy.
 Selective angiography.
Small bowel obstruction

 Causes of mechanical intestinal obstruction:

1. Extra-mural: adhesions, bands, hernia.
2. Intra-mural : inflammatory bowel diseases (Crohn's disease),
carcinoma, lymphoma.
3. Intra-luminal: swallowed F.B., bezoars, gall stones ileus.
 Clinical features:
1. Sudden onset, sharp, colicky abdominal pain (often central &
cramping in nature).
2. Nausea, frequent vomiting.
3. Abdominal distension.
4. Bowel sounds: hyper active & increased pitch.
 Laboratory data: increased HCT (dehydration), leukocytosis.
 AXR: multiple dilated loops with (step-ladder) air-fluid level and
non obstructed colon will appear devoid of gas & Faeces.
Intussusception

 Common in infant & children (3-18 months).

 Intussusception is caused by invagination (telescoping) of proximal
segment of bowel into adjacent distal segment.
 It may originate from a lead point e.g. inflamed payer's patches, mucosal
adenoma, polyp, sub-mucosal lipoma.
 Types:
1. Ileo-ileal
2. Ileo-cecal
3. Ileo-colic
4. Colo-colic.
 Clinical features of intestinal obstruction + current jelly stool.
 N.B. The blood supply of the involved bowel is compromised at early stage
→ infarction & peritonitis supervene.
Large bowel obstruction

 Common causes:
1. Carcinoma of the colon
2. Acute diverticulitis
3. Volvulus
 Clinical Features:
1. Vomiting (vomiting is marked feature of high small bowel obstruction, also vomiting
with sequestration of fluid in the dilated loops of bowel leads to dehydration with
significant water & electrolytes deficits.
2. Colicky abdominal pain (supra-pubic region).
3. Abdominal distension, minimal tenderness in the L.L.Q. (unless peritonitis exist),
tympanatic percussion note, B.S. (hyper active), P.R. examination: empty rectum and
may be lower rectal mass.
 AXR:
 the descending & sigmoid colon dilated to the point of the obstruction - the small
bowel may dilated, if the ileo-caecal valve is an incompetent.
Volvulus

 Volvulus is 360 degree rotation of loop or loops of intestine, the rotation

causes obstruction of the vascular pedicle supplying the affected portion
and this will leads to ischemic necrosis, perforation & peritonitis.
 Types:
1. Small bowel volvulus: congenital malrotation of the gut - acquired:
adhesions or bands between the ante mesenteric border of the bowel &
anterior abdominal wall.
2. Caecal Volvulus: less common than volvulus of the sigmoid colon -
sudden onset of cramping pain in the R.L.Q & EPIGASTRIUM
ASSOCITED WITH NAUSEA and vomiting.
3. Volvulus of the colon: encountered in the elderly patient with chronic
constipation & redundant, elongated pelvic mesocolon and result in closed
obstruction (i.e. the segment of the bowel is closed at proximal & distal
ends) which give rise to ischemic necrosis, perforation & peritonitis.
 AXR : Coffee bean sign (sigmoid volvulus ).
 AXR: distended caecum & ascending colon, often with the gas
distended caecum in left U.O. (Caecal volvulus).
 N.B. PLAIN X-RAYS OF THE Abdomen, Erect and Supine films :
A. Erect Film: demonstrates air-fluid levels.
B. Supine Film: gives a clue to wither, the obstruction is in small
intestine or large intestine.
Pseudo-obstruction of the colon

 Unknown pathogenesis, may be autonomic imbalance ( decrease

para sympathetic tone & increase sympathetic output).
 This rarer functional obstruction is usually occurs in elderly patients
with severe extra-abdominal illness or injury e.g. heart failure, chest
infection diabetes mellitus, myxedema, retro-peritoneal hematoma,
e.g. fracture of the spines, pancreatitis, drugs: opiates, chronic renal
disease, respiratory or cerebral diseases
 There are signs & symptoms of colonic obstruction, but without
mechanical obstruction.
 AXR: Colonic Distension (Maximal In The Transverse Colon &
RIGHT COLON).
 N.B. If the condition not treated, distension of the caecum, increase
intra-luminal pressure, perforation & peritonitis.
Paralytic ileus (adynamic ileus)

 Functional intestinal obstruction secondary to absence of the normal

peristalsis.
 Causes:
I. P. ILEUS is common after intra-abdominal surgery (physiological
ileus), temporary cessation of the intestinal motor activity due to
handling & exposure of the bowel loops.
II. Peritonitis.
III. Hypokalemia, uremia, Burns, acute pancreatitis.
IV. Retro-peritoneal blood e.g. fractures pelvis or spines, renal injuries,
rupture of A.A.A.
Acute gynecologic diseases

 Acute abdominal pain resulting from gynecological disorders.

 ACUTE SALPINGITIS:
 Acute Salpingitis is bacterial infection of the fallopian tubes including
Gonorrheal & Chlamydial infection.
 Clinical features: the pain begins caudal to the umbilicus in the midline
& radiates to R.&L. L.Q.
 Abdominal examination: tenderness in both lower quadrants, decrease
B.S., P.V. examination: cervical tenderness +++ and vaginal discharge.
 Laboratory data: CBC, U.G., vaginal smear.
 USS.
 Ovarian cyst Torsion:
 Ovarian cyst torsion present with sudden onset of pain, located in the
lower abdomen & most severe in either right or left L.Q.
 P.V. examination : palpable mass confirm the diagnosis.
 USS.
 Ectopic Pregnancy:
 Tubal pregnancy may present as acute intra abdominal condition with
sudden lower abdominal pain, that is sharp in character & persistent,
with or without nausea & vomiting.
 Missed menstrual period or abnormally short scanty menstrual period
will have preceded the abdominal pain, these symptoms indicate
ruptured Fallopian tube, and occurs in the first trimester.
 Diagnosis: B-HCG + Ultrasound
Medical conditions of Acute
Abdomen

1. Acute Gastroenteritis
2. Diabetic Ketoacidosis (DKA)
3. Basal Pneumonia
4. Inferior MI
5. Others: Herpes Zoster Virus, Sickle Cell Anemia Crisis