Approach to a patient with

Acute abdomen
By: Dr. Fasil Wondmu (MD,Assistant
professor of surgery)
 Acute abdominal pain
• The term acute abdominal pain generally refers to previously
undiagnosed pain that arises suddenly and is of less than 7 days'
(usually less than 48 hours') duration.
• Acute abdominal pain is the most common general surgical
problem presenting to the emergency department.
• It may be caused by:
 intraperitoneal disorders, many of which call for surgical
treatment
 extraperitoneal disorders which typically do not call for surgical
treatment
• Abdominal pain that persists for 6 hours or longer is usually
caused by disorders of surgical significance
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 Con….
• The primary goals in the management of patients with acute
abdominal pain are
1. to establish a differential diagnosis and a plan for confirming
the diagnosis through appropriate imaging studies
2. to determine whether operative intervention is necessary &
3. to prepare the patient for operation in a manner that
minimizes perioperative morbidity and mortality

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 Con …
• The acute abdomen does not always signify the need for
surgical intervention; however, surgical evaluation is
warranted.

l. Pathophysiology
• The abdomen is analogous to a box.
• Abdominal pain arising from intra-abdominal pathophysiology
originates in the peritoneum, which is a membrane
comprising two layers
• Visceral or Parietal pain

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 Con….
A. Visceral pain
• Visceral peritoneum is innervated bilaterally by the autonomic
nervous system. The bilateral innervation causes visceral pain
to be midline, vague, deep, dull, and poorly localized.
• Visceral pain is triggered by inflammation, ischemia, and
geometric changes such as distention, traction, and pressure.
• Visceral pain signifies intra-abdominal disease but not
necessarily the need for surgical intervention

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 Con….
B. Parietal pain
• Parietal peritoneum is innervated unilaterally via the spinal
somatic nerves that also supply the abdominal wall.
• Unilateral innervation causes parietal pain to localize to one or
more abdominal quadrants .
• Parietal pain is sharp, severe, and well localized.
• Parietal pain is triggered by irritation of the parietal peritoneum
by an inflammatory process. It may also be triggered by
mechanical stimulation.
• Parietal pain is associated with physical examination findings of
local or diffuse peritonitis and frequently signifies the need for
surgical treatment
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 Con….
C. Embryologic origin
• Embryologic origin of the affected organ determines the
location of visceral pain in the abdominal midline.
• Foregut-derived structures (stomach to the 2nd portion of
duodenum, liver & biliary tract, pancreas, spleen) present
with epigastric pain.
• Midgut-derived structures (2nd portion of duodenum to
the proximal two thirds of the transverse colon)
present with periumbilical pain
• Hindgut-derived structures (distal transverse colon to the
anal verge) present with suprapubic pain.
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 Con….
8

D. Referred pain
• Referred pain arises from a
deep visceral structure but
is superficial at the
presenting site .
• It results from central
neural pathways that are
common to the somatic
nerves and visceral organs.

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 II. Evaluation
• Evaluation of the acute abdomen remains
heavily influenced by patient history and
physical exam findings.
• Ancillary imaging and lab tests can help to
complete the diagnosis and guide treatment
decisions

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 Cont…
A. History of present illness
1. Onset and duration of pain
– Sudden onset of pain (within seconds) suggests perforation or rupture
[e.g., perforated peptic ulcer or ruptured abdominal aortic aneurysm ].
Infarction, such as myocardial infarction or acute mesenteric occlusion, can
also present with sudden onset of pain.
– Rapidly accelerating pain (within minutes) may result from several sources.
• Colic syndromes, such as biliary colic, ureteral colic, and small-bowel obstruction.
• Inflammatory processes, such as acute appendicitis, pancreatitis, and diverticulitis.
• Ischemic processes, such as mesenteric ischemia, strangulated intestinal
obstruction, and volvulus.
– Gradual onset of pain (over several hours) increasing in intensity may be
caused by one of the following

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 Cont…
• Inflammatory conditions, such as appendicitis and cholecystitis.
• Obstructive processes, such as nonstrangulated bowel obstruction
and urinary retention.
• Other mechanical processes, such as ectopic pregnancy and
penetrating or perforating tumors
2. Character of pain
– Colicky pain waxes and wanes. It usually occurs secondary
to hyperperistalsis of smooth muscle against a mechanical
site of obstruction .
– Pain that is sharp, severe, persistent, & steadily increases in
intensity over time suggests an infectious or inflammatory
process .
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 Cont…
• Location of pain
– Pain caused by inflammation of specific organs may be
localized .
– Careful attention must be given to the radiation of pain.
• Alleviating and aggravating factors
– Patients with diffuse peritonitis describe worsening of
pain with movement (i.e., parietal pain); the pain is
ameliorated by lying still.
– Patients with intestinal obstruction have visceral pain
and usually experience a transient relief from symptoms
after vomiting.
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• Associated symptoms
– Nausea and vomiting frequently accompany
abdominal pain and may hint at its etiology.
– The sequence as well as the character of the
emesis should be documented.
– Fever or chills suggests an inflammatory or an
infectious process, or both.
– Anorexia is present in the vast majority of patients
with acute appenicitis

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 B. Past medical history, surgical history, and
organ-system review
• Pathologic medical conditions may precipitate
intra-abdominal pathology.
– Patients with peripheral vascular disease or
coronary artery disease may have abdominal
vascular disease (e.g., AAA or mesenteric ischemia).
– Patients with a history of cancer may present with
bowel obstruction from recurrence.
– Major medical problems are important to recognize
early in the patient and may call for urgent surgical
exploration.
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 Cont…
• A thorough medical history and organ-system
review must be carried out to exclude various
extra-abdominal causes of abdominal pain.
– Diabetic patients or patients with known coronary
artery disease or peripheral vascular disease who
present with vague epigastric symptoms may have
myocardial ischemia as the cause of the
abdominal symptoms.
– Right-lower-lobe pneumonia may present as RUQ
pain in association with cough and fever
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 Cont…

• A thorough menstrual history must be obtained in

women.
– Pelvic inflammatory disease (PID) typically occurs early in
the cycle and may be associated with a vaginal discharge.
– Ectopic pregnancy must be considered in every woman of
child-bearing age with lower abdominal pain, especially if
accompanied by a history of amenorrhea.
– Ovarian cysts can cause sudden pain by enlarging,
rupturing, or causing ovarian torsion.
– Abdominal pain that occurs monthly suggests
endometriosis
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 Cont…
• Previous abdominal surgery in a patient with colicky
abdominal pain may suggest intestinal obstruction
secondary to adhesions, incarceration of an incisional
hernia, or recurrence or malignancy. These are generally
accompanied by nausea and vomiting.
• NSAID medications place patients at risk for the
complications of peptic ulcer disease.
• Corticosteroids may mask classic signs of inflammation,
such as fever and peritoneal irritation, making the
abdominal examination less reliable.

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 Medications

• Antibiotics consumed by patients may aid or

hinder diagnosis.
– Patients with peritonitis may have decreased pain.
– Patients who have diarrhea and abdominal pain
may have antibiotic-induced pseudomembranous
colitis caused by Clostridium difficile.
– Be aware of the elderly patient on
immunosuppressants or antibiotics

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 Physical examination
• Overall appearance should be assessed.
– Patients with diffuse peritonitis appear acutely ill
and tend to lie quietly on their side with their
knees drawn toward their chest.
– Patients with colic tend to be restless and unable
to find a comfortable position.
– Patients who are jaundiced may have biliary
obstruction.
– Patients who appear weak and lethargic may be
septic
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 Cont…
• Vital signs are important indicators of a patient's overall
condition.
– Fever suggests the presence of inflammation or infection. Marked
fever (>39°C) suggests an abscess, cholangitis, or pneumonia.
– Hypotension or tachycardia, or both, may indicate hypovolemia
or sepsis
• Abdominal examination should be carried out thoroughly
and systematically.
– inspected for distention, surgical scars, bulging masses, & areas of
erythema.
– Auscultation .
– Percussion .
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 Cont…

• Areas of tenderness and guarding should be noted.

Rebound tenderness is not a very reliable sign of
peritonitis.
• The presence of involuntary guarding (localized or
diffuse) due to muscular rigidity from underlying
peritoneal irritation is often a better sign of
peritonitis.
• Pain out of proportion to physical examination
findings suggests mesenteric ischemia.
• Thoroughly search for hernias
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Any palpable masses should be noted. 21
 Cont…
– Rectal examination should be performed routinely
in all patients with abdominal pain.
• Tenderness or a mass .
• occult blood
– Pelvic examination must be performed in all
women of child-bearing age who present with
lower abdominal pain.
• Cervical discharge and overall appearance of the cervix.
• Bimanual examination should be performed to assess
cervical motion tenderness, adnexal tenderness, and the
presence of adnexal masses
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 Cont…
– Testicular and scrotal examination is essential in all
males who complain of abdominal pain.
• Testicular torsion produces a painful, swollen, and
tender testicle that is retracted upward in the scrotum.
• Epididymitis may coexist with urinary tract infection.
The epididymis is swollen and tender, and the vas
deferens may also be inflamed.

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 Laboratory evaluation
• CBC .
– WBC elevation- presence of an infectious source.
– Left shift on the differential to more immature
forms is often helpful .
– Hct elevation or low hematocrit
• An electrolyte - reveal clues to the patient's
overall condition.
– Hypokalemic, hypochloremic, metabolic alkalosis
may be seen in patients with prolonged vomiting
and severe volume depletion.
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 Cont …

• Liver enzyme .
• Pancreatic enzymes (amylase and lipase)
• Lactic acid level may be obtained when
considering intestinal ischemia.
• Urinalysis is helpful in assessing urologic causes
of abdominal pain.
• β-Human chorionic gonadotropin .
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 Radiologic evaluation
• should be very selective to avoid unnecessary cost and
possible morbidity associated with some modalities.
• Plain abdominal x-rays often serve as the initial radiologic
evaluation
– X-rays should be obtained in the supine and erect positions.
– Free intraperitoneal air is best visualized on an upright chest x-ray
• If the patient is unable to assume an upright position, a left lateral
decubitus x-ray should be obtained.
• Free air may not be detectable in up to 20% of cases of perforated viscus.
– The bowel gas pattern is assessed for dilation, air-fluid levels, and
the presence of gas throughout the small and large intestine.
• A sentinel loop (i.e., a single, dilated loop of bowel) may be seen adjacent
to an inflamed organ (as in pancreatitis) and is due to localized ileus.

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 Cont…
• Ultrasonography (US).
US visibility is limited in settings of obesity, bowel
gas, & subcutaneous air.
– RUQ US is particularly useful in biliary tract disease.
– US can be used in the evaluation of RLQ pain.
• Its utility and accuracy are operator dependent.
– Pelvic or transvaginal US is particularly useful in
women
– Testicular US is adjunctive to physical exam in
diagnosing testicular pathology (e.g., testicular
torsion, epididymitis, orchitis).
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 Cont…
• Contrast studies, although rarely indicated in
the acute setting, may be helpful in some
situations.
– In most instances, a water-soluble contrast agent
should be used to avoid possible barium
peritonitis in the event of bowel perforation.
– Contrast enema is particularly useful in
differentiating adynamic ileus from distal colonic
obstruction

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 – Calcifications should be noted.
• The vast majority of urinary stones (90%) contain calcium and are visible
on plain x-rays, whereas only 15% of gallstones are calcified.
• Calcifications in the region of the pancreas may indicate chronic
pancreatitis.
• Fecalith in the RLQ may suggest appendicitis.
• Calcification in the wall of the aorta may suggest an AAA.
• The most common calcifications seen in the abdomen are “phleboliths”
(benign calcifications of the pelvic veins). Phleboliths can be
distinguished from renal stones by their central lucency, which
represents the lumen.
– The presence of gas in the portal or mesenteric venous systems,
intramural gas in the GI tract, or gas in the biliary tree (in the
absence of a surgical enteric anastomosis) is an ominous finding
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 • Computed tomographic scanning It is of
particular benefit in certain situations, including
the following:
– When an accurate history cannot be obtained (e.g.
obtunded pt or an atypical history).
– When a patient with a chronic illness (e.g., Crohn
disease) experiences acute abdominal pain.
– When evaluating retroperitoneal structures (e.g., in
a stable patient with a suspected leaking AAA).
– When evaluating patients with a history of intra-
03/21/2024 abdominal malignancy. 30
 Differential Diagnosis for Acute Abdominal Pain
31

Upper abdominal • Other

• Perforated peptic ulcer OB/GYN
• PID
• Acute cholecystitis • Ectopic pregnancy
• Acute pancreatitis • Ruptured ovarian cyst
Mid & lower abdominal Urological
• Nephrolithiasis
• Acute appendicitis
• Pyelonephritis/cystitis
• Acute diverticulitis Nonsurgical
• Intestinal obstruction • Acute MI
• Mesenteric ischemia • Gastroenteritis
• Pneumonia DKA
• Ruptured AAA 03/21/2024
 Con….

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 Disorders which may cause pain in the umbilical and hypogastric regions

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 Disorders which give rise to acute abdominal pain are grouped by the
quadrant in which pain tends to occur

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 Treatment
• Accordingly
• Medical
• Surgical
immediate surgical intervention
observation

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 Thank You

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