CMT05209: Surgery

Session 1: Acute Abdomen

 Learning tasks
At the end of this session, students are expected
to be able to:
• Define acute abdomen
• Identify different causes of acute abdomen
• Describe the pathophysiology of abdominal
pain in acute abdomen
• Describe clinical features of acute abdomen.
 Learning tasks cont..
• Identify the possible investigations acute
abdomen
• Describe the differential diagnoses of acute
abdomen
• Describe the treatment of acute abdomen
 Activity: Brainstorming
• What is acute abdomen?
 Definition
• Acute abdomen is a term used to encompass a
spectrum of surgical, medical and
gynecological conditions (in a patient
previously well) and is characterized by:-
– Acute/Rapid onset of abdominal pain
accompanied +/- NAUSEA and
VOMITING
– Life-threatening
– Requires urgent surgical, medical or
gynecological attention
 Causes: Surgical
• Congenital
- imperforate anus
- intestinal atresia
- mal-rotation of the intestine
- congenital bands
 Causes: Surgical cont..
• Acquired
- Trauma: blunt or penetrating
- Perforation: stomach, gallbladder or
intestines
- Obstruction: Intestinal, biliary colic, ureteric
colic, acute urinary retention
- Vascular diseases: dissecting aneurysm,
superior mesenteric occlusion
 Causes: Surgical cont..
• Inflammation: Acute appendicitis, acute
cholecystitis, acute pancreatitis
• Non-specific abdominal pain
 Causes: Medical
• Diabetic ketoacidosis-25% cases
• Sickle cell disease during abdominal crisis
• Uremic syndrome
• Thoracic conditions: spontaneous
pnuemothorax
• Cardiac diseases: acute pericarditis, angina
pectoris
 Causes: Gynacological
• Ruptured ectopic pregnancy
• Twisted ovarian cyst
• Acute Pelvic inflammatory diseases
• Tubo-ovarian abscess
• Torsion or degeneration of a uterine fibroid
 Pathophysiology
• Main symptom of acute abdomen is abdominal
pain: abdominal pain can either be:-
– Visceral abdominal pain
– Somatic abdominal pain
– Referred abdominal pain
 Pathophysiology cont..
Visceral abdominal pain
• Mediated through the sympathetic branches of
the autonomic nervous system
• It is diffuse, dull aching, poorly localized and
is referred to cutaneous dermatomes
• It can also be associated with motor and
autonomic reflexes (e.g. nausea & vomiting)
 Pathophysiology cont..
Somatic/Parietal abdominal pain
• Arises from abdominal wall or parietal
peritoneum
• It is usually sharp, intense and can be localized
accurately to the site of origin
• Pain receptors are in the parietal peritoneum and
abdominal wall
• Information is passed centrally via segmental
somatic sensory nerves
 Pathophysiology cont..
Referred abdominal pain
• Is pain that results from irritation of an
abdominal organ not felt in the viscus, but in
somatic structure that may be at a considerable
distance from it
• Pain is usually referred to a structure that
developed from the same embryonic segment
as the organ of origin of the pain
 Activity: Brainstorming
• What are the clinical features of acute
abdomen?
 Abdominal pain
• The most important symptom
• History of pain should include:-
– Onset and severity
– Type of pain
– Radiation of pain
– Change in nature of pain
– Associated bowel or urinary symptoms
– Aggrevating or relieving factors
 Abdominal pain: Onset of pain
• Sudden onset pain which wakes the patient
from sleep
– E.g. perforation or strangulation of bowel
• Slow insidious onset
– Inflammation of visceral peritonium
– Contained process such as abscess
• Crampy or colicy pain
– Biliary, ureteric or intestinal colic
 Associated bowel symptoms
• Constipation
– Progressive intestinal obstruction
– Paralytic ileus
– Postoperative
– Obstructed inguinal hernia
Associated bowel symptoms cont..
• Diarrhoea with pain is mainly medical with
exception of the following:-
– Gall stone ileus
– Superior mesenteric vascular occlusion
– Spurious diarrhoea in chronic feacal
impaction
 Nausea and Vomiting
• Frequency of vomiting
• Character of vomiting e.g. projectile, non-projectile
or self-induced
• Nature of vomiting
– Bilious vomiting- small bowel obstruction
– Non-bilious vomiting- obstruction proximal to
Ampulla of Vater
– Faeculent vomiting in distal small bowel
obstruction, large gut obstruction, strangulation
 Anorexia
• Anorexia or decreased appetite with pain is
usually seen in acute appendicitis
 Fevers & chills/ rigors
• Infective liver abscess
• Peri-nephric abscess
• Intra-abdominal pus collection
 Investigations
• Consider those useful in the first 24 hrs.
• Useful in making a diagnosis
• Divided into 4 categories;
– Laboratory studies
– Imaging studies
– Diagnostic procedures
– Endoscopic studies
 Laboratory studies
• Urine
- Urinalysis
- Pregnancy test
• Blood
- Full blood count
- Urea and electrolytes
- Liver function test
- Random blood glucose
 Imaging studies
• Radiography
- Chest radiography(erect spine)
- Abdominal radiography(erect and supine)
• Ultrasound scan
• Contrast studies
• CT-scan
• Endoscopic studies: Sigmoidoscopy in
sigmoid volvulus
 Differential diagnosis
• Differential diagnosis will depend on the
cause of acute abdomen or on the anatomical
location.

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 Treatment
• Definitive treatment depends on:-
– Specific disease
– General condition of the patient
• Treatment modalities can be:-
– Conservative
– Surgical
 Conservative Treatment
• Conservative management is indicated in:
– Acute cholecystitis
– Acute PID
– Sealed perforations-local peritonitis
– Acute pancreatitis
– Other medical conditions
 Surgical Treatment
• Surgery is indicated in case of:-
– Peritoneal irritation-traditionally an
indication for an emergency operation
– Evidence of continuing leakage leading to
generalised peritonitis
– Failure to respond to non-operative
measures
 Key points
• Acute/Rapid onset of abdominal pain
conditions (in a patient previously well)
accompanied +/- NAUSEA and VOMITING

• The causes of acute abdomen depends on the

underlying pathology
 Key points cont..
• Abdominal pain is a main symptom in acute
abdomen

• Acute abdomen warranting first identifying

and then treating the underlying pathology
 Review questions
1. What is acute abdomen?

2. Mention causes of acute abdomen?

3. Outline management of acute abdomen?

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 References
• Surgery Notes from Prof. Aziz, compiled by
Dr. Ndile 2003.MNH,Pg 61-66.
• S.DAS,A Manual on clinical surgery 2011