ACUTE ABDOMEN

Ekpemiro Uchechi C MB.BS;FWACS

Gregory University Uturu
OUTLINE

1. Introduction
2. Anatomy and Physiology
3. Aetiology
4. Clinical Presentation
5. Differential Diagnosis
6. Ancilliary Investigations
7. Treatment
8. Conclusion
INTRODUCTION
Acute Abdomen is a potentially life threatening condition of
short duration that usually presents with severe abdominal
pain. It often requires emergency surgical therapy.

The most common cause of acute abdominal pain is non-

specific abdominal pain (24 – 44’3 % of the study populations),
followed by acute appendicitis (15.9 – 28.1 %), acute biliary
disease (2.9 – 9.7 %) and bowel obstruction or diverticulitis in
elderly patients (RT Grundman et al. 2010). Bowel perforation is
more common in Nigeria (and other tropical regions) than acute
biliary disease (JO Agboola et al 2014; M. Srujan Kumar et al
2019)
ANATOMY AND PHYSIOLOGY
There are three types of Abdominal Pain: Visceral;
Parietal(somatic); and Referred.
Visceral Pain is the one related to the internal organs within the
abdominal cavity and tends to be vague and poorly localized.
Parietal (somatic) Pain follows the nerve roots innervating the
parietal peritoneum (Abdominal wall) and tends to be sharper and
better localized.
Referred Pain is perceived at a location distant from the source of
the stimulus for the pain.
AETIOLOGY
The causes of Acute Abdomen can be grouped into:
1.Inflammatory causes (Infective and Non-infective)
2.Obstruction of Hollow viscus
3.Ischaemia
4.Non-surgical causes of acute abdominal pain
Inflammatory causes of acute abdomen:
1.Acute appendicitis
2.Acute cholecystitis
3.Acute pancreatitis
4.Cholangitis
5.Acute diverticulitis
6.Acute peritonitis (including hollow viscus perforation)
Obstruction of hollow viscus: Normal flow of content is
impeded by a lesion within the viscus or in its wall or outside it by
external compression.
1. Bowel obstruction from adhesions, hernias, volvulus,
intussusception, colorectal cancers, strictures etc.
2. Biliary obstruction from cholelithiasis (gall stones), cancer of
the pancreas, cancer of the bile duct, cancer of the gall
bladder, iatrogenic injuries, choledochal cysts.
3. Urinary tract obstruction from kidney stones, prostatic
enlargement, pregnancy, endometriosis, uterine prolapse, scar
tissue, intra-abdominal tumours or cysts, blood clots.
Ischaemia: Acute mesenteric ischaemia is the interruption of
intestinal blood flow by embolism, thrombosis, or a low flow
state.

The stomach, duodenum, and rectum rarely develop

ischaemia because of abundant collateral vessels.

The splenic flexure is a watershed between the superior

mesenteric artery and the inferior mesenteric artery and is
therefore at risk of ischaemia.
Non-surgical causes of acute abdomen:
1.Endocrine and metabolic causes like diabetic crisis, uraemia,
addisonian crisis, acute intermittent porphyria, acute
hyperlipoproteinaemia, and hereditary Mediterranean fever.
2.Haematologic disorders e.g Sickle Cell crisis, acute leukaemia,
and other blood dyscrasias.
3.Toxins and Drugs e.g lead and other heavy metal poisoning,
narcotic withdrawal, and black widow spider poisoning.
CLINICAL FEATURES
The making of an accurate diagnosis depends mainly on a careful
and thorough history taking and physical examination.
The information obtained is matched with the patient’s
demographics such as Age, Gender, Race, ethnicity, Marital status,
Number of Children (if any), Occupation, income, education,
religion, sexual orientation, health and disability status, and
psychiatric diagnosis.

Give the required attention to the onset of symptoms, their

progress, and chronology.
Pain
Ask to know the onset, severity, site, radiation, character,
duration, timing, periodicity, progress, aggravating factors,
relieving factors, and associated symptoms.

Note “OPQRST” mneumonic.

Explore other symptoms – fever, nausea, vomiting,

constipation, diarrhea, pruritus, melaena, haematochaezia, and
haematuria.
Past Medical History of pain, previous illnesses, surgical care
and operations, and coexisting medical conditions.

History of Medications and Drug Allergies (including

recreational drugs)

Gynaecologic history.
Physical Examination
General observation of the patient may reveal painful distress
and attempts by the patient to gain some relief. There may be
diaphoresis, pallor, jaundice, respiratory distress, cyanosis,
dehydration, tachypnea, tachycardia, hypotension, altered
mental status etc.

Inspection of the abdomen would show the contour, the

presence or absence of scars, hernias, mass effects, erythema,
oedema, ecchymosis.

Careful palpation of the abdomen from the site of no pain or less

pain to the site of maximal pain and tenderness. Guarding may
Percussion of the abdomen may reveal gaseous distention of the
intestines, loss of liver dullness, localized dullness, ascites (shifting
dullness; fluid thrill), as well as tenderness.

Auscultation would show absence (as in ileus) or presence of bowel

sounds and their quantity and character. Bowel sounds are rushing
(frequent), high pitched, and associated with pain in mechanical
obstruction but far away echoing sounds occur in significant
distention. Bruit are frequently heard in high grade arterial stenosis
of 70% – 95% and if arteriovenous fistula is present.
Rectal and Pelvic examinations.

Atypical presentation can occur in pregnancy, paediatrics, critically ill,

DIFFERENTIAL DIAGNOSIS
ANCILLIARY INVESTIGATIONS

Laboratory tests include:

1. Complete blood count and differential
2. Serum Electrolyte, blood urea nitrogen, andcreatinine
3. Serum amylase and lipase
4. Liver function test
5. Serum Lactate
6. Arterial blood gases
7. Urinalysis
8. Urine culture
9. Urine human chorionic gonadotrophin
10.Stool occult blood, microscopy, culture, and toxin assay.
Imaging include:
1. Abdominopelvic ultrasonography
2. Plain radiographs of the chest and abdomen
3. Computerized Tomographic scan (CT Scan)
4. Magnetic Resonance Imaging (MRI)
5. Paracentesis Abdominis
6. Diagnostic Laparoscopy
TREATMENT
Prompt assessment and resuscitation of patients with acute
abdomen is top- priority in the management of this condition.

Airway must be maintained and protected (position, insertion of an

airway if necessary, decompression of the GI tract with nasogastric
tube to avoid aspiration/drowning). Seek help early.

Optimize breathing and ensure adequate ventilation and oxygen

therapy

Manage shock effectively as well as fluid and electrolyte

abnormalities (use wide-bore cannula for venous access).
Monitor patient frequently and ideally place on
continuous monitoring – oxygen saturation,
respiratory rate, pulse, blood pressure, ECG,
temperature, hourly urine output, serial arterial
blood gases, CBC, SEUC etc.

Definitive treatment and follow-up would depend

on the cause of acute abdomen.
.
. CONCLUSION
Acute Abdomen is a condition with numerous causes.

A thorough and careful clinical evaluation based on knowledge,

with support from ancillary investigations is required for diagnosis

Of utmost importance however is the emergency care of this condition

Definitive treatment depends on the underlyimg cause.