Acute Abdomen

Dr. AHMED M.
Outline

• Definition
• Basic Anatomy and Embryology
• Pathophysiology and differential
diagnosis
• Investgigation and management
Definition

07/12/2024
acute abdomen refers to the signs and
symptoms of abdominal pain and

Abdominal trauma
tenderness that requires prompt diagnosis
and surgical treatment.

3
Pathogenesis and Differential
Diagnosis of Acute Abdomen
Pathogenesis
Abdominal pain is divided into
• visceral or
• parietal peritoneal origins.
• Visceral pain
 vague and poorly localized to the epigastrium, periumbilical or
hypogastrium regions depending on its origin
 result of distention of a hollow viscus.
 required stimulus for pain in a hollow viscus is
stretch/distension or excessive contraction against an
obstruction.
 colic is the severe form of bowel contraction
Path……visceral pain
Path..

Parietal pain
segmental nerve roots innervating the peritoneum and tends
to be sharper and better localized
In general the pain is
 Focal in an early and well-localized disease process
 Diffuse if there is extensive inflammation or during late

presentations.
Path…
Referred pain
 perceived at a site distant from the source of stimulus
• Irritation to the diaphragm --- pain in the shoulder as the
diaphragm has its origin from the 4th cervical segment and
is supplied by the cervical segment via phrenic nerve
• Pain may be felt in the shoulders in
subphrenic abscess,
diaphragmatic pleursy,
acute pancreatitis,
ruptured spleen etc
• The pain is felt in supraspinatous fossa over the acromion,
clavicle or in subclavicular fossa
• The shoulder pain is often overlooked as it is attributed to
arthritis.
 DDx of acute abdomen
• Based on need for surgery

Non surgical or medical Vs Surgical

• Based on assessment

Emergent Vs non emergent

• Based on pattern of presentation

 DDX…
SURGICAL CAUSES
 Acute appendicitis
 Acute diverticulitis
 Acute pancreatitis
 Acute cholecystitis
 Intestinal obstruction
 Billiary colic
 Ureteric colic
 Acute retention of urine
 Perforation of peptic ulcer
 Perforation of appendix
 Ruptured AAA
 Perforated esophagus
 Ruptured ectopic pregnancy
 Ovarian torsion
MEDICAL CAUSES
 Acute Gastroenteritis
 Hepatic abscess
 Rectal sheath hematoma
 Herpes Zoster
 UTI
 Tabes dorsalis
 Sickle cell disease
 Diabetes Mellitus
 Addisonians disease
 Poryphyria
 Hereditary Spherocytosis
Surgical acute abdomen conditions

Hemorrhage
 solid organ trauma
ruptured ectopic pregnancy*
Spontaneous rupture of spleen
leaking or ruptured arterial aneurysm
 Surgical ….
Infection
Perforation
 Appendicitis

Cholecystitis  Perforated GI ulcer

Pancreatitis
 Perforated GI cancer
Merckel's diverticulitis

 Peritonitis  Perforated
Hepatic abscess diverticulum
salpingo-oopheritis*
 Surgical…
Obstruction Ischemia
Adhesion related small or large
Testicular torsion*
bowel obstruction

Sigmoid volvulus Ovarian torsion*

Cecal volvulus Mesenteric thrombosis

Incarcerated hernias
or embolism
Inflammatory bowel disease
Ischemic colitis
Gastrointestinal malignancy
Strangulated hernias
DDX… assessment
A. Emergent abdominal pain-Sudden/ severe pain/ hemodynamic
changes—Fall in B.P/ tachycardia
 AAA
 Bowel obstruction,
 Ruptured spleen,
 Ruptured ectopic pregnancy
B. Non-emergent abdominal pain- When emergent causes are
reasonably excluded, non-emergent causes can be considered.
 Renal stones
 Cholelithiasis
 Gastroenteritis
 Dysmenorrhea
DDx……pattern of presentation
1. Abdominal pain and shock
2. Generalized peritonitis
3. Localized peritonitis
4. Intestinal obstruction
5. Medical illness/Aspecific abdominal pain
1. Abdominal pain and shock
Patient presents with
• Severe abdominal pain
• Pale, tachycardic, hypotensive

DDx
• Ruptured AAA
• Ruptured ectopic pregnancy
• Spontaneous splenic rupture
• Abdominal trauma (spleen, liver, mesenteric, major vessel)
• (Spontaneous) retroperitoneal bleeding
2. Generalized peritonitis
Patient presents with
• Severe abdominal pain , ‘looks sick’
• Diffuse pertonial signs
• Systemic inflammatory response, sepsis, shock

DDx
• Perforated gastric/duodenal ulcer (tumor)
• Colonic perforation
• Appendicitis
• Acute mesenteric ischemia
• Acute pancreatitis
 3. Localized pertionitis
Patient presents with
• One quadrant peritonitis
• Systemic inflammatory response +/- sepsis

DDx
• RUQ: cholecystitis
• RLQ: acute appendicitis
• LLQ: acute divericulitis
• LQ pain from gynecologic origin
Lower abdominal pain from gynecologic origin
• Ovarian torsion
• Extra-uterine pregnancy
• Corpus luteum bleeding
• Pelvic inflammatory disease
4. Intestinal obstruction
Patient presents with
• Central colicky abdominal pain
• Constipation
• Vomiting (early/late)
• abdominal distention
• Dehydration
DDx
• Small bowel (vomiting, colicky abdominal pain)
-Adhesions
-Hernia
• Colon (abdominal distention +/- vomiting)
-Tumor
-Volvulus
-Fecal impaction
5. Medical illnesses

-Inferior wall myocardial infarction

-Diabetic keto-acidosis
-Basal pneumonia
-Porphyria

6. Aspesific abdominal pain

• Gynecological causes
• Irritable bowel syndrome
• Psychosomatic pain
• Abdominal wall pain
• Viral gastroenteritis
• Bacterial gastroenteritis
 Path….DDx
1. Ruptured AAA
2. Ruptured ectopic pregnancy Abdominal pain with shock
3. Ruptured spleen
4. Acute pancreatitis
5. Appendicitis
6. Perforated peptic ulcer Generalized peritonitis
7. Acute mesenteric ischemia
8. Acute cholecystitis
9. Acute appendicitis
10. Acute diverticulitis
11. Ovarian torsion Localized peritonitis
Lower quadrant pain
12. Ectopic pregnancy
13. PID
14. Renal colic
15. Intestinal obstruction
1,Acute appendicitis
• Inflammation and infection of the appendix
• Etiologic factors are
-obstruction of the lumen usually by Fecalith
-low fiber and high carbohydrate diet
-individuals with long retrocecal appendix

• Proximal obstruction of the appendiceal lumen produces a

closed loop obstruction swelling of the mucosa due
to secretions intraluminal pressure rises
increased pressure exceeds capillary pressure and causes
mucosal ischemia luminal bacterial overgrowth
result in inflammation, edema, and ultimately necrosis
Acute app…
• If the appendix is not removed, perforation will occur
• Primary symptom is pain----Shifting pain
First in the lower epigastric or umbilical area with a
steady, diffuse and severe pain due to distention of the
appendix---visceral pain
4 to 6 hours later pain localizes to the RLQ and
becomes more intense due to the involvement of the
parietal peritoneum---parietal pain
 Acute app…
• Variations in the anatomic location of the appendix-
multiple locus of the somatic phase of the pain.
• For example, a retrocecal appendix principally may
cause flank or back pain; a pelvic appendix, principally
suprapubic pain
• Vomiting can be there in 75% of patients
• Anorexia is common
 Acute app…
• Signs- RLQ tenderness
• Rebound tenderness
• Febrile- if rupture
Mgt’- open appendectomy- either a McBurney
(oblique) or Rocky-Davis (transverse) right
lower quadrant muscle-splitting incision
- centred over either the point of maximal
tenderness or a palpable mass
Inflamed appendix
2, Acute pancreatitis
• Inflammation of the pancreas
• Alcohol abuse and obstruction of the pancreatic duct
by gallstones are the most common causes of the
disease;
• Less causes
-drugs (e.g., thiazide diuretics, pentamidine, and
many others);
-hypertriglyceridemia;
-hypercalcemia;
-abdominal trauma
-viral infections (e.g., mumps or coxsackie virus)
 Acute panc…
• Pathophysiology– the digestive enzymes the pancreas
produces are kept in an inactive form (zymogens) in zymogen
granules.
• There is also a trypsin inhibitor (since trypsin is the one that
activates all the other enzymes)
• When this process fails…pancreas gets digested by the enzymes
it produced…pancreatitis
• trypsinogen is activated because it erroneously colocalizes in
cytoplasmic vacuoles with cathepsin B acinar cell injury
inflammatory response
Acute panc…
• All episodes of acute pancreatitis begin with severe
pain following a meal
pain is usually epigastric, but can occur anywhere in the
abdomen or lower chest, can be described as "knifing" or
"boring through" to the back, and may be relieved by the
patient leaning forward
• Then onset of nausea and vomiting, with retching often
continuing after the stomach has emptied
Hyper amylasemia
ultrasound
• conservative intensive care with the goals of oral food and
fluid restriction, replacement of fluids and electrolytes
parenterally and control of pain
3, Perforated PUD
• Peptic ulcers are the result of imbalance of the protective
and damaging factors of the stomach and the duodenum
• Common causes of peptic ulcer include
- use of NSAIDs
Increased risk of
-H. pylori infection
perforation
-tobacco smoking
-physiological stressors
• Ulcers are more common in men than in women and occur
most frequently in patients over age 65.
3, Perforated…
• Perforation tends to occur more with duodenal ulcers, and
with those on the anterior while those on the posterior tend
to bleed
• Three stages
-stage of chemical peritonitis
-stage of reactions
-stage of bacterial peritonitis
• golden time- the first 6hrs
• The patient is in distress and common symptoms and signs of
peritonitis
• the patient is given analgesia and antibiotics, resuscitated
with isotonic fluid, and taken to the operating room
suturing
CXR of a pt with a perforated PU
4,Acute Cholecystitis
• Either calculous or acalculous
• Acalculous- in pts with serious systemic diseses and
are bed ridden
• Calculous- inflammation of the gall bladder due to
stones (90-95%)
• Stones obstruct the cystic duct and the bile salt erodes
the wall of the GB causing edema and exposing it to
bacterial infection
• Bacteria invasion - acute gangrenous cholecystitis
develops and an abscess or empyema forms within the
gallbladder
 Acute chole...
• right upper quadrant pain that occurs after a
fatty meal with radiation into the right shoulder
or right side of the back(billiary colic)
• but in contrast to biliary colic, the pain does not
subside; it is unremitting and may persist for several
days.
• often febrile, complains of anorexia, nausea, and
vomiting, and is reluctant to move, as the
inflammatory process affects the parietal peritoneum.
Ultrasound
Cholecystectomy is the definitive treatment for acute
cholecystitis.
 5,Acute diverticulitis
• Diveticulum- outpocketing of the intestinal tract that is usually
asymptomatic until it becomes inflamed
• Diveticulitis- inflammation and infection of these diverticula
• ranges from uncomplicated diverticulitis - free perforation and diffuse
peritonitis that requires emergency laparotomy
 Acute dive....

• . Pts have pain and tenderness in the left lower

quadrant if uncomplicated
• diverticulitis with abscess, obstruction, diffuse
peritonitis (free perforation), or fistulas
between the colon and adjacent structures-
complicated
Antibiotics= uncompliated diverticulitis
sigmoid colectomy with a primary
anastomosis
6, uretric colic
• Ureteric colic is an agonising pain passing from the loin to the
groin usually caused by stones in the kidney and ureter
• starts suddenly causing the patient to writhe to find comfort.
• Pain is the leading symptom in 75% of people with urinary
stones followed by gross or microscopic hematuria
• Fixed renal pain is located posteriorly in the renal angle
anteriorly in the hypochondrium, or in both
• worse on movement, particularly on climbing stairs.
 Majority pass spontaniously
 extracorporeal shock wave lithotripsy
 retrograde ureteroscopy and percutaneous nephroscopy
Others…
Ruptured AAA
• Dilatations of localized segments of the arterial system are called
aneurysms.
• Abdominal aortic aneurysm is the commonest large vessel
aneurysm.
• 95% occur below the renal arteries.
• Abdominal aortic aneurysms can rupture anteriorly into the
peritoneal cavity (20%) or posterolaterally into the retroperitoneal
space (80%).
• Symptomatic aneurysms may cause minor symptoms, such as back
and abdominal discomfort
• sudden, severe back and/or abdominal pain develops from
expansion and rupture
• If no operation is performed, death is inevitable
Ruptured ectopic pregnancy
• A pregnancy that grows outside the uterus, it could be in the fallopian
tube, ovary, cervix or the broad ligament.
• As the ectopic grows the placenta infiltrates blood vessels within the
fallopian tube, which can cause bleeding within the tube and bleeding
into the peritoneal cavity.
• Further growth of the ectopic pregnancy can rupture the fallopian
tube causing substantial intraperitoneal blood loss.
• history of lower abdominal pain with a small amount of vaginal
bleeding at 4–6 weeks’ gestation
Ruptured spleen
• The causes of splenic rupture, in which the organ's
parenchyma or capsule is disrupted, include
-penetrating trauma
-non penetrating or blunt trauma
-operative trauma
-spontaneous rupture
• the spleen is often injured by direct energy applied to
the overlying ribs 9th to 11th ribs
Acute mesenteric ischemia
• Mesenteric vascular diseases can be from the arteries or
veins and can be occlusive or not.
• The SM vessels are the visceral vessels most likely to be
affected by embolisation (most commonly) or thrombosis
• sudden onset of severe abdominal pain in a patient with
atrial fibrillation or atherosclerosis.
• The pain is typically central and out of all proportion to
physical findings
• Abdominal tenderness may be mild initially with rigidity
being a late feature
• Whether the cause of the ischemia is venous or arterial,
haemorrhagic infarction occurs.
• The mucosa is the only layer of the intestinal wall that has
little resistance to ischemia.
• The intestine and its mesentery become swollen and
edematous
• If the main trunk of the SMA is involved, the infarction
covers an area from just distal to the duodenojejunal
flexure to the splenic flexure.
• Fortunately, its a branch of the main trunk that’s usually
implicated thus the area of infarction is less.
Ovarian/Testicular torsion
• Abnormal twisting of the ovaries or the testes which
may impair their blood and causing infarction
• Acute onset of sever lower abdominal pain
• In female it’s common in those who have a history of
ovarian cysts
• If torsion is repaired within 6 hours of the initial insult,
salvage rates of 80-100% are typical. These rates
decline to nearly 0% at 24 hours.
Thank
You
Reference
• SCHWARTZ’S PRICIPLES OF SURGERY
• BAILEY & LOVE’S SHORT PRACTICE OF SURGERY