Acute Abdomen
Prof.Dr. Serdar Yüceyar
General Surgery
Nontraumatic disorder whose chief
manifestation is pain in the abdomen, urgent
operation may be necessary.
Starts suddenly and patients may present to a
hospital within 7 or 10 days .
Symptoms arise from disease within the
abdominal cavity itself , but occasionally they
originate elsewhere.
Disease may be life- threatening and attempts to reach a
diagnosis must be rapid for the immediate treatment .
Commonly there is time to take a history , to examine
the patient , and to organize the investigations ....
Some patients require early surgery .
The approach to a patient with an acute abdomen
must be orderly and thorough .
The history and physical examination should suggest
to the probable causes and guide the choice of
diagnostic studies .
Abdominal Anatomy
– Variations
individual
Age
posture
respiration
disease
previous surgery
The abdominal surface is best divided into six
areas by a transverse line going through the
umblicus and longitudinal lines running
through the tip of the ninth rib on each side
History
Abdominal pain :
Pain is usually the predominant and presenting feature
of an acute abdomen
A - Location of pain:
Visceral Pain
– The embryological development of the abdomen is relevant in
two respects .
The intestine and all its associated organs ( liver , pancreas )
develop initially as midline structures . Visceral pain is felt in the
midline and also because of the bilateral sensory supply to the
spinal cord .
The gut also has a segmental origin
( correlates with the vascular supply )
–
–
–
Foregut --------- epigastric pain
Midgut ---------- umblical area ( pain )
Hindgut --------- Hipogastric pain
Visceral sensation is mediated by afferent C fibers
located in the walls of hollow viscera and in the
capsule of solid organs .
Visceral pain is elicited either by distension , by
inflammation or ischemia stimulating the receptor
neurons , or by direct involvement ( eg , malignant
infiltration ) of sensory nerves .
The centrally perceived sensation is generally slow in
onset , dull , poorly localized , and protracted .
Increased wall tension due to luminal distension or
forceful smooth muscle contraction ( colic ) leads to
diffuse deep-seated pain felt in the midline
Parietal Pain is mediated by both C and A delta
nerve fibers
The parietal peritoneum is innervated by somatic
nerves .
– more acute ,
– sharper ,
– better localized pain sensation .
Direct irritation by pus , bile , urine or gastrointestinal
secretions is associated with more exact localization of
pain .
The cutaneous distribution of P P corresponds to the
T6 - L1 areas , P P is more easily localized than
visceral pain because the somatic afferent fibers are
directed to only one side of the nervous system .
Parietal Pain is accurately localized and is
accompanied by a reflex contraction of the
abdominal wall muscle ( muscle rigidity ).
– Two examples ;
psoas spasm from acute appendicitis ,
scoliosis concave to the side of intra-abd . inflammation
Inflammation confined to the pelvis may not be
accompanied by anterior abdominal muscle
spasm and this may cause clinical confusion .
Abdominal pain may be referred or may
shift .
– Referred pain is ( usually cutaneous ) the sensation
perceived at a site distant from the site of a primary
stimulus .
- C4 mediated pain - Kehr sign - phrenic nerve - { the
irritation of diaphragm by air , peritoneal fluid , mass or also
pleurisy and basal pneumonia } .
- Biliary pain --- right scapula
Spreading or shifting pain
– The site of pain at onset should be distinguished
from the site at presentation .
– ( acute appendicitis , perforated peptic ulcer )
B- Mode of onset and Progression of pain
–
–
–
–
reflects the nature and severity of the inciting process.
explosive ( within seconds )
rapidly progressive ( within 1 - 2 hours )
gradual ( over several hours )
Explosive pain
- excruciating generalized pain suggests an intraabdominal catastrophe
perforated viscus
rupture of an aneursym , ectopic pregnancy or abscess
need for prompt resuscitation and laparotomy
Rapidly progressive
A less dramatic clinical picture is steady mild pain ( within 1-2 hours )
more typical of acute cholecystitis , acute pancreatitis , strangulated
bowell , mesenteric infarction , renal or ureteral colic , and proximal s.
bowell obst.
Finally ,
–
–
–
–
vague
abdominal discomfort
unclear
medical or surgical problem ?
Become more pronounced and steady over several hours or
days
- this pattern also may reflect a slowly developing condition or the
body's defensive efforts to cordon off an acute process.
acute appendicitis
incarcerated hernia
low small bowel and large bowel obst .
uncomplicated peptic uls. dis.
walled of perf. ( visc. )
some genitourinary and gynecologic conditions
C - Character of pain :
Nature , severity , periodicity
–
–
–
–
–
–
–
–
–
–
Steady pain
--- most common
Sharp superficial costant pain perforated ulcer , ruptured appendix
The gripping , mounting pain -- small bowel obst.
Disquieting and bearable pain may be originated by small conduits problems (
Bile duct , uterine tube , ureters )
" biliary colic " is a misnomer - because do not have peristaltic movements .
" aching discomfort " ulcer pain
" stabbing , breathtaking " acute pancreatitis and mesenteric infarction
" searing " pain - ruptured aortic aneurysm
Agonizing pain denotes serious or advanced disease
Colicy pain is usually promptly alleviated by analgesics .
Ischemic pain due to strangulated bowell or mesenteric thrombosis is only
sligthly assuaged even by narcotics .
Gas stoppage sign is due to reflex ileus induced by an inflammatory lesion
walled off from the free peritoneal cavity , as in retrocecal appendicitis .
Other symptoms associated with abdominal
pain :
– A- Vomiting :
" Pain in the acute surgical abdomen usually precedes vomiting ,
whereas the reverse holds true in medical conditions ."
absence of bile
bile - stained
feculent
– B - Constipation
Reflex ileus is often induced by visceral afferent fibers stimulating
efferent fibers of the sympathetic autonomic nervous system (
splanchnic nerves ) to reduce intestinal peristaltis.
Obstipation " the absence of passage of both stool and flatus "
C - Diarrhea :
– Copious watery - gastroenteritis and other
medical causes of an acute abdomen.
– Blood - stained diarrhea - ulcerative colitis ,
bacillary or amebic dysentery , ischemic colitis
D - Spesific gastrointestinal symptoms:
– Jaundice
– Hematochezia
– Hematemesis
Other Relevant Aspects of History
– A - Menstrual history
ectopic pregnancy
Mittelschmerz ( ruptured ovarian follicle )
endometriosis
– B- Drug History
Anticoagulant ( hematomas or bleeding )
Oral contraceptive ( Hepatic adenomas , mesenteric venous infarction )
Corticosteroids - may masks the clinical signs
– C - Family history
– D - Travel history
Amebic diseases ,
tuberculosis,
Hydatid disease ,
Malariasis ,
salmonellosis
Physical examination
– 1- General observation :
The writhing patients - intestinal or ureteral colic
rigidly motionless patients --- acute appendicitis , generalized
peritonitis
– 2- Systemic signs :
Extreme pallor
hypothermia
Tachycardia - intraabdominal hemorhage ( aortic aneu. , ectopic
preg.)
tachypnea
sweating
– 3- Fever :
Low grade - diverticulitis , cholecystitis , appendicitis
High fever - Acute salpingitis
Disorientation or extreme lethargy , very high fever ---- septic shock
( advan
ced peritonitis , acute cholangitis , pyelonephritis
4- Examination of the acute abdomen
– a- inspection :
" The abdomen should be carefully inspected before palpation"
distention
surgical scar
Scaphoid - contracted abdomen
visible peristalsis
soft doughy fullness " paralytic ileus or mesenteric thrombosis "
– b- Auscultation :
" auscultation of the abdomen should also precede palpation "
– c- Coughing to elicit pain :
– d- Percussion :
Tenderness
Free air under the diaphragma ( absence of Liver dullness )
e - Palpation :
– Guarding --- Voluntary spasm , involuntary spasm
– Tenderness --- perhaps the most important finding
first by one- or two - finger
begining away from the area of cough tenderness and gradually advancing
toward it .
-well demarcated in a. cholecystitis , a. appendicitis
and diverticulitis
-diffuse tenderness without guarding in a.
gastroenteritis
– Rebound tenderness
– Carnett ' s test ( tenderness intraabdominal or abdominal wall )
– Hyperesthesia ( localized peritonitis , but more prominent herpes
zoster or spinal root compression )
– Murphy ' s sign
– Abdominal Masses (palpation )
Superficial - Distended gallbladder , appendiceal abscess
Deeper ---- often partially walled off by overlying omentum and small
bowell .
Fothergill’s sign an intraabdominal mass or tenderness that disappears
when the rectus muscles are contracted by arising the head .
indirectly found
– ileopsoas sign
– obturator sign
– Punch tenderness ( hepatic , splenic and subphrenic or also a.
cholecystitis , a. hepatitis , splenic infarct )
– Costovertebral angle tenderness ( a. pyelonephritis )
f - Inguinal and femoral rings ; male genitalia
g - Rectal examination ; must always be performed
Tenderness , masses , stool colour
h - Pelvic examination :
Investigative studies :
History and physical examination provide the diagnosis in two-third
of the cases
Laboratory investigation
A - Blood Studies :
– Hemoglobin
– Hematocrit
– White blood cell
marked leucocytosis > 13.000 / L is indicative of serious infection .
moderate L , commonly encountered in medical as well as surgical inflam.
conditions.
Low WBC < 8.000 / L ---- mesenteric adenitis and non spesific abd. pain
– Croos matching
– Serum electrolyte
– Urea
“in shock,copious vomiting and diarrhea,tense
– Creatinine
abd and distention”
– Arterial Blood gas determination ( shock )
– Serum amylase - pancreatitis
- Strangulated / ischemic bowell
- Twisted ovarian cyst
- Perforated ulcer
Cloudy ( lactescent ) serum
pancreatitis ?
– Liver function tests ( serum bilirubin , alkaline phosphatase ,
AST , ALT
, albumin , globulin ) --- surgical hepatic
disease
– Clotting studies : ( platelet counts , , PT , PTT )
– Peripheral blood smear --- hematologic abnormality ( cirrhosis
,
petechiae , etc. )
– Erythrocyte sedimentation rate ; not important
B - Urine tests :
–
–
–
–
–
Dark urine or high gravity --- dehydration , porphyria
Hyperbilirubinemia
Hematuria
pyuria
Dipstick testing ( albumin , bilirubin , glucose and
ketones )
C - Stool tests :
– occult fecal blood
– Warm stool smear for bacteria , ova and animal
parasites
– amebic trophozoites
– Stool samples for culture in gastroenteritis ,
dysentery or cholera
IMAGING STUDIES :
A - Plain chest X - Ray studies :
Supradiaphragmatic conditions that simulate an acute
abdomen ( basal pneumonia or ruptured esophagus )
Elevated hemidiaphragm or pleural effusion--attention to
subphrenic inflammatory lesions .
B - Plain Abdominal X - Ray Studies :
intestinal obstruction
perforated viscus
renal - ureteral calculi
acute cholecystitis
Other findings in Plain X-ray
– free or abnormal gas pattern - under diaphragm
– Massive pneumoperitoneum - colonic perforation
– Biliary tree air - biliary enteric communication
choledochoduodenal fistula - gallstone ileus
– Air in the portal venous system - phylephlebitis
– Gaseous distention -- bowell obstruction
– air-fluid levels
– right lower quadrant ileus - acute appendicitis
– " thumbprint " on the colonic wall - ischemic
colitis
– Obliteration of the psoas muscle margins retroperitoneal disease
C - Angiography ( contraindicated in unstable patients )
–
–
–
intestinal ischemia
ruptured liver adenoma or carcinoma
aneursym ( splenic artery or others )
D - Contrast X - Ray studies
– suspected perforation of the esophagus or gastroduodenal area
without pneumoperitoneum
--- with water soluble contrast
media ( gastro -grafin -- meglumine diatriozate )
– Barium enema - diagnosis large bowell obstruction or reduce
sigmoid volvulus or intususseption .
– Emergency IVP---- seldom in nontraumatic events
E - Ultrasonography and CT Scan :
useful in pregnant patient
80 % sensitivity in acute appendicitis
pancreatic or retropancreatic lesion
Acute diverticulitis
Intramural bowell or venous gas --- bowell infarction
F - Radionuclide scans :
Liver - splenn scans ,
HIDA scans
Gallium scans ( intra abdominal abscess )
Tec- Pertechnetate scans - ectopic gastric mucosa in
Meckel div.
ENDOSCOPY
Proctosigmoidoscopy
Colonoscopy
Gastroduodenoscopy and ERCP
PARACENTESIS
Aspiration of blood , bile or bowell contens
infected ascites ---- spontaneous peritonitis , TBc peritonitis ,
chylous ascites
Culdocentesis
LAPAROSCOPY
ruptured graffian follicle
pelvic inflam. etc.
in critically ill patients
PREOPERATIVE MANAGEMENT
Analgesics - should not be used!- if diagnosis is un
clear!.
– But in moderate doses , in some conditions may be used after
initial assesment
-also masses may become obvious
An Attention to
– Cardiac drugs ,
– corticosteroid
– diabetes
Antibiotics - therapeutic or prophylactic
A nasogastric tube
References:
– 1-Boey JH. Acute Abdomen. In, Way LW (Ed) Current
Surgical Diagnosis & Treatment. Ninth
Edition.Appleton&Lange . 1991; 430-441.
– 2-Boey JH,Doherty GM. The Acute Abdomen. In, Way
LW , Doherty GM. ( Eds). Current Surgical Diagnosis
& Treatment. Eleventh Edition. Mc Graw-Hill
companies. 2003 ; 503-516.
– 3-Britton J. The Acute Abdomen. (In) Morris PJ,Malt
RA. Oxford Textbook of Surgery. First Edition ,
Volume One, Oxford UniversityPress inc. , 1994 ;
1375-96.