The Acute Abdomen

Andik Kusbiantoro
SMF Ilmu Bedah RSUD Dr.R.Soedjono Selong

Definition
Acute abdomen describes clinical condition as result of emergency situations intra abdominal condition that needs immediate surgical intervention with pain as main symptom

Introduction
Challenge to Surgeons & Physicians Most common cause of surgical emergency admission Clinical course can vary from from minutes to hours to weeks. It can be an acute exacerbation of a chronic problem.

Assesment
Well elicited history Proper physical examination Diagnosis can be made most of the time by a good history and a proper physical examination.

Assesment (cont)
Investigations are usually carried out : only to support the diagnosis. or to narrow down the differential diagnoses.

History
History of Present illness Family history Past medical history History of drugs taken or Medication eg. ingestion of certain toxic drugs or Alcohol intake

Drug history
Corticosteroids mask pain Anticoagulants can lead to an intramural haematoma of the gut causing obstruction Oral Contraceptives - rupture of hepatic adenomas NSAIDs - erosive gastritis & peptic ulcers

Other history
Past surgical history: previous operations- leading to adhesions Past medical history: Sickle cell disease, Diabetes or Cancer or Renal failure Menstrual History in females Missed period- ectopic pregnancy Mid of period-ovulation pain (Mittel- schmerz) With heavy periods- endometriosis Family history of colon cancer, any other malignancy or inflammatory bowel disease

Pain
The Most Important Symptom History of pain should include: 1. Onset 2. Severity 3. Type of pain 4. Radiation of Pain 5. Change in nature of Pain 6. Associated bowel or urinary symptoms 7. Aggravating or relieving factors

Onset of Pain (cont)

Sudden onset pain which wakes the patient from sleep eg. perforation or strangulation of bowel Slow insidious Onset a. Inflammation of visceral peritoneum. b. Contained process such as evolving abscess. Crampy or colicky pain Biliary colic, Ureteric colic or Intestinal colic

Progression of Pain (cont)

Progression from : Dull, aching, poorly localized character To: Sharp, constant & better localized pain
indicates involvement of Parietal peritoneum

Table 1. Sensory innervations of intra abdominal structures

Structure
Middle part of Diaphragm Edge of diaphragm, stomach, pancreas, gall bladder, intestine Appendix,proximal colon

Nerve
Phrenicus Plexus celiac Plexus mesentericus

Level
C 3-5 Th 6-9 Th 10-11

Distal colon, rectum, kidney, urethra & testis

Vesica urinary, recto sigmoid

Splanchnic caudal

Th 11-L 1
S 2-4

Figure 1. Innervations of diaphragm and shoulder

Referred Pain

Shifting Pain

Figure 2.Referred pain and shifting pain in the acute abdomen

Abrupt, excruciating pain

IMA Colic billier Perforated ulcer Ruptured aneurysm

Rapid onset of severe, constant pain

Acute pancreatitis

Mesenteric thrombosis, strangulated bowel

Colic ureter

Ectopic pregnancy

Gradual, steady pain

Acute cholecystitis, acute cholangitis, acute hepatitis Appendicitis, salpingitis

Intermittent, colicky pain with free interval

Early pancreatitis (rare) Small bowel obstruction

IBD

Colic billier

Figure 3. The location and character of the pain are useful in the differential diagnosis of the acute abdomen

Nausea & Vomiting

Frequency of vomiting Character of vomiting: projectile, non-projectile or self-induced Nature of vomiting: a. Bilious vomiting of small bowel obstruction b. Non-bilious vomiting in obstruction proximal to ampulla of vater c. Faeculent vomiting in distal small gut obstruction, large bowel obstruction , strangulation

Nausea & Vomiting

Pain first, followed by Vomiting is usually surgical. The vomiting is due to reflex pylorospasm Nausea & vomiting first , followed by pain is usually due to a medical condition

Urinary Symptoms with Pain

Ureteric colic Cystitis

Table 2. Physical findings with various causes of acute abdomen

Conditions
Perforated viscous

Helpful sign
Scaphoid (early), tense abdomen, diminished bowel sound (late), loss of liver dullness, guarding or rigidity
Motionless, absent bowel sound (late), rebound tenderness, guarding Tender mass, special sign (Murphy's, obturator or psoas) Distention, visible peristaltis (late), hyperperistaltis (early) or quiet abdomen (late), diffuse pain, hernia (some) Distention, minimal bowel sound

Peritonitis Inflamed mass or abscess Intestinal obstruction

Paralytic ileus

Ischemic or strangulated bowel

Bleeding

Not distended (until late), severe pain, rectal bleeding (some)

Pallor, shock, distention, pulsatile (aneurysm)

Figure 3. Causes of shock in patients with acute abdomen

Consideration of Surgery Intervention

Decision of surgery intervention on acute abdomen depends on correct diagnosis. If we got difficulties to make decision, we should observe patient closely. Meanwhile patient must fasting, apply naso gastric tube and IV line

Table 3. Indications for urgent operations in patients with acute abdomen

Physical findings Involuntary guarding or rigidity, especially if spreading Increasing or severe localized tenderness Tense or progressive distention Tender or abdominal or rectal mass with high fever or hypotension Rectal bleeding with shock or acidosis Radiologic findings Pneumoperitoneum Gross or progressive bowel distention Free extravasations of contrast material Space occupying lesion on scan, with fever Mesenteric occlusion on angiography

Summary
Acute abdomen is serious surgical emergency requiring the surgeon to combine the result of the history and physical examination with properly selected laboratory and radiographic studies Correct preoperative diagnosis will usually lead to a successful operation

Physical Examination
General Appearance a. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitis b. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colic c. Writhing in Pain: Mesenteric Ischemia

Physical Examination (cont...)

d. Bending Forward: Chronic Pancreatitis e. Jaundiced: CBD obstruction f. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

Physical Examination (cont...)

Vital Charting Temperature, Pulse, BP, Respiratory rate Ruptured AAA or ectopic pregnancy can lead to -Pallor -Hypotension -Tachycardia -Tachypnea

Physical Examination (cont...)

Low grade temp. is seen with - Appendicitis - Acute cholecystitis High grade temp. is seen with - Salpingitis - Abscess Very High Grade Temp.with increasing lethargy seen in imminent septic shock - Peritonitis - Acute cholangitis - Pyonephrosis

Extra abdominal conditions that causes abdominal pain These may rarely present as referred abdominal pain. The most important to remember :
Pneumonia (especially lower lobe) Myocardial Infarction.

Those diseases tend to be Medical diseases and surgery is not generally indicated

Systemic Examination
Cardiopulmonary examination Check for: - Possible MI - Basal Pneumonia - Pleural Effusion

Systemic Examination
Per Abdomen: Inspection - Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

Systemic Examination
Per abdomen: Palpation Be gentle Start away from site of pathology then towards Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & boardlike. Indicates peritonitis.

Systemic Examination
Local Right Iliac Fossa tenderness: a. Acute appendicitis b. Acute Salpingitis in females c. Amoebiasis of Caecum Low grade, poorly localized tenderness: Intestinal Obstruction Tenderness out of proportion to examination: a. Mesenteric Ischemia b. Acute Pancreatitis Flank Tenderness: a. Perinephric Abscess b. Retrocaecal Appendicitis

Systemic Examination
Rovsings Sign in Acute Appendicitis Obturator Sign in Pelvic Appendicitis Psoas Sign
Retrocaecal appendicitis Crohns Disease Perinephric Abscess

Murphy's sign in Acute Cholecystitis

Systemic Examination
Per Rectal Examination: - tenderness - induration - mass - frank blood

Investigations
Complete Blood Count with differential C-reactive protein estimation Electrolyte, Blood Urea, Creatinine Urine dipstick Amylase or Lipase Liver Function Test

Radiology
Chest x ray Abdominal x ray

Investigations
Other Investigations - USG - CT abdomen for AAA, Pancreatic disease, or ureteric colic (non- Contrast) - IVU - Mesenteric Angiography for Ischaemia, Haemorrhage

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