Acute Abdomen

Syed Mohammad Abdullah Bukhari

The term acute abdomen refers to signs and symptoms

of abdominal pain and tenderness, a clinical
presentation that often requires emergency surgical
therapy

Many diseases, some of which are not surgical or even

intra-abdominal, can produce acute abdominal pain and
tenderness.

Therefore, every attempt should be made to make a

correct diagnosis so that the therapy selected, often a
laparoscopy or laparotomy, is appropriate.

The diagnoses associated with an acute abdomen vary

according to age and gender

Appendicitis is more common in younger individuals,

whereas biliary disease, bowel obstruction, intestinal
ischemia and infarction, and diverticulitis are more
common in older adults.

Most surgical diseases associated with an acute

abdomen result from

infection,

obstruction,

ischemia,

or perforation.

Nonsurgical causes of an acute abdomen can be divided

into three categories,

endocrine and metabolic,

hematologic,

and toxins or drugs

Because of the potential surgical nature of the acute

abdomen, an expeditious workup is necessary

The workup proceeds in the usual order

history,

physical examination,

laboratory tests,

and imaging studies

ANATOMY

Abdominal pain is divided into visceral and parietal

components.

Visceral pain tends to be vague and poorly localized to the

epigastrium, periumbilical region, or hypogastrium,
depending on its origin from the primitive foregut, midgut,
or hindgut

It is usually the result of distention of a hollow viscus.

Parietal pain corresponds to the segmental nerve roots

innervating the peritoneum and tends to be sharper and
better localized.

Referred pain is pain perceived at a site distant from

the source of stimulus.

For example, irritation of the diaphragm may produce

pain in the shoulder.

PATHOPHYSIOLOGY

Introduction of bacteria or irritating chemicals into the

peritoneal cavity can cause an outpouring of fluid from the
peritoneal membrane.

The peritoneum responds to inflammation by increased

blood flow, increased permeability, and formation of a
fibrinous exudate on its surface.

The bowel also develops local or generalized paralysis.

The fibrinous surface and decreased intestinal movement

cause adherence between the bowel and omentum or
abdominal wall and help localize inflammation.

As a result, an abscess may produce sharply localized

pain, with normal bowel sounds and gastrointestinal
function,

whereas a diffuse process, such as a perforated

duodenal ulcer, produces generalized abdominal pain,
with a quiet abdomen.

Peritonitis may affect the entire abdominal cavity or

part of the visceral or parietal peritoneum.

PERITONITIS

Peritonitis is peritoneal inflammation of any cause.

It is usually recognized on physical examination by

severe tenderness to palpation, with or without
rebound tenderness, and guarding.

Peritonitis is usually secondary to an inflammatory

insult, most often a gram-negative infection with an
enteric organism or anaerobe.

It can result from noninfectious inflammation; a

common example is pancreatitis

Primary peritonitis occurs more commonly in children

and is most often caused by Pneumococcus or hemolytic
Streptococcus spp.

Adults with end-stage renal disease on peritoneal dialysis

can develop infections of their peritoneal fluid, with the
most common organisms being grampositive cocci.

Adults with ascites and cirrhosis can develop primary

peritonitis and, in these cases, the organisms are usually
Escherichia coli and Klebsiella spp.

HISTORY

A detailed and organized history is essential to

formulating an accurate differential diagnosis and
subsequent treatment regimen.

Questions should be open-ended whenever possible,

and structured to disclose the onset, character,
location, duration, radiation, and chronology of the pain
experienced

Pain identified with one finger is often more localized

and typical of parietal innervation or peritoneal
inflammation

as compared with indicating the area of discomfort with

the palm of the hand, which is more typical of the
visceral discomfort of bowel or solid organ disease.

The intensity and severity of the pain are related to the

underlying tissue damage.

Sudden onset of excruciating pain suggests conditions

such as intestinal perforation or arterial embolization
with ischemia, although other conditions, such as biliary
colic, can present suddenly as well.

Pain that develops and worsens over several hours is

typical of conditions of progressive inflammation or
infection such as cholecystitis, colitis, and bowel
obstruction.

The history of progressive worsening versus

intermittent episodes of pain can help differentiate
infectious processes that worsen with time compared
with the spasmodic colicky pain associated with bowel
obstruction, biliary colic from cystic duct obstruction,
or genitourinary obstruction

Equally as important as the character of the pain is its location and

radiation.

Tissue injury or inflammation can trigger visceral and somatic pain.

Solid organ visceral pain in the abdomen is generalized in the quadrant of

the involved organ, such as liver pain across the right upper quadrant of
the abdomen.

Small bowel pain is perceived as poorly localized periumbilical pain,

whereas colon pain is centered between the umbilicus and pubis symphysis

As inflammation expands to involve the peritoneal

surface, parietal nerve fibers from the spine allow for
focal and intense sensation

This combination of innervation is responsible for the

classic diffuse periumbilical pain of early appendicitis
that later shifts to become an intense focal pain in the
right lower abdomen at McBurneys point

Activities that exacerbate or relieve the pain are also

important.

Eating will often worsen the pain of bowel obstruction,

biliary colic, pancreatitis, diverticulitis, or bowel perforation.

Food can provide relief from the pain of nonperforated

peptic ulcer disease or gastritis

Patients with peritoneal inflammation will avoid any activity

that stretches or jostles the abdomen. They describe
worsening of the pain with any sudden body movement and
realize that there is less pain if their knees are flexed.

Associated symptoms can be important diagnostic clues.

Nausea, vomiting, constipation, diarrhea, pruritis,

melena, hematuria can all be helpful symptoms if
present and recognized.

Vomiting may occur because of severe abdominal pain of any

cause or as a result of mechanical bowel obstruction or ileus.

Vomiting is more likely to precede the onset of significant

abdominal pain in many medical conditions,

whereas the pain of an acute surgical abdomen presents first

and stimulates vomiting via medullary efferent fibers that are
triggered by visceral afferent pain fibers.

Constipation can be a result of mechanical obstruction or

decreased peristalsis.

It may represent the primary problem and require laxatives

and prokinetic agents, or merely be a symptom of an
underlying condition.

A careful history should include whether the patient is

continuing to pass any gas or stool from the rectum.

A complete obstruction is more likely to be associated with

subsequent bowel ischemia or perforation caused by the
massive distention

Diarrhea is associated with several medical causes of

acute abdomen, including infectious enteritis,
inflammatory bowel disease or parasitic contamination.

Bloody diarrhea can be seen in these conditions, as well

as in colonic ischemia

Previous illnesses or diagnoses can greatly increase or decrease

the likelihood of certain conditions that would otherwise not be
strongly considered.

for example, report that the current pain is similar to the kidney
stone passage that they experienced a decade previously.

On the other hand, a prior history of appendectomy, pelvic

inflammatory disease, or cholecystectomy can significantly
influence the differential diagnosis.

Medications can both create acute abdominal conditions or

alternatively mask their symptoms.

Gynecologic health, specifically the menstrual history, is

crucial in the evaluation of lower abdominal pain in a young
woman.

The likelihood of ectopic pregnancy, pelvic inflammatory

disease, mittelschmerz, and/or severe endometriosis are all
heavily influenced by the details of the gynecologic history.

PHYSICAL EXAMINATION

An organized and thoughtful physical examination is

critical to the development of an accurate differential
diagnosis and the subsequent treatment algorithm

Patients with peritoneal irritation will experience

worsened pain with any activity that moves or stretches
the peritoneum.

These patients will typically lie very still in bed during the
evaluation and often maintain flexion of their knees and
hips to reduce tension on the anterior abdominal wall.

Abdominal inspection should address the contour of the

abdomen, including whether it appears distended or
scaphoid or whether a localized mass effect is observed.

attention should be paid to all scars present and, if

surgical in nature, should correlate with the surgical
history provided.

Evidence of erythema or edema of skin may suggest

cellulitis of the abdominal wall, whereas ecchymosis is
sometimes observed with deeper necrotizing infections of
the fascia or abdominal structures, such as the pancreas.

Auscultation can provide useful information about the

gastrointestinal tract and vascular system.

Bowel sounds are typically evaluated for their quantity and quality.

A quiet abdomen suggests an ileus, whereas hyperactive bowel

sounds are found in enteritis and early ischemic intestine.

Mechanical bowel obstruction is characterized by high-pitched

tinkling sounds that tend to come in rushes and are associated with
pain.

Far away, echoing sounds are often present when significant

luminal distention exists.

Bruits heard within the abdomen reflect turbulent

blood flow in the vascular system.

These are most frequently encountered in the setting

of high-grade arterial stenoses (70% to 95% but can also
be heard if an arteriovenous fistula is present

Percussion is used to assess for gaseous distention of the bowel, free intraabdominal air, degree of ascites, and/or presence of peritoneal
inflammation.

Hyperresonance, commonly termed tympany to percussion, is

characteristic of underlying gas-filled loops of bowel. In the setting of bowel
obstruction or ileus, this tympany is heard throughout all but the right
upper quadrant, where the liver lies beneath the abdominal all.

If localized dullness to percussion is identified anywhere other than the

right upper quadrant, an abdominal mass displacing the bowel should be
considered.

When liver dullness is lost and resonance is uniform throughout, free

intraabdominal air should be suspected. This air rises and collects beneath
the anterior abdominal wall when the patient is in a supine position.

Ascites is detected by looking for fluctuance of the

abdominal cavity. A fluid wave or ripple can be generated by
a quick firm compression of the lateral abdomen. The
resulting wave should then travel across the abdominal wall.

Movement of adipose tissue in the obese abdomen can be

mistaken for a fluid wave. False-positive examinations can
be reduced by first pressing the ulnar surface of the
examiners open palm into the midline soft tissue of the
abdominal wall to minimize any movement of the fatty
tissue while generating the wave with the opposite hand.

The major step in the abdominal examination is

palpation.

Palpation typically provides more information than any

other component of the abdominal examination

reveals the severity and exact location of the abdominal

pain,

can further confirm the presence of peritonitis and

identify organomegaly or an abnormal mass lesion.

Pain, when focal, suggests an early or well-localized disease

process,

whereas diffuse pain on palpation is present with extensive

inflammation or a late presentation.

If pain is diffuse, careful investigation should be carried out to

determine where the pain is greatest.

Even in the setting of extreme contamination from perforated

peptic ulcers or colonic diverticula, the site of maximal
tenderness often indicates the underlying source.

Numerous unique physical findings have come to be

associated with specific disease conditions and are well
described as examination signs

A digital rectal examination needs to be performed in

all patients with acute abdominal pain, checking for the
presence of a mass, pelvic pain, or intraluminal blood.

A pelvic examination should be included for all women

when evaluating pain located below the umbilicus.

Gynecologic and adnexal processes are best

characterized by a thorough speculum and bimanual
evaluation.

Laboratory Studies

Imaging Studies

Plain radiographs

Upright chest radiographs can detect as little as 1 mL of air injected

into the peritoneal cavity.

Lateral decubitus abdominal radiographs can also detect

pneumoperitoneum effectively in patients who cannot stand; as
little as 5 to 10 mL of gas may be detected with this technique.

These studies are particularly helpful for patients suspected of

having a perforated duodenal ulcer, because approximately 75% of
these patients will have a large enough pneumoperitoneum to be
visible

Plain films also show abnormal calcifications.

Approximately 5% of appendicoliths, 10% of gallstones,

and 90% of renal stones contain sufficient amounts of
calcium to be radiopaque

Upright and supine abdominal radiographs are helpful in identifying

gastric outlet obstruction, and obstruction of the proximal, mid, or
distal small bowel.

They can also aid in determining whether a small bowel obstruction

is complete or partial by the presence or absence of gas in the colon.

Colonic gas can be differentiated from small intestinal gas by the

presence of haustral markings caused by the taenia coli present in
the colonic wall. An obstructed colon appears as distended bowel
with haustral markings

Plain films can also suggest volvulus of the cecum

orsigmoid colon.

Cecal volvulus is identified by a distended loop of colon in

a comma shape, with the concavity facing inferiorly and to
the right.

Sigmoid volvulus characteristically has the appearance of a

bent inner tube, with its apex in the right upper quadrant

Abdominal ultrasonography

extremely accurate for detecting gallstones and assessing

gallbladder wall thickness and presence of fluid around the
gallbladder

It is also helpful for determining the diameter of the

extrahepatic and intrahepatic bile ducts.

Abdominal and transvaginal ultrasonography can aid in the

detection of abnormalities of the ovaries, adnexa, and uterus.

Ultrasound can also detect intraperitoneal fluid.

The presence of abnormal amounts of intestinal air in

most patients with an acute abdomen limits the ability
of ultrasonography to evaluate the pancreas or other
abdominal organs.

CT scans

As CT has become more widely available and less likely to be

hindered by abdominal air it is becoming the secondary
imaging modality of choice in the patient with an acute
abdomen, following plain abdominal radiography.

Many of the most common causes of the acute abdomen are

readily identified by CT scanning, as are their complications.

Examples include acute appendicitis, acute pancreatitis and

complications

Diagnostic Laparoscopy

Purported advantages include a high sensitivity and

specificity, the ability to treat a number of the
conditions causing an acute abdomen laparoscopically,
and decreased morbidity and mortality, length of stay,
and overall hospital costs.

Diagnostic accuracy is high; the accuracy ranges from

90% to 100%

PERITONEAL LAVAGE

peritoneal lavage can provide information that suggests pathology

requiring surgical intervention.

The lavage can be performed under local anesthesia at the patients

bedside.

A small incision is made in the midline adjacent to the umbilicus and

dissection is carried down to the peritoneal cavity.

A small catheter or IV tubing is inserted and 1000 mL of saline is

infused. A sample of fluid is allowed to siphon back out into the
empty saline bag and is then analysed for cellular or biochemical
anomalies.

This technique can provide sensitive evidence of hemorrhage or

infection, as well as some types of solid or hollow organ injury

ALGORITHMS IN THE ACUTE ABDOMEN