Management of the Acute Abdomen

Mr Ravi Pararajasingam Consultant Surgeon Manchester Royal Infirmary

Definition

Someone who becomes acutely ill and signs are chiefly related to the abdomen has an acute abdomen

A systematic approach

History, Examination, Investigations, Treatment Plan May require simultaneous resusitation and treatment.

Final diagnosis in UK

Non-specific abdo pain Appendicitis Cholecystitis / Biliary Colic Peptic ulcer disease Urinary retention Acute pancreatitis Small bowel Obstruction Renal Colic Trauma Malignant disease Medical dx Acute diverticulitis Large bowel obstruction Vascular Disease Gynaecological disease

30-40% 20-25% 7-8% 4% 4% 3% 3% 3% 3% 2-4% 2-4% 2% 2% 2% 1%

History

Pain: dull, constant, stabbing, pain on movement, colicky pain (comes and goes) Radiation: to right upper quadrant, loin to groin, through to the back History of pain: Initially central than to right iliac fossa Relieveing and exacerbating factors: comes on after eating Associated symptoms: nausea, vomiting, sweats

History of presenting complaint

Prior episodes Swellings in groin on abdo Past surgery Gynae / menstrual history ( ectopic pregnency) Vag discharge / PID Past specific illnesses

History
Past medical history Past surgical history Drug history and allergies inc alcohol and tobacco Social history/ family history Systemic inquiry

Clinical Examination
Look, Feel, Palpate, Percuss: Look: General state & demeanour of patient: sweating, reluctance to move Look: Dehydration, Jaundice, Anaemia, Cynosis, Oedema, Lymphadenopathy Record: Temp, pulse rate, Blood pressure. Rashes: Singles as a cause of acute abdo

Clinical Examination
Examine the abdo, back, groins (hernial orfices), perineum and genitalia. Consider patients dignity Clinical Signs: Murphys sign, Rovsing sign. Iliopsoas sign. Peritonitis: board like rigidity and silent abdo

Clinical Examination
Cardiovascular and Respiratory Examination: Signs of shock, blood loss, dehydration. MI as a cause of acute abdo Pneumonia as a cause of acute abdo

Bedside investigations
Vomit Stools Urine Pulse Oximetry

Basic Blood Tests

Full Blood Count Urea and Electrolytes Liver Function Tests Bone Profile Amylase Coagulation Screen PREGNENCY TEST MSU

Radiology
Chest X-Ray: Pneumonia, Perforation, Subphrenic abcess Abdominal X-Ray: Ileus, Obstruction, Stones, Air above liver. Contrast studies: gastrograffin, barium enema.

Ultrasound
Gallstones, Liver abcess, Biliary tree, Pancreas Urinary Tract: Hydronephrosis, Stones Pelvis: Abcess, appendicitis, Gtynae disease, ectopic pregnancy Ascites Abdominal Aortic Aneurysm

CT Scan
Useful for retroperitoneal structures Pancreatitis Abdominal Aortic aneurysm

Management
Resusitate Conservative treatment Medical management Surgical treatment

Case 1
23 year old lady. Central abdo pain over 48 hours moving to RIF Nausea, Anorexia

Case 2
40 year old lady Central upper abdominal pain Temperature Jaundice

Case 3
65 year old man Central abdo pain radiating to the back Hypotensive, Sweaty