ACUTE ABDOMEN

by Abirami Shavani
 Overview
 Definition
 History
 Clinical Diagnosis
 Investigation
 Forming Dx
 Decision to Operate
 Management
 Key Points
 Acute Abdomen
General name for presence of signs,
symptoms of inflammation of peritoneum
(abdominal lining)
 HISTORY
 Have a routine method of taking a HPI
 OPQRST
Onset
Provocation
Quality
Radiation
Severity
Timing
 Ask about: vomiting, bowel function, bleeding,
anorexia, menstruation
 Clinical Diagnosis
 Characterizing the pain is the key
Onset, duration, location, character
 Visceral pain → dull & poorly localized
i.e. distension, inflammation or ischemia
 Parietal pain → sharper, better localized
Sharp “RUQ pain”(chol’y), “LLQ
pain”(divertic)
 Kidney / ureter → flank pain
Clinical Diagnosis – Pain cont’d
 Location
Upper abdomen → PUD, chol’y, pancreatitis
Lower abdomen → Divertic, ovary cyst, TOA
Mid abdomen → early app’y, SBO
 Migratory pattern
Epigastric → Peri-umbil → RLQ = Acute
app’y
Localized pain → Diffuse = Diffuse
peritonitis
 Additional History
 Make sure to ask about:
Prior episodes of similar complaints
Prior abdominal surgeries
PUD, diverticular disease, cholelithiasis,
nephrolithiasis
Medications: steroids, NSAIDS
 Physical Exmnation
 Palpation & percussion
 Rigidity
 Hyperesthesia
 Check for hernias
 Rectal exam
 Vaginal exam when appropriate
 Auscultation
 Signs
 Obturator sign
 Psoas sign
 Rovsing’s sign
 Dance’s sign
 Cullen’s sign
 Grey Turner’s sign
 McBurney’s sign
 Murphy’s sign
 Referred Pain
 Cholecystitis = R scapula
 Appendicitis = periumbilical
 Pancreatitis = back
 Rectal disease = back
 Nephrolithiasis = flank
 Diaphragm irritation = shoulder
 Labs & Imaging
Test Reason Test Reason
CBC w diff Left shift can be CXR/AXR/ SBO/LBO,
very telling KUB free air,
BUSE N/V, lytes, Flat & Upright stones
acidosis,
dehydration Ultrasound Chol’y, jaundice
GYN pathology
Amylase Pancreatitis,
perf DU, bowel
ischemia
LFT Jaundice,hepati CT scan Anatomic dx
tis -Diagnostic Case not
accuracy straightforward
UA GU- UTI, stone,
hematuria

Beta-hCG Ectopic
 Forming a DDx
 Start with broad categories:
Inflammation
Obstruction
Ischemia
Perforation
Clinical Diagnosis
 Diagnosis: Exm & DDx
 Central/epigastric: pancreatitis, obstruction, early appendicitis,
ruptured AAA, MI, gastric volvulus, gastritis

 RUQ: cholecystitis, appendicitis (in pregnancy)

 LUQ: perforated gastric ulcer, splenic rupture, gastritis, GER,

Boerhaave’s syndrome, Mallory-Weiss tear, perinephric abscess,
splenic artery aneurysm

 RLQ: leaking duodenal ulcer, appendicitis, Meckel’s diverticulum,

intussusception, ectopic pregnancy

 LLQ: diverticulitis, sigmoid volvulus, UTI, SBO, IBD, ectopic

pregnancy, endometriosis, CA

 Generalized: perforated peptic ulcer, dAA, mesenteric ischemia

 Flank: pyelonephritis
 Non-Surgical Dx
 Respiratory: PE
 Cardiac: pericarditis, MI
 GI: gastroenteritis, pancreatitis, hepatitis
 GU: obstructive nephrolithiasis, pyelonephritis,
cystitis, testicular torsion
 OB/GYN: torsion or rupture of ovarian cyst,
ectopic pregnancy, endometritis, salpingitis
 Heme: sickle cell crisis, leukemia,
 Endocrine: Diabetic ketoacidosis
 MS: rectus sheath hematoma
 Decision to Operate
 Peritonitis
 Severe / unrelenting pain
 Hemodynamically unstable
 Intestinal ischemia
 Pneumoperitoneum
 Complete obstruction
 Management Plan
Think about:

 A–B–C

 RESUS first
 Neuro: pain management
 CV: appropriate monitoring
 Pulm: incentive spiro, chest physio
 GI: NPO, NGT
 GU: Foley
 Fluids: IVF
 Heme: DVT prophylaxis
 ID: pre-op antibiotics
 Key Points
 Careful history (pain, other GI symptoms)
 Remember DDx in broad categories
 Narrow DDx based on hx, exam, labs, imaging
 Always perform ABC, Resuscitate before Dx
 If patient’s sick or “toxic”, get to OT (surgical
emergency)
 Ideally, resuscitate patients before going to the OR
 Don’t forget GYN/medical causes, special
situations
 For acute abdomen, think of these commonly 
Perf DU Appendicitis Diverticulitis Bowel
+/- perforation +/- perforation obstruction

Cholecystitis Ischemic or Ruptured Acute

perf bowel aneurysm pancreatitis
THE END.