Acute Abdomen

Immediate
iate Management of Life
Life-Threatening
Threatening Problems
Perform Brief Examination
Determine if the patient is stable or not , through multiple, simultaneous steps :
First, Ass general appearance.
Second, evaluate responsiveness, focusing on"
eye opening and verbal and motor responses.
Third, assess airway, breathing, and circulation.
Fourth, record and review a complete set of vital signs.
Fifth, Gentle palpation of the abdomen, looking for signs of an acute abdomen:
rebound tenderness, board-like rigidity or guarding, or an obvious pulsatile
mass to suggest an aortic aneurysm.
Sixth, perform a rectal examination , inspecting for blood.
If instability is confirmed, measures to stabilize the patient must be done immediately.

Caution: A number of patients with abdominal pain will have a source of that pain outside
the abdomen, anatomically, as when epigastric or upper abdominal pain is caused by:
Acute myocardial infarction,
Pulmonary embolus
Pneumonia.
Diabetic ketoacidosis.

Identify Candidates for Urgent Surgery

Those requiring early surgical evaluation or intervention include patients with :
1- Acute abdomen,
2- Pulsatile abdominal mass
3- Shock ( hypotension or or hemodynamic instability ) with abdominal pain.,
especially with GIT bleeding or a rigid abdomen,
there is a strong possibility of underlying life-threatening pathology.

Treat Shock ( if present ) :

After the patient has been stabilized, reassess as described below unless immediate surgery is required (Table 132).
A- History
1- Mode of Onset of Abdominal Pain :
Abrupt Onset Gradual Onset
The abrupt onset of severe Gradual onset of slowly
abdominal pain should suggest:
1- Vascular accident or
2- Rupture of a hollow viscus.
Abrupt onset of moderate pain
at time of onset, and worsens
rapidly with time suggests :
1- Acute pancreatitis,
2- Mesenteric thrombosis,
3- Small-bowel strangulation.
Abrupt onset of pain of lower
abdominal in female suggests :
1- Ruptured ectopic pregnancy or
2- Ovarian follicle cyst
Further Evaluation of the Patient with Abdominal Pain
Severe Pain
Severe abdominal pain may be
worsening pain is the caused by :
characteristic of : 1- Renal colic,
2- Biliary colic,
peritoneal inflammation
3- Various vascular conditions
This suggests : such as :
1- Appendicitis or Myocardial infarction,
2- Diverticulitis Mesenteric ischemia,
Rupture of an abdominal
aortic aneurysm.
4- Acute pancreatitis,
5- Perforation of a hollow viscus,
6- Peritonitis.
Intermittent, crampy pain
1- Gastroenteritis.
Intermittent, crampy
abdominal pain .
2- Mechanical small-bowel
obstruction :
Crampy pain that occurs in
regular cycles, rising & falling
in a crescendo fashion,
especially with pain-free
intervals suggests :
Mechanical Small bowel
Obstruction.
1- Insert two large-bore (>= 16-gauge) IV catheters in an upper extremity.
2- Obtain blood for : + send a tube of blood for typing and crossmatching.
a complete blood count (CBC) with differential, serum electrolyte
measurements, lipase measurement, renal function tests, liver function tests,
serum pregnancy test, serum lactate, and a rapid bedside glucose test. Also,
send a tube of blood for typing and crossmatching.
3- solution.. Titrate rate of
Immediately begin rapid infusion of crystalloid solution
infusion to the blood pressure; ini9ally, give a 1-L bolus over 1020 minutes
(adult dose). Remember to exercise caution in patients with congestive heart failure.
Dull Pain 4- Give oxygen : Rate 210 L/min by nasal canula or mask.
Dull, vague, poorly localized .. Oxygen saturation : above 95%.
pain + is typically gradual in
5- Insert a urinary catheter to monitor urine output.
onset.
Send a urine sample for analysis.
6- Obtain an arterial blood gas to assess :
When these two findings are
..- The patient's acidbase status and
coupled, they suggest:
1- Inflammatory process - Overall physiologic condition.
2- low-grade infection, 7- Insert a nasogastric tube if the patient shows evidence of :
3- Appendicitis peritonitis, severe ileus, intestinal obstruction, or GIT bleeding.
4- Diverticulitis.
8- Obtain a 12-lead ECG , begin continuous cardiac monitoring.
9- If bacterial peri
peritonitis
tonitis is suspected, begin antibiotics after appropriate
cultures have been obtained
10- Note: Persistent shock despite fluid resuscitation in the patient with acute
abdominal pain requires urgent laparotomy.

2- Location of Pain
The parietal peritoneum is innervated by :
1- Somatic nerve fibers producing pain that is well localized :
- Localized Abdominal Pain In general, when abdominal pain becomes localized, it does so over or near the involved viscus,
.. for example : tthe
he right lower quadrant pain of appendicitis or the right upper quadrant pain of cholecystitis.
2- Visceral fibers alone Produced pain tends to be poorly localized.
- Common examples of condi ons associated with visceral pain sensa on are: 1- hollow viscus disten on and 2- visceral ischemia.
3- Radiation of Pain or Shift in Localization :
a- Shoulder Pain :
Ipsilateral diaphragmatic irritation by air, blood, or infection in the peritoneal cavity can cause shoulder pain.
A classic example is cholecystitis, which may be associated with right shoulder pain.
b- Diffuse Periumbilical and Epigastric Pain :
Diffuse periumbilical and epigastric pain that gradually localizes to the right lower quadrant is a classic sign of appendicitis.
With early appendicitis, only the visceral peritoneum surrounding the appendix is inflamed, and the localization is therefore poor.
As the inflammation spreads to the parietal peritoneum, the pain localizes to the right lower quadrant.
The retrocecal appendix, which is found in 15% of cases, is an important excep on, with pain remaining poorly localized secondary to lack of
parietal peritoneum involvement.
c- Pain Radiating from the Flank :
Pain radiating from the flank to the groin or genitalia usually signifies ureteral colic, as seen in urolithiasis.
The physician must also consider testicular pathology such as testicular torsion in any male patient with abdominal pain, whether that pain radiates to the
groin or not.
4- Associated symptoms with pain :
A- Anorexia, Nausea, & Vomiting
Anorexia and nausea and vomiting are common with abdominal pain, especially abdominal pain having its its source in the upper abdomen;
BUT also, severe intra-abdominal processes can occur wit
without
hout any of these symptoms For example, one may retain a normal appetite with appendicitis if
the appendix is isolated from the peritoneum, as may be the case with a retrocecal appendix or an appendix that is isolated b
byy omentum.
If these symptoms preceding abdominal pain are more indicative of less acute conditions such as food poisoning, gastroenteritis, acute gastritis, and acute
pancreatitis, BUT these symptoms may have developed after initial onset of pain in abdominal emergencies by the time patient has sought medical attention.
B- Fever & Rigors
If fever present with abdominal pain Usually suggesting infection.
Fever with continual rigors suggests : infections of the biliary and urinary system (e.g., cholangitis and pyelonephritis).
Fever with chills, jaundice, and hypotension suggests : suppurative cholangitis ( Surgical emergency ) .
High fever with peritoneal signs in a female patient suggests : acute salpingitis with pelvic peritonitis.
Interestingly, appendicitis with high fever and rigors is uncommon unless peritonitis, most likely from viscus perforation, has developed.
Recall that absence of fever is common in the elderly and immunosuppressed patients.
C- Diarrhea, Constipation, & Obstipation
Constipation and obstipation may suggest intestinal obstruction or ileus .
Diarrhea ( though common with gastroenteritis ) is a nonspecific symptom that can be associated with : Colitis, Diverticulitis, Appendicitis, and Salpingitis.
B- Physical Examination :
1- Inspection: Inspection the abdomen & external genetalia
Significant findings include masses, distention, pregnancy, previous surgical scars, ecchymosis, a board-like abdomen, and stigmata of severe hepatic disease.
2- Auscultation
Silent abdomen, i.e., complete absence of audible peristalsis, suggests: peritonitis , BUT also peristalsis may persist in t he face of established peritonitis. High-pitched bowel sounds suggests : bowel obstruction.
3- Palpation
a- Examine Hernial Rings and Genitalia : Examine the inguinal and femoral canals and the genitalia for incarcerated hernias that may be causing intestinal obstruction.
b- Elicit Cough Tenderness: coughing may elicits pain in the involved area ( in most inflammatory processes).
c- Directing the patient to point one finger to the area of pain
pain:: With this information, the examiner can proceed to examine the abdomen and examine last the area now known to be most tender.
d- Feel for Spasm of Rectus Abdominis Muscle (Guarding): Detect presence or absence of true muscle spasm by gently depressing the rectus abdominis muscle without causing pain. a- Diffuse pain suggests a certain set of diagnostic possibilities
If the spasm is voluntary, the muscle will immediately relax underneath the gentle pressure of the palpating hand. b- Differing groups of disorders give rise to abdominal pain in the epigastric, umbilical and hypogastric regions
If there is true spasm, the muscle will remain taut and rigid through the respiratory cycle establish the presence of peritonitis. c- Disorders that give rise to acute abdominal pain according to the quadrant of the abdomen.
In renal colic, the spasm is confined to the entire rectus muscle on the involved side.
In generalized peritonitis, both muscles are involved to same degree.
e- Perform One-Finger Palpation
Abdominal tenderness must be assessed with one finger, because it is impossible to localize peritoneal inflammation accuratel
accuratelyy if palpation or tenderness is done with the entire hand.
Careful one-finger palpation, beginning as far away as possible from the area of tenderness elicited by coughing and gradually working toward
toward it, will usually enable the examiner to delineate area
of abdominal tenderness precisely.
e.g. In early acute appendici s, this area is o%en no larger than 23 cm in diameter.
Diffuse abdominal tenderness without involuntary rigidity of musculature suggests : 1- gastroenteritis or 2- other inflammatory process of the intestines without peritonitis.
f- Gentle percussion of the costovertebral angles should follow palpation
palpation.. This should elicit pain in individuals with : 1- pyelonephri s 2- retroperitoneal abscesses 3- retrocecal appendicitis.
g- Perform Deep Palpation
The examiner now palpates more deeply for the presence of abdominal masses. Often, it is difficult to perform a reliable physical
physical examination of the abdomen in an anxious patient.
Among the more common lesions identifiable by careful palpation in patients with acute abdominal pain are:
1- Distended, tender gallbladder found in acute cholecys99s 2- the right lower quadrant tender mass of appendicitis with early abscess formation,
3- the left lower quadrant mass of sigmoid diverticulitis, 4- the midline pulsatile mass of abdominal aortic aneurysm.
4- Percussion: It can be used in estimation of liver, spleen, or bladder size and in differentiating etiologies of abdominal distention, specifically
specifically organomegaly, ascites, and obstruction.
5- Special Signs: Several maneuvers in physical
ical exam
examination may help localize an acute abdominal lesion. liopsoas S , Obturator Sign , Murphy's Sign (Inspiratory Arrest)
iopsoas Sign
Pelvic & Rectal Examination
In men, rectal examination plus simultaneous
eous low ized pain not disclosed by abdominal examination alone.
lower abdominal palpation often reveals masses or localized
Likewise, pelvic examination in women provides
rovides essential information not revealed by other maneuvers.
s. Evalua9on
Evalua of lower abdominal pain in women is discussed further
urther in Chapter 36.
C- Investigations :
Definitive Diagnosis of Conditions Causing Acute Abdominal Pain : 1- Laboratory investigations :
Blood Count
Location of Pain Condition Most Sensitive and Specific Signs and Diagnostic Tests 1- Hematocrit:
Cholecystitis Right upper quadrant sonogram; radionuclide scan Reflects changes both in plasma volume & red cell volume.
It is diagnostically most useful if markedly - elevated (indicating dehydration) or
Biliary colic Right upper quadrant sonogram - depressed (indicating anemia).
Right upper Assess or estimate the degree of blood loss.
Cholangitis Right upper quadrant sonogram
quadrant 2- The white cell count :
Hepatitis Liver function tests, especially transaminases A normal or low white count, particularly with lymphocytosis suggest viral infection.
A progressively rising white count indicates progression of an inflammatory process.
Liver abscess or tumor Right upper quadrant sonogram; CT scan; radionuclide liver scan Recall that in elderly and immunosuppressed patients the count may be low or normal.

Right lower lobe pneumonia Chest X-ray Serum Amylase & Lipase
Patients with abdominal pain and elevated (>3 x normal) serum amylase or lipase
Peritonitis Smear and culture of peritoneal fluid; laparoscopy or laparotomy usually have: acute pancreatitis.
Serum lipase; CT scan Serum amylase is less specific But still frequently measured (Lipase is specific).
Pancreatitis
Epigastrium or Duodenal perforation Upright or left decubitus flat plate of abdomen; CT scan with water
water-soluble oral Hepatic Function Tests
midline contrast media Hepatic function testing is indicated for patients who have right upper quadrant pain
or tenderness, jaundice, light-colored stools, or tea-colored urine and for patients in
Abdominal aortic aneurysm Sonogram; CT scan whom hepatitis is a possibility.
Myocardial infarction ECG; CK/troponin isoenzymes
Urine
Urinalysis (including microscopic examination of the sediment)
sediment) is critical in ruling out : -
Left upper Rupture of spleen Sonogram, peritoneal lavage; CT scan of abdomen - Urinary tract infection
quadrant Splenic infarct CT scan - Urolithiasis,
- Uncontrolled diabetes.
Low urine specific gravity associated with severe vomiting may be the earliest clue to
Pyelonephritis Urinalysis and Gram's stain of urine; urine culture renal disease.
Flank Renal colic Urinalysis; noncontrast CT scan of abdomen; excretory urogram Hematuria strongly suggests urolithiasis,
BUT urolithiasis with complete obstruction of the ureter is occasionally
occasionally associated with
Renal infarct Urinalysis; renal scan or angiography normal results on urinalysis.
Pyuria :
Appendicitis History and examination; CT scan with oral and intravenous contrast; sonogram; Lower abdominal inflammatory conditions such as appendicitis or pelvic inflammatory
laparoscopy or laparotomy disease can cause pyuria
Diverticulitis History and examination; CT scan with oral and intravenous contrast Serum Electrolytes & Tests of Renal Function
Lower Both tests are required to : document the nature & extent of fluid losses if
Ectopic pregnancy Pelvic sonogram; laparoscopy or laparotomy; positive urine pregnancy test
abdomen - Vomiting or diarrhea has been significant or
Salpingitis History and examination; pelvic sonogram - The illness has lasted for more than 48 hours with diminished oral intake.
An elevated BUN may noted with : gastrointestinal bleeding.
Ruptured ovarian follicle cyst Pelvic sonogram
Pregnancy Test
Gastroenteritis History and examination; stool smear and culture A serum pregnancy test should be obtained iin
n all women of childbearing age.
History and examination; supine and upright abdominal X-ray
X Women with a history of : are at increased risk for ectopic pregnancy.
Intestinal obstruction
- Pelvic infection,
Volvulus and intestinal Supine and upright abdominal X-ray
X - Current intrauterine device use,
strangulation - Prior ectopic pregnancy,
- Failed tubal ligation
Intestinal perforation Supine and upright abdominal X-ray;
X ray; CT scan with intravenous and water
water-soluble oral
contrast Electrocardiogram
Diffuse or Ischemic colitis CT scan; visceral angiography; barium enema A 12-lead ECG should be obtained in patients with :
epigastric or upper abdominal pain
variable Idiopathic IBD CT scan with intravenous and water-soluble
water oral contrast in whom no clear cause of the pain is identified and cardiac ischemia is a possibility.

Retroperitoneal hemorrhage CT scan Peritoneal Fluid

History and examination; visceral angiography; laparotomy; CT scan with intravenous In peritoneal dialysis or chronic liver disease patients examination of the
Mesenteric thrombosis
and soluble oral water-contrast peritoneal fluid is often warranted if : abdominal pain, tenderness, & fever present.

Porphyria History; hirsutism; elevated urinary porphobilinogens

2- Radiological examinations :
Addison's disease Low serum sodium and high serum potassium; low serum cortisol level
Abdominal x-ray
Poisoning Toxicology screen (lead, arsenic, iron) Ultrasonography,
Computed tomography (CT)
Familial Mediterranean fever Historypatient
patient and family
Barium Enema
Diabetic Ketoacidosis Diabetes, previous attacks Angiography
Tertiary syphilis Presence of syphilis; previous attacks

Preeruptive zoster Unilateral dermatomal distribution

Differential Diagnosis of the Common Causes of Acute Abdominal Pain.

Disease Location of Pain and Prior Attacks Mode of Onset and Type of Pain Associated Gastrointestinal Symptoms Physical Examination Helpful Tests and Examinations

Acute appendicitis Periumbilical or localized generally Insidious to acute and persistent Anorexia common; nausea and vomiting in Low-grade
grade fever, epigastric Slight leukocytosis; CT scan of the abdomen or
to right lower abdominal quadrant some tenderness initially; later, right ultrasound of the appendix may be helpful if
lower quadrant diagnosis is uncertain

Intestinal obstruction Diffuse Sudden onset; Crampy Vomiting common Abdominal distention; high
high- Dilated, fluid-filled loops of bowel on abdominal X-ray
pitched rushes

Perforated duodenal ulcer Epigastric; history of ulcer in many Abrupt onset; steady Anorexia; nausea and vomiting Epigastric tenderness; involuntary Upright abdominal X-ray
ray shows air under diaphragm;
guarding CT scan

Diverticulitis Left lower quadrant; history of Gradual onset; steady or crampy Mild diarrhea common Fever common; mass and CT scan shows inflammatory mass
previous attacks tenderness in left lower quadrant

Inflammatory bowel Diffuse; primarily in lower abdomen; Gradual onset; often crampy Diarrhea common, often with blood and Fever; diffuse abdominal Blood and leukocytes in stool; CT scan; abnormal
prior attacks common mucus tenderness results on proctosigmoidoscopy or barium enema
disease
Acute cholecystitis Epigastric or right upper quadrant; Insidious to acute Anorexia; nausea and vomiting Right upper quadrant tenderness Right upper quadrant sonography shows gallstones;
may be referred to right shoulder radionuclide scan shows nonvisualization of
gallbladder

Biliary colic Intermittent right upper quadrant; Often abrupt onset; dull to sharp Anorexia; nausea and vomiting common Right upper quadrant tenderness Sonography shows gallstones
prior attacks common

Ischemic colitis Epigastric; diffuse; prior attacks Often abrupt; crampy Diarrhea, commonly bloody Diffuse abdominal tenderness; Barium enema shows "thumbprinting" of mucosa; CT
common vascular disease elsewhere scan; visceral angiography shows vascular obstruction

Ruptured abdominal aortic Epigastrium and back Abrupt; sharp and severe Variable; may be none Hypotension or shock; abdominal Sonography, CT scan, or anglography shows
aneurysm aneurysm
aneurysm
Rupture of spleen Left upper quadrant or diffuse; may Abrupt; severe Usually none Hypotension or shock; Peritonitis; CT scan or liverspleen
spleen scan shows rupture;
be referred to left shoulder; history Left upper quadrant tenderness; peritoneal lavage reveals blood
of trauma common fractured left ribs in some

Renal colic Costovertebral or along course of Sudden; severe and sharp Frequently nausea and vomiting Flank tenderness Hematuria; abnormal; noncontrast CT scan of the
ureter abdomen or excretory urogram (obstruction,
hydronephrosis)

Acute pancreatitis Epigastric penetrating to back Acute; persistent, dull, severe Anorexia; nausea and vomiting common Epigastric tenderness Elevated serum lipase; CT scan shows pancreatic
inflammation

Acute salpingitis Bilateral adnexal; later, may be Gradually becomes worse Nausea and vomiting may be present Cervical motion elicits tenderness; Ultrasound can rule out tubo-ovarian
ovarian abscess
generalized mass if tubo-ovarian abscess is
present

Ectopic pregnancy Unilate

Unilateral early; may have shoulder Suddenn or intermittently
inte vague to Frequently none Adnexal mass; tenderness
derness Pelvic ultrasound reveals adnexal
exal ma
mass or blood;
pain af
after rupture sharp positive urine pregnancy test