Acute Abdomen

The “Black Hole” of

Medicine
 Introduction
Defined as any clinical condition
characterized by severe abdominal pain
which develops over a period of 8 hrs. In pt
who have been previously well.

Rapid and accurate diagnosis is essential for

morbidity and mortality process.
 Pathophsiology
• Visceral pain; due to stimulation of visceral
afferent nerve plexus usually in midline result
from contraction or distension against
resistance & chemical irritation usually colicky
in nature.
 Pathophsiology

• Parietal pain; 2dry to partial peritoneum

irritation perceived through segmental
somatic fibers reflex, involuntary muscle
wall rigidity may result from irritation of
segmental sensory nerves.
• Hyperesthesia of the skin may result
from ipsilateral peritoneal irritation
usually a sharp ache.
Abdomen
Epidemiology
Abdominal quadrant
 Causes
• Gastrointestinal tract*
• Acute appendicitis
• Meckel”s diverticulitis
• Perforated bowel
• Perforated peptic ulcer
• Small and large bowel obstruction
• Strangulated hernia
• Diverticulitis
• Gastritis
• Gastroenteritis
• Inflammatory bowel disease
• Mesenteric lymphadinitis
 spleen, liver, BiliaryTract
• Acute Cholangitis
• Acute Cholecystitis
• Hepatic abscess
• Ruptured hepatic tumor
• Splenic infarct
• Ruptured spleen
• Biliary colic
• Acute Hepatitis
Peritoneum
• Intra-abdominal
abscess
• Primary peritonitis
• Tuberculosis peritonitis
Pancreas
• Pancreatitis, acute
• Pancreatic Ka
Urinary Tract
• Cystitis acute
• Pyelonephritis acute
• Renal infarct
• Ureteral colic
Gynecological
• Ruptured ectopic pregnancy
• Ruptured ovarian follicular cyst
• Twisted ovarian tumor
• Dysmenorrheal
• Endometriosis
• Acute salpingitis.
• PIDs
Male reproductive tract.
• Prostatitis
• Cystitis
Torsion of testes
• Vascular causes
• Acute ischemic colitis
• Mesenteric thrombosis
• Ruptured arterial aneurysm
 Medical causes

• Pneumonia.
• Myocardial infarction
• Sickle cell crisis.
• DKA
• Leukemia
• Herpes zoster
• psychogenic
 Approach to acute abdomen

History.
1. Pain
2. Associated symptoms (nausea, vomiting,
Change of bowel habits, jaundice, anorexia,
Hematemesis, melena, dyspepsia)
3. Menstruation & sexual history.
 Cont..

4. ROS
5. Past medical & surgical hx
6. Medications
7. Familay Hx
8. Social Hx
 Examination
Acute appendicitis
• constant , progressive start per umbilical
move toward RLQ.
• nausea, vomiting, low grade fever,
anorexia
&/or constipation.
Inflamed appendix
Acute cholecytitis
•Constant moderate pain in RUQ radiated to
Rt shoulder tip.
•nausea, bilious vomitus, low grade fever &
jaundice
Perforated peptic ulcer,
•Sudden onset of pain in midepigastrium that
spreads and aggravated by movement.
•Patient appears acutely ill and is reluctant to
move; rigid abdomen; grunting respiration;
bowel sounds absent
Ectopic pregnancy,
•Pain sudden, severe, persistent, following a missed
or abnormal cycle, typically epigastric; associated
with hypotension and tachycardia
•Ovarian cyst
Pain constant with sharp, sudden onset, usually in
ipsilateral hypogastrium; may have nausea and
vomiting following the pain.
Pelvic inflammatory disease.
•Pain at end of or after normal menstrual
cycle, bilateral lower quadrant pain
aggravated by cervical manipulation;
•anorexia, nausea, and vomiting rare;
possible cervical discharge; fever
Urinary stone,
•Pain location changes with movement of
stone, may radiate to testicle, groin of
involved side,
•pain very severe; patient cannot get
comfortable, nausea
 Physical examination

1.General appearance
2.Vital signs.
3.Abdomial exam
4.Rectal exam
5.Pelvic exam (female pt)
?
 Investigation

1.CBCs
•WBCs & differential.
•RBC & hct, degree of anemia.
•Platelet count, evidence of cougalopathy.
2.electrolyte,
•(G, Na, K, Cl, Ca ,Mg, Po)
•Indicative of volume status, GIT loss,
 .
3.ABG,
•Indicate metabolic acidosis or alkalosis. M.
Acidosis with generalized abdominal pain in
elderly is bowel ischemia till proven other
wise.
 .
4.liver function test
•Bilirubin (D or ID), ALP elevation in biliary
obstruction & transaminase elevation in case
of hepatocellular injury.
5.RFT
•Urea, creatinin elevation in renal
insufficiency
•Serum albumin decrease in edema / ascitis.
 .
6. serum amylase
•Seen in pancreatitis although non specific
may be elevated in mesenteric ischemia,
perforated peptic ulcer, rupture ovarian cyst
& renal failure.
•lipase more sensitive.
 .
7.serum B_HCG
•Mandatory for all women of
childbearing age.
8.urinalysis
•See WBC RBC & casts.
 Radiological evaluation

1.CXR,
•Look for pneumonia, free gases under
diaphragm .pleural effusion suggest sub
diaphragmatic inflammatory process.
2.abdominal Xray.
• (Erect & supine position )
• bowel distension & air fluid level
• bowel gas cut off vs air through rectum.
• sentinel loop vs pancreatitis
• abn calcification vs ch.pancreatitis,stone
• pnumatosis vs omnious sign of dead
gut.
Intestinal obstruction
3.Ultrasound,
•hepatobiliray tree(stones, mass,
thickining of the wall)
•pancreases
•kidney
•pelvic organ
•intraabdominal fluid collection
Gall stone\ appendicolith
4.CT_scan
•Helpful in case of abdominal pain
without clear etiology better in
evaluation of abdominal aortic
aneurysm.
Acute pancreatitis\dilated loop
4.contrast study
•barium study
•perforation,
•Point out level of obstruction in small
bowel.
•avoid if colonic diverticuilitis is
suspected
Multiple stones in CBD
5. Intravenous pyelogram
• For dignosis of ureteral stone or
obstuction

6. Angiography
• For mesenteric ischemia
Angiograph
 Other study

7.Endoscopy,
•EGE, for evaluation epigastric pain in non
acute setting & git bleeding
Sigmoid\colonoscopy
•colonic obstruction
•dig IBD, ischemic colitis, lower bleeding
•Non-strangulated sigmoidal volvulus
ERCP
8. paracentesis &\or peritoneal lavage
•spontaneous bacterial peritonitis in
cirrhotic pt
•peritoneal lavage may be a useful bedside
test in diagnosis of mesenteric infarction in
critically ill pt.
9.culdocentesis
•Valuable in diagnosis of rupture ectopic
pregnancy.

10.laproscopy
•D & ttt of suspected gynec. cause
•appendectomy if appendicitis is found in a
women in childbearing period.
laparoscopy
 Plan of treatment

• promote timely work up in first 4-6hrs.

• keep pt NPO till the diagnosis is firm & ttt
plan is formulated.
• IV fluid. based on expected fluid loss.
• heamodynamic monitoring.
• NGT- bleeding ,vomiting ,sign of
obstruction or when urgent laparoscopy
is planned in pt not NPO.
• Foley catheter to monitor fluid out put
decisions
• Immediate surgery
• what is the timing of operative
intervention
(does pt need time for resuscitation)
• what incision should be used?
• what are the likely findings?
• develop primary operative plan.
• consider alternative diagnosis & plan.
• use appropriate pre-operative
antibiotic based on suspected
pathology.
 If not urgent

• admit & observe for possible operation.

• serial examination every 2-4 hrs during the
first 12-24 hrs in case without definite
diagnosis; minimal use of narcotics &
sedatives to avoid masking physical sign &
symptoms.
• monitor vital signs frequently
• serial lab exam may be useful ; repeat CBC.
• If no operation develop ttt plan for further
diagnostic workup or non operative
therapy.
 Case
• 36 yrs old female pt status post aoratic valve
replacement who present with one week hx of
acute abdominal pain becoming severe over
last 24hrs
• O\E tachycardia, PR=145\min, B.P=100\45
temp=38. abd. Distended , rigid with
moderate tenderness. wbc=23000.
amylase=200 LDH=1500.
• What is mostly like diagnosis?
• What is the investigation of
choice?
• Management plan?
Thanks