Acute
 Abdomen
dr. Liza Nursanty, SpB, Mkes, FINACS
 

Acute Abdomen 
•Challenge to Surgeons & hysi!ians
•Most !o""on !ause o# surgi!al
e"ergen!y ad"ission
•Clini!al !ourse !an $ary #ro" "inutes to
hours to %eeks.
•It !an e an acute e'a!eration o# a
!hroni! prole" e.g. Chroni!
an!reatitis,(as!ular Insu)!ien!y.
 

DEFINITION
Acute Abdomen is a ter" used
synony"ously #or a !ondition that needs
i""ediate surgi!al inter$ention

*iagnosis !an e "ade "ost o# the ti"e

y a good history and a proper physi!al
e'a"ination.
 

ASSESMENT
•+ell eli!ited history
•roper physi!al
e'a"ination

Investigations are usually carried

out :
•only to support the diagnosis.
•or to narro% do%n the dierential
diagnoses.
 

History 
•-istory o# resent illness
•Fa"ily -istory
•ast Medi!al history
•-istory o# drugs taken or
Medi!ation eg. ingestion o#
!ertain to'i! drugs or Al!ohol
intake
 

Free Peritoneal Air

 

This plain abdominal radiograph of a 55-year-old woman presenting with

features of intestinal obstruction shows dilated loops of the small bowel
associated with thickened edematous valvulae conniventes and a strangulated
left inguinal hernia (arrow).
 

AIN 
 he Most I"portant Sy"pto" 

-istory o# pain should in!lude/

0.1nset
2.Se$erity
3.ype o# pain
4.5adiation o# ain
6.Change in nature o# ain
7.Asso!iated o%el or urinary
sy"pto"s
8.Aggra$ating or relie$ing #a!tors
 

!i" Onset o# ain 

• Sudden onset pain %hi!h %akes the
patient #ro" sleep
eg. per#oration or strangulation o#
o%el
• Slo% insidious 1nset
a. In9a""ation o# $is!eral
peritoneu".
. Contained pro!ess su!h as
e$ol$ing as!ess.
• Cra"py or !oli!ky pain
Biliary !oli!$ :reteri! !oli! or
Intestinal !oli!
 

!ii" rogression o# ain 

Progression from:
*ull, a!hing, poorly lo!alized !hara!ter
To:
  Sharp, !onstant & etter lo!alized pain
  indi!ates in$ol$e"ent o# arietal
peritoneu"
 

!iii" Associated %o&el

Sym'toms 
(ONSTIATION  
a. rogressi$e intestinal ostru!tion
#ro" a
neoplas" or in9a""atory o%el
disease
. aralyti! Ileus
  !. ost 1perati$e
  d. 1stru!ted groin hernia
 

!iv" Associated %o&el

Sym'toms
DIA))HOEA
*iarrhoea %ith pain is "ainly "edi!al.
 he #ollo%ing are the e'!eptions /
a.1stru!ted 5i!hter;s -ernia
.<all Stone ileus
!.Superior "esenteri! $as!ular
o!!lusion
d.Intestinal 1stru!tion asso!iated
%ith pel$i! as!ess
e.Spurious diarrhea in !hroni! #ae!al
i"pa!tion
 

D)*+ HISTO),
•(orticosteroids = "ask pain
•Anticoagulants = !an lead to an
intra"ural hae"ato"a o# the gut
!ausing ostru!tion
•Oral (ontrace'tives - ru'ture o#
.e'atic adenomas
•NSAIDs - erosive gastritis / 'e'tic
ulcers
 

NA*SEA / 0OMITIN+
i. Fre>uen!y o# $o"iting
ii. Chara!ter o# $o"iting/
pro?e!tile, non@pro?e!tile or sel#@
indu!ed
iii. Nature o# $o"iting/
a. Bilious $o"iting o# s"all o%el
ostru!tion
. Non@ilious $o"iting in
ostru!tion pro'i"al to a"pulla o#
$ater
!. Fae!ulent $o"iting in distal s"all
gut ostru!tion, large o%el
ostru!tion , stran ulation
 

NA*SEA / 0OMITIN+
•ain 1rst$ #ollo&ed by 0omiting is
usually surgical2
T.e vomiting is due to re9e'
pylorospas"
•Nausea / vomiting 1rst $ #ollo&ed
by 'ain is usually due to a medical
condition 

(o"iting is $ery pro"inent in

a.Mallory@+eiss syndro"e.
.Boerhaa$e syndro"etrans@ "ural
esophageal tearD
 

ANO)E3IA
Anore'ia or de!reased appetite %ith
pain is usually seen in Acute 
appendi!itis

*rinary Sym'toms &it. ain

:reteri! !oli!
•

Cystitis
•

FE0E) / (HI44S5)I+O)S
A"oei! Li$er As!ess
•

ygeni! Li$er As!ess

•

erinephri! As!ess
•

Intra@ado"inal us !olle!tion
•
 

OTHE) HISTO),
•ast Surgi!al history/ pre$ious operations@
leading to adhesions
•ast Medi!al history/ Si!kle !ell disease,
*iaetes or Can!er or 5enal #ailure
•Menstrual -istory in #e"ales
iD Missed period@ e!topi! pregnan!y
  iiD Mid o# period@o$ulation pain Mittel@
s!h"erzD
  iiiD +ith hea$y periods@ endo"etriosis
•Fa"ily history o# !olon !an!er, any other
"alignan!y or in9a""atory o%el disease
 

.ysical E6amination
+eneral A''earance
a.An'ious atient lying "otionless/
iD Acute appendi!itis
iiD eritonitis
.5olling in ed & restless/
iD :reteri! Coli!
iiD Intestinal !oli!
!.+rithing in ain/
Mesenteri! Is!he"ia
d. Bending For%ard/
  Chroni! an!reatitis
 

.ysical E6amination !contd2"

e. Eaundi!ed/
  CB* ostru!tion
#. *ehydrated
  iD eritonitis
  iiD S"all Bo%el ostru!tion
g. (ital Charting
 e"perature, ulse, B, 5espiratory
rate
5uptured AAA or e!topi! pregnan!y
!an lead to
@ allor
  @ -ypotension
  @ a!hy!ardia
 

.ysical E6amination !contd2"

h. Lo% grade te"p. is seen %ith
@ Appendi!itis
  @ Acute !hole!ystitis
i. -igh grade te"p. is seen %ith
@ Salpingitis
  @ As!ess
 ?. (ery -igh <rade e"p.%ith in!reasing
lethargy
seen in i""inent septi! sho!k
  @ eritonitis
  @ Acute !holangitis
  @ yonephrosis
 

Systemic E6amination
Cardiopul"onary e'a"ination
Che!k #or/
  @ ossile MI
  @ Basal neu"onia
  @ leural usion

er Abdomen/
Inspe!tion
@ S!aphoid or 9at in pepti! ul!er
@ *istended in as!ites or intestinal
ostru!tion
@  (isile peristalsis in a thin or
"alnourished
 

Systemic E6amination
•rythe"a or dis!olouration
a. eri@u"ili!al @ Cullen sign
. Inguinal = Fo' sign
!. Flanks @ <rey urner sign
Seen in Hemorr.agic 'ancreatitis
or any other !ause o#
hae"operitoneu"
•Any (isile "asses
•Any $isile !ough i"pulse at hernia site
 

Systemic E6amination
er abdomen/
  alpation
• Be gentle
• Start a%ay #ro" site o# pathology then
to%ards
• Che!k #or -ernia sites
 enderness
•

• 5eound tenderness
• <uarding@ in$oluntary spas" o# "us!les
during palpation
• 5igidity@ %hen ado"inal "us!les are
tense & oard@like. Indi!ates peritonitis.
 

Systemic E6amination
•Lo!al 5ight Ilia! Fossa tenderness /
a. Acute appendi!itis
. Acute Salpingitis in #e"ales
!. A"oeiasis o# Cae!u"
•Lo% grade, poorly lo!alized tenderness /
Intestinal 1stru!tion
 enderness out o# proportion to
•

e'a"ination/
a. Mesenteri! Is!he"ia
. Acute an!reatitis
•Flank enderness/
a. erinephri! As!ess
. 5etro!ae!al Appendi!itis
 

Systemic E6amination
•5o$sings Sign in Acute Appendi!itis
•1turator Sign in el$i! Appendi!itis
•soas Sign
@ 5etro!ae!al appendi!itis
@ Crohns *isease
@ erinephri! As!ess
•Murphy;s sign in Acute Chole!ystitis
 hu"ping tenderness o$er lo%er ris in
•

in9a""ation o#
@ *iaphrag"
@ Li$er or spleen
 

Systemic E6amination
•ulsatile Ado"inal Mass %ith
-ypotension
Leaking AAA
•(utaneous Hy'eraest.esia indi!ates
in$ol$e"ent o# arietal eritoneu"
•er 5e!tal 'a"ination/
@ tenderness
@ induration
@ "ass Blu""ers shel#D
@ #rank lood
 

Systemic E6amination
er (aginal 'a"ination
  @ Bleeding
  @ *is!harge
  @ Cer$i!al "otion tenderness
  @ Adne'al "asses or tenderness
  @ :terine Size or Contour
 
 

IN0ESTI+ATIONS

GCo"plete Blood Count %ith dierential

GC@rea!ti$e protein esti"ation
Gle!trolyte ,Blood :rea , Creatinine
G:rine dipsti!k
GA"ylase or Lipase
GLi$er Fun!tion est
 

IN0ESTI+ATIONS
5adiology
:pright H ray !hest #or
•

  Basal neu"onia
  5uptured 1esophagus
  le$ated -e"i diaphrag"
  Free <as under diaphrag"
Ado"inal H ray l"
•

Air@Fluid Le$els
Stones
As!ites
ggshell !al!i!ation in AAA
Air in Biliary tree.
1literation o# soas Shado% in retro@
peritoneal disease
5ight lo%er >uadrant sentinel loop in acute 
appendi!itis
 

IN0ESTI+ATIONS

Ot.er Investigations
 :S<
 C abdomen #or AAA, an!reati! disease,
or ureteri! !oli! non@ ContrastD
 I(:
 Mesenteri! Angiography #or
Is!hae"ia, -ae"orrhage