APPROACH

TO PATIENT WITH
ACUTE ABDOMEN
NOOR DIANA & MAHIRAH

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TLOs
1. Definition and causes of acute abdominal pain
2. How to take history taking for acute abdominal pain
3. How to examine - physical examination
4. How to manage if you see patient with acute abdominal pain
- Investigation
- Management

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 Definition

‘Acute abdomen’ is a general term used to describe a variety of

serious intra-abdominal pathologies that mandate emergency or
urgent surgical or major medical intervention
[definitions source: Hamilton Bailey’s Demonstration Of Physical Signs In Clinical Surgery- 19th Edition.]

- Abdominal pain is the most important and the most frequent

complaint in patients presenting with an acute abdomen in
emergency settings.
- The pain is of acute onset, often very severe, and non-traumatic.

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 Characteristic of abdominal pain
1) Visceral pain
▪ Dull, cramping and poorly localized
▪ Foregut (oesophagus, stomach, duodenum, pancreatobiliary system) → epigastrium
▪ Midgut (small bowel to right colon) → periumbilical area
▪ Hindgut (the rest of the colon) → lower abdomen

2) Somatic (parietal) pain

▪ Sharp, constant and generally more severe.
▪ It is felt in a precise location corresponding to the somatic innervation of the overlying
muscle group and corresponds to the organs that underlie the area anatomically.

3) Referred pain
▪ Is a type of pain in which pain is perceived in a location remote from the diseased
organ, based upon its embryological origin rather than its adult location.
▪ For example, ipsilateral subscapular or shoulder pain may be felt with diaphragmatic
irritation
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Common causes of acute abdominal pain

Hamilton Bailey’s Demonstration Of Physical Signs In Clinical Surgery- 19th Edition

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Common causes of acute abdominal pain

Browse's Introduction to the Symptoms and Signs of Surgical Disease 5th Edition
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Common causes of acute abdominal pain

1. Inflammation: may result from infectious (purulent, faeculent) or chemical

(bilious) irritation of the peritoneal cavity.
2. Perforation: is a disruption of the integrity of a hollow viscus.
• The gastrointestinal contents leak into the peritoneal cavity, causing first
chemical, then inflammatory and finally infectious peritoneal irritation.
• The rupture of other structures (e.g. from trauma to a solid organ, rupture of a
hepatic adenoma or an ovarian cyst) also results in acute pain and may be
associated with intra-abdominal bleeding.

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Common causes of acute abdominal pain

3. Bowel obstruction is associated with nausea, vomiting, constipation and

distension as material fails to pass normally through the gastrointestinal tract.
• The abdominal pain is of a visceral type and is due to intestinal distension and
peristalsis.
• With ongoing distension (as in complete bowel obstruction), bowel wall
ischaemia may develop
4. Ischaemia of a hollow or solid organ develops from an interruption of its blood
supply (arterial or venous thrombosis), inadequate blood flow within the
bowel wall (a ‘low-flow state’) or extrinsic compression of the vessels (volvulus
or strangulation in a hernia).

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Common causes of acute abdominal pain

5. Torsion is an acute twist of the organ (such as the bowel or ovary)

around its axis.
• The pain is typically sudden and severe
• Torsion of a segment of the gastrointestinal tract (volvulus) typically results in
bowel obstruction.
• Whereas a rotation of less than 180° around the axis may result in partial
obstruction, a rotation of over 360° results in complete visceral obstruction
and interruption of the blood supply (one of the causes of ischaemia).

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 References

➢Browse's Introduction to the Symptoms and Signs of Surgical Disease

5th Edition
➢Hamilton Bailey’s Demonstration Of Physical Signs In Clinical Surgery-
19th Edition

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HISTORY TAKING IN ACUTE
ABDOMEN

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 Acute Abdomen: The History
History of Presenting Illness - Pain
SOCRATES

Site & Duration

Onset Record the time and date of onset, and the way the pain began – suddenly or
gradually
Character/Nature - Aching, burning, stabbing, constricting, throbbing, distending, colicky

Radiation Record the time and direction of any radiation of the pain; remember to ask if the
nature of the pain changed at the time it moved

Associated symptoms Discussed later

Timing Constant, coming and going

Exacerbating and
alleviating factors

Severity Assess the severity of the pain by its effect on the patient
Pain score
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Additional:

• Progression - Describe the progression of the pain. Did it change or

alter?

• The end of the pain - Describe how the pain ended. Was the end
spontaneous, or brought about by some action by the patient or
doctor?

• Duration - Record the duration of the pain

• Referral - Was the pain experienced anywhere else?

• Cause - Note the patient’s opinion of the cause of the pain

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1. SITE

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2. Time & Mode of Onset
• The part of the day or night when the pain began should be recorded.

• Began gradually or suddenly.

• When pain has a truly acute/sudden onset, patients often remember

the time precisely, or exactly what they were doing at the time.

• This occurs when a viscus perforates or a blood vessel splits (dissects)

or ruptures.

• Inflammation, infarction or obstruction of a hollow viscus all produce

a pain of more insidious onset

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3. Severity
• Individuals react differently to pain.
• What is a ‘severe pain’ to one person might be described as a ‘dull ache’ by another.
• Avoid adjectives used by a patient to describe the severity of their pain.
• A far better indication of severity is the effect of the pain on the patient’s life:

1. Did it stop the patient going to work?

2. Did it make the patient go to bed?
3. Did they try proprietary analgesics?
4. Did they have to call their doctor?
5. Did it wake the patient up at night, or stop them going to sleep?
6. Was the pain better lying still, or did it make them roll around?

The answers to these questions provide a better indication of the severity of a pain than words
such as mild, severe, agonizing or terrible.
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Pain Score

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4. Character/Nature
Nature Description

Burning . Almost everyone has experienced a burning sensation in the skin following contact
with intense heat, so when a patient spontaneously states that their pain is
‘burning’ in nature, it is likely to be so.
Throbbing Most have experienced a throbbing sensation at some time in their life from an
inflammatory process such as toothache, so this description is also usually accurate

Stabbing Sudden, severe, sharp and short-lived

Constricting a pain that encircles the relevant part (chest, abdomen, head or limb) and
compresses it from all directions
Colicky - Comes and goes like a sine wave.
- It feels like a migrating constriction in the wall of a hollow tube that is
attempting to force the contents of the tube forwards.
- Most of us have experienced intestinal colic during an episode of diarrhoea, and
many females have suffered colicky pains with their periods or in labour.

• ‘Just a pain, doctor.’

-When a patient cannot describe the nature of their pain, do not press the point. You
will only make them try to fit their description to your suggestions, which may be
misleading
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5. Progression of the pain

• Once it has started, a pain may progress in a variety of ways:

➢It may begin at its maximum intensity and remain at this level until it disappears.
➢It may increase steadily until it reaches a peak , or conversely it may begin at its peak and decline
slowly.
➢The severity may fluctuate. The intensity of the pain at the peaks and troughs of the fluctuations,
and the rate of development and regression of each peak, may vary.
➢The pain may disappear completely between each exacerbation.
➢The time between the peaks of an abdominal colic indicates the likely site of a bowel obstruction.
In upper small bowel obstruction, the frequency of the colic is approximately every 1–2 minutes,
whereas in the ileum it is every 20 minutes, and in the large bowel every 30–60 minutes.
➢It is essential to find out how the pain has progressed and ascertain the timing of any fluctuations
before its nature can be determined

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 6. End of the pain

• A pain may end spontaneously, or as a result of some action taken by the patient or doctor.

• The end of a pain is either sudden or gradual.

• The way in which a pain ends may give a clue to the diagnosis, or indicate the development of a new
problem.

• Patients always think that an improvement in their pain means that they are getting better.

• They are usually right, but sometimes their condition may have become worse, for example an intestinal
perforation relieving the colic but causing peritonitis and septicaemia.

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7. Duration of the pain

• Ask the patient how long the pain last

8. Factors that relieve the pain

• Position, movement, a hot-water bottle, aspirins and other analgesics, food

or antacids may all relieve the pain.
• The natural response to a pain is to search for relief.

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 9. Factors that exacerbate the pain
• Anything that makes the pain worse, such as movement, eating or opening the bowels, is also
likely to be known to the patient.

• The type of stimulus that exacerbates a pain will depend on the organ from which it emanates
and on its cause.

• For example, intestinal pains may be made worse by eating particular types of food.

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 10. Radiation and 11. Referral
• Always ask if the pain is experienced anywhere else or has moved from its initial site.

• Radiation
➢This is the extension of the pain to another site while the initial pain persists.
➢For example, patients with a posterior penetrating duodenal ulcer usually have a persistent pain in
the epigastrium, but the pain may also spread through to the back.
➢The extended pain usually has the same character as the initial pain.
➢ A pain that occurs in one site and then disappears before reappearing in another site is not
radiation: it is a new pain in another place.

• Referred
➢This is pain that is felt at a distance from its source.

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 12. Cause
• It is often worthwhile asking patients what they think is the cause of their pain.
• Even if they are hopelessly wrong - may get some important insight into their worries.
• A patient will sometimes appear obsessed with the cause of their condition.
• Always listen to the patient’s views with care and tolerance.

Psychogenic cause
• Beware of patients whose mental attitude to their pain symptoms seems out of proportion – either
over-responding to them or ignoring them.

• The patient whose symptoms do not fit any known pattern who tells you with a big smile that they have
‘terrible’ pain, or who, while complaining of severe pain, appears quite unconcerned may well be
neurotic, hysterical or fabricating their symptoms.

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Acute Abdomen: The History
Associated symptoms
 GI: bowels last opened, bowel habit (diarrhoea/constipation), PR
bleeding/melaena, dyspeptic symptoms, vomiting

 Urine: dysuria, heamaturia, urgency/frequency

 Gynaecological: normal cycle, LMP, IMB,

dysmenorrhoea/menorrhagia, PV discharge

 Constituitional symptoms: fever, loss of appetite, weight loss

 Any previous abdominal investigations and findings

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 Acute Abdomen: The History
Other components of history:

Past Medical History

Could patient be having a complication of a known condition e.g. Known diverticular disease, previous
peptic ulcers, known gallstones

Drug history
Steroids, NSAIDs – peptic ulcer disease

Social History
Alcoholics – acute pancreatitis
Smokers

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 References

➢Browse's Introduction to the Symptoms and Signs of Surgical Disease 5th Edition

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Physical Examination

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 Preparation
1. Environment
• The examination room must be warm and private if the patient is to lie undressed and relaxed.
• A good light is essential
• Comfortable and flat surface

2. Exposure
The full extent of the abdomen must be visible and, ideally, patients should be uncovered from nipples to
knees.

3. Getting the patient to relax

It is not possible to feel anything within the abdomen if the patient is tense.
There are several ways in which relaxation can be achieved:
• Ask the patient to rest their head on the couch or a pillow to avoid tensing the rectus abdominis
muscles.
• Ask the patient to place their arms by their sides, not behind their head.
• Encourage the patient to sink their back into the couch and breathe regularly and slowly.

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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 481)
 Inspection
Position:
Patient - lying supine (flat)
Doctor - at feet side

1. Symmetry
2. Contour (size, shape)
3. Skin
4. Additional observations:
• breathing movements
• umbilicus state
5. Special test: cough impulse → hernia?

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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 482 & 483)
 Palpation
Position:
Patient - lying supine (flat)
Doctor – beside the patient (sit or kneel so that your
forearm is horizontal and level with the anterior
abdominal wall)

✓ Ask the patient if they are aware of any areas

of abdominal pain (if present, examine these
areas last).
✓ Kneel beside the patient to carry out palpation
and observe their face throughout the
examination for signs of discomfort.

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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 482 & 483)
 Palpation
Superficial palpation of the abdomen
Lightly palpate each of the nine abdominal regions, assessing for clinical signs suggestive
of gastrointestinal pathology:
• Tenderness: note the abdominal region(s) involved and the severity of the pain.
• Rebound tenderness: The sudden withdrawal of manual pressure may cause a sharp
exacerbation of the pain
• Guarding: The tightening of the patient’s abdominal muscles in response to pressure,
indicates severe tenderness.
• Masses: large or superficial masses (e.g. hernias) may be noted on light palpation.

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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 482 & 483)
 Palpation
Deep palpation of the abdomen
Palpate each of the nine abdominal regions again, this time applying greater pressure to
identify any deeper masses. Warn the patient this may feel uncomfortable and ask
them to let you know if they want you to stop. You should also carefully monitor the
patient’s face for evidence of discomfort (as they may not vocalise this).

If any masses are identified during deep palpation, assess the following characteristics:

ONE HAND TWO HAND

Tenderness Fluctuancy test
Temperature
Size
Consistency
Surface
Margin
Mobility
Compressible
Reducible
Pulsability
+ Mass move with respiration?
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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 482 & 483)
 Acute Abdomen: The Examination
• Liver (hepatitis)
• Gall bladder (gallstones)
• Liver (hepatitis) • Stomach (peptic ulcer, • Spleen (rupture)
• Gall bladder (gallstones) gastritis) • Pancreas (pancreatitis)
• Transverse colon (cancer) • Stomach (peptic ulcer)
• Stomach (peptic ulcer, gastritis)
• Pancreas (pancreatitis) • Splenic flexure colon (cancer)
• Hepatic flexure colon (cancer) • Heart (MI) • Lung (pneumonia)
• Lung (pneumonia)

• Descending colon (cancer)

• Ascending colon (cancer,)
• Kidney (stone,
• Kidney (stone, hydronephrosis, hydronephrosis, UTI)
UTI)

• Appendix (Appendicitis)
• Caecum (tumour, volvulus, closed • Sigmoid colon (diverticulitis,
loop obstruction) colitis, cancer)
• Terminal ileum (crohns, mekels) • Ovaries/fallopian tube
• Ovaries/fallopian tube (ectopic, (ectopic, cyst, PID)
cyst, PID) • Ureter (renal colic)
• Ureter (renal colic)
• Small bowel
• Uterus (fibroid, cancer) (obstruction/ischaemia)
• Bladder (UTI, stone) • Aorta (leaking AAA)
• Sigmoid colon
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(diverticulitis)
 Palpation
Palpation of the normal solid viscera
The liver
1. Begin palpation in the right iliac fossa, starting at the edge of
the superior iliac spine
2. Ask the patient to take a deep breath and as they begin to do
this palpate the abdomen. *Feel for a step as the liver edge
passes below your hand during inspiration (a palpable liver edge
this low in the abdomen suggests gross hepatomegaly).
3. Repeat this process of palpation moving 1-2 cm superiorly from
the right iliac fossa each time towards the right costal margin.
4. As you get close to the costal margin (typically 1-2 cm below it)
the liver edge may become palpable in healthy individuals.

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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 484)
 Palpation
Palpation of the normal solid viscera
The spleen
1. Begin palpation in the right iliac fossa, starting at the edge of
the superior iliac spine
2. Ask the patient to take a deep breath and as they begin to do
this palpate the abdomen with your fingers aligned with the
left costal margin. Feel for a step as the splenic edge passes
below your hand during inspiration (the splenic notch may be
noted).
3. Repeat this process of palpation moving 1-2 cm superiorly from
the right iliac fossa each time towards the left costal margin.

In healthy individuals, you should not be able to palpate the

spleen. A palpable spleen at the edge of the left costal margin
would suggest splenomegaly (for the spleen to be palpable at this
location it would need to be approximately three times its normal
size).
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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 484)
 Palpation
Palpation of the normal solid viscera
Ballot the kidneys
1. Place your left hand behind the patient’s back, below the ribs
and underneath the right lumbar.
2. Then place your right hand on the anterior abdominal wall just
below the right costal margin in the right lumbar.
3. Push your fingers together, pressing upwards with your left
hand and downwards with your right hand.
4. Ask the patient to take a deep breath and as they do this feel
for the lower pole of the kidney moving down between your
fingers.
5. If a kidney is ballotable, describe its size and consistency.
6. Repeat this process on the opposite side to ballot the left
kidney.

In healthy individuals, the kidneys are not usually ballotable,

however, in patients with a low body mass index, the inferior pole
can sometimes be palpated during inspiration.
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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 484)
 Percussion
Percuss the liver
1. Percuss upwards 1-2 cm at a time from the right iliac
fossa (the same position used to begin palpation) towards
the right costal margin until the percussion note changes
from resonant to dull indicating the location of the lower
liver border.
2. Continue to percuss upwards 1-2 cm at a time until the
percussion note changes from dull to resonant indicating
the location of the upper liver border.
3. Use the knowledge of the upper and lower border of the
liver to determine its approximate size.

Percuss the spleen

Percuss upwards 1-2 cm at a time from the right iliac fossa
(the same position used to begin palpation) towards the left
costal margin until the percussion note changes from resonant
to dull indicating the location of the spleen (in the absence of
splenomegaly the spleen should not be identifiable using
percussion).

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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 485)
TRAUBE’S (SEMILUNAR) SPACE

• Anatomical markings: It is a crescent-shaped space, encompassed by

the lower edge of the left lung, the anterior border of the spleen, the left
costal margin and the inferior margin of the left lobe of the liver.
• Surface markings: left 6TH rib superiorly, the left anterior axillary line
laterally, and the left costal margin inferiorly.
• Splenomegaly is an important clinical sign (Normal spleen 125 mm)
• Percussion can be done in this space.
• Beneath Traube’s space lies the stomach, which produces a tympanic
sound on percussion.
• Dullness to percussion over Traube’s space may indicate splenomegaly,
although this can also be a normal finding after a meal or indicates left
pleural effusion.

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 Percussion
Assess shifting dullness
1. Percussion can also be used to assess for the presence of
ascites by identifying shifting dullness
2. Percuss from the umbilical region to the patient’s left
lumbar. If dullness is noted, this may suggest the
presence of ascitic fluid in the lumbar.
3. Whilst keeping your fingers over the area at which the
percussion note became dull, ask the patient to roll onto
their right side (towards you for stability).
4. Then repeat percussion over the same area.
5. If ascites is present, the area that was previously dull
should now be resonant (i.e. the dullness has shifted).

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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 485)
 Auscultation
Tool: stethoscope
Assess bowel sounds
1. Auscultate over at least two positions on the
abdomen to assess bowel sounds:
• Normal bowel sounds: low-pitched gurgles
that occur every few seconds
• Tinkling bowel sounds: high-pitched sound
• Hypoactive bowel sounds: one every three to
five minutes
• Absent bowel sounds: indicates that
peristalsis has ceased
2. Listen for bruits: Auscultate over
the aorta and renal arteries to
identify vascular bruits suggestive of turbulent
blood flow

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Browse’s Introduction to the Symptoms & Signs of Surgical Diseases 5th Edition (page 485)
APPROACH

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43
ABDOMINAL IMAGING

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 CHOLELITHIASIS

Abdominal X-ray:
❖ Gallstones are radiopaque only in 15-20% of cases
❖ May be laminated (lamellated): radiopaque outline with lucent
center
Ultrasound:
❖ echogenic focus within gallbladder lumen
❖ normally with prominent posterior acoustic
shadowing
❖ gravity-dependant movement is often seen with a45
change of patient position
ACUTE CHOLECYSTITIS

Ultrasound:
1) Sonographic Murphy sign: tenderness from pressure
of the ultrasound probe over the visualized gallbladder
2) Gallbladder wall thickening (>3 mm)
3) Pericholecystic fluid

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 ACUTE PANCREATITIS
Normal: Acute pancreatitis:

CT scan:
1) focal or diffuse parenchymal enlargement
2) changes in density because of edema
3) indistinct pancreatic margins owing to inflammation
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4) surrounding retroperitoneal fat stranding
 PERFORATION - Pneumoperitoneum

1) Double wall sign (also known as Rigler sign) 2) Football sign: massive pneumoperitoneum, where the
abdominal cavity is outlined by gas
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 PERFORATION - Pneumoperitoneum

4) Lucent liver sign: reduction of hepatic radiodensity on supine

radiograph when there is a collection of free intraperitoneal gas located
3) Falciform ligament sign: the falciform ligament being anterior to the liver.
outlined with free abdominal gas 5) Continuous diaphragm sign 49
SMALL BOWEL OBSTRUCTION

Abdominal X-ray:
1) Predominantly at center
2) Dilated loops of small
bowel proximal to the
Obstruction
3) Valvulae conniventes are
visible
4) Gas-fluid levels if the
study is erect

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LARGE BOWEL OBSTRUCTION

Abdominal x-ray:
1) Dilated proximal part
2) Collapsed distal colon: very few or no air-fluid levels are
found in the large bowel because water is reabsorbed
3) Rectum has little or no air

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SIGMOID VOLVULUS

Abdominal X-ray:
1. Ahaustral wall (A feature differentiating from cecal volvulus)
2. The lower end pointing to the pelvis
3. Coffee bean sign
4. Absent rectal gas

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CECAL VOLVULUS

Abdominal radiograph:
❖ Haustration is maintained
❖ Marked distension of a loop of large bowel with its long axis
extending from the right lower quadrant to the epigastrium
or left upper quadrant

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THANK YOU!

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