Acute Abdomen

Prof Dr/ Mohamed Mahmoud Ali

Acute abdominal pain
Acute abdomen can be defined as severe, persistent
abdominal pain of sudden onset that is likely to
require surgical intervention to treat its cause. The pain may
frequently be associated
with nausea and vomiting, abdominal distention, fever and
signs of shock. One of the most common conditions
associated with acute abdominal pain is acute appendicitis.
Selected causes :
 Traumatic: blunt or perforating trauma to the stomach, bowel, spleen, liver,
or kidney
 Inflammatory:
 Infections such
as appendicitis, cholecystitis, pancreatitis, pyelonephritis, Peritonitis, pelvic
inflammatory disease, hepatitis, mesenteric adenitis, or a
subdiaphragmatic abscess
 Perforation of a peptic ulcer, a diverticulum, or the caecum
 Complications of inflammatory bowel disease such as Crohn's
disease or ulcerative colitis
 Mechanical:
 Small bowel obstruction secondary to adhesions caused by previous
surgeries, intussusception, hernias, benign or malignant neoplasms
 Large bowel obstruction caused by colorectal cancer, inflammatory bowel
disease, volvulus, fecal impaction or hernia
 Vascular: occlusive intestinal ischemia, usually caused by thromboembolism of
the superior mesenteric artery .
By system
A more extensive list includes the following :
 Gastrointestinal
 GI tract
 Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn's
disease, ulcerative colitis, microscopic colitis
 Obstruction: hernia, intussusception, volvulus, post-surgical adhesions, tumors,
severe constipation, hemorrhoids
 Vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina,
blood vessel compression (such as celiac artery compression syndrome), superior
mesenteric artery syndrome, postural orthostatic tachycardia syndrome
 Digestive: peptic ulcer, lactose intolerance, celiac disease, food allergies, indigestion
 Glands
 Bile system
 Inflammatory: cholecystitis, cholangitis
 Obstruction: cholelithiasis, tumours
  Liver
 Inflammatory: hepatitis, liver abscess
 Pancreatic
 Inflammatory: pancreatitis
 Renal and urological
 Inflammation: pyelonephritis, bladder infection
 Obstruction: kidney stones, urolithiasis, urinary retention, tumours
 Vascular: left renal vein entrapment
 Gynaecological or obstetric
 Inflammatory: pelvic inflammatory disease
 Mechanical: ovarian torsion
 Endocrinological: menstruation, Mittelschmerz
 Tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer
 Pregnancy: ruptured ectopic pregnancy, threatened abortion
 Abdominal wall
 muscle strain or trauma
 muscular infection
 neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve
entrapment syndrome (ACNES), tabes dorsalis
 Referred pain
 from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
 from the spine: radiculitis
 from the genitals: testicular torsion
 Metabolic disturbance
 uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal
insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal
 Blood vessels
 aortic dissection, abdominal aortic aneurysm
 Immune system
 sarcoidosis
 vasculitis
 familial Mediterranean fever
 Idiopathic
 irritable bowel syndrome (IBS)(affecting up to 20% of the population, IBS is the most
common cause of recurrent and intermittent abdominal pain)

By location
The location of abdominal pain can provide information about what may be causing the pain. The
abdomen can be divided into four regions called quadrants. Locations and associated conditions
include:
 Diffuse
 Peritonitis
 Vascular: mesenteric ischemia, ischemic colitis, Henoch-Schonlein purpura, sickle cell
disease, systemic lupus erythematosus, polyarteritis nodosa
 Small bowel obstruction
 Irritable bowel syndrome
 Metabolic disorders: ketoacidosis, porphyria, familial Mediterranean fever, adrenal crisis
 Epigastric
 Heart: myocardial infarction, pericarditis
 Stomach: gastritis, stomach ulcer, stomach cancer
 Pancreas: pancreatitis, pancreatic cancer
 Intestinal: duodenal ulcer, diverticulitis, appendicitis
 Right upper quadrant
 Liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess
 Gallbladder and biliary tract: inflammation, gallstones, worm infection, cholangitis
 Colon: bowel obstruction, functional disorders, gas accumulation, spasm,
inflammation, colon cancer
 Other: pneumonia, Fitz-Hugh-Curtis syndrome
 Left upper quadrant
 Splenomegaly
 Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation,
colon cancer
 Peri-umbilical (the area around the umbilicus, aka the belly button)
 Appendicitis
 Pancreatitis
 Inferior myocardial infarction
 Peptic ulcer
 Diabetic ketoacidosis
 Vascular: aortic dissection, aortic rupture
 Bowel: mesenteric ischemia, Celiac disease, inflammation, intestinal spasm, functional
disorders, small bowel obstruction
 Lower abdominal pain
 Diarrhea
 Colitis
 Crohn's
 Dysentery
 Hernia
 Right lower quadrant
 Colon: intussusception, bowel obstruction, appendicitis (McBurney's point)
 Renal: kidney stone (nephrolithiasis), pyelonephritis
 Pelvic: cystitis, bladder stone, bladder cancer, pelvic inflammatory disease, pelvic pain
syndrome
 Gynecologic: endometriosis, intrauterine pregnancy, ectopic pregnancy, ovarian
cyst, ovarian torsion, fibroid (leiomyoma), abscess, ovarian cancer, endometrial cancer
 Left lower quadrant
 Bowel: diverticulitis, sigmoid colon volvulus, bowel obstruction, gas accumulation, Toxic
megacolon
 Right low back pain
 Liver: hepatomegaly
 Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection
 Left low back pain
 Spleen
 Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection
 Low back pain
 kidney pain (kidney stone, kidney cancer, hydronephrosis)
 Ureteral stone pain
Pathophysiology

Abdominal pain can be referred to as visceral pain or peritoneal pain. The contents of
the abdomen can be divided into the foregut, midgut, and hindgut . The foregut contains
the pharynx, lower respiratory tract, portions of the esophagus, stomach, portions of the
duodenum (proximal), liver, biliary tract (including the gallbladder and bile ducts), and
the pancreas.The midgut contains portions of the duodenum (distal), cecum, appendix,
ascending colon, and first half of the transverse colon. The hindgut contains the distal
half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal
canal.

Each subsection of the gut has an associated visceral afferent nerve that transmits
sensory information from the viscera to the spinal cord, traveling with the autonomic
sympathetic nerves.The visceral sensory information from the gut traveling to the spinal
cord, termed the visceral afferent, is non-specific and overlaps with the somatic afferent
nerves, which are very specific. Therefore, visceral afferent information traveling to the
spinal cord can present in the distribution of the somatic afferent nerve; this is
why appendicitis initially presents with T10 periumbilical pain when it first begins and
becomes T12 pain as the abdominal wall peritoneum (which is rich with somatic afferent
nerves) is involved.

Diagnosis
A thorough patient history and physical examination is used to better understand the underlying
cause of abdominal pain
The process of gathering a history may include:
 Identifying more information about the chief complaint by eliciting a history of present
illness; i.e. a narrative of the current symptoms such as the onset, location, duration,
character, aggravating or relieving factors, and temporal nature of the pain. Identifying
other possible factors may aid in the diagnosis of the underlying cause of abdominal
pain, such as recent travel, recent contact with other ill individuals, and for females, a
thorough gynecologic history.
 Learning about the patient's past medical history, focusing on any prior issues or surgical
procedures.
 Clarifying the patient's current medication regimen, including prescriptions, over-the-
counter medications, and supplements.
 Confirming the patient's drug and food allergies.
 Discussing with the patient any family history of disease processes, focusing on
conditions that might resemble the patient's current presentation.
 Discussing with the patient any health-related behaviors (e.g. tobacco use, alcohol
consumption, drug use, and sexual activity) that might make certain diagnoses more
likely.
 Reviewing the presence of non-abdominal symptoms (e.g., fever, chills, chest
pain, shortness of breath, vaginal bleeding) that can further clarify the diagnostic picture.
  Using Carnett's sign to differentiate between visceral pain and pain originating in the
muscles of the abdominal wall.
After gathering a thorough history, one should perform a physical exam in order to identify
important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung
exam, thorough abdominal exam, and for females, a genitourinary exam.
Additional investigations that can aid diagnosis include:
 Blood tests including complete blood count, basic metabolic panel, electrolytes, liver
function tests, amylase, lipase, troponin I, and for females, a serum pregnancy test.
 Urinalysis
 Imaging including chest and abdominal X-rays
 Electrocardiogram
If diagnosis remains unclear after history, examination, and basic investigations as above, then more
advanced investigations may reveal a diagnosis. Such tests include:
 Computed tomography of the abdomen/pelvis
 Abdominal or pelvic ultrasound
 Endoscopy and/or colonoscopy

Management

The management of abdominal pain depends on many factors, including the etiology of the
pain. In the emergency department, a person presenting with abdominal pain may initially
require IV fluids due to decreased intake secondary to abdominal pain and possible emesis or
vomiting.Treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and
opioid medications (morphine, fentanyl). Choice of analgesia is dependent on the cause of the
pain, as ketorolac can worsen some intra-abdominal processes. Patients presenting to the
emergency department with abdominal pain may receive a "GI cocktail" that includes an antacid
(examples include omeprazole, ranitidine, magnesium hydroxide, and calcium chloride) and
lidocaine. After addressing pain, there may be a role for antimicrobial treatment in some cases
of abdominal pain. (Buscopan) is used to treat cramping abdominal pain with some
success.Surgical management for causes of abdominal pain includes but is not limited
to cholecystectomy, appendectomy, and exploratory laparotomy .