Acute Abdomen

YIN Detao MD Department of General Surgery, the First Affiliated Hospital of ZhengZhou University

Term
The term acute abdomen denotes any

sudden nontraumatic disorder whose chief manifestation is in the abdominal area and for which urgent operation may be necessary.

The approach to a patient with acute abdomen must be orderly and thorough. Acute abdomen must be suspected even if the patient has only mild or atypical complaints. The history and physical examination should suggest the probable causes and guide the choice of diagnostic studies.

一 . HISTORY

( 一 ). Abdominal Pain
presenting feature of acute abdomen.

 Pain is usually the predominant and

1. Location of Pain:
 Visceral pain is elicited either by distention,

inflammation, or ischemia stimulating the receptor neurons or by direct involvement of sensory nerves.  The centrally perceived sensation is generally slow in onset, dull, poorly localized, and protracted. Parietal pain is responsible for the transmission of more acute, sharper, better-localized pain sensation.  So parietal pain is more easily localized than visceral pain.

Abdomen pain may be referred or may

shift to sites far removed from the primarily affected organs. The term referred pain denotes noxious sensations perceived at a site distant from the site of a strong primary stimulus.

Pain may be referred to the shoulder

from lesions such as pleurisy or basal pneumonia, especially in young patients. Although more often perceived in the right scapular region, referred biliary pain may mimic angina pectoris if it is felt in the epigastric or left shoulder areas.

Spreading or shifting pain parallels the

course of the underlying condition. Beginning classically in the epigastric or periumbilical region, the incipient visceral pain of acute appendicitis later shift to become sharper parietal pain in the right lower quadrant.

The location of pain serves only as

rough guide to the diagnosis and typical descriptions are reported in only two-thirds of cases.

2.Mode of onset and progression of pain:
The mode of onset of pain reflects the

nature and severity of the inciting process. Onset may be explosive (within seconds), rapidly progressive (within1-2 hours), or gradual (over several hours).

A less dramatic clinical picture is

steady mild pain becoming intensely centered in a well-defined area within 1-2 hours, especially in acute cholecystitis, acute pancreatitis, strangulated bowel, renal or ureteral colic, etc.

3. Character of pain:
The nature, severity, and periodicity of

pain provide useful clues to the underlying cause. Steady pain is most common.

 Agonizing pain denotes serious or advanced

disease. Colicky pain is usually promptly alleviated by analgesics.  Nonspecific abdominal pain is usually mild, but mild pain may also be found with perforated ulcers or mild acute pancreatitis.  Past episodes of pain and factors that aggravate or relieve pain should be noted.

( 二 ). Other symptoms associated with abdominal pain

1. Vomiting:
Pain in acute surgical abdomen usually

precedes vomiting;in medical conditions, the reverse is true. Severe incontrollable retching provides temporary pain relief a moderate attacks of pancreatitis. The absence of bile in the vomitus is a feature of pyloric stenosis.

2. Constipation:
Constipation itself is hardly an absolute

indicator of intestinal obstruction. However, obstipation strongly suggests mechanical bowel obstruction if there is progressive painful abdominal distention or repeated vomiting.

3. Diarrhea:
Blood-stained diarrhea suggests

ulcerative colitis, crohn’s disease, or bacillary or amebic dysentery.

4. Specific gastrointestinal symptoms:
These are extremely helpful if present.

Jaundice suggests hepatobiliary disorders; hematuria, ureteral colic or cysititis.

( 三 ). Other relevant aspects of history

1. Menstrual history:
The menstrual history is crucial to the

diagnosis of ectopic endometriosis.

pregnancy

and

2. Drug history:
The drug history is important not only

in perioperative management but also because it may offer a diagnostic clue.

3. Family history:
The family history often provides the

best information about medical causes of acute abdomen.

4. Travel history:
 A travel history may raise the

possibility of amebic liver abscess, malarial spleen, tuberculosis, etc.

二 . Physical examination

1. General observation:
General observation affords a fairly

reliable indication of the severity of the clinical situation.

2. Systemic signs:
Systemic signs usually accompany

rapidly progressive or advanced disorders associated with acute abdomen. Extreme pallor, tachycardia, tachypnea, and sweating suggest major intra-abdominal hemorrhage.

3. Fever:
Low-grade fever is common in

inflammatory conditions such as acute cholecystitis, and appendicitis. High fever with lower abdominal tenderness in a young woman without signs of systemic illness suggests acute salpingitis.

4. Examination of abdomen
Inspection of abdomen:
The abdomen should be carefully inspected before palpation.

Auscultation of abdomen:
Auscultation of the abdomen should also precede palpation. An abdomen that is silent except for infrequent tinkly or squeaky sounds marks late bowel obstruction or diffuse peritonitis.

Percussion of abdomen:
With a perforated viscus, free air accumulating under the diaphragm may efface normal liver dullness.

Palpation of abdomen:
Palpation is performed with the patient resting in a comfortable supine position. If there is voluntary spasm, the muscle will be felt to relax when the patient inhales deeply through the mouth.

Tenderness that connotes localized peritoneal

inflammation is perhaps the most important finding in patients with acute abdomen. Compared with the degree of pain, unexpectedly little and only poorly localized tenderness is elicited in uncomplicated hollow viscus obstruction.

5. Abdominal masses

Abdominal masses are usually detected by deep palpation.

Superficial lesions such as a distended

gallbladder or appendiceal abscess are often tender and have discrete borders. Deeper masses may be adherent to the posterior or lateral abdominal wall. As a result, their borders are ill-defined, and only dull pain may be elicited by palpation.

三 . Diagnostic imaging

The role of the radiologist in the

evaluation of the patient with an acute abdomen has evolved greatly in the past decade. Moreover, CT and ultrasonography play an increasing role in the evaluation of this complex, emergent clinical problem.

四 . Treatment

1. Nonoperative treatment:
General supportive therapy; Antibiotics.

2. Operative treatment:

If the nonoperative treatment is inefficient, then we need operation.

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