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ACUTE ABDOMEN
- Department of Surgery -
PRECEPTOR : dr. Andanu Indratnoto, Sp.B-
KBD
By : Soraya Olyfia (03010258)
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INTRODUCTION
Abdominal pain is a common complaint in all settings of
medical practice.
Abdominal pain may be symptom of severe, life
threatening disease or symptom of benign underlying
condition.
Many diseases with abdominal pain do not require surgical
treatment so the evaluation of patients with acute
abdominal pain must be methodical and careful.
An acute abdomen must be suspected even if the patient
has only mild or atypical complaints.
Proper management of patients with acute abdominal pain
requires a timely decision.
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DEFENITION

An acute abdomen denotes any sudden, spontaneous, both

traumatic and non-traumatic disorder whose chief manifestation
is in the abdominal area and for which urgent operation may be
necessary.

Because there is frequently a progressive underlying intra-

abdominal disorder, undue delay in diagnosis and treatment
adversely affects outcome.
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History Taking
+Abdominal Pain
Visceral
Mediated primarily by afferent C fibers located in the walls of hollow
viscera and in the capsules of solid organ.
Vague, deep-seated pain and poorly localized to the epigastrium,
periumbilical or hypogastrium region.
Elicited by distention, inflammation or ischemia or by direct
involvement of sensory nerves
Most often felt in midline because of the bilateral sensory supply to the
spinal cord.

Parietal
Mediated by both C and A delta nerve fibers
Corresponds to the segmental nerve roots innervating the peritoneum
The cutaneous distribution of parietal pain orresponds to the T6-L1
areas.
The somatic afferent fibers are directed to only one side of the nervous
system.
Acute, sharper, better-localized pain sensation.
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Referred
Noxious (cutaneous) sensation perceived of the site distand
from that of a strong primary stimulus.
Distorted central perception of the site of pain is due to the
confluence of afferent nerve fibers from widely disparate
areas within the posterior horn of the spinal cord.
For example : pain due to subdiaphragmatic irritation by
air, peritoneal fluid, blood or mass lesion is referred to the
shoulder via the C4-mediated nerve. Pain may also be
referred to the shoulder from supradiafragmatic lesions
such as pleurisy or lower lobe pneumonia. Posterolateral
right flank pain may be seen in retrocecal appendicitis.
Billiary pain may be perceived in the right scapular reg
+Abdominal Pain

Sensory Levels Associated with Visceral Structures

Visceral pain sites

+Abdominal Pain
+Abdominal Pain
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Spreading or shifting pain
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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 :
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Character of pain

The nature, severity, and periodicity of pain provide

useful clues to the underlying cause
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Other symptoms associated with abdominal pain :

Anorexia
Nausea
Vomitting
Constipation
Diarrhea
etc

Other specific symptom :

Jaundice : Hepatobiliary disorders
Hematochezia or hemtemesis : gastroduodenal lesion or
Mallory-Weiss syndrome
Hematuria : Ureteral colic or cystitis
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Other relevant aspects of the history :

Gynecologic history : menstrual history, vaginal discharge,
dysmenorrhea
Drug and smoking history : analgetics,oral contracetive,
anticoagulants, corticosteroid, narcotics
Family history
Past History
Travel history
Operation history
PHYSICAL
EXAMINATION

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PHYSICAL EXAMINATION
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INVESTIGATIVE STUDIES

Additional studies are worthwhile only if they are likely

to significantly alter or improve therapeutic decisions.

A more liberal use of diagnostic studies is justified in

elderly or seriously ill patients, in whom the history and
physical findings may be less reliable and an early
diagnosis vital to ensure a successful outcome.
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Laboratory Studies
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Imaging Studies
Plain Chest X-Ray Studies :
Preoperative assessment and may also demonstrate supra-
diaphragmatic conditions that simulate an acute abdomen (lower lobe
pneumonia or ruptured esophagus)
An elevated hemidiaphragm or pleural effusion may direct attention
to subphrenic inflamamatory lesions.
Plain Abdominal X-Ray Studies : bowel obstruction, peritoneal free air,
pneumoperitoneum in lateral decubitus positions, calcification
apendicoliths, gallstones, renal stones , pancreatitis calcification,
abdominal aortic calcification, etc.
Ultrasonography detecting gallstones, diameter of extrahepatic and
intrahepatic bile ducts, abnormalities in adnexa, uterus and ovaries,
intraperitoneal fluid.
CT-scan
Endoscopy
Paracentesis
Diagnostic Laparoscopy
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Differential Diagnosis
Based on etiology acute abdomen is classified into :
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Peritonitis
Pneumoperitoneum
Peritonitis is defined as inflammation of the serosal
membrane that lines the abdominal cavity and the
organs contained therein.

Depending on the underlying pathology, the resultant

peritonitis may be infectious or sterile (ie, chemical or
mechanical).

The inflammatory process may be localized (abscess)

or diffuse in nature.

Xray thickened abdominal wall with or without free

air.

Goal : target correction of the underlying process,

administration of systemic antibiotics and supportive
therapy to prevent secondary complication due to
organ system failure.
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PATHOPHYSIOLOGY
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Peritoneal infections are classified as :

Primary (ie, from hematogenous dissemination, usually in
the setting of immunocompromise, most often
spontaneous bacterial peritonitis caused by chronic liver
disease.
Secondary (ie, related to a pathologic process in a visceral
organ, such as perforation or trauma, including iatrogenic
trauma) the most common form
Tertiary (ie, persistent or recurrent infection after
adequate initial therapy). Often develops in the absence of
the original visceral organ pathology.
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Based on etiology, peritonitis is classified into :

Hollow viscus perforation
Acute diverticulitis, perforated peptic ulcer/gaster
perforation, perforated appendicitis, IBD perforation,
Meckel divertivulum, etc
Non-hollow viscus perforation
Acute pancreatitis , ruptured spleen, TB peritonitis,
Hepatic abcess, ruptured aorta abdominalis, ruptured
ovarium cyst, etc
+Hollow Viscus Perforation
free air under
diaphragm
+ACUTE DIVERTICULITIS
80% of affected patients are older than 50 yo.
Presents as a spectrum of disease from mild abdominal
discomfort to gross fecal peritonitis.
Present with constant, dull, left lower quadrant pain and
fever, may complaint of constipation or obstipation.
PF : left lower quadrant tenderness, a left lower quadrant
mass, localized peritoneal sign may be present. In severe
cases, generalized peritonitis may be present.
CT is reliable in confirming the diagnosis (sensitivity of
97%), can be used to determined the severity of
diverticulitis by using Hinchey grading system.
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Hinchey Grading system
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Perforated Peptic Ulcer

Presents with : sudden onset of severe, diffuse,

excruciating abdominal pain.
PF : reveals peritonitis, with rebound tenderness,
guarding or abdominal rigidity.
Radiology :
Xray : Pneumoperitoneum
CT : edema in the regio of the gastric antrum and
duodenum associated with extraluminal air.

Laparotomy is acceptable as the primary diagnostic

maneuver in such patients especially in patients with
diffuse peritonitis and hemodynamic collapse
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Perforated appendicitis
Appendicitis is an acute inflammatory process of the
appendix resulting from obstruction of the lumen with
subsequent bacterial invasion, distension, ischemia and
ultimate rupture.
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Present with : migrating pain, anorexia, nausea and

vomiting.
PF : Low grade fever, RLQ tenderness, positive Rovsing
sign, Blumberg etc with guarding and rebound as the
process progresses (perforation)
Laboratory : leukocytosis with neutrophilia
Most significant complication of acute appendicitis is
perforation which leads into peritonitis and sepsis
The mortality rate of perforated appendicitis is 1.66%, 7
times greater than that of patients ongoing appendectomy
for simple acute appendicitis (0.24%) and 12 times greater
than that of appendectomy for a normal appendix (0.14%).
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There are few reliable clinical features that distinguish non-perforated from
perforated appendicitis.

Sign of perforated appendicitis :

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Perforated Ileum et Causa Typhoid
Fever
Typhoid fever, a severe febrile illness caused by a gram
negative bacillusSalmonella typhi.
Complication : Intestinal perforation (on ilealcecal junction)
high mortality and morbidity
The most serious complications of typhoid fever are
gastrointestinal hemorrhage (2%10%) and perforation
(1%3%). They occur toward the end of the second week
or during the third week of the disease.
Intestinal perforation is one of the principal causes of
death.
The clinical manifestations are indistinguishable from
those of acute appendicitis, with pain, tenderness, and
rigidity in the right lower quadrant.
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Perforation of Inflammatory
Bowel Disease
Inflammatory bowel disease (IBD) is an immune-mediated chronic
intestinal condition. Ulcerative colitis (UC) and Crohn's disease (CD) are
the two major types of IBD.

The peak age of onset of UC and CD is between 15 and 30 years. A

second peak occurs between the ages of 60 and 80.

Pathophysiology :

UC involves rectum and extends proximally to involve all or part of

colon

CD affect any part of GI tract from mouth to anus

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Ulcerative Colitis

Major symptoms : Diarrhea, rectal bleeding, tenesmus, passage of mucus, crampy abdominal pain. Colonic
motility is altered as the disease progressing. Severe condition liquid stool containing blood, pus and fecal
matter accompanied by systemic symptom.

Abdominal pain is not a prominent symptom, some just experience vague lower abdominal discomfort or mild
central abdominal cramping.

Perforation peritoneal signLaparotomy

Diagnostic :
Lab : rise CRP, platelet count, ESR and decrease in Hb, leukocytosis.
Radiography : thickened mucosa, ulcer, collar button ulcer (deeper ulcer), edematous and thickeded
haustral fold, shorten and narrowed colon]
CT scan : is not too helpful. Mural thickening, increase perirectal, presacral fat, adenopathy.
Endoscopy :
Mild : erythema, decrease vascular pattern, mild friability.
Moderate : marked erythema, absent vascular pattern, friability and erosions.
Severe disease : spontaneous bleeding and ulceration.

Unlike with Crohn disease, surgery offers a therapeutic option in ulcerative colitis.
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Crohn Disease

Site of disease influence the clinical manifestation

Ileocolitis : RLQ colicky pain, precedes and relived by defecation , diarrhea, fever, weight loss, palpated inflammatory mass.
Jejunoileitis : diarrhea, malabsorption and steatorrhea which lead to anemia, hypoalbuminemia, hypocalcemia,
hpomagnesemia, coagulopathy and hyperoxaluria.
Colitis and Perianal disease : low grade fevers, malaise, diarrhea, crampy abdominal pain, hematochezia. Colonic disease
may fistulize into stomach or duodenum, causing feculent vomiting, malabsorption.
Gastroduodenal disease : nausea, vomiting, epigastric pain may lead into chronic gastric

Perforation Peritoneal sign outlet obstruction laparotomy

Diagnostic :
Lab : Elevated ESR, CRP,, if severe hypoalbuminemia, anemia and leukocytosis
Endoscopic : rectal sparing, apthous ulceration, fistula and skip lesions
Radiographic : thickened folds, apthous ulceration, cobblestoning, strictures, fistula, inflammatory
masses and abcesses may be detected.
CT
MRI

Surgery in Crohn disease is frequently required to address complications of stricturing, penetrating, or

fistulizing disease. Because recurrence at anastomotic sites is common, surgery is not recommended as a
primary treatment strategy.
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Meckel Diverticulum
Meckel diverticulum is a congenital anomaly of the GI tract in which an outpouching portion of the intestine (> terminal ileum),
derived from the fetal yolk stalk, contains gastric or pancreatic tissue which can secrete enzyme that can erode mucosal wall.

Congenital anomaly of GI tract - failure or incomplete vitelline duct obliteration

Bleeding associated with Meckels diverticulum is usually the result of ileal mucosal ulceration that occurs adjacent to acid-
producing, heterotopic gastric mucosa located within the diverticulum. Intestinal obstruction associated with Meckels
diverticulum can result from several mechanisms:
1. Volvulus of the intestine around the fibrous band attaching the diverticulum to the umbilicus
2. Entrapment of intestine by a mesodiverticular band
3. Intussusception with the diverticulum acting as a lead point
4. Stricture secondary to chronic diverticulitis

Clinical presenting : asymptomatic abdominal pain, nausea, vomit, intestinal bleeding (<18yo), intestinal obstruction (>30yo).

Complication : diverticulitis, intussusception, perforation and obstruction.

Diagnostic :
Usually discovered incidentally, radiography, during endoscopy or during surgery.
Radionuclide scans (99mTc-pertechnetate) can be helpful if the diverticulum consist .ectopic gastric mucosa that capable of uptake of the tracer. (accuracy
90%), angiography to localize the site of bleeding.

The surgical treatment of symptomatic Meckels diverticula should consist of diverticulectomy with removal of associated bands
connecting the diverticulum to the abdominal wall or intestinal mesentery.
+NON-HOLLOW VISCUS
PERFORATION
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Acute Pancreatitis
Present with : acute pain in the episgastrium that is constant,
frequently described as boring pain through the back or left
scapular, fever, anorexia, nausea and vomiting.
Patients usually more comfortable sitting upright, leaning
forward slightly .
PF : tachycardia, tachypnea, hypoactive bowel sounds,
tenderness to percussion and palpation in the epigastrium,
abdominal rigidity. Rarely, patients + flank or periumbilical
ecchymoses pancreatic necrosis with hemorrhage.
Lab : Leukocytosis (12.000 to 20000/mm3), elevated serum
and urine amylase levels, abnormal serum electrolyte,
calcium, blood glucose levels, liver biochemical test and ABG.
USG may identify gallstones as a cause of pancreatitis. CT is
reserved for severe or complicated pancreatitis.
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Although most cases of acute pancreatitis are self-limited,

as many as 20% of patients have severe disease with local
or systemic complications, including hypovolemia, and
shock, renal failure, liver failure and hypocalcemia.
A minority of patients with severe acute pancreatitis
present with a profound intra-abdominal catastrophe,
usually caused by thrombosis of the middle colic artery or
right colic artery, which travels in proximity to the head of
pancreas, with resulting colonic infarction.
This process may not be seen clearly on CT scans obtained
early in the course of disease and should be suspected in
any case marked by rapid hempdynamic collapse. Such
patients require immediate laparatomy.
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Abdominal Aortic Aneurysm
Rupture of an abdominal aortic aneurysm is heralded
by the sudden onset of acute, severe abdominal pain
localized to the mid-abdomen or paravertebral or flank
areas. The pain is tearing in nature and associated with
prostration, lightheadedness and diaphoresis.

If the patient survives transit to the hospital, shock is

the most common presentation.

Physical examination reveals a pulsatile, tender

abdominal mass in about 90% of cases. The classic
triad of hypotension, a pulsatile mass and abdominal
pain is present in 75% of cases and mandates
immediate surgical intervention.
+Obstruction

An interruption in the forward flow of intestinal contents.

Etiology :
Intramural : chrons disease, tumor,
carcinoma, limfoma, stricture, ileus, intussuception
Extramural : volvulus, adhesion, hernia,
tumor compression
Intraluminal : fecal impaction, ascarys
ball, gallstone ileus

The clinical presentation : nausea and emesis, colicky

abdominal pain, and a failure to pass flatus or bowel
movements.
The classic physical examination findings of abdominal
distension, tympany to percussion, and high-pitched
bowel sounds suggest the diagnosis

Management of uncomplicated obstructions includes

fluid resuscitation with correction of metabolic
derangements, intestinal decompression, and bowel rest.
Evidence of vascular compromise or perforation, or
failure to resolve with adequate bowel decompression is
an indication for surgical intervention.
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Small Bowel Obstruction

SBOs can be partial or complete, simple (ie,

nonstrangulated) or strangulated.

Strangulated obstructions are surgical emergencies.

SBO accounts for 20% of all acute surgical admissions.

Etiology : post-surgical adhesion, incarcerated groin

hernia, malignant tumor, inflammatory bowel disease,
volvulus, etc.

Pain on central and mid abdominal that tends to be

colicky (cramping and intermittent), spasm lasting for a
few minutes, vomitting occurs before constipation.
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Some signs and symptoms associated with SBO include the following:
Nausea
Vomiting - Associated more with proximal obstructions
Diarrhea - An early finding
Constipation - A late finding, as evidenced by the absence of flatus or bowel movements
Fever and tachycardia - Occur late and may be associated with strangulation
Previous abdominal or pelvic surgery, previous radiation therapy, or both - May be part of the patient's medical
history
History of malignancy - Particularly ovarian and colonic malignancy

Physical examination :
Abdominal distention (>>distal bowel)
Hyperactive bowel sound (early finding)
Hypoactive bowel sound (late finding)
Rectal Examination : Gross or occult blood Strangulation or malignancy, masses
obturator hernia
Intestinal ischemia : fever (>1000F), tachycardia (>100bpm), peritoneal signs

Radiology finding : Dilated small bowel, fighting loops, little gas in

colon, esp rectum
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Large Bowel Obstruction
The most common causes of adult LBO are as follows :
Neoplasm
Obstructions caused by tumors tend to have a gradual onset
and result from tumor growth narrowing the colonic lumen.
Diverticulitis
Diverticulitis is associated with muscular hypertrophy of the
colonic wall. Repetitive episodes of inflammation cause the
colonic wall to become fibrotic and thickened, leading to
luminal narrowing.
Volvulus
A colonic volvulus results when the colon twists on its
mesentery, which impairs the venous drainage and arterial
inflow. Symptoms of this condition are usually abrupt. The
cecum and sigmoid colon are most commonly affected. Volvulus
typically occurs in elderly, debilitated individuals; patients
living in an institutionalized setting; or patients with a history
of chronic constipation.Volvulus may also be seen during
pregnancy, most commonly occurring in the third trimester
when the gravid uterus displaces the colon.
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Intussusception
Intussusception is primarily a pediatric disease; however, it is estimated that between 5%
and 16% of all intussusceptions in the Western world occur in adults. Two thirds of adult
intussusception cases are caused by tumors. Two main types of intussusception affect the
large bowel: enterocolic and colocolic.
Enterocolic intussusceptions involve both the small bowel and the large bowel. These are
composed of either ileocolic intussusceptions or ileocecal intussusceptions, depending on
where the lead point is located. Colocolic intussusceptions involve only the colon. They
are classified as either colocolic or sigmoidorectal intussusceptions

In large bowel obstruction the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs
earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small
bowel obstruction.

Radiologic finding : Dilated colon to point of obstruction, little or no air in sigmoid/rectum, little or no gas in
small bowel if ileocecal valve remains competent.
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Vascular Problem
Volvulus
Ischemic mesenteric artery
Strangulated incarcerated hernia
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Strangulated Hernia

Hernia is the protrusion of a structure or organ through

the tissues that normally contain it.

A strangulated hernia the blood supply to the

herniated structure is compromised Gangrene may
occur if the vascular compromised is not relieved.

A strangulated hernia is a life-threatening situation

requiring emergency treatment and surgical
intervention.

All strangulated hernias are irreducible or incarcerated,

but not all irreducible or incarcerated hernias are
strangulated
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Hernia with a small neck or opening and a large sac

have a tendency to strangulate.

Femoral hernia which has a narrow neck or opening are

frequently incarcerate. Umbilical hernias in adults often
incarcerate with strangulation occurring in 20% to 30%
of adult umbilical hernias. Ulceration and perforation
can also occur in adults with umbilical hernias.

If strangulation is present , the patient may present

with pain, distention, peritonitis, vomiting, fever and
sepsis.
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Physical examination may reveal for any bulges or masses.

In such cases, leukocytosis with a left shift is often present,
although it may not occur in geriatric patients. Dehydration
with electrolyte abnormalities and an elevated blood urea
nitrogen also occurs frequently in incarceration or
strangulation.
The patients with strangulated hernia requires :
Aggressive resuscitation with fluids and blood
Emergent surgical consultation for operative intervention
Gastric decompression with a nasogastric tube is appropriate if
bowel obstruction is present.
Broad-spectrum antibiotics are also adviced in the acutely ill or
potentially septic patients.
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Acute Mesenteric Ischemia

Acute mesenteric ischemia can result from occlusion of

a mesenteric vessel arising from an embolus, which may
emanate from an atheroma of the aorta or cardiac mural
thrombus or from primary thrombosis of a mesenteric
vessel, usually at a site of atherosclrerotic stenosis.

>>superior mesenteric artery

Nonocclusive mesenteric ischemia results from

inadequate visceral perfusion and can also lead to
intestinal ischemia and infarction. Such cases are
usually consequent to catastrophic systemic illnesses
such as cardiogenic or septic shock.
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The hallmark of the diagnosis of acute mesenteric

ischemia :
Abrupt onset
Intense cramping epigastric
Periumbilical pain
Other symptoms : diarrhea, vomiting, bloating, melena

Shock is present about 25% of cases.

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Diagnostic :
CT best initial diagnostic test
Mesenteric angiography useful for determining the cause of
intestinal ischemia and defining the extent of vascular disease

Management :
Patients with acute embolic or thrombotic intestinal ischemia
should be referred for immediate revascularization and bowel
resection.
Patients with nonocclusive mesenteric ischemia are best
managed by treatment of the underlying shock state.
Transcatheter vasodilator therapy may be helpful for patients
who are found to have vasospasm on visceral arteriography.
For those with persistent symptoms, laparotomy for resection
of infracted intestine may necessary
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Preparation for Emergency
Operation
IV access
Antibiotic infusion (common bacteria in acute abdominal
emergencies are gram-negative enteric organism and
anaerobes).
Nasogastric tube (for hematemesis or copious vomiting
patients, suspected bowel obstruction or severe paralytic
ileus to prevent aspiration)
Foley catheter bladder drainage

Parenteral analgesics should not be withheld after initial

assessment- abdominal masses may become obvious once
rectus spasm is relieved. Pain that persists in spite of adequate
doses of narcotics suggests a serious condition often requiring
operative correction.
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Indications for urgent operation in
Patients with an acute abdomen
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