ACUTE ABDOMEN

PRESENTERS
1. NAKASULE HALIMA ABUBAKAR MBCHB IV
2. KEMIGISA ALLELUA MARGRET MBCHB IV
 Definition
• This is sudden severe abdominal pain which is of unclear etiology of
duration of less than 24 hours.
• The cause of acute abdomen remains a mystery (diffecult to understand)
even after examinations and baseline investigations until an exploratory
laparatomy is done then you can establish the actual cause.
• It is a surgical emergency
 The physiology of abdominal pain
• There are three types of abdominal pain :- visceral pain, somatic pain and referred pain.
1. Visceral pain: is deep, dull ,aching, cramping and poorly localized .it is stimulated by
stretching , distention or contraction of the gut .
2. Parietal /somatic pain: it is sharper and better localized .it is aggravated by stimulation
or irritation of the parietal peritoneum with movements , coughing.
3. Referred pain: it is pain felt over the site other than the primary noxious stimulus. It
occurs in the area supplied by the same neural segment as the involved organ .
For example:
--in appendicitis there is pain in the umblical region.
--biliary tract involvement there is right shoulder pain.
--small bowel involvement there is back pain.
 Layers of the abdominal wall
1. Skin (epidermis ,dermis, subcutaneous fat )
2. Superficial fascia: campers fascia
3. Deep fascia: scarpa fascia
4. External oblique
5. Internal oblique
6. Transversalis abdominis
7. Transversalis fascia
8. Supraperitoneal fat
9. Parietal peritoneum
 The four anatomical quadrants and their contents

Right upper quadrant left upper quadrant

1. Gall bladder 1.left lower part of the liver
2. Liver 2. upper lobe of the left kidney
3. Duodenum 3. splenic flexure of colon
4. Head of pancreas 4. sections of transverse, descending colon
5. Right adrenal gland 5. the stomach
6. Upper lobe of the right kidney 6. The spleen
7. Hepatic flexure of the organ 7. the pancreas
8. Section of ascending , transverse colon 8. the left adrenal gland
 Cont..
Right lower quadrant
1.lower lobe of right kidney
2. section of descending colon
3. Right fallopian tube in females
4. Right ovary in females
5. Part of uterus if enlarged
6. Right spermatic cord in male
7. Caecum
8. appendix
9. Right ureter
left lower quadrant
1. lower lobe of left kidney
2. part of the descending colon
3. left fallopian tube
4. left ovary
5. part of uterus if enlarged
6.left spermatic cord
7.sigmoid colon
8. left ureter
Subphrenic abscess
 Differentials of pain in those quadrants

• Right upper quadrant

• Gall bladder/biliary tract involvement eg
cholelithiasis ,choledocholithiasis
• Liver related like hepatitis, hepatic abcess, hepatic malignancy
• Myocardial infarction
• Renal related: pyelonephritis, nephrolithiasis, ureterolithiasis
• Appendicitis (retrocecal,
Right lower quadrant pain

1. Appendicitis
2. Intestinal obstruction /perforation
3. Diverticulitis, merkels
4. Ectopic pregnancy
5. Ovarian cyst or torsion
6. Salphingitis ,PID
7. Ureteral calculi, UTI
8. Endometriosis
Left upper quadrant

1. Pancreatitis
2. Splenic rupture, infarct ,aneurysm
3. Peptic ulcer
4. Gastritis, GERD,hiatus hernia, myocardial infarction .
5. Pneuonia ,pleurisy
6. Empyema,tumour,abscess
Left lower quadrant
• Leaking aneurysms
• Intestinal obstruction /perforation/volvulus
• Diverticulitis
• Psoas abscess
• Ectopic pregnancy
• Ovarian cyst
• Salphingitis
 CAUSES OF ACUTE ABDOMEN
These can be surgical and non-surgical causes Ischaemia
Surgical causes include; • Mesenteric ischaemia
1. Inflammation • Torsion of a viscus
• Inflammatory bowel disease
• Acute appendicitis
• Acute diverticulitis
Perforation
• Acute pancreatitis • Perforated peptic ulcer disease
• Acute cholecystitis • Perforated diverticular disease
• Acute cholangitis • Perforated appendix
• Meckel’s diverticulitis • Toxic megacolon with perforation
• Acute cholecystitis and perforation
2. Obstruction • Perforated oesophagus
• Intestinal obstruction • Perforated bladder
• Biliary colic • Perforation of a length of strangulated
• Ureteric colic bowel
• Acute retention of urine • Ruptured abdominal aortic aneurysm
CAUSES OF ACUTE ABDOMEN
Medical causes include;
Genitourinary
Cardiovascular • Urinary tract infection
• Myocardial ischaemia • Pyelonephritis
• Myocardial infarction (inferior)
Neurological
Gastrointestinal • Tabes dorsalis
• Gastritis
• Gastroenteritis Haematological
• Mesenteric adenitis • Sickle cell disease
• Hepatitis • Malaria
• Hepatic abscess • Hereditary spherocytosis
• Curtis–FitzHugh syndrome Endocrine
• Primary peritonitis • Diabetes mellitus
Abdominal wall conditions • Thyrotoxicosis
• Rectus sheath haematoma • Addison’s disease
CAUSES OF ACUTE ABDOMEN
• Metabolic
• Uraemia
• Hypercalcaemia
• Porphyria
• Infective
• Herpes zoster

• Gynaecological
• Ectopic pregnancy
• Ovarian cyst (Torsion, Rupture, Haemorrhage, infarction
Infection
• Pelvic inflammatory disease
• Fibroid degeneration
• Salpingitis
• Mittelschmerz
• Endometriosis
THE PHYSIOLOGY OF ABDOMINAL PAIN
• Abdominal pain is conveniently divided into visceral
or parietal components.
1. Visceral pain tends to be vague and poorly localized to the epigastrium,
periumbilical region, or hypogastrium, depending on its origin from the
primitive foregut, midgut, or hindgut
• It is usually the result of distention of a hollow viscus.
2. Parietal pain corresponds to the segmental nerve roots innervating the
peritoneum and tends to be sharper and better localized.
3. Referred pain is pain perceived at a site distant from the source of stimulus.
For example, irritation of the diaphragm may produce pain in the shoulder.
 THE PHYSIOLOGY OF ABDOMINAL PAIN
Locations of Referred Pain and Its Causes
Right Shoulder
• Liver
• Gallbladder
• Right hemidiaphragm
Left Shoulder
• Heart
• Tail of pancreas
• Spleen
• Left hemidiaphragm
Scrotum and Testicles
• Ureter
SOMATIC PAIN
• The parietal peritoneum covers the anterior
and posterior abdominal walls, the
undersurface of the diaphragm and the
pelvic cavity.
• It develops from the somato-pleural
layer of the lateral plate mesoderm
• Its nerve supply is therefore derived from
somatic nerves supplying the abdominal
wall musculature and the skin (T5–L2).
• The exception to this is the diaphragmatic
portion, which is supplied centrally by
afferent nerves in the phrenic nerve (C3–
C5), and peripherally in the lower six
intercostal and subcostal nerves.
• The parietal peritoneum is sensitive to
mechanical,
thermal or chemical stimulation, and
cannot be handled, cut or cauterized
painlessly.
• As a result of its innervation, when the
parietal peritoneum is irritated, there is
reflex
contraction of the corresponding segmental
area of muscle, causing rigidity of the
abdominal wall (guarding) and
hyperaesthesia of the overlying skin.
• When the diaphragmatic portion of the
parietal peritoneum is irritated peripherally,
there will be pain, tenderness and rigidity
in the distribution of the lower spinal
nerves
• When it is irritated centrally, pain is
referred to
the cutaneous distribution of C3, 4 and 5
(i.e. the shoulder area
• Somatic pain is classically described as
sharp
or knife-like in nature, and is usually well
localized to the affected area
 VISCERAL PAIN
• The visceral peritoneum forms a partial or
complete investment of the intra-abdominal
viscera.
• It is derived from the splanchno-pleural layer of
the lateral plate mesoderm, and shares its nerve
supply with the viscera (i.e. the autonomic
nerves).
• Visceral pain is mediated through the
sympathetic branches of the autonomic nervous
system, with afferent nerves joining the pre-
sacral and splanchnic nerves, which eventually
join thoracic (T6–T12) and lumbar (L1–L2)
segments of the spinal cord.
• The visceral peritoneum and the viscera are
insensitive to mechanical, thermal or chemical
stimulation, and can therefore be handled, cut
or cauterized painlessly.
• However, they are sensitive to tension, whether
due to overdistension or traction on
mesenteries, visceral muscle spasm and
• Visceral pain is typically described as dull and
deepseated.
• It is usually localized vaguely to the area
occupied
by the viscus during development, and is
referred to the overlying skin of the abdominal
wall according to the dermatome level with
the sympathetic supply, as mentioned
above.
• Therefore, pain arising from the intestine and
its
outgrowths (the liver, biliary system and
pancreas) is usually felt in the midline.
• Irritation of foregut structures is usually felt in
the epigastric area.
• Pain from midgut structures is felt around the
umbilicus.
• Pain from hindgut structures is felt in the
hypogastrium.
 History taking
• Where is the pain? (Site)
The patient may speak or point towards that point. You can use the nine abdominal
regions or the four quadrants
• What does pain feel like? (nature/character)
• Steady pain - inflammatory process
• Crampy pain - obstructive process
• Was onset of pain gradual or sudden?
• Sudden = perforation, hemorrhage, infarct
• Gradual = peritoneal irritation, hollow organ distension
 history
• As described in the patient’s own words they include:
• colicky pain – appendicitis, bowel obstruction
• nagging, grumbling pain- biliary colic and cholecystitis
• stabbing - abdominal aortic aneurysm
• burning, boring -- peptic disease
• gnawing - pancreatitis and ca pancreas
• Aching- ischeamia
 history
• Does pain radiate anywhere?
• Right shoulder, angle of right scapula -- gall bladder
• Around flank to groin = kidney, ureter
Nausea, vomiting, Bloody? “Coffee Grounds”? (associated symptoms)
• Is it mild, moderate or severe (intensity)
• What makes you feel better/worse? (precipitating and relieving factors)
• Change
• in urinary/bowel habits?
• In urine/stool appearance (meleana)?
• Females
• Last menstrual period?
• Abnormal bleeding?
 Relieving or precipitating factors
• Precipitated by food:- gastric ulcer
• Relieved by food-duodenal ulcer
• Relieved by defecation -constipation
• Micturition-urinary retension
• Sitting forward-pancreatitis
• Applying a warm/hot water bottle -musculoskeletal pain
Physical examination
• General Appearance
• Lies perfectly still  inflammation, peritonitis
• Restless, writhing  obstruction
• Abdominal distension?
• Vital signs
• Tachycardia ? Early shock (more important than BP)
• Rapid shallow breathing peritonitis
• Palpate each quadrant
• Work toward area of pain ( with warm hands)
• Patient on back, knee bent (if possible)
• Note tenderness, rigidity, involuntary guarding,voluntary guarding, masses

• Bowel Sounds
• Listen 1 minute in each quadrant (b4 feeling)
• Absent bowel sounds  ileus, peritonitis, shock
Investigations
• Blood tests:
• full blood count
• serum amylase - pancreatitis
• urea and electrolytes
• glucose
• blood group and cross match
• blood gases - adult respiratory distress syndrome, particularly in
pancreatitis
investigations
• Blood tests:
• pregnancy test, in women of child bearing age.
• liver function tests and calcium - pancreatitis and acute biliary disease
• clotting studies - acute pancreatitis, septicaemia and DIC, history of
bleeding disorders, on anticoagulant therapy, liver disease
investigations
• Urine tests:
• Dipstick test
• microscopy
• culture and sensitivity
• if ureteric colic then strain urine for stones
• pregnancy test, if a blood test is not available
investigations
• Radiology:
• chest radiology, erect - looking for gas under the diaphragm
• plain abdominal radiology, erect
• ultrasound, for example in suspected pancreatitis or gynaecological
pathology
• IVU - if suspecting renal / ureteric colic
• Others are ECG / cardiac enzymes if appropriate
 immediate management
1. Immediate insertion of a large bore iv and start with rather normal
saline or ringers lactate solution are used (for fluid and and electrolyte
correction) usual requirements is 2ml/kg/hour
2. Iv/im pain medication/analgesic
3. Nasogastric tube if vomiting or concerned about obstruction
4. Foleys catheter: for maintenance of adequate urine output (30ml/hour)
(0.5ml/kg/hour). to follow hydration status and obtain urinalysis
• 5. Antibiotic administration: Ampicillin, gentamicin, metronidazole,
ceftazidime, cefotaxime, if suspicious of inflammation or perforation
• 6. Defenitive treatment or emergency laparotomy
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