Acute Abdomen

Acute Abdomen

 Anatomy review
 Non-hemorrhagic abdominal pain
 Gastrointestinal hemorrhage
 Assessment
 Management
Abdominal Anatomy
Review
 Abdominal Cavity

 Superior border = diaphragm

 Inferior border = pelvis
 Posterior border = lumbar spine
 Anterior border = muscular
abdominal wall
 Peritoneum

 Abdominal cavity lining

 Double-walled structure
» Visceral peritoneum
» Parietal peritoneum
 Separates abdominal cavity into two parts
» Peritoneal cavity
» Retroperitoneal space
 Primary GI Structures
 Mouth/oral cavity
» Lips, cheeks, gums, teeth, tongue
 Pharynx
» Portion of airway between nasal cavity and
larynx
 Primary GI Structures

 Esophagus
» Portion of digestive
tract between
pharynx and stomach
 Stomach
» Hollow digestive
organ
» Receives food from
esophagus
 Primary GI Structures
 Small intestine
» Between stomach and cecum
» Composed of duodenum,
jejunum and ileum
» Site of nutrient absorption
into body
 Large intestine
» From ileocecal valve to anus
» Composed of cecum, colon,
rectum
» Recovers water from GI tract
secretions
 Accessory GI Structures
 Salivary glands
» Produce, secrete saliva
» Connect to mouth by ducts
 Accessory GI Structures
 Liver
» Large solid organ in right upper quadrant
» Produces, secretes bile
» Produces essential proteins
» Produces clotting factors
» Detoxifies many substances
» Stores glycogen
 Gallbladder
» Sac located beneath liver
» Stores and concentrates bile
 Accessory GI Structures

 Pancreas
» Endocrine pancreas secretes insulin into
bloodstream
» Exocrine pancreas secretes digestive
enzymes, bicarbonate into gut
 Vermiform appendix
» Hollow appendage
» Attached to large intestine
» No physiologic function
 Major Blood Vessels

 Aorta
 Inferior vena cava
 Solid Organs

 Liver
 Spleen
 Pancreas
 Kidneys
 Ovaries (female)
 Hollow Organs

 Stomach
 Intestines
 Gallbladder and bile ducts
 Ureters
 Urinary bladder
 Uterus and Fallopian tubes (female)
 Right Upper Quadrant

 Liver
 Gallbladder
 Duodenum
 Transversecolon (part)
 Ascending colon (part)
 Left Upper Quadrant:

 Stomach
 Liver(part)
 Pancreas
 Spleen
 Transverse colon (part)
 Descending colon (part)
 Right Lower Quadrant

 Ascending colon
 Vermiform appendix
 Ovary (female)
 Fallopian tube (female)
 Left Lower Quadrant

 Descending colon
 Sigmoid colon
 Ovary (female)
 Fallopian tube (female)
Acute Abdomen
 Abdominal Pain

 Visceral
 Somatic
 Referred
 Abdominal Pain
 Visceral pain
» Stretching of peritoneum or organ
capsules by distension or edema
» Diffuse
» Poorly localized
» May be perceived at remote locations
related to organ’s sensory innervation
 Abdominal Pain
 Somatic pain
» Inflammation of parietal peritoneum or
diaphragm
» Sharp
» Well-localized
 Abdominal Pain
 Referred pain
» Perceived at distance from diseased organ
» Pneumonia
» Acute MI
» Male GU problems
Non-hemorrhagic
Abdominal Pain
 Esophagitis

 Inflammation of distal esophagus

 Usually from gastric reflux, hiatal
hernia
 Esophagitis
 Signs and Symptoms
» Substernal burning pain, usually epigastric
» Worsened by supine position
» Usually without bleeding
» Often temporarily relieved by nitroglycerin
 Acute Gastroenteritis

 Inflammation of stomach, intestine

 May lead to bleeding, ulcers
 Causes
 acid secretion
» Chronic EtOH abuse
» Biliary reflux
» Medications (ASA, NSAIDS)
» Infection
 Acute Gastroenteritis
 Signs and Symptoms
» Epigastric pain, usually burning
» Tenderness
» Nausea, vomiting
» Diarrhea
» Possible bleeding
 Chronic Infectious
Gastroenteritis

 Long-term mucosal changes or permanent

damage
 Due primarily to microbial infections
(bacterial, viral, protozoal)
 Fecal-oral transmission
 More common in underdeveloped countries
 Nausea, vomiting, fever, diarrhea, abdominal
pain, cramping, anorexia, lethargy
 Handwashing, BSI
 Peptic Ulcer Disease

 Craters in mucosa of
stomach, duodenum
 Males 4x > Females
 Duodenal ulcers 2 to 3x
> Gastric ulcers
 Causes:
» Infectious disease:
Helicobacter pylori (80%)
» NSAIDS
» Pancreatic duct blockage
» Zollinger-Ellison Syndrome
 Peptic Ulcer Disease

 Duodenal Ulcers  Gastric Ulcers

» 20 to 50 years old » > 50 years old
» High stress » Work at jobs
occupations requiring physical
» Genetic activity
predisposition » Pain after eating
» Pain when or when stomach
stomach is empty is full
» Pain at night » Usually no pain at
night
 Peptic Ulcer Disease
 Complications
» Hemorrhage
» Perforation, progressing to peritonitis
» Scar tissue accumulation, progressing to
obstruction
 Peptic Ulcer Disease
 Signs and Symptoms
» Steady, well-localized pain
» “Burning”, “gnawing”, “hot rock”
» Relieved by bland, alkaline
food/antacids
» Worsened by smoking, coffee,
stress, spicy foods
» Stool changes, pallor associated
with bleeding
 Pancreatitis
 Inflammation of pancreas in which
enzymes auto-digest gland
 Causes include:
» EtOH (80% of cases)
» Gallstones obstructing ducts
» Elevated serum triglycerides
» Trauma
» Viral, bacterial infections
 Pancreatitis

 May lead to:

» Peritonitis
» Pseudocyst formation
» Hemorrhage
» Necrosis
» Secondary diabetes
 Pancreatitis
 Signs and Symptoms
» Mid-epigastric pain radiating to back
» Often worsened by food, EtOH
» Bluish flank discoloration (Grey-Turner
Sign)
» Bluish periumbilical discoloration
(Cullen’s Sign)
» Nausea, vomiting
» Fever
 Cholecystitis

 Gall bladder
inflammation, usually
2o to gallstones (90% of
cases)
 Risk factors
» Five Fs: Fat, Fertile,
Febrile, Fortyish,
Females
» Heredity, diet, BCP
use
 Cholecystitis

 Acalculus cholecystitis
» Burns
» Sepsis
» Diabetes
» Multiple organ systems failure
 Chronic cholecystitis (bacterial
infection)
 Cholecystitis
 Signs and Symptoms
» Sudden pain, often severe, cramping
» RUQ, radiating to right shoulder
» Point tenderness under right costal
margin (Murphy’s sign)
» Nausea, vomiting
» Often associated with fatty food intake
» History of similar episodes in past
» May be relieved by nitroglycerin
 Appendicitis

 Inflammation of
vermiform appendix
 Usually secondary to
obstruction by fecalith
 May occur in older
persons secondary to
atherosclerosis of
appendiceal artery and
ischemic necrosis
 Appendicitis
 Signs and Symptoms
» Classic: Periumbilical pain  RLQ pain/cramping
» Nausea, vomiting, anorexia
» Low-grade fever
» Pain intensifies, localizes resulting in guarding
» Patient on right side with right knee, hip flexed
 Appendicitis
 Signs and Symptoms
» McBurney’s Sign: Pain on palpation of RLQ
» Aaron’s Sign: Epigastric pain on palpation
of RLQ
» Rovsing’s Sign: Pain in LLQ on palpation of
RLQ
» Psoas Sign: Pain when patient:
– Extends right leg while lying on left side
– Flexes legs while supine
 Appendicitis
 Signs and Symptoms
» Unusual appendix position may lead to atypical
presentations
– Back pain
– LLQ pain
– “Cystitis”
» Rupture: Temporary pain relief followed by
peritonitis
 Bowel Obstruction

 Blockage of intestine
 Common Causes
» Adhesions (usually 2o to surgery)
» Hernias
» Neoplasms
» Volvulus
» Intussuception
» Impaction
 Bowel Obstruction
 Pathophysiology
» Fluid, gas, air collect near obstruction site
» Bowel distends, impeding blood flow/ halting
absorption
» Water, electrolytes collect in bowel lumen
leading to hypovolemia
» Bacteria form gas above obstruction further
worsening distension
» Distension extends proximally
» Necrosis, perforation may occur
 Bowel Obstruction
 Signs and Symptoms
» Severe, intermittent, “crampy” pain
» High-pitched, “tinkling” bowel sounds
» Abdominal distension
» History of decreased frequency of bowel
movements, semi-liquid stool, pencil-thin
stools
» Nausea, vomiting
» ? Feces in vomitus
 Hernia

 Protrusion of abdominal contents into

groin (inguinal) or through diaphragm
(hiatal)
 Often secondary to  intra-abdominal
pressure (cough, lift, strain)
 May progress to ischemic bowel
(strangulated hernia)
 Hernia
 Signs and Symptoms
» Pain  by abdominal pressure
» Past history
» Inguinal hernia may be palpable as
mass in groin or scrotum
 Crohn’s Disease

 Idiopathic inflammatory bowel disease

 Occurs anywhere from mouth to rectum
 35-45%: small intestine; 40%: colon
 Runs in families
 High risk groups
» White females
» Jews
» Persons under frequent stress
 Crohn’s Disease

 Pathophysiology
» Mucosa of GI tract becomes inflamed
» Granulomas form, invade submucosa
» Muscular layer of bowel become fibrotic,
hypertrophied
» Increased risk develops for
– Obstruction
– Perforation
– Hemorrhage
 Ulcerative Colitis

 Idiopathic inflammatory bowel disease

 Chronic ulcers develop in mucosal
layer of colon
 Spread to submucosal layer
uncommon
 75% of cases involve rectum (proctitis)
or rectosigmoid portion of large
intestine
 Inflammation can spread through entire
large intestine (pancolitis)
 Ulcerative Colitis

 Severity of signs, symptoms depends

on extent
 Classic presentation
» Crampy abdominal pain
» Nausea, vomiting
» Blood diarrhea or stool containing mucus
 Ischemic damage with perforation may
occur
 Diverticulitis

 Diverticula
» Pouches in colon
wall
» Typically in older
persons
» Usually
asymptomatic
» Related to diets with
inadequate fiber
 Diverticulitis
 Diverticula trap feces, become inflamed
 Occasionally result in bright red rectal
bleeding
 Rupture may cause peritonitis, sepsis
 Diverticulitis
 Signs and Symptoms
» Usually left-sided pain
» May localize to LLQ (“left-sided
appendicitis”)
» Alternating constipation, diarrhea
» Bright red blood in stool
 Hemorrhoids

 Small masses of veins in anus, rectum

 Most frequently develop when patients
are in 30s or 40s; common past 50
 Most are idiopathic, can be associated
with pregnancy, portal hypertension
 Cause bright red bleeding, pain on
defecation
 May become infected, inflamed
 Peritonitis
 Inflammationof abdominal cavity lining
 Signs and Symptoms
» Generalized pain, tenderness
» Abdominal rigidity
» Nausea, vomiting
» Absent bowel sounds
» Patient resistant to movement
Hemorrhagic Abdominal
Problems
Gastrointestinal Hemorrhage
Intraabdominal Hemorrhage
 Esophageal Varices

 Dilated veins in
esophageal wall
 Occur 2o to hepatic
cirrhosis, common
in EtOH abusers
 Obstruction of
hepatic portal blood
flow results in
dilation, thinning of
esophageal veins
 Esophageal Varices

 Portal hypertension
» Hepatic scarring
slows blood flow
» Blood backs up in
portal circulation
» Pressure rises
» Vessels in portal
circulation become
distended
 Esophageal Varices

 Signs and Symptoms

» Hematemesis (usually bright red)
» Nausea, vomiting
» Evidence of hypovolemia
» Melena (uncommon)
 Mallory-Weiss Syndrome

 Longitudinal tears at
gastroesophageal
junction
 Occur as result of
prolonged, forceful
vomiting, retching
 Common in alcoholics
 May be complicated by
presence of esophageal
varices
 Peptic Ulcer Disease

 Ulcererodes through blood vessel

 Massive hematemesis
 Melena may be present
 Aortic Aneurysm
 Localized dilation due to weakening of aortic
wall
 Usually older patient with history of
hypertension, atherosclerosis
 May occur in younger patients secondary to

» Trauma
» Marfan’s syndrome
 Aortic Aneurysm

 Usually just
above aortic
bifurcation
 May extend to
one or both iliac
arteries
 Aortic Aneurysm
 Signs and Symptoms
» Unilateral lower quadrant pain; low back
or leg pain
» May be described as tearing or ripping
» Pulsatile palpable mass usually above
umbilicus
» Diminished pulses in lower extremities
» Unexplained syncope, often after BM
» Evidence of hypovolemic shock
 Ectopic Pregnancy

 Any pregnancy that

takes place outside of
uterine cavity
 Most common location
is in Fallopian tube
 Pregnancy outgrows
tube, tube wall ruptures
 Hemorrhage into pelvic
cavity occurs
 Ectopic Pregnancy
 Suspect in females of child-bearing age with:
» Abdominal pain, or
» Unexplained shock
 When was last normal menstrual period?

Ectopic pregnancy does

NOT necessarily cause
missed period
Assessment of Acute
Abdomen
 History
 Where do you hurt?
» Try to point with one finger
 What does pain feel like?
» Steady pain = Inflammatory process
» Cramping pain = Obstructive process
 Onset of pain?
» Sudden = Perforation or vascular occlusion
» Gradual = Peritoneal irritation, distension of
hollow organ
 History

 Does pain travel anywhere?

» Gallbladder = Angle of right scapula
» Pancreas = Straight through to back
» Kidney/ureter = Around flank to groin
» Heart = epigastrium, neck/jaw, shoulders,
upper arms
» Spleen = Left scapula, shoulder
» Abdominal Aortic Aneurysm = low back
radiating to one or both legs
 History
 How long have you been hurting?
» >6 hours = increased probability of surgical
significance
 Nausea, vomiting
» How much, How long?
– Consider possible hypovolemia
» Blood, coffee grounds?
– Any blood in GI tract = emergency until
proven otherwise
 History

 Urine
» Change in urinary habits?
– Frequency
– Urgency
» Color?
» Odor?
 History
 Bowel movements
» Change in bowel habits? Color? Odor?
– Bright red blood
– Melena = black, tarry, foul-smelling stool
– Dark stool
 Suspect bleeding
 Other causes possible (iron or bismuth

containing materials)
 History

 Last normal menstrual period?

 Abnormal bleeding?
 In females, lower abdominal pain =
GYN problem until proven otherwise
 In females of child-bearing age, lower
abdominal pain = ectopic pregnancy
until proven otherwise
 Physical Exam
 Position and General Appearance
» Still, refusing to move = Inflammation,
peritonitis
» Extremely restless = Obstruction
 Gross appearance of abdomen
» Distended
» Discolored
» Consider possible third spacing of fluids
 Physical Exam
 Vital signs
» Tachycardia = more important sign of
volume loss than falling BP
» Rapid, shallow breathing = possible
peritonitis
» Consider performing “tilt” test
 Physical Exam

 Bowel sounds
» Auscultate BEFORE palpating
» One minute in each abdominal quadrant
» Absent sounds = possible peritonitis,
shock
» High-pitched, tinkling sounds = possible
bowel obstruction
 Physical Exam

 Palpation
» Palpate each quadrant
» Palpate area of pain LAST
» Do NOT check rebound tenderness in
prehospital setting
» ALL abdominal tenderness significant until
proven otherwise
 Management

 Oxygen by non-rebreather mask

 IV LR or NS
 PASG (demonstrated benefit in
intrabdominal hemorrhage)
 Keep patient from losing body heat
 Monitor vital signs
 Management
 Monitor EKG

Consider possible MI with pain

referred to abdomen in patients
>30 years old

 Keep patient npo

 Analgesia controversial
 Demerol is preferred narcotic analgesic