ACUTE ABDOMEN

differential diagnosis
• 23 yr old presents with 2/7 history abdominal
pain localised in the RIF associated with
nausea and vomiting 1x
• 35 yr old male presenting with 4 days history
of generalised abdominal pain. He is a farmer
and smokes cigarette.
• 35 yr old female presents with 1 yr history of
abdominal pain localised in the RUQ. Pain is
worse on eating fatty meals.
6 yr old boy presents with 2 hrs history of severe
abdominal which was sudden in onset.
• 26 yr old female presents with sudden onset
of lower abdominal pain localised in the LIF.
 INTRODUCTION
• Acute abdomen accounts for over 50% of
emergency surgical admissions.
• It is defined as an abdominal condition of
sudden onset (? Less than 24hrs duration) that
demands urgent and specific diagnosis and
may require immediate operative treatment.
• Pain is a usual but not a constant feature. May
be absent in acute abdomen in the 3rd
trimester of pregnancy and the aged.
 DEFINITE DIAGNOSIS MAY BE DIFFICULT
BECAUSE OF THE FOLLOWING
• Many different organs contained within the
peritoneal cavity with their pathologies
presenting in different ways.

• Potential for referred pain.

Surface anatomy of the abdomen
Surface anatomy of the abdomen
• The clinical scenario can change rapidly such
that conclusions previously reached may need
to be revised as events evolve.

• It is therefore necessary to be open-minded so

that previous diagnoses can be changed when
the need arises.
 CLASSIFICATION
• 1.Based on the area of the abdomen most
affected by pain.

• Based on the condition that give rise to acute

abdomen.
CLASSIFICATION BASED ON CONDITION THAT
GAVE RISE TO ACUTE ABDOMEN:
• 1.Inflamatory: Initially cause local peritonitis
that may become generalized. E.g. acute
appendicitis, acute cholecystitis, acute
salpingitis.
• 2.Perforation of hollow viscera: Typhoid
perforation, perf. DU,traumatic perforations.
• 3. intestinal obstruction
• 4.colics: Biliary, ureteric
• 5.Haemoperitoneum: Ruptured ectopic,
traumatic rupture of viscera
• 6.Acute pancreatitis
• 7.Acute tuberculous peritonitis
• 8.Gynaecological conditions other than
ectopic pregnancy: twisted ovarian cyst,
degenerating fibroids
• 9.Testicular torsion
• 10.Medical conditions: SCD, DM, malaria,
porphyria, pneumonia etc.

• 11. Non specific abdominal pain(NSAP)

• Acute appendicitis accounts for the majority
of cases in our local setting

• NSAP accounts for the majority of cases in the

western countries
NON SPECIFIC ABDOMINAL PAIN(NSAP)
• Defined as acute abdominal pain for which no
specific cause can be found during the acute
admission
• Usually self-limiting
• Does non require specific treatment
• Accounts for 13-40% of surgical admissions
• Diagnosis of NSAP should only be made when
investigations are complete and the other
causes of acute abdomen ruled out
Follow-up of patients upon discharge from hospital
with diagnosis of NSAP gives diverse outcomes:
• In one study, 10% of those aged over 50yrs were found to
have intra-abdominal malignancies during follow-up
• Some studies have also shown 10% of patients discharged
with diagnosis of NSAP to have celiac disease. 19-37%
were found to have irritable bowel syndrome during
follow-up

• Other investigators have reported 77% of patients with

being symptom-free after 5yrs of follow-up
ASSESSMENT OF THE PATIENT WITH ACUTE
ABDOMEN
• Initial impression
• Detailed and focused history
• Careful physical examination
• Appropriate investigations
 INITIAL IMPRESSION
• ABC
• ?ILL-LOOKING: septic, shock
• Lying still in bed, avoids movement: peritonitis
• Rolling around in agony: Intestinal obstruction,
biliary colic, ureteric colic
 HISTORY
• Must be focused and detailed
• Failure to take good history often leads to
wrong diagnosis
• Demographic details- Age and sex may help
limit scope of differential diagnosis
• Occupation
• Recent abdominal trauma
• Recent travel
 PAIN
• Onset (previous experience of similar pain)
• Nature of pain: constant/intermitent/colicky
• Severity: Visceral pain(dull, Poorly localised) ;
Somatic pain(severe)
• Radiation
• Relieving and aggravating factors
 ASSOCIATED SYMPTOMS
• Vomiting
• Hematemesis, melena
• Last meal
• Bowel movement:
constipation/Diarrhoea/Flatus
• Stool/urine colour
• Fever
• Recent weight loss
• Dizziness, palpitations
• Swellings in abdomen and groin
• Previous surgical history
• Previous medical history
• Medications
 O&G HISTORY
• Parity
• LMP
• Contraceptive use
• Treatment for infertility
• Previous gynaecological or tubal surgery
• Previous ectopic pregnancy
• Vaginal bleeding
• Vaginal discharge
• Drug history
 EXAMINATION
• Thorough general examination
• Thorough abdominal examination
• Examination of genitalia(R/O testicular torsion
in male)
• PR
 INVESTIGATIONS
• Must be appropriate
• Should be used to confirm or rule out
diagnoses made after clinical assessment
• Limitations of various investigations to be
noted
• REMEMBER TO DIRECT TREATMENT AT THE
PATIENT AND NOT AT THE RESULTS OF
INVESTIGATIONS
THE OUTCOME OF ASSESSMENT DETERMINES
THE TREATMENT TO BE OFFERED
• 1.Diagnosis made requiring surgical treatment

• 2.Diagnosis made, surgical treatment not

indicated

• 3.Diagnosis uncertain
 DIAGNOSIS MADE REQUIRING SURGICAL
INTERVENTION
• Resuscitation done and surgery performed
• Timing of surgery depends upon diagnosis and
adequacy of resuscitation
• Bleeding cases may require immediate surgery
which is done concurrently with resuscitation
• In very sick patients(typhoid perforation)
resuscitation is done gradually to optimize the
patient’s condition before surgery
 DIAGNOSIS MADE SURGICAL
INTERVENTION NOT INDICATED
• Resuscitation done
• Appropriate medical treatment offered
• Exploratory surgery may become necessary if
condition fails to improve on non-operative
management
 DIAGNOSIS UNCERTAIN
• Resuscitation done
• IVF, NG aspiration
• Analgesia withheld
• Frequent clinical re-assessment
• Diagnosis becomes certain: Appropriate treatment offered
• Diagnosis still uncertain, clinical condition fails to improve:
Exploratory surgery becomes necessary
• Diagnosis still uncertain but patient gets well: Patient is
left alone. Further investigations may reveal diagnosis.
Specific cause may not be found (NSAP)
ACUTE ABDOMEN DURING PREGNANCY
• 2% of all pregnancies are complicated by non-
obstetrical abdominal problems

• Acute appendicitis tops the list

 DIAGNOSIS OF ACUTE ABDOMEN IN
PREGNANCY IS MADE DIFFICULT BY:
• Enlarged uterus
• Difficulty in evaluation of abdomen
• Blunting of abdominal symptoms
• Physiological leukocytosis in pregnancy
 RISK OF IONISING RADIATION
INVESTIGATIONS DURING PREGNANCY
• Risk is highest during the first 25 weeks of
gestation
• However with good maternal indications
benefits to mother may outweigh risk to fetus
• Shielding of fetus can be done
• USG IS HOWEVER SAFE AND SHOULD BE THE
FIRST CHOICE
 ACUTE APPENDICITIS IN PREGNANCY
• Diagnosis made difficult by:1.Many of the
symptoms of appendicitis are also seen in
pregnancy 2. The position of the appendix changes
during pregnancy
• The single most important symptom of acute
appendicitis in pregnancy is right lower quadrant
abdominal pain
• Tenderness and RBT are less frequently found
• USG is investigation of choice. CT may also be used
Anatomy of the appendix in pregnancy
• Early diagnosis and immediate surgery is the
aim of management

• Incision is placed over the point of maximum

tenderness

• If perforation of appendix occurs, maternal and

fetal mortality are 4% and 20% respectively
 ACUTE CHOLECYSTITIS IN PREGNANCY
• Second most common cause of acute
abdomen in pregnancy (after acute
appendicitis)
• Pregnancy predisposes to gallstone formation
because of increased bile stasis and reduced
gall bladder contraction
• Symptoms are the same as those of non-
pregnant patients but Murphy’s sign is less
common in pregnancy
• USG confirms diagnosis

• Treatment is medical(3rd generation

cephalosporins)
• Surgery is performed when medical treatment
fails or complications occur
 ACUTE INTESTINAL OBSTRUCTION IN
PREGNANCY
• Same incidence as occurs in general
population
• Diagnosis is delayed because of confusion with
hyperemesis gravidarum
• Adhesions account for 60-70% in western
countries
• If diagnosis is delayed, maternal mortality is
up to 6% whilst fetal mortality is 25-40%
 SURGERY DURING PREGNANCY
• Safest during 2nd trimester

• 1st trimester: risk of abortion

• 3rd trimester: risk of premature labour

• Precautions:1. Minimal manipulation of uterus

during surgery 2. Use of tocolytic agents
 LAPAROSCOPIC VRS OPEN SURGERY IN
PREGNANCY
• Laparoscopic surgery is preferable in early
pregnancy. Minimizes manipulation of gravid
uterus
• After 26wks gestation: Open surgery
preferable because size of uterus interfere
with laparoscopic view
ADVANTAGES OF LAPARASCOPIC SURGERY
IN PREGNANCY
• Less fetal depression because of reduced
narcotic requirements
• Reduced manipulation of uterus
• Reduced post-operative maternal
hypoventilation (less post-operative pain)
• Reduced risk of wound complications
 MAJOR CONCERNS OF LAPAROSCOPIC
SURGERY IN PREGNANCY
• Injury to uterus
• Reduced blood flow to uterus
• Risk of preterm labor (increased intra-
abdominal pressure
• Risk of fetal acidosis
• Unknown effects of CO2 pneumoperitoneum
 Conclusion

• Acute abdomen has many differential

diagnosis
• Key to successful treatment is a detailed
history and examination
• Not all acute abdomen cases require surgical
intervention