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Approach to a patient with acute abdomen

Sapna Philip Sr. Vinaya, Sr. Benit

Acute abdomen: Definition

Severe abdominal pain with duration of onset less than eight hours

Approach • History • Clinical examination • Laboratory data • Extra-abdominal causes • Special circumstances .

Approach • History • Clinical examination • Laboratory data • Extra-abdominal causes • Special circumstances .

History: Chronology Onset • Rapidity of onset is a measure of severity • Sudden-onset. well localized pain: intraabdominal catastrophe (perforated viscus. ruptured aneurysm) Duration • Longer duration before consultation suggests less severe disease . severe. mesenteric infarction.

small bowel obstruction. ruptured ectopic pregnancy Cholecystitis.Onset of common causes Onset Sudden Condition Perforated peptic ulcer. diverticulitis. ruptured aneurysm. mesenteric ischemia / infarction. pelvic inflammatory disease . pancreatitis Rapid Gradual Appendicitis. gastroenteritis.

History: Chronology Progression • Self-limited (e.... appendicitis) • Colicky – crescendo-decrescendo (e. ureteric) . gastroenteritis) • Progressive (e.g.g.g.

Patterns of pain Self-limited Colic Progressive Catastrophic .

or development of diffuse peritoneal irritation .History: Location • A stimulus may cause confusion by resulting in visceral. somatoparietal and referred pain • Knowledge of neuroanatomic pathways therefore essential • Change in location may represent progression from visceral to parietal irritation.

Location of common causes Location Periumbilical Conditions Appendicitis (later. mesenteric ischemia / infarction. pelvic inflammatory disease. RLQ). ruptured aortic aneurysm Right upper quadrant Epigastric. gastroenteritis Cholecystitis Pancreatitis Diverticulitis (left). ruptured ectopic pregnancy Pancreatitis. left upper quadrant Lower quadrants Back . small bowel obstruction.

cultural differences • Generally. past experiences. personality.History: Intensity and character • Intensity difficult to characterize • Depends on individual. severity of pain reflects magnitude of stimulus . setting.

ruptured ectopic pregnancy Perforated peptic ulcer. ruptured aneurysm Severe . small bowel obstruction. pelvic inflammatory disease.Intensity of common causes Intensity Mild Moderate Condition Gastroenteritis. pancreatitis (or severe). cholecystitis. mesenteric ischemia / infarction. diverticulitis Appendicitis.

ruptured ectopic pregnancy Gastroenteritis. mesenteric ischemia / infarct. pelvic inflammatory disease. perforated peptic ulcer (later. diverticulitis. appendicitis (later. diffuse). small bowel obstruction. ruptured aneurysm Diffuse . localized).Character of common causes Character Localized Condition Cholecystitis. pancreatitis.

History: Aggravating and alleviating factors • Position (motionless in peritonitis. relieved by meal in duodenal ulcer) • Bowel movements • Medication (antacid in ulcer disease) • Stress . writhing in colic) • Meal type (fatty food and biliary colic) • Meal time (aggravated by meal in gastric ulcer and mesenteric ischemia.

weight loss. diarrhea / constipation) • Jaundice • Dysuria • Menstrual disturbances . myalgia) • Digestive disturbances (anorexia. flatulence.History: Associated symptoms • Constitutional symptoms (fever. nausea / vomiting.

lupus. family and social history • Similar previous history • Systemic illness (scleroderma. porphyria.History: Past. sickle cell) • Medication • Substance abuse • Occupation • Travel .

discomfort.Physical examination Systemic • Appearance. position. breathing. facial expression • Vital signs • Lungs (pneumonia). extremities (perfusion) .

visible peristalsis • Palpation: Degree and location of tenderness. bruits Genitals. pelvis . hernia. mass • Light percussion • Auscultation: Hyperperistalsis. rigidity. rectum. scars.Physical examination Abdomen • Inspection: Distension. ecchymoses.

Addison’s. hyperlipidemia Thoracic Neurologic Metabolic . endocarditis Pneumonia. pneumothorax. esophageal rupture Radiculitis. porphyria.Extra-abdominal causes Cardiac Myocardial infarction. diabetes [DKA]. hyperparathyroidism. abdominal epilepsy. tabes Uremia. myocarditis. pulmonary infarction. pleurodynia.

Extra-abdominal causes Hematologic Sickle cell. familial Mediterranean fever. heat stroke Toxins Infections Miscellaneous . hemolysis. typhoid. lead Herpes zoster. Henoch-Schönlein purpura Hypersensitivity reactions. psychiatric disorders. acute leukemia. narcotic withdrawal. osteomyelitis Muscular lesions.

Special circumstances • Extremes of age • Pregnancy • Immunocompromised host • If symptoms disproportionate to abdominal signs. consider – Metabolic causes – Extra-abdominal causes – Ischemic events .

but essential preoperatively • Amylase. urinalysis. pregnancy test where indicated .Laboratory data Tailor to individual need • Complete blood count. metabolic parameters in all • Renal and liver profile as indicated.

trauma. and upright or left lateral decubitus): 10% diagnostic for pathology • Chest radiograph in all (pneumoperitoneum.Radiology • Plain abdominal series in all (supine. calcifications. vascular lesions. pneumonia) • Ultrasonography • Doppler studies as indicated • CT abdomen and pelvis: most versatile (gas. hemorrhage) . mass lesions.

Specialist diagnostic tests • Peritoneal lavage (hemoperitoneum. purulent or feculent material) • Laparoscopy (may also be therapeutic) • Exploratory laparotomy (where diagnosis is obvious or where delay in therapy is life-threatening) .

Management in ER • Emergency management – Supportive – Symptomatic • Specific measures .

ABG. sugar. grouping. Circulation • Ensure – IV access (large bore) – Oxygenation – Monitoring vitals (oxymetry. ECG. BP. amylase.Management in ER • Airway. electrolytes. Breathing. blood culture [if indicated]) . creatinine. urine output) • Send labs (counts.

USG / CT) • Inform specialist .Management in ER • NPO / NG tube • IV fluids (crystalloids / colloids) • Analgesics as indicated • Empiric antibiotic if indicated • Imaging as appropriate (X-ray abdomen / chest.