Evaluation of Acute Abdomen

By Dr. Conrad DCosta, MS, DNB (Senior House Officer) Mr.Sudhir Jain,MS,FRCS,FACS, (Specialist Registrar Surgery) North Middlesex University Hospital,London

Acute Abdomen
Challenge to Surgeons & Physicians Most common cause of surgical emergency admission Clinical course can vary from from minutes to hours to weeks. It can be an acute exacerbation of a chronic problem e.g. Chronic Pancreatitis,Vascular Insufficiency.

DEFINITION
Acute Abdomen is a term used synonymously for a condition that needs immediate surgical intervention

ASSESMENT
Well elicited history Proper physical examination Diagnosis can be made most of the time by a good history and a proper physical examination.

Assesment(cont.)
Investigations are usually carried out : only to support the diagnosis. or to narrow down the differential diagnoses.

History
History of Present illness Family History Past Medical history History of drugs taken or Medication eg. ingestion of certain toxic drugs or Alcohol intake

PAIN
The Most Important Symptom History of pain should include: 1. Onset 2. Severity 3. Type of pain 4. Radiation of Pain 5. Change in nature of Pain 6. Associated bowel or urinary symptoms 7. Aggravating or relieving factors

(i) Onset of Pain

Sudden onset pain which wakes the patient from sleep eg. perforation or strangulation of bowel Slow insidious Onset a. Inflammation of visceral peritoneum. b. Contained process such as evolving abscess. Crampy or colicky pain Biliary colic, Ureteric colic or Intestinal colic

(ii) Progression of Pain

Progression from: Dull, aching, poorly localized character To: Sharp, constant & better localized pain
indicates involvement of Parietal peritoneum

(iii) Associated Bowel Symptoms

CONSTIPATION
a. Progressive intestinal obstruction from a neoplasm or inflammatory bowel disease b. Paralytic Ileus c. Post Operative d. Obstructed groin hernia

(iv) Associated Bowel Symptoms

DIARRHOEA
Diarrhoea with pain is mainly medical. The following are the exceptions: a. b. c. d. Obstructed Richter's Hernia Gall Stone ileus Superior mesenteric vascular occlusion Intestinal Obstruction associated with pelvic abscess e. Spurious diarrhea in chronic faecal impaction

DRUG HISTORY
Corticosteroids mask pain Anticoagulants can lead to an intramural haematoma of the gut causing obstruction Oral Contraceptives - rupture of hepatic adenomas NSAIDs - erosive gastritis & peptic ulcers

NAUSEA & VOMITING

(i) Frequency of vomiting (ii) Character of vomiting: projectile, non-projectile or self-induced

(iii) Nature of vomiting:

a. Bilious vomiting of small bowel obstruction b. Non-bilious vomiting in obstruction proximal to ampulla of vater c. Faeculent vomiting in distal small gut obstruction, large bowel obstruction , strangulation

NAUSEA & VOMITING

Pain first, followed by Vomiting is usually surgical. The vomiting is due to reflex pylorospasm Nausea & vomiting first , followed by pain is usually due to a medical condition

Vomiting (cont.)
Vomiting is very prominent in a. Mallory-Weiss syndrome. b. Boerhaave syndrome(transmural esophageal tear) c. Acute gastritis d. Acute pancreatitis

ANOREXIA
Anorexia or decreased appetite with pain is usually seen in Acute appendicitis

Urinary Symptoms with Pain

Ureteric colic Cystitis

FEVER & CHILLS/RIGORS

Amoebic Liver Abscess Pygenic Liver Abscess Perinephric Abscess Intra-abdominal pus collection

OTHER HISTORY
Past Surgical history: previous operationsleading to adhesions Past Medical history: Sickle cell disease, Diabetes or Cancer or Renal failure Menstrual History in females (i) Missed period- ectopic pregnancy (ii) Mid of period-ovulation pain (Mittelschmerz) (iii) With heavy periods- endometriosis Family history of colon cancer, any other malignancy or inflammatory bowel disease

Physical Examination
General Appearance a. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitis b. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colic c. Writhing in Pain: Mesenteric Ischemia

Physical Examination (contd.)

d. Bending Forward: Chronic Pancreatitis e. Jaundiced: CBD obstruction f. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

Physical Examination (contd.)

Vital Charting Temperature, Pulse, BP, Respiratory rate Ruptured AAA or ectopic pregnancy can lead to -Pallor -Hypotension -Tachycardia -Tachypnea

Physical Examination (contd.)

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Low grade temp. is seen with Appendicitis Acute cholecystitis High grade temp. is seen with Salpingitis Abscess Very High Grade Temp.with increasing lethargy seen in imminent septic shock Peritonitis Acute cholangitis Pyonephrosis

Systemic Examination
Cardiopulmonary examination Check for: - Possible MI - Basal Pneumonia - Pleural Effusion

Systemic Examination
Per Abdomen: Inspection - Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

Systemic Examination
Erythema or discolouration a. Peri-umbilical - Cullen sign b. Inguinal Fox sign c. Flanks - Grey Turner sign Seen in Hemorrhagic pancreatitis or any other cause of haemoperitoneum Any Visible masses Any visible cough impulse at hernia site

Systemic Examination
Per abdomen: Palpation Be gentle Start away from site of pathology then towards Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis.

Systemic Examination
Local Right Iliac Fossa tenderness: a. Acute appendicitis b. Acute Salpingitis in females c. Amoebiasis of Caecum Low grade, poorly localized tenderness: Intestinal Obstruction Tenderness out of proportion to examination: a. Mesenteric Ischemia b. Acute Pancreatitis Flank Tenderness: a. Perinephric Abscess b. Retrocaecal Appendicitis

Systemic Examination
Rovsings Sign in Acute Appendicitis Obturator Sign in Pelvic Appendicitis Psoas Sign - Retrocaecal appendicitis - Crohns Disease - Perinephric Abscess

Systemic Examination
Murphy's sign in Acute Cholecystitis Thumping tenderness over lower ribs in inflammation of -Diaphragm - liver or spleen

Systemic Examination
Pulsatile Abdominal Mass with Hypotension Leaking AAA Cutaneous Hyperaesthesia indicates involvement of Parietal Peritoneum

Systemic Examination
Per Rectal Examination: - tenderness - induration - mass (Blummers shelf) - frank blood

Systemic Examination
Per Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

INVESTIGATIONS
Complete Blood Count with differential C-reactive protein estimation Electrolyte ,Blood Urea , Creatinine Urine dipstick Amylase or Lipase Liver Function Test

Radiology
Upright X ray chest for - Basal Pneumonia - Ruptured Oesophagus - Elevated Hemi diaphragm - Free Gas under diaphragm

Radiology
Abdominal X ray film
Air-Fluid Levels Stones Ascites Eggshell calcification in AAA Air in Biliary tree. Obliteration of Psoas Shadow in retroperitoneal disease - Right lower quadrant sentinel loop in acute appendicitis

INVESTIGATIONS
Other Investigations - USG - CT abdomen for AAA, Pancreatic disease, or ureteric colic (nonContrast) - IVU - Mesenteric Angiography for Ischaemia, Haemorrhage

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