Acute abdomen

Part One
History,Physical examination and
Investigations
Prof. Qassim Baker
FRCS England,FRCS Glasgow
Examiner for Royal College of Surgeons of
England ,United Kingdom

What is acute abdomen ?

An acute abdomen refers to a rapid onset
of severe abdominal pain which lasts more
than few hours and may indicate a
significant life-threatening intra-abdominal
pathology. It can also be referred to as a
surgical abdomen.

Pitfalls
Not taking a thorough history in a
methodical manner excluding common
differential diagnosis
Failing to examine the appropriate
systems during clinical examinations
Document a list of provisional diagnosis
and differentials
Admit the patient for observation and
monitoring if the diagnosis unclear

Key to making the correct

diagnosis
Thorough history taking and good physical
examination
Interpretation of laboratory and imaging
results and correlate them with the history
and examination findings
Correlate the investigations results with
the history and examination findings
Make a decision and management plan in
a timely manner

History taking
As for any pain elsewhere inquire about the
criteria of pain
Duration: ask about the duration of pain
since the onset. Should be recorded in
hours for accurate assessment
Radiation: where does the pain radiate to?
Pain from loin to groin may suggest renal
colic, or pain radiating to the back may
suggest pancreatitis.

History taking cont.

Location of the pain: Localization of pain is an important
guide to the exact diagnosis
Aggravating and relieving factors: pain which increases
when the patients cough or moves may suggest
peritonitis.
Intensity of the pain: Ask the patients to score the pain
out of 10 helps to assess the severity
Character: pain that is colicky in nature may suggest
renal colic or biliary colic, constant severe pain may
suggest pancreatitis
Other associated symptoms: Such as nausea and
vomiting, change in bowel habit or looser stools, loss of
appetite etc.

History cont.

Menstrual history is very important when assessing adult female

patient presenting with acute abdomen e.g. amenorrhea (ectopic
gestation), mid-cycle pain (Mittelschmerz), vaginal bleeding, or
discharge etc.
Past medical history: what are the patient co-morbidities? Do they
need optimizing prior to possible surgery?
Past surgical history: Has the patient had a previous abdominal
surgery? Important factor in assessing patients with possible
intestinal obstruction
Drug history: Is the patient on any medication that may mask the
inflammatory response making the diagnosis particularly difficult,
such as steroids or immunosuppressants?
Is the patient on anti-coagulants such as warfarin which may need to
be reversed or monitored prior to surgery?
Family history: any history of abdominal cancers or inflammatory
bowel disease?

Pitfalls
Do not forget medical causes of acute
abdomen such as myocardial infarction,
pleurisy, diabetic ketoacidosis, herpes
zoster and spinal pathologies that can give
rise to referred abdominal pain.
Beware of unilateral or bilateral loin pain
with or without back pain in patients over
the age of 60 as they may have leaking
abdominal aortic aneurysm.

Clinical examples
Loin pain radiating to the groin or to the
external genitalia with urinary symptoms.
?Ureteric colic
Epigastric or periumbilical pain which
shifts to the RIF. ? Acute appendicitis
Right hypochondrial pain with pain refereed
to the tip of the right shoulder or to the
back. ?Acute cholecystitis.

Clinical Examples cont.

Epigastric pain, severe, radiating to the
back relieved by sitting up and leaning
forward. ?Acute pancreatitis.
Abdominal pain attacks with vomiting,
constipation (although not necessarily)
and abdominal distension.
?Intestinal obstruction.

Physical examination
General inspection:
General look of the patient (looking well or ill),
posture in bed e.g. lying still and reluctant to
move as in cases due to peritonitis or rolling in
bed in acute abdomen due to ureteric colic.
Jaundice e.g. hepatitis, acute cholecystitis,
cholangitis, carcinoma of the head of pancreas
Signs of dehydration (dry tongue, loss of skin
turgor and sunken eyes) e.g. in gastroenteritis,
intestinal obstruction.

Observations
Pulse rate e.g. tachycardia due to severe pain, shock or
pyrexia. The pulse may be irregular e.g. atrial fibrillation
which can cause mesenteric ischemia by embolization
from the heart.
Temperature e.g. pyrexia or hypothermia, which is a bad
prognostic sign in cases due to septic shock.
Blood pressure e.g. hypotension due to peritonitis and
sepsis, acute pancreatitis, ruptured aortic aneurysm etc.
Respiratory rate and oxygen saturations: Raised
respiratory rate is an early sign in those presenting with
sepsis. Tachyapnoea may also be a sign of metabolic
acidosis with respiratory compensation

Local abdominal examination

Inspection:
Movements of the abdominal wall with respiration e.g. shallow
breathing that is mainly thoracic with peritonitis.
Evidence of obstructed inguinal, femoral, para-umbilical or incisional
hernias.
Scars from previous abdominal operations (adhesive intestinal
obstruction).
Visible peristalsis in acute intestinal obstruction.
Abdominal distension whether central, generalized or mainly in the
periphery.
Areas of abdominal wall cauterization, which indicates chronic
abdominal pain and mainly applied for people in rural areas in
developing countries.

Abdominal examination cont.

Palpation:
Tenderness and rebound tenderness are signs of
peritonitis, positive Murphy's sign in acute cholecystitis.
Rigidity whether localized or generalized, board-like as in
generalized peritonitis. e.g. perforated peptic ulcer.
Palpable liver or gallbladder e.g. mucocele or empyema
of the gallbladder.
Loin mass e.g. hydronephrosis or pyonephrosis.
Tenderness at the renal angle e.g. pylonephritis.
Evidence of supra-umbilical pulsatile mass e.g. aortic
aneurysm.
Suprapubic mass e.g. distended bladder or fibroids.

Physical examination cont.

Auscultation:

Silent abdomen e.g. peritonitis.

Excessive or exaggerated bowel sounds e.g. mechanical intestinal obstruction.

Percussion

Resonant in gaseous abdominal distension (bowel obstruction).

Dullness and shifting dullness on percussion in fluid collection (ascites).

Per-rectal exam.

PR examination is a must in any patient with acute abdominal pain. Look for fecal
impaction, tenderness in case of pelvic peritonitis or pelvic collection, any palpable tumor
in the rectum. Blood on the glove may indicate intussusception, ischemic colitis, or amebic
dysentery. Any gynecological problem as ectopic gestation might be felt as adnexal mass
on PV exam.
Lymphadenopathy

Check for cervical lymphadenopathy in children suspected of having mesenteric

lymphadenitis

Patients with malignancies may also have palpable lymphadenopathy

Pitfalls in physical examination

Dont forget to examine the external genitalia
especially in male child presented with
abdominal pain (think of testicular torsion).
Adult male may present with iliac fossa or
suprapubic pain due to torsion or
epididymoorchitis.
Chest examination is needed to exclude thoracic
causes e.g. pleural rub of pleurisy
Throat and ear exam. Children with tonsillitis,
otitis media, or pharyngitis may present with
abdominal pain.

Investigations
What investigations are you going to
request?
When requesting laboratory investigations,
think about the differential diagnosis and
tailor the tests to confirm and exclude
those diagnosis.

Urine analysis

Exclude UTI
Look for red blood cells for renal colic
Pus and bacteria (pyelitis)
Sugar and ketons (DM)
Exclude pregnancy

Blood test
Full Blood Count (FBC)
Leukocytosis with inflammatory conditions (non-specific test)
Urea and Electrolytes (U&E)
In patients with repeated vomiting or ileus
Liver Function Tests (LFT)
Is indicated if hepatitis, cholecystitis or cholangitis are suspected.
To identify gallstones as a possible cause in acute pancreatitis
Serum amylase
When there is a suspicion of acute pancreatitis (non-specific).
Other intra-abdominal conditions can cause elevation of this enzyme
such as perforated peptic ulcer, ruptured ectopic pregnancy and
cholangitis.
C reactive protein (CRP)
Non- specific marker of inflammation but useful for monitoring response
to treatment

Other tests
Clotting Screen
If patients on anti-coagulation
Jaundiced patients may have abnormal clotting which
may need to be corrected prior to intervention
ECG:Myocardial ischaemia can cause upper abdominal
pain
Arterial Blood Gas (ABG) Check for metabolic acidosis
Lactate levels may be raised in ischaecmic bowel, or
septicaemia.
Blood cultures:If septicaemia is suspected

Imaging in acute abdomen

Plain abdominal X ray

Look for:
Dilated bowel loops and air-fluid levels: in dilated small bowel look
for circular transverse ridges that goes across the lumen due to
valvulae conniventis, and in large bowel look for colonic haustra
which does not cross the bowel lumen.
Calcifications: some stones are radio-opaque (90% of urinary stones
and 10% of gall stones). Faecolith may also be radio-opaque. Other
calcified structures include aortic aneuryms, pancreatic calcifications,
calcified hydatid cyst, and TB lymph nodes.
Presence of gas in the abnormal space: air under the diaphragm in
cases of perforated viscus, in the biliary system in cholecysto-entric
fistula, in the wall of gallbladder in emphysematous cholecystitis.
They often need urgent surgical intervention.

Plain X-ray abdomen

small bowel obstruction

Chest X-ray
air under the diaphragm

Abdominal Ultrasound
Abdominal ultrasound is very helpful in diagnosis of
biliary origin. It can detect gallstones and thickened
gallbladder wall (cholecystitic) and used to measure the
common bile duct (CBD) diameter and the presence of
stones in the CBD.
Ultrasound can also identify hydronephsosis, hydroureter, mass in the head of pancreas, presence of aortic
aneurysm.
In female patients with right iliac fossa pain, pelvic and
trans-vaginal ultrasound can be used to identify
gynaecological pathology such as ovarian cyst rupture or
torsion.

USS abdomen

Abdominal CT scan
CT scans are increasingly used to identify
causes of acute abdomen. It can localize the site
of viscus perforation; identify intra-abdominal
abscesses and collections, and causes of bowel
obstruction. It can be used to look for leaking
abdominal aortic aneurysm (AAA)
CT Kidney Ureter and Bladder (CT KUB) is now
replacing IVU in identifying renal stones.

CT scan abdomen

Other investigations
Diagnostic laparoscopy
Laparoscopy is useful to elucidate the cause of
abdominal pain in equivocal cases commonly mistaken
for appendicitis i.e. gynaecological problems and pelvic
inflammatory disease presenting as right iliac fossa pain.
Contrast studies
Intravenous urogramme (IVU) are now largely replaced by
CT KUB but can still be used to identify renal stones by
looking for a delay in excretion on the contrast on the
effected side and dilated system proximal to the
obstructing stone.
Barium studies are also used less frequently in the acute
setting due to the availability of the CT scan.

Role of endoscopy
Oesophagogastroduodenoscopy (OGD) to
exclude peptic ulceration, duodenitis,
gastritis, reflux esophagitis (important
causes for upper abdominal pain).
Flexible sigmoidoscopy can be used to
identify diverticular disease or cause of
colitis.