THE

ACUTE ABDOME
an overview
By
Hamdy Sedky.MD,MRCS
Lecturer Of GI Surgery
 Definition
 Etiology
 Presenting symptoms
 Physical examination
 Investigations
 Treatment
Any unexpected spontaneous (non-
traumatic) disorder whose chief
manifestations are in the abdominal area
and for which urgent operation may be
necessary.
 Definition

 Etiology
 Presenting symptoms
 Physical examination
 Investigations
 Treatment
 Surgical causes
 Gastrointestinal tract disorders
 Appendicitis

 Small and large bowel obstruction

 Perforated peptic ulcer

 Incarcerated hernia

 Bowel perforation

 Meckel's diverticulitis
 Boerhaave's syndrome

 Diverticulitis

 Inflammatory bowel disorders

  Mallory-Weiss syndrome

 Gastroenteritis

 Acute gastritis

  Mesenteric adenitis

 Parasitic infections
 Pancreatic disorders
 Acute pancreatitis

 Liver, spleen, and biliary tract disorders

 Acute cholecystitis
 Acute cholangitis
 Hepatic abscess
 Ruptured hepatic tumor
 Spontaneous rupture of the spleen
 Splenic infarct
 Biliary pain
 Acute hepatitis
Urinary tract disorders
 Ureteral or renal colic

 Acute pyelonephritis

 Acute cystitis

 Renal infarct

Gynecologic disorders
 Ruptured ectopic pregnancy

 Twisted ovarian tumor

 Ruptured ovarian follicle cyst

 Acute salpingitis

 Dysmenorrhea

 Endometriosis
 Vascular disorders
 Ruptured aortic and visceral aneurysms

 Acute ischemic colitis

 Mesenteric ischaemia

 Peritoneal disorders
 Intra-abdominal abscesses

 Peritonitis

 Tuberculous peritonitis

 Retroperitoneal disorders
 Retroperitoneal hemorrhage
 MEDICAL CAUSES
 Endocrine and metabolic disorders
 Uremia

 Diabetic crisis

 Addisonian crisis

 Acute intermittent porphyria

 Acute hyperlipoproteinemia

 Hereditary Mediterranean fever

 Hematologic disorders
  Sickle cell crisis
 Acute leukemia

 Other dyscrasias
 Toxins and drugs

 Lead and other heavy metal poisoning

 Narcotic withdrawal

 Black widow spider poisoning

 Infections and inflammatory disorders

 Tabes dorsalis

 Herpes zoster

 Acute rheumatic fever

 Henoch-Schonlein purpura

 Systemic lupus erythematosus

 Polyarteritis nodosa
 Referred pain
 Thoracic region
 Myocardial infarction
 Acute pericarditis
 Pneumonia
 Pleurisy
 Pulmonary embolus
 Pneumothorax
 Empyema
 Hip and back
 Definition
 Etiology

 Presenting symptoms
 Physical examination
 Investigations
 Treatment
 Abdominal pain

 The most common,

 The most predominant and
 The most important

symptom of an acute abdomen.

 (1) Location of Pain

 The abdominal region has a dual nerve

supply; visceral and somatic, abdominal pain
may be visceral or parietal
 Visceral pain

Stimuli:
Stretching of peritoneum or organ capsules

Traction on the bowel mesentery

 Inflammation

 Ischemia

Sensation:
Diffuse and poorly localized, deep seated, slow in onset, dull in character, and protracted.

May be perceived at remote locations related to organ’s sensory innervation that corresponds to

its embryologic origin (foregut, midgut, hindgut)

Example:
Visceral pain sites.
 Somatic pain
 Stimuli
› Irritation of parietal peritoneum

 Sensation
› Well-localized pain

› Of acute onset

› Sharp pain

› More superficial

› Easily described

 Example:
Change in pain location

› Referred pain

› Radiating pain

› Shifting pain

› Spreading pain
Change in pain location
 (2) Mode of Onset and Progression of
Pain

May be
 Explosive (within seconds),
 Rapidly progressive (within 1-2 hours), or
 Gradual (over several hours).
 Sudden, excruciating generalized pain suggests an
intra-abdominal catastrophe

Examples:
 perforated viscus or
 rupture of an aneurysm,
 ectopic pregnancy.
A less dramatic onset of a mild pain that increases

gradually over 1-2 hours

Examples:
 acute cholecystitis,

 acute pancreatitis,

 strangulated bowel,

 mesenteric infarction,

 high small bowel obstruction.

 (3) Character of Pain
 The sharp superficial constant pain is typical of perforated ulcer or a ruptured

appendix.

 The gripping pain of small bowel obstruction is usually intermittent, vague, deep-

seated, and crescendo decrescendo

 Pain associated with bowel obstruction is severe but bearable, while pain caused

obstruction of smaller conduits (bile ducts and ureters) rapidly becomes unbearably

intense.

 The aching discomfort of ulcer pain,

 The stabbing pain of acute pancreatitis and mesenteric infarction,

 The tearing pain of ruptured AAA.

Location and character of pain
 Definition
 Etiology
 Presenting symptoms

 Physical examination
 Investigations
 Treatment
 General condition
 Disturbed conscious level
 Facies
 Gait
 Decubitus:
 The rolling patients
 The rigidly motionless patient
 The bent sitting patient
 The patient with a flexed Rt. hip
 Fever
 Constant low-grade fever:
 diverticulitis,
 acute cholecystitis, and
 appendicitis.

 High fever (> 39 °C), disorientation, and rigors indicate impending septic shock:
 advanced peritonitis,
 acute cholangitis, or
 pyelonephritis.

 Pitfall:
 elderly,
 chronically ill, or
 immunosuppressed patients.
 Systemic signs
 extreme pallor,
 Cyanosis
 Jaundice
 Hypo hyperthermia,
 hypotension
 tachycardia,
 tachypnea
 Sweating
 Foeter hepaticus, fruity odour
 Inspection
 Your eyes are always first
 A distended abdomen with a scar or a hernia
 A scaphoid contracted abdomen
 Visible peristalsis
 Diminished respiratory abdominal wall movements
 Pulsations
 A visible swelling
 Skin abnormalities
 Palpation
 Guarding and rigidity
 Tenderness:
 is the most important finding in acute abdomen.
 Types:
 Localized
 Rebound
 Cross
 Cough
 Percussion
 Palpation

 Murphy's sign
 Iliopsoas sign
 Obturator sign
 Costovertebral angle tenderness
 Palpation
 Swellings:
 Inflammatory mass

 Tumours

 Intussusception

 Ischaemic bowel

 The tense tympanic balloon

 Palpation

 Hyperaesthesia:
 Sherren’s triangle
 Boas’s sign
 In renal inflammatory lesions
 In salpingitis

 Hernial orifices
 The scrotum
 Percussion

 Percussion tenderness
 Liver dullness.
 Free peritoneal fluid
 The diffusely dull abdomen
 Auscultation

 Loud peristalsis synchronous with colic are heard in mid small bowel
obstruction
 The high-pitched hyperperistaltic sounds unrelated to the crampy pain in
enteritis.
 A silent abdomen except for infrequent tinkling sounds in late bowel
obstruction or diffuse peritonitis.
 Pelvic examination

 Rectal examination
 Pelvic examination:
 Definition
 Etiology
 Presenting symptoms
 Physical examination

 Investigations

 Treatment
The abdominal series

 Advantages
 Readily available
 Mobile
 Don’t need radiologist

 Disadvantages
 2D image
 Radiation dose (40x effective dose of CXR)
 Relatively low sensitivity
 The abdominal series

 It includes:
 PA erect chest,
 AP supine and
 AP erect abdomen

 If patient unable to sit/stand:

 supine and
 left lateral decubitus abdomen
The abdominal series
What to look for:
 Bowel distension
 Bowel wall thickening/oedema (>3mm)
 Intramural gas
 Free intraperitoneal gas
 Calcification
 Stones
 Pancreatic
 Vascular
 Psoas shadows
Free intraperitoneal gas
 Ultrasonography
 Ultrasonography is helpful in evaluating:
 Acute cholecystitis, cholangitis
 Acute appendicitis
 Complicated external hernias
 Renal and ureteric lesions
 Intra-abdominal free and localized fluid collections
 Transanal and transvaginal probes for evaluating pelvic
pathology specially in females
 Young/pregnant patients with abdominal symptoms
Ultrasonography
 Advantages
 No radiation
 Mobile
 Allows real time visualisation, eg peristalsis
 Excellent contrast between fluid and soft tissue, eg gallbladder

 Disadvantages
 Operator dependent
 Poor images in larger patients
 Bowel gas
CT scan

 Advantages
 Very high resolution images (esp. multislice CT)
 Higher diagnostic accuracy
 No problems with obese patients/bowel gas

 Disadvantages
 High radiation dose (approximately 200x CXR)
 Side effects of IV contrast (nephrotoxicity, allergy, etc)
 Not portable (cf AXR and ultrasound)
 CT Scan
 CT is helpful in:
 Examining retroperitoneal organs (Acute pancreatitis)

 Detecting sites of inflammatory diseases that may prompt (appendicitis, tubo-

ovarian abscess) or postpone (diverticulitis, pancreatitis, hepatic abscess) operation.

 Identifying small amounts of free intraperitoneal gas

 Free localized intraperitoneal and retroperitoneal fluid

 Bowel ischaemia/perforation/obstruction

 Vascular pathology, eg intraabdominal aneurysm, MVO

 Obese patients

 Unresolved diagnosis following AXR/US

 angiography

 Selective visceral angiography is useful in:

 mesenteric infarction,
 ruptured liver adenoma or carcinoma or
 ruptured abdominal aneurysm
 Endoscopy

 Proctosigmoidoscopy is indicated in any patient with acute

abdomen and suspected segmoid volvulous
 Paracentesis
 In patients with free peritoneal fluid, aspiration of blood, bile,
or bowel contents is an indication for urgent laparotomy.
 Infected ascitic fluid may establish a diagnosis in
spontaneous bacterial peritonitis, tuberculous peritonitis, or
chylous ascites which rarely require surgery.
 Culdocentesis may be useful for suspected ruptured corpus
luteum cyst.
 Laparoscopy
 In female patients in the child bearing period presenting with
lower abdominal pain.
 In obtunded, elderly, or critically ill patients.
 In adhesive bowel obstruction
 Definition
 Etiology
 Presenting symptoms
 Physical examination
 Investigations

 Treatment
Indications for surgery in acute abdomen

 Physical findings
 Involuntary guarding or rigidity, especially if spreading

 Increasing or severe localized tenderness

 Tense or progressive distention

 Tender abdominal or rectal mass with high fever or hypotension

 Equivocal abdominal findings along with Sepsis

 Suspected ischemia (acidosis, fever, tachycardia)

 Deterioration on conservative treatment

 Indications for surgery in acute abdomen

 Radiologic findings

 Pneumoperitoneum

 Gross or progressive bowel distention

 Free extravasation of contrast material

 Space-occupying lesion on scan, with fever

 Mesenteric occlusion on angiography

 Endoscopic findings

 Perforated or uncontrollably bleeding lesion

 Paracentesis findings

 Blood, bile, pus, bowel contents, or urine

 Treatment of the Acute Abdomen

 ABCDE
 large bore IV lines with either saline or lactated Ringer’s solution
 IV pain medication
 Nasogastric tube if vomiting or concerned about obstruction
 Foley catheter to follow hydration status and to obtain urinalysis
 Antibiotic administration if suspicious of inflammation or perforation
 Definitive therapy or procedure will vary with diagnosis
THANK YOU