ACUTE ABDOMEN

Dr. M. Hafidh Komar, SpB(K)BD

DEPARTEMEN ILMU BEDAH

RUMAH SAKIT DR. MOH. HOESIN PALEMBANG
UNIVERSITAS SRIWIJAYA
 Acute Abdomen
Pain less than one week
Sudden onset
Surgery needed
Peritonitis
Severe pain

Any condition that need rapid decision

making and/or operative intervention
 Causes of Acute Abdomen
Intestinal
Acute appendicitis, mesenteric adenitis, mekels diverticulitis, perforated peptic
ulcer, gastroenteritis, diverticulitis, intestinal obstruction, strangulated hernia

Hepatobiliary
Biliary colic, cholecystitis, cholangitis, pancreatitis, hepatitis

Vascular
Ruptured AAA, acute mesenteric ischaemia, ischaemic colitis

Urological
Renal colic, UTI, testicular torsion, acute urinary retention

Gynaecological
Ectopic pregnancy, ovarian cyst pathology (rupture/haemorrhage into cyst/torsion),
salpingitis, endometriosis, mittelschmerz (mid-cycle pain)

Medical (can mimic an acute abdomen)

Pneumonia, MI, DKA, sickle cell crisis, porphyria
 Acute Abdomen: The

Examination
Liver (hepatitis)

Liver (hepatitis)
Gall bladder (gallstones)
Stomach (peptic ulcer,
gastritis) Spleen (rupture)
Gall bladder (gallstones) Transverse colon (cancer) Pancreas (pancreatitis)
Stomach (peptic ulcer, gastritis) Pancreas (pancreatitis) Stomach (peptic ulcer)
Hepatic flexure colon (cancer) Heart (MI)
Lung (pneumonia)
Splenic flexure colon
(cancer)
Lung (pneumonia)

Descending colon
Ascending colon
(cancer)
(cancer,)
Kidney (stone,
Kidney (stone,
hydronephrosis, UTI)
hydronephrosis, UTI)

Appendix (Appendicitis) Sigmoid colon

Caecum (tumour, (diverticulitis, colitis,
volvulus, closed loop cancer)
obstruction) Ovaries/fallopian tube
Terminal ileum (crohns, (ectopic, cyst, PID)
mekels) Ureter (renal colic)
Ovaries/fallopian tube
(ectopic, cyst, PID)
Ureter (renal colic) Small bowel
Uterus (fibroid, cancer) (obstruction/ischaemia)
Bladder (UTI, stone) Aorta (leaking AAA)
Sigmoid colon
(diverticulitis)
Acute Abdomen: The History
Abdominal pain features will point you towards
diagnosis

SOCRATES
Site and duration
Onset sudden vs gradual
Character colicky, sharp, dull, burning
Radiation e.g. Into back or shoulder
(Associated symptoms discussed later)
Timing constant, coming and going
Exacerbating and alleviating factors
Severity
2 other useful questions about the pain:
Have you had a similar pain previously?
What do you think could be causing the pain?
Acute Abdomen: The History
Associated symptoms
GI: bowels last opened, bowel habit
(diarrhoea/constipation), PR bleeding/melaena,
dyspeptic symptoms, vomiting
Urine: dysuria, heamaturia, urgency/frequency
Gynaecological: normal cycle, LMP, IMB,
dysmenorrhoea/menorrhagia, PV discharge
Others: fever, appetite, weight loss, distention

Any previous abdominal investigations

and findings
 Acute Abdomen: The
Examination
Inspection: scars/asymmetry/distention

Palaption:
Point of maximal tenderness
Features of peritonitis (localised vs generalised)
Guarding
Percussion tenderness
Rebound tenderness
Mass
Specific signs (Rosvigs sign, murphys sign, cullens sign, grey-turners sign)

Percussion: shifting dullness/tympanic

Auscultation: bowel sounds

Absent
Normal
Hyperactive

The above will point you to potential diagnosis

 Radiographic Test
Plain abdominal radiographs or
abdominal series has several
limitations and is subject to reader
interpretation.

CT scan in conjunction with

ultrasound is superior in identifying
any abnormality seen on plain film.
 Specific Diagnoses
In patients above fifty years of age the top four
reasons for acute abdominal pain are: Biliary Tract
Disease (21%,) NSAP (16%), Appendicitis(15%),
and Bowel Obstruction (12%).

In patients under fifty years of age the top three

reasons for acute abdominal pain are: NSAP
(40%,) Appendicitis (32%,) and Other (13%.)
 Acute Appendicitis
Clinical features with some predictive
value include:
Pain located in the RLQ
Pain migration from the periumbilical area to
the RLQ
Rigidity
Pain before vomiting
Positive psoas sign
Note: Anorexia is not a useful symptom
(33% pts not anorectic preoperatively.)
 Acute Appendicitis
Ultrasound can be used for detection,
but CT is preferred in adults and non-
pregnant women.

The CT scan can be with and without

contrast (oral & IV.)

A neg. CT does not exclude diagnosis,

but a positive scan confirms it.
 Appendicitis
Classic presentation
Periumbilical pain
Anorexia, nausea, vomiting
Pain localizes to RLQ
Occurs only in to 2/3 of
patients
26% of appendices are
retrocecal and cause pain in
the flank; 4% are in the RUQ
A pelvic appendix can cause
suprapubic pain, dysuria
Males may have pain in the
testicles
Findings
Depends on duration of
symptoms
Rebound, voluntary guarding,
rigidity, tenderness on rectal
exam
Psoas sign
Obturator sign
Fever (a late finding)
Urinalysis abnormal in 19-40%
Abdominal xrays
Appendiceal fecalith or gas,
localized ileus, blurred right
psoas muscle, free air
CT scan
Pericecal inflammation,
abscess, periappendiceal
phlegmon, fluid collection,
localized fat stranding
Appendicitis: Psoas Sign
Appendicitis: Psoas Sign
Appendicitis: Obturator Sign

Passively flex
right hip and knee
then internally
rotate the hip
 Appendicitis: CT findings

Cecum

Abscess, fat
stranding
 Biliary Tract Disease
Most common diagnosis in ED of pts
> 50.
Composed of:
Acute Cholecystitis (acalculus / calculus)
Biliary Colic
Common Duct Obstruction (Ascending
Cholangitis painful jundice / fever ).
 Biliary Tract Disease

Patients may complain of:

Diffuse pain in upper half of abdomen

Generalized tenderness

RUQ or RLQ pain.

 Biliary Tract Disease
Sonography (US) is the initial test of choice for
patients with suspected biliary tract disease. More
sensitive than CT scan to detect CBD obstruction.

CT scan is better in the identification of

cholecystitis than in the detection of CBD
obstruction.

Cholescintigraphy (radionclide / HIDA scan) of the

biliary tree is a more sensitive test than US for the
diagnosis of both of these conditions.
 Biliary Tract Disease
MR cholangiography (MRCP)

Has good specificity and sensitivity in

picking up stones and common duct
obstructions.

Less invasive / less complications than

ERCP
(ERCP can induce GI perforation, pancreatitis, biliary duct
injury)
 Cholecystitis
Clinical Features Physical Findings
RUQ or epigastric Epigastric or RUQ
pain pain
Radiation to the Murphys sign
back or shoulders Patient appears ill
Dull and achy Peritoneal signs
sharp and localized suggest perforation
Pain lasting longer
than 6 hours
N/V/anorexia
Fever, chills
 Cholecystitis
Diagnosis Treatment
CBC, LFTs, Lipase Surgical consult
Elevated alkaline IV fluids
phosphatase Correct electrolyte
Elevated lipase suggests abnormalities
gallstone pancreatitis
RUQ US
Analgesia
Thicken gallbladder wall
Antibiotics
Pericholecystic fluid NGT if intractable vomiting
Gallstones or sludge
Sonographic murphy sign
HIDA scan
more sensitive & specific
than US

H&P and laboratory

findings have a poor
predictive value if you
suspect it, get the US
 Small Bowel Obstruction
SBO may result from previous abdominal
surgeries.

Patient may present with intermittent, colicky

pain, abdominal distention, and abnormal BS.

Only 2 historical features (previous abd surgery

and intermittent / colicky pain) and 2 physical
findings (abd distention and abn BS) appear to
have predictive value in diagnosing SBO.
 Small Bowel Obstruction
Plain abd films has a large number of
indeterminate readings and can be
very limited due to the following:

Pt is obese

Pt is bedridden / contracted (limited lateral

decub / upright view)

Technical limitations
ABDOMINAL XR
 Bowel Obstruction
Small Bowel Large
Bowel
Central Peripheral
Valvulae conniventes Haustrae
Dia > 5cm > 10cm
SBO LBO
 Small Bowel Obstruction
CT scan is better than plain film in
detecting high grade SBO.

CT scan can also give more info that

might not be seen on plain film (i.e.
ischemic bowel)

Low grade SBO may require small bowel

follow through.
 Bowel Obstruction
Mechanical or Physical Findings
nonmechanical causes
Distention
#1 - Adhesions from
previous surgery Tympany
#2 - Groin hernia Absent, high pitched or
incarceration tinkling bowel sound or
Clinical Features rushes
Crampy, intermittent pain
Abdominal tenderness:
Periumbilical or diffuse
diffuse, localized, or
Inability to have BM or
flatus
minimal
N/V
Abdominal bloating
Sensation of fullness,
anorexia
 Bowel Obstruction
Diagnosis Treatment
CBC and electrolytes Fluid resuscitation
electrolyte abnormalities NGT
WBC >20,000 suggests Analgesia
bowel necrosis, abscess or Surgical consult
peritonitis
Hospital observation for
Abdominal x-ray series ileus
Flat, upright, and chest x- OR for complete
ray
obstruction
Air-fluid levels, dilated loops
of bowel
Lack of gas in distal bowel
and rectum
CT scan
Identify cause of obstruction
Delineate partial from
complete obstruction
 Acute Pancreatitis
80% of cases are due to alcohol abuse or gallstones.

Other common causes:

Drugs ( Valproic acid, Tetracycline, Hydrochlorothiazide,
Furosemide)
Pancreatic cancer
Abdominal trauma/surgery
Ulcer with pancreatic involvement
Familial pancreatitis (Hypertriglycerides / Hypercalcemia)
Iatrogenic (ERCP)
In Trinidad, the sting of the scorpion Tityus trinitatis is the most common cause
of acute pancreatitis

Definition :
Inflammation of the pancreas
Associated with edema, pancreatic autodigestion, necrosis and
possible hemorrhage
 Acute Pancreatitis
The inflammatory process around the
pancreas may cause other signs and
symptoms such as:
Pleural effusion
Grey Turner's sign ( flank discoloration )
Cullen's sign ( discoloration around the
umbilicus )
Ascites
Jaundice
 Acute Pancreatitis

Lipase testing is preferred in ED.

The height of the pancreatic enzyme

elevations do not have prognostic
value

A double contrast helical CT scan

stages severity and predicts mortality
sooner than Ransons Criteria.
 Acute Pancreatitis
Should consider ICU admission for
pts with high Ransons Criteria.

When making the diagnosis of Acute

Pancreatitis, it maybe necessary to
assess the pt for the following:
1. Biliary pancreatitis
2. Peripancreatic complications
 Acute Pancreatitis

Biliary pancreatitis
-Due to CBD obstruction.
-Can lead to Ascending Cholangitis

Clinical findings: May have a fever, jaundice / icterus

Lab findings: AST / ALT, Total Bilirubin

Radiological std:
MRCP - Test of choice to get clear images of the pancrease and CBD .
Double contrast CT - can also be use, may have limited view of the
CBD 2nd most common test to be ordered in ED

Ultrasound 1st most common test to be order in ED to evaluate for

CBD obstruction. More sensitive than CT scan to evaluate the CBD. Its
use is safer in pregnancy.
 Acute Pancreatitis
Peripancreatic complications:
Necrosis (Necrotizing Pancreatitis)
Hemorrhage (Hemorrhagic Pancreatitis)
Drainable fluid collections (Ruptured Pancreatic
Pseudocyst)

Clinical findings: May have a distended Abd,

appear septic, Cullens sign, and / or Grey Turners
Sign.

Radiological test: of choice to evaluate for the

above complications is a double contrast CT scan.
 Pancreatitis
Risk Factors Physical Findings
Alcohol Low-grade fevers
Gallstones Tachycardia, hypotension
Drugs Respiratory symptoms
Amiodarone, antivirals, Atelectasis
diuretics, NSAIDs, Pleural effusion
antibiotics, more.. Peritonitis a late finding
Severe hyperlipidemia
Ileus
Idiopathic
Cullen sign*
Clinical Features Bluish discoloration
Epigastric pain around the umbilicus
Constant, boring pain Grey Turner sign*
Radiates to back Bluish discoloration of
Severe the flanks
N/V
bloating *Signs of hemorrhagic pancreatitis
 Pancreatitis
Treatment
Diagnosis NPO
Lipase IV fluid resuscitation
Elevated more than 2 Maintain urine output of
times normal 100 mL/hr
Sensitivity and NGT if severe, persistent
specificity >90% nausea
Amylase No antibiotics unless severe
disease
Nonspecific E coli, Klebsiella,
Dont bother enterococci,
RUQ US if etiology staphylococci,
unknown pseudomonas
CT scan Imipenem or cipro with
Insensitive in early or metronidazole
mild disease Mild disease, tolerating oral
NOT necessary to fluids
diagnose pancreatitis Discharge on liquid diet
Useful to evaluate for Follow up in 24-48 hours
complications All others, admit
 Acute Diverticulitis
Less than of pts present with LLQ pain.

1/3 of pts present with pain to the lower

half of the abdomen.

20% of elderly pts with operatively

confirmed diverticulitis lacked abdominal
tenderness.

Elderly pts are at risk for a severe and often

fatal complication of diverticulitis.
(Free perforation of the colon)
 Diverticulitis
Risk factors Physical Exam
Diverticula Low-grade fever
Increasing age Localized tenderness
Clinical features Rebound and
Steady, deep guarding
discomfort in LLQ Left-sided pain on
Change in bowel rectal exam
habits Occult blood
Urinary symptoms Peritoneal signs
Tenesmus Suggest perforation
Paralytic ileus or abscess rupture
SBO
 Diverticulitis
Diagnosis Treatment
CT scan (IV and oral Fluids
contrast) Correct electrolyte
Pericolic fat abnormalities
stranding NPO
Diverticula Abx: gentamicin AND
Thickened bowel metronidazole OR
wall clindamycin OR
Peridiverticular levaquin/flagyl
abscess For outpatients (non-
Leukocytosis present toxic)
in only 36% of liquid diet x 48 hours
patients cipro and flagyl
 Perforated Peptic Ulcer
Abrupt onset of severe epigastric pain
followed by peritonitis
IV, oxygen, monitor
CBC, T&C, Lipase
Acute abdominal x-ray series
Lack of free air does NOT rule out perforation
Broad-spectrum antibiotics
Surgical consultation
Here is your patients x-
ray.
 Renal Colic
Pts may present with abrupt, colicky, unilateral flank
pain that radiates to the groin, testicle, or labia.

Hematuria and plain abd films can be helpful

however do not provide a strong support in the
diagnostic evaluation of suspected renal colic.

Noncontrast helical CT is standard for the diagnosis.

IVP has poor sensitivity and time consuming in ED
setting.

Must rule out AAA.

 Renal Colic
Clinical Features Physical Findings
Acute onset of severe, non tender or mild
dull, achy visceral pain tenderness to
Flank pain palpation
Radiates to abdomen Anxious, pacing,
or groin including writhing in bed
testicles unable to sit still
N/V and sometimes
diaphoresis
Fever is unusual
Waxing and waning
symptoms
 Renal Colic
Diagnosis Treatment
Urinalysis IV fluid boluses
RBCs Analgesia
WBCs suggest infection or Narcotics
other etiology for pain (ie NSAIDS
appendicitis) If no renal insufficiency
CBC Strain all urine
If infection suspected Follow up with urology in 1-2
BUN/Creatinine weeks
In older patients
If patient has single
kidney
If stone > 5mm, consider
If severe obstruction is admission and urology
suspected consult
CT scan If toxic appearing or
In older patients or infection found
patients with IV antibiotics
comorbidities (DM, SCD)
Not necessary in young Urologic consult
patients or patients with
h/o stones that pass
spontaneously
 Ovarian Torsion
Acute onset severe pelvic Obtain ultrasound
pain
May wax and wane Labs
Possible hx of ovarian cysts CBC, beta-hCG,
Menstrual cycle: midcycle electrolytes, T&S
also possibly in pregnancy
Can have variable exam: IV fluids
acute, rigid abdomen,
peritonitis
NPO
Fever Pain medications
Tachycardia
Decreased bowel sounds GYN consult
May look just like
Appendicitis
 Testicular Torsion
Sudden onset of severe Detorsion
testicular pain
Emergent urology
If torsion is repaired within 6
consult
hours of the initial insult, Ultrasound with
salvage rates of 80-100% are doppler
typical. These rates decline
to nearly 0% at 24 hours.

Approximately 5-10% of
torsed testes spontaneously
detorse, but the risk of
retorsion at a later date
remains high.
Most occur in males less than
20yrs old but 10% of affected
patients are older than 30
years.
 Ectopic Pregnancy
Symptoms include abdominal pain
(most common) and vaginal bleeding
(maybe the only complaint).

Female pts (child bearing age) that

present with these symptoms
automatically get a pregnancy test
and HCG quantitative level.
 Abdominal Aortic Aneurysm
Risk increases with age, women >70, men >55
Abdominal pain in 70-80% (not back pain!)
Back pain in 50%
Sudden onset of significant pain
Atypical locations of pain: hips, inguinal area, external genitalia
Syncope can occur
Hypotension may be present
Palpation of a tender, enlarged aorta on exam is an important
finding
May present with hematuria
Suspect it in any older patient with back, flank or abdominal pain
especially with a renal colic presentation
Ultrasound can reveal the presence of a AAA but is not helpful for
rupture. CT abd/pelvis without contrast for stable patients. High
suspicion in an unstable patient requires surgical consult and
emergent surgery.
 Mesenteric Ischemia (MI)
Diagnosis can be divided into the
following:

1. Arterial insufficiency
Occlusive Embolic (A. Fib) / Thrombotic
Embolic MI has the most abrupt onset.

Nonocclusive Low flow state (AMI / Shock)

Usually has clinical evidence of a low flow state
( acute cardiac disease)
Mesenteric Ischemia (MI)
2. Venous Mesenteric Venous
Thrombosis
Occurs in hypercoagulable states.

Usually is found in younger pts.

Has a lower mortality.

Can be treated with immediate

anticoagulation.
 Mesenteric Ischemia
Pt is usually older, has significant co-
morbidity, and with visceral type abdominal
pain poorly localized without tenderness.
Pt may have a diversion for food or weight
loss.
Elevated Lactate level may help in the
diagnosis.
Abd films may have findings of perforated
viscus and / or obstruction.
May find pneumotosis intestinalis, free fluid,
dilated bowel consistent with an ileus and / or
obstructive pattern on CT scan.
Angiography is the diagnostic and initial
therapeutic procedure of choice.
 Mesenteric Ischemia
Consider this diagnosis in all elderly patients with risk
factors
Atrial fibrillation, recent MI
Atherosclerosis, CHF, digoxin therapy
Hypercoagulability, prior DVT, liver disease
Severe pain, often refractory to analgesics
Relatively normal abdominal exam
Embolic source: sudden onset (more gradual if thrombosis)
Nausea, vomiting and anorexia are common
50% will have diarrhea
Eventually stools will be guiaic-positive
Metabolic acidosis and extreme leukocytosis when
advanced disease is present (bowel necrosis)
Diagnosis requires mesenteric angiography or CT
angiography
 Ischemic Colitis

It is a diagnosis of an older patient.

Pain described as diffuse, lower
abdominal pain in 80% of pts.
Can be accompanied by diarrhea often
mixed with blood in 60% of patients.
Compares to mesenteric ischemia, this is
not due to large vessel occlusive disease.
Angiography is not indicated. If it is
performed it is often normal.
 Ischemic Colitis

Can be seen post Abd Aorta surgery

The diagnosis is made by colonoscopy.
A color doppler ultrasound can also be
used.
In most cases only segmental areas of the
mucosa and submucosa are affected.
Chronic cases can lead to colonic stricture.
Treatment may include conservative
management or if bowel necrosis occurs
surgery may be needed for colectomy.
 Extrabdominal Diagnoses of Acute
Abdominal Pain: Hernias
Characterized by a defect through which
intraabdominal contents protrude during
increases in the intraabdominal pressure
Several types exist: inguinal, incisional,
periumbilical, and femoral (common in
Female).
Uncomplicated hernias can be
asymptomatic, aching / uncomfortable, and
reducible on exam.
Significant pain could mean strangulation
(blood supply is compromised) /
incarceration (not reducible).
 GI Bleeding
Upper
Proximal to Ligament of Treitz
Peptic ulcer disease most common
Erosive gastritis
Esophagitis
Esophageal and gastric varices
Mallory-Weiss tear
Lower
Hemorrhoids most common
Diverticulosis
Angiodysplasia
Acute Abdomen: Indication for
theatre
Urgent surgery should not be delayed for time
consuming tests when an indication for surgery is
clear

The following three categories of general surgical

problems will require emergency surgery
Generalised peritonitis on examination (regardless
of cause except acute pancreatitis, hence all
patients get amylase)
Perforation (air under diaphragm on E-CXR)
Irreducible and tender hernia (risk of strangulation)
Thank You