The Acute Abdomen
Andik Kusbiantoro
SMF Ilmu Bedah RSUD Dr.R.Soedjono Selong
Definition
• Acute abdomen describes clinical condition as result of emergency situations intra abdominal condition that needs immediate surgical intervention
• with pain as main symptom
Introduction
• 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.
Assesment
• Well elicited history• Proper physical examination Diagnosis can be made most of the time by Diagnosis can be made most of the time by
a good history and a proper physical a good history and a proper physical examination.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
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
Other history• Past surgical history: previous operations- leading
to adhesions• Past medical history: Sickle cell disease, Diabetes
or Cancer or Renal failure• Menstrual History in females
– Missed period- ectopic pregnancy– Mid of period-ovulation pain (Mittel- schmerz)– With heavy periods- endometriosis
• Family history of colon cancer, any other malignancy or inflammatory bowel disease
Pain The Most Important Symptom
History of pain should include:1. Onset2. Severity3. Type of pain4. Radiation of Pain5. Change in nature of Pain6. Associated bowel or urinary symptoms7. Aggravating or relieving factors
Onset of Pain (cont…)• 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
Progression of Pain (cont…)
Progression from : Dull, aching, poorly localized character
To:Sharp, constant & better localized painindicates involvement of Parietal peritoneum
Table 1. Sensory innervations of intra abdominal structures
Structure Nerve LevelMiddle part of Diaphragm
Phrenicus C 3-5
Edge of diaphragm, stomach, pancreas, gall bladder, intestine
Plexus celiac Th 6-9
Appendix,proximal colon
Plexus mesentericus Th 10-11
Distal colon, rectum, kidney, urethra & testis
Splanchnic caudal Th 11-L 1
Vesica urinary, recto sigmoid
S 2-4
Figure 1. Innervations of diaphragm and shoulder
Figure 2.Referred pain and shifting pain in the acute abdomen
Referred Pain
Shifting Pain
Abrupt, excruciating pain Rapid onset of severe, constant pain
Gradual, steady pain Intermittent, colicky pain with free interval
Figure 3. The location and character of the pain are useful in the differential diagnosis of the acute abdomen
Colic billier
Colic ureter
IMA
Perforated ulcer
Ruptured aneurysm
Acute pancreatitis
Mesenteric thrombosis, strangulated bowel
Ectopic pregnancy
Acute cholecystitis, acute cholangitis, acute hepatitis
Appendicitis, salpingitis
Colic billier
Early pancreatitis (rare)
Small bowel obstruction IBD
Nausea & Vomiting
• Frequency of vomiting• Character of vomiting:
projectile, non-projectile or self-induced• 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
Urinary Symptomswith Pain
• Ureteric colic • Cystitis
Table 2. Physical findings with various causes of acute abdomen
Conditions Helpful signPerforated viscous Scaphoid (early), tense abdomen, diminished
bowel sound (late), loss of liver dullness, guarding or rigidity
Peritonitis Motionless, absent bowel sound (late), rebound tenderness, guarding
Inflamed mass or abscess Tender mass, special sign (Murphy's, obturator or psoas)
Intestinal obstruction Distention, visible peristaltis (late), hyperperistaltis (early) or quiet abdomen (late), diffuse pain, hernia (some)
Paralytic ileus Distention, minimal bowel sound
Ischemic or strangulated bowel
Not distended (until late), severe pain, rectal bleeding (some)
Bleeding Pallor, shock, distention, pulsatile (aneurysm)
Figure 3. Causes of shock in patients with acute abdomen
Consideration of Surgery Intervention
• Decision of surgery intervention on acute abdomen depends on correct diagnosis. If we got difficulties to make decision, we should observe patient closely.
• Meanwhile patient must fasting, apply naso gastric tube and IV line
Table 3. Indications for urgent operations in patients with acute abdomen
Physical findings Involuntary guarding or rigidity, especially if spreading Increasing or severe localized tenderness Tense or progressive distention Tender or abdominal or rectal mass with high fever or hypotension Rectal bleeding with shock or acidosis Radiologic findings Pneumoperitoneum Gross or progressive bowel distention Free extravasations of contrast material Space occupying lesion on scan, with fever Mesenteric occlusion on angiography
Summary
• Acute abdomen is serious surgical emergency requiring the surgeon to combine the result of the history and physical examination with properly selected laboratory and radiographic studies
• Correct preoperative diagnosis will usually lead to a successful operation
Physical Examination
General Appearancea. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitisb. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colicc. Writhing in Pain: Mesenteric Ischemia
Physical Examination (cont...)
d. Bending Forward: Chronic Pancreatitise. Jaundiced: CBD obstructionf. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction
Physical Examination (cont...)
• Vital Charting• Temperature, Pulse, BP, Respiratory rate• Ruptured AAA or ectopic pregnancy can lead to -Pallor -Hypotension -Tachycardia -Tachypnea
Physical Examination (cont...)
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
Extra abdominal conditions that causes abdominal pain
• These may rarely present as referred abdominal pain.
• The most important to remember :– Pneumonia (especially lower lobe) – Myocardial Infarction.
• Those diseases tend to be “ Medical” diseases and surgery is not generally indicated
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
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
• Rovsing’s Sign in Acute Appendicitis• Obturator Sign in Pelvic Appendicitis• Psoas Sign
– Retrocaecal appendicitis– Crohn’s Disease– Perinephric Abscess
• Murphy's sign in Acute Cholecystitis
Systemic Examination
Per Rectal Examination: - tenderness - induration - mass - frank blood
Investigations
• Complete Blood Count with differential• C-reactive protein estimation• Electrolyte, Blood Urea, Creatinine• Urine dipstick• Amylase or Lipase• Liver Function Test
Radiology
Chest x rayAbdominal x ray
Investigations
Other Investigations- USG- CT abdomen for AAA, Pancreatic disease,
or ureteric colic (non- Contrast)- IVU- Mesenteric Angiography for Ischaemia, Haemorrhage
THANK YOU
Recommended