Acute abdomen

Acute Abdomen
Dr Uvaish Parmar
2nd year resident (General surgery)
Apollo hospital

What is acute abdomen?
An “acute abdomen” denotes
any sudden, spontaneous,severe abdominal pain typically of less
than 24 hours duration. with sign of tenderness
The acute abdomen requires rapid and specific diagnosis as several etiologies demand
urgent operative intervention. Because there is frequently a progressive underlying
intra-abdominal disorder, undue delay in diagnosis and treatment may adversely
affect outcome.

Causes of acute abdomen
 Hemorrhage
Solid organ trauma
Leaking or ruptured arterial aneurysm
Ruptured ectopic pregnancy
Bleeding gastrointestinal diverticulum
Arteriovenous malformation of gastrointestinal tract
Intestinal ulceration
Aortoduodenal fistula after aortic vascular graft
Hemorrhagic pancreatitis
Mallory-Weiss syndrome
Spontaneous rupture of spleen
 Infection
Appendicitis
Cholecystitis
Meckel’s diverticulitis
Hepatic abscess
Diverticular abscess
Psoas abscess

 Perforation
Perforated gastrointestinal ulcer
Perforated gastrointestinal cancer
Boerhaave syndrome
Perforated diverticulum
 Blockage
Adhesion induction small or large bowel obstruction
Sigmoid volvulus
Cecal volvulus
Incarcerated hernias
Inflammatory bowel disease
Gastrointestinal malignant neoplasm
Intussusception
 Ischemia
Buerger disease
Mesenteric thrombosis or embolism
Ovarian torsion
Ischemic colitis
Testicular torsion
Strangulated hernias

Non surgical cause of acute abdomen
 Endocrine and Metabolic Causes
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria Hereditary Mediterranean fever
 Hematologic Causes
Sickle cell crisis
Acute leukemia
Other blood dyscrasias
 Toxins and Drugs
Lead poisoning
Other heavy metal poisoning Narcotic withdrawal
Black widow spider poisoning

Anatomy and Physiology of abdominal
pain
Abd.pain
Visceral
component
Reffered
pain
Parietal
component

 Visceral pain tends to be vague and
poorly localized to the epigastrium,
periumbilical region, or hypogastrium,
depending on its origin from the
primitive foregut, midgut, or hindgut
 It is usually the result of distention of
a hollow viscus
 Parietal pain corresponds to the
segmental nerve roots innervating
the peritoneum and tends to be
sharper and better localized.

Referred pain
pain perceived at a site distant from the source of stimulus. For example,
irritation of the diaphragm may produce pain in the shoulder.
Determining whether the pain is visceral, parietal, or referred is important and can
usually be done with a careful history

As a result, an abscess may produce sharply localized pain with normal bowel sounds and gastrointestinal function
whereas a diffuse process, such as a perforated duodenal ulcer, produces generalized abdominal pain with a quiet abdomen
The fibrinous surface and decreased intestinal movement cause adherence between the bowel and omentum or abdominal wall and
help to localize inflammation
The bowel also develops local or generalized paralysis
increased blood flow, increased permeability, and the formation of a fibrinous exudate on its surface
Introduction of bacteria or irritating chemicals into the peritoneal cavity
Inflamatory response of peritoneal membrane

 Peritonitis is peritoneal inflammation from any cause.
 It is usually recognized on physical examination by severe tenderness to palpation,
with or without rebound tenderness, and guarding.
 Peritonitis is usually secondary to an inflammatory insult, most often gram
negative infections with enteric organisms or anaerobes.
 It can result from noninfectious inflammation, a common example being
pancreatitis.
 Primary peritonitis occurs more commonly in children and is most often due to
pneumococcus or hemolytic streptococcus.
 Adults with end-stage renal disease on peritoneal dialysis can develop infections of
their peritoneal fluid, with the most common organisms being gram-positive cocci.
 Adults with ascites and cirrhosis can develop primary peritonitis, and in these cases
the organisms are usually Escherichia coli and Klebsiella.

History taking
 A detailed and organized history is essential to formulating an accurate differential diagnosis and
subsequent treatment regimen.
 Modern advancements in imaging cannot and will never replace the need for a skilled clinician’s
careful history and bedside examination.
 Questions should be open ended whenever possible and structured to disclose the onset,
character, location, duration, radiation, and chronology of the pain experienced.

Sudden onset of
excruciating pain
e.g.
-Perforation
-Arterial
embolization
with ischemia
Progressively
worsening pain
Inflamation
or infection
-cholecystitis
-colitis
-ostruction
Intermittent
episodes of pian
-Bowel
obstruction
-Biliary colic
-Renal colic

 Solid organ visceral pain in the abdomen is generalized in the quadrant of the involved
organ, such as liver pain across the right upper quadrant of the abdomen.
 Small bowel pain is perceived as poorly localized periumbilical pain, whereas
 colon pain is centered between the umbilicus and the pubic symphysis. As inflammation
expands to involve the peritoneal surface, parietal nerve fibers from the spine allow focal
and intense sensation.
 This combination of innervation is responsible for the classic diffuse periumbilical pain of
early appendicitis that later shifts to become an intense focal pain in the right lower
abdomen at McBurney point.

 Aggravating and relieveing factors
 nausea
 Vomitting
 Constipation
 Diarrhea
 Pruriotus
 Melena
 Hematochezia
 Hematuria
 Gynecological history
 Medical history
 Surgical history etc

Physical examination
INSPECTION
Contour
Scars
Fascial hernias
Edema erythema
Ecchymosis
AUSCULTATION
Bowel sounds
Pitch and pattern of sound
Bruits
PERCUSSION
Air
Fluid

Palpation
 Start away from the pain area
 Differentiate voluntary guarding and involuntary guarding
 Site of maximum tenderness
 Digital rectal examinatrion
 Pervaginal examination

Laboratory investigations
o Hemoglobin
o White blood cell count with differential
o Electrolyte, blood urea nitrogen, and creatinine concentrations Urinalysis
o Urine human chorionic gonadotropin
o Amylase and lipase levels
o Total and direct bilirubin concentration
o Alkaline phosphatase
o Serum aminotransferase
o Serum lactate levels
o Stool for ova and parasites
o C. difficile culture and toxin assay

 A complete blood count with differential is valuable as most but not all patients with an acute
abdomen will have either a leukocytosis or bandemia.
 Serum electrolyte, blood urea nitrogen, and creatinine measurements will assist in evaluating
the effect of such factors as vomiting and third space fluid losses. In addition, they may suggest
an endocrine or metabolic diagnosis as the cause of the patient’s problem.
 Serum amylase and lipase determinations may suggest pancreatitis as the cause of the
abdominal pain, but levels can also be elevated in other disorders, such as small bowel
infarction and duodenal ulcer perforation.
 Normal serum amylase and lipase levels do not exclude pancreatitis as a possible diagnosis
because of the effects of chronic inflammation on enzyme production and timing factors.
 Liver function tests including total and direct bilirubin, serum aminotransferase, and alkaline
phosphatase are helpful in evaluating potential biliary tract causes of acute abdominal pain.
 Lactate levels and arterial blood gas determinations can be helpful in diagnosis of intestinal
ischemia or infarction.
 Urine testing, such as urinalysis, is helpful in the diagnosis of bacterial cystitis, pyelonephritis,
and certain endocrine abnormalities, such as diabetes and renal parenchymal diseases

IMAGING STUDIES
X ray
Upright chest radiographs can detect as little as 1 mL of air injected into the peritoneal cavity.
Lateral decubitus abdominal radiographs can also detect pneumoperitoneum effectively in
patients who cannot stand. As little as 5 to 10 mL of gas may be detected with this technique.
These studies are particularly helpful in patients suspected of having a perforated duodenal ulcer
as about 75% of these patients will have a large enough pneumoperitoneum to be visible
 Plain films also show abnormal calcifications. Approximately 5% of appendicoliths, 10% of
gallstones, and 90% of renal stones contain sufficient amounts of calcium to be radiopaque.
 Pancreatic calcifications seen in many patients with chronic pancreatitis are visible on plain
films, as are the calcifications in abdominal aortic aneurysms, visceral artery aneurysm, and
atherosclerosis in visceral vessels.

Upright and supine abdominal radiographs are helpful in identifying gastric outlet obstruction and
obstruction of the proximal, mid, or distal small bowel.
They can also aid in determining whether a small bowel obstruction is complete or partial by the presence or
absence of gas in the colon.
Colonic gas can be differentiated from small intestinal gas by the presence of haustral markings from the
taeniae coli in the colonic wall. Obstructed colon appears as distended bowel with haustral markings
Associated distention of small bowel may also be present, especially if the ileocecal valve is incompetent.
Plain films can also suggest volvulus of either the cecum or sigmoid colon.
Cecal volvulus is identified by a distended loop of colon in a comma shape with the concavity facing inferiorly
and to the right.
Sigmoid volvulus characteristically has the appearance of a bent inner tube with its apex in the right upper
quadrant

Ultrasonography
 Abdominal ultrasonography is extremely accurate in detecting gallstones and in assessing
gallbladder wall thickness and the presence of fluid around the gallbladder
 It is also good at determining the diameter of the extrahepatic and intrahepatic bile ducts. Its
usefulness in detecting common bile duct stones is limited.
 Abdominal and transvaginal ultrasonography can aid in the detection of abnormalities of the
ovaries, adnexa, and uterus. Ultrasound can also detect intraperitoneal fluid.
 The presence of abnormal amounts of intestinal air in most patients
with an acute abdomen limits the ability of ultrasonography to evaluate
the pancreas or other abdominal organs. There are important limits to
the value of ultrasonography in the diagnosis of diseases that are
manifested as an acute abdomen. Ultrasound has been found to be
clinically inferior to CT scanning for the diagnosis of appendicitis.
 In addition, ultrasound images are more difficult for most surgeons to interpret than are plain
radiographs and CT images. Many hospitals have radiologic technologists available at all times to
perform CT, but this is often not the case with ultrasonography. As CT has become more widely
available and less likely to be hindered by abdominal air, it is becoming the secondary imaging
modality of choice in the patient with an acute abdomen, following plain abdominal radiographs.

CT scan
 Computed tomography (CT) scan of the abdomen is now generally routinely and rapidly available.
 This has proved extremely useful in the evaluation of abdominal complaints for patients who do not
already have clear indications for laparotomy or laparoscopy. CT provides excellent diagnostic
accuracy.
 Whether contrast is used should be carefully weighed on an individual basis. IV contrast administration
may be limited by creatinine impairment.
 Oral contrast is useful to distinguish bowel from remaining abdominal contents. It can be administered
orally or rectally; oral administration adds significant time to obtaining imaging and may not be
appropriate in severely ill patients. With newer scanners the use of oral contrast is often unnecessary
unless looking for bowel perforation or anastomotic leak.
 Newer low-dose CT scans are becoming available which reduce radiation exposure and provide
advantages for pediatric imaging.
 CT scans should be used sparingly in pregnancy because of the risk radiation poses to the fetus,
especially in the first trimester. Ultrasound or MRI are preferred imaging techniques in pregnancy.
 CT can identify small amounts of free intraperitoneal gas and sites of inflammatory diseases that may
prompt (appendicitis, tuboovarian abscess) or postpone (noncomplicated diverticulitis, pancreatitis,
hepatic abscess) operation.
 It should not replace or delay operation in a patient for whom the findings will not change the decision
to operate. CT has proven helpful in the diagnosis of appendicitis, especially where examination and
laboratory data may not be clear, and is recommended in women, where other pelvic pathology may
explain the presence of right lower quadrant pain.

Other imaging madalities
 Angiography
 Gastrointestinal contrast study
 Radionucleotide scan
 Endoscopy
 Paracentesis
 Diadnostic laproscopy

Intra abdominal pressure monitoring
An elevated intra-abdominal pressure can be a symptom of an acute abdominal process or it can be the
cause of the process.
Abnormally increased intra-abdominal pressures diminish the blood flow to abdominal organs and
decrease venous return to the heart while increasing venous stasis. Increased pressure in the abdomen
can also press upward on the diaphragm, thereby increasing peak inspiratory pressures and decreasing
ventilatory efficiency.
Risk of esophageal reflux and pulmonary aspiration has also been associated with abdominal
hypertension.
It is important to consider the possibility of abdominal hypertension in any patient who presents with a
rigid or significantly distended abdomen.

Indications for urgent operation in patients with
an acute abdomen
 Physical Findings
 Abdominal compartment pressures >30 mm Hg
 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 Rectal bleeding with shock or acidosis
 Equivocal abdominal findings along with septicemia (high fever, marked or rising leukocytosis, mental changes, or increasing
glucose intolerance in a diabetic patient)
 Bleeding (unexplained shock or acidosis, falling hematocrit) Suspected ischemia (acidosis, fever, tachycardia) Deterioration
on conservative treatment
 Gastrointestinal haemorrhage requiring >4 units of blood without stabilization
 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

Diagnostic Peritoneal Lavage (1000 mL)
 >250 white blood cells per milliliter of aspirate
 >300,000 red blood cells per milliliter of aspirate
 Bilirubin level higher than plasma level (bile leak) within aspirate Presence of
particulate matter (stool)
 Creatinine level higher than plasma level in aspirate (urine leak)

Preparation for emergency surgery
 Patients with an acute abdomen vary greatly in their overall state of health at the time the decision
to operate is made. Regardless of the patient’s severity of illness, all patients require some degree of
preoperative preparation.
 Intravenous access should be obtained and any fluid or electrolyte abnormalities corrected.
 Nearly all patients will require antibiotic infusions. The bacteria common in acute abdominal
emergencies are gram-negative enteric organisms and anaerobes.
 Infusions of antibiotics to cover these organisms should be begun once a presumptive diagnosis is
made. Patients with generalized paralytic ileus or vomiting benefit from nasogastric tube placement
to decrease the likelihood of vomiting and aspiration.
 Foley catheter bladder drainage to assess urine output, a measure of adequacy of fluid resuscitation,
is indicated in most patients.
 Preoperative urine output of 0.5 mL/ kg/hr,
 systolic blood pressure of at least 100 mm Hg
 pulse rate of 100 beats/min or less are indicative of an adequate intravascular volume.
 A common electrolyte abnormality requiring correction is hypokalemia.
 Preoperative acidosis may respond to fluid repletion and intravenous bicarbonate infusion.
 Acidosis due to intestinal ischemia or infarction may be refractory to preoperative therapy.
 Placement of a central venous catheter may facilitate resuscitation and allow accelerated correction
of potassium concentration.

 Significant anemia is uncommon, and preoperative blood transfusions are usually
unnecessary. However, most patients should have blood typed and crossmatched and
available at operation.
 There is an inherent uncertainty in the operation that will be required in these patients, and
having crossmatched blood available avoids transfusion delay if unexpected intraoperative
events occur.
 The need for preoperative stabilization of patients must be weighed against the increased
morbidity and mortality associated with a delay in the treatment of some of the surgical
diseases that are manifested as an acute abdomen. T
 he underlying nature of the disease process, such as infarcted bowel, may require surgical
correction before stabilization of the patient’s vital signs and restoration of acid-base
balance can occur.
 Resuscitation should be viewed as an ongoing process and continued after the surgery is
completed. Deciding when the maximum benefit of preoperative therapy in these patients
has been achieved requires good surgical judgment.

Causes of Acute Abdominal Pain in the
Immunocompromised Patient
 Opportunistic Infections
Endemic mycoses (coccidioidomycosis, blastomycosis, histoplasmosis)
Tuberculin peritonitis
Aspergillosis
Neutropenic colitis (typhlitis)
Pseudomembranous colitis
Cytomegalovirus colitis, gastritis, esophagitis, nephritis Epstein-Barr virus
Hepatic abscesses (fungal or pyogenic)
Iatrogenic Conditions
 Graft-versus-host disease with hepatitis or enteritis
 Peptic ulcer or perforation from steroid use
 Pancreatitis caused by steroids or azathioprine
 Hepatic veno-occlusive disease (secondary to primary immunodeficiency or chemotherapy)
 Nephrolithiasis caused by indinavir treatment of HIV

Common Pitfalls
• Failure to thoroughly examine and document findings
• Failure to perform a rectal or vaginal examination when
appropriate
• Failure to evaluate for hernias, including the scrotal region
• Failure to conduct a pregnancy test or to consider pregnancy
in the diagnosis
• Failure to reassess the patient frequently while developing a
differential diagnosis
• Failure to reconsider an established diagnosis when the clinical
situation changes
• Failure to recognize immune compromise and to appreciate its
masking effect on the historical and examination findings
• Allowing a normal laboratory value to dissuade a diagnosis
when there is cause for clinical concern
• Failure to consult colleagues when appropriate
• Failure to take age- and situation-specific diagnoses into
consideration
• Failure to make specific and concrete follow-up arrangements
when monitoring a clinical situation on an outpatient basis
• Hesitancy to go to the operating room without a firm diagnosis
when the clinical situation suggests surgical disease

References
-Sabiston textbook of surgery
-ACS surgery:principles and practice
-Bailey and love’s short practice of surgery
-current diagnosis and treatment surgery 14th edition

Acute abdomen

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