Acute Abdomen Presentation Alx

ACUTE ABDOMEN
Prepared by:- Alemu Daniel (MSC in Emergency Medicine and CC)

Outline
• Introduction
• Evaluating patients
• Common acute surgical abdomen
• Management
• Case presentation
Introduction
• The term acute abdomen refers to

abdominal pain of short duration
that requires a decision regarding
whether an urgent intervention is
necessary.
• This problem is the most common cause that
needs surgical consultation
Causes may be surgical, medical, gynecologic

Pathophysiology
• Visceral Pain
 Occurs with the stretching of nerve fibers in the

walls of hollow organs or the capsules of solid
organs
 Foregut (epigastrium)
esophagus, stomach, doudenum,
pancreas, liver, gallbladder
 Midgut (umbilical )
small intestine, Rt. Colon,
transverse colon, appendix
 Hindgut (hypogastrium)
Lt. colon, sigmoid, rectum
Parietal pain
Due to irritation of the parietal peritoneum.
• The patient is more readily able to

localize the pain (eg, LLQ pain in
diverticulitis), but when the entire
peritoneal cavity is involved, the pain is
diffuse.
REFERRED PAIN
Is felt at a location distant from the diseased organ
Evaluation of a patient
• History
• Physical exam
• Laboratory
• Radiological exam
History
focus on details of the pain. This
includes
• The onset (sudden, gradual)
– Sudden-- perforation, hemorrhage, infarction
– Gradual --peritoneal irritation, hollow organ distension
• Character (burning,tearing)
• Duration (intermitent, continuous)

Cont…..
• location (RUQ,RLQ,LUQ,LLQ)
• radiation of pain(shared innervations)
 Right shoulder, angle of right scapula = gall bladder
• Associated symptoms(N/V, diarrhea, constipation)

• Aggravating/alleviating factors(position, eating)
Cont’d
• Past medical and surgical history

• Comorbidity (DM,HTN)
• Medication use(anticoagulant, NSAID)
• Social history
(drug, alcohol, cocaine, gynecologic history

Physical exam
• Come to the rt side of the patient
• Take consent from the patient
• Properly expose the patient
Inspection
• for distention (with air, fetuse, or fluid),
scars, hernia and masses.
Palpation
• Ask the patient whether there is a
pain in abdomen or not
• Warm your hands
• Superficially and then deeply
• Check for pain ﬁrst with superﬁcial palpation
• Masses can be localized by checking for mobility
• Guarding(Voluntary, involuntary)
– Board-like rigidity suggests generalized
peritonitis
– Can produce various signs (murphy’s,

Rovsing’s)
– PR exam
Percussion
Dull mass, pneumoperitonium
Organ size ,ascites
Auscultation
• Gurgling and high pitched =
Obstruction
• Absent = Peritonitis or paralytic ileus
• Bruits = Vascular(renal artery
stenosis)
Laboratory investigation
»CBC
»HCT
»Serum electrolyte, BUN, Cr
»LFT
»Serum amylase and
lipase
»Urine analysis, HCG
Radiology
• Plain abdominal film (perforated
viscus, intestinal obstruction)
• U/S
(hepatobiliary ,pregnancy)
• CT (appendicitis)
• MRI less ideal
• Diagnostic laparoscopy (NSAP)
Differential Diagnosis
Clinical pattern
• Abdominal pain and shock
• Generalized peritonitis
• Localized peritonitis
• Intestinal obstruction
• Medical illness
• Two additional patterns
trauma
gynecological
Abdominal pain and shock
• Most dramatic and least common
• Patient typically present pale and

diaphoretic, in severe abdominal pain
and with hypotension, the so called abdominal
apoplexy
Cont….
• E.g. Ruptured AAA, mesenteric ischemia,
ruptured EP
• The only management option is

immediate surgery now!
Generalized peritonitis
• Diffuse severe abdominal pain in a patient who

looks sick and toxic
• Motionless and extremely tender abdomen
• Peritoneal signs (guarding, rigidity, rebound

tenderness)
Cont…
E.g.. Perforated PUD, Perforated colon,
Perforated appendicitis
• Pre operative preparation and operation

( surgery tonight !)
Localized peritonitis
Clinical signs are localized to one quadrant

of the abdomen
• Acute appendicitis RLQ

• Acute cholecystitis RUQ
• Acute diverticulitis LLQ
• Management depend on etiology
Intestinal obstruction
• Small bowel obstruction(SBO) 80%

Causes:
 adhesion,
 hernias,
 neoplasm band(abnormal growth of tissue)
 volvulus
• Obstruction of the gastrointestinal tract may occur at
any level, but the small intestine is most often involved
due to its narrow lumen.
• The causes of small and large intestinal obstruction are

presented in Tumors and infarction, although the most
serious, account for only about 10% to 15% of small-
bowel obstructions. Four of the entities—hernias,
intestinal adhesions, intussusception, and volvulus—
collectively account for 80% .
• The clinical manifestations of intestinal
obstruction include abdominal pain and
distention, vomiting, constipation, and
failure to pass flatus.
• If the obstruction is mechanical or vascular in

origin, immediate surgical intervention is usually
required.
HERNIAS
• A weakness or defect in the wall of the peritoneal cavity
may permit protrusion of a pouch-like, serosa-lined sac of
peritoneum called a hernial sac.
• The usual sites of such weakness are anterior at the

inguinal and femoral canals, umbilicus, and in surgical
scars. Rarely, retroperitoneal hernias may occur, chiefly
about the ligament of Trietz.
• Hernias are of concern chiefly because segments of

viscera frequently protrude and become trapped in them
(external herniation). This is particularly true with
inguinal hernias, since they tend to have narrow orifices
and large sacs.
HERNIA
• The most frequent intruders are small-bowel loops, but
portions of omentum or large bowel also may become
trapped. Pressure at the neck of the pouch may
impair venous drainage of the trapped viscus.
• The resultant stasis and edema increase the bulk of

the herniated loop, leading to permanent trapping, or
incarceration. With time, compromise of arterial
supply and venous drainage (strangulation) leads to
infarction of the trapped segment.
ADHESIONS
• Surgical procedures, infection, often cause
localized or more general peritoneal inflammation
(peritonitis).
• As the peritonitis heals, adhesions may develop

between bowel segments and/or the abdominal
wall and operative site. These fibrous bridges can
create closed loops through which other viscera
may slide and eventually become trapped
(internal herniation).
INTUSSUSCEPTION
• Intussusception occurs when one segment of the

intestine, constricted by a wave of peristalsis,
suddenly becomes telescoped into the
immediately distal segment of bowel. Once
trapped, the invaginated segment is propelled by
peristalsis farther into the distal segment, pulling
its mesentery along behind it.
INTUSSUSCEPTION
• When encountered in infants and children,

there is usually no underlying anatomic
lesion or defect in the bowel, and the
patient is otherwise healthy. Some cases of
intussusception are associated with
rotavirus infection, suggesting that
localized intestinal inflammation may serve
as a traction point for the intussusception.
INTUSSUSCEPTION
• However, intussusception in
adults signifies an intraluminal
mass or tumor as the point of
traction. In both settings,
intestinal obstruction ensues,
and trapping of mesenteric
vessels leads to infarction.
VOLVULUS
• Complete twisting of a loop of bowel about its
mesenteric base of attachment also produces
intestinal obstruction and infarction.
• This lesion occurs most often in large redundant

loops of sigmoid, followed in frequency by the
cecum, small bowel (all or portions), stomach, or
(rarely) transverse colon. Recognition of this
seldom-encountered lesion demands constant
awareness of its possible occurrence.
Cont….
• Large bowel obstruction (LBO)20%
Cause:
sigmoid volvulus(twisting of intestine)
 predisposing factors high residue
diet, constipation
Features of obstruction
• In high small bowel
obstruction,
vomiting occurs early and is
profuse with rapid dehydration.
Distension is minimal with little
evidence of fluid levels on
abdominal radiography
• In low small bowel
obstruction,
Pain is predominant with central
distension. Vomiting is delayed.
Multiple central fluid levels are
seen on radiography
In large bowel obstruction
 Distension is early and pronounced.
 Pain is mild and vomiting and

dehydration are late.
 The proximal colon and cecum are

distended on abdominal radiography
Cardinal clinical features of acute obstruction
¦
• Abdominal pain
• Distension
• Vomiting
• Absolute constipation
Medical causes
• Inferior wall MI and DKA must be kept in mind
• Others include basal pneumonia
• History and thorough physical exam is needed

Management options
• Immediate operation (surgery now)
• Pre operative preparation and

operation(surgery tomorrow)
• Conservative treatment (active

observation, IV fluids, antibiotics)
• Discharge home
THANK YOU!

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ACUTE ABDOMEN

Prepared by:- Alemu Daniel (MSC in Emergency Medicine and CC)

• The term acute abdomen refers to

Causes may be surgical, medical, gynecologic

 Occurs with the stretching of nerve fibers in the

• The patient is more readily able to

• Duration (intermitent, continuous)

• Associated symptoms(N/V, diarrhea, constipation)

• Past medical and surgical history

(drug, alcohol, cocaine, gynecologic history

– Can produce various signs (murphy’s,

• Two additional patterns

• Most dramatic and least common

• Patient typically present pale and

• The only management option is

• Diffuse severe abdominal pain in a patient who

• Motionless and extremely tender abdomen

• Peritoneal signs (guarding, rigidity, rebound

• Pre operative preparation and operation

Clinical signs are localized to one quadrant

• Acute appendicitis RLQ

• Small bowel obstruction(SBO) 80%

• The causes of small and large intestinal obstruction are

• If the obstruction is mechanical or vascular in

• The usual sites of such weakness are anterior at the

• Hernias are of concern chiefly because segments of

• The resultant stasis and edema increase the bulk of

• As the peritonitis heals, adhesions may develop

• Intussusception occurs when one segment of the

• When encountered in infants and children,

• This lesion occurs most often in large redundant

 Distension is early and pronounced.

 Pain is mild and vomiting and

 The proximal colon and cecum are

• Others include basal pneumonia

• History and thorough physical exam is needed

• Pre operative preparation and

• Conservative treatment (active

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