UNDERSTANDING

ACUTE ABDOMEN

Dr.Md. Majedul Islam

MBBS, FCPS(Surgery)
Specialist, Department of General Surgery

Square Hospital Ltd

 ACUTE ABDOMEN

The acute abdomen characterised by the any sudden,

spontaneous, nontraumatic, severe abdominal pain of less
than 24 hours duration.

The acute abdomen requires rapid and specific diagnosis as several etiologies
demand urgent operative intervention. Because undue delay in diagnosis and
treatment may adversely affect outcome.
 COMMON CAUSES OF THE ACUTE
ABDOMEN
GIT Hepatobiliary and Urinary Gynaecological Others
pancreatic Tract

NSAP* Acute cholecystitis* Urolithiasis* Rupture EP Ruptured AAA

Appendicitis* Acute cholangitis Acute Acute salphingitis* Ischemic colitis

pyelonephritis*
Small & large Acute pancreatitis* Acute cystitis* Twisted ovarian Mesenteric
bowel tumour thrombosis
obstruction*
Perforated PUD* Hepatic abscess Testicular torsion Dysmenorrohea Intra abdominal
Meckel’s abscess
diverticultis

Incarcerated Endometriosis Primary Peritonitis

hernia
Bowel Mittelsmerz Tubercular peritonitis
perforation*
Gastroenteritis* Retroperitoneal Hge
Acute gastritis etc
MEDICAL CAUSES OF ACUTE ABDOMINAL
PAIN
Endocrine and Hematological Referred pain Inflammatory Toxin & Drug
metabloic

Uremia Sickle cell crisis MI Herpes Zoster Lead poisoning

Diabetic crisis Acute Leukemia Pneumonia SLE Narcotic

withdrawal

Addisonian crisis Other dyscrasias Pleurisy Rheumatic fever

Porphyria Pneumothorax PAN

Hereditary Empyema, etc HSP

Mediterranean
fever . etc
 DIAGNOSIS OF ACUTE ABDOMEN

A. History
• Abdominal pain & Other Symptoms Associated with Abdominal Pain
• Past medical history / Past Surgical history
• Gynaecological history
• Medication history
• Family History
• Travel history

B. Physical Examination
C. Laboratory Investigation
D.Imaging studies
E. Diagnostic Laparoscopy.
 ABDOMINAL PAIN IN ACUTE ABDOMEN

Pain is the most common and predominant presenting feature of an

acute abdomen. Careful consideration of the
• Location,
• severity,
• mode of onset and progression,
• the character of the pain will suggest a preliminary list of diagnoses.
Abdominal pain may be :
1. Visceral pain
2. Parietal Pain
3. Referred pain and shifting pain
 ABDOMINAL PAIN CONTD.

Visceral Pain:
* Distention, inflammation, ischemia or malignant infiltration of
sensory nerves.
* Slow in onset, dull, poorly localized.
* Most often felt in the midline because of the bilateral sensory
supply to the spinal cord.
FIGURE: VISCERAL PAIN SITES.
 ABDOMINAL PAIN CONTD.

Parietal Pain:
• Direct irritation parietal peritoneum by pus, bile, urine, or GI
secretions.
• More acute, sharper, better localized pain.
• The cutaneous distribution of parietal pain corresponds to the T6-
L1 areas.
 ABDOMINAL PAIN CONTD.

• Referred pain/Radiation pain : Extension of the

pain(usually cutaneous sensations) from
original site to another site with persisting pain
at the originial site.

• Spreading or shifting pain: Origin of the pain is

in one site later pain shifts to another site
where pain at the initial site disappear.
• The mode of onset of pain:

1. explosive (within seconds),

2. rapidly progressive (within 1-2 hours), or
3. gradual (over several hours).
TYPICAL SITE OF VARIOUS ABDOMINAL PAIN
 CHARACTER OF PAIN
1. Colicky pain – Sharp intermitten gripping pain i.e – obsturction to a
hollow organ.
2. Constant burning pain – feature of peritonitis
3. Severe Agonising pain – Characterstics of acute pancreatitis.
4. Throbbing pain – suggestive of inflammation i.e – Cholecystitis

Change in character of pain i.e – colicky pain sometime change into

constant pain indicate strangulation.
VOMITING (OTHER ASSOCIATED SYMPTOMS)

Differential diagnosis of characterstics of vomit with abdominal pain

1. Billous(green) : Intestinal obstruction, Malrotation or sepsis
2. Coffee ground : Gastritis, gastric ulcer, esophagitis.
3. Fresh blood : Esophagitis, gastritis, Gastric/duodenal ulcer, Mallory-
Weiss tear
4. Food/Stomach content: Gastroenteritis, Early small intestinal
obstruction.
5. Feculent: Late intestinal content.
 OTHER SYMPTOMS ASSOCIATED WITH ABDOMINAL PAIN

1. Constipation : Suggest mechanical bowel obstruction.

2. Diarrhea: Suggests Pelvic abscess, blood stained suggests ischemic
colitis, IBD etc
3. Fever: marker of inflammation
4. Other symptom:
• Hematemesis
• Hematochezia or melena a lower GI bleed or colonic ischemia and
• Hematuria, ureteral colic, or cystitis.
 PAST MEDICAL & SURGICAL HISTORY

Past Medical History: Past Surgical History:

1. Pulmonary TB 1. Previous abdominal surgery.
2. Cardiac Disease: AF 2. Mode of operation (laparoscopic, open,
3. PUD endovascular)

4. Biliary colic & Pancreatitis 3. Operative notes and pathology reports

should be obtained and reviewed.
5. IBD
6. Abdominal trauma i.e Delayed splenic
bledding. etc
 OTHER RELEVANT ASPECTS OF THE HISTORY

Gynaecological History: 1. Medication History: NSAIDS or aspirin,

Anticoagulants or antiplatelet drug. OCP,
Corticosteroid or chemotherapeutic or
• 1. The menstrual history is is crucial to the diagnosis of immunosuppressive drugs.
ectopic pregnancy, mittelschmerz (due to a ruptured
ovarian follicle) and endometriosis.
2. Family history: Hereditary pancreatits
• 2. A history of vaginal discharge or dysmenorrhea may
denote pelvic inflammatory disease.
3. Travel History : amebic liver abscess
or hydatid cyst, malarial spleen, tuberculosis,
Salmonella typhi infection of the ileocecal area, or
dysentery.
 PHYSICAL EXAMINATION

1. Appearance:
• Hippocratic facies
• Facies of dehydration

2. Attitude
3. Vitals
Pulse, BP, Respiratory rate, Temp, dehydration

4. Anaemia, cyanosis, Jaundice

 ABDOMINAL EXAMINATION

1. Inspection: 2. Palpation:
• Hernial Orifices • Hyperasthesia
• Abdominal contour • Tenderness
• Respiratory Movement • Distension
• Peristaltic movement • Lump
• Visible swelling • Hernial Site
• Skin condition
 ABDOMINAL FINDINGS IN DIFFERENT CONDITION

Perforated Viscus/Peritonitis : Intestinal Obstruction:

• Tenderness ± guarding/rigidity/rebound of • Diffuse pain without rebound tenderness
abdominal wall • Abdominal distension(late)
• Pain/tenderness on rectal/vaginal • Hyperperistalsis(Early)
examination (pelvic peritonitis) • Quiet Abdomen(late)
• Absent or reduced bowel sounds • No localized tenderness(Paralytic ileus)
• Tenderness, rigidity & P/R bleeding(Strangulation)
 SPECIAL SIGN
Four sign that may prove helpful in deciding the momentous question

“Is this an acute abdomen”

1. The pointing test /pointing sign
2. The cough test/Dunphy’s sign
3. Rebound tenderness/release sign/Blumberg ‘s sign
4. The Bed-Shaking Test/Bapat’s sign.

Other’s
* Alder’s Sign : Shifting tenderness helpful to differentiate between appendicitis
with uterine origin tenderness.
 IMPORTANT SIGN IN PT WITH ABDOMINAL
PAIN

1. Murphy’s sign – Acute cholecystitis

2. Kehr’s sign – Splenic ruptute, Ectopic pregnancy rupture.
3. McBurney’s sign – Appendicitis
4. Iliopsoas sign _ Appendicitis
5. Rovsin sign- Appendicitis.
6. K sign – Appendicitis
7. Grey Turners sign – Hemoperitoneum.
8. Chandelier sign – PID .
9. Dance sign – Intussusception. etc
 OTHER EXAMINATION
1. Percussion:
• Shifting dullness – presence of free fluid
• Obliteration of liver dullness – pneumoperitoneum

2. Auscultaion :
• Silent – peritonitis
• Increase peristaaltic sound in intestinal obstruction
3. Rectal examination
4. Vaginal examination
 LABORATORY INVESTIGATION

A. Blood Studies:
• Neutrophilic leucocytosis
• CRP
• Electrolyte, Creatinine & BUN
• ABG
• Serum Lactate(Raised in ischemic bowel)
• Lipase
• Liver function tests if suspect hepato-biliary disease
• Beta HCG (women of childbearing age.)

B. Urine Tests:
RE & ME to see hematuria, pyuria
Dipstick Test - (for albumin, bilirubin, glucose and ketones), Pregnancy test.
 IMAGING STUDIES
A. Plain Chest X-Ray Studies:

• lower lobe pneumonia or ruptured esophagus

• An elevated hemidiaphragm or pleural effusion
• In CXR Subdiaphragmatic air(Pneumoperitoneum) more sensitive
than abdominal plain films for free intraperitoneal air.
B. Abdominal X Ray Studies:

• Multiple air fluid level or 3 , 6 , 9 rules or string of Pearl sign to

identify intestinal obstruction.
• Pneumoperitoneum
• Calculous, Calcification, intraperitoneal and retroperitoneal collections
etc.
 X RAY CONTD.
Pneumoperitoneum: usually by suggests a perforated viscous
1 ml air in peritoneum produce pneumoperitoneum in upright CXR
5-10 ml air in peritoneum produce pneumoperitoneum in lateral decubitus position
(after 10 minutes)
Pneumoperitoneum is usually not found in Burst appendix.

90% renal stone

10 % gall stone Radio – Opaque

5% appendicolith
Also pancreatic calcification, AAA calcification are seen.
 ULTRASONOGRAPHY

• Identify inflammatory conditions, stone disease, free fluid collection.

• Most useful in pregnant patients
• Gynecologic causes of abdominal pain.
• Color Doppler distinguish from inflammatory and infectious processes
& evaluating for flow through the mesenteric vessels.

Pitfall :
• obesity;
• following previous surgery;
• ascites;
• gaseous distension of upper abdominal viscera
 CT SCAN
Provides excellent diagnostic accuracy whom do not already have
clear indications for laparotomy or laparoscopy.
• Mis- or delayed diagnosed?
• Unknown diagnosis?
• Young female patient, GI or GYN problem?
• Intractable abdominal pain (infarction or vascular lesion?)
• High risk patient (sometimes…VIP)
• With or without contrast medium?
 CT ANGIOGRAPHY (CTA),OR MAGNETIC
RESONANCE ANGIOGRAPHY (MRA)

• Intestinal ischemia or ongoing hemorrhage.

• May identify the bleeding site in Pt with massive lower GI bleeding,
• Additionally it can be therapeutic for coiling or embolizing of bleeding vessel's
 ROLE OF ENDOSCOPY IN ACUTE ABDOMEN

• Urgent ERCP may be indicated in cases of suspected cholangitis.

• Sigmoidoscopy to reducing a sigmoid volvulus
• colonoscopy to locate the source of bleeding in cases of lower GI
hemorrhage
 ROLE OF LAPAROSCOPY IN ACUTE
ABDOMEN

• Laparoscopy is a therapeutic as well as diagnostic modality

• In cases of unclear diagnosis, it guide surgical planning and avoid
unneeded laparotomies.
• In young women, it may distinguish a nonsurgical problem (ruptured
graafian follicle, pelvic inflammatory disease, tubo-ovarian disease) from
appendicitis
 CAREFUL ABOUT SPECIAL POPULATION

1. Extremes of age (Children & Elderly)

2. Obese
3. Pregnant
4. Critically ill patient
5. Immunocompromised Pt
 PATIENTS WITH ACUTE ABDOMEN ATTENDING
IN ER OF SHL FROM JAN2017 – JUNE2017
Patients (%)

Dept. No.

Surgery 234
23.02%
Urology 62 Surgery
Urology
Gynae 36 46.43%
Gynae
Paediatric 56 11.11% Paediatric Surgery
Surgery Gastro
Gastro 116 7.14%

Total 504 12.30%

 GENERAL SURGERY

Total: 234

Diagnosis Patients
1.79%

No. % 19.60% 20.50% Appendicitis

Appendicitis 48 20.5%
Cholecystitis
2%
Int. Obstruction
Cholecystitis 69 29.5% Vis. Perforation
26.50% 29.50% IP Abscess
Intestinal 62 26.5%
Obstruction NSAP
Visceral 5 2.1%
perforation
Intra peritoneal 4 1.7%
abscess
Non specific 46 19.7%
abdominal pain
 UROLOGY

Total 64 Pt
40.62% Urolithiasis
43.75%
Renal Colic
Diagnosis No of Pt Ureteric colic
Urolithiasis 28 UTI

Renal Colic 4

Ureteric colic 6 9.37%

UTI 26 6.25%
 PAEDIATRIC SURGERY

Total 56 Pt
Appendicitis
Diagnosis No. of Pt
Appendicitis 24 41.07% 42% Biliary colic

Biliary colic 2 Intestinal

Intestinal Obstruction 7 Obstruction
NSAP
NSAP 23
12.50%
3.57%
 GYNAECOLOGY
Sales
2.70% 2.70%

Total 36 Pt
Ectopic
Diagnosis No. of Pt
pregnancy
Ovarian Cyst
Ectopic Pregnancy 22 33%

Ovarian cyst 12 Mittelsmerz

61%
Miitelsmerz 1 Others

Others 1
 TAKE HOME MESSAGE
Acute abdominal pain remains a challenging part of surgeons life.

So appropriate focus to approach such ways and to set the plan of action whether the
patient will need to:
• go directly to the operating room,
• be admitted for surgical observation and expected operative intervention,
• be admitted for surgical observation or further diagnostics, or
• be admitted to medical service for nonoperative abdominal pain.