Describes the concept of a surgical abdomen, acute abdominal pain, emergency intervention and approach to management, including the controversial use of analgesic and antibiotics in emergency room.

1. ACUTE ABDOMEN
BY DR KD DELE
DEPARTMENT OF FAMILY MEDICINE
DORA NGINZA HOSPITAL

2. OUTLINE – ACUTE ABDOMINAL PAIN
• Definition
• Epidemiology
• Pathophysiology
• History / Physical Exam of Abdominal Pain
• Laboratory / Radiographic Test for Abdominal Pain
• Differential Diagnosis of an Acute Abdomen
• Indications for Surgical Exploration
• Treatment
• Disposition

4. DEFINITION AND EPIDEMIOLOGY

5. DEFINITION
• “An acute abdomen” denotes any sudden, spontaneous, nontraumatic
disorder whose chief manifestation is in the abdominal area and for
which urgent operation may be necessary.
• (alt) Sudden, spontaneous severe abdominal pain, tenderness and
muscular rigidity that is less than 24 hours in duration which may require
emergency surgery…
• Because there is frequently a progressive underlying intra-abdominal
disorder, undue delay in diagnosis and treatment adversely affects
outcome.

6. EPIDEMIOLOGY
• Acute abdominal pain accounts for 7–10% of all Emergency
Department visits.
• The most frequent causes is nonspecific abdominal pain
(accounting for about one-thirds of all acute abdominal pain and is
more prevalent in women
• The diagnosis and treatment of acute abdominal pain is a
collaborative effort, often starting in the emergency department.

7. PATHOPHYSIOLOGY

8. PATHOPHYSIOLOGY
• Acute conditions of the abdomen are produced by inflammatory,
obstructive, or vascular mechanisms.
• They are manifested by sudden onset of abdominal pain,
gastrointestinal symptoms and varying degrees of local and
systemic reaction.

9. PATHOPHYSIOLOGY (CONT)
Inflammatory causes of an acute abdomen: These may be divided
into two subgroups:
• 1) Bacterial – examples would include acute appendicitis,
diverticulitis, and some cases of pelvic inflammatory disease.
• 2) Chemical – for example a perforation of a peptic ulcer, where
spillage of acid gastric contents causes an intense peritoneal
reaction.

10. PATHOPHYSIOLOGY (CONT)
Mechanical causes of an acute abdomen:
• These include such obstructive conditions as incarcerated hernia,
post-operative adhesions, intussusception, malrotation of the gut
with volvulus, congenital atresia or stenosis of the gut.
• The most common cause of large bowel mechanical obstruction is
carcinoma of the colon.

11. PATHOPHYSIOLOGY (CONT)
• Vascular: When the blood supply is cut off, necrosis of tissue results,
with gangrene of the bowel.
• Examples include mesenteric arterial thrombosis or embolism.
• Congenital defects: These can produce an acute abdominal surgical
emergency any time from birth
• Examples include duodenal atresia, omphalocele or diaphragmatic
hernia and others like chronic malrotation of the intestine.

12. HISTORY & PHYSICAL EXAMINATION OF
AN ACUTE ABDOMIN

13. PAIN!
• Pain is the most prominent presenting complaint in a patient with
an acute abdomen
• It is important to know the origin, location, progression, radiation
and character of abdominal pain in order to understand its
significance.
• Less likely causes can also be systemically eliminated using the
above

14. CONDITIONS
ASSOCIATED
WITH
ABDOMINAL
PAINS

15. ORIGIN OF PAIN
• Three types of pain identified: Visceral, Parietal and Referred
1. Visceral Pain
• Due to stretching of fibres innervating the walls of hollow or solid
organs.
• It occurs early and poorly localized
• It can be due to early ischemia or inflammation.

16. ORIGIN OF PAIN, CONT.
2. Parietal Pain: Caused by irritation of parietal peritoneum fibers.
• It occurs late and better localized.
• Can be localized to a dermatome superficial to site of the painful stimulus.
3. Referred Pain: Pain is felt at a site away from the pathological organ.
• Pain is usually ipsilateral to the involved organ and is felt midline if
pathology is midline.
• Pattern based on developmental embryology.

17. PAIN LOCATION
• From the organ
• distention,
inflammation or
ischemia.
• less severe pain
• poorly localized
• usually dull or
aching, constant or
intermittent
visceral
• From an irritated
peritoneal lining
often by pus,
urine, bile
• easily localized
• more severe pain
• sharp, constant
parietal
• visceral pain felt
in other areas of
the body and
occurs when
organs share a
common nerve
pathway.
• poorly localized
• usually a
referred

18. ONSET, PROGRESSION AND CHARACTER
1. Abrupt excruciating pain:
Biliary colic
Ureteric colic
Acute MI
Perforated ulcer
Ruptured aneurysm
2. Rapid onset, severe, constant
pain:
Acute appendicitis
Mesenteric thrombosis
Strangulated bowel
Ectopic

19. ONSET, PROGRESSION AND CHARACTER
3. Gradual steady pain:
Acute cholecystitis
Cholangitis
Hepatitis
Salpingitis
Appendicitis
Diverticulitis
4. Intermittent colicky pain:
Early pancreatitis
Small bowel obstruction
Ureters

20. VOMITING
• Reflex, or irritative non-specific vomiting
occurs in many conditions; and a
Prominent symptom in upper GI disease
• For Surgical abdomen, pain usually
precedes vomiting.
• Bowel obstruction: onset and character of
vomiting may suggest level

21. OTHERS INCLUDE:
Diarrhoea
• most common with acute gastroenteritis or food poisoning, but it
may occur with appendicitis or other focal inflammatory lesions of
the gut
Constipation or obstipation
• With complete small bowel obstruction - unrelenting constipation
(obstipation) after fecal material below obstruction has been
passed. Progressive constipation with carcinoma of the large bowel.
Gas stoppage with decreased or absent bowel sounds – paralytic
ileus

22. HISTORICAL FEATURES OF ABD PAIN
• Location, quality, severity, onset, and duration of pain, aggravating
and alleviating factors
• Gastrointestinal symptoms (Nausea/Vomiting/Diarrhoea)
• Genitourinary symptoms
• Vascular symptoms (Atrial fibrillation / Acute Myocardial Infarction /
Abdominal Aortic Aneurysm)
• Can overlap i.e. Nausea seen in both GI / GU pathologies.

23. PAST MEDICAL HSITORY
• Recent / current medications
• Past hospitalizations
• Past surgery
• Chronic disease
• Social history
• Occupation / Toxic exposure
(CO / lead)
• Gynaecological:
• Menstrual history
• Endometriosis
•Vaginal discharge
•Dysmenorrhea
• Travel history
• Drug and alcohol history

24. PHYSICAL EXAMINATION
• Note patients’ general appearance.
• Note that the intensity of the abdominal pain may have no
relationship to severity of illness.
• One of the initial steps is obtaining and interpreting the vitals.
• Patients with visceral pain are unable to lie still.
• Patients with peritonitis like to stay immobile.

25. PHYSICAL EXAMINATION CONT.
• Do not focus on the abdomen only – look for specific signs that confirm or rule out
other possibilities
General observation:
• Is the patient writhing (in visceral pain) or motionless (in parietal pain)?
Systemic signs:
• Pallor, Tachycardia, Hypothermia, Tachypnoea, Sweating, Fever, Associated
disorientation and lethargy
• Ps, fever is often mild or absent in established shock.

26. PHYSICAL EXAMINATION CONT.
• LOOK – INSPECT for abdominal distention, peristalsis, scars, masses, rash.
• PALPATION – to look for guarding, rigidity, rebound tenderness, organomegaly,
or hernias, Murphy’s
• PERCUSSION – tenderness, rebound, shifting dullness
• AUSCULATE for hyperactive, obstructive, absent, or normal bowel sounds.
• Women should have pelvic examination.
• Anyone with a rectum should have rectal examination (If no rectum check the
ostomy).
• Cough to elicit pain: parietal pain generally has pain on coughing

27. PHYSICAL EXAMINATION CONT
• Severe abdominal pain in patients who have been fairly well, and which
persists as long as six hours.
• Localized peritoneal inflammation – Persistent localized tenderness with
muscle spasm, indicative of. The tenderness may be best determined by
rectal or pelvic exam.
• Obstruction of a hollow viscus – Characteristic, severe, intermittent
cramping, colicky pain.
• Small bowel obstruction - Repeated vomiting of copious amounts of bile-
stained or faecal material.

28. PHYSICAL EXAMINATION CONT
• Small intestinal obstruction – Markedly hyperactive bowel sounds.
• Paralytic ileus – Decreased to absent bowel sounds.
• Paralytic ileus not secondary to other abdominal pathology is treated
non-surgically.
• Paralytic ileus as an end-result of mechanical small bowel obstruction or
perforated duodenal ulcer requires surgical intervention to relieve the
underlying pathology.

29. PHYSICAL EXAMINATION CONT
• Small bowel obstruction – distended loops of small bowel above the
level of obstruction in with absence of gas below by x-ray
• generalized distention of large and small bowel - paralytic ileus
• Perforation of a hollow viscus – e.g. a duodenal ulcer – free air under
diaphragm in an upright X-ray film
• Acute pancreatitis – Markedly elevated serum amylase levels

30. PHYSICAL EXAMINATION CONT
• Palpation of a mass.
• In RLQ or RUQ - with intussusception.
• Adnexal mass by pelvic exam - ectopic pregnancy.
• Tender and thickened adnexae by pelvic in PID.
• An irreducible incarcerated inguinal hernia.
• A tender RLQ mass by abdominal palpation or rectal exam appendiceal
abscess.

31. LABORATORY / RADIOGRAPHIC TEST
FOR ABDOMINAL PAIN

32. LABORATORY TEST
• Full Blood Count (WCC is significant if raised)
• UEC / CMP
• ABG – in hypotension, generalised peritonitis, pancreatitis,
ischaemic bowel, septicaemia
• Amylase – mildly elevated with perforated peptic ulcer, strangulated
or ischaemic bowel, 3x normal for pancreatitis
• LFT – may distinguish medical from surgical conditions

33. LABORATORY TEST
• Urinalysis / Urine MC&S
• Blood glucose
• Cardiac Enzymes / Troponin
• b-HCG (ICON / Quantitative)
• Lactic acid
• Stool MC&S
• Group and Crossmatch blood if indicated

34. ERECT CHEST X-RAY
• Pre-operative assessment
• Exclude supra-diaphragmatic lesions that simulate acute abdomen
• Elevated hemidiaphragm or effusion = subphrenic inflammatory
lesions
• Air under diaphragm

35. AIR UNDER
DIAPHRAGM

36. ABDOMINAL X-RAY
• Supine views
• Size of bowel- distention
• Where is the bowel distended?
Centrally tends to be small
bowel
• Air fluid levels
• Haustra or vina coniventese
• Erect view
• little information except in
suspected obstruction
• Air in the rectum?
• Foreign body
• Renal or ureteric calculi

37. SMALL BOWEL
OBSTRUCTION

38. ULTRASONOGRAPHY
• Upper abdominal pain not resembling ulcer pain or bowel
obstruction
• Abdominal masses
• Helpful in acute appendicitis, pregnant or young woman with mid
or lower abdominal pain.
• CT more helpful in patients with  bowel gas
• CT scan in conjunction with ultrasound is superior in identifying any
abnormality seen on plain film.

39. ACUTE
APPENDICITIS
Non-compressible,
inflamed appendix
(arrowheads) lies
next to the normal
well-compressible
ileum

40. OTHER IMAGING MODALITIES
Angiography
• If intestinal ischaemia or haemorrhage suspected
Contrast X-ray
• Gastrograffin for suspected upper GI perforation.
• Barium enema may identify site of large bowel obstruction,
intussusception or sigmoid volvulus.

41. CT SCAN
• Becoming more readily available
• Useful in patients who don’t have clear indication for surgery
• May prompt or postpone operation

42. ENDOSCOPY
Proctosigmoidoscopy
• Any patient with suspected large bowel obstruction, excessively
bloody stool or rectal mass.
• May reduce sigmoid volvulus
Gastroscopy and ERCP
• Usually less urgently performed
• More in patients with mostly inflammatory conditions.

43. LAPAROSCOPY
• Also a diagnostic tool
• Especially young females e.g. to distinguish appendicitis from other
non-surgical problems

44. DIFFERENTIAL DIAGNOSIS

45. DIFFERENTIAL DIAGNOSIS OF AN ACUTE ABDOMEN
• GIT disorders
• Liver Spleen and Biliary disorders
• Pancreatic disorders
• Urinary tract disorders
• Gynaecological disorders
• Vascular disorders
• Peritoneal disorders
• Retroperitoneal disorders

46. GIT DISORDERS
• Appendicitis – especially in children
• Small and large bowel obstruction
• Perforated peptic ulcer
• Incarcerated hernia
• Bowel perforation
• Diverticulitis
• Gastroenteritis
• Acute gastritis
• Parasitic infections

47. LIVER, SPLEEN, PANCREAS AND OTHER BILIARY
DISORDERS
• Acute cholecystitis
• Acute cholangitis
• Hepatic abscess
• Ruptured hepatic tumour
• Biliary colic
• Acute hepatitis
• Acute Pancreatitis

48. URINARY TRACT DISORDERS
• Ureteral or renal colic
• Acute pyelonephritis
• Acute cystitis
• Renal infarct

49. GYNECOLOGICAL DISORDERS
• Ruptured ectopic
• Dysmenorrhea
• Endometriosis
• Twisted ovarian tumors
• Ruptured ovarian follicle cyst
• Acute salpingitis

50. VASCULAR DISORDERS
• Ruptured aortic or visceral aneurysm
• Acute ischaemic colitis
• Mesenteric thrombosis

51. MEDICAL CAUSES OF ACUTE ABDOMEN
• Endocrine and metabolic
• Uremia
• Diabetic crisis
• Porphyria
• Acute hyperlipoproteinemia
• Haematologic disorders:
• Acute leukemia
• Sickle cell crisis

52. • Toxins and drugs:
• Lead and other heavy metal poisoning
• Narcotic withdrawal
• Black widow spider poisoning

53. INFECTIONS AND INFLAMMATORY DISORDERS
• Tabes dorsalis
• Herpes Zoster
• Acute Rheumatic fever
• Henoch-Schonlein purpura
• SLE

54. REFERRED PAIN
• Myocardial Infarction
• Acute pericarditis
• Pneumonia
• Pulmonary Embolism
• Pneumothorax
• Conditions of the hip and back

55. INDICATIONS FOR SURGICAL
EXPLORATION

56. INDICATIONS FOR SURGICAL EXPLORATION
• Surgery is sometimes necessary without precise diagnosis
• Physical findings that indicate laparotomy:
• Involuntary guarding or rigidity
• Increasing or severe localised tenderness
• Tense or progressive distension of abdomen
• Tense abdomen or rectal mass with ↑fever
• Rectal bleeding with shock or acidosis

57. INDICATIONS FOR SURGICAL EXPLORATION
(CONT.)
• Endoscopic findings:
• Perforated or uncontrollable bleeding lesion
• Radiological findings:
• Pneumoperitoneum
• Gross or progressive bowel distension (obstruction)
• Free extravasation of contrast (perforations)
• Mesenteric occlusion

58. INDICATIONS FOR SURGICAL EXPLORATION
(CONT.)
• Paracentesis
• Blood
• Bile
• Pus
• Bowel content
• urine

59. TREATMENT OF ACUTE ABDOMINAL
PAIN

60. TREAT HYPOTENSION
• If due to volume depletion from vomiting, diarrhea, decreased
oral intake or third spacing.
• Treatment would be isotonic crystalloid.
• If associated with abdominal sepsis (septic shock).
• Treatment would include isotonic crystalloid, antibiotics, and
vasopressors (levophed or dopamine).

61. PAIN MANAGEMENT
• Emergency Room physicians did not treat acute abdominal pain with
analgesics for fear of altering or obscuring the diagnosis.
• Current literature however favours the use of opioids judiciously in these
patients.
• Do not withhold analgesia
• Moderate doses don’t obscure or mask physical findings
• Abdominal masses may become apparent
• Pain in spite of adequate analgesia suggests serious condition

62. ANTIBIOTICS
• Must be consider when treating suspected abdominal sepsis or diffuse
peritonitis.
• Coverage should be aimed at anaerobes and aerobic gram negatives.
• If Spontaneous Bacterial Peritonitis: suspected, must cover for gram
positive aerobes.
• Examples of monotherapy are ceftriaxone, cefoxitin, cefotetan, ampicillin-
clavulanate, ampicillin-sulbactam, ticarcillin-clavulanate etc.

63. INDICATIONS FOR ADMISSIONS:
• Manage As indicated
• Other Indications for Admissions:
• Pts who appear ill.
• Very young / Elderly
• Immunocompromised
• Unclear diagnosis
• Intractable pain, nausea, or vomiting
• Altered mental status
• Those using drugs, alcohol, or that lack social support.
• Pts with poor follow-up and/or noncompliant.

64. • Non-specific abdominal pain
• If this is the working diagnosis, patients must be re-examined in
24 hours.
• This may be done in the outpatient setting.

65. THANK YOU FOR LISTENING