The Acute Abdomen

Andik KusbiantoroSMF Ilmu Bedah RSUD Dr.R.Soedjono Selong

DefinitionAcute abdomen describes clinical condition as result of emergency situations intra abdominal condition that needs immediate surgical interventionwith pain as main symptom

IntroductionChallenge to Surgeons & PhysiciansMost common cause of surgical emergency admissionClinical course can vary from from minutes to hours to weeks.It can be an acute exacerbation of a chronic problem.

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AssesmentWell elicited historyProper physical examination

Diagnosis can be made most of the time by a good history and a proper physical examination.

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Assesment (cont)Investigations are usually carried out :only to support the diagnosis.or to narrow down the differential diagnoses.

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HistoryHistory of Present illnessFamily historyPast medical historyHistory of drugs taken or Medication eg. ingestion of certain toxic drugs or Alcohol intake

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Drug historyCorticosteroids mask painAnticoagulants can lead to an intramural haematoma of the gut causing obstructionOral Contraceptives - rupture of hepatic adenomasNSAIDs - erosive gastritis & peptic ulcers

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Other historyPast surgical history: previous operations- leading to adhesionsPast medical history: Sickle cell disease, Diabetes or Cancer or Renal failureMenstrual History in femalesMissed period- ectopic pregnancyMid of period-ovulation pain (Mittel- schmerz)With heavy periods- endometriosisFamily history of colon cancer, any other malignancy or inflammatory bowel disease

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Pain

The Most Important SymptomHistory 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

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Onset of Pain (cont)Sudden onset pain which wakes the patient from sleep

eg. perforation or strangulation of bowelSlow 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

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Progression of Pain (cont)Progression from : Dull, aching, poorly localized character

To:Sharp, constant & better localized painindicates involvement of Parietal peritoneum

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Table 1. Sensory innervations of intra abdominal structures

StructureNerveLevelMiddle part of DiaphragmPhrenicusC 3-5Edge of diaphragm, stomach, pancreas, gall bladder, intestinePlexus celiacTh 6-9Appendix,proximal colonPlexus mesentericusTh 10-11Distal colon, rectum, kidney, urethra & testisSplanchnic caudalTh 11-L 1Vesica urinary, recto sigmoidS 2-4

Figure 1. Innervations of diaphragm and shoulder

Figure 2.Referred pain and shifting pain in the acute abdomen Referred PainShifting Pain

Abrupt, excruciating pain

Rapid onset of severe, constant pain Gradual, steady pain Intermittent, colicky pain with free intervalFigure 3. The location and character of the pain are useful in the differential diagnosis of the acute abdomenColic billierColic ureterIMAPerforated ulcerRuptured aneurysmAcute pancreatitisMesenteric thrombosis, strangulated bowelEctopic pregnancyAcute cholecystitis, acute cholangitis, acute hepatitisAppendicitis, salpingitisColic billierEarly pancreatitis (rare)Small bowel obstructionIBD

Nausea & VomitingFrequency of vomitingCharacter of vomiting:

projectile, non-projectile or self-inducedNature 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

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Nausea & Vomiting Pain first, followed by Vomiting is usually surgical.

The vomiting is due to reflex pylorospasmNausea & vomiting first , followed by pain is usually due to a medical condition

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Urinary Symptomswith PainUreteric colic Cystitis

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Table 2. Physical findings with various causes of acute abdomen

ConditionsHelpful signPerforated viscousScaphoid (early), tense abdomen, diminished bowel sound (late), loss of liver dullness, guarding or rigidityPeritonitisMotionless, absent bowel sound (late), rebound tenderness, guardingInflamed mass or abscessTender mass, special sign (Murphy's, obturator or psoas)Intestinal obstructionDistention, visible peristaltis (late), hyperperistaltis (early) or quiet abdomen (late), diffuse pain, hernia (some)Paralytic ileusDistention, minimal bowel soundIschemic or strangulated bowelNot distended (until late), severe pain, rectal bleeding (some)BleedingPallor, shock, distention, pulsatile (aneurysm)

Figure 3. Causes of shock in patients with acute abdomen

Consideration of Surgery InterventionDecision 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

SummaryAcute abdomen is serious surgical emergency requiring the surgeon to combine the result of the history and physical examination with properly selected laboratory and radiographic studiesCorrect preoperative diagnosis will usually lead to a successful operation

Physical ExaminationGeneral 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

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Physical Examination (cont...)d. Bending Forward: Chronic Pancreatitise. Jaundiced: CBD obstructionf. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

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Physical Examination (cont...)Vital ChartingTemperature, Pulse, BP, Respiratory rateRuptured AAA or ectopic pregnancy can lead to

-Pallor -Hypotension -Tachycardia -Tachypnea

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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

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Extra abdominal conditions that causes abdominal painThese 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 ExaminationCardiopulmonary examination Check for: - Possible MI - Basal Pneumonia - Pleural Effusion

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Systemic ExaminationPer Abdomen: Inspection- Scaphoid or flat in peptic ulcer- Distended in ascites or intestinal obstruction- Visible peristalsis in a thin or malnourished patient (with obstruction)

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Systemic ExaminationPer abdomen:Palpation Be gentleStart away from site of pathology then towardsCheck for Hernia sitesTendernessRebound tendernessGuarding- involuntary spasm of muscles during palpationRigidity- when abdominal muscles are tense & board-like. Indicates peritonitis.

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Systemic ExaminationLocal Right Iliac Fossa tenderness:

a. Acute appendicitis b. Acute Salpingitis in females c. Amoebiasis of CaecumLow grade, poorly localized tenderness:

Intestinal Obstruction Tenderness out of proportion to examination:

a. Mesenteric Ischemia b. Acute PancreatitisFlank Tenderness:

a. Perinephric Abscess b. Retrocaecal Appendicitis

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Systemic ExaminationRovsings Sign in Acute AppendicitisObturator Sign in Pelvic AppendicitisPsoas Sign Retrocaecal appendicitisCrohns DiseasePerinephric AbscessMurphy's sign in Acute Cholecystitis

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Systemic ExaminationPer Rectal Examination: - tenderness - induration - mass - frank blood

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Investigations

Complete Blood Count with differentialC-reactive protein estimationElectrolyte, Blood Urea, CreatinineUrine dipstickAmylase or LipaseLiver Function Test

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RadiologyChest x rayAbdominal x ray

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InvestigationsOther Investigations- USG- CT abdomen for AAA, Pancreatic disease, or ureteric colic (non- Contrast)- IVU- Mesenteric Angiography for Ischaemia, Haemorrhage

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