ACUTE

ABDOMEN

Definition: Acute abdomen is a term

applied to acute abdominal pain.
That is spontaneous, non-traumatic for
which urgent interference may be
necessary
The items of this lecture are discussed in details in their
corresponding chapters. The intention is to discuss in brief the
important points in clinical presentation and investigations.

Retroperitoneal structures???????????????????????????

TYPES OF PAIN
VISCERAL ,SOMATIC , REFERRED PAIN AND SHIFTING PAIN

Visceral pain: is usually due to distension or spasm of a hollow

viscus, ischemic pain and inflammation. It is felt in the segment
of the abdominal wall having the same nerve supply of the
affected organ and it is vague ill defined pain so;
Mediated by autonomic nerve fibers
FOREGUT PAIN (stomach and duodenum) is felt in the
epigastrum.

Spasm or
distension

inflammatio
n

The abdominal
organs are
sensitive to

strangulation

Somatic pain is due to irritation of the parietal peritoneum and

so it is well localized over the affected organ.
Mediated by afferent somatic nerve fibers.

The presence of these two types of pain

explains

why the initial pain of acute appendicitis is vague

and is felt in the umbilical region, but later it becomes localized

to the right iliac fossa.

REFERRED PAIN
Definition : Pain Sensations
perceived at a site distant from that
of a strong primary stimulus
Due to Confluence of afferent nerve
fibers from widely disparate areas
within the posterior horn of the
spinal cord. This may cause
distorted central perception of the
site of pain.

Usually ipsilateral to the involved organ

ureteric obstruction - ipsilateral
testicular pain
supra/subdiaphragmatic irritationipsilateral supraclavicular

Classification of causes of acute abdomen:

According to the mode of presentation:
abdominal pain may be due to:

o Colics ; Intestinal and Biliary.

o inflammation:

Appendicitis,
Cholecystitis,
Diverticulitis, as Meckels diverticulitis.

o Perforations

Pancreatitis,

: Perforated appendix, Peptic ulcer, gall bladder,

Diverticulum, and typhoid ulcer of the small bowel.

o Intestinal obstruction: Simple, Strangulation

According to the site

Upper abdominal
o Perforated peptic ulcer,
o Leaking abdominal aortic aneurysm,
o Biliary colic and acute cholecystitis,
o Mesenteric vascular occlusion,
o Acute pancreatitis,
o Acute myocardial infarction.
Mid-abdominal
o Mesenteric vascular occlusion
o Intestinal obstruction
Right lower abdomen
o Acute appendicitis,
o Mesenteric adenitis
o Meckels diverticulitis
o Regional ileitis (Crohns disease)
o Right ureteric colic o Colitis

Left lower abdomen

o Colonic diverticulitis
o Left ureteric colic
o Colitis
Pelvic pain
o Mid menstrual pain
o Pelvic inflammatory disease
o Proctitis
o Cystitis
o Complicated ovarian cyst
o Prostatitis o Ectopic pregnancy
o Pelvic appendicitis
Abdominal and back pain
o Biliary colic and acute cholecystitis
o Acute pancreatitis
o Renal and ureteric colic
o Leaking abdominal aortic aneurysm
o Posterior duodenal ulcer penetrating pancreas,

Retroperitoneal
structures

ACUTE
ABDOMINAL
PAIN
CAN PRESENT
TO
(which
spatiality)

surgeon

urologist

medicine

gynecologist

SOME DETAILS ON COMMON

CAUSES

Acute appendicitis
Acute cholecystitis
Acute pancreatitis
Perforated peptic ulcer
Acute intestinal obstruction

 Gynecological Pathologies
Ruptured ectopic pregnancy
Twisted ovarian cyst
Salphingitis
Ruptured ovarian cyst
Tubo-ovarion abscess
Mid cyclic pain

EXTRA ABDOMINAL CAUSES

Myocardial infarction
Pneumonia
Diaphragmatic pleurisy
Herpeszoster
Medical causes
Malaria
Porphyria
Sickle cell anemia

COMMON
CONDITIONS

INFLAMMATORY

ACUTE APPENDICITIS
It can affect any age, but is commonest in the second and third decades. There is usually a
characteristic shifting pattern of pain from the center to the right lower abdomen.
o Pain always occurs before vomiting.
o Diarrhoea is usually against the diagnosis.
Anorexia and nausea are almost always present.

INVESTIGATIONS ARE DONE IN DIFFICULT CASES:

o Leucocytic count: Polymorphnuclear leucocytosis
Abdominal and pelvic ultrasonography: if in doubt
o If a ureteric calculus or UTI is suspected, urine examination, plain X-ray PUT, IVU and
ultrasound are diagnostic,
o In females, if a tubo-ovarian or uterine problem is suspected, a pelvic ultrasound and
laparoscopy are helpful.

ACUTE CHOLECYSTITIS
The initial pain is diffuse and colicky in the upper abdomen. Later it
localizes in the right hypochondrium.
It is difficult to palpate the gall bladder (20%), due to the overlying
tenderness and rigidity.
ULTRASOUND IS DIAGNOSTIC:
o Gall stones are detected in 95% of cases,
o Distension of the gall bladder,
o Thickened walls,
o Pericholecystic fluid collection,

ACUTE PANCREATITIS
Severe epigastric pain that increases in intensity
Pain is referred to the back.
Profuse vomiting is a prominent feature.
The patient may be shocked.
Tenderness and guarding are slight.
Serum amylase rises. Many other conditions raise the serum amylase.
CT may reveal enlargement of the pancreas, peripancreatic fluid
collection, or pancreatic necrosis.

ACUTE DIVERTICULITIS
Rare before the age of 40.
Sigmoid colon is the commonest site.
Diagnosis relies mainly on the clinical picture.
Gastrografin enema may be helpful.
Barium enema should be postponed till after resolution of the
acute attack.
CT may reveal localized thickening of the colonic wall,
density in the pericolic fat or a pericolic abscess.

INTESTINAL
OBSTRUCTION

SIMPLE BOWEL OBSTRUCTION

Colicky abdominal pains
Vomiting
Abdominal distension
Absolute constipation.

Plain X-ray will reveal distended loops

or

fluid levels.

STRANGULATION INTESTINAL OBSTRUCTION

Severe pain which is persistent and is not relieved by nasogastric suction.

Localized tenderness and guarding.

Fever and tachycardia.

Leucocytosis.

MESENTERIC ISCHAEMIA

This is actually a type of strangulation intestinal obstruction.

Suspect the diagnosis in patients over 50 years with valvular or atherosclerotic heart disease,
arrhythmias, hypotension, hypovolaemia, myocardial infarction, or polycythaemia.

The pain is out of proportion to abdominal findings.

Plain X-ray may reveal ground glass appearance.

Ultrasound and CT scans may show the occluding thrombus, bowel wall oedema or abnormal
gas patterns.

GYNAECOLOGICAL
CAUSES

Ruptured ovarian cyst

There is lower abdominal pain, tenderness and guarding.

No toxemia.

Abdominal and pelvic ultrasound examinations are diagnostic.

Torsion of an ovarian cyst

Severe lower lateral abdominal pain.

Adnexal mass may be palpable.

Ultrasound is diagnostic.

Laparoscopy is diagnostic and therapeutic.

Pelvic inflammatory disease (PID)

Suspect the disease in females in the reproductive period.

UD increases the possibility.

Inflammation is usually bilateral, but may be severer on one side.

There is lower abdominal tenderness and guarding with high pyrexia.

Per vaginal examination and movement of the cervix are tender.

Ruptured ectopic pregnancy

History of menstrual abnormalities may be present.
Severe lower abdominal pain.
Pallor is usually a striking feature.
Abdominal examination reveals tenderness and guarding.
Per vaginal examination reveals tender cervix.
Chorionic gonadotropin testing is positive.
Ultrasound. The presence of a gestational sac in the
uterus is against the diagnosis. Free blood is present in
the pelvis.
Laparoscopy is very helpful.

MANAGEMENT PLAN
Resuscitation and monitoring
History: personal history menstrual
history, analysis of pain, past history of
(surgery medical diseases drugs)
Examination
Investigation
Treatment

ABDOMINAL PAIN(HISTORY)
Onset; course (Progression of pain)
Duration.
Site of pain: at onset, at present.
Radiation of Pain
Severity.
Type: intermittent colicky, sharp persistent
Aggravating factors: movement, coughing, food
Relieving factors: position, drug, food

OTHER GIT SYMPTONS

VOMITING
ABDOMINAL DISTENTION
CONSTIPATION/DIARRHOEA

OTHER SYSTEMS
Urinary Symptoms
Gynecological Symptoms

GENERAL EXAMINATION:

Pulse
Temperature
Respiratory rate
Blood pressure
Dehydration

INSPECTION:
Mobility : limited mobility on inspiration
Contour: may show abdominal distension

Dont forget to examine Hernial orifices , DRE

PALPATION:

Guarding
Voluntary abdominal wall spasm elicited by palpation,
make the examination difficult specially in children.
Over come by distracting the patient with simple
conversation.
It is mediated consciously by the patient

RIGIDITY:This is involuntary spasm of abdominal wall muscle

in the presence of peritonitis.

REBOUND TENDERNESS:Characteristic feature of peritonitis

Elicited by sudden release of hand over the tender
area, patient experiences severe pain as inflamed
peritoneum hit the abdominal musculature.

 PERCUSSION
Tympanitic air /dull fluid or pus in the peritoneum

Auscultation
Listen bowel sounds for at least two minutes
Exaggerated in mechanical intestinal obstruction
Absent (ileus) due to toxic effect of the pus on the
abdominal motility

Rectal and vaginal examination

 Special signs of some causes of acute abdomen

(discussed in the clinical part)
Appendicitis
Cholecystitis

AFTER COMPLETE HISTORY AND EXAMINATION WE PUT

Provisional
diagnosis

INVESTIGATIONS
LABORATO
RY

IMAGIN
G

LAPAROSCO
PY

In the majority of cases accurate clinical examination supplemented by

few tests can confirm the diagnosis.
The following are some useful investigations.

Laboratory investigations

Full blood picture.

Urea and electrolytes.
Blood sugar.
Serum amylase.
Urine analysis.

Radiological investigations
Plain x ray
Plain X-ray of the chest in the erect position may show free gas under the
cupola of the diagram in perforation of a viscus. A basal pneumonia will
be detected.

Free air under

diaphragm

No free Air under

diaphragm

Distended loops of bowel or

fluid levels in intestinal
obstruction.

Plain X-ray of the abdomen may

reveal: Calculi of the urinary tract

Abdominal ultrasound can diagnose the

following:
Acute calcular cholecystitis.
Stones are detected in 95% of cases. The gall bladder is distended, its wall is thickened
and subserosal oedema may be visualized.

Acute pancreatitis.
Enlargement of the pancreas, pancreatic pseudocyst or abscess

Leaking aortic aneurysm.

Distended pelvicalyceal system in cases where ureteric stones
cause colic.
Gynaecological disorders. Ruptured ovarian cyst, twisted
ovarian cyst, ectopic pregnancy and pelvic inflammatory
disease are easily detected by pelvic ultrasound.

CT scan of the abdomen:

The main advantage of CT scan is that its picture is neither affected by
obesity nor by the presence of gases. It is very helpful for the diagnosis of
the following conditions:

Acute pancreatitis.
Retroperitoneal haemorrhage.
Bowel infarction.
Splenic infarction.
Diverticulitis. bowel wall thickness is detected And abscess can be
visualized.
Localized fluid collection or free fluid in the peritoneal cavity.

Diagnostic laparoscopy:
Diagnostic laparoscopy is valuable especially for
gynecological problems

TREATMANT OF EACH
CAUSE

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