Approach to acute abdomen presntation slides.pdf

About acute abdomen

1. Approach to Acute
Abdomen
Supervised by
Prof. Dr. Ali Mohammed Saleh
Dr. Mohammed Moqbil
Prepared by
Dr. Muataz Al-Akhali

2. Overview
Acute abdomen denotes any sudden, spontaneous, non-
traumatic sever abdominal pain

Acute abdomen is a challenging to surgeons and physicians
because it often represent an underlying surgical problem
and life threatening. Also, it may be a benign complain.

3. Overview
About 5 to 10 % of ER visits.

About 25 % of acute abdomen discharged with
undifferentiated abdominal pain

80 % of discharged Pt improved within 2 weeks of
presentation
UpToDate (2022)

4. Overview
According to ASGBI & RCSE commission guide 2014

Annually 600,000 emergency admission under the care of
general surgeons in England.

Over half present with abdominal pain.

Around 90,000 admitted with non-specific diagnosis and
with no further diagnosis .

5. Causes of Acute Abdomen
Acute abdomen has variety of causes that could be
surgical and Non-surgical causes.

6. Surgical acute abdominal
conditions
Infection
Appendicitis
Cholecystitis
Pancreatitis
Diverticulitis
Hepatic abscess
Meckel diverticulitis
Ischemia
Ischemic colitis
Mesenteric thrombosis or
embolism
Ovarian torsion
Strangulated hernia
Testicular torsion 
Perforation
Boerhaave syndrome
Perforated diverticulum
Perforated gastrointestinal cancer
Perforated gastrointestinal ulcer

7. Surgical Acute Abdominal
Conditions
Obstruction
- Volvulus
- GIT malignancy
- Incarcerated hernias
- IBD
- Intussusception
- Small bowel obstruction
Hemorrhage
- Bleeding gastrointestinal
diverticulum
- Hemorrhagic pancreatitis
- Intestinal ulceration
- Leaking or ruptured
arterial aneurysm
- Mallory-Weiss syndrome
- Ruptured ectopic
pregnancy

8. Nonsurgical Causes Of The Acute
Abdomen
Endocrine and Metabolic
Causes
- Acute intermittent porphyria
- Addisonian crisis
- DKA
- Hereditary Mediterranean
fever
- Uremia
Toxins and Drugs
- Black widow spider
poisoning
- Lead poisoning
- Narcotic withdrawal
Hematologic
Causes
- Acute leukemia
- Sickle cell crisis

9. Assessment of acute abdomen
Early diagnosis of acute abdomen is the key to improve
outcome.

1- History

2- Examination
( General and Local examination )

3- Investigations
( Lab and Imaging )

10. History
Despite advances in laboratory studies and imaging a detailed and focused
history and examination is the most important part in the assessment of
acute abdomen
History
- Abdominal pain
(Site, onset, course, character, radiation, or factors, Associated
Symptoms)
- Past medical and surgical history
- Gynecological history
- Drug history
- Family history

11. Abdominal pain
Pain is the most common and predominant presentation

Pain may be (visceral, somatic or referred).
Visceral pain: characterized by dull, poorly localized, deep pain
Somatic pain: characterized by localized, sharp, more intense
Referred pain: Pain that perceived at a location other than that of the
causative stimulus.


Beware of minimal or absent abdominal symptoms and signs in
immunocompromised patients.

12. Site of Abdominal Pain

13. Abdominal pain
Onset of pain
Sudden Onset:
- Perforated viscus
- Ruptured AAA
- Ectopic pregnancy
- Ovarian torsion
Acute Onset (Within hours):
- Appendicitis
- Cholecystitis
- Pancreatitis
- Intestinal obstruction
- Diverticulitis
Gradual Onset (Within
days):
- Inflammatory bowel
disease
- Gastroenteritis
- PUD
- Tumor

Course of pain
Progressive Pain:
- Appendicitis
- Cholecystitis
- Pancreatitis
- Intestinal obstruction
- Diverticulitis
Intermittent Pain :
- Intestinal obstruction
- Kidney stone
- Biliary colic
- Ureteral obstruction
Constant Pain :
- Perforated viscus
- Ruptured AAA
- Tumor
- Pancreatitis
- Peritonitis

14. Abdominal pain
Nature of pain
Dull Aching Pain
- Acute Appendicitis - Diverticulitis - Acute Cholecystitis - Pancreatitis
- Mesenteric Ischemia - IBD - Peritonitis - Constipation
Colicky Pain
- Bowel Obstruction - Renal Colic - biliary colic - Ureteral Stones
Sharp Stabbing Pain
- Ruptured Ectopic Pregnancy - Perforated Viscus - Acute Pancreatitis
- Acute Mesenteric Ischemia - Ruptured AAA - Ovarian Torsion
Burning Pain
- Peptic Ulcer Disease – GERD – Gastroenteritis – Peritonitis
- Esophageal Spasm - UTI and Cystitis

15. Other Symptoms Assoc. with
Abdominal pain
Vomiting
Vomiting is due to reflex pylorospasm
Nausea and vomiting first followed by pain is usually to a medical condition,
pain first followed by vomiting is usyally surgical.

-Billous : SBO
-Coffee ground: Gastritis, Esophagitis, Gastric ulcer.
-Fresh Blood: Gastritis, Esophagitis, Gastric ulcer, Mallory-Weiss
syndrome
-Food content : Gastroenteritis, early SBO, Pyloric stenosis.
-Feculent : Late intestinal obstruction.

16. Other Symptoms Assoc. with
Abdominal pain
Constipation and Obstipation.
May suggest bowel obstruction.

Diarrhea.
Diarrhea with pain usually due to medical causes with exception:
Obstructed Richter hernia, Gall stone ileus, Pelvic abscess.

Blood stained stool.
Ischemic colitis, IBD.

Fever.
Marker of inflammation.

Hematuria.
Urolithiasis, UTI.

17. Other Relevant Aspects of the History
Past medical history
Cardiac disease AF, COPD, HTN, DM.
Past surgical history
Hx of previous operation
Gynecological history
- Menstrual history
Missed period >> Ectopic pregnancy
Mid of period >> Ovulation
Heavy period >> Endometriosis
- History of vaginal bleeding or discharge
Drug history
- NSAID >> PUD
- OCD >> Rupture of hepatic adenomas
- Corticosteroid >> Mask of pain
- Anticoagulant >> Intramural hematoma of the gut causing obstruction
Family history
Hx of colon cancer or other malignancy or IBD

18. Physical Examination
General examination
General examination and vital signs are important indicators.
Pallor, hypothermic, hypotensive, tachypnic , tachycardic may indicate
intra-abdominal bleeding.
Local examination
Inspection
Abdominal contour
Scars
Respiration
Visible swelling
Hernial orifices
Skin condition
Auscultation
For bowel sound
For Bruit and Hum
sounds
Palpation
Light palpation for
Superficial mass
Tenderness
Hotness
Deep palpation
Don not forget to do rectal examination.
Pelvic exam of female pt is important , a study in 2014 found that
women with RLQ pain thought to have acute appendicitis, 12.8% of
them had gynecological problem with normal appendix .

20. Investigations
Laboratory Investigations

- CBC with differential count >>
Decrese in Hb & Hct indicator for internal bleeding
Increase in Hb & Hct indicator of dehydration
Increase in WBC indicator of inflammatory process
- RBS>> DKA
- LFT>> Cholecystitis, cholangitis, hepatitis
- Amylase and Lipase >> Acute Pancreatitis
- Urine analysis>> Urolithiasis, UTI, DKA
- B-HCG>> Ectopic pregnancy
- S.Electrolyte
- S. Lactate>> Mesenteric ischemia

21. Investigations
Imaging study

- Erect chest X ray
- Abdominal X ray erect and supine
- USG
- CT Scan

Diagnostic Laparoscopy

22. Air under
diaphragm
Erect Chest
X-Ray

23. Multiple air
fluid level
Erect
Abdominal
X-Ray

24. Distended loops
of small bowel
Supine
Abdominal
X-Ray

25. coffee bean sign
Sigmoid volvulus
Abdominal
plain X-Ray

26. Gall stone
Abdominal
Ultrasound

27. Appendicitis
Abdominal
Ultrasound
Abdominal
CT

28. Normal
Abdominal
CT
Acute pancreatitis

29. Management
Pre-Operative
-NPO
-IV line start IV fluid and correction of dehydration and
electrolyte imbalance
-NGT tube in intestinal obstruction or persistent
vomiting
-Analgesia after initial assessment.
-Antibiotics if inflammatory condition associated.
-Urinary catheter and monitor urine output.

Operative
- According to cause

30. Management
Findings that
suggest need
for surgical
intervention

31. - 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.
Indications for admissions:

32. - Acute abdomen requires rapid and specific diagnosis as
several etiologies demand urgent operative intervention.
- The approach to a patient with an acute abdomen must be
orderly and thorough.
- Should be suspected even in a patient with only mild or
atypical presentations.
- The history and physical examination suggest the probable
cause, allow formation of a differential diagnosis, and guide the
choice of initial diagnostic studies.
Conclusion

33. Thank You