Acute abdomen

Tamás Fenyvesi
November, 2016

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Acute abdomen is an abdominal emergency no
temporizing is ever justifiable.
Patients present more likely in the evening
hours
Never wait with your decision for the next
morning

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 Characteristics of acute
abdomen
has been present for less than 24 hours
Sudden and unexpected onset of
abdominal pain
associated symptoms:
nausea, vomiting, abdominal dystension,
diarrhea, constipations, anorexia
The pain may arise from intra-and extra-
abdominal structures
acute abdomen not invariable operation
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Neural innervation of the gastrointestinal
tract

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 History
allow the patient to give his/her entire
current history before asking specific
questions
the character and onset of pain are
essential
–colicky pain: obstructive processes
–sustained pain :infectious processes
Referred pain patterns may give a clue

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Abdominal pain onset patterns
I. sudden(seconds)
–A. perforation or rupture of a viscus:peptic
ulcer, abdominal aortic aneurysm,
esophagus, ectopic pregnancy,PTX

–B. infarction:gut, heart, lung

P.D. White etc

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Abdominal pain onset patterns

II. rapid(minutes)
–A. colic syndromes: biliary, ureteral, small
bowel obstruction(high)
–B. inflammatory processes:
pancreatitis, diverticulitis,
appendicitis, penetrating ulcer,
cholecystitis
–C. ischemic processes:
strangulation, torsion 9
Abdominal pain onset patterns
III. Gradual(hours)
A. inflammatory :appendicitis, cholec.,
pancreat., divertic., salpingitis, ¤
prostatitis, inflamm.bowel dis., intra-
abdominal abscess
B. obstruction:distal small bowel or
colon,ectopic pregnancy,urinary retention,
incarcerated hernia
C. neoplastic:perforating or penetrating
tumors (colon, stomach, small intestine)
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 Physical examination

Observation of the patients body

habitus and facial expression
–peritonitis :unwillingness to change

posture, hip flexion with the knees

drawn up, shallow breathing
–colicky pain: intense movements to

alleviate
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 Physical examination

Inspection of the abdomen:localized or

generalized dystension, visible
peristaltsis, hernial bulges, erythema
Auscultation of bowel sounds, if no
sounds are heard : paralytic ileus
Percussion absence of hepatic
dullness (!!) : perforation
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 Physical examination
Palpation : superficial, gentle of all
quadrants, first at the least painful areas,
after this deeper
classic rebound tenderness (deep
palpation followed by rapid release) is not
specific
have the patient laugh, cough, distend or
maximally reduce his/her abdominal girth
A very old and forgotten means to palpate
the abdomen in a bath tub (in only the
patient !!) 14
•A rectal digital examination is obligatory

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Characteristic
scars,
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Now often laparoscopy
 Laboratory evaluation
Complete blood count:WBC differential,
CRP, sed.rate
urinalysis:
serum amylase (urine)
beta human chorionic gonadotropin in
females
serum electrolytes,BUN,creatinine and
glucose
liver function test in upper abdominal pain
use only relevant laboratory
investigations
the results of which effect therapy !!
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 X-ray evaluation
upright PA and lateral film of the chest
supine and erect plain film of the
abdomen
–the upright film should include the
diaphragm
to detect free intraperitoneal air
only horizontal beam films detect fluid
levels within the bowel

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 X-ray evaluation

contrast study may be required (dangers!)

abdominal ultrasound mandatory
in some instances endoscopic
CT , MRI, nuclear (PET scan if
cost/benefit !! O K)
angiography
may add to diagnostic accuracy

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 Causes of acute abdomen
Appendicitis
Acute cholecystitis
Acute pancreatitis
Diverticulitis
Perforated peptic ulcer
Bowel obstruction
Mesenteric ischemia
Ruptured abdominal aortic aneurysm
Gynecologic causes
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 Appendicitis

History: tipically midabdomonal pain ¤

onset of nausea and vomiting
relocation of pain to the right
lower quadrant
elevation of temperature

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ZETA (Sir Zachary Cope) 23
Appendicitis
. : bacterial infection with
contributory factors:intraluminal
obstruction -fecalith lymphoid
hyperplasia, parasites, carcinoid tu.
–typical symptoms:midabdominal
pain moving to the right lower
quadrant- elicited by coughing
laughing or bumping, nausea and
vomiting, anorexia,fever.
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Appendicitis
.
:
physical : tenderness and guarding over
the right lower quadrant (McBurney
point-1/3 distance superior iliac
spine-umbilicus)
– psoas sign, rebound tenderness
laboratory:WBC,CRP, urinalysis

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 Differntial dg of appendicitis
Localization of the appendix
ascending:
cholec,perf pyonephr
duodenal ulc pyelitis
perinephr absc nephrolith
hydronephr omental torsion
Iliacal
penetrating duod ulc Meckel’s diverticulum
Crohn diseas !! Psoas absc
Ileocecal cc. hip !!
Tbc muscle rupture
uretolith typhlitis
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Appendicitis 2 :
abdominal X-ray rarely useful,
ultrasound(periappendicular
fluid,edema,abscess,visualization of
the lumen) increasing significance
Peak incidence 15-24 years
choice of treatment ,surgery:10-20%
negative appendectomy

Keep in mind the danger of perforation

in the elderly
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 Acute cholecystitis

obstruction of the bile duct by stone

1. bacterial in 50-85% of cases
2. Chemical agents : lysolecithin,
other tissue factors
3. Inflammation from mechanical
strech

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 Acalculous cholecystitis with dilated
gallbladder and thickened gallbladder wall

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Diagnosis of stone disease by ultrasound
shadow

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Cholesterol stones gall bladder

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Appearance of gallstones

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Characteristic symptoms:
colic, localized to the right upper
quadrant
RUQ tenderness
patient suddenly stops inspiration
(Murphy‘sign)
irradiates to the right shoulder or
scapula
vomiting , exsiccosis
fever usually moderate, but also
chills

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The „convergence projection” :
in the lateral spinothalamic tract the fiber
number is less than the sensory fibers
somatic> visceralis

the brain “learns” that on the given tract

the somatic signals are transmitted

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 Acute pancreatitis

Increasing incidence: 36 to 44/100 000 adults

in California (1994-2001)
200 000 hospital admission/year in the USA

Bile reflux is the trigger (1856 Claude Bernard)

2 enzymes are released from acinar cells

amylase and lipase

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Causes

gallstones 38%
alcohol abuse 36%
pancreas divisum ( congenital abnormality of
the pancreatic duct)
intraductal papillary tumors
ERCP (increase of serum amylase
after the procedure )
Serum triglyceride >11mmol/L
some drugs
infections
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 Diagnosis
Symptoms of acute abdomen
•Constant acute pain in the epigastric area or the
right upper quadrant
•Nausea , vomiting
•Tenderness in the upper abdomen
•Cullen’s sign:

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20% severe (4% die)

Early development
sequential organ failure
increased capillary permeability
decreased intravascular volume
hypovolemia
renal dysfunction
pulmonary complication
Pancreatic necrosis a very severe complication

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Severity is assessed by CT and contrast enhanced CT

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 Treatment

Correct fluid losses

monitor respiratory, cardiovascular and
renal function. Multidisciplinary

Stop parenteral nutrition : a rule!??

Infection
antibiotic prophylaxis is debated in
proven infection: imipenem

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Lancet 2008;371:143 ¤ 43
BMJ 2004;328:1407 44
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 Causes of acute abdomen
Diverticulitis
prevalence 5% , increases with age
the sigmoid colon is most commonly involved
in 50% the only segment, right sided 0,1-2,5%
signs and symptoms protean
left lower quadrant pain, low grade fever,
leucocytosis,nausea, vomiting, distension
Sigmoidoscopy not indicated(perforation!!),nor
barium enema, not in acute phase ,only later
"elective "
X-ray or CT scanning
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 Causes of acute abdomen
Mesenteric ischemia: 0,4% of abdominal surgery
vascular disorders-usually catastrophic illness
– embolic occlusion or thrombosis:intestinal infarction--
gangrenous bowel
– mortality 40-70%
abdominal pain,vomiting diarrhea, melena ,
distension,tenderness
bowel sounds from hypoactivity to absent
Bloody peritoneal transsudate,leucocytosis 20 t
hemoconcentration
history of abdominal angina,atrial fibrillation
rapid visceral angiography
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 Causes of acute abdomen
Perforated peptic ulcer 10% of hospital
admission for ulcer 7-10 pts/100000/year
undiagnosed pts die,duodenal 6-8x more often¤
sudden onset epigastric pain"hit with a knife"
– spreading to the entire abdomen:rigidity, diffuse
tenderness-hypovolemia, shock
upright or left lateral decubitus X-ray 55-85%
pneumoperitoneum:on physical disappearance of
hepatic dullness, X-ray
may heal spontaneously,dudenal anterior wall ¤
surgery,broad spect.antibiot,fluid
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Succussion splash
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Colonic perforation

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 Causes of acute abdomen

Ruptured abdominal aortic aneurysm

pain,sudden onset ,midabdominal,paravertebral

pulsatile abdominal mass,hypotension "triad"
risk: atheroscler.diameter and rate of increase
– 5,5 cm threshold for elective surgery
– Abdominal ultrasound
X-ray (contrast iv.deviation of the ureters,aortic
wall,CT,angio time consuming
MR
emergency operation-high mortality 51
Classification of thoraco-abdominal aortic
aneurysms

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Atherosclerotic abdominal aortic aneurysm after
fatal rupture

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 Causes of acute abdomen

Bowel obstruction: ileus 20% of all acute

surgical hospital admissions
causes: mechanical
extrinsic: adhesions,hernias,volvulus,masses
intraluminal objects: fecal impaction,gallstone,
gastric bezoars,foreign bodies
intrinsic lesions:neoplasms,inflammation,
intussusception,hematoma
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 Causes of acute abdomen
Ileus 2 : adynamic(paralytic)
reflex inhibition:laparotomy,trauma
inflammation:peritonitis,toxic megacolon,
acute irradiation
infectious process:appendicitis,cholecystitis
ischemic processes:arterial insuff.
retroperitoneal :ureter,kidney
drug induced:opiates,anticholinergic drugs
metabolic:porphyria ,ketoacidosis
X-ray diagnosis: air-fluid levels -small or large bowel
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 Causes of acute abdomen
Gynecoligical:in reproductive age
pelvic inflammatory, ectopic pregnancy, ovarian
cyst hemorrhage,adnexal or ovarian torsion
pain,delayed menstrual period,diffuse pelvic
tenderness, acute rupture of blood filled
fallopian tube
SYNCOPE,pelvic examination,pregnancy test

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„A good eater must be a good man,
for a good eater must have good
digestion, and good digestion
depends upon good conscience”

Benjamin Disraeli
1804-1881
Prime minister of Great-Britain: 1868, 1874-80

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Some reminder of anatomy and
pathophysiology

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 .
The foregut,midgut and hindgut have and
retain their own innervation and blood
supply
forgut : oropharynx to the duodenum (bile
duct)
midgut: distal duodenum,jejunum,
ileum,appendix, ascending colon,
proximal 2/3 transverse colon

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 .

hindgut: distal1/3 of transverse colon to

anus
peritoneum: visceral autonomic
innervation dull,crampy or aching pain
:parietal somatic innervation
sharp, severe and persistent pain

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 Acute abdomen

Abdominal pain :visceral, somatic or referred

abdominal wall: anterior and lateral spinal T7-L1
Two types of nociceptors
– A-delta fibers rapid : sharp well localized

– C-fibers slow:dull, poorly localized

:posterior L2-L5
pain fibers enter spinal cord ipsilaterally
visceral pain arises in the midline
fibers enter spinal cord bilaterally
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“ To study the phenomenon of disease
without books is to sail an uncharted
sea,
while to study books without patients
is not to go sea at all”
William Osler

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A University should be
a place of light,
of liberty, and of learning.
Benjamin DISRAELI, 1873

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Diagnosis:

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