ACUTE ABDOMEN

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ACUTE ABDOMEN

• 13th CME
• Presented by
• Dr. Ankur Gupta
• Gurgaon

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ACUTE ABDOMEN

• Acute Abdomen refers to a sudden, severe pain
  in the abdomen that is less than 24 hours in
  duration,which suggests a disease that possibly
  threatens life and demands an immediate or urgent
  diagnosis for early treatment.

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POINTS TO REMEMBER
   
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• Clinical course can vary from from minutes to
  hours to weeks.
• It can be an acute exacerbation of a chronic
  problem e.g. Chronic Pancreatitis,Vascular
  Insufficiency.
• Well elicited history
• Proper physical examination
• Diagnosis can be made most of the time by a good
  history and a proper physical examination.

 

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• Investigations are usually carried out    
  only to support the diagnosis.    or to narrow
  down the differential diagnoses.

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CAUSES OF ACUTE ABDOMEN

• SURGICAL CAUSES
• Acute appendicitis
• Acute diverticulitis
• Acute pancreatitis
• Acute cholecystitis
• Intestinal obstruction
• Billiary colic
• Ureteric colic
• Acute retention of urine
• Perforation of peptic ulcer
• Perforation of appendix
• Ruptured AAA
• Perforated oesophgagus

• MEDICAL CAUSES
• Gastritis
• Acute Gastroenteritis
• Hepatic abscess
• Rectal sheath hematoma
• Herpes Zoster
• UTI
• Tabes dorsalis
• Sickle cell disease
• Diabetes Mellitus
• Thyrotoxicosis
• Addisonians disease
• Poryphyria
• Hereditary Spherocytosis

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GYNAECOLOGICAL CAUSES

• Ectopic pregnancy
• PID
• Salpingitis
• Mittelschmerz
• Endometriosis
• Dysmenorrhoea
• Fibroid degeneration
• Ovarian cyst rupture, torsion , hemorrhage

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ASSESSMENT

• A. Emergent abdominal pain. Sudden/ severe pain/
  hemodynamic changesFall in B.P/ tachycardia
• AAA
• Bowel obstruction,
• Ruptured spleen,
• Ruptured ectopic pregnancy.
•  B. Nonemergent abdominal pain.When emergent
  causes are reasonably excluded, nonemergent
  causes can be considered.
• UTI,
• constipation,
• Renal stones,
• Cholelithiasis,
• Gastroenteritis
• Dysmenorrhea

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APPROACH TO ACUTE ABDOMEN

• CLINICAL HISTORY
• EXAMINATION
• INVESTIGATIONS
• DIFFERNTIAL DIAGNOSIS
• RECOGNISING SEVERE CASES / RED FLAGS TO
  RAISE SUSPICION OF SERIOUS PATHOLOGY
• . CRITERIA FOR ADMISSION
• PRE- HOSPITAL / EMERGENCY CARE OF SUSPECTED
  ACUTE ABDOMEN.

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HISTORY

• History of pain
• History of Associated Symptoms-
• Bowel symptoms
• Urinary symptoms
• Fever
• Drug history
• Past Surgical history
• Past Medical history
• Menstrual History in females

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HISTORY OF PAIN

•  
• Time of onset
• Pain early morning- Acute Appendicitis
• Sudden pain after the lunch break ,eating
  Perforation of Peptic Ulcer
• Mode of onset
• Sudden - perforation, colic,torsion ,volvulus.
• Gradual increasing -acute intestinal obstruction
• Referred pain and site of pain
• Stomach, duodenum and jejunum(T5-8) -
  Epigastrium.
• Ileum and appendix (T9-10) -umbilicus
• Colon (T11-L2) in the hypogastrium.
• In Renal colic - loin to groin,testis innerside
  of thigh(L1L2).
• Billiary colic pain radiates from right
  hypochondrium to inferior angle of scapula
•     

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• Character of pain
• COLICKY- intestinal,billiary, renal or
  uretric colic
• BURNING PAIN - peptic ulcer. acute gastritis
  ,perforated pepticulcer.
• AGONISING - acute pancreatitis or torsion
• What makes the pain better or worse?
• PERITONITIS- pain relieved on lying still
• CHOLECYSTITIS- fatty foods will aggravate whereas
  fatfree diet will give some relief.
• PEPTIC ULCER, ACUTE GASTRITIS- alcohol, spicy
  food or drugs like asprin will aggravate the pain
  while alkalis make the pain better.Sometimes
  vomiting relieves the pain in peptic
  ulcer,application of local pressure relieves
  colicky pain.

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HISTORY OF ASSOCIATED SYMPTOMS

• BOWEL SYMPTOMS
• 1.Constipation d/d
• a. Progressive intestinal obstruction
• from a neoplasm or inflammatory
• bowel disease
• b. Paralytic Ileus
• c. Post Operative
• d. Obstructed groin hernia
• 2. Diarrhoea
• Diarrhoea with pain is mainly medical.
• Following are the exceptions
•  a. Obstructed Richter's Hernia
• b. Gall Stone ileus

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NAUSEA VOMITING

• Frequency of vomiting
•  
• Character of vomiting
• projectile, non-projectile or self-induced
• Nature 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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Continued.

• Pain first, followed by Vomiting is usually
  surgical.
• The vomiting is due to reflex pylorospasm
• Nausea vomiting first , followed by pain is
  usually due to a medical condition
• Vomiting is very prominent in
• a. Mallory-Weiss syndrome.
• b. Boerhaave syndrome(trans- mural
  esophageal tear)
• c. Acute gastritis
• d. Acute pancreatitis
• Anorexia or decreased appetite with pain is
  usually seen in Acute appendicitis.

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URINARY SYPMTOMS

• Ureteric colic
• Hematuria
• Painful frequent attempts at micturition.

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FEVER CHILLS/ RIGORS

• Amoebic Liver Abscess
•  Pyogenic Liver Abscess
•  Perinephric Abscess
•  Intra-abdominal pus collection.
• Low grade temp. --
• Appendicitis
• Acute cholecystitis
• High grade temp-
• Salpingitis
• Abscess
• Very High Grade Temp.with
• imminent septic shock
• Peritonitis
• Acute cholangitis
•     Pyonephrosis

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DRUG HISTORY

• Corticosteroids mask pain
•   Anticoagulants can lead to an intramural
  haematoma of the gut causing obstruction
•   Oral Contraceptives - rupture of hepatic
  adenomas
•   NSAIDs - erosive gastritis peptic ulcers

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• PAST SURGICAL MEDICAL HISTORY
• previous operations- leading to adhesions
• Sickle cell disease
• Diabetes
• Cancer
• Renal failure
• Poryphyria
• Menstrual History in females
• (i) Missed period- ectopic pregnancy
• (ii) Mid of period-ovulation pain (Mittel-
  schmerz)
• (iii) With heavy periods- endometriosis

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PHYSICAL EXAMINATION

• APPEARANCE
• Anxious Patient lying motionless
• (i) Acute appendicitis
• (ii) Peritonitis
• Rolling in bed restless
• (i) Ureteric Colic
• (ii) Intestinal colic
• Writhing in Pain, Bending Forward
• Chronic Pancreatitis
• Jaundiced
• CBD obstruction
• Dehydrated
• (i) Peritonitis
• (ii) Small Bowel obstruction

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VITALS

•  ALWAYS CHECK      -
• Temperature - Fevere high grade or low
  grade
• Pulse - Tachycardia or
  bradycardia
• BP - Hypotension in
  case of Shock
• Respiratory rate - Tachypnoea

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SYSTEMIC EXAMINATION
Scaphoid or flat in peptic ulcer
- Distended in ascites or intestinal obstruction
- Visible peristalsis in a thin or malnourished
patient (with obstruction)
 
Systemic Examination
     Erythema or discolouration
a

• INSPECTION-
• Scaphoid / flat - peptic ulcer
• Distended - ascites or intestinal obstruction
• Visible peristalsis - obstruction
•  
• Systemic Examination
• Erythema or discolouration- Hemorrhagic
  pancreatitis
• Peri-umbilical - Cullen sign
• Inguinal Fox sign
• Flanks - Grey Turner sign

 
   
Systemic Examination
Per abdomen
Palpation
     Be gentle
     Start away from site of pathology then
towards
     Check for Hernia sites
     Tenderness
     Rebound tenderness
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PALPATION

• Per abdomen
• Be gentle
• Start away from site of pathology then towards
•   Check for Hernia sites
•   Tenderness
•   Rebound tenderness
•   Guarding- involuntary spasm of muscles during
  palpation
•   Rigidity- when abdominal muscles are tense
  board-like. Indicates peritonitis.

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    Local Right Iliac Fossa tenderness
a. Acute appendicitis b. Acute
Salpingitis in females c. Amoebiasis
of Caecum     Low grade, poorly localized
tenderness Intestinal Obstruction
     Tenderness out of proportion to
examination a. Mesenteric Ischemia b.
Acute Pancreatitis     Flank Tenderness
a. Perinephric Abscess b. Retrocaecal
Appendicitis  
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SPECIFIC SIGNS-

•     Rovsings Sign - Acute Appendicitis
•     Obturator Sign - Pelvic Appendicitis
•     Psoas Sign
• - Retrocaecal
  appendicitis
• - Crohns
  Disease
• -
  Perinephric Abscess
•     Murphy's sign - Acute Cholecystitis
•     Thumping tenderness over lower ribs in
  inflammation of
• -Diaphragm
• - liver
  or spleen

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Per Rectal Examination - tenderness -
induration - mass (Blummers shelf) - frank
bloodxaminationPer Vaginal Examination -
Bleeding - Discharge - Cervical motion
tenderness -Adnexal masses or tenderness. 
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AUSCULTATION

• Auscultate abdomen in all four quadrants.
• Absent bowel sounds - Paralytic Ileus
• -
  Generalised Peritonitis
• -
  Absolute Intestinal Obstruction
• High pitched and tinkling SubAcute intestinal
  obstruction
• Abdominal Illiac Bruits Abdominal Aortic
  Aneursym

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INVESTIGATIONS

• CBC ,LFT,CRP
• Electrolyte ,Blood Urea , Creatinine
• ECG
• UPT- female patients with suspected
  appendicitis,PID,Ectopic pregnancy and prior to
  radiological investigations in reproductive age
  group.
• Amylase or Lipase(if pancreatitis suspected)
• Diagnostic imaging
• -X RAYS
• -BARIUM ENEMA
• -ENDOSCOPY
• -INTRAVENOUS CHOLANGIOGRAPHY
• -USG- abscesses,ovarian cyst,stones etc.
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• -CT- AAA,Pancreatic,A.appendicitis etc
• EXPLORATORY LAPAROTOMY

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RADIODIAGNOSIS BY XRAY-

• Upright X ray chest for - Basal Pneumonia -
  Ruptured Oesophagus - Elevated Hemi diaphragm
  - Free Gas under diaphragm Abdominal X ray
  film -  Air-Fluid Levels -  Stones -  Ascites
  -  Eggshell calcification in AAA -  Air in
  Biliary tree. -  Obliteration of Psoas Shadow
  -retroperitoneal disease -  Right lower
  quadrant sentinel loop A.pancreatitis

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TABLE I - Differential Diagnosis of Diseases
Causing Upper Abdominal Pain

• ACUTE APPENDICITIS
• Usually lt 40 Yrs
• Common in both sex
• Umbilical pain shifting later to RIF
• Vomiting exception but anorexia
• Appears not acutely ill unless peritonitis.
• Temp 99 100 F
• Tenderness RIF
• LAB- Leucocytosis
• Xray No help

• ACUTE CHOLECYSTITIS
• Usually gt 40 Yrs
• Female, Fat
• Severe radiates to back shoulder
• Vomiting Reflex may be retching
• Appears Worn because of pain.
• Temp- 99-102 F
• Tenderness Localized in RUQ
• LAB- Leucocytosis
• Xray - May show stones or non visualisation of
  G.B

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Differential Diagnosis of Diseases Causing Upper
Abdominal Pain .cont-

• PERFORATED PEPTIC ULCER
• 30 50 Yrs
• Rare in females.
• H/O ulcer sudden onset pain.
• Vomiting Not prominent .
• Appears Acutely ill, keeps abdomen immobile.
  Shock may be .
• Temp -Subnormal
• Tenderness- Diffuse,more in upper abdomen, board
  like rigidity.absent bowel sounds.
• LAB- Leucocytosis
• Xray -Free air in 85 ,4 hr aftr onset.

• ACUTE PANCREATITIS
• 30 50 Yrs
• Females
• Pain sudden radiate to back
• Vomiting Always .
• Appears acutely ill, Shock if necrosis.
• Temp subnormal at onset.
• Tenderness Epigastric ,rebound . Decreased bowel
  sounds.
• LAB- Serum amylase,lipase elevated,
• Xray Sentinal loop of small bowel.

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TABLE II - Differential Diagnosis of Diseases
Causing Lower Abdominal Pain

• URETERAL OBSTRUCTION
• lt 4OYrs
• Seen in both sex.
• Pain severe knife like ,begins in lumbar area,
  radiates to groin, scrotum, thigh.Dysuria,frequenc
  y
• Temp normal
• Tenderness costovertebral,none in abdomen
• LAB hematuria, leucocytosis.
• Xray seen stone in 85. IVP helps in diagnosis.

• SALPINGITIS
• lt 40 Yrs
• Females
• Pain dull ,constant.
• Menorrhagia /-
• Temp -99-102 F
• Tenderness-Bilateral LQ, suprapubic
• Exquisite tenderness on moving the cervix,
  profuse purulent discharge.
• LAB- Vaginal or cervical culture for gonococcus
  etc
• Xray of no help

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Differential Diagnosis of Diseases Causing Lower
Abdominal Pain  cont.-

• ECTOPIC PREGNANCY-
• lt 40 Yrs
• Female
• Sharp knife like
• Missed or scanty period
• Temp- Normal
• Tenderness Unilateral LQ,rebound
• Cervix moderately tender to movement, bloody
  discharge
• LAB- Hcg,USG,cul- de sac aspirate
• Xray of no help

• DIVERICULITIS
• gt40 Yrs
• Male
• Dull, crampy ,LL pain, Diarrhoea
• Temp- 99-101 F
• Tenderness LLQrebound .mass
• LAB Leucocytosis.
• Xray of no help, unless Barium enema.

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Recognising severe cases/red flags to raise
suspicion of serious pathology

• Hypotension
• Confusion/impaired consciousness
• Signs of shock
• Systemically unwell/septic-looking
• Signs of dehydration
• Rigid abdomen
• Patient lying very still or writhing
• Absent or altered bowel sounds
• Associated testicular pathology
• Marked involuntary guarding/rebound tenderness
• Tenderness to percussion
• History of haematemesis/melaena or evidence of
  latter on PR examination
• Suspicion of medical cause for abdominal pain

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Criteria for admission

• There are no hard-and-fast rules by which to make
  this judgement. It will vary with the clinical
  situation and confidence/experience of the
  clinician involved. Any of the above red flags
  would indicate a need for admission in the vast
  majority of cases.
• If there is significant co-morbidity such as
  diabetes or ischaemic heart disease you should
  have a low threshold for admission

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Pre-hospital/emergency department care of
suspected 'acute abdomen'
 

• Resuscitation initial assessment. ( AIRWAY ,
  BREATHING,CIRCULATION)
• NPO.
• Intracath insertion for i/v access. 
• Analgesic Anti-Spasmodic for Colicky pain -
  Inj. BUSCOPAN 1ml. amp
  
  
  (20mgm). I.V
• Non Narcotic analgesics for Non Colicky pain- Inj
  Diclofenac sodium
• Anti- Emetics in cases of gastritis and
  gastroenteritis Inj Emset 4mg IV Inj
  Meteclopromide IV 
• Antacids, H2 Blockers , Proton pump
  inhibitors in cases of Acute gastritis etc.- Inj
  Ranitidine ,Inj Pantocid I.V
•  

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- IV Fluids start with Ringer Lactate. 
-Nasogastric tube should be kept in suspected
intestinal obstruction / peritonitis. 
-Antibiotics in inflammatory / infective
conditions as per antibiotic guidelines. 
-Urinary catheterization in selected situations
DEFINATIVE TREATMENT DEPENDS ENTIRELY ON THE
CAUSE DEPENDING ON THE SURGICAL OR MEDICAL
CONDITION DIAGNOSED REQUIRING SURGICAL OR MEDICAL
INTERVENTION.
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