ACUTE ABDOMEN

William G. Cheadle, MD PURPOSE: To introduce the concept of the acute abdomenits pathophysiology, diagnosis, management, and treatment. OVERVIEW: There are few situations in clinical medicine that demand prompt and decisive action as frequently as does acute abdominal pain. Acute conditions of the abdomen are produced by inflammatory, obstructive, or vascular mechanisms and are manifested by sudden onset of abdominal pain, gastrointestinal symptoms and varying degrees of local and systemic reaction. They require urgent treatment, often including emergency operation. Their urgency usually precludes prolonged investigation and there are few specific tests or examinations, which may be relied upon to give clear-cut answers as to the exact cause of the acute condition. The diagnosis of acute conditions, therefore, frequently resolves itself into arriving at a fairly immediate judgment derived from an accurate and detailed history, a careful physical examination and a few selected lab tests and x-ray studies. While gathering the evidence, changes should be evaluated in terms of pathophysiologic alterations rather than specific diagnoses, and attention must be given to the need for supportive measures while investigation is under way. 1. LECTURE OBJECTIVES A. Recognize the symptoms: abdominal pain, nausea, vomiting, absence of gastrointestinal function, and signs which include involuntary guarding, rebound tenderness, and referred tenderness, which are hallmarks of the diagnosis of acute abdomen. B. Differential diagnosis includes acute appendicitis, perforated diverticulitis, perforated peptic ulcer, ruptured abdominal aortic aneurysm, blunt or penetrating trauma with viscus injury and gynecologic conditions such as ovarian torsion and ectopic pregnancy. C. Understand the underlying pathophysiologic basis for inflammation of a hollow viscus, which is, in general, the most common cause of peritonitis. D. Treatment which includes resuscitation, often in the intensive care unit, correction of fluid and electrolyte abnormalities including hypokalemia, hyponatremia, and hyperglycemia, other diagnostic measures, and abdominal exploration with resection or repair of the diseased viscus. E. Complications that would include persistent peritonitis and death without operation, and such complications as wound infection, anastamotic leak, and intra-abdominal abscess after operation. F. The outcome of this disease is still very poor in that mortality rates run from 20-40% depending on the type of peritonitis that is encountered. Generally, patients who form abscesses have mortality rates lower than those who develop generalized peritonitis. G. Follow-up required includes monitoring the status of the wound, checking for ventral hernia, which may occur in these patients, and overall rehabilitation, which takes 2 to 3 months or even longer, depending on the severity of illness and the time spent in the hospital.

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2. DEFINITION: Acute abdomen is the term used for an episode of severe abdominal pain that lasts for several hours or longer and requires medical attention. 3. SYMPTOMS: The history obtained from the patient should elicit both specific symptoms typical of a disease process and nonspecific symptoms. A. Nonspecific symptoms should be elicited first. 1. Pain a. Gradual periumbilical pain indicates visceral peritoneal irritation, such as appendicitis, diverticulitis, or other inflammatory conditions. The pain may become more specifically localized as the disease process progress. b. Severe, explosive pain indicates a process that immediately soils the parietal peritoneum, such as perforation of a hollow viscus. The pain may be either localized or generalized. c. Progressive, severe pain suggests a worsening intra-abdominal conditions, such as occurs with ischemic necrosis of the bowel or other organs. d. Localized pain that recurs as a generalized pain suggests that the inflamed organ has been perforated. Acute appendicitis, for example, causes right lower quadrant pain, which then becomes generalized if perforation occurs. e. Crampy pain indicates an obstruction in the gastrointestinal tract. This type of pain has a crescendo component, building up to intense pain, followed by a decrescendo component; the patient may then have an interval with no pain. i. Distinguishing between crampy pain versus constant or other types of pain is very important because crampy pain is associated with bowel obstruction. ii If crampy pain develops into constant severe pain, it suggests that the involved bowel segment is now ischemic or gangrenous. 2. Anorexia, nausea, and vomiting are common accompanying symptoms in acute inflammatory abdominal processes. Although they are reliably present when a problem is surgical, they also accompany nonsurgical diseases, in which case, they often precede the pain (as in gastroenteritis). 3. Changes in bowel habits are so common that they are seldom helpful unless very specific changes occur. For example: a. Bloody diarrhea suggests colitis, Salmonella infestation, or colonic ischemia. b. Patients with intestinal obstruction usually pass no flatus or bowel movement by rectum for 1-2 days prior to seeking medical attention. 4. Symptoms of sepsis, such as chills and fever, may be nonspecific, although certain patterns are typical of certain diseases. For example: a. The fever of uncomplicated appendicitis rarely exceeds 101F, whereas that of perforation often exceeds 101F. b. Cholangitis with choledocholithiasis is often accompanied by a shaking chill. B. Specific symptoms should be elicited as clues to specific diseases. 1. Previous surgery. A history of previous surgery yields important information. a. Adhesions may have formed within the peritoneal cavity, leading to intestinal obstruction. b. If the surgery was for malignant disease, the malignancy may have recurred, causing pain, sepsis, intestinal obstruction, and other symptoms.

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c. Previous removal of any organ (most likely the appendix, the gallbladder, or the uterus, ovaries, and fallopian tubes) eliminates that organ from consideration. d. Previous surgery may point to a specific problem; for example, suppurative cholangitis in a patient with previous choledocholithiasis and retained common duct stone. 2. Previous episodes of similar pain warrant questions about the subsequent disease course and the results of any diagnostic studies that were performed. 3. Characteristic maneuvers in certain diseases that provide temporary relief of pain must be sought. a. A patient with acute peritonitis will lie very still; any movement results in excruciating pain. b. A patient with a common duct stone or a kidney stone will pace the floor, unable to find a comfortable position. c. The pain of an acute peptic ulcer may be relieved by food or antacids, whereas pain from acute cholecystitis or pancreatitis may be exacerbated by food. 4. Previous illnesses. A history of disease in other body systems may be very useful. a. Urinary tract. Symptoms such as dysuria, hematuria, or changes in urinary habits should be sought. b. Reproductive tract in the female patient. The patient should be asked about past or present vaginal discharge, dysmenorrhea, a history of pelvic inflammatory disease, time of last menstrual period, and so forth. c. Cardiovascular system. Atrial fibrillation of recent onset or digitalis therapy might suggest intestinal ischemia. d. Diabetes mellitus is associated with sepsis. Poorly controlled blood sugars in a previously well-controlled diabetic may indicate infection. 4. PHYSICAL EXAMINATION of the patient with acute abdominal pain should yield new information that reinforces impressions obtained from the history. As with the history, there are both specific and nonspecific findings. A. Complete physical examination must be performed so that an important related or unrelated extra-abdominal diagnosis will not be missed. Points requiring particular attention include the following: 1. Changes in vital signs, particularly fever, tachypnea, hypotension, or cardiac rhythm irregularities. 2. Inspection for jaundice, dehydration, feculent breath, pneumonia, or mental disorientation or obtundation. 3. Examination of the extremities for loss of pulses B. Abdominal examination 1. Overall inspection a. A distended abdomen with visible peristalsis suggests small bowel obstruction. b. Prominent muscle guarding or rigidity may be visible, particularly if localized to one area of the abdomen in a thin and muscular patient. c. A scaphoid abdomen may suggest herniation of the abdominal contents through the diaphragm and into the thoracic cavity, particularly after blunt abdominal trauma.

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d. Hernias are frequently visible, particularly when the patient is standing. 2. Palpation of the abdomen should be done gently and should begin away from the area of maximum tenderness. a. The inguinal area should be examined for hernias or inflammatory conditions. b. The abdomen should be examined to determine the points of maximum tenderness or the presence of referred tenderness. Rebound tenderness is tenderness that occurs when the examining hand is quickly removed from the abdominal wall. It is indicative of acute peritoneal irritation. c. Spasm is determined by gently depressing the abdominal wall muscles. i. Comparing two areas simultaneously allows the examiner to distinguish an abnormal area from a normal one. ii. A spasm is voluntary if the patient is tensing the muscle in response to pain and involuntary if the muscle is taut secondary to the underlying inflammatory process. d. Palpation for abdominal masses should be done systematically. A mass in a particular abdominal quadrant suggests a specific diagnosis. i. Right upper quadrant: Acute cholecystitis or a complication of this diagnosis, such as subhepatic or intrahepatic abscess. ii. Left lower quadrant: Acute diverticulitis or peridiverticular abscess. iii. Right lower quadrant: Acute appendicitis or appendicieal abscess. iv. Left upper quadrant (uncommon in the acute abdomen): Complication of gastric or colonic malignancy, subphrenic abscess, or some acute inflammatory process related to the spleen, such as infarction. v. Midabdominal area: Pancreatic malignancy or abscess, complication of a perforated ulcer, or leaking abdominal aortic aneurysm. 3. Percussion of the abdomen a. Percussion is useful because it confirms areas of maximum tenderness and the presence of rebound tenderness. b. On rare occasions, the hollow sound of tympany indicates free intraperitoneal air, but it usually is present because of air in the intestine. c. A large area of tympany in the left upper quadrant suggests acute gastric dilation, a condition that can cause reflex hypotension through vagal pathways. 4. Auscultation is useful in many acute abdominal problems. a. A silent abdomen indicates the absence of peristalsis, suggesting diffuse peritonitis, which occurs with major abdominal sepsis, intestinal ischemia or gangrene, or prolongs (longer than 3 days) mechanical obstruction with marked distention of the bowel. Absent peristalsis may also indicate an ileus resulting from some other process, such as pneumonia, a renal stone, or trauma. b. Intermittent peristaltic rushes that have a crescendo followed by silence suggest an intestinal obstruction. This sign is particularly useful when the peristaltic rush coincides with the onset of episodic abdominal pain. Certain nonsurgical inflammatory conditions, such as gastroenteritis, produce highpitched intermittent peristaltic rushes. The pain pattern is usually not synchronous with the rushes.

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C. Rectal examination should be performed routinely in patients with acute abdominal pain. 1. Rectal palpation may localize the tenderness. In acute appendicitis, if the patients appendix is located in the pelvis, the only physical finding may be a right pelvic tenderness found on rectal examination. 2. The presence of blood in the stool suggests a malignancy, hemorrhoids, or an acute inflammatory gastrointestinal process, such as an ulcer or colitis. 3. A mass palpable on rectal examination may be a pelvic abscess secondary to a perforated viscus, a sign of pelvic inflammatory disease, or a metastatic malignancy. 4. Acute prostatitis in men is diagnosed rectally even though it may present with vague abdominal pain. Rectal examination reveals a tender, sometimes warm prostate gland. D. Gynecologic examination should be performed in all women and girls with abdominal pain. (The patients bladder should be empty.) 1. Cervical or parauterine tenderness suggests pelvic inflammatory disease. 2. A uterine, ovarian, or pelvic mass suggest: a. Intrauterine pregnancy b. Ectopic pregnancy with rupture and hemorrhage c. Pelvic, ovarian, or tubal inflammatory disease with or without abscess formation d. Pelvic or gynecologic malignancy 3. Cervical discharge should be examined microscopically for gonococci. E. Examination of the genitalia should be performed for all men and boys. Torsion of the testicle, a urologic emergency, may present as sudden onset of lower quadrant or scrotal tenderness. F. Special signs are useful in diagnosing acute abdominal pain. 1. Tenderness to percussion over the liver or kidney suggests acute hepatitis or pyelonephritis. 2. Iliopsoas sign is pain in the lower abdomen and psoas region that is elicited when the thigh is flexed against resistance. It suggests that an inflammatory process, such as appendicitis or perinephric abscess, is in contact with the psoas muscle. Patients may also limp while walking and may lie with the ipsilateral hip flexed to minimize psoas muscle use. 3. Obturator sign is pain elicited when the thigh is flexed and then rotated internally and externally. It suggests an inflammatory process in the region of the obturator muscle, such as an obturator hernia. 4. Murphys sign is elicited by palpating the right upper quadrant during inspiration: As the gallbladder descends during inspiration, acute pain is elicited. It suggests acute cholecystitis. 5. Cough tenderness occurs in the area of maximum tenderness when the patient coughs. The tenderness may also be elicited by shaking the patient or by any other sudden jarring movement. 6. Ecchymosis is the flank, periumbilical region, or back suggests a retroperitoneal hemorrhage. Possible causes include trauma, acute hemorrhagic pancreatitis, a leaking abdominal aortic aneurysm, and intestinal gangrene.

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5. A. B.

C. D. 6. A. B. C.

D. E.

F.

7. A. B.

7. Subcutaneous, subfascial, or pelvic crepitus suggests a rapidly spreading gasforming infection. These infections must be rapidly diagnosed and explored surgically if they are to be cured. DIFFERENTIAL DIAGNOSIS: Medical illnesses that can cause an acute abdomen Life-threatening medical illness, such as lower lobe pneumonias, acute myocardial infarction, diabetic ketoacidosis, and acute hepatitis, should be sought. Acute polyserositis (occurring with collagen vascular diseases), rheumatic fever, porphyria, and chronic lead intoxication are uncommon causes of acute abdominal pain that can be exceedingly difficult to diagnose preoperatively. A careful history and physical examination may, however, raise them as possibilities. Musculoskeletal problems, particularly vertebral compression of abdominal wall nerves, can also mimic acute general surgical conditions. A high index of suspicion is necessary for acute abdominal emergencies in immunosuppressed patients (i.e., transplantation or steroid-dependent patients), whose symptoms and finding may be minimal. RADIOGRAPHIC STUDIES Plain x-ray films of the abdomen in the supine and upright positions can often provide immediate information, which helps to confirm a diagnosis or exclude certain diagnoses that have been considered. Gas below the diaphragm in the upright film is almost pathognomonic or perforation of a hollow viscus, usually a ruptured peptic ulcer or a traumatic perforation. In mechanical small bowel obstruction, plain films in the upright position reveal dilated distended loops of gut with fluid levels above the obstruction, and absence of gas below the obstruction, i.e., terminal ileum and colon. Generalized distention of large and small bowel occurs in paralytic ileus. Plain films may reveal the presence of radiopaque gallstones or kidney stones. Usually upper GI barium studies are contraindicated because of the possibility of barium leakage into the peritoneal cavity when perforation is impending or perforation exists. Barium enema is an important diagnostic aid in intussusception of infants and children, and sometimes is used therapeutically under low pressure to reduce the intussusception. Barium enema may also be helpful in diverticulosis of the colon and in large bowel neoplasm, where sigmoidoscopy and biopsy may be helpful. When acute cholecystitis is suspected, intravenous cholangiography is useful for differential diagnosis. When the patient is acutely ill, investigation and supportive treatment should proceed concurrently, if a specific diagnosis is not immediately apparent. Supportive treatment includes nasogastric suction to relieve distention, intravenous fluids to correct fluid, and electrolyte imbalance, and to provide maintenance during periods of no oral intake, and typing and cross- matching of blood for possible transfusion. GENERAL PRINCIPLES used in the approach to the patient with acute abdominal pain are discussed below. A careful and systematic evaluation of the patient should be routinely performed. Most patients will have a well-documented diagnosis if this principle is followed. Statistically speaking, certain diagnoses are very common, such as appendicitis and gastroenteritis, whereas other diagnoses are quite rare, such as pylephlebitis. This

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C.

D.

E.

F.

G. 8. A. B. C. 9. A. B.

physician should not search for an occult diagnosis when a common diagnosis is more likely to be correct. When the diagnosis is not initially clear, continued observation and repeated blood studies (complete blood count, arterial blood gases, amylase, and electrolytes) may lead to the correct diagnosis as the disease process evolves. 1. Although this practice might be desirable in a patient with gastroenteritis, delay can be catastrophic in acute appendicitis, ischemic bowel, small bowel obstruction, volvulus, or incarcerated hernia. 2. If the diagnosis is not certain but the patient may have a potentially lethal condition that could be cured by an early operation, then an early operation should be performed that is, a small percentile of negative laparotomies are justified in patients with acute abdomens. This premise is best illustrated by the case of a patient with acute appendicitis. Here, a policy of watchful waiting may convert a simple appendicitis into a perforated appendicitis with generalized peritonitis and septic shock. The risk of death from this complication is many times higher than the risk from a small right lower quadrant incision in a patient who proves to have a normal appendix and mesenteric adenitis. Analgesics, particularly narcotics, should be withheld from the patient until the diagnosis is established or until the decision to proceed to surgery has been made. Serial physical examination will be totally useless if the patient has been given narcotics. Antibiotics should also be withheld until a diagnosis has been made and the antibiotic therapy is needed. The only exception to this is the patient who presents with septic shock from an unknown cause. In that situation, broad-spectrum antibiotics should be a part of patients resuscitation. Fluid deficits and electrolyte imbalances should be corrected before surgery. The few exceptions are: 1. Conditions that threaten immediate exsanguinations, such as a ruptured abdominal aortic aneurysm. 2. Conditions in which the fluid or electrolyte abnormality cannot be corrected in a reasonable amount of time that is, conditions that cause profound acidosis, such as necrotic bowel, where the acidosis cannot be corrected until the bowel is surgically removed. Nasogastric tubes should be placed before the induction of anesthesia to empty the stomach, thus minimizing the risk of pulmonary aspiration. WHEN TO REFER Abdominal pain lasting 6 hours or longer. Second visit to ER for same illness. Three or more air-fluid levels on abdominal films. PITFALLS Be careful of patient on steroids, which may mask symptoms and signs of peritonitis. Be careful of patient with symptoms of severe abdominal pain out of proportion to physical exam. Patient may have ischemic bowel.

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10. SUGGESTED READING Wrightson WR. Acute abdomen. In: Wrightson WR, ed. Pocket Surgery. Malden, MA: Blackwell Science 2002:119-128. Carter MB, Wohltmann CD. Acute abdomen. In: Galandiuk S, Carter MB, Abby M, eds. When to refer to a surgeon. St. Louis: Quality Medical Publishing 2001:157-162.

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