THE ACUTE ABDOMEN

This section deals with the acute abdominal conditions that cause the patient to be
hospitalized within a few hours of the onset of pain (Table 6.29). The diagnosis when made
quickly reduces morbidity and mortality. Although a specific diagnosis should be attempted,
the immediate problem in management is to decide whether an 'acute abdomen' exists and
whether surgery is required.

History
This should include previous operations, any gynaecological problems and whether any
concurrent medical condition is present.
Pain

Table 6-29. Common causes of acute abdominal pain

Diagnosis No. of patients

Non-specific abdominal pain 46
Acute appendicitis 44
Renal colic 6
Gynaecological disorders 4
ntestinal obstruction 3
Urinary tract infection 3
Gall bladder disease 1
Perforated ulcer/dyspepsia 1
Diverticular disease
Other diagnoses 5
No diagnosis established 3

The onset, site, type and subsequent course of the pain should be determined as accurately
as possible. In general, the pain of an acute abdomen can either be constant (usually owing
to inflammation) or colicky because of a blocked 'tube'. The inflammatory nature of a constant
pain will be supported by a raised temperature, tachycardia and/or a raised white cell count. If
these are normal, then other causes (e.g. musculoskeletal, aortic aneurysm) or rare causes
(e.g. porphyria) should be considered. Colicky pain can be due to an obstruction of the gut,
biliary system, urogenital system or the uterus. These will probably initially require
conservative management along with analgesics. If a colicky pain becomes a constant pain,
then inflammation of the organ may have supervened (e.g. strangulated hernia, ascending
cholangitis or salpingitis).

A sudden onset of pain suggests:

 a perforation (e.g. of a duodenal ulcer)

 a rupture (e.g. of an aneurysm)
 torsion (e.g. of an ovarian cyst)
 acute pancreatitis.

Back pain suggests:

 pancreatitis
 rupture of an aortic aneurysm
 renal tract disease.

Inflammatory conditions (e.g. appendicitis) produce a more gradual onset of pain. With
peritonitis the pain is continuous and may be made worse by movement.
Vomiting
Vomiting may accompany any acute abdominal pain but, if persistent, it suggests an
obstructive lesion of the gut. The character of the vomit should be asked - does it contain
blood, bile or small bowel contents?
Other symptoms
Any change in bowel habit or of urinary frequency should be documented and, in females, a
gynaecological history should be taken.

Physical examination
The general condition of the person should be noted. Does the patient look ill? Is he or she
shocked? Large volumes of fluid may be lost from the vascular compartment into the
peritoneal cavity or into the lumen of the bowel, giving rise to hypovolaemia, i.e. a pale cold
skin, a weak rapid pulse and hypotension.
The abdomen
 Inspection. Look for the presence of scars, distension or masses.
 Palpation. The abdomen should be examined gently for sites of tenderness and the
presence or absence of guarding. Guarding is involuntary spasm of the abdominal
wall and it indicates peritonitis. This can be localized to one area or it may be
generalized, involving the whole abdomen.
 Bowel sounds. Increased high-pitch tinkling bowel sounds indicate fluid obstruction;
this occurs because of fluid movement within the large dilated bowel lumen. Absent
bowel sounds suggest peritoneal involvement. In an obstructed patient, absent bowel
sounds suggest strangulation, ischaemia or ileus. It is essential that the hernial
orifices be examined if intestinal obstruction is suspected.

Vaginal and rectal examination

Vaginal examination can be very helpful, particularly in diagnosing gynaecological causes of
an acute abdomen (e.g. a ruptured ectopic pregnancy). Rectal examination is less helpful as
localized tenderness may be due to any cause; it may show blood on the finger stall.
Sigmoidoscopy
If diarrhoea is present, sigmoidoscopy is indicated to aid exclusion of infective, inflammatory
and ischaemic causes of acute pain. A specimen of stool should be taken for stool culture for
bacterial pathogens (e.g. Campylobacter, Salmonella, Shigella) when diarrhoea is present -
stool should also be tested for Clostridium difficile toxin if antibiotic therapy or hospital
precedes onset of diarrhoea and acute abdominal pain (see p. 131).
Other observations
 Mouth. The tongue is furred in some cases and a fetor is present.
 Temperature. Fever is more common in acute inflammatory processes.
 Urine. Examine for:
o blood - suggests urinary tract infection or renal colic
o glucose and ketones - ketoacidosis can present with acute pain
o protein and white cells - to exclude acute pyelonephritis.
 Think of medical causes (Table 6.30).

Investigations
 Blood count. A raised white cell count occurs in inflammatory conditions.
 Serum amylase. High levels (more than five times normal) indicate acute
pancreatitis. Raised levels below this can occur in any acute abdomen and should not
be considered diagnostic of pancreatitis.
 Serum electrolytes. These are not particularly helpful for diagnosis but useful for
 general evaluation of the patient.
 Pregnancy. A urine dipstick is used with women of child-bearing age.
 X-rays. A chest X-ray is useful to detect air under the diaphragm owing to a
perforation. Dilated loops of bowel or fluid levels are suggestive of obstruction (erect
and supine abdominal X-ray).
 Ultrasound. This is useful in the diagnosis of acute cholangitis, cholecystitis and
aortic aneurysm, and in expert hands is reliable in the diagnosis of acute appendicitis.
Gynaecological and other pelvic causes of pain can be detected.
 CT scan. Spiral CT is the most accurate investigation in most acute emergencies. It
should be used more often to avoid unnecessary laparotomies.
 Laparoscopy. This has gained increasing importance as a diagnostic tool prior to
proceeding with surgery, particularly in men and women over the age of 50 years. In
addition, therapeutic manoeuvres, such as appendicectomy, can be performed.

Table 6-30. Medical causes of acute abdomen

Referred pain
Pneumonia
Myocardial infarction
unctional gastrointestinal disorders
Renal causes
Pelviureteric colic
Acute pyelonephritis
Metabolic causes
Diabetes mellitus
Acute intermittent porphyria
ead poisoning
amilial Mediterranean fever
Haematological causes
Haemophilia and other bleeding disorders
Henoch-Schönlein purpura
Sickle cell crisis
Polycythaemia vera
Paroxysmal nocturnal haemoglobinaemia
Vasculitis
Embolic

Acute appendicitis
This is the most common surgical emergency. It affects all age groups. Appendicitis should
always be considered in the differential diagnosis if the appendix has not been removed.

Acute appendicitis mostly occurs when the lumen of the appendix becomes obstructed with a
faecolith; however, in some cases there is only generalized acute inflammation. If the
appendix is not removed at this stage, gangrene occurs with perforation, leading to a
localized abscess or to generalized peritonitis.

Clinical features and management

Most patients present with abdominal pain; in many it starts vaguely in the centre of the
abdomen, becoming localized to the right iliac fossa in the first few hours. Nausea, vomiting,
anorexia and occasional diarrhoea can occur.

Examination of the abdomen usually reveals tenderness in the right iliac fossa, with guarding
due to the localized peritonitis. There may be a tender mass in the right iliac fossa. Although
raised white cell counts, ESR and CRP are helpful, other laboratory tests can be unhelpful.
An ultrasound scan can detect an inflamed appendix and can also indicate an appendix mass
or other localized lesion. CT is highly sensitive and specific, and reduces the incidence of
removing the 'normal' appendix. With the use of these investigations the incidence of 'normal'
appendix histology has fallen to 15-20%.

Differential diagnosis
 Non-specific mesenteric lymphadenitis - may mimic appendicitis.
 Acute terminal ileitis due to Crohn's disease or Yersinia infection.
 Gynaecological causes.
 Inflamed Meckel's diverticulum.
 Functional bowel disease.

Treatment
The appendix is removed by open surgery or laparoscopically. If an appendix mass is
present, the patient is usually treated conservatively with intravenous fluids and antibiotics.
The pain subsides over a few days and the mass usually disappears over a few weeks.
Interval appendicectomy is recommended at a later date to prevent further acute episodes.

Gynaecological causes
Ruptured ectopic pregnancy.
The fallopian tube is the commonest extrauterine site of implantation. Delayed diagnosis is
the major cause of morbidity. Most patients will present with recurrent low abdominal pain
associated with vaginal bleeding. Diagnosis is usually made with abdominal and transvaginal
ultrasound. Most patients can be managed by laparoscopic salpingostomy or salpingectomy.
Ovarian:
 Rupture of 'functional' ovarian cysts in the middle of the cycle (Mittelschmerz).
 Torsion or rupture of ovarian cysts.

Acute salpingitis.
Most cases are associated with sexually transmitted infection. Patients commonly present
with bilateral low abdominal pain, a fever and vaginal discharge. In the Fitz-Hughes-Curtis
syndrome the Chlamydia infection tracks up the right paracolic gutter to cause a perihepatitis.
Patients can present with acute right hypochondrial pain, fever and mildly abnormal liver
biochemistry.

Acute peritonitis
Localized peritonitis
There is virtually always some degree of localized peritonitis with all acute inflammatory
conditions of the gastrointestinal tract (e.g. acute appendicitis, acute cholecystitis). Pain and
tenderness are largely features of this localized peritonitis. The treatment is for the underlying
disease.

Generalized peritonitis
This is a serious condition resulting from irritation of the peritoneum owing to infection (e.g.
perforated appendix), or from chemical irritation due to leakage of intestinal contents (e.g.
perforated ulcer). In the latter case, superadded infection gradually occurs; E.
coli and Bacteroides are the most common organisms.

The peritoneal cavity becomes acutely inflamed, with production of an inflammatory exudate
that spreads throughout the peritoneum, leading to intestinal dilatation and paralytic ileus.

Clinical features and management

In perforation, the onset is sudden with acute severe abdominal pain, followed by general
collapse and shock. The patient may improve temporarily, only to become worse later as
 generalized toxaemia occurs.

When the peritonitis is secondary to inflammatory disease, the onset is less rapid with the
initial features being those of the underlying disease.

Investigations should always include an erect chest. X-ray is used to detect free air under the
diaphragm, and a serum amylase to diagnose acute pancreatitis, which is treated
conservatively. Imaging with ultrasound and/or CT should always be performed for diagnosis.

Peritonitis is treated surgically after adequate resuscitation with the re-establishment of a

good urinary output. This includes insertion of a nasogastric tube, intravenous fluids and
antibiotics. Surgery has a twofold objective:

 peritoneal lavage of the abdominal cavity

 specific treatment of the underlying condition.

Complications
Any delay in treatment of peritonitis produces more profound toxaemia and septicaemia which
may lead to development of multiorgan failure (see p. 909). Local abscess formation can
occur and should be suspected if a patient continues to remain unwell postoperatively with a
swinging fever, high white cell count and continuing pain. Abscesses are commonly pelvic or
subphrenic and can be localized and drained using ultrasound and CT scanning techniques.

Intestinal obstruction
Most intestinal obstruction is due to a mechanical block. Sometimes the bowel does not
function, leading to a paralytic ileus. This occurs temporarily after most abdominal operations
and with peritonitis. Some causes of intestinal obstruction are shown in Table 6.31.

Obstruction of the bowel leads to bowel distension above the block, with increased secretion
of fluid into the distended bowel. Bacterial contamination occurs in the distended stagnant
bowel. In strangulation the blood supply is impeded, leading to gangrene, perforation and
peritonitis unless urgent treatment of the condition is undertaken.

Clinical features
The patient complains of abdominal colic, vomiting and constipation without passage of wind.
In upper gut obstruction the vomiting is profuse but in lower gut obstruction it may be absent.

Examination of the abdomen reveals distension with increased bowel sounds. Marked
tenderness suggests strangulation, and urgent surgery is necessary. Examination of the
hernial orifices and rectum must be performed. X-ray of the abdomen reveals distended loops
of bowel proximal to the obstruction. Fluid levels are seen in small bowel obstruction on an
erect film. In large bowel obstruction, the caecum and ascending colon are distended. An
instant water-soluble gastrografin enema without air insufflation may help to demonstrate the
site of the obstruction. CT can localize the lesion accurately and is the investigation of choice.

Management
Initial management is by resuscitation with intravenous fluids (mainly isotonic saline with
potassium) and decompression. Many cases will settle on conservative management, but an
increasing temperature, raised pulse rate, increasing pain and a rising white cell count require
urgent scanning and possible exploratory laparotomy.

Table 6-31. Some causes of intestinal obstruction

Small intestinal obstruction
Adhesions (80% in adults)
Hernias
Crohn's disease
ntussusception
Obstruction due to extrinsic involvement by cancer
Colonic obstruction
Carcinoma of the colon
Sigmoid volvulus
Diverticular disease

Laparotomy with removal of the obstruction will be necessary in some cases of small bowel
obstruction. If the bowel is gangrenous owing to strangulation, gut resection will be required.
A few patients (e.g. those with Crohn's disease) may have recurrent episodes of incomplete
intestinal obstruction that can be managed conservatively. In large bowel obstruction due to
malignancy, colorectal stents are being used, followed by elective surgery. In critically ill
patients, a defunctioning colostomy may be required. Volvulus of the sigmoid colon can be
managed by the passage of a flexible sigmoidoscope or a rectal tube to un-kink the bowel,
but recurrent volvulus may require sigmoid resection.

Acute colonic pseudo-obstruction

It is now recognized that a clinical picture mimicking mechanical obstruction may develop in
patients who do not have a mechanical cause. In more than 80% of cases it complicates
other clinical conditions, for example:

 intra-abdominal trauma, pelvic spinal and femoral fractures

 postoperatively (abdominal, pelvic, cardiothoracic, orthopaedic, neurosurgical)
 intra-abdominal sepsis
 pneumonia
 metabolic (e.g. electrolyte disturbances, malnutrition, diabetes mellitus, Parkinson's
disease)
 drugs - opiates (particularly after orthopaedic surgery), antidepressants,
antiparkinsonian drugs.

Patients present with rapid and progressive abdominal distension and pain. X-ray shows a
gas-filled large bowel. Management is of the underlying problem (e.g. withdraw opiate
analgesia) together with a trial of i.v. neostigmine therapy (Box 6.13). Patients should be
monitored carefully and consideration should be given to surgery if the diameter of the
caecum exceeds 14 cm.

Box 6.13 Treatment of acute colonic pseudo-obstruction

 Neostigmine 2.0 mg i.v. over 3-5 min in presence of doctor with
ECG monitor
 0.3-1 mg atropine if symptomatically bradycardic. Nurse the
patient supine for 60 min
 Monitor abdominal circumference and the diameter of the
caecum, ascending, transverse and descending colon on
straight abdominal X-ray

Small intestinal pseudo-obstruction is a rare chronic condition that can occur in association
with systemic sclerosis, systemic lupus erythematosus (SLE), Sjögren's syndrome, thyroid
disease, amyloidosis and paraneoplastic syndromes. Primary myopathic and neuropathic
forms also exist, with the former sometimes being familial. There are other patients with
clinical and manometric features of small intestinal pseudo-obstruction who have normal full-
thickness biopsies of smooth muscle but α actin deficiency in the inner circular layer of the
smooth muscle. Myopathic forms can present with attacks of non-mechanical obstruction
and/or functional small intestinal failure with dilated non-propulsive intestines and coexisting
bacterial overgrowth. These patients are managed in specialist centres with facilities to
manage home total parenteral nutrition (TPN). The other patients, including those with enteric
neuropathies, often present with a long history of abdominal pain and other intractable midgut
symptoms. Many have extraintestinal symptoms, and a multidisciplinary approach to
management is required, including, in a number, access to facilities to provide needle
catheter jejunostomy enteral feeding as well as home TPN.