ACUTE ABDOMEN

Acute Abdomen: Definition

 An abdominal condition of abrupt onset associated with

severe abdominal pain (resulting from inflammation,
obstruction, infarction, perforation, or rupture of intra-
abdominal organs).

 Acute abdomen requires urgent evaluation and

diagnosis because it may indicate a condition that
requires urgent surgical intervention
 Physiology of Abdominal Pain
 Visceral pain
 Comes from abdominal/pelvic viscera
 Transmitted by visceral afferent nerve fibres in response to stretching
or excessive contraction
 Dull in nature and vague
 Poorly localised
 Foregut  epigastrium
 Midgut  para-umbilical
 Hindgut  suprapubic

 Somatic pain
 Comes from parietal peritoneum (which is innervated by somatic nerves)
 Sharp in nature
 Well localised
 Made worse by movement, better by lying still
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Physiology of Abdominal Pain

 Referred pain
 Pain felt some distance away from its origin
 Mechanism not clear
 Most popular theory: nerves transmitting visceral and somatic
pain (e.g. from viscera or parietal peritoneum) travel to
specific spinal cord segment and can result in irriation of
sensory nerves that supply the corresponding dermatomes
 E.g. Gallbladder inflammation can irritate diaphragm which is
innervated by C3,4,5. Dermatomes of these spinal cord
segments supplies the shoulder, hence referred shoulder tip
pain.
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Learning Objectives
 Causes of an acute abdomen
 Differential Diagnosis
 History / Examination
 Investigations
 Management
 Clinical Cases
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Causes of Acute Abdomen

 Intestinal

 Acute appendicitis, mesenteric adenitis, mekel’s diverticulitis, perforated peptic

ulcer, gastroenteritis, diverticulitis, intestinal obstruction, strangulated hernia
 Hepatobiliary

 Biliary colic, cholecystitis, cholangitis, pancreatitis, hepatitis

 Vascular

 Ruptured AAA, acute mesenteric ischaemia, ischaemic colitis

 Urological

 Renal colic, UTI, testicular torsion, acute urinary retention

 Gynaecological

 Ectopic pregnancy, ovarian cyst pathology (rupture/haemorrhage into cyst/torsion),

salpingitis, endometriosis, mittelschmerz (mid-cycle pain)
 Medical (can mimic an acute abdomen)

 Pneumonia, MI, DKA, sickle cell crisis, porphyria

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Acute Abdomen: The Examination

• Liver (hepatitis)
• Gall bladder (gallstones)
• Stomach (peptic ulcer, gastritis)
• Liver (hepatitis)
• Gall bladder (gallstones)
• Stomach (peptic ulcer, gastritis) • Spleen (rupture)
• Transverse colon (cancer)
• Pancreas (pancreatitis)
• Pancreas (pancreatitis)
• Heart (MI) • Stomach (peptic ulcer)

• Hepatic flexure colon (cancer)

• Splenic flexure colon (cancer)

• Lung (pneumonia)
• Lung (pneumonia)

• Descending colon (cancer)

• Ascending colon (cancer,) • Kidney (stone, hydronephrosis,
• Kidney (stone, UTI)
hydronephrosis, UTI)

• Appendix (Appendicitis)
• Caecum (tumour, volvulus, closed
loop obstruction)
• Terminal ileum (crohns, mekels)
• Ovaries/fallopian tube (ectopic, cyst,
PID) • Sigmoid colon (diverticulitis, Small bowel
• Uterus (fibroid, cancer) •
colitis, cancer) (obstruction/ischaemia)
• Ureter (renal colic) • Bladder (UTI, stone)
• Ovaries/fallopian tube • Aorta (leaking AAA)
(ectopic, cyst, PID)
• Sigmoid colon (diverticulitis)

• Ureter (renal colic)

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Intestinal
PU: H.pylori, NSAIDs, steroids, >55, M, alcohol, bloating,
epigastric/retrosternal pain, worse with food, GI bleed
Gastric Ca: Wt loss, smoking, blood grp A, GI bleed, epigastric pain,
virchow’s node, acanthosis nigricans

Hiatus hernia: F, obese, >55, GORD, epigastric, N+V high

DU: epigastric pain, improves with food, worse at night

Chrohns: transmural = air in abdomen, apthous ulcers, anal fissures,

smoking, terminal ileum, younger, PR bleed

UC: non-smoker, PSC, large bowel, PR bleed, lead pipe, nodosum

IBS: Distension, bloating, generalised pain, improves with defacation,

>45, F, stress, change in habit, diarrhoea

Coeliac: steatorrhoea, diarrhoea, dermatitis herpetiformis, anaemia

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Intestinal (Large Bowel)

Appendicitis: RIF pain, Mc Burney’s point tenderness, peritonitic

Diverticulitis: LIF pain, PR bleed, Elderly, common

Colorectal Ca: Fe deficient anaemia, Wt loss, altered bowel habit, PR

bleed, fatigue, mass palpable, obstructed

Large bowel obstruction: Distension, colicky pain, absolute

constipation, N+V (faeculent), tinkling BS

Small bowel obstruction: early billious vomiting, late

obstruction,chrohns

Perforation: shock, rigid abdomen, severe tenderness, pyrexia, air under

diaphragm, Rigler’s sign
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Hepatobilliary

Biliary Colic: constant, writhing, RUQ pain radiating to back, worsens with fatty meals

Cholecystitis: female, obese, >40, pregnant, RUQ pain radiating to shoulder blade,
amylase, Murphy’s sign

Acute Pancreatitis: gallstones, alcohol, grey turners/cullens sign, RUQ pain radiating to
back, improved by leaning forward, amylase

Cholangitis: Fever ~40, Jaundice, RUQ pain, rigors, female, obese, gallstones

Cirrhosis: Jaundice, splenomegaly, telangectasia, spider naevi, high JVP, duputren’s

contractures, clubbing, palmer erythema, gynaecomastia, ascites, liver flap,
xanthelasma, high INR, low Albumin
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Vascular

AAA: severe central pain, back pain, collapse, expansile

abdominal mass, >50, smoker, HTN, marfan’s, renal failure/colic,
M

Dissection: tearing retrosternal pain radiating to back, high BP,

reduced leg pulses, renal involvement

Mesenteric ischaemia: severe colicy generalised pain, reduced

bowel sounds, air in intestinal walls, AF, elderly, angina

MI: central, crushing pain, N+V, unstable, elderly, exertional, pale,

SOB
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Genitourinary

UTI: female, common, suprapubic tenderness, positive dip, retention,

prolapse, DM

Urinary Retention: UTI, post-op, spinal injury, elderly, stones, severe

constant suprapubic pain, well localised, resonant to percussion

Renal colic: sudden very severe loin to groin pain, tachycardic,

pyrexia, sweating, writhing

Testicular Torsion: Severe sudden lower abdo pain with unilateral

groin tenderness and swelling, young
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Obstetric-gynaecologia
Ectopic: young, amennorrhoea, collapse, shock, severe sudden lower abdo
pain radiating to shoulder, PV bleed

PID: fertile, previous surgery, previous STI, purulent discharge, pyrexia

Endometriosis: 35-40, nulliparous, cyclical pelvic pain, assoc PR bleed,

dysmennorhoea, deep dyspareunia

Fibroids: afro-carribean, nulliparous, mennorhagia, miscarriages, palpable

mass, pressure/cyclical pain

Ovarian Cyst torsion: sudden severe RUQ/LUQ pain, vomiting, shock,

pyrexia – intermittent if incomplete

Ovarian Ca: 60-70, wt loss, PV bleed, abdo distension

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Medical

Gastroenteritis: high diarrhoea, dehydration, fatigue, high

pyrexia, elderly, travel hx, Abx use

Pneumonia: SOB, cough, elderly, diabetic, COPD, sharp

upper abdo pain, worse with inspiration, creps, CXR

DKA: young, thin, kussmaul’s respiration, dehydration,

generalised abdominal pain, N+V, high BM, low pH

Sickle cell crisis: afro-carribean, auto-recessive,

dehydration, pleuritic, splenic pain, jaundice, gallstones

Porphyria: hereditary, generalised neuropathic abdominal

pain, anaemia, response to certain drugs, muscle weakness
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Acute Abdomen: The History

 Abdominal pain – features will point you towards diagnosis

 SOCRATES
 Site and duration
 Onset – sudden vs gradual
 Character – colicky, sharp, dull, burning
 Radiation – e.g. Into back or shoulder
 (Associated symptoms – discussed later)
 Timing – constant, coming and going
 Exacerbating and alleviating factors
 Severity
 2 other useful questions about the pain:
Have you had a similar pain previously?
What do you think could be causing the pain?
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Acute Abdomen: The History

 Associated symptoms
 GI: bowels last opened, bowel habit (diarrhoea/constipation), PR bleeding/melaena,
dyspeptic symptoms, vomiting
 Urine: dysuria, heamaturia, urgency/frequency
 Gynaecological: normal cycle, LMP, IMB, dysmenorrhoea/menorrhagia, PV
discharge
 Others: fever, appetite, weight loss, distention

 Any previous abdominal investigations and findings

 Other components of history

 PMH e.g. Could patient be having a flare up/complication of a known condition e.g.
Known diverticular disease, previous peptic ulcers, known gallstones
 DH e.g. Steroids and peptic ulcer disease/acute pancreatitis
 SH e.g. Alcoholics and acute pancreatitis
Common abdominal history…Abdomen_histories.pdf
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Acute Abdomen: The Examination

 Inspection: scars/asymmetry/distention
 Palaption:
◦ Point of maximal tenderness
◦ Features of peritonitis (localised vs generalised)
 Guarding
 Percussion tenderness
 Rebound tenderness
◦ Mass
◦ Specific signs (Rosvig’s sign, murphy’s sign, cullen’s sign, grey-turner’s
sign)
 Percussion: shifting dullness/tympanic
 Auscultation: bowel sounds
 Absent
 Normal
 Hyperactive
 tinkling
 The above will point you to potential diagnosis
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RIF Pain: APPENDICITIS

• Appendix/ abscess
• Pelvic inflammation/ period pain
• Pancreas
• Ectopic/ endometriosis
• Neoplasm
• Diverticulitis
• Intussusseption
• Chrohn’s/ Cyst
• IBD
• Torsion
• IBS
• Stones
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LIF Pain: SUPERCLOTS

• Sigmoid diverticuli, volvulous
• Ureteric colic
• Pelvic inflammation/ period pain
• Ectopic/ endometriosis
• Rectal Haematoma

• Colon cancer
• Left lower pneumonia
• Ovarian cyst
• Torsion
• Stones
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Acute Abdomen: Investigations

 Simple Investigations:
 Bloods tests (FBC, U&E, LFT, amylase, clotting, CRP, G&S/ Xmatch,
ABG)
 BM
 Urine dipstick
 Pregnancy test (all women of child bearing age with lower abdominal
pain)
 AXR/e-CXR
 ECG

 More complex investigations:

 USS
 Contrast studies
 Endoscopy (OGD/colonoscopy/ERCP)
 CT – MSCT / Angiography
 MRI
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Aortic Abdominal Aneurism

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Symptom and sign AAA

• Asymptomatic
• Inflammatory AAA may cause back pain
• Pulsatile abdominal mass
• Mid-abdomen just above and left of the umbilicus

• Ruptured AAA

• Triad (50%):
• Sudden onset abdominal pain
• Pulsatile mass
• Hypotension
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Investigation AAA
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AXR

Demographics/ Type of XR

Black: dilated loops / Air

•Small = central, valvulae conniventes
•Large = Peripheral, Haustrae
White: Calcification
•Renal stones/ Gallstones
•Foreign Bodies
•Bone
Grey: soft tissue
•Liver, spleen, pancreas, gall bladder, ovary, uterus
•Enlargement, calcification
•Abdominal wall muscles, hernias
•Stool
Re-review and summarise
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Air in Abdomen
• Post-op/ Post-ERCP
• Perforation
• Cholangitis
• Abscess
• Gallstone Ileus
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Acute Abdomen: Indication for theatre

 Urgent surgery should not be delayed for time consuming tests
when an indication for surgery is clear

 The following three categories of general surgical problems will

require emergency surgery
 Generalised peritonitis on examination (regardless of cause
– except acute pancreatitis, hence all patients get
amylase)
 Perforation (air under diaphragm on e-CXR)
 Irreducible and tender hernia (risk of strangulation)
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Management - Conservative

Lifestyle:
• Weight loss,
• smoking cessation
• alcohol reduction
• exercise
• modified diet (low fat/ high fibre)
MDT: Physio/ OT/ Nutrition Team/ Dietician/ Specialist
Nurses, other specialties
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Management - Medical
• A - Secure airway
• B – Oxygen 15L
• C - Fluid Balance: large bore, IVF, catheter, bloods, Xmatch
• C - Blood Transfusion
• D - Analgesia
• E – IV Antibiotics
• E –Thromboprophylaxis?
• Anti-emetics/ NG aspiration
• Supportive nutrition/ NBM
• Re-assess
• Therapeutic procedures: ERCP
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Management - Surgical

Emergency Laparotomy or Watch+Wait ?

• Monitor Pain
• Serial CTs
• Unstable?
e.g :
• Appendicectomy
• Cholecystectomy
• Defunctioning Ileostomy
• Abscess drainage/ Necrosectomy
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Clinical Scenarios

87 yr M worsening LIF pain associated PR bleed,

tachycardic, hypotensive

Diverticulitis, IBD, AdenoCa ?

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Clinical Scenarios

50 yr old obese female presents with 2 day. Hx : right

upper quadrant tenderness, yellow sclera and high pyrexia.
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Clinical Scenarios

35 year old female smoker with known depression

presents with generalised hypertenderness, diarrhoea and
bloating sensations worse after meals
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Clinical Scenarios

Thin 21 y.o. male presents with generalised abdo

tenderness, polydipsia and sunken eyes, with reduced skin
turgor.
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Clinical Scenarios

56 yr old female non-smoker with known primary

sclerosing cholangitis, presents with change in bowel habit
and PR bleed, she is found to have tender symmetrical
purple shin nodules
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Clinical Scenario

A 22 year old lady presents with one day history of right

iliac fossa pain associated with vomiting and diarrhoea.
She is normally fit and well and takes the oral
contraceptive pill. She has no known allergies, does not
smoke, and drinks alcohol infrequently
Peritonitis
 Peritonitis – inflammation of the peritoneum which maybe
localised or generalised

 Peritonism – refers to specific features found on abdominal

examination in those with peritonitis
 Characterised by tenderness with guarding,
rebound/percussion tenderness on examination
 Peritonism is eased by lying still and exacerbated by any
movement
 Maybe localised or generalised

 Generalised peritonitis is a surgical emergency – requires

resuscitation and immediate surgery
Causes of Generalised Peritonitis
 Infective – bacteria cause peritonitis e.g. due to gangrene or
perforation of a viscus (appendicitis/diverticulitis/perforated ulcer).
This is the most common cause of peritonitis

 Non-infective – leakage of certain sterile body fluids into the

peritoneum can cause peritonitis.
 Gastric juice (peptic ulcer)
 Bile (liver biopsy, post-cholecystectomy)
 Urine (pelvic trauma)
 Pancreatic juice (pancreatitis)
 Blood (endometriosis, ruptured ovarian cyst, abdominal trauma)
 Note: although sterile at first these fluids often become infected
within 24-48 hrs of leakage from the affected organ resulting in
a bacterial peritonitis
Clinical features of Peritonitis
 Pain
 Constant and severe (site will give clue as to
cause, or maybe generalised)
 Worse on movement (hence shallow breathing in
those with generalised peritonitis to keep the
abdomen still)
 Eased by lying still
 If localised peritonitis – peritonism is in a single
area of the abdomen
 If generalised peritonitis – peritonism is all over
abdomen with board like rigidity
Clinical features of Peritonitis
 Signs of ileus (generalised peritonitis > localised
peritonitis)
 Distention
 Vomiting
 Tympanic abdomen with reduced bowel sounds
 Signs of systemic shock
 Tachycardia, tachypnoea, hypotension, low urine
output
 More prominent with generalised than localised
peritonitis
Investigations for Peritonitis

 Diagnosis most often made on history and examination

 If localised peritonitis
 Investigations are those listed on “investigations for
acute abdomen” slide
 All patients get simple investigations
 Complex investigations are requested depending on
suspected diagnosis (remember that some
diagnoses do not require complex investigations and
are entirely based on history and examination e.g.
Appendicitis
Investigations for Peritonitis

 If generalised peritonitis
 Surgical emergency – will require emergency
operation
 Following investigations should be performed:
Bloods: FBC, U&E, LFT, Amylase!! (acute
pancreatitis can present with generalised peritonitis
and does not require emergency surgery), CRP,
clotting, G&S, ABG
AXR and Erect CXR
Investigations for Peritonitis

 CT scan
 Only if this can be performed urgently and patient is
stable
 If this can not be performed urgently or patient is
unstable then for surgery without delay
 Does not change management (i.e. Patients will
need emergency surgery regardless) but useful as
will identify cause of peritonitis therefore helping to
plan surgical procedure
 Other Time consuming complex investigations should
not be performed as they will only delay definitive
treatment (emergency surgery) and add very little
Resuscitation of Generalised Peritonitis

• ABC
• Oxygen
• Fluid resuscitation (large bore cannule, bloods, IVF,
catheter)
• IV antibiotics (Augmentin and metronidazole)
• Analgesia
• Surgery (with or without preceeding CT depending
on availability and stability of patients)
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Questions?
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Thank you