Acute Abdomen Flashcards
Acute abdomen is a condition that demands urgent attention and treatment. The acute abdomen may be caused by an infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of abdominal pain with associated nausea or vomiting.
The nine regions of the abdomen
- Right hypochondria
- Epigastric region
- Left hypochondriac
- Right lumber
- Umbilical region
- Left lumbar
- Right iliac
- Hypogastric region
- Left iliac
Causes of Acute abdomen
- Inflammatory Conditionsi. Acute appendicitis
ii. Acute cholecystitis
iii. Acute salpingitis
iv. Acute diverticulitis
v. Primary peritonitis - Perforations of Hollow Viscus
I. Typhoid perforation of the ileum
ii. Perforated DU or GU
iii. Perforated Ca stomach or colon
iv. Traumatic perforations
v. Perforated amoebic colitis
vi. Perforated diverticular disease
- Intestinal Obstruction
i. Strangulated hernia
ii. Bands and Adhesions
iii. Volvulus
iv. Intussusceptions
v. Mesenteric Infarction
vi. Stricture Benign or Malignant
- Haemorrhage
i. Ruptured ectopic pregnancy ii. Ruptured viscus e.g. spleen iii. Ruptured primary liver all carcinoma (PLCC) iv. Ruptured aortic aneurysm
- Acute pancreatitis
- Colic
i. Ureteric colic ii. Biliary colic iii. Intestinal colic
- Gynaecological conditions
i. Ruptured Graafian follicle
ii. Twisted ovarian cyst
iii. Degenerating myoma
- Medical Conditions
i. Gastroenteritis
ii. Dysentery
iii. Gastritis
iv. Sickle cell disease
v. Urinary tract infection
vi. Malaria
vii. Myocardial infarction
viii. Pneumonia
ix. Herpes Zoster
x. Hepatitis
xi. Pre-diabetic coma
xii. Acute non-specific mesenteric adenitis xiii. Measles, poliomyelitis, mumps
xiv. Spinal root pain
xv. Porphyria
xvi. Non-specific Abdominal Pain
xvii. Munchausen’s syndrome
●The abdominal type
●The bleeding type
●The neurogenic type
faints
fits
palsies
Common Causes
1. Acute Appendicitis
2.Acute Pancreatitis
3. Cholecystitis and cholangitis
4. Diverticulitis
- Ovarian torsion
- Rupture or perforation of an organ
- Acute bowel obstruction
- Acute mesenteric ischemia
- Heart attack
Other possible causes
A number of other conditions can cause acute abdominal pain:
Peptic ulcer disease
Hepatitis (inflammation of liver)
Spontaneous bacterial peritonitis (infection and inflammation of the abdominal space in people with cirrhosis)
Abdominal abscess (collection of infection and inflammation in the abdomen)
Colitis (infection/inflammation of colon)
Inflammatory bowel disease
Kidney stones
Kidney infection
Abdominal tumors
Obstetrical and gynecological conditions (pregnancy complications, miscarriage, pelvic inflammatory disease, fibroids, etc.)
Most common causes of acute abodomen
Acute appendicitis 87 (23.5)
Non-specific abdominal pain 79 (21.4)
Intestinal obstruction 40 (10.8)
Gynaecological 35 (9.5)
Peptic ulcer 34 (9.2)
Typhoid perforation 17 (4.6)
Cholecystitis 14 (3.8)
Abdominal trauma 12 (3.2)
Urinary tract infection 10 (2.7)
Total 328(88.7)
Values in parenthesis are percentage
Less common causes of acute abdomen
Acute pancreatitis 8
Liver abscess 7
Gastroenteritis 6
Ureteric colic 6
Gastritis 4
Carcinoma of the stomach 2
Oesophagitis 2
Pyomyositis abdominal wall 2
Tuberculous peritonitis 1
Renal tumour
Primary liver cell carcinoma 1
Mesenteric thrombosis 1
Porphyria 1
Total 42 (11.3)
Value in parenthesis is a percentage
The primary symptom of acute abdomen is
Abdominal pain
Assessment
Full history
Thorough physical examination
Relevant investigations.
PAIN
RADIATION
From epigastrium to the back
●Chronic DU
●Pancreatitis
●From right hypochondrium to between the shoulder blades
●Gallstone colic
●From the loin to the groin
●Ureteric Colic
RELIEVING OR AGGRAVATING FACTORS
●PERITONITIS
Pain is relieved by lying still and aggravated by movement
●COLIC – Intestinal, Biliary or Renal
- The patient finds it impossible to lie still ●All foods aggravate GU pain ●Fatty foods aggravate gallbladder pain ●Food and Antacids relieve DU pain ●Vomiting relieves pain in acute gastritis, GU and intestinal obstruction
DURATION OF PAIN
●A short history suggests acute inflammation
–Acute appendicitis
–Acute cholecysitits
–Acute pancreatitis
●A long history of abdominal pain before the acute episode may suggest
–Perforated DU
–Typhoid perforation
–Intestinal obstruction due to
- Neoplasm
- Volvulus
AGE OF PATIENT
●Children - Intussusception
●Young adults - Acute appendicitis
●Adults – Colorectal cancer Vascular disease e.g. infarction
ANOREXIA, NAUSEA, VOMITING
●Anorexia – Prominent in Acute Appendicits
●Nausea & Vomiting is frequent in
●Gastritis
●Gastroenteritis
●Pancreatitis
●High intestinal obstruction
●Bilary colic
Vomiting is profuse in
●Gastroenteritis
●High intestinal obstruction
●Gastric outlet obstruction
●In intestinal obstruction it is
●Initially clear
●Then bile-stained
●Finally brown or faeculent
CONTENT OF VOMITUS
●Old food – suggests G.O.O
●Presence of blood
●Erosive gastitis
●Gastric carcinoma
●Reflux Oesophagitis
●Mallory-Weiss syndrome
BOWEL ACTION
●Constipation - Appendicitis, Int. obstruction
●Diarrhoea – Gastroenteritis
●Blood & Mucus - Dysentery, U. Colitis
●Red-current
Jelly stools - Intussusception
●Bleeding PR – Peptic ulcer
- Amoebiasis
- Enteric Fever
- Diverticular Disease
Mesenteric infarction
URINARY SYMPTOMS
●Urinary tracts infection
●Frequency
●Dysuria
●Renal & Ureteric Calculi
●Haematuria
●A missed period raises the possibility of an ectopic pregnancy and vaginal discharge will suggest salpingitis
OTHER SYMPTOMS
●Alcohol abuse
–Irritant Gastritis
–Acute Pancreatitis
●Drugs
–NSAID - Gastric Irritation or erosive gastritis
PREVIOUS HISTORY
Dyspepsia - Perforated DU
Abd. Surgery
Intestinal obstruction
due to adhesions
Abd. Sepsis
NON SPECIFIC ABDOMINAL PAIN (NASAP)
●Leading cause of acute abdominal in western countries
●Second to appendicitis in some developing countries
●No definite diagnosed reached
●Patients improve without specific treatment
●Abdominal pain of varying intensity
●Abdomen soft usually
●There may be some guarding
PHYSICAL EXAMINATION
●Thorough general examination
●Temperature, Pulse, BP
●Jaundice
●Sign of dehydration
●Signs of shock
●Cardiovascuar system
●Respiratory system
Abdomen and rectum
i) Inspection
ii) Palpation
iii) Percussion
iv) Auscultaion
INVESTIGATIONS
•WBC and differential
•Blood film
•Hb and sickling
•Urine sugar + Blood sugar
•X’ray of Chest + Abdomen
•Ultrasound
•4-quadrant abdominal tap
•Peritoneal lavage
- Urine examination
i. Renal colic
ii. UTI
iii. Diabetic Ketoacidosis
iv. Porphyria - Serum + Urineary amylase
- Pregnancy Test (Serum βHCG)
- Laparoscopy
Types of abdominal pain
- Visceral
- Parietal
- Referred
TYPES OF PAIN
●Bowel colic is usually punctuated by pain free periods
●Renal colic is characterized by severe spasm superimposed on a more constant pain in a restless
●Biliary colic is a steadily increasing pain which crescendoes over 1-3hours
●Visceral pain is vague and poorly localized
●Sometic or peritoneal pain is accurately localized and constant
Visceral pain
It can be due to early ischemia or inflammation
It occurs early and it’s poorly localized
Parietal pain
It’s caused by irritation of parietal peritoneum fibers
It occurs late and better localized
Can be localized to a dermatome superficial to site of the painful stimulus.
Referred pain
Pain is felt at a site away from the pathological organs
Definition of Acute abdomen
The “Acute Abdomen” is defined as sudden onset severe abdominal pain.
Within this, there are large number of possible causes, including serious and life-threatening conditions, and therefore a structured approach is essential to ensure appropriate triage and timely management.
Initial Assessment
Initial Assessment
Any initial assessment for a patient presenting with an acute abdomen needs to identify whether this patient is acutely or critically unwell, that may require immediate surgical intervention or urgent medical therapy
A short assessment of clinical status can be made by a general look (the “end-of-bed-o-gram”) and their observations. Any unwell patient should be approached with an A to E assessment and be urgently resuscitated.
Once the patient is appropriately resuscitated, further history and examination can be elicited. This will help further tailor the next investigation and management steps.
Presentations Needing Urgent Intervention
Presentations Needing Urgent Intervention
Acute Bleeding
There are multiple causes of intra-abdominal bleeding, both intra-luminal and extra-luminal.
The most serious cause of intra-abdominal bleeding is often the ruptured abdominal aortic aneurysm, which requires swift referral to the vascular team and immediate surgical intervention.
Other causes of intra-abdominal bleeding may require either interventional radiology, endoscopic, or surgical intervention, such as ruptured ectopic pregnancy, bleeding peptic ulcer (Fig. 1), or traumatic injury.
If untreated, these patients will go into hypovolemic shock, with clinical features including tachycardia, looking pale and clammy, and hypotension (importantly, patients may not necessarily present with abdominal pain)
Whilst each pathology has its own nuanced approach, key features of management include ensuring blood products are made available (including the use of major haemorrhage protocol if required), and early investigation and intervention.
Perforated Viscus
Patients who present with a perforated viscus will often be very unwell. There are multiple causes of gastrointestinal perforation, including peptic ulcer disease, untreated bowel obstruction (either small or large bowel), diverticular disease, or inflammatory bowel disease.
Perforation can be small perforations, such a localised diverticular perforation, to large perforations with four-quadrant peritonitis, such a perforated colorectal cancer:
Patients with a localised perforation can often present with localised pain and peritonism, tachycardia, and pyrexia (however may not necessarily look unwell!)
Patients with generalised peritonitis will often present with tachycardia (+/- hypotension), pyrexia, and a rigid abdomen (and will look unwell!)
These patients need urgent resuscitation and nearly always requiring cross-sectional imaging, prior to final management be decided.
Ischaemic Bowel
Any patient who has severe pain out of proportion to the clinical signs should be assumed to have visceral ischaemia (typically ischaemic bowel) until proven otherwise.
Acute mesenteric ischaemia occurs when there is occlusion of a mesenteric vessel*, which will result in tissue infarction. Patients will typically present with severe and constant abdominal pain, however their examination may be otherwise unremarkable
Blood tests will often show a biochemical derangement (e.g. raised WCC and CRP) and a raised lactate and acidosis (although normal in approximately 25% of cases). Definitive diagnosis is made a CT scan with intravenous contrast, and nearly always requires early surgical intervention (Fig. 3).
*This is different to ischaemic colitis, where reduced blood supply to the smaller vessels of the bowel can result is inflammation (but not necessarily causing any actual infarction of tissues)
Presentations Needing Further Investigation
Presentations Needing Further Investigation
Colic
Colic is an abdominal pain that crescendos to become very severe and then goes away completely.
The most common types of colic are biliary colic, ureteric colic, and bowel obstruction. They can be differentiated based on any triggers and timings with regards to the onset of pain, yet almost always further investigations are required
Once haemodynamically stable, patients should have routine blood tests and appropriate imaging, depending on the suspected pathology.
Peritonism
Peritonism (not peritonitis) refers to the localised inflammation of the peritoneum, usually due to inflammation of a viscus that then irritates the visceral (and subsequently parietal) peritoneum.
As such, patients will often report their pain starts in one place (irritation of the visceral peritoneum) before localising to one area (irritation of the parietal peritoneum) or becoming generalised.
The classic example of this is in acute appendicitis, where the pain will often migrate from the umbilical region (irritation of visceral peritoneum) to the right iliac fossa (irritation of parietal peritoneum)
Differential Diagnosis
Differential Diagnosis
The location of abdominal pain is one useful feature that helps narrow the differential. These can be classified based upon quadrant or region affected, as shown in Fig. 4.
It must be remembered to always consider extra-abdominal organs as the cause for abdominal pain, including cardiac, respiratory, gynaecological, or urological conditions.
Remember there are medical causes of abdominal pain to consider in patients presenting with abdominal pain, including diabetic ketoacidosis, myocardial infarction, Addisonian crisis, or porphyria.
Investigations
Investigations
Initial Tests
The investigations in all cases of the acute abdomen share the same generic outline:
Urine dipstick – for signs of infection or haematuria (and send for MC&S as required)
Ensure a pregnancy test is performed for all women of reproductive age
Arterial Blood Gas– useful in bleeding or acutely unwell patients, especially for the pH, pO2, pCO2, HCO3-, and lactate, for assessment of tissue hypoperfusion and rapid haemoglobin level
Routine bloods– FBC, U&Es, LFTs, CRP, amylase, and a G&S
Ensure to crossmatch if blood products or urgent surgery required
Electrocardiogram (ECG) – to assess for potential referred myocardial pain and for pre-operative work-up if any surgery required
Imaging
Following assessment, initial imaging may help to further help focus the diagnosis if still unclear:
An erect chest plain film radiograph (eCXR) – for evidence of free abdominal air (Fig. 5) or lower lobe lung pathology
Ultrasound imaging, most useful in assessing the renal tract (for hydronephrosis and cortico-medullary differentiation), biliary tree and liver (for gallstones, gallbladder thickening, or duct dilatation), and the uterus and adenexa (particularly if a transvaginal scan)
CT imaging of the abdomen and pelvis, most useful in assessing for pathology in the gastrointestinal tract, such as bowel perforation
