Acute Abdomen

Question 1

What’s Acute Abdomen

Answer 1

An acute abdomen refers to a sudden, severe abdominal condition that often necessitates emergency surgery. The causes are numerous, and if misdiagnosed or improperly treated, it can result in high mortality

Question 2

Acute abdomen is a frequent reason for surgical emergency admissions, accounting for around ____ to ___of emergency room visits**.

Answer 2

. Acute abdomen is a frequent reason for surgical emergency admissions, accounting for around 10-15% of emergency room visits. Conditions involved in acute abdomen can range from minor issues to life-threatening emergencies.

Question 3

What are the Causes of Acute Abdomen:

Answer 3

• Inflammation (e.g., appendicitis, cholecystitis)
• Perforation (e.g., perforated peptic ulcer)
• Obstruction (e.g., intestinal obstruction)
• Hemorrhage (e.g., ruptured ectopic pregnancy)
• Trauma (e.g., blunt or penetrating injury)

It can also be an exacerbation of a chronic problem, such as peptic ulcer disease (PUD), chronic pancreatitis, or vascular insufficiency.

Question 4

Whatare the Key Challenges: in acute abdomen?

Answer 4

• Misdiagnosis due to atypical presentations.
• Atypical presentation of common diseases, leading to confusion.
• Mortality risk if incorrect treatment is administered.

Question 5

The Main Symptom: Abdominal Pain

The hallmark symptom of acute abdomen is abdominal pain, which can present in different forms depending on the underlying cause.

Question 6

Classification of Acute Abdominal Pain are?

Answer 6

There are three primary types of abdominal pain seen in acute abdomen:

1. Visceral Abdominal Pain
2. Parietal (Somatic) Pain
3. Referred Pain

Question 7

What are the features of Visceral Abdominal Pain:

Answer 7

• Caused by stretching, distension, or contraction of hollow abdominal organs like the gut.
• This pain is typically colicky (comes and goes in waves) or cramping.
• It occurs early in the disease process and is poorly localized because visceral nerves are less precise in their localization.
• The pain is generally felt in the midline (due to early ischemia or inflammation) and is not associated with tenderness.

Question 8

What are the features of Parietal (Somatic) Pain:

Answer 8

• Parietal pain arises from the irritation or stimulation of the parietal peritoneum, the outer lining of the abdominal cavity.
• The pain is sharper and often worsens with movement or coughing.
• This type of pain occurs later in the disease process and is well localized, meaning the patient can point directly to where it hurts.
• Key signs include:
• Guarding (tensing of abdominal muscles to protect the inflamed area)
• Rebound tenderness (pain upon the release of pressure on the abdomen)
• Absent bowel sounds
• Parietal pain is more likely to indicate a surgical cause of the acute abdomen.

Question 9

What can you tell me about Referred Pain:

Answer 9

• Referred pain is felt in a location different from the actual site of the underlying problem. This happens due to shared nerve pathways between the affected organ and another area of the body.
• This type of pain is usually intense and often stems from inflammatory lesions.
• The pain typically occurs on the same side (ipsilateral) as the affected organ, although it may be felt in the midline if the pathology is central.
• The pattern of referred pain is determined by embryological development.

Question 10

What are the Clinical Course:

The clinical course of acute abdomen can vary significantly:

• Minutes to hours in cases like perforation or hemorrhage.
• Weeks in more chronic or slower-developing conditions.

Understanding the types of pain and their characteristics helps differentiate between different causes of abdominal pain and is essential for appropriate diagnosis and management.

Question 11

Examples of Referred Pain:

Referred pain is felt in areas of the body that are not directly connected to the injured or affected organ due to shared nerve pathways. Some common examples include:

Answer 11

• Right shoulder or scapular pain: Typically associated with gallbladder or liver pathology, such as acute cholecystitis or liver inflammation.
• Left shoulder pain (Kehr’s sign): Often related to splenic injury or rupture, where blood irritates the diaphragm, causing referred pain to the shoulder.
• Jaw, neck, or left arm pain: Common in acute myocardial infarction (heart attack), where the pain originating from the heart is felt in distant areas.
• Pain in the back or loin: Can be associated with kidney or ureteric problems, such as renal colic or pyelonephritis.
• Epigastric pain: Can be referred pain from a heart attack (AMI) or lower lobe pneumonia.

Question 12

What are the Classifications of Abdominal Pain and it’s causes

Answer 12

1. Intra-Abdominal Pain

• Arises from within the abdominal cavity or retroperitoneum.
• Common causes include:
• Gastrointestinal tract (GIT): Appendicitis, diverticulitis, enteritis, pancreatitis.
• Genitourinary (GU) system: Renal or ureteric colic (kidney stones).
• Gynecological causes: Acute pelvic inflammatory disease (PID), acute salpingitis, twisted ovarian cyst.
• Vascular system: Abdominal aortic aneurysm, mesenteric ischemia.

2. Extra-Abdominal Pain

• Less common, arises from structures outside the abdominal cavity.
• Common causes include:
• Cardiopulmonary causes: Acute myocardial infarction (AMI), pneumonia.
• Abdominal wall: Obstructed or strangulated hernia, herpes zoster (shingles).
• Toxic-metabolic causes: Diabetic ketoacidosis (DKA), chronic kidney disease (CKD).
• Neurogenic pain: Shingles (herpes zoster), peripheral nerve disease.
• Psychogenic causes: Anxiety, depression, and other psychological conditions that can manifest as abdominal pain.

Question 13

Physiology of Pain:

Several factors influence how pain is expressed:

• Extremes of age: Younger and older patients may present differently.
• Pain tolerance: Varies significantly between individuals.
• Vascular compromise: Can lead to pain that is out of proportion to physical findings (e.g., mesenteric ischemia).

Question 14

What are the Common Causes of Abdominal Pain by Region:

Answer 14

1. Right Upper Quadrant (RUQ):

• Biliary colic, acute cholecystitis, acute cholangitis, acute hepatitis, liver abscess, liver rupture, portal vein thrombosis.

2. Right Lower Quadrant (RLQ):

• Acute appendicitis, colitis, inflammatory bowel disease (IBD), obstructed hernias, urinary retention, diverticulitis, cystitis, ectopic pregnancy, ovarian torsion.

3. Left Upper Quadrant (LUQ):

• Peptic ulcer disease (PUD), acute gastritis, splenic infarction, splenic rupture, splenic abscess.

4. Left Lower Quadrant (LLQ):

• Diverticulitis, inflammatory bowel disease (IBD).

5. Epigastrium:

• Acute esophagitis, acute pancreatitis, acute mesenteric ischemia, peptic ulcer disease (PUD), Mallory-Weiss syndrome, pericarditis, abdominal aortic aneurysm (AAA), aortic dissection.

6. Periumbilical:

• Acute appendicitis, ischemia, aortic dissection, ruptured abdominal aortic aneurysm (AAA).

Question 15

What are the Clinical Features of Abdominal Pain:

The character and associated symptoms

Answer 15

• Character of pain:
• Colicky, burning, stabbing, dull aching.
• Can be localized (e.g., in one quadrant) or generalized (diffuse across the abdomen).
• Associated Symptoms:
• Fever, vomiting.
• Changes in bowel habits: diarrhea, constipation.
• Jaundice, pruritus (itchiness), dyspepsia.
• Changes in urinary habits: hematuria (blood in urine), lithuria (passage of stones).
• Cough, dyspnea (difficulty breathing).
• Vaginal discharge, itching, dyspareunia (painful intercourse), vaginal bleeding (PV-bleeding).

Question 16

How do you assess one with acute abdomen?

Answer 16

Assessment:

1. Full History:

• Obtain a detailed history of the pain onset, location, character, duration, and associated symptoms.

2. Thorough Physical Examination:

• Perform a systematic abdominal examination to identify tenderness, guarding, rebound tenderness, or any other significant findings.

3. Clinical Investigations:

• Imaging: Ultrasound, CT scan, X-ray.
• Blood tests: Complete blood count, liver function tests, amylase/lipase for pancreatitis.
• Urine tests: Urinalysis for infections, stones.

This systematic approach helps in differentiating between various causes of acute abdominal pain and guiding appropriate management, especially in emergency settings.

Question 17

Physical Examination

1. General Physical Examination:
   
   • Assess vital signs: Pay close attention to abnormalities such as:
     
     • Tachycardia (increased heart rate)
     • Systolic hypertension
     • Tachypnea (rapid breathing)
2. Abdominal Examination:
   
   • Conduct this quadrant by quadrant:
     
     • Inspection:
       
       • Look for signs like:
         
         • Still abdomen (lack of movement)
         • Visible peristalsis (intestinal movement)
         • Previous surgical scars
         • Movement of the abdomen with respiration
     • Palpation:
       
       • Check for tenderness, warmth, rigidity, guarding, or the presence of any mass.
       • Carnett’s Sign: If the pain persists or worsens with tensing of the abdominal muscles, it suggests parietal (somatic) pain rather than visceral pain.
       • Patients with visceral pain often cannot stay still.
       • Patients with peritonitis tend to remain immobile to avoid aggravating their pain.
     • Percussion:
       
       • Check for signs of ascites (fluid in the abdomen).
     • Auscultation:
       
       • Listen for bowel sounds:
         
         • Hyperactive: May indicate obstruction or irritation.
         • Absent: Suggests ileus or peritonitis.
         • Normoactive: Normal functioning.
   • Examine the genitalia for possible causes of pain.
   • Per rectal examination to evaluate rectal and pelvic pathologies.

Question 18

What are the Laboratory Tests you will like to do and why?

Answer 18

• CBC (Complete Blood Count): To assess for infection or anemia.
• Urinalysis / Urine Culture: To rule out urinary tract infections or other urinary abnormalities.
• Lactic Acid: Useful in detecting sepsis or tissue hypoxia.
• Liver Function Tests (LFTs): To check for liver or biliary involvement.
• Cardiac Enzymes (CE) / Troponin: For suspected cardiac causes, especially in epigastric pain.
• hCG (Human Chorionic Gonadotropin): To check for pregnancy, especially in women of childbearing age.
• Stool MCS (Microscopy, Culture, Sensitivity): For suspected infections or gastrointestinal issues.
• Electrolytes / Urea / Creatinine (E/U/C): To assess renal function.
• Amylase, Lipase: Primarily for diagnosing pancreatitis, especially with epigastric pain.
• Coagulation profile (PT, PTT, INR): To evaluate bleeding risk and clotting function.
• ECG, Echocardiogram, CK: For older patients or those with epigastric pain to rule out cardiac causes.

Question 19

What Imaging Studies would you do and why?

Answer 19

• Plain Abdominal X-ray: To look for bowel obstruction, perforation, or air-fluid levels.
• Chest X-ray: To rule out pneumonia or diaphragmatic hernia.
• Abdomino-pelvic Ultrasound: First-line imaging for gallstones, liver pathology, gynecological issues.
• CT Abdominal Scan: Preferred in diagnosing abdominal emergencies like appendicitis, diverticulitis, or abscesses.
• MRI: For detailed soft tissue imaging, especially when CT findings are inconclusive.
• Endoscopy: For upper gastrointestinal evaluation (esophagus, stomach, duodenum).
• Laparoscopy: Minimally invasive, both diagnostic and therapeutic.
• Exploratory Laparotomy: Open surgery to explore the abdominal cavity when non-invasive methods are inconclusive.

Question 20

What are the signs that someone is a High-Risk Patients?

Answer 20

• Elderly patients (>65 years)
• Signs of shock (hypotension, tachycardia, altered mental status)
• Peritonitis: Severe inflammation of the peritoneum causing abdominal pain and rigidity.
• Silent bowel sounds: Indicative of ileus or bowel perforation.
• Pulsatile abdominal mass: Suggestive of an abdominal aortic aneurysm.
• Refractory abdominal pain: Persistent pain despite treatment.
• Immunocompromised patients: Higher risk for infections.
• Women of child-bearing age: Suspect ectopic pregnancy.
• Elevated band WBC: Suggests infection or sepsis.
• High-grade fever, hypothermia
• Hypotension, tachycardia: In cases of splenic rupture, aortic rupture, ectopic pregnancy, or ruptured ovarian cyst.
• Acute renal failure: Seen in advanced sepsis, dehydration, or shock.

Question 21

What are the types of Peritonitis

Answer 21

• Primary Peritonitis:
• Caused by spontaneous bacterial infection without gastrointestinal perforation (e.g., in cirrhosis).
• Secondary Peritonitis:
• Due to gastrointestinal or genitourinary leaks (e.g., perforated peptic ulcer, ruptured appendix).
• Tertiary Peritonitis:
• Chronic infection following a resolved secondary peritonitis after surgical repair.

Question 22

Complications of Acute Abdomen

The complications depend on several factors:

• Etiology: Cause of the condition (e.g., appendicitis, diverticulitis).
• Duration: How long the condition has remained untreated.
• Age of the patient: Elderly patients are more vulnerable to complications.
• Premorbid/Comorbid conditions: Existing health issues such as diabetes or heart disease.
• Potential complications include:?

Answer 22

• Peritonitis
• Sepsis or septic shock
• Dehydration and related electrolyte imbalances
• Malnutrition
• Organ failure: Kidney, liver, or multi-organ failure.

Question 23

How do you manage acute abdomen?

Answer 23

1. Initial Care:

• Resuscitation:
• Intravenous fluids (for dehydration or shock)
• Blood transfusion (if needed)
• Medications: Antibiotics for infection, analgesics for pain relief, inotropes for shock.
• Nutritional Rehabilitation: Support with proper nutrition, especially in malnourished or septic patients.
• Monitor Urinary Output: To assess kidney function and fluid status.
• Gastric Decompression: In cases of bowel obstruction or severe vomiting.

2. Definitive Care:

• The exact treatment depends on the specific diagnosis.
• Operative: Surgery for conditions like perforated peptic ulcers, appendicitis, or bowel obstruction.
• Non-Operative: Conservative management for conditions such as uncomplicated diverticulitis or pancreatitis.
• Multidisciplinary: Involvement of various specialists (e.g., surgeons, gastroenterologists, cardiologists) depending on the case.

Question 24

When do you Operate: Surgical Consult in an acute abdomen case?

Answer 24

1. Peritonitis: This is an emergency situation where the peritoneum, the lining of the abdominal cavity, becomes inflamed. Surgical intervention is needed to address the underlying cause (e.g., perforation, infection).
2. Protracted Abdominal Pain with or without Sepsis: Persistent abdominal pain, especially when associated with sepsis (systemic infection), may require surgery to identify and treat the source of infection or injury.
3. Acute Intestinal Ischemia: When blood flow to the intestines is reduced or blocked, the affected tissue may become necrotic, requiring urgent surgery to restore blood flow or remove damaged tissue.
4. Pneumoperitoneum: The presence of free air in the peritoneal cavity, often indicating a perforated organ such as the stomach or intestines, usually necessitates immediate surgery.
5. Hemoperitoneum: Blood in the peritoneal cavity due to trauma or ruptured blood vessels often requires surgical exploration to identify and stop the source of bleeding.
6. Exclude Pancreatitis: Surgery is generally avoided in pancreatitis unless there are complications like infection or abscess formation. Non-surgical management is preferred initially, but surgical intervention is possible if the condition worsens.
7. Operable Tumor: If a tumor in the abdomen is deemed operable, surgery is performed to remove it. This may be indicated for tumors causing obstruction, bleeding, or pain.
8. Intestinal Obstruction: Surgery may be needed if conservative measures (such as nasogastric decompression) fail, or if there is suspicion of strangulation or ischemia of the bowel.

Question 25

When Not to Operate in an acute abdomen case

Answer 25

1. Cholangitis: Inflammation of the bile ducts is typically managed with antibiotics, fluids, and drainage procedures (e.g., ERCP) rather than surgery unless there are complications.
2. Appendiceal Abscess: A contained abscess from a ruptured appendix may be treated with antibiotics and drainage without immediate surgery.
3. Acute Diverticulitis with Abscess: Similar to an appendiceal abscess, an abscess from diverticulitis can often be managed with antibiotics and drainage, reserving surgery for severe or recurrent cases.
4. Acute Pancreatitis / Hepatitis: These conditions are generally managed medically with supportive care, fluids, and close monitoring unless complications arise.
5. Diabetic Ketoacidosis (DKA): This is a metabolic emergency that requires fluid replacement, insulin therapy, and electrolyte management, not surgery.
6. Myocardial Infarction (Heart Attack): Surgery is not indicated; the focus is on managing the heart attack with medications, angioplasty, or other cardiac interventions.
7. Acute Pericarditis: Inflammation of the pericardium around the heart is treated with anti-inflammatory medications and monitoring rather than surgery.
8. Pulmonary Infarction, Pneumonia: These respiratory conditions are managed medically, not surgically.
9. Adrenal Insufficiency: This hormonal disorder is treated with hormone replacement therapy rather than surgery.
10. Acute Porphyria: A rare metabolic disorder that is managed medically through supportive care and avoiding triggers.
11. Rectus Muscle Hematoma: A localized collection of blood in the abdominal muscles, often from trauma or anticoagulation, is typically treated with observation and supportive care rather than surgery.
12. Pyelonephritis: A kidney infection that is managed with antibiotics and supportive care.
13. Sickle Cell Crises: Managed with hydration, oxygen, pain control, and sometimes blood transfusions, but does not require surgery unless there are specific complications.

Question 26

Prognosis

The prognosis of acute abdomen depends on several factors: such as?

Answer 26

• Etiology (Cause): The underlying cause of the acute abdomen (e.g., appendicitis, pancreatitis, perforated ulcer) heavily influences outcomes.
• Duration of Onset to Time of Intervention: The quicker the diagnosis and treatment, the better the outcome. Delayed intervention can lead to complications like sepsis or organ failure.
• Onset of Complications: The development of complications like sepsis, peritonitis, or organ failure worsens the prognosis.
• Age of the Patient: Older patients tend to have poorer outcomes due to decreased physiological reserves and higher rates of comorbidities.
• Performance Status of the Patient: A patient’s overall health and ability to withstand surgery or intensive medical treatment can affect the prognosis.
• Organ Involvement: The specific organ affected (e.g., bowel, liver, pancreas) will determine the severity of the condition and likelihood of recovery.

Question 27

Conclusion

Acute abdomen is characterized by abdominal pain and requires a comprehensive evaluation to identify the cause. Prompt diagnosis and treatment significantly reduce morbidity and mortality, thereby improving the prognosis. The decision to operate depends on the underlying cause and the patient’s overall clinical condition.