Acute Abdomen

Question 1

Define the term the acute abdomen?

Answer 1

An acute abdominal pain which causes a patient to be hospitalised.

Question 2

Identify the cardinal symptoms of the acute abdomen and describe the pain associated with the common causes?

Answer 2

Peritonitis: Sudden onset pain worse on movement, very well localised any inflamed or ruptured organ.

Biliary Colic: Sudden constant pain lasting for several hours in the RUQ.

Obstruction: Generalised pain, vomiting,
abdominal distension, absolute constipation.

AAA: Pain anywhere in the abdomen classically centrally radiating through to the back, shock.

Ectopic pregnancy in left/right iliac fossa.

Bowel Ischaemia: Colicky pain followed by peritonitis

Question 3

Discuss the differentials of the acute abdomen depending on the location of the pain?

Answer 3

RUQ:
Hepatitis
Biliary: Cholelithiasis, Cholecystitis, Cholangitis
Basal Pneumonia

LUQ:
IBS
Basal Pneumonia
Splenic Rupture

Epigastric Pain:
Peptic Ulcer/Gastritis
Pancreatitis
AAA (but can cause pain anywhere)
ACS
Biliary Colic

Umbilical Pain:
Pancreatitis
AAA
Appendicitis

RLQ:
Appendicitis
Diverticulitis
Colitis and Colon Cancer
Renal/urethral Caliculi
Pyelonephritis
Ectopic Preganacy
Ovarian Torsion
PID

LLQ:
Diverticulitis
Renal/Urethral Caliculi
Colitis and Colon Ca
Pyelonephritis
Ectopic Pregnancy
PID
Ovarian Torsion

Note:
Obstruction, generalised peritonitis will present with unlocalised general abdominal pain.

AAA should always be considered in males >55 pain can present anywhere but classically epigastric/umbilical radiating through to the back.

Question 4

Describe how the pain distribution is related to the foregut, midgut and hindgut?

Answer 4

Foregut: Abdominal oesophagus to 2/3 of duodenum, including the organs associated, aka liver, pancreas, gallbladder, spleen. Pain localises to the the epigastric region.

Midgut: Last 1/3 of duodenum to the splenic flecture of the transeverse colon. Pain will localise to the umbilical region.

Hindgut: From the splenic flecture to the anus. Pain will localise to the suprapubic region.

Question 5

Identify and define the physical findings associated with the acute abdomen and relate these to the basic underlying pathology

Answer 5

Patient may look ill, shocked, pale, sweaty, weak rapid pulse. AAA, septic, generalised peritonitis, pancreatitis?

Guarding and Rigidity suggest peritonitis.

High pitched, tinkling bowel sounds/absent of sounds suggests bowel obstruction.

Question 6

What investigations would you do in a acute abdomen scenario?

Answer 6

Bloods:
FBC, U/E's, LFTs and CRP
Amylase (pancreatitis) or Lipase
VBG (lactate and pH abnormalaties)
Pregnancy test in women of child bearing age 

Imaging: 
Erect CXR (?haemoperitoneum)
AXR (obstruction)
USS (stones/biliary dilatation)
CT abdomen/KUB

Question 7

Outline the initial management plan for a patient with the acute abdomen?

Answer 7

ABCDE.

Analgesia

Nil by mouth in case need for emergency surgery. Give maintenance fluids.

Question 8

Identify the warning signs of a patient needing emergency resus and/or emergency surgery?

Answer 8

Is the patient in Shock or SIRS?
Peritonitis, AAA, Splenic Rupture, Ectopic Pregnancy, Sepsis

Does the patient have signs and symptoms of generalised peritonitis?

YES———-> Likely perforated viscus, urgent surgery is needed!

Question 9

List the signs, symptoms and causes of upper GI bleeding?

Answer 9

Signs and Symptoms:
Haematemesis
Melena
Signs of anaemia

Most common:

• Oesophageal varices
• Peptic ulcers
• Cancer

Other causes:

• Mallory Weiss tear
• Reflux oesophagitis
• Post PCI

Question 10

List the signs, symptoms and causes of lower GI bleeding?

Answer 10

Signs and symptoms:
Blood in stool
Signs of anaemia

Causes:
Colon ca and colitis (IBD or ischaemic)
Polyps
Diverticular disease
Haemorrhoids

Not in the UK but worldwide hookworm is the most common cause.

Question 11

Describe the arterial blood supply of the foregut, midgut and hindgut?

Answer 11

Foregut: Celiac trunk
Midgut: Superior Mesenteric aa
Hindgut: Inferior Mesenteric aa

Question 12

What are the branches of the coeliac aa?

Answer 12

The celiac artery has three branches. You’ve got the splenic artery, the left gastric artery and the common hepatic artery.

Question 13

Describe the parasympathetic and sympathetic supply of the foregut, midgut and hindgut?

Answer 13

Foregut:
Parasympathetic: Vagus nerve
Sympathetic: Splanchnic branches of the sympathetic chain

Midgut:
Parasympathetic: Vagus nerve
Sympathetic: Splanchnic branches of sympathetic chain (Lesser, least and lumbar)

Hindgut:
Parasympathetic: Pelvic splanchnic nn
Sympathetic: lumbar and sacral splanchnic nn