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: Mouth to 2/3 of duodenum, including the organs associated, aka liver, pancreas, gallbladder. 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.