Acute Abdomen Flashcards
ACUTE ABDOMEN
• History – Previous surgery, Constant pain (due to inflammation; Febrile, Tachycardia, ↑WBC;
Otherwise MSK, AAA or rare causes e.g. Porphyria to be considered), Colicky pain
(Obstruction of Gut, Biliary Tract, Urogenital system or Uterus); If Colicky becomes constant,
inflammation should possibly be superimposed onto obstruction (e.g. Strangulated Hernia)
• Sudden onset of Pain suggests Perforation (e.g. Duodenal Ulcer), Rupture (e.g. AAA), Torsion,
Infarction (Mesenteric), Acute Pancreatitis
o Back Pain suggests retroperitoneal involvement e.g. Pancreatitis, AAA, Renal Tract
o Inflammatory conditions produce more gradual onset of pain
o Peritonitis – Pain is continuous and made worse by movement
• Vomiting might accompany abdominal pain,
but if persistent suggests GI obstruction
• Change in Bowel Habit, Urinary Frequency
and Gynaecological history
Physical Examination
• General condition of patient, including
pulse, temperature, blood pressure
• Abdomen – Presence of scars, distention,
masses, visible pulsations
o Palpate on tenderness for guarding
(involuntary spasm of abdominal
wall, indicates peritonitis;
Generalised or Localised)
o Bowel sounds – High pitch tickling
sounds indicate fluid obstruction; Absent sounds might indicate Peritonitis or
Strangulation, Ischaemia or Ileus of the Bowel; Hernial orifices examined if
obstruction suspected
• Vaginal Examination – Diagnosis of gynaecological causes e.g. Ectopic Pregnancy
• Rectal Examination – Less helpful; identify bleeding
• Flexible Sigmoidoscopy – If diarrhoea is present, may be indicated to exclude Infective,
Inflammatory and Ischaemic causes; Stool sample sent for cultures
• Urine – Blood (UTI, Colic), Glucose and Ketones (Ketoacidosis), Protein and White Cells
(Exclude Acute Pyelonephritis)
Investigations in Acute Abdomen
• FBC – WBC raised in inflammatory conditions
• Serum Lipase/Amylase – Needs to be grossly raised to be diagnostic of Pancreatitis
• U/Es – Evaluation of patient, not helpful for diagnosis
• Pregnancy Test – For any woman of childbearing age
• Erect CXR – Pneumoperitoneum; AXR – Dilated loops of bowel and fluid levels
• Ultrasound – Acute Cholangitis, Cholecystitis, Aortic Aneurysm, Acute Appendicitis;
Gynaecological and Pelvic causes also detected
• CT Abdomen – Most accurate investigation in most acute emergencies
Acute Appendicitis
• Surgical Emergency – Affects all age groups; Should always be considered if Appendix intact
• Lumen of Appendix becomes impacted with Faecolith; Gangrene proceeds to Perforation
leading to Localised Abscess, or Generalised Peritonitis
• Most present with Abdominal pain vaguely in the centre before becoming localised to Right
Iliac Fossa with guarding due to Peritonitis; Tender mass in RIF
• Differentials – Nonspecific Mesenteric Lymphadenitis, Acute Terminal Ileitis (Crohn’s disease,
Yersinia infection), Gynaecological causes, Meckel’s Diverticulum, Functional Bowel Disease
Management of Acute Appendicitis
• ↑WBC, ESR and CRP; Ultrasound and CT (Highly sensitive)
• Removal by Laparoscopic surgery; If mass is present, surgeons might prefer to treat with IV
Fluids and Antibiotics initially and follow up electively with Lap Chole; Emergency Surgery if
Perforation Appendix/Peritonitis
Gynaecological Causes
• Ruptured Ectopic Pregnancy – Fallopian tube most common site of ectopic implantation;
present with Recurrent Low Abdominal Pain and Vaginal Bleeding; Diagnosis by Abdominal
and Transvaginal Ultrasound, treated with Laparoscopic Salpingostomy/Salpingectomy
• Rupture of Functional Ovarian Cysts in middle of cycle (Mittelschmerz)
• Torsion or Rupture of Ovarian Cysts
• Acute Salpingitis – Associated with STI; Bilateral Low
Abdominal Pain, Fever and Vaginal Discharge; Chlamydia
can track up right Paracolic gutter and cause
Perihepatitis (Fitz-Hugh-Curtis Syndrome)
Acute Peritonitis
• Localised – Present in some degree in all acute
inflammatory conditions; Pain and Tenderness
• Generalised – Irritation of the Peritoneum due to
Infection or Chemical Irritation due to leakage of intestinal contents
o Superadded infection in perforation; E coli and Bacteroides most common
o Peritoneal Cavity becomes acute inflamed with production of Inflammatory Exudate
leading to Intestinal Dilatation and Paralytic Ileus
• Presents with Sudden Onset Severe Abdominal Pain followed by general collapse and Shock;
Patient may improve temporarily but generalised Toxaemia develops after
o Less rapid onset of pain in Inflammatory disease than in Perforation
Management of Acute Peritonitis
• Same Investigations as the Acute Abdomen
• Preparation for Surgery – Fluid Resuscitation and establishment of good Urine Output (NG
tube, IV Fluids and Antibiotics); Make Nil by mouth (or use RSI during anaesthetic), Check
Clotting and Order Group and Save
• Surgical Intervention – Peritoneal Lavage and Specific Treatment of underlying condition
o Local Abscess formation suspected if Swinging fever, ↑WBC and Pain postop;
Commonly Pelvic/Subphrenic and drained under Ultrasound/CT guidance
Intestinal Obstruction
• Obstruction can be classified as Dynamic
(=Mechanical) or Adynamic (Pseudo-Obstruction)
• Paralytic Ileus – Cessation of GI tract motility;
Presents with N+V, Abdominal Distention (Dull on
percussion); Air/fluid filled loops of small ± large
bowel AXR
o Prolonged surgery, Bowel handling,
Peritonitis, Abdominal Trauma, Electrolytes,
Drugs e.g. Antimuscarinics/Opiates,
Prolonged Hypotension/Hypoxia
o Pass NGT to empty stomach contents if N+V;
Small volume of fluid might allow ileus to
resolve but otherwise NBM; IV infusion
(=Drip and suck)
o Ensure U/Es balanced; Reduced Opioids and
encourage mobilisation
o Consider alternative causes – E.g. Occult
Intra-Abdominal Sepsis
• Post-operative Mechanical SBO – Early Adhesions
(typically self-limiting), Intra-Abdominal Sepsis; Might
have similar presentation as Paralytic Ileus, except
with Colicky Abdominal Pain and Bowel sound
present (Tickling if severe obstruction)
Emergency Management of Perforation
• Leads to symptoms of Acute Peritonitis – Most
commonly Acute Perf Appendicitis, Diverticular
Disease (most common in Elderly), Upper GI, Perf
Tumours, Perf Ischaemic Bowel, Acute Pancreatitis, Post-Operative Complications
o Anorexia, Fever, Generalised Abdominal Pain (might radiate to shoulders and back,
pain on movement or straining, Guarding, Rigidity), Tachycardia
• Large IV access, Cath and monitor fluid status
• FBC, U/Es, CRP, Lipase, Group and Save; ABG if Shocked, or Ischaemic Bowel/Pancreatitis
o Neutrophilia, Lipase ?Pancreatitis
• IV Abx might be appropriate even without clear diagnosis
• CT Abdo first-line; Diagnostic Laparoscopy might be useful if formal laparotomy is undesirable
• Definitive Management depends on cause, typically requires Laparotomy
Acute Colonic Pseudo-obstruction (Paralytic Ileus)
• Presents as Rapid and Progressive Abdominal Distention and Pain; AXR shows gas-filled
bowel; Management of underlying aetiology
o Intra-abdominal Trauma, Pelvic Spinal and Femoral Fractures; Intra-abdominal Sepsis
o Postoperatively (Abdominal, Pelvic, Cardiothoracic, Orthopaedic, Neurosurgical)
o Metabolic – Electrolyte disturbances, Malnutrition, Diabetes, Parkinson’s Disease
o Drugs – Opiates, Antidepressants, Antiparkinsonian drugs
Intra-Abdominal Abscess
• Might present as Intra-Abdominal Sepsis; Sepsis contained within tissues or anatomy;
Commonly located along-side organ of origin, Pelvic and Sub-phrenic
• Causes – Diverticulitis, Acute Appendicitis/Cholecystitis, Upper GI Perforation, Post-operative
Complication, Infected Acute Pancreatitis
o Might present with non-specific symptoms (Malaise, Anorexia); Classically with
swinging fever that occurs twice a day; Accompanied by Tachycardia; Localised
abdominal tenderness might be present
• Emergency Management – Large IV access, Cath and monitor fluid status, Analgesia
o FBC, U/Es, CRP, Lipase, Group and Save
o CT Abdo first-line; Pelvic ultrasound might be suitable as management
o IV Abx; Radiological guided drainage (CT or US guided) where possible; Otherwise
Open Surgical Drainage
