Acute abdomen – definition, types, the role of general practitioner in first contact diagnosis.

Question 1

what is acute abdomen?

Answer 1

Acute onset of abdominal symptoms which can lead to a severe status / death.

• 50% appendicitis.
• Cholecystitis.
• Bowel obstruction (Ileus).
• Peptic ulcer.

Question 2

non-traumatic

Answer 2

inflammation: organ, diffuse

bowel obstruction (ileus): mechanical, vascular

bleeding: upper/lower GIT

Question 3

traumatic

Answer 3

hemoperitoneum (blood in peritoneal cavity)

peritonitis

combined

Question 4

taking history

Answer 4

history provides 60% of needed info:

describe the pain

“local radio character triggers guest during live show”

• localization
• radiation
• characteristics
• trigger
• duration

Question 5

history: types of pain

Answer 5

somatic: parietal, peritoneal, sharp, ability to localize pain

visceral pain: colic/diffused pain localization

Question 6

other questions during history

Answer 6

vomiting?
constipation?
dysuria?
allergy?
previous operations?
disease?
gynecological anamnesis: ectopic pregnancy, ruptured cyst, ovulation, torsion of ovary, inflammation

Question 7

physical examination

Answer 7

• 37°- 38°C typical for acute abdomen.
• Tachycardia.

‘Abdomen:

• Inspection (scars / hernias).
• Percussion (resonance).
• Auscultation (peristalsis).
• Palpation (resistance / tenderness / muscular defence).
• Digital rectal examination! → always when patient is in shock.

Question 8

1st recuscitation:

Answer 8

fluids, analgesia

Question 9

diagnosis

Answer 9

history, clinical presentation, examination, lab, imaging

Question 10

In acute abdomen, always review chest X-ray for:

Answer 10

1. Hiatus hernia.
2. Heart size.
3. Lung fields.
4. Pneumothorax.
5. Diaphragms (relative height / gas under (Pneumoperitoneum)).
6. Bony changes.
7. CVP line position.

Question 11

non-traumatic organ inflammation

Answer 11

• Acute appendicitis is the most common cause of acute abdomen, if perforation occurs it leads to abcess or diffuse peritonitis; on PE positive McBurney’s, Rovsing’s and obturator sign. Tx is appendectomy
• Acute cholecystitis presents with constant and progressive pain in the right hypochondrium, propagating along right costal margin to the back. N/V, tachycardia, fever, tenderness and positive Murphy’s sign (inspiration) are typical.
• Acute pancreatitis
• Perforated peptic ulcer

Question 12

non-traumatic diffuse inflammation

Answer 12

diffuse peritonitis is defined as generalized infection of the peritoneum and abdominal cavity. Primary (bacterial, chlamydial, fungal infection), secondary (spread of infection from intraabdominal organs) or tertiary (after surgical interventions).

Question 13

non-traumatic Bowel obstruction (Ileus):

❖ Mechanical:

Answer 13

• Obturative -without occlusion of vessels, classified as intraluminal (biliary ileus, parasites, congenital disorders), intramural (colorectal tumors, IBD), extramural (adhesions, compression)
• Strangulative – with occlusion of vessels, classified as strangulation by bands (omental band, Meckel’s diverticulum), volvulus (rotation of stomach or some part of bowel), intussusception (folding into lumen) or strangulated hernia

Question 14

non-traumatic Bowel obstruction (Ileus):

❖ Vascular:

Answer 14

results from impaired vascular supply of intestinal wall leading to dysfunction and necrosis

Question 15

non-traumatic Bowel obstruction (Ileus):

❖ Neurogenic:

Answer 15

• Paralytic – most commonly after surgery, but also diffuse peritonitis, intestinal ischemia, trauma of CNS, lead poisoning
• Spastic – nervous plexus irritation, can result from CNS diseases (tabes dorsalis, meningitis), hyperparathyroidism, biliary and renal colic

Question 16

non-traumatic bleeding.

❖ Upper GIT

Answer 16

variceal – portal hypertension; non-variceal – peptic ulcer disease, tumors, esophagitis, Mallory-Weiss tear

Question 17

non-traumatic bleeding.

❖ Lower GIT

Answer 17

diverticular disease, anorectal pathologies, neoplasia, colitis, IBD, Meckel’s diverticulum
❖ Into abdominal cavity – ruptured ectopic pregnancy, ruptured aortic aneurysm

Question 18

non-traumatic bleeding.

❖ Into abdominal cavity

Answer 18

ruptured ectopic pregnancy, ruptured aortic aneurysm