The Acute Abdomen

Question 1

What is an acute abdomen?

Answer 1

Someone who becomes acutely ill and in whom symptoms and signs are chiefly related to the abdomen. Potentially life-threatening domino pathology requiring urgent surgical intervention.

Question 2

What pathologies can be present in the right upper quadrant?

Answer 2

Right-sided pneumonia, hepatitis, congestive hepatomegaly, gallstone disease, duodenal ulcer, pyelonephritis, appendicitis.

Question 3

What pathologies can be present in the epigastric region?

Answer 3

Myocardial infarction, gallstone disease, pancreatitis, perforated oesophagus, peptic ulcer.

Question 4

What pathologies can be present in the left upper quadrant?

Answer 4

Left sided pneumonia, gastric ulcer, ruptured spleen, pyelonephritis, perforated colon.

Question 5

What pathologies can be present in the umbilical region?

Answer 5

Aortic aneurysm, early appendicitis, pancreatitis, mesenteric thrombosis, intestinal obstruction.

Question 6

What pathologies can be present in the right lower quadrant?

Answer 6

1. GI - perforated caecum, Crohn’s disease, mesenteric adenitis, appendicitis, strangulated hernia, Meckel’s diverticulum
2. Renal - renal colic, acute urinary retention.
3. GU - ruptured ectopic pregnancy, ovulation pain (Mittelschmerz), ruptured ovarian cyst, tubo-ovarian abscess, salpingitis, ovarian torsion.

Question 7

What pathologies can be present in the left lower quadrant?

Answer 7

Renal colic, perforated colon, ulcerative colitis, sigmoid diverticulitis, Crohn’s, strangulated hernia, ruptured ectopic pregnancy, ovulation pain (Mittelschmerz), ruptured ovarian cyst, tubo-ovarian abscess, salpingitis, ovarian torsion, acute urinary retention.

Question 8

What is this a presentation of?

Central acute abdomen, referring to back, tachycardia, tachypnoea, pallor, cold sweat, hypotensive.

Answer 8

Ruptured AAA

Question 9

What is this a presentation of?

Acute abdomen, tachycardia, tachypnoea, pallor, cold sweat, hypotensive, woman of childbearing age, PV bleeding.

Answer 9

Ruptured ectopic pregnancy

Question 10

What is this a presentation of?
Acute abdomen, tachycardia, tachypnoea, pallor, cold sweat, hypotensive, recent history of trauma to left upper quadrant.

Answer 10

Splenic rupture

Question 11

What is generalised peritonitis usually a manifestation of and what might you see on an erect chest X-ray?

Answer 11

1. Perforated hollow viscus - perforated peptic/duodenal ulcer, appendix, bowel, gallbladder.
2. Free air under the diaphragm.

Question 12

What is this describing?
Severe non colicky pain worse on cough or deep inspiration, lying still, percussive tenderness, board like abdominal rigidity, no bowel sounds, shallow breaths.

Answer 12

Generalised peritonitis

Question 13

What is the underlying pathology in localised peritonism?

Answer 13

1. Parietal peritoneum is irritated by inflamed appendix/diverticular abscess resulting in focal abdominal rigidity.
2. Progresses to generalised peritonitis if condition worsens.

Question 14

What is this a presentation of?

Colicky abdominal pain accompanied by vomiting, absolute constipation and/or abdominal distension.

Answer 14

Intestinal obstruction

Question 15

What is the difference between the clinical picture of a high small bowel obstruction and a low colonic obstruction and how are they diagnosed?

Answer 15

1. High SBO - vomiting and pain predominant
2. Low colonic - constipation and distention predominant
3. AXR/CT to diagnose

Question 16

What is this a presentation of?

Recent onset of acute diarrhoea with cramping abdominal pain +/- vomiting.

Answer 16

Gastroenteritis

Question 17

What is this a presentation of?

Elderly, bloody diarrhoea with vascular disease/AF.

Answer 17

Ischaemic colitis

Question 18

What is this a presentation of?
Severe, colicky unilateral pain that radiates to groin +/- testes/labia. Writhing in pain, able to find comfortable position. Haematuria.

Answer 18

Renal tract obstruction (exclude AAA with USS)

Question 19

What blood test should you measure severe epigastric pain, and what is it trying to identify?

Answer 19

1. Amylase

2. >1000U/L diagnostic of pancreatitis

Question 20

What should you do if a patient presents with upper abdominal pain and jaundice?

Answer 20

Urgent abdominal USS to look for biliary obstruction.

Question 21

What is this a presentation of?

Fever/high WCC, CRP and unremitting right upper quadrant pain.

Answer 21

Cholecystitis (could also be basal pneumonia)

Question 22

What is this a presentation of?

Severe right upper quadrant pain with no systemic inflammatory signs. Comes on after big fatty meal then goes.

Answer 22

Biliary colic

Question 23

What should be your immediate investigations in an acute abdomen with a positive pregnancy test?

Answer 23

Urgent gynaecology review and transvaginal USS

Question 24

What is this a presentation of?
Migration of pain from periumbilical region to right iliac fossa, right iliac fossa tenderness with local peritonitis. Mild fever, high WCC/CRP.

Answer 24

Acute appendicitis

Question 25

What is this a presentation of?

Elderly, left iliac fossa, evidence of systemic inflammation (fever, raised WCC/CRP).

Answer 25

Diverticulitis

Question 26

What bedside test is done to confirm the diagnosis of a UTI?

Answer 26

Urinalysis - positive leukocytes or nitrites

Question 27

What urgent imaging should you do in this presentation?

Woman of childbearing age (<35) with acute pelvic/lower abdominal pain. Nausea, vomiting, unilateral tenderness.

Answer 27

Urgent USS to look for ovarian torsion or cyst

Question 28

If ovarian torsion or cyst is ruled out what diagnosis should be considered in this presentation?
Woman of childbearing age. Bilateral lower abdominal pain +/- fever. Abnormal discharge, tenderness on moving cervix during bimanual examination.

Answer 28

Pelvic inflammatory disease

Question 29

What is this a presentation of?

Sudden onset pain out of proportion to clinical signs and risk factors of vascular disease.

Answer 29

Mesenteric ischemia

Question 30

Which medications should you ask about in the drug history and abdominal pain?

Answer 30

Antibiotics, NSAIDs, PPIs, steroids.

Question 31

Which pathologies cause absent bowel sounds and tinkling bowel sounds?

Answer 31

1. Absent - peritonitis

2. Tinkling - bowel