The Acute Abdomen

Question 1

What is the acute abdomen?

Answer 1

Sudden onset of severe abdominal pain of less than 24 hours duration

Question 2

What are some examples of presentations that require urgent surgery?

Answer 2

• Bleeding
  e. g. AAA rupture, ruptured ectopic pregnancy, bleeding ulcer & trauma
• Perforated viscus
• Ischaemic bowel

Question 3

What is the most serious cause of intra-abd bleeding?

Answer 3

Ruptured abdominal aortic aneurysm

Question 4

How does intra-abdominal bleeding present clinically?

Answer 4

Hypovolemic shock:

• Tachycardia and hypotension
• “Thready” pulse
• Pale and clammy on inspection
• Cool to touch

Question 5

What is peritonitis & what most commonly causes it?

Answer 5

Inflammation of the peritoneum

General peritonitis is most commonly caused by perforation of an abdominal viscus.

Question 6

Give some causes of vicsus perforation.

Answer 6

• Peptic ulceration
• Small / large bowel obstruction
• Diverticular disease
• Inflammatory bowel disease.

Question 7

What features do patients with peritonitis present with?

Answer 7

• Patients often lay completely still, trying not to move their abdomen
  
  • Important in comparison to renal colic patients who constantly move & can’t get comfortable.
• Tachycardia and potential hypotension
• Completely rigid abdomen w/ percussion tenderness
• Involuntary guarding
• Reduced / absent bowel sounds
  
  • Suggests paralytic ileus

Question 8

What is guarding?

Answer 8

Patient involuntarily tenses their abdominal muscles when you palpate the abdomen

Question 9

A patient presents with severe pain out of proportion to any of their clinical signs, what is the most likely diagnosis?

Answer 9

Ischaemic bowel until proven otherwise.

Question 10

Give the:

1. Clinical symptoms/signs
2. Investigations
3. Management

of ischaemic bowel

Answer 10

1. Diffuse & constant pain w/ typically unremarkable examination
2. CT scan with IV contrast
3. Early surgical involvement

Question 11

What are some less acute presentations seen in the surgical unit?

Answer 11

• Colic
• Peritonism

Question 12

What is colic? & when is it seen?

Answer 12

Abdominal pain that crescendos, becoming very severe and then goes away completely

Most typically seen in ureteric obstruction / bowel obstruction.

Question 13

Why is biliary colic not a true colic

Answer 13

Pain does not go away completely, instead periodically improves and worsens (colloquially termed ‘waxes and wanes’).

Question 14

What is peritonism? & how does it typically present?

Answer 14

Localised inflammation of the peritoneum due to inflammation of a viscus that irritates the visceral and subsequently, parietal peritoneum.

Pain starts in one place due before localising to another area / becoming generalised. Due to irritation of the visceral peritoneum initially, followed by irritation of the parietal peritoneum (e.g. migratory pain in acute appendicitis)

Question 15

What are your differentials when approaching an acute adomen?

Answer 15

Question 16

Give vascular causes of abdo pain

Answer 16

Vascular

• AAA rupture
• Mesenteric ischaemia
• MI

Question 17

Give examples of infective causes of abd pain

Answer 17

Infective

• Gastroenteritis
• Appendicitis
• Diverticulitis
• Pyelonephritis
• Cholecystitis
• PID
• Pneumonia

Question 18

Give examples of inflammatory causes of abdo pain

Answer 18

Inflammatory

• Pancreatitis
• Peptic ulcer disease

Question 19

Give examples of traumatic causes of abd pain.

Answer 19

Trauma

• Ruptured spleen
• Perforated viscus (oesophagus, stomach, bowel)

Question 20

Give metabolic causes of abd pain

Answer 20

Metabolic

• Renal/ureteric stone
• DKA

Question 21

How do you take a history from a patient presenting with an acute abdomen?

Answer 21

• Presenting complaint
  
  • SOCRATES/SQITAR
  • Associated symptoms (e.g. fever, chills, N&V)
  • Timing & nature of last bowel habit
• PMHx (Surgical & Medical)
  
  • Ask specifically about HT, DM, Heart, Blood clot, Asthma
• Personal Hx
  
  • Smoking & Alcohol Hx
  • Sexual history
  • Menstrual history
  • History of trauma
• Medication Hx
• Allergies
• Family Hx
• Travel Hx
• Occupational Hx
• Social Hx
• Type & timing of oral intake
• Anything else?

Question 22

How would you examine a patient presenting with abdo pain?

Answer 22

1. Abdominal exam (inc. auscultation of chest)
2. DRE
3. Pelvic exam (For women w/ lower abdo pain)
4. Testicular / Scrotal exam

Question 23

What lab investigations are indicated w/ presentation of an acute abdo?

Answer 23

1. Pregnancy test for all women of reproductive age.
2. Urine dipstick +/- MC&S
   * To look for sign of infection or haematuria ± MC&S.
3. ABG
   * In bleeding / septic patients to assess pH, pO2, pCO2, and lactate for signs of tissue hypoperfusion, as well as a rapid haemoglobin.
4. Routine bloods

• FBC, U&Es, LFTs, CRP, Amylase
• Serum calcium
  
  • In suspected pancreatitis.
• Group & save (G&S)
  
  • If patient is likely to need surgery soon

5. Blood cultures
   * If considering infection as a potential diagnosis

Question 24

What imaging is indicated for patients presenting with abdo pain

Answer 24

1. ECG
   * To exclude myocardial infarction.
2. USS:

• Kidneys, ureters and bladder (KUB)
  
  • For suspected renal tract pathology
• Biliary tree / liver
  
  • For suspected gallstone disease
• Ovaries, fallopian tubes and uterus
  
  • For suspected tubo-ovarian pathology

3. Erect chest X-ray (eCXR)
   * Presence of free air under diaphragm is diagnostic of perforated viscus
4. CT imaging (discussed with a senior)

Question 25

What sign is seen here?

Answer 25

Free air under the peritoneum (pneumoperitoneum), which is a sign of perforated viscus.

Question 26

What is the management of the acute abdomen

Answer 26

1. Admission
2. IV access
3. NBM
4. Analgesia +/- antiemetics
5. Imaging
6. VTE prophylaxis
7. Urine dip
8. Bloods
9. Consider a urinary catheter and/or nasogastric tube if necessary
10. IV fluids & fluid balance monitoring