Acute

Abdomen
dr. Liza Nursanty, SpB, Mkes, FINACS

Acute Abdomen
Challenge to Surgeons & Physicians
Most common cause of surgical
emergency admission
Clinical course can vary from minutes to
hours to weeks.
It can be an acute exacerbation of a
chronic problem e.g. Chronic
Pancreatitis,Vascular Insufficiency.

DEFINITION
Acute Abdomen is a term used
synonymously for a condition that needs
immediate surgical intervention

Diagnosis can be made most of the time

by a good history and a proper physical
examination.

ASSESMENT
Well elicited history
Proper physical
examination
Investigations are usually carried
out :
only to support the diagnosis.
or to narrow down the differential
diagnoses.

History

History of Present illness

Family History
Past Medical history
History of drugs taken or
Medication eg. ingestion of
certain toxic drugs or Alcohol
intake

Free Peritoneal Air

This plain abdominal radiograph of a 55-year-old woman presenting with

features of intestinal obstruction shows dilated loops of the small bowel
associated with thickened edematous valvulae conniventes and a strangulated
left inguinal hernia (arrow).

PAIN

The Most Important Symptom

History of pain should include:
1.Onset
2.Severity
3.Type of pain
4.Radiation of Pain
5.Change in nature of Pain
6.Associated bowel or urinary
symptoms
7.Aggravating or relieving factors

(i) Onset of Pain

Sudden onset pain which wakes the
patient from sleep
eg. perforation or strangulation of
bowel
Slow insidious Onset
a. Inflammation of visceral
peritoneum.
b. Contained process such as
evolving abscess.
Crampy or colicky pain
Biliary colic, Ureteric colic or
Intestinalcolic

(ii) Progression of Pain

Progression from:
Dull, aching, poorly localized character
To:
Sharp, constant & better localized pain
indicates involvement of Parietal
peritoneum

(iii) Associated Bowel

Symptoms
CONSTIPATION
a. Progressive intestinal obstruction
from a
neoplasm or inflammatory bowel
disease
b. Paralytic Ileus
c. Post Operative
d. Obstructed groin hernia

(iv) Associated Bowel

Symptoms

DIARRHOEA
Diarrhoea with pain is mainly medical.
The following are the exceptions :
a.Obstructed Richter's Hernia
b.Gall Stone ileus
c.Superior mesenteric vascular
occlusion
d.Intestinal Obstruction associated
with pelvic abscess
e.Spurious diarrhea in chronic faecal
impaction

DRUG HISTORY
Corticosteroids mask pain
Anticoagulants can lead to an
intramural haematoma of the gut
causing obstruction
Oral Contraceptives - rupture of
hepatic adenomas
NSAIDs - erosive gastritis & peptic
ulcers

NAUSEA & VOMITING

i. Frequency of vomiting
ii. Character of vomiting:
projectile, non-projectile or selfinduced
iii. Nature of vomiting:
a. Bilious vomiting of small bowel
obstruction
b. Non-bilious vomiting in
obstruction proximal to ampulla of
vater
c. Faeculent vomiting in distal small
gut obstruction, large bowel
obstruction , strangulation

NAUSEA & VOMITING

Pain first, followed by Vomiting is

usually surgical.
The vomiting is due to reflex
pylorospasm
Nausea & vomiting first , followed
by pain is usually due to a medical
condition

Vomiting is very prominent in

a.Mallory-Weiss syndrome.
b.Boerhaave syndrome(trans- mural
esophageal tear)

ANOREXIA
Anorexia or decreased appetite with
pain is usually seen in Acute
appendicitis

Urinary Symptomswith Pain

Ureteric colic
Cystitis

FEVER & CHILLS/RIGORS

Amoebic Liver Abscess
Pygenic Liver Abscess
Perinephric Abscess
Intra-abdominal pus collection

OTHER HISTORY
Past Surgical history: previous operationsleading to adhesions
Past Medical history: Sickle cell disease,
Diabetes or Cancer or Renal failure
Menstrual History in females
(i) Missed period- ectopic pregnancy
(ii) Mid of period-ovulation pain (Mittelschmerz)
(iii) With heavy periods- endometriosis
Family history of colon cancer, any other
malignancy or inflammatory bowel disease

Physical Examination
General Appearance
a.Anxious Patient lying motionless:
(i) Acute appendicitis
(ii) Peritonitis
b.Rolling in bed & restless:
(i) Ureteric Colic
(ii) Intestinal colic
c.Writhing in Pain:
Mesenteric Ischemia
d. Bending Forward:
Chronic Pancreatitis

Physical Examination(contd.)
e.

f.

g.

Jaundiced:
CBD obstruction
Dehydrated
(i) Peritonitis
(ii) Small Bowel obstruction
Vital Charting
Temperature, Pulse, BP, Respiratory
rate
Ruptured AAA or ectopic pregnancy
can lead to
- Pallor
- Hypotension
- Tachycardia

Physical Examination(contd.)
h.

Low grade temp. is seen with

- Appendicitis
- Acute cholecystitis
i.
High grade temp. is seen with
- Salpingitis
- Abscess
j.
Very High Grade Temp.with increasing
lethargy
seen in imminent septic shock
- Peritonitis
- Acute cholangitis
- Pyonephrosis

Systemic Examination
Cardiopulmonary examination
Check for:
- Possible MI
- Basal Pneumonia
- Pleural Effusion

Per Abdomen:
Inspection
- Scaphoid or flat in peptic ulcer
- Distended in ascites or intestinal
obstruction
- Visible peristalsis in a thin or
malnourished

Systemic Examination
Erythema or discolouration
a. Peri-umbilical - Cullen sign
b. Inguinal Fox sign
c. Flanks - Grey Turner sign
Seen in Hemorrhagic pancreatitis
or any other cause of
haemoperitoneum
Any Visible masses
Any visible cough impulse at hernia site

Systemic Examination
Per abdomen:
Palpation
Be gentle
Start away from site of pathology then
towards
Check for Hernia sites
Tenderness
Rebound tenderness
Guarding- involuntary spasm of muscles
during palpation
Rigidity- when abdominal muscles are
tense & board-like. Indicates peritonitis.

Systemic Examination
Local Right Iliac Fossa tenderness :
a. Acute appendicitis
b. Acute Salpingitis in females
c. Amoebiasis of Caecum
Low grade, poorly localized tenderness :
Intestinal Obstruction
Tenderness out of proportion to
examination:
a. Mesenteric Ischemia
b. Acute Pancreatitis
Flank Tenderness:
a. Perinephric Abscess
b. Retrocaecal Appendicitis

Systemic Examination

Rovsings Sign in Acute Appendicitis

Obturator Sign in Pelvic Appendicitis
Psoas Sign
- Retrocaecal appendicitis
- Crohns Disease
- Perinephric Abscess
Murphy's sign in Acute Cholecystitis
Thumping tenderness over lower ribs in
inflammation of
- Diaphragm
- Liver or spleen

Systemic Examination

Pulsatile Abdominal Mass with

Hypotension
Leaking AAA
Cutaneous Hyperaesthesia indicates
involvement of Parietal Peritoneum
Per Rectal Examination:
- tenderness
- induration
- mass (Blummers shelf)
- frank blood

Systemic Examination
Per

Vaginal Examination
Bleeding
Discharge
Cervical motion tenderness
Adnexal masses or tenderness
Uterine Size or Contour

INVESTIGATIONS

Complete Blood Count with differential

C-reactive protein estimation
Electrolyte ,Blood Urea , Creatinine
Urine dipstick
Amylase or Lipase
Liver Function Test

INVESTIGATIONS
Radiology
Upright X ray chest for
Basal Pneumonia
Ruptured Oesophagus
Elevated Hemi diaphragm
Free Gas under diaphragm

Abdominal X ray film

Air-Fluid Levels
Stones
Ascites
Eggshell calcification in AAA
Air in Biliary tree.
Obliteration of Psoas Shadow in retroperitoneal disease
Right lower quadrant sentinel loop in acute
appendicitis

INVESTIGATIONS

Other Investigations
USG
CT abdomen for AAA, Pancreatic disease,
or ureteric colic (non- Contrast)
IVU
Mesenteric Angiography for
Ischaemia, Haemorrhage