Acute Abdomen

Acute abdomen
Definition
All abdominal conditions that present with short duration
less than 10 days which might indicate a progressive

intra-abdominal condition, that is threatening to life or
capable of causing severe morbidity. Pain is usually chief
symptoms.
Surgical, Medical and Gynecological causes.
Not all acute abdomen require surgery and not all acute
abdomen is of short duration.
Classification
Operation necessary.
Operation not immediately necessary investigate
first.
Operation not necessary.
Severity scale for causes of acute

abdomen
Scale 1 to 10
Less than 5.
Scale of 5.
More than 5.
Origin of abdominal pain

Visceral pain
Parietal pain
Extra-abdominal
Rectus muscle hematoma, testicular torsion, MI, PE,
Pneumonia, herpes zoster, scorpion sting, sickle cell
disease ,opioid withdrawal , Ketoacidosis.
Hematoma of rectus muscle

Hematoma of the rectus sheath
is uncommon but Important,
since it is often overlooked.
It occurs most often on the
right side below the level of the
umbilicus.
The source of the bleeding is
the Inferior epigastric vein or,
more rarely, the Inferior
epigastric artery.
Origin of abdominal pain

Intra abdominal
GI, GU, Vascular , GYN.
Extra abdominal
Cardiopulmonary
Abdominal wall
Neurogenic.
Toxic metabolites
Visceral pain
Muscular contraction colic gut, ureter.
Stretching the wall of hollow organ GB.
Stretching the capsule of a solid organ liver.
Torsion or ischemia ovary.
Inflammation.
Dermatomes
Sensory dermatome with
which the viscera shares
innervations.
This may be in a
completely different place
to location of the viscera!
continue
Pain is not well localised ,vague , deep ,dull, diffuse,
central due to bilateral presentation by autonomic
nervous system .
Fore gut Epigastric.
Mid gut peri umbilical.
Hind gut Hypogastric and suprapubic.
Perception of Visceral Pain
DIFFERENCE BETWEEN COLIC,AND

DISTENSION
Colic comes and go.
Distension is same pain but continuous.
Parietal pain
Spinal Somatic nerves, from skin to peritoneum,
unilaterally.
Localized, sharp severe.
Bacterial or chemical irritation, mechanical as in
surgical incisions.
Appendicitis, cholecystitis.
Extra-abdominal pain
Pain that originate from sources that share same
innervations of abdominal wall T9-L1 example. Spinal
nerve .
Radiation: Pain start in one place and spread to

another place, and initial pain persist.
Pancreatitis ,abdominal aorta ,ureter , diaphragm.
Referred pain
From deep viscera , but

superficial at presenting
site.
Central neural pathway
common to somatic nerve
and deep viscera.
Biliary ,inferior scapular
region, diaphragm
irritation to shoulder tip.
Referred pain
Peritoneal irritation
Guarding Spinal reflex which
cause contraction of
abdominal muscles, at site of
peritoneal irritation.
(Inflamed visceral peritoneum
in contact with abdominal
wall).
Ex Murphys sign in acute
cholecystitis
Voluntary, Involuntary.
Continue
Rigidity
Board like Muscles are

held rigid, abdomen is held still.
Perforated viscus, Generalized

peritonitis.
Thoracic breathing.
Rebound tenderness Blumberg

sign
Cough sign
Auscultation
Exaggerated bowel sounds .
Absent bowel sounds.
PR examination
Irritation of pelvic peritoneum.
Pelvic mass.
Onset and duration of pain

Sudden onset of pain within seconds
Rupture AAA, Perforated ulcer.
Rapid accelerating pain within minutes
Colic syndromes
Inflammatory process
Ischemic process
Gradual onset of pain over hours.
Know conditions which commonly present

as GI emergency, according to GI site.
Know typical clinical presentation.
Know underlying pathology.
Know treatment strategy.
Right Hypochondrion
Epigastric
Left Hypochondrion
Acute Cholecystitis
Biliary colic
Cholangitis
Hepatomegaly (congestive)
Hepatitis
Basal pneumonia
Peptic ulcer
Acute pancreatitis
MI
AAA
Dissecting aortic aneurysm
Oesophagitis
Perforated oesophagus
Ruptured spleen
Splenic infarct
Splenomegaly
Subphrenic abscess
Basal pneumonia
Right Lumbar
Umbilical
Left Lumbar
Renal / ureteric colic

Renal infarct
Pyelonephritis
Acute pancreatitis
Early appendicitis
AAA
Dissecting arotic aneurysm
Bowel obstruction
Ischaemic bowel
Gastroenteritis

Renal infarct
Pyelonephritis
Right Iliac Fossa
Suprapubic
Left Iliac Fossa
Appendicitis
Meckels diverticulitis
Perforated caecal carcinoma
Terminal ileitis
Crohns disease
Ectopic pregnany
Testicular torsion
Other gynae pathology
Cystitis / UTI
Urinary retention
Diverticulitis
Colitis
Ectopic pregnancy
Testicular torsion
Other gynae pathology
Abdominal signs
Cullen
Ecchymosis around umbilicus
Hemoperitoneium,pancreatitis,ectopic
pregnancy
Grey Turner
Ecchymosis of flank
Hemoperitoneium,pancreatitis,
Kehr
Spleen rupture
Murphy
Abrupt cessation of inspiration
Cholecystitis
Dance
No bowel sounds RIF
Intussusceptions
Blumberg
Rebound tenderness
appendicitis
Rovsing
RIF pain on Lt IF pressure
Appendicitis
Markle
Raise on toes then heel hit ground
Appendicitis
Classify by site
Oesophagus
Acute Dysphagia
Perforation
Bleeding
Stomach/duodenum
Perforation.
Bleeding.
Gallbladder/Biliary Tract
Cholecystitis
Cholangitis
Obstructive jaundice
Pancreas
Acute pancreatitis.
Small intestine
Intestinal obstruction
Mesenteric Infarct
(Infectious diarrhoea)
Crohns Disease
Meckels Diverticulum
Large Bowel (+ App)

Acute Appendicitis
Acute Diverticulitis
Lower GI bleeding
Perforation
Uncontrolled
ulcerative colitis
e.g. Acute Appendicitis

Initial umbilical pain
Visceral pain
Appendix
inflammation
Secondary RIF pain

Localized parietal
peritoneum
inflammation
Peritoneal cavity
Peritonitis
Intra-abdominal abscess
Esophagitis, Mallory Weiss,

Varices.
Variceal bleeding Catastrophic
Treatment - Varices
Sengstaken tube
Sandostatin injection
(octreotide)
Sclerotherapy.
Esophageal transection.
ANATOMY OF THE INSERTION OF THE SENGSTAKENBLAKEMORE

BALLOON FOR ESOPHAGEAL HEMORRHAGE
The Sengstaken-Blakemore
balloon is used for the control
of massive esophageal
hemorrhage from esophageal
varices.
A gastric balloon anchors the
tube against the esophageal
gastric junction.
An esophageal balloon
occludes the esophageal
varices by counter pressure.
Presentation cannot
swallow
May have benign stricture or
cancer
Triggered by food bolus or
tablet
Treatment Remove bolus
Deal with underlying
oesophageal disease
High mortality
Spontaneous
(boerhaave syndrome)
May follow endoscopy
Presentation acute chest/abdominal
pain
Air in mediastinum.
and soft tissues
Treatment Surgery - benign
Intubation - malignant
Presentation
Abdominal pain
Rigidity
Peritonism, shock .
Air under diaphragm
Treatment
Antibiotics Resuscitate
Repair
Presentation
Hematemesis +/Melena
Severity
Increased PR > 90
Fall BP < 100
Causes
DU, erosions, GU
Stomach neoplasm
Treatment
Transfusion
Inject DU
Obstructive Jaundice
Yellow skin, sclera
Pale stools, dark urine
+/- Pain
+/- Courvoisiers sign
Ultrasound
CT dilated bile ducts
ERCP,MRCP
Establish diagnosis
Bile duct stone
Ca Head of Pancreas
Cholangio-carcinoma
Appropriate treatment
Acute Cholecystitis
Presentation
Acute RUQ pain
+/- Pyrexia
+/- Rigors, Murphy sign+ve
Diagnosis FBC, WBCC,
USS
(HIDA Scan)
Treatment Antibiotics,
Analgesics
Early surgery
Acute pancreatitis
Constant pain, vomiting,
shock
Causes
Gallstones, or
Alcohol,Trauma
Diagnosis
Serum amylase,lipase
elevation, USS,CT
complications
Pseudo cyst, phlegmon
abscess
Meckels Diverticulum
Rare
Diverticulum of terminal ileum
Can be lined by gastric epithelium
Can perforate
Can present like appendicitis
Can bleed
May arise due to
adhesions, hernia, tumour
Inflammation, impaction
Presentation
colicky abdominal pain,
vomiting, constipation,
distension
Treatment
Resuscitate/Operate
Mesenteric infarct
Sudden occlusion of small bowel
arterial supply
Sudden onset of abdominal
pain, shock
Peritonitis
Treatment
Resuscitate/ Operate
Acute diverticulitis
Maximal in (L) colon
Presentation LIF pain,
Fever, Tenderness,
leucocytosis.
Middle aged or elderly.
Treatment Conservative
Antibiotics, Fluids, Bed rest
Surgery.
Lower GI bleeding
Angiodysplasia
Diverticulum, Colitis,
Crohns , Tumour
Present with Fresh Red Blood P/R
Tendency to be more conservative
than with upper GI
Resuscitate, Transfusion,
Colonoscopy
Gastroscopy
Angiography.
Perforation
Neoplasm
Diverticulum,
colitis
sudden severe abdominal pain,
rigidity
Faecal peritonitis
Pyrexia, shock
Free gas on X-ray
Treatment
Resuscitate, Operate
Bloody, mucous diarrhoea

Abdominal colic's
Toxic mega colon.
Increased risk of tumor
transformation.
Ulcerative colitis
Presents bloody diarrhoea,
pyrexia
leucocytosis
May develop toxic mega
colon
Treatment Steroids
Surgery on failure
Acute peritonitis
Any perforation,
Pancreatitis
Abdominal pain, tenderness
guarding, silent abdomen
shock
Treatment Underlying
condition
Conditions which commonly present

GI emergency, according to
GI site.
Typical clinical presentation.
Underlying pathology.
Treatment strategy
What are the main five causes of

Intestinal obstruction?
1.
2.
3.
4.
5.
Adhesions
Strangulation
Inflammation
Neoplasm
Impaction
How to differentiate between small

and large Bowel Obstruction from
history?
Vomiting.
Constipation.
Distension.
Abdominal Pain.
How to differentiate acute from

chronic intestinal obstruction?
1.
2.
By examination
Signs of peritonitis
Tender caecum.
By radiological and blood investigations
Free air under diaphragm.
Dilated bowel > 7cm.
WCC .
Severe hypokalemia, urea
Metabolic acidosis.
How to diagnose acute large

bowel obstruction?
History & examination

Colonoscopy
Water soluble gastrograffin enema
C.T. colonography
What are the tumour markers for

cancer colon?
What are the tumour markers for

cancer colon?
CEA
CA 19.9
How to prepare a patient with acute

colonic obstruction for surgery?
NG tube
Foley catheter
Correct dehydration
Correct hypokalemia
Blood ??
Antibiotics 3rd generation cephalocporin +
metronidazole.
7. Anticoagulant,s Heparin, low molecular weight
heparin
1.
2.
3.
4.
5.
6.
What are the common sites for cancer

colon?
1.
2.
3.
4.
Rectum 40 %
Sigmoid colon 30%
Caecum 20%
Rest 10%
What are your surgical options?
1. Three stages operations (Colostomy

first)
2. Two stages operations (Hartmanns
procedure)
3. One stage operation (Resection
anastomosis)
Histological classification + prognosis

Dukes classification
A
95%
B
75%
C
45%
D
10%
1.
2.
3.
4.
5.
Post op care
Chemotherapy
Radiotherapy
Follow up by CT or MRI every three months
Tumour markers CEA CA 19.9 every three
months
6. Colonoscopy every one year

Acute Abdomen

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Acute abdomen

less than 10 days which might indicate a progressive

Severity scale for causes of acute

Origin of abdominal pain

Hematoma of rectus muscle

Origin of abdominal pain

Perception of Visceral Pain

DIFFERENCE BETWEEN COLIC,AND

Radiation: Pain start in one place and spread to

Pancreatitis ,abdominal aorta ,ureter , diaphragm.

From deep viscera , but

Board like Muscles are

Perforated viscus, Generalized

Rebound tenderness Blumberg

Absent bowel sounds.

Onset and duration of pain

Know conditions which commonly present

Renal / ureteric colic

Renal / ureteric colic

Right Iliac Fossa

Left Iliac Fossa

Ecchymosis around umbilicus

Abrupt cessation of inspiration

No bowel sounds RIF

RIF pain on Lt IF pressure

Raise on toes then heel hit ground

Large Bowel (+ App)

e.g. Acute Appendicitis

Secondary RIF pain

Esophagitis, Mallory Weiss,

ANATOMY OF THE INSERTION OF THE SENGSTAKENBLAKEMORE

Bloody, mucous diarrhoea

Conditions which commonly present

What are the main five causes of

How to differentiate between small

How to differentiate acute from

How to diagnose acute large

History & examination

What are the tumour markers for

What are the tumour markers for

How to prepare a patient with acute

What are the common sites for cancer

What are your surgical options?

1. Three stages operations (Colostomy

Histological classification + prognosis

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