This document discusses the acute abdomen, including its definition, pathophysiology, and common causes. It emphasizes the importance of a thorough history and physical exam in evaluating a patient with an acute abdomen. Key aspects of the history include the location, onset, and character of abdominal pain, as well as associated symptoms. The physical exam involves inspection, auscultation, palpation, and assessment of signs related to specific potential diagnoses. Laboratory tests and imaging studies can help diagnose certain surgical conditions causing an acute abdomen. An erect chest X-ray is recommended in all cases to evaluate for supradiaphragmatic conditions.
This document discusses the acute abdomen, including its definition, pathophysiology, and common causes. It emphasizes the importance of a thorough history and physical exam in evaluating a patient with an acute abdomen. Key aspects of the history include the location, onset, and character of abdominal pain, as well as associated symptoms. The physical exam involves inspection, auscultation, palpation, and assessment of signs related to specific potential diagnoses. Laboratory tests and imaging studies can help diagnose certain surgical conditions causing an acute abdomen. An erect chest X-ray is recommended in all cases to evaluate for supradiaphragmatic conditions.
This document discusses the acute abdomen, including its definition, pathophysiology, and common causes. It emphasizes the importance of a thorough history and physical exam in evaluating a patient with an acute abdomen. Key aspects of the history include the location, onset, and character of abdominal pain, as well as associated symptoms. The physical exam involves inspection, auscultation, palpation, and assessment of signs related to specific potential diagnoses. Laboratory tests and imaging studies can help diagnose certain surgical conditions causing an acute abdomen. An erect chest X-ray is recommended in all cases to evaluate for supradiaphragmatic conditions.
This document discusses the acute abdomen, including its definition, pathophysiology, and common causes. It emphasizes the importance of a thorough history and physical exam in evaluating a patient with an acute abdomen. Key aspects of the history include the location, onset, and character of abdominal pain, as well as associated symptoms. The physical exam involves inspection, auscultation, palpation, and assessment of signs related to specific potential diagnoses. Laboratory tests and imaging studies can help diagnose certain surgical conditions causing an acute abdomen. An erect chest X-ray is recommended in all cases to evaluate for supradiaphragmatic conditions.
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THE ACUTE ABDOMEN
• DR. E. NKHATA DEFINITION OF ACUTE ABDOMEN
• Abdomen anterior region of the trunk between thoracic
diaphragm superiorly and pelvic brim inferiorly. • Condition of the sudden onset usually associated with abdominal pain, perforation, obstruction, infarction or rupture of intra abdominal organs (Anderson, Novak, Keith and Elliot, 2012). • Synonym – Surgical abdomen • Its a surgical emergency. PATHOPHYSIOLOGY OF ACUTE ABDOMEN • There maybe: • inflammation secondary to infection (acute appendicitis and diverticulitis) • Obstruction (small and large bowel obstruction) • Malrotation of the gut • Mechanical distention, inflammation, ischaemia and intense contraction of smooth muscles as in colic pain i.e. visceral innervation visceral pain secondary to embryonic foregut, midgut and hindgut and somatic pain. HISTORY: Abdominal Pain
• Thorough history is essential to
come up with accurate diagnosis and rule out unlikely conditions. • The most common and chief presenting feature of an acute abdomen is pain. • Special attention should be paid to the location, the mode of onset and progression as well the character of the pain to come up with possible differential diagnoses A. Location of Pain
• The dual visceral and parietal
sensory innervation of the abdominal region is complex and thus pain is vaguely localized. • However general patterns provide clues to diagnosis. Visceral pain
• Is elicited by: 1. distention 2. inflammation or ischemia that stimulate the receptor neurons 3. direct involvement (by malignant infiltration) of sensory nerves Parietal pain
• Mediation of parietal pain is via both
C and A delta nerve fibers. • Accurate and exact location of pain results from direct irritation of the somatically innervated parietal peritoneum by pus, bile, urine or gastrointestinal secretions. The referred pain
• Noxious (usually cutaneous) sensation at a site distant
from strong primary stimulus. • The distortion in central perception of the site of pain results from the confluence of afferent nerve fibers within the posterior horn of the spinal cord. • Pain due to subdiaphragmatic irritation by air, peritoneal fluid, blood, or a mass lesion is referred to the shoulder via the C4-mediated (phrenic) nerve. Spreading or shifting pain
• The site of pain at onset should be differentiated
from the site at presentation. • The initial typical pain in the epigastric or periumbilical region, the incipient visceral pain of acute appendicitis (as a result of distention of the appendix) later shifts to become sharper parietal pain localized in the right lower quadrant due to direct inflammation of the overlying peritoneum. Common causes of the acute abdomen • Gastrointestinal tract disorders *Nonspecific abdominal pain *Appendicitis *Small and large bowel obstruction *Perforated peptic ulcer Incarcerated hernia Bowel perforation
1. gastrointestinal obstruction 2. pyloric stenosis 3. the reflex effect biliary or renal colic. Mode of Onset and Progression of Pain • Depict the nature and severity of the precipitating factor. • Onset may be explosive, rapidly progressive or gradual. • Unknown, excruciating generalized pain suggests perforated viscus or rupture of an abdominal aortic aneurysm, ectopic pregnancy or abdominal abscess Character of Pain
• The nature, severity and periodicity of pain
points to the underlying cause • Steady pain is most common. • Sharp superficial constant pain from severe peritoneal irritation occurs in perforated peptic ulcer or a ruptured appendix, ovarian cyst or ectopic pregnancy. • The gripping, mounting pain of small bowel obstruction and early pancreatitis is usually intermittent, vague, deep-seated, and crescendo initially then becomes sharp, unremitting and better localized. • The disquieting bearable pain associated with bowel obstruction, pain due to lesions that occlude smaller conduits (bile ducts, uterine tubes and ureters) rapidly becomes unbearably intense. • Colic Pain is pain with pain-free intervals that entails intermittent smooth muscle contractions, as in ureteral colic. Symptoms Associated with Abdominal Pain
afferent fibers of the medullary vomiting centers, activates efferent fibers to induce reflex vomiting. • Pain in the acute surgical abdomen usually occurs before vomiting, However vomiting precedes pain in medical conditions. B. Constipation
• Reflex ileus is frequently induced by visceral
afferent fibers which stimulate efferent fibers of the sympathetic autonomic nervous system (splanchnic nerves) to minimize intestinal peristalsis. • Therefore paralytic ileus undermines the value of constipation in the differential diagnosis of an acute abdomen C. Diarrhoea
• Copious watery diarrhoea is typical
of gastroenteritis and other medical causes of an acute abdomen. • Blood-stained diarrhoea is suggestive of ulcerative colitis, Crohn's disease, or bacillary or amoebic dysentery Relevant Aspects of the History
• A. Gynecologic History • B. Drug History • C. Family History • D. Travel History • E. Operation History PHYSICAL EXAMINATION
• A methodical and complete
general physical examination is essential. • Look for specific signs that confirm or exclude differential diagnoses. General observation
• General observation suggest reliable indication of
the severity of the clinical situation. • Though uncomfortable, most patients remain calm. • The writhing of patients with visceral pain as in intestinal or ureteral colic is in contrast with the rigidly motionless bearing of patients with parietal pain such as acute appendicitis or generalized peritonitis. Systemic signs
• Follow rapidly progressive or advanced
disorders associated with an acute abdomen. • Extreme pallor, hypothermia, tachycardia, tachypnea, and sweating suggest major intra- abdominal hemorrhage such as ruptured abdominal aortic aneurysm or tubal pregnancy. Fever
• Constant low-grade fever is common in
inflammatory conditions : diverticulitis, acute cholecystitis and appendicitis. • High fever with lower abdominal tenderness in a young woman without signs of systemic illness is typical acute salpingitis. Steps in physical examination of the acute abdomen • Inspection • Auscultation • Cough tenderness • Percussion • Guarding or rigidity • Palpation • One-finger • Rebound tenderness • Deep • Punch tenderness • Costal area • Costovertebral area • Special signs • External hernias and male genitalia • Rectal and pelvic examination Physical findings in various causes of acute abdomen. • Perforated viscus: Scaphoid, tense abdomen, diminished bowel sounds (late), loss of liver dullness, guarding or rigidity. • Peritonitis :Motionless, absent bowel sounds (late), cough and rebound tenderness, guarding or rigidity. Inflamed mass or abscess: Tender mass (abdominal, rectal, or pelvic),
• punch tenderness; special signs
(Murphy's, psoas, or obturator). • Intestinal obstruction Distention; visible peristalsis (late); hyperperistalsis (early) or quiet abdomen (late); • Paralytic ileus Distention; minimal bowel sounds; no localized tenderness. • Ischemic or strangulated bowel: Not distended (until late), bowel sounds variable, severe pain but little tenderness; rectal bleeding. • Bleeding: Pallor, shock, distention, pulsatile (Abdominal aortic aneurysm) or tender in ectopic pregnancy) mass, rectal bleeding. INVESTIGATIVE STUDIES
• The history and physical examination
provide the diagnosis in two-thirds of cases of an acute abdomen. • Supplementary laboratory and radiologic examinations are essential in diagnosis of several surgical conditions. LABORATORY INVESTIGATIONS • A. Blood Studies Hemoglobin, hematocrit, and white blood cell and differential counts should be taken on admission. B. Urine Tests Urinalysis. Dark urine or a raised specific gravity indicates mild dehydration in patients with normal renal function. • C. Stool Tests Gastrointestinal bleeding is not a common feature of the acute abdomen. Testing for occult faecal blood should be routinely performed. Imaging Studies
• A. Plain Chest X-Ray Studies
• An erect chest x-ray is essential in all cases of an acute abdomen. • For preoperative assessment and demonstration supradiaphragmatic conditions that simulate an acute abdomen such as lower lobe pneumonia or ruptured esophagus. B. Plain Abdominal X-Ray Studies Plain supine films of the abdomen should be obtained only selectively.
• In general, erect (or lateral
decubitus) views contribute little additional information except in suspected intestinal obstruction. • Radiologic abnormalities are present in up to 40% of patients and are diagnostic only half the time. • C. Angiography: Percutaneous invasive angiographic studies, or magnetic resonance angiography (MRA) indication intra-abdominal intestinal ischemia or suspicion of ongoing haemorrhage. • D. Gastrointestinal Contrast X-Ray Studies Gastrointestinal contrast studies should not be requested routinely or be regarded as screening studies. • E. Ultrasonography: Ultrasonography is of value evaluation in upper abdominal pain not related to ulcer pain or bowel obstruction and in investigating abdominal masses • F. CT Scan: Urgent or emergent CT scan of the abdomen is now generally routinely and rapidly available
• Endoscopy: Proctosigmoidoscopy is indication in any
patient with suspected large bowel obstruction, grossly bloody stools or a rectal mass. • Paracentesis: In patients with free peritoneal fluid, aspiration of blood, bile, or bowel contents is a strong indication for urgent laparotomy - DPL. • Laparoscopy: Laparoscopy is therapeutic and diagnostic modality • In young women, it may distinguish a nonsurgical or gynaecological condition (ruptured graafian follicle, pelvic inflammatory disease, tubo-ovarian disease) from appendicitis. In obtunded, elderly, or critically ill patients, who often have deceptive manifestations of an acute abdomen,
• It may facilitate earlier
treatment in those with positive findings while eliminating the added morbidity of a laparotomy in negative cases DIFFERENTIAL DIAGNOSIS
• The age and gender of the patient assist in the
differential diagnosis: • Mesenteric adenitis mimics acute appendicitis in the young. • Gynecologic disorders complicate the evaluation of lower abdominal pain in women of childbearing age; • Malignant and vascular diseases are more common in the elderly. INDICATIONS FOR SURGICAL EXPLORATION AND COMPLICATIONS
• The need for operation is apparent when the
diagnosis is certain, • surgery sometimes must be undertaken before a precise diagnosis is reached. • Sepsis • Necrosis and/or bowel gangrene • Fistula and death. BIBLIOGRAPHY
1. Anderson D. M, Novak P.D, Keith J and Elliot M. A
(2012) Dorland’s illustrated Medical Dictionary, Elsevier Saunders Company Philadelphia United States of America ISBN: 978-1-4160-6257-8 2. Mugala D. D (2012) The acute abdomen, the Copperbelt University Lecture notes 3. Patterson J. W, Kashyap S and Dominique E (2020) Acute abdomen ncbi.nlm.nih.gov.books/NBK459328
