acute abdomen

The Acute AbdomenThe Acute Abdomen

ByBy

PROF/ GOUDA ELLABBANPROF/ GOUDA ELLABBAN

Department of General Department of General SurgerySurgery

IntroductionIntroduction

CommonCommon 5 – 10 admissions / 5 – 10 admissions / dayday

per 500,000 per 500,000 populationpopulation

VariableVariable Onset usually within 7 daysOnset usually within 7 days May require early surgeryMay require early surgery

Anatomy and Anatomy and PhysiologyPhysiology

Surface anatomySurface anatomy EmbryologyEmbryology

Somatic vs Visceral Somatic vs Visceral painpain

PathophysiologyPathophysiology

PathologyPathology

InflammatoryInflammatory

ObstructionObstruction HaemorrhageHaemorrhage IschaemiaIschaemia

(Trauma)(Trauma)

Making a diagnosisMaking a diagnosis

Not always absolutely necessaryNot always absolutely necessary

Careful historyCareful history

ExaminationExamination

InvestigationsInvestigations

History iHistory i

PainPain Site, radiationSite, radiation OnsetOnset Frequency, periodicityFrequency, periodicity Aggravating / relieving factorsAggravating / relieving factors Severity & type of painSeverity & type of pain

History iiHistory ii

Nausea + vomiting, appetiteNausea + vomiting, appetite Bowel habitBowel habit Gynaecological symptomsGynaecological symptoms Urinary symptomsUrinary symptoms Pat surgical / medical historyPat surgical / medical history Drug historyDrug history

Examination iExamination i

Begins as you first clap eyes on the Begins as you first clap eyes on the patient!patient!

AnalgesiaAnalgesia

Vital signs, Vital signs, general appearancegeneral appearance

Examination iiExamination iiAbdominal Abdominal

examinationexamination InspectionInspection movementmovement

scarsscars PalpationPalpation signs of peritonitissigns of peritonitis

swellings, massesswellings, massesdistensiondistension

PercussionPercussion AuscultationAuscultation bowel soundsbowel sounds

Signs of peritonitisSigns of peritonitis

TendernessTenderness GuardingGuarding RigidityRigidity Rebound tendernessRebound tenderness

Examination iiiExamination iii

Groins + external genitaliaGroins + external genitalia Rectal examinationRectal examination

UrinalysisUrinalysis

Investigations for Investigations for diagnosisdiagnosis

UrineUrine BloodBlood WCCWCC

AmylaseAmylase ImagingImaging

erect CXRerect CXRAXRAXRIVUIVUU/SU/SCTCT

Initial managementInitial management

Immediate operationImmediate operation

Resuscitation Resuscitation Emergency operationEmergency operation

ObservationObservationRepeated examinationRepeated examination

Common conditionsCommon conditions

AppendicitisAppendicitis CholecystitisCholecystitis DiverticulitisDiverticulitis PancreatitisPancreatitis Perforated peptic Perforated peptic

ulcerulcer

(Ischaemic gut)(Ischaemic gut)

Renal colic Renal colic

Intestinal Intestinal obstructionobstruction

GI bleedingGI bleeding Ruptured AAARuptured AAA

NSAPNSAP

Investigations for Investigations for managementmanagement

HaemoglobinHaemoglobin U+Es, CreatinineU+Es, Creatinine LFTsLFTs ABGsABGs Contrast x-raysContrast x-rays EndoscopyEndoscopy

(DPL)(DPL)

Central abdominal pain shifting to Central abdominal pain shifting to right iliac fossaright iliac fossa

Anorexia, constipationAnorexia, constipation Low grade feverLow grade fever RIF tendernessRIF tenderness

in ~50% of in ~50% of cases!cases!

Appendicitis!Appendicitis!

2 -3 day history2 -3 day history RUQ pain radiating to back / RUQ pain radiating to back /

shouldershoulder Vomiting, feverVomiting, fever

FebrileFebrile RUQ tenderness +/- Murphy’s signRUQ tenderness +/- Murphy’s sign

Elderly patientElderly patient Lower abdominal / LIF pain Lower abdominal / LIF pain FeverFever +/- altered bowel +/- altered bowel

habithabit

FeverFever LIF peritonitisLIF peritonitis

Severe upper abdominal painSevere upper abdominal painradiating to back and flanksradiating to back and flanks

Vomiting++Vomiting++

Dehydrated++Dehydrated++ Generalised peritonitisGeneralised peritonitis

PancreatitisPancreatitis

Severe upper abdominal painSevere upper abdominal pain Sudden onsetSudden onset History of indigestion, NSAID History of indigestion, NSAID

usageusage

Dehydrated, unwell, lying stillDehydrated, unwell, lying still Generalised peritonitisGeneralised peritonitis

Colicky abdominal painColicky abdominal pain VomitingVomiting ConstipationConstipation

absolute constipationabsolute constipation Dehydration, tachycardiaDehydration, tachycardia Abdominal distension, tendernessAbdominal distension, tenderness Scars, herniasScars, hernias

Younger patientYounger patient Colicky loin painColicky loin pain

radiation to groin, genitaliaradiation to groin, genitalia

Well, distressed by painWell, distressed by pain Unremarkable abdominal examUnremarkable abdominal exam Microscopic haematuriaMicroscopic haematuria

Sudden onsetSudden onset Severe back / left loin painSevere back / left loin pain History of hypertensionHistory of hypertension

ShockShock Absent femoral pulsesAbsent femoral pulses Pulsatile massPulsatile mass

Non-specific Abdominal Non-specific Abdominal PainPain

Very commonVery common Only a small proportion are Only a small proportion are

admittedadmitted

Pain is the predominant symptomPain is the predominant symptom Normal vital signs, investigationsNormal vital signs, investigations

Irritable Bowel SyndromeIrritable Bowel Syndrome

More unusual More unusual conditionsconditions

Rectus sheath haematomaRectus sheath haematoma Abdominal wall herniaAbdominal wall hernia

eg Spigelianeg Spigelian Medical causesMedical causes

PneumoniaPneumoniaMyocardial InfarctionMyocardial InfarctionPulmonary EmbolismPulmonary Embolism


BYBY


OutcomesOutcomes

1. Identify the organs and structures within the peritoneum

2. List four causes of abdominal dysfunction

3. Consider the causes and signs and symptoms of acute intestinal obstruction

4. Discuss vomiting and bowel movement in relation to abdominal dysfunction

5. Consider appendicitis, pancreatitis and peritonitis in relation to their effects upon the peritoneal cavity

.

Kidneys (retro-peritoneal)

Abdominal StructuresAbdominal Structures

Bladder, ureters, urethraCervix

Also:

Intestinal ObstructionIntestinal Obstruction• Partial or complete blockage of the small or large intestine.

The blockage may be mechanical or functional.

Mechanical causes include:

TumoursForeign BodiesImpacted FaecesIschaemia (Volvulus, Interssusception, Hernia, Clot)Inflammatory Bowel Disease

Adhesions

Functional cause:

Ileus – peristalsis stops

Tumour obstructionTumour obstruction

VolvulusVolvulus

Intussusception Intussusception ObstructionObstruction

Ischaemic ObstructionIschaemic Obstruction

Hernia ObstructionHernia Obstruction

.

Adhesions ObstructionAdhesions Obstruction

.

Stages of obstructionStages of obstruction

Simple obstruction

Strangulated obstruction

Close-looped obstruction

©M.Bailey 2002

Problem ProgressionProblem Progression

• Depends upon site of problem

• Early – gas/fluid back-up behind obstruction

• Increased peristalsis / colicky pain/discomfort

• Abdominal distension increases

• Blood supply compromised (due to above), water drawn into bowel

• Sodium/Potassium pulled INTO intestines

• Bacteria activity increase

• Dehydration / Hypovolaemia signs appear

Clinical ManifestationsClinical Manifestations

• Pain / discomfort colicky in nature

• May have swollen abdomen

• May be abdominal guarding

• Nausea / vomiting may be evident

• May have slight fever

• Lack of bowel sounds / bowel movements as condition worsens

Principles of Principles of TreatmentTreatment

• Nil Orally (oral hygiene)

• Strict Input and Output Chart

• Drip and Suck

• Analgesia

• Antibiotics

• Surgical Investigation (Laparotomy then proceed)

VomitingVomiting

• Indicative of a problem developing

• Mucus and bile may be present – suggests upper GI tract obstruction

• Faecal matter/smell from vomit – suggests lower GI tract obstruction

• Risk of inhalation very real in the “ill patient”

• Keep Nil orally, Drip & Suck, Monitor

AppendicitisAppendicitis• General pain in abdomen – localises – RIF – rebound tenderness• May be vomiting and reduced/increased bowel sounds

• May have diarrhoea in the first instance – then nothing

• General Malaise, lethargy

• Low grade pyrexia

Management Principles:

• NBM

• Drip & Suck

• Monitor / Surgery


Many causes

• Digestive enzymes (Amylase) from the pancreas start to eat away at the gland

• Can be life threatening

• Classic symptoms – Pain, nausea/vomiting and fever

• Blood results show High WCC and VERY high Amylase levels

• Management is NBM, Drip & Suck, Antibiotics, Analgesia, Monitor closely

PeritonitisPeritonitis

Two main causes:

Chemical cause:

Perforated GU, Pancreatitis, rupture of bladder, ovary or fallopians

Bacterial cause:

Inflammation of any sort (appendicitis, peptic ulcer, UC, Volvulus, strangulated obstruction, Neoplasm, Stab wound)

• Presentation varies – often weakness, pain, cold and shocked, nausea/vomiting

• Abdominal tenderness with direct/rebound tenderness

• Dehydration signs and high temperature are common features©M.Bailey 2002

Management of Management of PeritonitisPeritonitis

NBM

Drip & Suck

Analgesia

Antibiotics (IV usually)

Surgery – lavage with drainage and identify/treat cause

Acute AbdomenAcute Abdomen


General name for presence of General name for presence of signs, symptoms of signs, symptoms of inflammation of peritoneum inflammation of peritoneum (abdominal lining)(abdominal lining)


Determining exact cause Determining exact cause irrelevant in pre-hospital careirrelevant in pre-hospital care

Important factor is recognizing Important factor is recognizing acute abdomen is presentacute abdomen is present

HistoryHistory

Where do you hurt?Where do you hurt?– Know locations of major organsKnow locations of major organs– But realize abdominal pain locations But realize abdominal pain locations

do not correlate well with sourcedo not correlate well with source

HistoryHistory

What does pain feel like?What does pain feel like?– Steady pain - inflammatory processSteady pain - inflammatory process– Crampy pain - obstructive processCrampy pain - obstructive process

HistoryHistory

Was onset of pain gradual or Was onset of pain gradual or sudden?sudden?– Sudden = perforation, hemorrhage, Sudden = perforation, hemorrhage,

infarctinfarct– Gradual = peritoneal irrigation, Gradual = peritoneal irrigation,

hollow organ distensionhollow organ distension

HistoryHistory

Does pain radiate (travel) Does pain radiate (travel) anywhere?anywhere?– Right shoulder, angle of right Right shoulder, angle of right

scapula = gall bladderscapula = gall bladder– Around flank to groin = kidney, Around flank to groin = kidney,

ureterureter

HistoryHistory

Duration?Duration?– > 6 hour duration = ? surgical significance> 6 hour duration = ? surgical significance

Nausea, vomiting? Bloody? “Coffee Nausea, vomiting? Bloody? “Coffee Grounds”?Grounds”?

Any blood in GI tract = Emergency until proven otherwise

HistoryHistory

Change in urinary habits? Urine Change in urinary habits? Urine appearance?appearance?

Change in bowel habits? Change in bowel habits? Appearance of bowel movements? Appearance of bowel movements? Melena?Melena?

HistoryHistory

Regardless of underlying cause Regardless of underlying cause vomiting or diarrhea can be a vomiting or diarrhea can be a problem because of associated problem because of associated volume lossvolume loss

HistoryHistory

FemalesFemales– Last menstrual period? Last menstrual period? – Abnormal bleeding? Abnormal bleeding?

In females, abdominal pain = Gyn problem until proven otherwise

Physical ExamPhysical Exam

General AppearanceGeneral Appearance– Lies perfectly still Lies perfectly still inflammation, inflammation,

peritonitisperitonitis– Restless, writhing Restless, writhing obstruction obstruction

Abdominal distension?Abdominal distension? Ecchymosis around umbilicus, Ecchymosis around umbilicus,

flanks?flanks?


Vital signsVital signs– TachycardiaTachycardia ? Early shock (more ? Early shock (more

important than BP)important than BP)– Rapid shallow breathingRapid shallow breathing peritonitis peritonitis

Tilt test should be done with non-traumatic abdominal pain


Palpate each quadrantPalpate each quadrant– Work toward area of painWork toward area of pain– WarmWarm handshands– Patient on back, knee bent (if Patient on back, knee bent (if

possible)possible)– Note tenderness, rigidity, Note tenderness, rigidity,

involuntary guarding,voluntary involuntary guarding,voluntary guarding, massesguarding, masses


Bowel SoundsBowel Sounds– Listen 1 minute in each quadrantListen 1 minute in each quadrant– Listen Listen beforebefore feeling feeling– Absent bowel sounds Absent bowel sounds ileus, ileus,

peritonitis, shockperitonitis, shock

Auscultating bowel sounds has no pre-hospital value in trauma patients

ManagementManagement

AirwayAirway High concentration OHigh concentration O22

Anticipate vomitingAnticipate vomiting Anticipate hypovolemiaAnticipate hypovolemia Nothing by mouthNothing by mouth No analgesics, sedativesNo analgesics, sedatives

ManagementManagement

In In adults > 30adults > 30, consider possibility , consider possibility of referred of referred cardiac paincardiac pain..

In In femalesfemales, consider possible gyn , consider possible gyn problem, especially problem, especially tubal ectopictubal ectopic pregnancypregnancy

AppendicitisAppendicitis

Usually due to obstruction with Usually due to obstruction with fecalithfecalith

Appendix becomes swollen, Appendix becomes swollen, inflamed gangrene, possible inflamed gangrene, possible perforationperforation

AppendicitisAppendicitis

Pain begins periumbilical; moves to Pain begins periumbilical; moves to RLQRLQ

Nausea, vomiting, anorexiaNausea, vomiting, anorexia Patient lies on side; right hip, knee Patient lies on side; right hip, knee

flexedflexed Pain may Pain may notnot localize to RLQ if localize to RLQ if

appendix in odd locationappendix in odd location Sudden relief of pain = possible Sudden relief of pain = possible

perforationperforation

Duodenal Ulcer Duodenal Ulcer DiseaseDisease Steady, well-localized epigastric Steady, well-localized epigastric

painpain ““Burning”, “gnawing”, “aching”Burning”, “gnawing”, “aching” Increased by coffee, stress, spicy Increased by coffee, stress, spicy

food, smokingfood, smoking Decreased by alkaline food, Decreased by alkaline food,

antacidsantacids

Duodenal Ulcer Duodenal Ulcer DiseaseDisease May cause massive GI bleedMay cause massive GI bleed Perforation = intense, steady Perforation = intense, steady

pain, pt lies still, rigid abdomenpain, pt lies still, rigid abdomen

Kidney StoneKidney Stone

Mineral deposits form in kidney, move Mineral deposits form in kidney, move to ureterto ureter

Often associated with history of recent Often associated with history of recent UTIUTI

Severe flank pain radiates to groin, Severe flank pain radiates to groin, scrotumscrotum

Nausea, vomiting, hematuriaNausea, vomiting, hematuria Extreme restlessnessExtreme restlessness

Abdominal Aortic Abdominal Aortic AneurysmAneurysm Localized weakness of blood Localized weakness of blood

vessel wall with dilation (like vessel wall with dilation (like bubble on tire)bubble on tire)

Pulsating mass in abdomenPulsating mass in abdomen Can cause lower back painCan cause lower back pain Rupture shock, exsanguinationRupture shock, exsanguination


Inflammation of pancreasInflammation of pancreas Triggered by ingestion of EtOH; large Triggered by ingestion of EtOH; large

amounts of fatty foodsamounts of fatty foods Nausea, vomiting; abdominal Nausea, vomiting; abdominal

tenderness; pain radiating from upper tenderness; pain radiating from upper abdomen straight through to backabdomen straight through to back

Signs, symptoms of hypovolemic Signs, symptoms of hypovolemic shockshock

CholecystitisCholecystitis

Inflammation of gall bladderInflammation of gall bladder Commonly associated with gall stonesCommonly associated with gall stones More common in 30 to 50 year old More common in 30 to 50 year old

femalesfemales Nausea, vomiting; RUQ pain, Nausea, vomiting; RUQ pain,

tenderness; fevertenderness; fever Attacks triggered by ingestion of fatty Attacks triggered by ingestion of fatty

foodsfoods

Bowel ObstructionBowel Obstruction

Blockage of inside of intestineBlockage of inside of intestine Interrupts normal flow of contentsInterrupts normal flow of contents Causes include adhesions, Causes include adhesions,

hernias, fecal impactions, tumorshernias, fecal impactions, tumors Crampy abdominal pain; nausea, Crampy abdominal pain; nausea,

vomiting (often of fecal matter); vomiting (often of fecal matter); abdominal distensionabdominal distension

Esophageal VaricesEsophageal Varices

Dilated veins in lower part of Dilated veins in lower part of esophagusesophagus

Common in EtOH abusers, Common in EtOH abusers, patients with liver diseasepatients with liver disease

Produce massive upper GI bleedsProduce massive upper GI bleeds


BYBY


Visceral PainVisceral Pain

To fully understand the patient’s To fully understand the patient’s complaint during a acute episode of complaint during a acute episode of abdominal pain the examiner must abdominal pain the examiner must possess a good understanding of the possess a good understanding of the neurophysiology and anatomy of painneurophysiology and anatomy of pain

Visceral pain reaches the central nervous Visceral pain reaches the central nervous system by three routes:system by three routes:– The parasympathetic nervesThe parasympathetic nerves– The sympathetic nervesThe sympathetic nerves– The somatic nervesThe somatic nerves

AnatoAnatomy and my and PhysiolPhysiology of ogy of VisceraVisceral Painl Pain

Multiple Faces of PainMultiple Faces of Pain

Pain can be characterized as:Pain can be characterized as:– SharpSharp– StabbingStabbing– BurningBurning– HeavyHeavy– DiffuseDiffuse– DullDull

Clinical ConsiderationsClinical Considerations

The patient with acute abdominal The patient with acute abdominal pain requires a thorough and pain requires a thorough and complete history and physical complete history and physical examination by an examination by an unhurriedunhurried examinerexaminer

It is important to assess the It is important to assess the clinical situation in detail including clinical situation in detail including pertinent laboratory studiespertinent laboratory studies

HistoryHistory

PainPain– The examiner should elicit the time of The examiner should elicit the time of

onset, its location and whether a change in onset, its location and whether a change in character occurs with various positionscharacter occurs with various positions

– The exact situation in which the onset of The exact situation in which the onset of pain occurs may be important in pain occurs may be important in establishing the diagnosisestablishing the diagnosis

– The original location of pain and its The original location of pain and its shifting or changing in position may shifting or changing in position may provide a clue to the diagnosisprovide a clue to the diagnosis

HistoryHistory

VomitingVomiting– May result from severe painMay result from severe pain– May be related to the GI tractMay be related to the GI tract– Almost always occurs with obstruction of the Almost always occurs with obstruction of the

small intestine (and provides temporary relief)small intestine (and provides temporary relief)– The timing of emesis to pain may provide The timing of emesis to pain may provide

important diagnostic cluesimportant diagnostic clues– The character of emesis, including the volume, The character of emesis, including the volume,

color and content is pertinent in regard to color and content is pertinent in regard to bowel obstructionbowel obstruction

HistoryHistory

AnorexiaAnorexia– Is uncommon for patients with acute Is uncommon for patients with acute

abdominal pain to desire foodabdominal pain to desire food– May precede the onset of painMay precede the onset of pain

HistoryHistory

BowelsBowels– Constipation, diarrhea and a recent Constipation, diarrhea and a recent

change in bowel habits are change in bowel habits are important in the diagnosis of important in the diagnosis of patients with abdominal painpatients with abdominal pain

– The failure to pass flatus associated The failure to pass flatus associated with cramping pain and vomiting with cramping pain and vomiting strongly supports mechanical strongly supports mechanical obstructionobstruction

HistoryHistory

MenstruationMenstruation– An accurate menstrual history is An accurate menstrual history is

especially valuable in the especially valuable in the assessment of abdominal pain in the assessment of abdominal pain in the femalefemale

– Any change in the volume of Any change in the volume of menstrual flow is also pertinentmenstrual flow is also pertinent

HistoryHistory

Past illnessesPast illnesses– Past illnesses especially previous Past illnesses especially previous

abdominal operations is importantabdominal operations is important– Any history of similar pain in the Any history of similar pain in the

pastpast


Should start with the patient’s Should start with the patient’s appearance, body posture and appearance, body posture and degree of obvious paindegree of obvious pain

Inspection, auscultation, Inspection, auscultation, palpation and percussionpalpation and percussion

Diagnostic ImagingDiagnostic Imaging

Flat and upright abdominal films (the most Flat and upright abdominal films (the most common first step)common first step)– AirAir– Calcific densities (stones, eggshell)Calcific densities (stones, eggshell)– Mechanical obstruction / ileusMechanical obstruction / ileus

UltrasonographyUltrasonography CT scanCT scan Specific organ studiesSpecific organ studies

– IVPIVP– HIDAHIDA

AngiographyAngiography

Laboratory StudiesLaboratory Studies

The results obtained from laboratory The results obtained from laboratory information may or may not play a information may or may not play a significant role in the decision for significant role in the decision for operationoperation– Complete blood countComplete blood count– UrinalysisUrinalysis– Serum amylase and lipaseSerum amylase and lipase– Liver function studiesLiver function studies– HCGHCG– Serum electrolytesSerum electrolytes

PeritonitisPeritonitis

Patients with abdominal pain may show Patients with abdominal pain may show tenderness to palpation of the abdomentenderness to palpation of the abdomen

If peritoneal irritation exist they have If peritoneal irritation exist they have rebound tendernessrebound tenderness

Localized inflammation of the anterior Localized inflammation of the anterior parietal peritoneum may lead to voluntary parietal peritoneum may lead to voluntary muscle guardingmuscle guarding

An inflammatory response may involve the An inflammatory response may involve the entire intra-abdominal cavity or only a entire intra-abdominal cavity or only a portion of either the visceral or parietal portion of either the visceral or parietal peritoneumperitoneum

Peritonitis (Continued)Peritonitis (Continued)

Primary or spontaneous peritonitisPrimary or spontaneous peritonitis– Caused by bacterial infection without an apparent Caused by bacterial infection without an apparent

intra-abdominal source of infectionintra-abdominal source of infection– There are different common bacteria for adults There are different common bacteria for adults

and childrenand children Secondary peritonitisSecondary peritonitis

– Caused as a result of bacterial contamination Caused as a result of bacterial contamination from a known source within the abdomen from a known source within the abdomen (perforation or trauma)(perforation or trauma)

Chemical peritonitisChemical peritonitis– Inflammation from substances other than bacteria Inflammation from substances other than bacteria

(gastric contents) bacterial infection soon follows(gastric contents) bacterial infection soon follows

Signs and Symptoms Signs and Symptoms of Peritonitisof Peritonitis

Usually associated with the abrupt onset of Usually associated with the abrupt onset of abdominal pain, often localized at first and then abdominal pain, often localized at first and then spreading throughout the abdomenspreading throughout the abdomen

The physical findings depend on etiology and The physical findings depend on etiology and duration and whether the process is diffuse or duration and whether the process is diffuse or localizedlocalized

Fever is usually present early and may disappearFever is usually present early and may disappear The abdomen is usually distended with hypoactive The abdomen is usually distended with hypoactive

bowel soundsbowel sounds Tenderness to percussion and palpation is present Tenderness to percussion and palpation is present

in all four quadrantsin all four quadrants

Signs and Symptoms Signs and Symptoms of Peritonitis of Peritonitis (Continued)(Continued) Early recognition of peritoneal Early recognition of peritoneal

irritation is importantirritation is important Management includesManagement includes

– NG tubeNG tube– Restoration of volumeRestoration of volume– Insertion of Foley catheterInsertion of Foley catheter– Intravenous antibiotics (broad Intravenous antibiotics (broad

spectrum)spectrum)– Hemodynamic monitoring (Swan)Hemodynamic monitoring (Swan)

Organ Subsystem Organ Subsystem AnalysisAnalysis

GastrointestinalGastrointestinal RenalRenal GynecologicGynecologic VascularVascular CardiacCardiac

NeurologicNeurologic HematologicHematologic MetabolicMetabolic PulmonaryPulmonary MusculoskeletalMusculoskeletal

Gastrointestinal Gastrointestinal SubsystemSubsystem The most common cause of acute The most common cause of acute

abdominal pain in the gastrointestinal abdominal pain in the gastrointestinal system is associated with an system is associated with an inflammatory or mechanical process of inflammatory or mechanical process of the:the:– StomachStomach– Small and large intestineSmall and large intestine– GallbladderGallbladder– Common bile ductCommon bile duct– LiverLiver– PancreasPancreas

Perforated Peptic Perforated Peptic UlcerUlcer More commonly results from a duodenal More commonly results from a duodenal

ulcer than a gastric ulcerulcer than a gastric ulcer Commonly seen in males between the Commonly seen in males between the

third and fourth decade of lifethird and fourth decade of life Manifest as sudden, sharp, severe pain Manifest as sudden, sharp, severe pain

located first in the epigastrium and later located first in the epigastrium and later over the entire abdomenover the entire abdomen

Nausea is frequent however vomiting is an Nausea is frequent however vomiting is an unusual occurrenceunusual occurrence

The patient usually lies in the supine The patient usually lies in the supine position avoiding any undue motionposition avoiding any undue motion

Perforated Peptic Perforated Peptic Ulcer (Continued)Ulcer (Continued)

Respirations are shallow (the patient avoids deep Respirations are shallow (the patient avoids deep breathing or coughing) breathing or coughing)

Palpation of the abdomen reveals a firm Palpation of the abdomen reveals a firm appearance (boardlike)appearance (boardlike)

Rebound tenderness is the rule in all four Rebound tenderness is the rule in all four quadrants and is worse in the epigastric region.quadrants and is worse in the epigastric region.

Rectal exam is unremarkableRectal exam is unremarkable White blood counts are usually elevated (12 to White blood counts are usually elevated (12 to

20,000)20,000) Abdominal films demonstrate free air in the Abdominal films demonstrate free air in the

abdomen (75 percent of cases)abdomen (75 percent of cases)

Acute CholecystitisAcute Cholecystitis

Most commonly occurs in females between Most commonly occurs in females between 30-60 years of age with a previous history of 30-60 years of age with a previous history of pregnancypregnancy

Younger patients have a family history of Younger patients have a family history of biliary tract disease biliary tract disease

The usual presentation is a constant dull The usual presentation is a constant dull right upper quadrant painright upper quadrant pain

Nausea and vomiting is common (emesis is Nausea and vomiting is common (emesis is green)green)

The blood pressure is usually not altered and The blood pressure is usually not altered and the heart rate is seldom greater than 100the heart rate is seldom greater than 100

Acute Cholecystitis Acute Cholecystitis (Continued)(Continued) Examination of the abdomen reveals Examination of the abdomen reveals

mild to moderate distention sometimes mild to moderate distention sometimes showing asymmetry(in RUQ)showing asymmetry(in RUQ)

Bowel sounds are hypoactiveBowel sounds are hypoactive Tenderness is maximal in the RUQ with Tenderness is maximal in the RUQ with

deep inspirationdeep inspiration Frequently a mass may be palpated Frequently a mass may be palpated

along the right costal marginalong the right costal margin The White blood count is elevated (10-The White blood count is elevated (10-

13,000)13,000)

Acute Cholecystitis Acute Cholecystitis (Continued)(Continued) Ultrasound can rapidly assess the Ultrasound can rapidly assess the

caliber of the biliary tree, stones or caliber of the biliary tree, stones or their absence, the contents of the their absence, the contents of the gallbladder and its appearancegallbladder and its appearance

HIDA (radioenuclide) studies may HIDA (radioenuclide) studies may assist in the diagnosis when not assist in the diagnosis when not confirmed by ultrasoundconfirmed by ultrasound

CT scan’s play limited role in its CT scan’s play limited role in its diagnosisdiagnosis

Acute PancreatitisAcute Pancreatitis

Presents with sudden onset of severe Presents with sudden onset of severe epigastric pain radiating directly to the back epigastric pain radiating directly to the back and around both costal marginsand around both costal margins

Can be confused with acute perforation of Can be confused with acute perforation of peptic ulcerpeptic ulcer

The disease is associated with biliary tract The disease is associated with biliary tract disease or chronic alcohol intakedisease or chronic alcohol intake

Is usually seen in patients between 30-50 Is usually seen in patients between 30-50 years of ageyears of age

Anorexia, nausea and vomiting are common Anorexia, nausea and vomiting are common (emesis rarely provides significant relief)(emesis rarely provides significant relief)

Acute Pancreatitis Acute Pancreatitis (Continued)(Continued)

Hypotension is rarely evident early in the Hypotension is rarely evident early in the disease but may develop 4-6 hours laterdisease but may develop 4-6 hours later

Abdominal tenderness is usually in the Abdominal tenderness is usually in the epigastric areaepigastric area

Bowel sounds are usually hypoactive or absentBowel sounds are usually hypoactive or absent Classic findings:Classic findings:

– Grey Turner’s signGrey Turner’s sign– Cullens signCullens sign

White blood count is elevated (12-22,000)White blood count is elevated (12-22,000) The key diagnostic test-serum amylaseThe key diagnostic test-serum amylase

Acute AppendicitisAcute Appendicitis

A common cause of abdominal painA common cause of abdominal pain Difficult to dx in patients <3 and >70Difficult to dx in patients <3 and >70 Abd pain usually starts in the epigastrium, Abd pain usually starts in the epigastrium,

gradually migrates to the periumbilical area gradually migrates to the periumbilical area and finally ends in the RLQ (after 6 hrs)and finally ends in the RLQ (after 6 hrs)

Anorexia, nausea and vomiting are all Anorexia, nausea and vomiting are all commoncommon

The abdomen is tender to palpation with The abdomen is tender to palpation with rebound tenderness rebound tenderness

Acute Appendicitis Acute Appendicitis (Continued)(Continued) Retrocecal appendix may cause Retrocecal appendix may cause

only mild abdominal tendernessonly mild abdominal tenderness Abdominal distention is rarely Abdominal distention is rarely

present in the early stagespresent in the early stages Rectal exam yields extreme pain to Rectal exam yields extreme pain to

palpation on the right palpation on the right WBC +/- elevationWBC +/- elevation Ultrasound and CT scan may be Ultrasound and CT scan may be

helpfulhelpful

Differential DiagnosisDifferential Diagnosis

Perforated ulcerPerforated ulcer Acute diverticulitisAcute diverticulitis Ruptured graafian follicleRuptured graafian follicle Ectopic pregnancyEctopic pregnancy PIDPID Renal or ureteral calculiRenal or ureteral calculi

Meckel’s DiverticulaMeckel’s Diverticula

May produce bleeding and May produce bleeding and intestinal obstructionintestinal obstruction

The disease is uncommon but The disease is uncommon but should be considered in patients should be considered in patients with appendicitiswith appendicitis

The diagnosis is made at time of The diagnosis is made at time of operationoperation

Acute DiverticulitisAcute Diverticulitis

Congenital or acquiredCongenital or acquired Results from an inflamed diverticulaResults from an inflamed diverticula Usually involves the left colon (sigmoid)Usually involves the left colon (sigmoid) Presents as LLQ pain, chills and fever Presents as LLQ pain, chills and fever

(101-104)(101-104) Presents with history of constipation but Presents with history of constipation but

anorexia and vomiting are uncommonanorexia and vomiting are uncommon The abdomen is usually slightly The abdomen is usually slightly

distended with LLQ tenderness distended with LLQ tenderness

Acute Diverticulitis Acute Diverticulitis (Continued)(Continued) Bowel sounds - hypoactiveBowel sounds - hypoactive WBC - increased (10-20,000)WBC - increased (10-20,000) Patients sometimes improve with Patients sometimes improve with

medical Tx if this is the case BE medical Tx if this is the case BE should be performed in 4-6 weeks should be performed in 4-6 weeks to R/O colon cancer to R/O colon cancer

Acute Obstruction of Acute Obstruction of the Small Intestinethe Small Intestine

Symptoms are usually sudden, sharp, colicky Symptoms are usually sudden, sharp, colicky abdominal pain that is often periumbilicalabdominal pain that is often periumbilical

Between episodes of pain the patient usually Between episodes of pain the patient usually feels quite wellfeels quite well

Nausea and vomiting occur soon after the onset Nausea and vomiting occur soon after the onset of pain and emesis may relieve the painof pain and emesis may relieve the pain

The color of emesis is green at first (contains bile) The color of emesis is green at first (contains bile) changing to a yellow brown with a feculent odorchanging to a yellow brown with a feculent odor

Inspection of the abdomen can provide important Inspection of the abdomen can provide important diagnostic clues (previous incisions, ventral or diagnostic clues (previous incisions, ventral or inguinal hernia or peristaltic waves)inguinal hernia or peristaltic waves)

Acute Obstruction of Acute Obstruction of the Small Intestine the Small Intestine (Continued)(Continued) Abdominal distention does not occur with Abdominal distention does not occur with

obstruction of the proximal jejunum but is obstruction of the proximal jejunum but is common with distal jejunum or ileal common with distal jejunum or ileal obstructionsobstructions

Auscultation of the abdomen reveals Auscultation of the abdomen reveals hyperactive bowel soundshyperactive bowel sounds

Visible peristaltic waves can be seen in Visible peristaltic waves can be seen in patients with distal obstructionpatients with distal obstruction

Laboratory data reveals an increase Laboratory data reveals an increase hematocrit due to dehydration. The white hematocrit due to dehydration. The white blood cell count is elevated (12-20K)blood cell count is elevated (12-20K)

Acute Obstruction of Acute Obstruction of the Small Intestine the Small Intestine (Continued)(Continued) Supine and erect abdominal films Supine and erect abdominal films

are most helpful in mid to distal SBOare most helpful in mid to distal SBO Barium contrast studies is valuable Barium contrast studies is valuable

in confirming the diagnosis and in confirming the diagnosis and upper obstructionsupper obstructions

Ultrasonography may also be of Ultrasonography may also be of benefitbenefit

Paralytic ileus vs. mechanical Paralytic ileus vs. mechanical obstructionobstruction

Most Common Causes Most Common Causes of Abdominal Pain of Abdominal Pain Secondary to Secondary to Obstructing Lesions of Obstructing Lesions of the Gastrointestinal the Gastrointestinal TractTract Jejunum and ileumJejunum and ileum

– MalignancyMalignancy– VolvolusVolvolus– AdhesionsAdhesions– IntussusceptionIntussusception

ColonColon– MalignancyMalignancy– Volvolus-cecal or sigmoidVolvolus-cecal or sigmoid– DiverticulitisDiverticulitis

Acute Obstruction of Acute Obstruction of the Large Intestinethe Large Intestine Occurs more often in patients older than 40Occurs more often in patients older than 40 Patients sometime complain of progressive Patients sometime complain of progressive

constipation (over several months) with or constipation (over several months) with or without thin pencil size stools streaked with without thin pencil size stools streaked with blood (distal colon)blood (distal colon)

Is gradual in onset and presents as Is gradual in onset and presents as constipation with abdominal distentionconstipation with abdominal distention

Pain is minimal or absent unless peritonitis Pain is minimal or absent unless peritonitis occursoccurs

Nausea and vomiting do not usually occur Nausea and vomiting do not usually occur until the later stages of diseaseuntil the later stages of disease

Acute Obstruction of Acute Obstruction of the Large Intestine the Large Intestine (Continued)(Continued) The abdomen appears distended The abdomen appears distended

and tympanic to percussionand tympanic to percussion Rectal exam is usually Rectal exam is usually

unremarkableunremarkable Laboratory studies-hematocrit and Laboratory studies-hematocrit and

WBC are usually normalWBC are usually normal Diagnosis can usually be made by Diagnosis can usually be made by

supine and erect abdominal filmssupine and erect abdominal films

Ruptured Abdominal Ruptured Abdominal Aortic AneurysmAortic Aneurysm Almost always presents as abdominal Almost always presents as abdominal

painpain With acutely expanding aneurysms With acutely expanding aneurysms

patients can present with a history of patients can present with a history of back pain for several daysback pain for several days

Physical exam demonstrates a Physical exam demonstrates a pulsatile midline abdominal masspulsatile midline abdominal mass

Abdominal films may demonstrate a Abdominal films may demonstrate a calcified “eggshell” aortacalcified “eggshell” aorta

Abdominal ultrasound can be helpfulAbdominal ultrasound can be helpful

Gynecologic DiseaseGynecologic Disease

Is a common cause of acute Is a common cause of acute abdominal painabdominal pain

A thorough history and complete A thorough history and complete pelvic and rectal exam is importantpelvic and rectal exam is important

Plain films of the abdomen usually Plain films of the abdomen usually are not helpfulare not helpful

Pelvic ultrasound is the diagnostic Pelvic ultrasound is the diagnostic examination of choiceexamination of choice

Acute SalpingitisAcute Salpingitis Most commonly due to gonococcal infectionMost commonly due to gonococcal infection Usually seen in the 15-35 year age groupUsually seen in the 15-35 year age group Pain is usually at the pubic symphysis (midline) Pain is usually at the pubic symphysis (midline)

and radiates to the right and left lower quadrantsand radiates to the right and left lower quadrants The pain usually does not have gastrointestinal The pain usually does not have gastrointestinal

complaintscomplaints Bowel sounds are hypoactiveBowel sounds are hypoactive Cervical tenderness is severeCervical tenderness is severe A vaginal discharge is frequent and diagnostic A vaginal discharge is frequent and diagnostic

when culturedwhen cultured

Ovarian TumorOvarian Tumor

Pain is usually sudden and Pain is usually sudden and located in either right or left lower located in either right or left lower abdomen depending on which abdomen depending on which ovary is involvedovary is involved

Pelvic examination is the key Pelvic examination is the key diagnostic maneuver, a palpable diagnostic maneuver, a palpable mass may confirm the suspicionmass may confirm the suspicion

Ectopic PregnancyEctopic Pregnancy May present as a sudden lower abdominal May present as a sudden lower abdominal

pain that is sharp persistent, with or without pain that is sharp persistent, with or without nausea and vomitingnausea and vomiting

Usually occurs during the first trimesterUsually occurs during the first trimester The patient’s history is the most important The patient’s history is the most important

factor in the diagnosisfactor in the diagnosis After rupture peritonitis insurersAfter rupture peritonitis insurers The pain worsens with timeThe pain worsens with time If blood loss is significant hypotension and If blood loss is significant hypotension and

tachycardia may developtachycardia may develop

Ectopic Pregnancy Ectopic Pregnancy (Continued)(Continued) Pelvic examination may demonstrate Pelvic examination may demonstrate

blood in the vagina or cervical osblood in the vagina or cervical os Motion to the cervix is painful and an Motion to the cervix is painful and an

adnexal mass is often palpableadnexal mass is often palpable The cervix is frequently blueThe cervix is frequently blue Laboratory data-hematocrit is low, Laboratory data-hematocrit is low,

WBC is slightly increased and HCG is WBC is slightly increased and HCG is positivepositive

The simplest and most accurate study The simplest and most accurate study is ultrasoundis ultrasound

Nonsurgical Causes of Nonsurgical Causes of the Acute Abdomenthe Acute Abdomen Bacterial peritonitisBacterial peritonitis Sickle cell anemiaSickle cell anemia GastroenteritisGastroenteritis Pseudomembranous colitisPseudomembranous colitis Lead poisoningLead poisoning Acute porphyriaAcute porphyria Right or left lower lobe pneumoniaRight or left lower lobe pneumonia Myocardial infarctionMyocardial infarction

The EndThe End

acute abdomen

Health & Medicine