The Acute Abdomen

Richard Aitken, DM General Surgery UHWI,Consultant General Surgeon KPH

Definition

• “Any sudden spontaneous non-traumatic disorder whose chief manifestation is in the abdominal area and for which urgent operation may be necessary”1

1 Gerald Doherty, Current Surgical diagnosis and Treatment, pg 503, 2003.

Symptoms

• Acute Abdominal Pain• Other associated Symptoms

– Vomiting– Distention– Alterations in Bowel Movement– Urinary Symptoms– Gynecologic

1 Rozycki GS, et al. J Trauma 19932 Rozycki GS, et al. J Trauma 19953 Ma OJ, et al J Trauma 1995

Abdominal Anatomy

Abdominal Anatomy

• Peritoneal cavity divided into greater and lesser sac– Connected by epiploic

foramen

• Greater sac divided into supramesocolic and inframesocolic (pelvis) compartments

From: Gray, H. Anatomy of the Human Body 20th ed. 2000

Abdominal Anatomy

• Paracolic gutters connect supramesocolic spaces with pelvis

• Right connects hepatorenal

• Left connects subphrenic and splenorenal– Obstructed by

phrenicocolic ligament

From: Gray, H. Anatomy of the Human Body 20th ed. 2000

Abdominal Contents

• Esophagus• Stomach• Duodenum• Liver• Biliary System• Pancreas• Kidneys/adrenals• Aorta/IVC• Spleen

• Small Intestine• Large intestine• Ureters/Bladder• Uterus/Ovaries/Tubes• Prostate/Urethra• Diaphragm/Abd wall• Retroperitoneum• Spinal column• Peritoneum

Pain vs Tenderness

• Based on abdominal innervation:– Visceral Pain

• Sense stretching and ischemia only

• mediated via Visceral Afferent fibers

– Follow the blood supply

– Difuse, not mapped 1:1 on sensory cortex

Pain and Tenderness(continued)

• Tenderness– Somatic Afferent

Innervation• Parietal peritoneum

• Abdominal Wall

– Precisely mapped on sensory cortex

Common Abdominal Conditions

• Appendicitis

• Cholecystitis/Biliary Colic

• Small Bowel Obstruction

• Perforated Peptic Ulcer

• Pancreatitis

• Constipation/Gastroenteritis

• Gastritis/PUD

• Gynecological Pathology

Causes of the Acute Abdomen

• Gynecologic Pathology– Pelvic inflammatory disease– Ectopic pregnancy– Ovarian Pathology– Uterine fibroids– Dysmenorrohea

Causes of the Acute Abdomen

• Inflammatory bowel disease

• Mesenteric adenitis• Aortic aneurysm• Mesenteric

thrombosis/ischemia• Hepatitis• Liver abscess• Splenic infarct• Renal colic

• Pyelonephritis• Intraabdominal abscess• Primary Peirtonitis• Volvulus of bowel• Many more• Including Medical

causes and extraabdominal pathology

Management Strategy

• Make a Diagnosis of cause within a reasonable time (24 hrs)

• Stability of patient/suspected cause determines how long we are willing to wait for Investigation/Observation

• Tailored Ix

• Final arbiter may have to be laparotomy/Laparoscopy

Management Strategy

• History

• Physical examination

• Resuscitation

• Tailored Investigations

• Diagnosis

• Treatment + or - Laparotomy

History

• Pain

• Associated Symptoms– Vomiting, diarrhoea, constipation, distension– Jaundice, fever, wt loss, bleeding per orifice

• PMH

• Menstrual Hx

• Drug Hx

• Family Hx

Pain

• Location

• Character

• Intensity

• Periodicity

• Radiation

• Relieving / Aggravation factors

Physical Examination

• General Obs

• Systemic signs / Vital signs

• Fever

• Abdominal signs– Inspection– Auscultation– Palpation– Percussion– Rectal Digital / Vaginal Ex

Investigation

• Urinalysis

• Bhcg

• Blood Studies

• Abd/C-xrays

• Abd U/S

• CT scan

• Other eg IVU , Contrast studies, Endoscopy

Pneumoperitoneum

Gallstones

Intestinal Obstruction

AAA

Bodypacker

Tongue Ornament Misadventure

Management/Resuscitation

• NG tube

• Urinary catheter

• IV line – Fluid, blood studies, cross-match

• Pain Mx

• Antibiotics?

• Definitive Mx determined by Stability and Diagnosis