Evaluation of Acute Abdomen

By

Dr. Conrad D’Costa, MS, DNB (Senior House Officer)

Mr.Sudhir Jain,MS,FRCS,FACS,(Specialist Registrar Surgery)

North Middlesex University Hospital,London

Acute Abdomen

• Challenge to Surgeons & Physicians• Most common cause of surgical

emergency admission• Clinical course can vary from 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

ASSESMENT

• Well elicited history• Proper physical examination Diagnosis can be made most of Diagnosis can be made most of

the time by a good history and a the time by a good history and a proper physical examination.proper physical examination.

Assesment(cont.)

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

PAIN

• The Most Important SymptomHistory of pain should include:1. Onset2. Severity3. Type of pain4. Radiation of Pain5. Change in nature of Pain6. Associated bowel or urinary symptoms7. 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 Intestinal colic

(ii) Progression of Pain

Progression from: Dull, aching, poorly localized character

To:Sharp, constant & better localized painindicates involvement of Parietal peritoneum

(iii) Associated Bowel SymptomsCONSTIPATION

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

DIARRHOEADiarrhoea 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 self-induced

(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 (cont.)

• Vomiting is very prominent in a. Mallory-Weiss syndrome. b. Boerhaave syndrome(trans-

mural esophageal tear) c. Acute gastritis d. Acute pancreatitis

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 operations- leading

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 (Mittel- schmerz) (iii) With heavy periods- endometriosis

• Family history of colon cancer, any other malignancy or inflammatory bowel disease

Physical Examination

General Appearancea. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitisb. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colicc. Writhing in Pain: Mesenteric Ischemia

Physical Examination(contd.)

d. Bending Forward: Chronic Pancreatitise. Jaundiced: CBD obstructionf. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

Physical Examination(contd.)

• Vital Charting• Temperature, Pulse, BP, Respiratory

rate• Ruptured AAA or ectopic pregnancy

can lead to -Pallor -Hypotension -Tachycardia -Tachypnea

Physical Examination(contd.)

Low grade temp. is seen with - Appendicitis- Acute cholecystitis

High grade temp. is seen with - Salpingitis- Abscess 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

Systemic Examination

Per Abdomen: Inspection

- Scaphoid or flat in peptic ulcer- Distended in ascites or intestinal

obstruction- Visible peristalsis in a thin or

malnourished patient (with obstruction)

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

• Rovsing’s Sign in Acute Appendicitis

• Obturator Sign in Pelvic Appendicitis

• Psoas Sign - Retrocaecal appendicitis - Crohn’s Disease - Perinephric Abscess

Systemic Examination

• Murphy's sign in Acute Cholecystitis

• Thumping tenderness over lower ribs in inflammation of

-Diaphragm - liver or spleen

Systemic Examination

Pulsatile Abdominal Mass withHypotension Leaking AAACutaneous Hyperaesthesiaindicates involvement of Parietal Peritoneum

Systemic Examination

Per Rectal Examination: - tenderness - induration - mass (Blummer’s 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

Radiology

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

Radiology

Abdominal X ray film

- Air-Fluid Levels- Stones- Ascites- Eggshell calcification in AAA- Air in Biliary tree.- Obliteration of Psoas Shadow in retro-

peritoneal 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

THANK YOU