APPROACH TO ACUTE ABDOMEN

What It Is

ACUTE ABDOMEN- acute attack of abdominal pain that may be sudden or gradual, with other symptoms

Denotes an underlying disorder that requires immediate attention and possibly surgical intervention

Careful history and examintaion, early diagnosis and treatment is crucial

Causes of Acute Abdomen

INTRA-ABDOMINAL / EXTRA-ABDOMINAL

Intra-abdominal1) Inflammation- acute appendicitis, acute cholecystitis, acute

salpingitis, amoebic liver abcess, acute pneumoccal peritonitis

2) Perforation- of peptic ulcer, typhoid ulcer, ulcerative colitis

3) Acute Intestinal Obstruction –

A) Mechanical- (i) in the lumen- gallstone, round worms

(ii) in the wall- tubercular stricture, intussception, growths

(iii) outside the wall- volvulus, external and internal hernia

B) Toxic – paralytic ileus

C) Neurogenic – Hirschsprungs’s

D) Vascular – Occlusion of mesentric vessels by embolism or thrombosis

4) Haemorrhage – spontaneous rupture of malarial spleen, rupture of ectopic gestation, ruptured lutein cyst

5) Tortion of pedicle- twisted of ovarian cyst, spleen

6) Colic – biliary, ureteric, appendicular, intestinal.

Extra-Abdominal

1. Parietal conditions: gas gangrene of the abdominal wall, abscess of the abdominal wall, rupture of rectus abdominus, superficial cellulitis of the abdominal wall

2. Thoracic conditions: lobar pneumonia, spontaneous pneumothorax, angina, pericarditis

3. Retro-peritoneal conditions- uremia, pyelitis, dissecting anwurysm of aorta

4. Diseases of spine, spinal cord, and intercostal nerves: pott’s disease, acute osteomyelitis, herpes zoster, tabes dorsalis

5. General diseases: malaria, typhoid, sickle cell anemia, purpura

HISTORY AND

EXAMINATION

HISTORY

Age Sex Occupation Social status

HISTORY: chief complaints

PAIN Time of onset: acute appendicitis, peptic ulcer Mode of onset: perforation, colic, torsion - sudden acute intestinal obstruction- gradual increase acute appendicitis- sudden increase Duration: periodicity, varying intensity Site of pain: pointing test flank- renal right costal margin- liver or gallbladder epigastric- perforation, pancreatitis Shifting: acute appendicitis- umbilicus to right iliac fossa due to parietal peritonitis Radiation: peptic perforation, spreading peritonitis Referred pain: epigastrium, around the umbilicus, hypogastrium, shoulder, loin to groin,

scapula Character of pain: colicky, constant burning pain, severe agonising pain, throbbing pain,

change in character of pain Pressure on pain Aggravating and relieving factors: jolting, walking, respiration, micturition (strangury),

lying still, fatty foods, alkalis, stooping, vomiting

VOMITING Character- projectile/regurgitation Vomitus- intestinal obstruction,

gastrocolic fistula, biliary colic, peptic ulcer, peritonitis and uremia

Frequency and quantity- frequent/periodical, nausea characteristic of appendicitis

With respect to pain: appendicitis, pancreatitis, colic, in high obstruction

BOWEL HABITS Constipation-obstruction,

appendicitis, peritonitis Tenesmus- pelvic appendicitis,

abcess, rectum Diarrhoea- colitis, acute enteritis,

ileitis

MICTURITION Strangury Hematuria – retrocaecal appendicitis

PERSONAL HISTORY

Menstrual history Smoking alcohol

PAST HISTORY: Previous operations Jaundice Malaena/hematochezia Previous episodes of pain Drug history Family history Travel history

General examination

Appearance Attitude Pulse Respiration Temperature tongue

inspection- Contour: - Scaphoid or flat in peptic ulcer- Distended in ascites or intestinal obstruction- Visible peristalsis: in a thin or malnourished

patient (with obstruction)-laddar pattern- Respiration-sluggish in peritonitis- Pulsating swelling- aneurysm- Skin discoloration- grey turner’s sign and

Cullen’s sign

palpation

Cutaneous hyperaesthesia

Either lift the skin or stimulate the skin with gentle jabbing with a sterile pinIndicates a zone of peritoneal irritation

RLQ -- appendicitisMid Epigastrium -- peptic ulcer

Tenderness

Degree and extent Bed-shaking test(Bapat)-peritonitis Spread Appendicular tenderness in left

lateral position

Rebound tenderness

Apply firm pressure for several seconds to the abdomen with hand at right angles and fingers extended Quickly release the pressure Test away from site where pain is initially determined

Pain at site is direct rebound tenderness

Pain at another site is referred rebound tenderness

Indicative of peritoneal inflammation

Rovsing’s sign

Press in the LLQ evenly for 5 seconds and note if patient has pain in RLQ – positive- Gas is pushed through the ileocecal valve thus distending the cecum-In acute appendicitis- positive

Cope’s Psoas Test Place your hand over the right thigh

and push downward as the patient is trying to raise the leg, flexing the hip

Positive RLQ pain associated with a retrocaecal or perforated appendicitis

Obturator Test

Flex the right leg at the hip and knee at a right angle then rotate the leg internally and externally

Pain indicative of inflammatory process over obturator muscle Ruptured appendix Pelvic abscess

Muscle Guarding Use both hands -- one on each rectus Check for tensing during expiration When positive it is indicative of

peritoneal irritation -- peritonitis

percussion

Shifting dullness Fluid thrill Obliteration of liver dullness

percussion

auscultation

Auscultation BS > 2min to confirm absent High pitched, hyperactive or tinkling Bruit in epigastrium Noisy abdomen-acute intestinal

obstruction Silent abdomen- peritonitis