ACUTE ABDOMENMANAGEMENT APPROACH

DR.M.HAZEM EL-FOLLFRCS-(UK)

Consultant General and Laparoscopic Surgery

Acute AbdomenDefinition And Epidemiology

Undiagnosed Abdominal Pain of less than 7-10 days

duration.

Abdomino-thoracic Trauma is excluded from this

definition.

It accounts for 5-10% of ER visits

It accounts for 1% of all hospital admission.

Most Patients-(70-75%) Discharged after ER

Evaluation.

Only 7-10% of Patients will Require Urgent Surgery

for Life-Threatening Conditions.

SURGICAL CAUSES—SURGICAL ABDOMEN

MEDICAL CAUSES---NON-SURGICAL

ABDOMEN

Acute Abdominal pain

Etio-Pathological Classification:-

Inflammatory/Infective

• Acute Cholecystitis

• Liver Abscess

• Acute Pancreatitis

• Inflammatory Bowel Disease

• Acute Appendicitis

• Acute Diverticulitis

• Meckle's Diverticulitis

• PID-(Salpingitis)/Tubo-ovarian abscess.

• UTI-Acute Pyelonephritis/Acute Cystitis

Perforation

• Perforated Peptic Ulcer Disease

• Perforated Appendicitis/Cholecystitis

• Perforated Small Bowel

• Esophageal Perforation

• Perforated Colon

• Aortic Dissection

Etio-Pathological Classification

Obstruction Infarction Thrombo-embolic

diseases• Acute Intestinal

Ischemia• Renal Infarction• Splenic Infarction GIT-Volvulus Omental Torsion Intussusception Torsion ovarian

cyst/sub-serous fibroid

Intestinal Obstruction

Biliary Colic

Renal Colic

Etio-Pathological ClassificationSpontaneous intra-peritoneal bleeding

Rupture AAA.Rupture visceral A.Aneurysms in

mesenteric; hepatic and renal arteries.Rupture pathologically enlarged spleenRupture Hepatic Tumor.Gynecological causes:-• Ruptured Ectopic pregnancy• Ruptured Ovarian Cyst• Ruptured Graffian's follicles( mid-cycle)• Ruptured Endometriosis.

Medial Causes of Acute Abdominal PainNon-Surgical Abdomen

Intra-Abdominal Conditions

• Gastro-Enteritis.

• Infective Colitis

• Mesenteric Adenitis

• Typhoid Fever

• UTI

• Acute Viral Hepatitis

• Congestive Hepatomegaly

• Liver Tumors

Intra-Thoracic Conditions

• MI

• Basal Lobar Pneumonia

and Lung Abscess

• Pericarditis.

• Spontaneous

Pneumothorax.

Non-Surgical Abdomen

Metabolic Causes

• D-Ketoacidosis• Uremia• Adreno-cortical

Insufficiency• Hypercalcemia• Acute Intermittent

Porphyria.• Heavy Metals

Poisoning

Haematological Diseases

• Haemolytic Crisis of Chronic Haemolytic Anaemia.

• Polycythemia.• Henoch- Schonelein

Purpura.• Lymphoma.• Leukemia.

Non-Surgical Abdomen

Neurological Causes Herpes Zoster-

commonly involving spinal nerves T3-L1.

Spinal cord Compression:-

• Degenerative-Disc Prolapse.

• Metastases. Nerve Entrapment:-• 2-3 localised areas just

medial to linea semilunaris of rectus muscle.

Collagen Diseases SLE.

Polyarteritis Nodosa.

• Abdominal Pain caused by thrombosis of visceral arteries lead to Visceral infarction.

Management Approach

• (I)-Clinical Evaluation:

• Accurate History and Complete Physical

Examination are Essential for Diagnosis

• (II)-Resuscitation and Immediate Diagnostic Tools.

• (III)-Other Investigations-according to clinical

progress of the patient.

History taking

Abdominal pain

Onset; Progression of pain

Duration.

Site of pain: at onset, at present.

Severity.

• Type: intermittent colicky, sharp persistent

Radiation of Pain

Aggravating factors: movement, coughing, food

Relieving factors: position, drug, food

Physiology of Pain-Visceral Pain

• Elicited by distention ;

inflammation of the serous

coat of hollow viscera and

in the capsules of solid

organs.

• Mediated by afferent

autonomic nerve fibres.

• Diffuse; felt in the midline

in regions related to the

embryological

development.

Somatic(Parietal)Pain

• Elicited by direct

irritation/inflammation of

the somatically innervated

parietal peritoneum.

• Mediated by afferent

somatic nerve fibres.

• localised in the

dermatomes supplied by

segmental nerve roots

innervating the parietal

peritoneum.

Referred Pain

• Pain Sensations perceived

at a site distant from that

of a strong primary

stimulus.

• Due to Confluence of

afferent nerve fibers from

widely disparate areas

within the posterior horn

of the spinal cord. This

may cause distorted

central perception of the

site of pain.

In Most causes of Surgical Abdominal pain

• There is insidious onset of pain started diffuse;

dull ach/or gripping pain. In hollow viscus

obstruction; the pain is sever gripping associated

with nausea; vomiting; and sweating; causing the

patient to move around in bed and inability to lie

still. There is no aggravating of relieving factors.

• In Early Inflammatory Processes of Solid Viscera;

there is diffuse dull ache pain

Visceral pain.

Progression of pain-In Inflammatory and Obstructed Causes

• There is progression of pain over several hours;

and change character of pain into sharp localised

stabbing pain. The pain is aggevated by moving;

coughing and relieved by lying still.

Somatic Pain

• There will be associated Abdominal localised

tenderness; rebound; and involuntary muscle

guarding. (Localised Peritonitis.)

In perforation; Strangulation(Infarction);and Spontaneous Bleeding

• The pain is sudden in onset with progression over

minutes to 1-2 hours; into sharp localised

stabbing pain. There will be Localised (Early) / or

Generalised Abdominal tenderness; rebound and

rigidity.

• Shoulder tip and sub-scapular pain; is common

due to blood/or pus in sub-phrenic space.

In Most of Non-Surgical causes of Abdominal Pain

• There will be Diffuse mild dull-ach/or vague

discomfort.

• Vomiting usually precedes the onset of

pain; especially in metabolic causes.

• There will be Diffuse; non-specific

abdominal tenderness. However there will

be NO Rebound tenderness and NO Muscle

Guarding.

Associated symptoms

• Nausea and vomiting

• Indigestion

• Anorexia and weight loss

• Bowel habit

• Urinary Symptoms

• Gynecological Symptoms

Menstrual History-in women in Reproductive age

• Sexual Activity and IUD

• Amenorrhea(Missed period)

• Vaginal Bleeding

• Vaginal Discharge

• Mid-Cycle

Medical History

• Medical Diseases; HTN ; CAD ; AF ; Vascular

Diseases ;Pulmonary Diseases.

• Previous Surgery.

• Current Medications.

• Alcohol and Smoking.

Physical examination

General Examination

• Vital Signs: Pulse ; Temp.; BP.

• Pallor ; Jaundice ; Cyanosis.

• Tongue:-Dry ; Coated ; acetone smell.

• Examination of Cervical LNs.

• Examination of Chest and Heart.

Abdominal Examination General Inspection

• Patient is agitated; the patient moves around in

bed and inability to lie still.= visceral pain.

In hollow viscus obstruction and Strangulation

• Patient is lying motionless in bed=Parietal pain

In Localised/Generalised Peritonitis.

• Patient is Drowsy with decrease

responsiveness .

Haemodynamic Collapse/Sepsis.

Abdominal ExaminationInspection

• Patient should be exposed from nipple to mid-

thigh.

• Abdominal Distension.

• Obvious Abdominal Swelling

• Scar ; Fistula ; Sinus.

• Distended Superficial Veins

• Ecchymosis,Cullen”s and Gray-Turner”s Signs

• Cullen sign Grey-Turner sign

Palpation and PercussionLight and deep palpation.

Start gently and away from reported area of pain. Palpation with pulp of fingers NOT Tips of fingers.

Palpation/Percussion

Rebound tenderness = “Peritoneal irritation can

be elicited by:-

Cough tenderness = Percussion tenderness.

Involuntary Muscle guarding=Peritonitis.

Areas of maximum tenderness.

Detect Organomegaly.

Tympanatic Abdomen.= gas in bowel loops.

Shifting dullness in Ascites.

Auscultation

• High-pitch “tinkling” sound = mechanical

bowel obstruction.

• Hyperactive bowel sounds = Enteritis and

early intestinal ischemia

• No sound within 1-2 min = absent bowel

sounds.

Do Not Forget

Examination of:-

• Hernial Orifices.

• External Genitalia-Testis and Scrotum.

• Examination of the Back of the patient.

PR and PV Examination.

Dip-stick testing of urine for sugar ;

ketone ; blood ; proteins and pus cells.

Resuscitation and Immediate Investigations

Resuscitation

• NPO

• NG-Tube in intestinal obstruction and if there is persistent vomiting.

• IV-Line and Start IV Fluids.

• Analgesia after initial assessment should be given for pain relief.

• Important:-Narcotic analgesia don't mask physical signs or obscure the diagnosis.

• Start broad spectrum IV Antibiotics if Inflammatory Conditions suspected.

• Correction of dehydration and electrolyte imbalance.

• Urinary catheter and monitor the urine output.

Resuscitation-In Critically Ill-Patients

• Air Way and Oxygen Supplement.

• Oxygen Saturation Monitoring

• ABG

• CV-Line ; Volume Replacement.

Laboratory studies

• CBC• Electrolytes• Blood urea nitrogen/creatinine• Amylase / lipase• Serum lactate levels• Liver function test• Pregnancy Test-In all Women in child-

bearing age.• Sickling Test• Blood Group and save the serum.• ECG.

Emergency Abdominal Ultrasonography--:

Detection of acute Cholecystitis; pancreatitis; pancreatic pseudo-cysts; liver abscess Detection of appendicitis/ appendicular abscess; diverticular

abscess; mesenteric cysts; Tubo-ovarian abscess; PID and pelvic abscess.

Useful in pregnant and young female patient (detect pelvic pathology);ovarian cysts ; sub-serous fibroid ;PID.

Diagnosis of suspected AAA. Diagnosis of free intra-peritoneal blood/fluid.

Contrast-enhanced CT-Scan (oral and IV Contrast)

• It is the secondary imaging modality of

choice in the patient with an acute abdomen,

following plain abdominal radiography; as

images not masked by bowel gas and most

surgeons can interpret the findings more

than US.• CT-Scan establishes the diagnosis of acute

abdominal pain in over 95% of cases.

Thick-walled,fluid-filled appendix with surrounding inflammation

Large Appendicular Abscess containing gas.

Acute Pancreatitis--An enlarged pancreas with indefinite border and infiltration of the surrounding fat-(the peri-pancreatic stranding)

Pancreatic Necrosis-- Lack of gland enhancement following IV contrast administration is diagnostic.

Multiple splenic abscess

CT-IV Contrast-Small Bowel Ischemia due to Strangulation

After the initial assessment the patients with acute abdominal pain should be categorized into:

(I)Patients with immediately Life Threatening conditions :-

Patients who need immediate Laparotomy

( Abdominal Crises )

(1)—Massive intra-abdominal bleeding; (Ruptured AAA. or visceral

aneurysms, ruptured ectopic pregnancies, and spontaneous hepatic or

splenic ruptures).

(2)—Acute Intestinal Ischemia with hypovolemia and resistant

acidosis.

(3)-Intra-abdominal sepsis; (due to perforated viscus/or strangulation;

volvulus; Intussusception; strangulated hernia ) ; with high fever;

tachypnea; sweating; frank hypotension; deterioration of mental

state(agitation, disorientation); indicating impending septic shock.

Medical life threatening conditions:-

Myocardial infarction.

Spontaneous tension Pneumothorax.

D-Ketoacidosis .

Acute AD.Cortical Failure.

(II)– Patients with Rapidly Life Threatening conditions.Patients who need; Urgent laparotomy;(with in 4-6H.)

Perforated hollow viscera.

Strangulated Bowel.

Intra-abdominal Abscesses; (Appendicular; and Diverticular);

with free intra-peritoneal perforation and diffuse peritonitis.

Clinical; Laboratory; and Radiological indicators for Urgent

Laparotomy:-

Increasing severe localized tenderness.

Progressive tense abdominal distention.

Spreading Involuntary muscle Rigidity.

High fever, tachycardia, confusion.

Marked Leukocytosis with left shift.

Pneumoperitoneum

(III)-Serious conditions:-that need early planned surgery/or need early supportive treatment and

close monitoring

Appendicitis/appendicular abscess; acute

Cholecystitis/peri-cholecystic abscess; acute

pancreatitis.

Diverticulitis/Diverticular abscess; PID /Tubo-

ovarian abscess; Localised intra-abdominal or

Pelvic abscess.

Small bowel obstruction.

Large bowel obstruction due to: diverticular abscess/ carcinoma

(IV-)Less serious conditions which require conservative treatment

Biliary colic; renal colic.

Inflammatory bowel disease.

Non-specific abdominal pain.

Gastro-enteritis and infective colitis.

UTI.

Un-complicated ovarian cyst and fibroid; and

endometriosis. Mid-ovulatory pain.

Un-complicated Diverticulitis.

Most of Medical causes.

Differential Diagnosis

Differential Diagnosis of patients with Acute Abdominal Pain

Each List Represents > 90-95% of Causes in each Group)

Infants less than one year old

• Infantile Colic.

• Gastro-enteritis.

• Intussusception.

• Incarcerated congenital

hernia

• Constipation.

• UT-Infection.

• Hirschsprung disease.

• Volvulus neonatorum

Children 1-5 years old

Appendicitis.

Non-specific abdominal pain

Intussusception.

Incarcerated congenital

hernia

Gastro-enteritis

UT-Infection

Constipation

Sickle cell crisis

Henoch scheneloin Purpura

Differential Diagnosis of patients with Acute Abdominal Pain

Young and middle age Adult• Appendicitis.

• Acute Cholecystitis.

• Acute Pancreatitis.

• Non-specific abdominal pain.

• Intestinal obstruction.

• Active/Perforated PU.

• UTI.

• Diverticulitis.

• Renal colic

Young and middle age Women• Salpingitis-PID.

• Appendicitis.

• Acute Cholecystitis.

• Acute Pancreatitis.

• Rupture ectopic pregnancy

• Rupture/Torsion Ovarian cyst.

• Mid-ovulatory Pain.

• UTI.

Suppruative Appendicitis

Meckle's Diverticulum

Volvulus of Meckle's Diverticulum

Torsion Ovarian Cyst

Ruptured Ectopic Pregnancy

Acute Cholecystitis

Sigmoid Volvulus.

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Acute Abdominal Pain in Elderly Patients

In Elderly patients >60 years old; after exclusion of the commonest causes of Acute Abdominal Pain; as:-

Acute Cholecystitis ' Acute Pancreatitis; Acute Appendicitis; the patients should be investigated as; they may have colonic obstruction/ perforation due to Colo-rectal carcinoma; diverticular abscess

In patients >70 years old; 10% of patients with Acute Abdominal Pain will have Vascular Accident; Acute Intestinal Ischemia; or MI.

Messages

Accurate History and complete clinical Examination are essential

to put provisional diagnosis/or short list of DD; and to institute

diagnostic tests and to decide if the patient will need urgent

surgery.

It is NOT Important to make specific diagnosis but to detect

Urgent and immediate Life-Threatening conditions.

The diagnosis of acute abdominal pain; particularly in early

stage of presentation is often difficult and is accurate only in 45-

65% of patients. So the patient should be re-examined by the

same physician after resuscitation.

Define Surgical from non-surgical Abdomen. The term Acute

Abdomen should never equate with the invariable need for

surgery.

Analgesia-Make the patient pain-free.

Opioids as (Morphine and Pethidine) don't mask the

physical signs or prevent accurate diagnosis.

The most common surgical diagnosis: -- acute

appendicitis, followed by acute Cholecystitis, small bowel

obstruction, and gynecologic disorders.

A useful rule is never to place appendicitis lower than

second in the differential diagnosis of acute abdominal

pain in a previously healthy person.

Indications of Surgical Consultation:-

(A.)-Severe Progressive Abdominal Pain.

(B.)-Involuntary Abdominal Muscles Guarding/Rigidity.

(C.)-Bile-stained or Faeculent Vomiting.

(D.)-Haemodynamically Instability(Fluid/Blood Loss)-

Signs of hypoperfusion as un-explained acidosis.