Approach to initial assessment; resusscitation; and managment of acute abdominal pain

1. ACUTE ABDOMEN
MANAGEMENT APPROACH
DR.M.HAZEM EL-FOLL
FRCS-(UK)
Consultant General and
Laparoscopic Surgery

2. Acute Abdomen
Definition 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.

3. SURGICAL CAUSES—SURGICAL ABDOMEN
MEDICAL CAUSES---NON-SURGICAL
ABDOMEN
Acute Abdominal pain

4. 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/Cholecystiti
s
• Perforated Small Bowel
• Esophageal Perforation
• Perforated Colon
• Aortic Dissection

5. 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

6. Etio-Pathological Classification
Spontaneous intra-peritoneal bleeding
Rupture AAA.
Rupture visceral A.Aneurysms in
mesenteric; hepatic and renal arteries.
Rupture pathologically enlarged spleen
Rupture Hepatic Tumor.
Gynecological causes:-
• Ruptured Ectopic pregnancy
• Ruptured Ovarian Cyst
• Ruptured Graffian's follicles( mid-cycle)
• Ruptured Endometriosis.

7. Medial Causes of Acute Abdominal Pain
Non-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.

8. 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.

9. 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.

10. 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.

11. History taking

12. 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

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.)

18. 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.

19. 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.

20. Associated symptoms
• Nausea and vomiting
• Indigestion
• Anorexia and weight loss
• Bowel habit
• Urinary Symptoms
• Gynecological Symptoms

21. Menstrual History-in women in Reproductive
age
• Sexual Activity and IUD
• Amenorrhea(Missed period)
• Vaginal Bleeding
• Vaginal Discharge
• Mid-Cycle

22. Medical History
• Medical Diseases; HTN ; CAD ; AF ; Vascular
Diseases ;Pulmonary Diseases.
• Previous Surgery.
• Current Medications.
• Alcohol and Smoking.

23. Physical examination

24. General Examination
• Vital Signs: Pulse ; Temp.; BP.
• Pallor ; Jaundice ; Cyanosis.
• Tongue:-Dry ; Coated ; acetone smell.
• Examination of Cervical LNs.
• Examination of Chest and Heart.

25. 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.

26. Abdominal Examination
Inspection
• 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

27. • Cullen sign Grey-Turner sign

28. Palpation and Percussion
Light and deep palpation.
Start gently and away from reported area of
pain. Palpation with pulp of fingers NOT Tips
of fingers.

29. 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.

30. 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.

31. 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.

32. Resuscitation and Immediate
Investigations

33. 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.

34. Resuscitation-In Critically Ill-Patients
• Air Way and Oxygen Supplement.
• Oxygen Saturation Monitoring
• ABG
• CV-Line ; Volume Replacement.

35. 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.

42. 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.

43. 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.

44. Thick-walled,
fluid-filled appendix with surrounding inflammation

45. Large Appendicular Abscess containing gas.

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

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

50. Multiple splenic abscess

51. CT-IV Contrast-Small Bowel Ischemia due to
Strangulation

52. 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.

53. Medical life threatening conditions:-
 Myocardial infarction.
 Spontaneous tension Pneumothorax.
 D-Ketoacidosis .
 Acute AD.Cortical Failure.

54. (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

55. (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

56. (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.

57. Differential Diagnosis

58. 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

59. 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.

60. Suppruative Appendicitis

61. Meckle's Diverticulum

62. Volvulus of Meckle's Diverticulum

63. Torsion Ovarian Cyst

65. Ruptured Ectopic Pregnancy

66. Acute Cholecystitis

67. Sigmoid Volvulus.

69. 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.

71. Messages

72.  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.

73.  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.

74.  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.