General principles and approach in ED

1. ACUTE ABDOMEN - General Principles and Approaching in ED
Daima Butt
(House Officer)

2. Acute Abdomen
35 years old man presents to ER with 3 days of crampy abdominal pain and diarrhea. He reports
subjective fever on physical examination. He is tender to palpation in all quadrants but
demonstrates no rebound or guarding.

3. Questions
• Does the patient has surgical emergency?
• What is Acute Abdomen?

4. Define Acute Abdomen
Sudden onset of abdominal pain regardless of cause

5. Presenting to ED
One of the real concerning thing is the patients presenting to
ED for pain abdomen is that there’s wide range of things that
could be causing abdominal pain varying from benign
conditions to more serious requiring hospital admissions and
surgical interventions to perforation, obstruction and
haemorrhage.

6. Introduction to Acute Abdomen
Acute abdomen refers to a sudden and severe
abdominal pain of unclear etiology of less than
24 hours of duration.
A medical/surgical(non traumatic) emergency
requiring urgent intervention.
Make up to 10-15% ER visits.
Almost 40% requiring surgical intervention.
Could be life threatening in patients with
atypical presentation ending up into death if
misdiagnosed or treated wrong.

7. General Overview
Mesothelium in intrauterine life goes by mesentery in later life.
Gut tube is a single tube in intra uterine life that later develops into
-foregut
-mid gut
-hindgut
Part of peritoneum adherent to gut wall is visceral peritoneum and the one adherent to
inside of abdominal wall goes by parietal peritoneum
Intra-Peritoneal organs are those covered by visceral peritoneum and supported by
mesentery.
Retro-Peritoneal organs lies behind peritoneum (kidney, ascending/descending colon)

8. General Overview
Pain from intra-peritoneal organs is represented on anterior
abdominal wall while the pain from retro-peritoneal
structures is represented in back.
Pain that occurs from visceral organs is being carried by
afferent neurons-going from gut tube to spinal cord on both
side on different levels.
Pain from visceral organs is vague and not body localized.
Foregut pain feels in Epigastrium
Mid-gut pain feels in para-umbilical area
Hindgut pain feels in supra-pubic area
Nerves distribution from parietal peritoneum is dermatomal.
Parietal pain is more localized because only one pain root is
stimulated in spinal cord at one specific site.
Parietal pain being more localized in caused by local
inflammation of parietal peritoneum.

9. Continue..
Visceral pain is associated with strong autonomic reflex
phenomenon
- Vomiting
- Sweating
- Tachycardia

10. Example
“Acute Appendicitis”
Visceral Pain
- vague, poorly localized around umbilicus.
- will gradually gets worse.
- maybe associated with vomiting.
Parietal Pain
- More localized.
- Specific to the right iliac fossa over Mcburney’s point.

11. Approaching a patient with undifferentiated abdominal pain
Does the patient need surgery?
How soon does the patient need
surgery?
Is there any additional work-up
necessary?

12. Continue..
Considering the later case scenarios think of
What disease process in going on?
• Inflammation
• Perforation
• Obstruction
• Ischemia
• Hemorrhage
What systems could be involved?
• GI
• Urological
• Vascular
• Gynaecological

13. Differentials
keeping surgical and medical causes in mind, depending on the site and radiation; abdominal pain is divided in 9 quadrants of
abdomen.
Right Hypochondrium: Hepato-biliary
system(cholangitis), cholecystitis.
Epigastrium: pain being of Gastritis, pancreatitis, peptic
ulcer disease.
Left hypochondrium: ruptured spleen in patients with
sickle cell disease, splenic tumor or infarct.
Loins or loins into groins: might be of ureteric obstruction. Any tubal
obstruction and by that think of the causes that might cause luminal
obstruction(stones, tumor inside/outside compression by retroperitoneal
fibrosis.

14. Continue..
Umbilical: due to visceral structures. Think of AAA in older patients with
backache and state of shock.
RIF: appendicitis, torsion testis/ovarian cyst, salpingitis, ectopic pregnancy,
pancreatitis.
LIF: diverticulitis, volvulus, strangulated hernia, colorectal cancer,
ulcerative colitis.
Supra-pubic: atypical presentation of appendicitis, pelvic inflammatory
disease.

15. Extra Abdominal Considerations
Considering the things outside the abdomin that might cause
abdominal pain mimicking acute abdomen.
These include an inferior wall MI classically presenting with
acute epigastic pain and discomfort associated with nausea
vomiting.
Ketoacidosis: get ABGs and consult medical ED
Pneumonia: typically RLL and LLL presenting with
hypochondric pain respectively.
Herpes zoster: these present with pain classically burning
and itchy type of pain. Look for a rash on abdomen and
dermatomal area.
Others.. Hepatitis, cystitis, IBD

16. Initial assessment
The “End-to-End-Bed-O-Gram” to see how sick the patient
is.
- ABCD approach
- History and examination
Meanwhile look for objective signs and symptoms
As a bare minimum one should ask 5 questions first.
1. onset (sudden or gradual)
2. Progression (what makes it better or worse)
3. Duration (when did it start, constant or intermittent)
4. Associated symptoms (nausea, vomiting, loss of appetite,
diarrhea, chest pain, backache, urinary symptoms)
5. Risk factors

17. Continue…
Also ask for
character of pain (stabbing, colicky, sharp)
Radiation
Alleviating factors
Severity
In females ask for LMP, any associated abnormal vaginal bleed/discharge. Rule out if any possibility that patient could be
pregnant.
Past medical
Past surgical
Drug history
Allergies
Family history
Social history

18. How to Examine Abdominal Pain
Get the patients current clinical status
Vitals signs assessment (pulse, BP, any sign of hypovolemic
shock)
Inspect
- Is patient laying still or restless (eg still patient with respiratory
distress indicative of peritonitis, restless might be indicative of
colicky abdominal pain)
- Prior surgical scars? (laproscopic scar around umbilicus)
Auscultate for bowel sounds for at least 2 minutes(over active,
underactive or not there)

19. Continue..
Palpate: start from the area away from the pain. If the pain
in on the right side in lower abdomen go ahead and start in
left abdomen and work away around that area.
Start with superficial light palpation then go with deep
palpation depending on patients tolerance.
Rebound tenderness (gently press the hand over area of
maximum tenderness under your hand and quickly release it-
shows signs or peritonism) and Guarding (involuntary
contraction of patients musculature under your hands-not
specific)
- shake the bed
- Have patient jump on one foot
- DRE

20. Special Exam Maneuvers
Murphy’s sign to look for disease of gall bladder
• Cholecystitis
• Patient stops inspiring when right upper quadrant is palpated
deeply.
Palpate Aorta
• Older patients with backache (AAA)
Psoas, Obturator, Rovsing’s sign
• Appendicitis
Genitourinary Exams
• Testicular exam (testicular pain)
• Pelvic exam (for women to rule out any torsion, ectopic
pregnancy or mass)
Extraabdominal findings: any rash, auscultate lungs, RR)

21. Laboratory tests
1. Bedside tests
2. Blood tests
3. Microbiology
4. Imaging
5. Specialist tests
- Complete blood workup
- Urine tests
- EKG to rule out any cardiac cause as a bare minimum
- ABGs to rule out metabolic acidosis
- Serum lactate levels (for end organ damage/hypoxia)
- Get cultures (urine, blood, sputum, taps)

22. Continue..
HCG testing for all women of childbearing age
Complete blood count: an increased TLC CRP or platelets are
markers of acute inflammatory condition.
A decreased Hb is indicative of chronic blood loss might be an
underlying malignancy.
Get metabolic panel, liver and pancreatic functions:
• Urea and electrolytes to rule out ARF as in shock
• isolated raise of urea think of GI bleed.
• Raised alkaline phosphatase/bilirubin indicative of biliary
obstruction(further evaluate through u/s scan for gall stones or
mass causing obstruction)
• Raised serum amylase is indicative of pancreatitis but it is also
secreted by bowel wall in general or saliva.
• Increased level of lipase suggestive of inflamed pancrease.
• Lactic acid levels: increase due to periods of ischemia(due to
volume depletion, not being enough blood flow to the tissues, due
to infection possibly sepsis)

23. Ancillary testing
• Evaluate for myocardial ischemia
• Urinalysis: blood (might be kidney stone) or WBC
infection, nitrites, pus cells.
In males for chlamydial infections.

24. Imaging studies: Plain Film
What its for:
Evaluate bowel obstruction or perforation of viscera
Advantages:
Performed quickly
Disadvantage:
Low yield test
Fast Fact:
Be sure to get an upright chest film which is more sensitive
for free air.

25. If you get an x-ray erect chest (lateral decubitus-air beneath abdominal wall) with free air under diaphragm as demonstrated in
this image this patient requires urgent Exploratory Lap without any further delay. Unfortunately this free air under diaphragm
or Pneumo-peritoneum doesn’t tell you with the underlying pathology is.

26. Obstruction is the most common diagnosis. Most of them does not require any surgery. Its mostly associated with previous surgeries.
Appears as multiple air fluid levels on x-ray erect abdomen.
- air fluid levels will be central in jejunal or ileal obstruction (step ladder appearance)
- in large bowel obstruction air fluid levels lies at periphery (picture frame appearance)

27. Bowel ischemia is less likely than perforation nonetheless very important cause of acute abdomen and surgical abdomen.
Classically described as Thumb-printing or Pneumatosis intestinalis.
Intestinal lining is most susceptible to ischemia – as the mucosa breaks down air is allowed to track down transmurally into
the linings of small intestines resulting in pnuematosis.

28. Although large majority of GI bleeds are due to non operatively; some of them occurs post-operatively, appears as low BP,
hypotension and peritoneal signs or they require significant amount of blood transfusion that might be an indication for
emergency surgery.

29. Imaging studies: Ultrasound scan
What its good for:
Evaluating for AAA, gallbladder conditions, genitourinary
conditions(ovarian torsions, cysts, bladder wall infections)
May also help with:
Renal colic, appendicitis, bowel obstruction.
Advantages:
No ionizing radiation, can be performed at bedside.
Disadvantages:
Operative dependent

30. Imaging studies: CT scan
What its for:
Most intra-abdominal diagnosis (any bowel obstruction,
infection, abscess in abdomen.
Advantage:
Readily available, improved image quality
Disadvantage:
Ionizing radiation exposure
Fast Fact:
IV contrast for vascular concerns

31. Specialist tests
ERCP and MRCP for biliary obstruction
Laproscopy if diagnosis is in doubt.

32. Management of Acute Abdomen
the definitive management of acute abdomen depends largely on underlying cause
• Does the patient need oxygen? (maintain up to 96%)
• Fluid balance: IV fluids? Urinary catheters? (if urinary retention or bedridden, also to check for urinary output in critically ill
patients)
• Drugs: analgesics, anti-emetics, antibiotics.
• VTE prophylaxis
• Escalation

33. Continue…
Keep the patient NBM and pass NG to decompress stomach and bowel.
Start with IV antibiotics (following respective guidelines) and IV fluids (crystalloids)
Catheterize (if necessary) to measure urinary out put. In haemo-dynamically stable patients urinary output will be
1ml/kg/hour.
Check for CVP in patients with concurrent diseases.
If the pain score is above 7 give morphine analgesics.
Before prescribing NSIADS rule out the shock state because they cause afferent arteriolar dilatation in kidney precipitating
pre renal failure.
It is important to correct fluid and electrolytes imbalance before surgery in first 24 hours to lower mortality and morbidity
rate. (if surgery required)
If symptoms are not getting improved in first 48hours, patient needs laparotomy

34. Indication for surgery
• Failure of conservative management.
• Suspected strangulation or peritonitis.
• If there is associated diseases i.e hernia obstruction,
tumors (causing obstruction).
then go for laparotomy without any further time wasting.
Laprotomy
Done through midline incision (upper/lower) following
peritoneal washing with normal saline and placement of
drains afterwards.
• To identify source of infection.
• To control or remove source of infection.
In obstruction recognize the bowel (gangrenous/foul
smelling, strangulated- purple/black coloured)
Palpate for mesenteric artery (pulsatile in normal bowel and
vice versa)
Resect the gangreneous bowel and do end-to-end
anastomosis.

35. Complications of Acute Abdomen
In general
Paralytic ileus
Residual or recurrent abscess
Intraperitoneal sepsis
Hypovolemic/septic shock
Portal pyemia/liver abscess
Multiple organ failure
DIC
Fistula
Adhesions

36. THANKS