main acute abdominal conditions

1. CLINICAL DIFFRENTIAL
DIAGNOSIS OF ACUTE ABDOMEN
Dr Shivay Gupta
2nd Year PG Scholar
Dept Of Shalya Tantra
KAHER’S Shri BMK Ayurveda Mahavidyalaya
Shahpur ,Belgavi.

2. 5/12/2019CLINICAL
DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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3. Contents
 Introduction
 Objective
 Anatomy
 Physical Examination
 Investigation
 Differential diagnosis
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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4. Introduction
• It is Acute attack of abdominal pain that may occur
suddenly or gradually over a period of several hours
• Presenting a symptom complex , which suggests a
disease
• That possibly threatens life and demands immediate
or urgent diagnosis.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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5. • More Than 1000 causes exist for Acute abdomen.
Acute abdominal pain accounts for 7-10% of all
Emergency department visits.
• Major portion is covered by Non specific abdominal
pain i.e. 24-44.3% , Acute appendicitis accounts for-
15.9-28.1% ,Acute Billiary disease – 2.9-9.7% ,
Perforated peptic ulcer – 3% & Pancreatitis – 3% ,
Diverticular disease – 2% , Others – 10%
• 50-65% initially inaccurate diagnosis.
• Mortality rate -13.9%.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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6. Objective
• To understand the Importance of acute abdomen i.e.
immediate diagnosis & management.
• To Establish the clinical differential diagnosis of
acute abdomen.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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7. Divison of Abdomen
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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8. As per Anatomical consideration
• Liver (hepatitis)
• Gall bladder
(gallstones)
• Liver abcess
• Ascending colon
(cancer,)
• Kidney (stone,
hydronephrosis, UTI)
• Appendix (Appendicitis)
• Caecum (tumour,
volvulus, closed loop
obstruction)
• Ovaries/fallopian tube
(ectopic, cyst, PID)
• Ureter (renal colic)
• Liver (hepatitis)
• Gall bladder (gallstones)
• Stomach (peptic ulcer, gastritis)
• Transverse colon (cancer)
• Pancreas (pancreatitis)
• Pancreas (pancreatitis)
• Stomach (peptic ulcer)
• Descending colon
(cancer)
• Kidney (stone,
hydronephrosis, UTI)
• Sigmoid colon (diverticulitis,
colitis, cancer)
• Ovaries/fallopian tube
(ectopic, cyst, PID)
• Ureter (renal colic)
• Uterus (fibroid, cancer)
• Bladder (UTI, stone)
• Sigmoid colon
(diverticulitis)
• Small bowel
(obstruction/ischaemia)
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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9. Causes Of Acute Abdomen
Intra-Abdominal Extra-Abdominal
1. Inflammation eg Appendicitis 1. Parietal conditions eg cellulitis of
anterior abdominal wall.
2. Perforation eg Peptic ulcer
perforation
2. Thoracic conditions eg
Diaphragmatic pleurisy
3. Acute Intestinal Obstruction 3. Retro peritoneal conditions eg
Dietl’s crisis
4. Haemorrhage eg Ruptured ectopian
gestation
4. Disease of spine eg Pott’s spine
5. Torsion of Pedicle eg Twisted
ovarian cyst
5. General diseases eg Typhoid
6. Colics eg Billiary
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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10. History
1. Age- A few Acute abdominal are peculiar to definite age
group.
2.Sex
Male Female
- Peptic ulcer - Ruptured ectopic pregnancy.
- Pancreatitis - Acute Salpingitis.
- Volvulus - Twisted ovarian cyst.
3.Occupation eg painters , Battery recyclers.
4.Residence.eg Peptic ulcer perforation more common in north
and south
5.Socioeconomic group eg Appendicitis.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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11. As per Chief complaints
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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Time of onset
(Early morning
or Afternoon)
Mode of
onset
(Sudden or
insidious)
History
of pain
Site of pain
Flanks – Renal origin
Epigastric – PU Perforation
Shifting of pain
eg Appendicitis
Pain

12. Referred pain
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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13. Colicky pain
eg Ureteric
Constant
burning pain
eg Peritonitis
Severe
Agonising
pain eg
pancreatitis
Throbbing
pain eg
Cholecystitis
Aggravating
factors
Relieving
factors
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DIAGNOSIS OF ACUTE
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Character of Pain

14. Vomiting
Bowel Habit
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DIAGNOSIS OF ACUTE
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CHARACTER
Projectile or
regurgitating
VOMITUS
Bilious
/Faceculent
Frequency
and
Quantity
Relationship
with pain
Obstipation
Mucus
Discharge
Diarrhoea/
Tenesmus

15. Micturition
- Strangury - Haematuria
Personal History
- Menstrual history
- Habits ( Alcohol , Smoking)
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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16. Physical Examination
1. Appearance
- Facies Hippocratica in Terminal stage of Peritonitis.
- Extreme Pallor
- Cyanosis
2. Attitude
- Tossing , Quiet , Excitable
3. Pulse
- Normal , Rapid
4. Respiration
- If temp rises respiration rate is increased.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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17. 5. Temperature
- In infective conditions temp will be raised
- Quite high in Acute Appendicitis.
- Moderate in Cholecystitis.
6. Tongue
- Dry , moist , coated
7. Anaemia ,Cyanosis , Jaundice.
- Haemorrhagic conditions
- Obstruction
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DIAGNOSIS OF ACUTE
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18. Inspection
1. Hernia orifices.
2. Contour of abdomen
- Distended eg Intestinal obstruction
- Scaphoid eg Diaphragmatic hernia
- Flat
3. Umbilicus
- Normally inverted
- Everted eg umbillical hernia , distention
4. Respiratory movement
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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19. 5. Peristaltic movements
- Step ladder
- Right to left Hypochondriac
6. Skin
- Discoloration eg Cullen's sign ,Turner’s sign
- Stretch Marks
- Edema
- scars eg Laparotomy
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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20. Palpation
1. Hyperaesthesia
- By gently picking the fold of abdomen & lifting it.
- Scratching the abdomen with fingers
- Sherren’s triangle in Appendicitis.
- Boas’s Sign in Cholecystitis.
2. Tenderness
- Pointing test
- Murphy’s Point
- Mcburny’s Point
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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21. 3.Rebound tenderness ( Blumberg’s sign)
- Mainly seen in Peritonitis , Acute intestinal obstruction
4. Muscle guarding
- Involuntary / Voluntary
- Occurs due to Inflammation , blood .
- Also seen in chest wall and joints.
5. Distention
- Acute intestinal obstruction
6. Lump – Careful palpation of lump
- Position , shape , size
- Eg1. Appendicular abscess
2.Sausage shaped lump (Sign-de-dance)
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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22. Percussion
1. Shifting dullness
- Peptic ulcer perforation
- Typhoid ulcer
- Ruptured ectopian cyst
2. Fluid thrill
- Ascites
3. Obliteration of liver dullness
- Replacement indicates Gas
Under Diaphragm.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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23. Auscultation
1. Bowel sounds
- Hypoactive /Hyperactive or Absent
- Gurgle / rumbling/ tinkle
- Frequency 2-4/min
-Silent abdomen or Noisy abdomen
- Borborygmi sounds
Rectal Examination
- Tenderness in Rectovesical pouch in PU perforation.
- Red Currant jelly in Intussusception.
Vaginal Examination
- Acute Salpingitis
- Ruptured ectopian gestation
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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24. Acute Appendicitis
1) Site of pain – Initially umbilicus / Epigastrium then RIF.
2) Murphy’s Syndrome – Pain Vomiting Temprature
3) Sherren’s Triangle
4) Rovsing’s Sign
5) Blumberg’s Sign
6) Cope’s Psoas test
7) Obturator test
8) Baldwing sign
9) Bastede sign
10) Dumphy’s Cough sign
11) Alvarado Scoring
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DIAGNOSIS OF ACUTE
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27. Acute Cholecystitis
• 4 F ( Fat , Fertile , Female , Forty)
• Main Incidence in 4th or 5th decade of life.
• Onset sudden , Following heavy Fatty meal
• Pain in Right Hypochondrium / Epigastrium
• Tenderness , Rigidity , Guarding, Radiation to inferior angle of
scapula or tip of right shoulder.
• Pyrexia , nausea , vomiting , Retching
• Murphy’s Sign
• Boas’s Sign
• Blood investigation – 85% Leucocytosis present
Elevated S.Bilirubin , S.Amylase
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DIAGNOSIS OF ACUTE
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28. Acute Pancreatitis
1. Sudden onset of Upper abdominal pain Radiating to back.
2. Severity increases if patient lies down so stooping position.
3. Signs of shock ( Tachycardia , sweating , hypotension)
4. Cullen’s sign
5. Grey turner sign
6. Fox sign
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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29. 7. Blood investigation
- Elevated Serum amylase above 400su
- Urinary Amylase – 300units/hr
- Elevated Serum lipase
- Hypocalcaemia – A value less than 7.5mg/100ml Poor Prognosis.
8. X ray – Straight abdomen x ray may reveal Pancreatic and
biliary Calcifications.
-Sentinel loop sign
- Cut off sign
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DIAGNOSIS OF ACUTE
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30. 9. Double Bubble sign
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DIAGNOSIS OF ACUTE
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31. Acute peritonitis
1. Sudden onset of pain , fever , vomiting.
2. Localised then diffuse.
3. Rebound tenderness , muscle guarding , tachycardia,
tachypnea.
4. Silent abdomen. Septicemic shock.
5. Hippocrates Facies , loss of consciousness.
6. X ray – Ground glass , gas under diaphragm
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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32. Intestinal obstruction
1. Main Cardinal signs – Intestinal colic , vomiting , distention
2. Initially colicky Intermittent Continuous Severe.
3. Vomiting – Depends upon site of obstruction
4. Distention – Absent or minimal in jejunum obstruction.
- VIP and Borborygmi sounds in illeal obst.
5. Dehydration- Higher the Obstruction more is dehydration.
Jejunum – Dehydration more distention less
Terminal ileum – Distention more Dehydration less
Oliguria Renal failure.
6. Features of toxaemia and septicaemia.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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33. Colics
1. Sudden Appearance of gripping pain
2. Nausea , vomiting , Belching , Retching
3. Absence of muscle guard
• Biliary Colics
• Ureteric colic's
- Severe pain from loin to groin , testis , inner side of thigh.
-Vomiting and profuse sweating.
-Tenderness at renal angle
-Strangury may be present
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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34. Acute Salpingitis
1. Pain mainly in hypogastrium/ Both iliac fossa
2. During menstruation or after 1st week of abortion or delivery
3. Temp rises upto 102 f
4. Difficulty in micturation (scalding pain)
5. Vaginal discharge
6. Vaginal examination reveals enlarged uterus
7. Cervix may be soft and little movement causes tremendous
pain
8. Unilateral or bilateral mass may be palpated.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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35. Haemorrhage and Torsion
1. Ruptured ectopian gestation
- Acute pain over Hypogastrium with tremendous
Shock .
- H/o one or two missed abortions.
- Radiation of pain to backwards or downwards.
- Blue discolouration around umbilicus.
Vaginal examination
- Cervix feels softer than normal .
- All fornices will be tender .
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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36. Ruptured Lutein cyst
1. Lower abdominal pain in middle of menstruation.
2. May mimics as Appendicitis if Right is affected
3. Pain mainly occurs in RIF not in umbilicus.
4. H/o Last menstrual cycle is important.
Twisted Ovarian cyst
1. Colicky abdominal pain with bouts of vomiting.
2. Patient may collapse suddenly.
3. Lump – Tense , tender , cystic & smooth margin, Movable.
4. Past h/o ovarian cyst.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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37. Acute Intussusception
1. Telescoping of one segment of bowel to adjacent bowel.
2. Most common – Ileocolic.
3. Age group – 6 to 12 months.
4. Child screams in abdominal pain and draws his legs
upwards.
5. Red currant jelly may be seen .
6. Sign de dance may be seen.
7. Sausage shape lump in Epigastric
May be seen.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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38. Perforations
• Peptic ulcer Perforations (Hurry worry curry)
- Stage of Peritonism.
- Stage of Reaction.
- Stage of diffuse peritonitis.
• Perforation of typhoid ulcer
- 3rd or 4rth week after typhoid fever.
- Sudden collapse , Fast thready pulse, Subnormal temperature
- Liver dullness and shifting dullness may be positive.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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39. Investigations Required
1. Leucocyte count- Leucocytosis
- Acute appendicitis , Acute Cholecystitis, Acute pancreatitis
2. Blood Sugar and urea , Electrolytes
- Diabetic crisis , Uraemia
3. Serum Amylase
- Acute Pancreatitis 400units somogyi
- Highest value 1000-2000units
4. Serum Lipase- More Sensitive than amylase.
Serum Calcium
- Normal level 8.5-10.5mg
- Level below 7.5mg/100ml is dangerous.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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40. 5. C protein
- Crp value more than 6mg/l indicates appendicitis
6. Urine
-Blood or pus in Appendicitis
- Haematuria in Renal colic's
- Glycosuria
7. X ray
- Straight x-ray multiple fluid levels & gas – Acute intestinal
obstruction.
- Straight X- ray sitting position – GIT Perforation.
- In Intussusception – Pincer shaped end
- Toxic megacolon – Dilatation of transverse colon.
- Ground glass – Acute peritonitis
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DIAGNOSIS OF ACUTE
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42. 8. Barium Enema
- Loss of haustral markings, irregularities, small ulcers
- Cobble stone pattern
- skip lesions
9.Endoscopy
10.Ultrasonography
- Non invasive Imaging technique
- Accuracy 90%
11.CT scan
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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44. Conclusion
1. Acute abdomen is often a surgical emergency &
challenge, as it mimics as Pandora's Box so need
of hour is to diagnose & Differentiate various
Conditions thus reaching Final Diagnosis.
2. Right Decision at the right time should be taken
as acute abdomen is fatal condition that may
lead to irreversible damage or even death.
3. Even though the latest techniques like USG , CT,
MRI is a great help but still careful clinical
examination leads in ruling out various
underlying pathologies thus reaching final
diagnosis.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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45. References
• A manual on clinical surgery by S.das
• Srb’s manual of clinical surgery
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
ABDOMEN
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46. Acknowledgement
• Respected faculty of Shalya Tantra Department ,
Seniors and juniors.
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DIFFRENTIAL
DIAGNOSIS OF ACUTE
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