A detailed presentation on the Common causes of Acute Abdomen and their Initial Assessment

1. ACUTE ABDOMEN:
COMMON CAUSES &
INITIAL ASSESSMENT
DR. MD. ZAKI SHAHRIAR SOURAV (MBBS)
-Intern Doctor; Dept. Of General Surgery, EMCH
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2. 2

3. Acute Abdomen:
 “ACUTE ABDOMEN” is a general term used to
describe a variety of serious, non-traumatic
intra-abdominal pathologies that mandate
emergency or urgent surgical or major medical
intervention.
[definitions source: Hamilton Bailey’s Demonstration Of Physical Signs In Clinical Surgery- 19th Edition.]
Etiologies of acute abdomen vary greatly and are also
dependent on age, gender, geography etc.
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4. Etiology
Causes of Acute Abdomen can be classified as:
1. Intra-abdominal cause:
A. Inflammatory: Acute appendicitis, Acute cholecystitis, Acute pancreatitis, Acute
peritonitis, Acute salpingitis, Acute diverticulitis, Acute Crohn’s disease etc.
B. Perforation of bowel: perforated duodenal or gastric ulcer
C. Acute intestinal obstruction: in the wall (intussusception, stricture, hernia), in the
lumen (roundworms), outside the wall (hernia, bands, adhesion & volvulus)
D. Mesenteric ischemia by thrombosis or embolism.
E. Hemorrhage: ruptured aortic aneurism, ruptured ectopic pregnancy, ruptured tropical
spleen
F. Torsion: twisted splenic pedicle or ovarian cyst
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5. A. Retroperitoneal: Acute pyelonephritis, retroperitoneal lymphadenitis
and lymphangitis
B. In the Abdominal wall: Abdominal wall abscess, Meleney’s spreading
gangrene, rupture of abdominal wall muscles or inferior epigastric
artery tear
C. Medical causes:
Myocardial Infarction, Angina pectoris, Pulmonary embolism,
Pneumonia, Pneumothorax, Pericarditis, Acute leukaemia, Sickle cell
crisis, Uremia, Diabetic crisis, Pb-poisoning, Narcotics withdrawl, Herpes
Zoster of intercostal nerves Pott’s tuberculosis etc.
2. Extra Abdominal causes: 5

6. ASSESSMENT
Approach to a patient with acute abdomen must be
orderly and thorough. An acute abdomen must be
suspected even though the patient has only mild or
atypical symptoms. The history and Physical
examinations should suggest the probable cause and
guide the clinical diagnosis.
In almost 2/3rd of all hospital cases, proper history and
physical examinations are adequate for proper
diagnosis of acute abdomen.
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7. HISTORY TAKING
1. Age: Common disorders according to different age groups:
 Old age: Sigmoid volvulus, carcinoma of the colon, diverticulitis
 Adults: Acute pancreatitis, Acute Cholecystitis and perforation
 Young adults: Appendicitis
 Children: Roundworm infection, appendicitis, acute non-specific mesenteric
lymphadenitis
 Infants: Intussusception, Midgut volvulus, congenital hypertrophic pyloric
stenosis
 Newborn: anorectal malformations, intestinal atresia, meconium ileus
2. Gender:
 Male: volvulus, intussusception, perforated peptic ulcer
 Female: Acute Cholecystitis, primary acute peritonitis ruptured ectopic pregnancy,
twisted ovarian cyst
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8. 3. Socioeconomic condition: eg. Appendicitis is more common in high
income groups as they tend to take more protein rich diet and ignore
vegetables. Perforation and roundworm infection is more common in
low socioeconomic groups.
4. Occupation: painters and factory workers are more likely to be
hospitalized for lead poisoning causing abdominal colic and discomfort.
5. Geographical area: people in japan are renowned for having raw fish
(sushi) or smoked fish while Indians are well known for spicy food-
resulting in peptic ulcer disease common in both regions and hence
perforation.
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9. PAIN
It is the most prominent presenting
complaint in a patient of acute
abdomen.
For this reason it must be looked
into with meticulous detail to find
out the origin, nature, character,
duration, intensity, precipitating
and relieving factors of pain along
with any associated symptoms.
Pain usually corresponds to the
anatomical region of the organ or
pathological site involved
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10. Three types of pain have been
identified. They are:
1. Visceral pain
2. Parietal pain
3. Referred pain
1. Visceral pain:
Due to stretching of fibres innervating the
walls of hollow viscus.
Slow in onset, dull, poorly localized
Occurs early
Due to early ischaemia and inflammation
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11. 2. Parietal pain:
 Due to irritation of parietal peritoneum fibres
 Acute, sharper, better localized
 Occurs late
 Can be localized to a dermatome superficial
to the site of painful stimulus.
 Aggravated by jolts and movements
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12. 3. Referred pain:
Pain felt at a site away from the
pathological region having the same
segmental innervation as the site of
lesion. Pain is always ipsilateral to
involved organ.
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13. SITE:
Site of pain should be confirmed by asking the patient to point
using a single finger (pointing test). In case of diffuse pain the
patient will prefer using multiple fingers or the entire hand.
NATURE OF PAIN:
 Continuous: perforation, torsion, haemorrhage, inflammation
 Colicky: spasm of hollow viscus eg. Intestinal, biliary, ureteric
 Throbbing: cholecystitis
 Severe agonizing: Acute pancreatitis
 Twisting: torsion
 Continuous and burning: acute peritonitis and duodenal ulcer
perforation
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14. Change in position of pain or spread of pain:
Radiation of pain
 Pain in acute pancreatitis radiates to the back in 50% of
cases
 In peptic perforation, pain initially originating in the right
hypochondriac region radiates to the RIF due to leakage
and spillage of gastric contents along the right para-colic
gutter.
Shifting of pain
The site of pain in a. appendicitis is initially around the
umbilicus (visceral) but later shifts to the RIF (parietal).
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15. Aggravating and relieving factors:
 Colicky pain is relieved by local pressure
 Inflammatory pain gets aggravated by pressure
 Pain aggravates on movement in cholecystitis,
appendicitis, ureteric stone
 Coughing and deep breathing aggravates pain due to
diaphragmatic irritation
 Fatty meal aggravates pain of gastric ulcer.
 In acute pancreatitis leaning forward relieves the pain
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16. COMMON CAUSES OF ABDOMINAL PAIN
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17. VOMITING
 Character: it may be of two types
1. Projectile: involuntary forceful ejection of upper intestinal contents
2. Non-projectile: regurgitation of mouthful contents seen in general
peritonitis.
 Contents: whether partly digested food particles or fluid, bilious or
not, haematemesis, or intestinal contents (faeculent) which is rare.
 Frequency and quantity: whether constant or frequent (upper GI
obstruction and a. pancreatitis) or periodic (peptic ulcer)
 Relationship with pain: pain preceeds vomiting in acute
appendicitis, acute pancreatitis, peptic ulcer and biliary and renal
colics; in high intestinal obstruction vomiting and pain appear almost
simultaneously and later in distal GI obstruction. In PUD vomiting
relieves pain.
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18. Associated features:
1. Diarrhoea: copious in gastroenteritis; blood stained in ulcerative colitis,
Crohn’s disease and bacterial or amoebic dysentery
2. Constipation: may be absolute or relative
3. Bowel habits: quantity, nature, frequency, odor, color, tenesmus (painful,
futile straining on defecation with passage of mucus and blood)
4. Abdominal distention
5. Urinary symptoms: burning sensation, frequency, strangury (frequent
attempts of micturition resulting in only passage of blood stained urine) as
seen in case of impacted calculi or irritation of the bladder by an inflamed
appendix or in pelvic peritonitis.
6. History of fever, chills and rigor, jaundice, melena etc.
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19. Other Relevant History:
 Recent/current medications
 Past hospitalization
 Past surgery
 Chronic disease such as DM,
HTN etc
 Socioeconomic history
 Occupation/toxic exposure
 Drug and alcohol history
 Gynecological history
 Menstrual history
 Dysmenorrhea
 Endometriosis
 Vaginal discharge
 Travel history
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20. PHYSICAL EXAMINATION
 General Examination:
Facies, pallor, attitude of the patient, pulse,
blood pressure, respiratory rate, temperature,
tongue, eyes, skin, Urine output
 Local examination:
 Inspection: contour of the abdomen, position of the
umbilicus, movement with respiration, visible peristalsis
or pulsation,skin condition, hernia orifice and external
genitalia
 Palpation: look for guarding, rigidity, rebound
tenderness, organomegally, hernia, hyperesthesia and
special signs like Murphy’s sign, Cope Psoas sign etc.
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23.  Percussion: free fluid can be checked by shifting dullness, fluid thrill;
tenderness may be elicited by percussion; obliteration of liver dullness
maybe discovered in pneumoperitoneum following perforated hollow
viscus.
 Auscultations: some studies suggest that in case of acute appendicitis,
auscultation should precede other examinations in order to exclude a
“silent abdomen” which is seen in peritonitis, paralytic ileus.
 Digital rectal examinations
 Pervaginal examination
 Systemic examinations:
examinations of the respiratory and cardiovascular systems, neurological
examinations and the spine in order to rule out other possible cause of
acute abdomen.
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24. INVESTIGATIONS :Some commonly performed investigations include:
 IMAGING:
1. Radiology: Plain X-ray of the abdomen, contrast X-
ray.
2. Ultrasonography of the abdomen or of specific
regions
3. CT-scan: in selective cases; especially in acute
pancreatitis.
HAEMATOLOGICAL
1. Complete blood count
2. S. creatinine
3. S. electrolytes, S. calcium etc.
4. BT, Ct, APTT
BIOCHEMICAL
1. S. lipase
2. S. amylase
3. Urinary amylase
4. Liver function tests
URINE
1. Routine examination
2. Urine culture and
sensitivity
3. Pregnancy tests for
women of reproductive
age
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25. Role of Ultrasound in Acute Abdomen:
1. Detection of Gall Bladder
pathology
2. Detection of biliary tract
pathology/obstruction.
3. Ureteric stone etc.
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26. Some Common Differential
Diagnosis Of Acute Abdomen
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27. ACUTE APPENDICITIS
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28. CLINICAL FEATURES
1. Common in children and adolescent age groups;
rare before 2years of age
2. Pain: visceral pain starts around umbilicus due to
distention of the appendix, later somatic pain
occurs in RIF due to irritation of the parietal
peritoneum by inflamed appendix. Maximum
point of tenderness can be elicited on the
McBurney’s point. O/E special tests can be
performed to elicit pain which varies depending
on the position of the appendix.
3. Vomiting: due to reflex pylorospasm.
“If vomiting or distinct nausea precedes pain, the
case is not one of acute appendicitis”
4. Anorexia is a constant feature.
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29. Clinical features (cont.d)
5. Altered bowel habit: constipations is usually seen, early morning diarrhea is more
common in post-ileal or pelvic position due to irritation of gut wall.
6. Constitutional features: fever, tachycardia, fetor oris etc.
Tachycardia and fever are not usually present unless peritonitis has developed.
7. Tenesmus and stangury (along with increased frequency and urgency may be seen)
8. Rectal examination: tenderness on the right side in the rectovesical pouch or the recto-
uterine pouch
9. 1/4th cases have atypical presentation due to variable length and position of the
appendix
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30. Special Tests To Elicit Tenderness In
Acute Appendicitis:
 Pointing sign
 Rovsing’s Sign
 Cope’s psoas sign
 Cope’s obturator sign
 P/R examination shows
tenderness in right side
of rectum
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31. Special considerations for Acute appendicitis in different age
groups:
 Infancy: rare, but has high chances of perforation; signs include pyrexia,
abdominal pain, vomiting and local tenderness
 Children: localization not present so high chances of developing peritonitis
 Elderly: gangrene and perforation is common; laxity of abdominal wall and
poor localization allows peritonitis to occur easily; atherosclerosis of the
appendicular artery increases the likelihood of gangrene
 Pregnancy: appendix shifts to upper abdomen; increase mortality and
chances of premature labour,; becomes more difficult to diagnose as
pregnancy progresses
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32. INVESTIGATIONS
 Complete blood count:
Rise in neutrophil count is
indicative of infection and
severity of the condition
 USG of abdomen:
Confirmatory
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33. Acute Cholecystitis
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34. CLINICAL FEATURES
 Sudden onset of severe colicky pain in
the right hypochondriac region. (Biliary
colic; lasting 2-3 hours, variable)
 Associated features: Nausea, vomiting,
retching, rise in temperature,
tachycardia.
 Murphy’s sign positive
 Jaundice is present in 25% cases
 In case of cholangitis, pain, jaundice
and fever with chills and rigor may be
present (Char tot’s triad)
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35. INVESTIGATIONS:
 Ultrasonography of the
Abdomen (preferably
RUQ) is the
investigation f choice.
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36. ACUTE INTESTINAL
OBSTRUCTION
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37. Clinical features:
 Cardinal features: abdominal pain, vomiting, distention and constipation
 Abdominal pain: initially colicky and intermittent and then continuous and
severe.
 Vomiting: in upper GI obstruction, it is an early feature. And develops late in
case of large gut obstruction
 Distention: absent or minimal in case of jejunal obstruction and, obvious
and visible peristalsis seen in ileal obstruction and associated with
“borborygmi”; enormous in case of large bowel obstruction.
 Constipation: usually absolute. Exceptional cases where it may not be
absolute are: Richter’s hernia, mesenteric vascular occlusions etc
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38.  Other features:
 Dehydration, oliguria, renal failure
 Features of toxemia and septicemia: tachycardia, tachypnea, fever, cold periphery
 Features of strangulation: shock, tenderness, rebound tenderness, guarding and
rigidity, absence of bowel sounds
 P/R examination: empty and dilated rectum
 Investigations:
1. Plain-x-ray abdomen: shows multiple air fluid level: number of air-fluid
levels increases with the distance of the obstruction. Jejunum is
identified by valvulae conniventes, Ileum is smooth and otherwise
featureless and large bowel shows haustrations.
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39. Fig: Illustration showing different levels of
obstruction in the alimentary tract.
Large bowel obstruction: Plain X-ray
abdomen in erect posture A-P view
showing multiple dilated bowel loops
located peripherally and containing
haustrations
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40. Plain X-ray abdomen in erect posture A-
P view showing multiple air-fluid levels
placed centrally in step-ladder pattern
and also containing valvulae conniventes.
Small bowel obstruction: 40

41. ACUTE PANCREATITIS
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42. Clinical features:
 Can occur at any age, common in adult, rare in childhood.
 Common causes are gall stones and alcoholism
 Pain: dull, agonizing, constant pain in the epigastric region;
radiating to the back in about 50% of the cases; relieved by
patient leaning forward and remaining still
 Vomitting: usually following pain
 General examination: tachycardia, hypothermia, shock (25%
cases), less commonly cyanosis and jaundice
 Patient may also present with complications of acute
pancreatitis
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43. KEY INVESTIGATIONS:
1. S. amylase (IU/L)-shows marked rise in
24 hours and Urinary Amylase.
2. S. lipase (0-160 IU/L)- rises within4-8
hours from onset and normalizes by 7-
14th day.
3. Ultrasound of abdomen: confirmatory.
Shows gallstones, biliary obstructions.
4. CT-scan: can be done 6-10 days after
admission; can show condition of
neighboring organs.
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44. Perforated Peptic Ulcer
Disease
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45. CLINICAL FEATURES:
 Patientusuallyhas previousH/O pepticulcer disease,smoking,
NSAID use etc.
 On examination:patientis toxicwithfeaturesof tachycardia,
hypotension,tachypneaand vomiting
 Fever,dehydration,oliguria,
 Tendernessandreboundtendernessseen in abdomen
 Dullnessover flankdue to fluid;obliterationof liver dullness
 Silentabdomen
 P/R examination:tendernessfound.
 Gastriccontenttricklingdown therightpara-colicguttersettles
in theRIF and mighteven mimican acuteappendicitis.
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46. Investigations:
 Plain X-ray abdomen:
It shows crescentic gas shadow under
the domes of the diaphragm (Cupola sign) in
70% of the case.
In the other 30% case there will be no gas
under diaphragm due to leakage of less than 1
mL of gas or due to previous surgeries causing
adhesions.
 Ultrasonography of abdomen: shows
free fluid and gas
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47. Acute Non-specific Mesenteric
Lymphadenitis
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48. Clinical features:
 It is common in the first 10yrs of life, rare beyond 15 years.
 Pain: abdominal colic, usually referred to the umbilicus; not seen in obstructive
appendicitis
 Vomiting: occurs simultaneously with abdominal pain
 Per-abdominal examination:
Inspection: child points to a relatively vague area over and around the umbilicus,
usually at a slightly higher spot than that seen in a. appendicitis.
Palpation: voluntary rigidity is seen; deep palpation after calming/distracting the
child enlarged lymph nodes can be palpated at the region below and to the right
of the umbilicus
Rebound tenderness is absent.
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49. Munchausen Syndrome:
It is an abdominal malingering where the patient usually gives a
long history of his disease. There are usually several scars in the
stomach due to multiple previous surgeries. Regardless of the
patient’s complains the physical examination findings fail to
support this claim.
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50. References:
1. Bailey & Love’s Short Practice Of Surgery 26th Edition
2. Hamilton Bailey’s Demonstration Of Physical Signs In Clinical
Surgery- 17th And 19th Edition.
3. A Manual On Clinical Surgery By S. Das
4. SRB’s Clinical Methods In Surgery
5. Lectures Of Prof. Dr. Khalilur Rahman Sir.
6. Various Scientific Journals and The Internet.
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51. END OF
PRESENTATION
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