ppt. acute abdomen definition and management

1. Acute
Abdomen By
Dr. Haitham A. Hammoud

2. Definition:
• "An acute abdomen" denotes any
sudden, spontaneous, nontraumatic disorder
whose chief manifestation is in the abdominal
area and for which urgent operation may be
necessary. Because there is frequently a
progressive underlying intra-abdominal
disorder, undue delay in diagnosis and
treatment adversely affects outcome

3. • The approach to a patient with an acute
abdomen must be orderly and thorough.
An acute abdomen must be suspected
even if the patient has only mild or
atypical complaints. The history and
physical examination should suggest the
probable causes and guide the choice of
initial diagnostic studies. The clinician
must then decide if in-hospital observation
is warranted, if additional tests are

4. Common Causes of the Acute Abdomen.
• Gastrointestinal tract disorders
 *Nonspecific abdominal pain
 *Appendicitis
 *Small and large bowel obstruction
 *Perforated peptic ulcer
 Incarcerated hernia
 Bowel perforation
 Meckel's diverticulitis
 Boerhaave's syndrome
 *Diverticulitis
 Inflammatory bowel disorders
 Mallory-Weiss syndrome
 Gastroenteritis
 Acute gastritis
 Mesenteric adenitis
 Parasitic infections

5. • Liver, spleen, and biliary tract disorders
 *Acute cholecystitis
 Acute cholangitis
 Hepatic abscess
 Ruptured hepatic tumor
 Spontaneous rupture of the spleen
 Splenic infarct
 Biliary colic
 Acute hepatitis
 Pancreatic disorders
 *Acute pancreatitis

6. • Urinary tract disorders
 *Ureteral or renal colic
 Acute pyelonephritis
 Acute cystitis
 Renal infarct
• Gynecologic disorders
 Ruptured ectopic pregnancy
 Twisted ovarian tumor
 Ruptured ovarian follicle cyst
 *Acute salpingitis
 Dysmenorrhea
 Endometrios

7. • Vascular disorders
 Ruptured aortic and visceral aneurysms
 Acute ischemic colitis
 Mesenteric thrombosis
• Peritoneal disorders
 Intra-abdominal abscesses
 Primary peritonitis
 Tuberculous peritonitis
• Retroperitoneal disorders
 Retroperitoneal hemorrhage

8. Sensory Levels Associated with Visceral
Structures
Structures Nervous System Pathways Sensory Level
Liver, spleen, and Phrenic nerve C3–5
central part of
diaphragm
Peripheral Celiac plexus and T6–9
diaphragm, greater splanchnic
stomach, nerve
pancreas,
gallbladder, and
small bowel
Appendix, colon, Mesenteric plexus T10–11
and pelvic viscera and lesser
splanchnic nerve

9. History
Abdominal Pain
 Location of Pain
 visceral pain :is elicited by distention, by
inflammation or ischemia stimulating the receptor neurons, or by
direct involvement (e.g., malignant infiltration) of sensory nerves.
The centrally perceived sensation is generally slow in
onset, dull, poorly localized, and protracted
 parietal pain : is mediated by both C and A delta nerve
fibers, the latter being responsible for the transmission of more
acute, sharper, better-localized pain sensation. Direct irritation of
the somatically innervated parietal peritoneum (especially the
anterior and upper parts) by pus, bile, urine, or gastrointestinal
secretions leads to more precisely localized pain
 Referred pain :denotes noxious (usually cutaneous)
sensations perceived at a site distant from that of a strong primary

10.  Spreading or shifting pain
parallels the course of the underlying
condition. The site of pain at onset should
be distinguished from the site at
presentation
•
 Mode of Onset and Progression of Pain
The mode of onset of pain reflects the
nature and severity of the inciting process.
Onset may be explosive (within

11.  Character of Pain : The nature, severity, and
periodicity of pain provide useful clues to the
underlying cause
• Sharp superficial constant pain due to severe peritoneal irritation is typical of perforated ulcer or a ruptured
appendix, ovarian cyst, or ectopic pregnancy
• The gripping, mounting pain of small bowel obstruction (and occasionally early pancreatitis) is usually
intermittent, vague, deep-seated, and crescendo at first but soon becomes sharper, unremitting, and better localized
• Unlike the disquieting but bearable pain associated with bowel obstruction, pain caused by lesions occluding
smaller conduits (bile ducts, uterine tubes, and ureters) rapidly becomes unbearably intense
• colic if there are pain-free intervals that reflect intermittent smooth muscle contractions, as in ureteral colic
• "biliary colic" is a misnomer because biliary pain does not remit. The reason is that the gallbladder and bile
duct, in contrast to the ureters and intestine, do not have peristaltic movements
• The "aching discomfort" of ulcer pain
• the "stabbing, breathtaking" pain of acute pancreatitis and mesenteric infarction
• the "searing" pain of ruptured aortic aneurysm

12. • Despite the use of such descriptive terms, the quality of
visceral pain is not a reliable clue to its cause.
• gas stoppage sign : An occasional patient will deny pain but
complain of a vague feeling of abdominal fullness that feels as though it
might be relieved by a bowel movement. It is due to reflex ileus induced by
an inflammatory lesion walled off from the free peritoneal cavity, as in
retrocecal or retroileal appendicitis.
 factors that aggravate or relieve pain
Pain caused by localized peritonitis, especially
when it affects upper abdominal organs, tends
to be exacerbated by movement or deep
breathing.

13. Other Symptoms Associated with
Abdominal Pain
Vomiting When sufficiently stimulated by secondary
visceral afferent fibers, the medullary vomiting centers
activate efferent fibers to induce reflex vomiting. Hence, pain
in the acute surgical abdomen usually precedes
vomiting, whereas the reverse holds true in medical
conditions.
• The absence of bile in the vomitus is a feature of pyloric
stenosis. Where associated findings suggest bowel
obstruction, the onset and character of vomiting may indicate
the level of the lesion.
• Severe, uncontrollable retching provides temporary pain
relief in moderate attacks of pancreatitis.
• The absence of bile in the vomitus is a feature of pyloric
stenosis. Where associated findings suggest bowel
obstruction, the onset and character of vomiting may indicate
the level of the lesion.

14. Constipation
• Reflex ileus is often induced by visceral afferent
fibers stimulating efferent fibers of the
sympathetic autonomic nervous system
(splanchnic nerves) to reduce intestinal
peristalsis. Hence, paralytic ileus undermines the
value of constipation in the differential diagnosis
of an acute abdomen.
• Constipation itself is hardly an absolute
indicator of intestinal obstruction.
• However, obstipation (the absence of

15. Diarrhea
• Copious watery diarrhea is characteristic of
gastroenteritis and other medical causes of an
acute abdomen.
• Blood-stained diarrhea suggests ulcerative
colitis, Crohn disease, or bacillary or amebic
dysentery. It is also common with ischemic
colitis but often absent in intestinal infarction
due to superior mesenteric artery occlusion.

16. Other Specific Symptoms
• Jaundice suggests hepatobiliary
disorders.
• hematochezia or hematemesis, a
gastroduodenal lesion or Mallory-Weiss
syndrome.
• hematuria, ureteral colic or cystitis.
• The passage of blood clots or necrotic
mucosal debris may be the sole evidence
of advanced intestinal ischemia.

17. Other Relevant Aspects of the History :
 Gynecologic History
• The menstrual history is crucial to the diagnosis of
ectopic pregnancy, mittelschmerz (due to a ruptured
ovarian follicle), and endometriosis.
• A history of vaginal discharge or dysmenorrhea may
denote pelvic inflammatory disease.
 Drug History
• Anticoagulants have been implicated in retroperitoneal
and intramural duodenal and jejunal hematomas.
• Oral contraceptives have been implicated in the
formation of benign hepatic adenomas and in
mesenteric venous infarction.
• Corticosteroids, in particular, may mask the clinical
signs of even advanced peritonitis.
• Pyloric perforation has been caused by "crack"

18. Family History often provides the best
information about medical causes of an acute
abdomen
• .
Travel History may raise the possibility of:
• Amebic liver abscess .
• Hydatid cyst.
• Malarial spleen.
• Tuberculosis.
• Salmonella typhi infection of the ileocecal
area.
• Dysentery.

19. • Operation History
• Any history of a previous
abdominal, groin, vascular, or thoracic
operation may be relevant to the current
illness.
• Particular attention to the mode of
operation
(laparoscopic, open, endovascular) and
any anatomic reconstructions may clarify
aspects of the current complaint.
• If possible within the time constraints

20. Physical Examination
• The tendency to concentrate on the abdomen
should be resisted in favor of a methodical and
complete general physical examination.
• A systematic approach to the abdominal
examination.
• One should search for specific signs that confirm
or rule out differential diagnostic possibilities.
 General observation: affords a fairly reliable
indication of the severity of the clinical situation.
• The writhing of patients with visceral pain
(e.g., intestinal or ureteral colic) contrasts with the
rigidly motionless bearing of those with parietal
pain (e.g., acute appendicitis, generalized
peritonitis).

21.  Systemic signs: usually accompany rapidly progressive or
advanced disorders associated with an acute abdomen.
Extreme pallor, hypothermia, tachycardia, tachypnea, and
sweating suggest major intra-abdominal hemorrhage
(e.g., ruptured aortic aneurysm or tubal pregnancy).
 Fever:
• Constant low-grade fever is common in inflammatory
conditions such as diverticulitis, acute cholecystitis, and
appendicitis.
• High fever with lower abdominal tenderness in a young
woman without signs of systemic illness suggests acute
salpingitis.
• Disorientation or extreme lethargy combined with a very high
fever (> 39 C) or swinging fever or with chills and rigors
signifies impending septic shock. This is most often due to
advanced peritonitis, acute cholangitis, or pyelonephritis.
• However, fever is often mild or absent in elderly, chronically
ill, or immunosuppressed patients with a serious acute

22. Examination of the acute abdomen :
 Inspection: The abdomen should be
thoughtfully inspected before palpation.
• A tensely distended abdomen with an old
surgical scar suggests both the presence
and the cause (adhesions) of small bowel
obstruction.
• A scaphoid contracted abdomen is seen
with perforated ulcer. visible peristalsis
occurs in thin patients with advanced
bowel obstruction.

23.  Auscultation: Auscultation of the abdomen
should also precede palpation.
• Peristaltic rushes synchronous with colic
are heard in mid small bowel obstruction
and in early acute pancreatitis.
• They differ from the high-pitched
hyperperistaltic sounds unrelated to the
crampy pain of
gastroenteritis, dysentery, and fulminant
ulcerative colitis.
• An abdomen that is silent except for

24.  . Coughing to elicit pain: Thepatient should
be asked to cough and point to the area of
maximal pain.
• Peritoneal irritation so demonstrated may
be confirmed afterward without causing
unnecessary pain by rigorous testing for
rebound tenderness.
• Unlike the parietal pain of peritonitis, colic
is visceral pain and is seldom aggravated
by deep inspiration or coughing.

25.  Percussion: Percussion serves several
purposes.
• Tenderness on percussion is akin to
eliciting rebound tenderness; both reflect
peritoneal irritation and parietal pain.
• With a perforated viscus, free air
accumulating under the diaphragm may
efface normal liver dullness.
• Tympany near the midline in a distended
abdomen denotes air trapped within
distended bowel loops.

26. • Palpation: Palpation is performed with the
patient resting in a comfortable supine position.
• Guarding is assessed by placing both hands over
the abdominal muscles and depressing the fingers
gently. If there is voluntary spasm, the
muscle will be felt to relax when the patient
inhales deeply through the mouth. With true
involuntary spasm, however, the muscle will
remain taut and rigid ("boardlike") throughout
respiration. Except for rare neurologic disorders—
and, for unknown reasons, renal colic—only
peritoneal inflammation (by reflex afferent

27. • Tenderness that connotes localized peritoneal
inflammation is the most important finding in patients
with an acute abdomen.
• Its extent and severity are determined first by one- or
two-finger palpation, beginning away from the area of
cough tenderness and gradually advancing toward it.
• Tenderness is usually well demarcated in acute
cholecystitis, appendicitis, diverticulitis, and acute
salpingitis.
• If there is poorly localized tenderness unaccompanied
by guarding, one should suspect gastroenteritis or
some other inflammatory intestinal process without
peritonitis.
• Compared with the degree of pain, unexpectedly little
and only vague tenderness is elicited in uncomplicated
hollow viscus obstruction, walled-off or deep-seated

28. • Carnett test: When the patient raises his or
her head from the bed or examination
table, the abdominal muscles will be tensed.
Tenderness persists in abdominal wall
conditions (e.g., rectus hematoma), whereas
deeper peritoneal pain due to intraperitoneal
disease is lessened. Hyperesthesia may be
demonstrable in abdominal wall disorders or
localized peritonitis, but it is more prominent
in herpes zoster, spinal root compression, and
other neuromuscular problems.
• Trigger point sensitivity, lateral costal rib tip

29. • Abdominal masses
Are usually detected by deep palpation. Superficial
lesions such as a distended gallbladder or
appendiceal abscess are often tender and have
discrete borders.
 Murphy sign: If one suspects that abdominal
guarding is masking an acutely inflamed
gallbladder, the right subcostal area should be
palpated while the patient inhales deeply.
Inspiration will be arrested abruptly by pain
(Murphy sign), or the gallbladder fundus may be
felt as it strikes the examining fingers during
descent of the diaphragm.
Deeper masses may be adherent to the
posterior or lateral abdominal wall and are often

30. •If a mass cannot be directly felt?
Even if a mass cannot be directly felt, its presence
may be inferred by other maneuvers:
 Iliopsoas sign A large psoas abscess arising from a
perinephric abscess or perforated Crohn enteritis may
cause pain when the hip is passively extended or
actively flexed against resistance .
 Obturator sign Similarly, internal and external
rotation of the flexed thigh may exert painful pressure
on a loop of the small bowel entrapped within the
obturator canal (obturator hernia).
 Bump tenderness Over the lower costal ribs indicates
an inflammatory condition affecting the
diaphragm, liver, or spleen or its adjacent structures.
While this may suggest a hepatic, splenic, or
subphrenic abscess, it is also common in acute
cholecystitis, acute hepatitis, or splenic infarct.

31. • Inguinal and femoral rings; male genitalia: The inguinal
and femoral rings in both sexes and the genitalia in
male patients should be examined next.
• Rectal examination: Diffuse tenderness is
nonspecific, but right-sided rectal tenderness
accompanied by lower abdominal rebound tenderness
is indicative of peritoneal irritation due to pelvic
appendicitis or abscess. Other useful findings include a
rectal tumor, blood-stained stool, or occult blood
(detected by guaiac testing).
• Pelvic examination: A pelvic examination is vital in
women with a vaginal
discharge, dysmenorrhea, menorrhagia, or left lower
quadrant pain. A properly performed pelvic
examination is invaluable in differentiating among
acute pelvic inflammatory diseases that do not require

32. Investigative Studies
• The history and physical examination by
themselves provide the diagnosis in two
thirds of cases of an acute abdomen.
Supplementary laboratory and radiologic
examinations are indispensable for
diagnosis of many surgical conditions, for
exclusion of medical causes ordinarily not
treated by operation, and for assistance in
preoperative preparation. Test results
must always be interpreted within the

33. General Principles of Timing of Diagnostic Studies in an Acute
Abdomen
Immediate Same Day Next Day
Blood Hematocrit, white Clotting studies, Specific tests.
blood cell count, amylase, liver
urea, creatinine, function tests.
crossmatching,
arterial gases.
Urine Microscopy, Specific tests.
dipstick testing,
culture.
Stool Occult blood. Warm smear,
culture.
Radiography and Chest, abdomen Ultrasonography Repeat abdominal
ultrasound or CT scan, films; barium
angiography, enema or small
water-soluble bowel follow-
upper through,

34. Laboratory Investigations
 Blood Studies:
o Hemoglobin, hematocrit, and white
blood cell and differential counts taken
on admission are highly informative.
• Only a rising or marked leukocytosis (>
13,000/L), especially in the presence of a
shift to the left on the blood smear, is
indicative of serious infection.
• Moderate leukocytosis, commonly
encountered in medical as well as surgical
inflammatory conditions, is nonspecific and
may be even absent in elderly or debilitated
patients with infections.

35. o A specimen of clotted blood for crossmatching should be
sent whenever urgent surgery is anticipated. An additional tube of
clotted blood may be reserved in case of such need.
o Serum electrolytes, urea nitrogen, and creatinine
are important, especially if hypovolemia is expected (i.e., due to
shock, copious vomiting or diarrhea, tense abdominal distention, or
delay of several days after onset of symptoms).
o Arterial blood gas determinations should be obtained in
patients with hypotension, generalized
peritonitis, pancreatitis, possible ischemic bowel, and septicemia.
Unsuspected metabolic acidosis may be the first clue to serious
disease.
o serum amylase :
• A raised serum amylase level corroborates a clinical diagnosis of
acute pancreatitis.
• Moderately elevated values must be interpreted with caution, since
abnormal levels frequently accompany strangulated or ischemic
bowel, twisted ovarian cyst, or perforated ulcer.
• Moreover, a normal or even low amylase value may be seen in

36. o liver function tests (serum bilirubin, alkaline
phosphatase, aspartate aminotransferase, alanine
aminotransferase, albumin, and globulin.are useful to
differentiate medical from surgical hepatic disorders
and to gauge the severity of underlying parenchymal
disease.
o Clotting studies (platelet counts, prothrombin time,
and partial thromboplastin time) and a peripheral
blood smear. be requested if the history hints at a
possible hematologic abnormality (cirrhosis, petechiae,
etc).
o The erythrocyte sedimentation rate: Often
nonspecifically raised in the acute abdomen, is of
dubious diagnostic value; a normal value does not
exclude serious surgical illness.
o Antibody titers: For amebic, typhoid, or viral disease,

37. Urine Tests
• Dark urine or a raised specific gravity reflects
mild dehydration in patients with normal
renal function.
• Hyperbilirubinemia may give rise to tea-
colored urine that froths when shaken.
• Microscopic hematuria or pyuria can confirm
ureteral colic or urinary tract infection and
obviate a needless operation.
o Dipstick testing (for albumin, bilirubin,
glucose, and ketones) may reveal a medical
cause of an acute abdomen.
o Pregnancy tests should be ordered if
there is a history of a missed period.

38. Stool Tests
o Occult fecal blood :
• positive test points to a mucosal lesion
that may be responsible for large bowel
obstruction or chronic anemia, or it may
reflect an unsuspected carcinoma.
o Warm stool smears :for bacteria, ova, and
animal parasites may demonstrate amebic
trophozoites in patients with bloody or
mucous diarrhea.
o Stool samples for culture should be taken
in patients with suspected gastroenteritis,

39. Imaging Studies
o Plain Chest X-Ray Studies : An erect chest x-ray is essential
in all cases of an acute abdomen. it is vital for preoperative
assessment, but it may also demonstrate supradiaphragmatic
conditions that simulate an acute abdomen (e.g., lower lobe
pneumonia or ruptured esophagus). An elevated
hemidiaphragm or pleural effusion may direct attention to
subphrenic inflammatory lesions.
o Plain Abdominal X-Ray Studies: Plain supine films of the
abdomen should be obtained only selectively. erect (or lateral
decubitus) views contribute little additional information except
in suspected intestinal obstruction. Plain films are indicated in
patients who have appreciable abdominal tenderness or
distention, abnormal bowel sounds, a history of abdominal
surgery, suspected foreign body ingestion, or who have a
depressed sensorium or are in a high-risk category. They are
helpful in patients with possible intestinal obstruction or
ischemia, perforated viscus, renal or ureteral calculi, or acute
cholecystitis. They are seldom of value in patients suspected
to have appendicitis or urinary tract infection. They are

40. • An abnormal bowel gas pattern suggests paralytic
ileus, mechanical bowel obstruction, or pseudo-
obstruction. A diffuse gas pattern with air outlining
the rectal ampulla suggests paralytic
ileus, especially if bowel sounds are absent.
Gaseous distention is the rule in bowel
obstruction. Air-fluid levels are usually seen in
distal small bowel obstruction and a distended
cecum with small bowel dilation in large bowel
obstruction. Adynamic ileus associated with
longstanding acute appendicitis or with an atypical
appendix location often produces a pattern that
suggests localized right lower quadrant ileus.
"Thumbprint" impressions on the colonic wall are
noted in about half of patients with ischemic
colitis. A displaced gastric or colonic air shadow

41. • Biliary tree air designates a biliary-enteric
communication, such as a spontaneous or
surgically created choledochoduodenal fistula or
gallstone ileus. Air delineating the portal venous
system characterizes pylephlebitis. Air between
loops of small bowel may arise from a small
localized perforation.
• Obliteration of the psoas muscle margins or
enlargement of the kidney shadows indicates
retroperitoneal disease. Radiopaque densities of
characteristic appearance and location may
confirm a clinical suspicion of biliary, renal
staghorn, or ureteral calculi; appendicitis; or aortic
aneurysm. Whereas pelvic phleboliths are readily

42. o Angiography: Percutaneous invasive angiographic
studies, or magnetic resonance angiography
(MRA), are indicated if intra-abdominal intestinal
ischemia or ongoing hemorrhage is suspected. They
should precede any gastrointestinal contrast study
that might obscure film interpretation. Selective
visceral angiography is a reliable method of
diagnosing mesenteric infarction. Emergency
angiography may confirm a ruptured liver adenoma or
carcinoma or an aneurysm of the splenic artery or
other visceral artery. In patients with massive lower
gastrointestinal bleeding, angiography may identify
the bleeding site, may suggest the likely diagnosis
(e.g., vascular ectasia, polyarteritis nodosa) and may
even be therapeutic if embolization can be performed.
Angiography is of little value in ruptured aortic
aneurysm or if frank peritoneal findings (peritonitis)

43. oGastrointestinal Contrast X-Ray Studies
• should not be requested routinely or be
regarded as screening studies.
• For suspected perforations of the esophagus
or gastroduodenal area without
pneumoperitoneum, a water-soluble contrast
medium (eg, meglumine diatrizoate
[Gastrografin]) is preferred.
• If there is no clinical evidence of bowel
perforation, a barium enema may identify the
level of a large bowel obstruction or even
reduce a sigmoid volvulus or intussusception.
• Only if there is no likelihood of large bowel
obstruction should a barium small bowel

44. o An emergency intravenous urogram is seldom necessary to
evaluate nontraumatic causes of hematuria. It should be
performed electively after microscopic examination of a
stained and centrifuged urine specimen and cystoscopic
examination.
o Ultrasonography : Is useful in evaluating upper abdominal
pain that does not resemble ulcer pain or bowel obstruction
and in investigating abdominal masses. Ultrasonography has a
diagnostic sensitivity of about 80% for acute appendicitis and
is most useful in pregnant patients and those presenting with
features suggestive of atypical appendicitis or in young
women with midabdominal or lower abdominal pain. Color
Doppler studies can distinguish avascular cysts and twisted
masses from inflammatory and infectious processes. CT
scanning may be more useful if excessive bowel gas, so
common in elderly and ill patients, precludes satisfactory
ultrasound examination. It is particularly helpful in pancreatic
and retroperitoneal lesions and any severe localized infections
(eg, acute diverticulitis).

45. o CT Scan:
• Urgent or emergent CT scan of the abdomen is now
generally routinely and rapidly available. This has
proved extremely useful in the evaluation of
abdominal complaints for patients who do not already
have clear indications for laparotomy or laparoscopy.
CT is helpful in identifying small amounts of free
intraperitoneal gas and sites of inflammatory diseases
that may prompt (appendicitis, tubo-ovarian abscess)
or postpone (diverticulitis, pancreatitis, hepatic
abscess) operation. It should not replace or delay
operation in a patient for whom the scan will not
change the decision to operate
o Radionuclide Scans : Liver-spleen scans, HIDA
scans, and gallium scans may be useful for localizing
intra-abdominal abscesses in rare cases. Radionuclide

46.  Endoscopy:
o Proctosigmoidoscopy is indicated in any
patient with suspected large bowel
obstruction, grossly bloody stools, or a rectal
mass. Minimal air should be used for bowel
insufflation. Besides reducing a sigmoid
volvulus, colonoscopy may also locate the
source of bleeding in cases of lower
gastrointestinal hemorrhage that has
subsided.
o Gastroduodenoscopy and endoscopic
retrograde cholangiopancreatography

47.  Paracentesis:
• In patients with free peritoneal fluid, aspiration of
blood, bile, or bowel contents is a strong
indication for urgent laparotomy. On the other
hand, infected ascitic fluid may establish a
diagnosis in spontaneous bacterial peritonitis,
tuberculous peritonitis, or chylous ascites, which
rarely require surgery. Culdocentesis may be
useful for suspected ruptured corpus luteum cyst.
• Peritoneal cytology (obtained by direct aspiration
through a fine catheter) or diagnostic peritoneal
lavage may disclose tumor or an acute intra-
abdominal inflammatory problem. These

48.  Laparoscopy:
• Laparoscopy is now a therapeutic as well as a
diagnostic modality. In young women, it may
distinguish a nonsurgical problem (ruptured
graafian follicle, pelvic inflammatory disease, tubo-
ovarian disease) from appendicitis. In
obtunded, elderly, or critically ill patients, who
often have deceptive manifestations of an acute
abdomen, it may facilitate earlier treatment in
those with positive findings while eliminating the
added morbidity of a laparotomy in negative
cases. Where appendicitis is
confirmed, laparoscopic appendectomy may be
performed. Increasingly, surgeons must acquire

49. Differential Diagnosis
• The age and gender of the patient help in the
differential diagnosis: Mesenteric adenitis
mimics acute appendicitis in the
young, gynecologic disorders complicate the
evaluation of lower abdominal pain in women
of childbearing age, and malignant and
vascular diseases are more common in the
elderly. The clinical picture in early cases is
often unclear. The following observations
should be borne in mind:
 (1) Any patient with acute abdominal pain
persisting for over 6 hours should be
regarded as having a surgical problem

50.  (2) Acute cholecystitis, appendicitis, bowel
obstruction, cancer, and acute vascular conditions are the
most common causes of the surgical acute abdomen in older
patients. In children, appendicitis accounts for one third of all cases
and nonspecific abdominal pain for nearly all of the remainder.
 (3) Acute appendicitis and intestinal obstruction are the
most frequent final diagnoses in cases erroneously believed at first
to be nonsurgical. Appendicitis should always remain a foremost
concern if sepsis or an inflammatory lesion is suspected. It is the
commonest cause of bizarre peritoneal findings that produce ileus or
intestinal obstruction. Half of children with appendicitis present with
a marked facial flush (due to high serotonin levels). The presence of
the gas stoppage sign or x-ray findings of right lower quadrant ileus
should raise the possibility of retrocecal or retroileal appendicitis.
Appendicitis is less likely in previously healthy individuals if the
history exceeds 3 days' duration and the patient has no
fever, appreciable tenderness, ileus, or leukocytosis.
• Pelvic appendicitis, with mild abdominal pain, vomiting, and
frequent loose stools, simulates gastroenteritis. The initial
abdominal signs may be mild and the rectal and pelvic examinations

51.  (4) Salpingitis, dysmenorrhea, ovarian lesions, and
urinary tract infections complicate the evaluation of the
acute abdomen in young women. Many diagnostic errors can
be avoided by taking a careful menstrual history and
performing a pelvic examination and urinalysis. Ultrasound
study and pregnancy tests are helpful in appropriate cases.
Compared with patients with appendicitis, patients with acute
salpingitis tend to present with a longer history of pain, often
related to the menstrual cycle, and to have higher
fever, bilateral pelvic signs, and a markedly elevated white
blood cell count.
 (5) Unusual types or atypical manifestations of intestinal
obstruction, especially early cases, are easily missed.
Emesis, abdominal distention, and air-fluid levels on x-ray
may be negligible in Richter hernia, proximal or closed-loop
small bowel obstructions, and early cecal volvulus.
• Intestinal obstruction in an elderly woman who has not had a
previous operation suggests an incarcerated femoral hernia

52.  (6) Elderly or cardiac patients with severe unrelenting diffuse
abdominal pain but without commensurate peritoneal signs or
abnormalities on plain abdominal films may have intestinal ischemia.
Arterial blood pH should be measured and visceral angiography
performed expediently.
 (7) Medical causes of the acute abdomen should be
considered and excluded if possible before exploratory laparotomy is
planned . Upper abdominal pain may be encountered in myocardial
infarction, acute pulmonary conditions (pneumothorax, lower lobe
pneumonia, pleurisy, empyema, infarction), and acute hepatitis.
Generalized or migratory abdominal discomfort may be felt in acute
rheumatic fever, polyarteritis nodosa and other types of diffuse
vasculitis, acute intermittent porphyria, and acute pleurodynia.
Sharp flank pain, often accompanied by rectus spasm and
cutaneous hyperesthesia, may be caused by osteoarthritis with
thoracic or spinal nerve compression. Likewise, acute bursitis and

53. Medical Causes of an Acute Abdomen for which
Surgery Is Not Indicated
Endocrine and metabolic disorders Infections and inflammatory disorders
Uremia Tabes dorsalis
Diabetic crisis Herpes zoster
Addisonian crisis Acute rheumatic fever
Acute intermittent porphyria Henoch-Schönlein purpura
Acute hyperlipoproteinemia Systemic lupus erythematosus
Hereditary Mediterranean fever Polyarteritis nodosa
Hematologic disorders Referred pain
Sickle cell crisis Thoracic region
Acute leukemia Myocardial infarction
Other dyscrasias Acute pericarditis
Toxins and drugs Pneumonia
Lead and other heavy metal poisoning Pleurisy
Narcotic withdrawal Pulmonary embolus

54. Indications for Surgical Exploration
Indications for Urgent Operation in Patients with an Acute Abdomen.
Physical findings
Involuntary guarding or rigidity, especially if spreading.
Increasing or severe localized tenderness.
Tense or progressive distention.
Tender abdominal or rectal mass with high fever or hypotension.
Rectal bleeding with shock or acidosis.
Equivocal abdominal findings along with septicemia (high fever,
marked or rising leukocytosis, mental changes, or increasing glucose
intolerance in a diabetic patient).
Bleeding (unexplained shock or acidosis, falling hematocrit).
Suspected ischemia (acidosis, fever, tachycardia).

55. • A liberal policy of exploration is advisable
in patients with inconclusive but persistent
right lower quadrant tenderness.
• Pain in the left upper quadrant
infrequently requires urgent laparotomy,
and its cause can usually await elective
confirmatory studies

56. Preoperative Management
• After initial assessment, parenteral analgesics for pain
relief should not be withheld. In moderate
doses, analgesics neither obscure useful physical
findings nor mask their subsequent development.
• Indeed, abdominal masses may become obvious
once rectus spasm is relieved. Pain that persists in
spite of adequate doses of narcotics suggests a
serious condition often requiring operative
correction.
• Resuscitation of acutely ill patients should proceed
based on their intravascular fluid deficits and
systemic diseases.
• Medications should be restricted to only essential
requirements. Particular care should be given to
use of cardiac drugs and corticosteroids and to

57. • A nasogastric tube should be inserted in patients
likely to undergo surgery and for those with
hematemesis or copious vomiting, suspected
bowel obstruction, or severe paralytic ileus.
• A urinary catheter should be placed in patients
with systemic hypoperfusion. In some elderly
patients, it eliminates the cause of pain
(acute bladder distention) or unmasks
relevant abdominal signs.
• Informed consent for surgery may be difficult to
obtain when the diagnosis is uncertain. It is
prudent to discuss with the patient and

58. • For your patience !!!