Acute Abdomen

Emergency Medicine HO teaching

by Ang Chai Liang
26/01/18
Objectives
• Definition of acute abdomen
• Types of pain
• Causes of acute abdomen and etiology
• Approach to patients with acute abdomen
• Management ( Investigation and treatment)
• Special populations
Define
• acute abdomen (surgical abdomen) an acute intra-abdominal
condition of abrupt onset, usually associated with severe pain due to
inflammation, perforation, obstruction, infarction, or rupture of
abdominal organs, and usually requiring emergency surgical
intervention.
• within 24 hours
Triage
G1 - pain score mild/moderate
Yellow- pain score severe
Red- those with signs of peritonitis / vital signs unstable which require
resuscitation
Pathophysiology of pain

• Types of pain:
1) visceral
2) somatic/ parietal
3) referred
Visceral pain
• Visceral pain arises from visceral
peritoneum
• Stretching of nerve fibres of walls or
capsules of organs
• Crampy
• Dull
• Achy
• Often unable to lie still
• Sensitive to tension but not
mechanical, thermal or chemical
• Bilateral innervation
Somatic/ Parietal pain
• Parietal peritoneum irritated
• Usually anterior abdominal wall
• Localised to the dermatome superficial to the site of painful
stimulus
• Sensitive to mechanical, thermal or chemical stimulation
• Causes guarding & hyperasthaesia
Referred pain
 Visceral pain is sometimes perceived  Foregut  upper abdomen
 Many different origins, with different
as coming from more superficial patterns
areas of the body, often distant from • Stomach
viscus • Duodenum
• Hepatobiliary system
 Afferents from skin and viscera • Pancreas
converge on same neurone  Midgut  mid abdomen
(convergence  projection  Small bowel – jejunum, ileum

 Ascending colon
hypothesis)
 Appendix
 Upper abdo pain  irritation of  Hindgut  lower abdomen
diaphragm  referred to C3,4,5   Hindgut - hepatic flexure  rectum

shoulder pain  Reproductive organs

• Localised tenderness
• Guarding Parietal
• Rigidity
• Rebound
Visceral
• Non specific
Progression
 Division of the Abdomen
Epigastrium
Left
Right hypochondrium
hypochondrium

Umbilical
Left flank/
Right flank/
lumbar
lumbar

Right iliac
Left iliac
fossa
fossa
Suprapubic/
Hypogastrium
1.Oesophagitis
2.Gastritis
3.Gastric Cancer
4.Gastric Ulcers
5.Duodenal Ulcers
6.Pancreatitis
7.Pancreatic Cancer

Epigastrium

Umbilical
 i a c tion
m on far
n
n eu nic I titis tis
a i
1.PSple cre phr ction
2. Pan lone far
3. Pye al In olic
4. Ren al C
5. Ren
6.

Left Upper
Quadrant
Umbilical
Umbilical
1.Renal Colic
Left iliac 2.UTI
3.Sigmoid Volvolus
Fossa 4.Colitis
5.Diverticulitis
6.Ovarian Cyst
7.Salphingitis
8.Ectopic Pregnancy
 Umbilical

Suprapubic

1.Pelvic Appendicitis
2.Salphingitis
3.Cystitis
4.Diverticulitis
5.Uterine Fibroid
6.Ovarian Cyst
1.Renal Colic Umbilical
2.UTI Right iliac
3.Acute Appendicitis Fossa
4.Perforated Caecal
Carcinoma
5.Crohn’s Disease
6.Merkel’s Diverticulitis
7.Salphingitis
8.Cystitis
9.Ectopic Pregnancy
 1.
2. Pne
3. Hep um
4. Hep at on
5. Hep at itis ia
6. Bili at ic T
7. Cho ary ic A um
8. Cho la Co bs or
9. Pye le ngi lic ces
10 Ren lon cys tis s
11 .Re al ep titi
Ap .Re na Inf hri s
pe tro l C arc tis
nd ce oli tio
ic a c c n
iti al
s

Right Upper
Quadrant
Umbilical
1.Aortic aneurysm
2.Intussusception
3.Obstruction
4.Enteritis
5.Infarction
6.Crohn’s Disease
7.Merkel’s Diverticulitis

Umbilical
Central
 Aetiology
 Inflammatory
- bacterial : acute pancreatitis, acute
cholecystitis, acute appendicitis
- chemical : peptic ulcer, acute pancreatitis
 Mechanical
- obstruction : intussusception, crohn’s
disease, gallstone
 Neoplastic : cholangiocarcinoma, CA gallbladder
 Vascular : ruptured abdominal aortic aneurysm,
gangrene of the bowel
 Congenital defects : Meckel’s Diverticulum, duodenal
atresia, diaphragmatic hernia
 Traumatic : stab, gunshot, blunt object causing splenic
rupture
Do not forget medical causes!!!
History
• HPC
• Pain Associated Symptoms –
• Location • Gastro – intestinal
• Characteristic • Genito-urinary
• Radiation • Gynaecologic (including
• Aggravating factors menstrual history )
• Relieveing factors
• Symptoms associated with
• Timing
History
• PMH
• DM
• HT
• Liver Disease
• Renal Disease
• Sexually Transmitted Infections
• PSH
• Abdominal Surgery
• Pregnancies
• Deliveries/ Abortions/ Ectopics
• Trauma
History
• Medications
• NSAIDs
• Steroids
• OCP/ Fertility Drugs
• Narcotics
• Immunosuppressants
• Chemotherapy agent
• Allergics
• Contrast
• Analgesic
High Yield Questions
• Which came first – pain or vomiting?
• How long have you had the pain?
• Constant or intermittent?
• History of cancer, diverticulosis, gall stones,Inflammatory BD?
• Vascular history, HT, heart disease or AF?
Examination
• Lots of information from the end of the bed
• Distressed vs. non distressed
• Lying still - peritonitis
• Writhing – Renal Colic
• Vital Signs
• NEVER ignore abnormal vital signs!
• Always document as part of your assessment

Examine abdomen (inspection, palpation, percussion,

auscultation, look for ingunal hernia, PR, PV PRN)
- Special tests
Investigations
• Bedside:
- Bedside TAS
- UPT
- DXT, serum ketone
- ECG

• Urine: UFEME, Urine diastase

• Blood: FBC, RP, LFT, serum amylase, VBG/ABG, Coag profile, GSH/GXM
* trop I (if suspicious)
• Imaging: CXR, AXR, formal USG, CT, CT angiogram, OGDS/ Colonoscopy
Which of the following is NOT an indication for plain abdominal
imaging?
1. Bowel Obstruction
2. Constipation
3. Tracking Renal Calculi
4. Foreign Body
64 year old p/w acute abdomen to ED, associated
with dysphagia and GERD symptoms for 3 months.
32 year old female, h/o laparoscopic appendicectomy p/w
abdominal pain associated with multiple times vomiting for 1/7.
• Q: 5 ddx of radioopaque seen in
abd x ray?
• USS
• Biliary Disease
• Good for gynae complaints
• Rule out Ectopic pregnancy
• No radiation
• bedside
• CT is accurate for diagnosis of • Avoid repeated CT scans
• Renal colic • Limit use in younger patients
• Appendicitis
•
• Avoid where possible in
Diverticulitis
• AAA
pregnant females
• Intraabdominal Abscesses
• Mesenteric Ischaemia
• Bowel Obstruction
Management
• Resuscitate
• Large bore access
• N Saline bolus 20ml/kg x 2 if shocked
• If bleeding think hypotensive resuscitation
• All should be NBM until provisional diagnosis
• Ensure normothermia
• Maintenance fluids and fluid balance
• Analgesia doesn’t mask signs
• Use a the pain scale
• Morphine titrated to pain. Normally 0.1mg/Kg
• Paracetamol adjunct
• NSAIDs for renal colic
• Correct Electrolytes, Why so important???
• Refer to primary team ASAP.
Evidences
• It was standard practice for many years for clinicians in the ED to
withhold pain medication during the diagnostic process in patients with
acute, severe, undifferentiated abdominal pain, based on a
recommendation proposed by Sir Zachary Cope in a 1957 publication of
a monograph on the subject.The rationale for his recommendation was
that analgesia would impair diagnostic accuracy
• Systematic reviews of the literature are the highest form of evidence.
Reviews over the years, including a 2011 Cochrane review of 8 eligible
studies,have demonstrated that opioid administration during diagnosis
of acute abdominal pain does not increase the risk for diagnostic error
or the risk for error in making decisions about treatment.
Special populations: Low threshold for
investigations and referrals/admission.
Elderly
• May lack physical findings despite having serious pathology
• As patients age increases, diagnostic accuracy declines
• Risk of Vascular Catastrophes
• Assume surgical cause until proven otherwise
• 30-40% of elderly with abdo pain need surgery
• Biliary tract Disease is one of the commonest cause
• Age > 65 need to think of reasons not to CT!
• Mortality is 7% in the over 80’s - equivalent to AMI!
Elderly Patient think Nasties!
• AAA
• Ischaemic Gut
• Bowel Obstruction
• Diverticulitis
• Perforated Peptic Ulcer
• Cholecystitis
Women of Childbearing Age
• Must Ascertain whether PREGNANT
• ALL WOMEN OF CHILDBEARING AGE WITH ABDO PAIN NEED BHCG
• Gravid uterus displaces intra-abdominal organs making presentations
atypical
• Pregnant women still get common surgical abdominal conditions
Bring home messages:
• acute abdomen (surgical abdomen) an acute intra-abdominal condition
of abrupt onset, usually associated with severe pain and usually
requiring emergency surgical intervention.
• Visceral pain may progress to parietal pain, which may indicate viscus
perforation/peritonitis.
• Approach by triage correctly, taking proper history, examination,
investigation to reach proper diagnosis ASAP, give adequate
resuscitation.
• Proper analgesia did not mask the symptoms/ delay diagnosis
• Special population: low threshold for investigate and referral.
REFERENCES & THANK YOU
• https://lifeinthefastlane.com/resources/abdominal-pain-ddx/
• http://www.emed.theclinics.com/article/S0733-8627(11)00014-9/
fulltext
• Baley and Love surgical text book
• https://www.radiologymasterclass.co.uk/
• http://www.ultrasoundpaedia.com/
• Medscape
• https://www.slideshare.net/haitham112002/acute-abdomen-
11051193