acute abdomen (3)

8/18/2019 Acute Abdomen (3)

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Acute AbdomenSyed Mohammad Abdullah Bukhari


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The term acute abdomen refers to signs and symptomsof abdominal pain and tenderness, a clinicalpresentation that often requires emergency surgicaltherapy


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Many diseases, some of which are not surgical or evenintra-abdominal, can produce acute abdominal pain andtenderness.

Therefore, every attempt should be made to make acorrect diagnosis so that the therapy selected, often a

laparoscopy or laparotomy, is appropriate.


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The diagnoses associated with an acute abdomen varyaccording to age and gender

Appendicitis is more common in younger individuals,whereas biliary disease, bowel obstruction, intestinalischemia and infarction, and diverticulitis are more

common in older adults.


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Most surgical diseases associated with an acuteabdomen result from

infection,

obstruction,

ischemia, or perforation.


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Nonsurgical causes of an acute abdomen can be dividedinto three categories,

endocrine and metabolic,

hematologic,

and toins or drugs


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!ecause of the potential surgical nature of the acuteabdomen, an epeditious workup is necessary

The workup proceeds in the usual order"

history,

physical eamination,

laboratory tests,

and imaging studies


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ANAT#M$

Abdominal pain is divided into visceral and parietalcomponents.

%isceral pain tends to be vague and poorly locali&ed to theepigastrium, periumbilical region, or hypogastrium,depending on its origin from the primitive foregut, midgut,

or hindgut 't is usually the result of distention of a hollow viscus.

(arietal pain corresponds to the segmental nerve rootsinnervating the peritoneum and tends to be sharper andbetter locali&ed.


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)eferred pain is pain perceived at a site distant fromthe source of stimulus.

*or eample, irritation of the diaphragm may producepain in the shoulder.


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(AT+#(+$'##$

'ntroduction of bacteria or irritating chemicals into theperitoneal cavity can cause an outpouring of fluid from theperitoneal membrane.

The peritoneum responds to inflammation by increasedblood flow, increased permeability, and formation of a

fibrinous eudate on its surface. The bowel also develops local or generali&ed paralysis.

The fibrinous surface and decreased intestinal movementcause adherence between the bowel and omentum orabdominal wall and help locali&e inflammation.


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As a result, an abscess may produce sharply locali&edpain, with normal bowel sounds and gastrointestinalfunction,

whereas a diffuse process, such as a perforatedduodenal ulcer, produces generali&ed abdominal pain,

with a quiet abdomen. (eritonitis may affect the entire abdominal cavity or

part of the visceral or parietal peritoneum.


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(/)'T#N'T'

(eritonitis is peritoneal inflammation of any cause.

't is usually recogni&ed on physical eamination bysevere tenderness to palpation, with or withoutrebound tenderness, and guarding.

(eritonitis is usually secondary to an inflammatoryinsult, most often a gram-negative infection with anenteric organism or anaerobe.

't can result from noninfectious inflammation0 acommon eample is pancreatitis


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(rimary peritonitis occurs more commonly in childrenand is most often caused by Pneumococcus or hemolyticStreptococcus spp.

Adults with end-stage renal disease on peritoneal dialysiscan develop infections of their peritoneal fluid, with the

most common organisms being grampositive cocci. Adults with ascites and cirrhosis can develop primary

peritonitis and, in these cases, the organisms are usuallyEscherichia coli and Klebsiella spp.


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+'T#)$

A detailed and organi&ed history is essential toformulating an accurate differential diagnosis andsubsequent treatment regimen.

1uestions should be open-ended whenever possible,

and structured to disclose the onset, character,location, duration, radiation, and chronology of the paineperienced


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(ain identified with one finger is often more locali&edand typical of parietal innervation or peritonealinflammation

as compared with indicating the area of discomfort withthe palm of the hand, which is more typical of thevisceral discomfort of bowel or solid organ disease.


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The intensity and severity of the pain are related to theunderlying tissue damage.

udden onset of ecruciating pain suggests conditionssuch as intestinal perforation or arterial emboli&ationwith ischemia, although other conditions, such as biliary

colic, can present suddenly as well. (ain that develops and worsens over several hours is

typical of conditions of progressive inflammation orinfection such as cholecystitis, colitis, and bowelobstruction.


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The history of progressive worsening versusintermittent episodes of pain can help differentiateinfectious processes that worsen with time compared

with the spasmodic colicky pain associated with bowelobstruction, biliary colic from cystic duct obstruction,or genitourinary obstruction


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/qually as important as the character of the pain is its location andradiation.

Tissue in2ury or inflammation can trigger visceral and somatic pain.

olid organ visceral pain in the abdomen is generali&ed in the quadrant of

the involved organ, such as liver pain across the right upper quadrant ofthe abdomen.

mall bowel pain is perceived as poorly locali&ed periumbilical pain,

whereas colon pain is centered between the umbilicus and pubis symphysis


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As inflammation epands to involve the peritonealsurface, parietal nerve fibers from the spine allow forfocal and intense sensation

This combination of innervation is responsible for theclassic diffuse periumbilical pain of early appendicitisthat later shifts to become an intense focal pain in theright lower abdomen at Mc!urney3s point


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Activities that eacerbate or relieve the pain are alsoimportant.

/ating will often worsen the pain of bowel obstruction,biliary colic, pancreatitis, diverticulitis, or bowel perforation.

*ood can provide relief from the pain of nonperforated

peptic ulcer disease or gastritis (atients with peritoneal inflammation will avoid any activity

that stretches or 2ostles the abdomen. They describeworsening of the pain with any sudden body movement andreali&e that there is less pain if their knees are fleed.


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Associated symptoms can be important diagnostic clues.

Nausea, vomiting, constipation, diarrhea, pruritis,melena, hematuria can all be helpful symptoms ifpresent and recogni&ed.


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%omiting may occur because of severe abdominal pain of anycause or as a result of mechanical bowel obstruction or ileus.

%omiting is more likely to precede the onset of significantabdominal pain in many medical conditions,

whereas the pain of an acute surgical abdomen presents firstand stimulates vomiting via medullary efferent fibers that aretriggered by visceral afferent pain fibers.


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4onstipation can be a result of mechanical obstruction ordecreased peristalsis.

't may represent the primary problem and require laativesand prokinetic agents, or merely be a symptom of anunderlying condition.

A careful history should include whether the patient iscontinuing to pass any gas or stool from the rectum.

A complete obstruction is more likely to be associated withsubsequent bowel ischemia or perforation caused by themassive distention


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5iarrhea is associated with several medical causes ofacute abdomen, including infectious enteritis,inflammatory bowel disease or parasitic contamination.

!loody diarrhea can be seen in these conditions, as well

as in colonic ischemia


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(revious illnesses or diagnoses can greatly increase or decreasethe likelihood of certain conditions that would otherwise not bestrongly considered.

for eample, report that the current pain is similar to the kidneystone passage that they eperienced a decade previously.

#n the other hand, a prior history of appendectomy, pelvicinflammatory disease, or cholecystectomy can significantlyinfluence the differential diagnosis.


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Medications can both create acute abdominal conditions oralternatively mask their symptoms.

ynecologic health, specifically the menstrual history, iscrucial in the evaluation of lower abdominal pain in a young

woman. The likelihood of ectopic pregnancy, pelvic inflammatory

disease, mittelschmer&, and6or severe endometriosis are allheavily influenced by the details of the gynecologic history.


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(+$'4A /7AM'NAT'#N

An organi&ed and thoughtful physical eamination iscritical to the development of an accurate differentialdiagnosis and the subsequent treatment algorithm

(atients with peritoneal irritation will eperienceworsened pain with any activity that moves or stretchesthe peritoneum.

These patients will typically lie very still in bed during theevaluation and often maintain fleion of their knees andhips to reduce tension on the anterior abdominal wall.


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Abdominal inspection should address the contour of theabdomen, including whether it appears distended orscaphoid or whether a locali&ed mass effect is observed.

attention should be paid to all scars present and, ifsurgical in nature, should correlate with the surgicalhistory provided.

/vidence of erythema or edema of skin may suggestcellulitis of the abdominal wall, whereas ecchymosis issometimes observed with deeper necroti&ing infections ofthe fascia or abdominal structures, such as the pancreas.


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Auscultation can provide useful information about thegastrointestinal tract and vascular system.

!owel sounds are typically evaluated for their quantity and quality.

A quiet abdomen suggests an ileus, whereas hyperactive bowelsounds are found in enteritis and early ischemic intestine.

Mechanical bowel obstruction is characteri&ed by high-pitched

tinkling sounds that tend to come in rushes and are associated withpain.

*ar away, echoing sounds are often present when significantluminal distention eists.


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!ruits heard within the abdomen reflect turbulentblood flow in the vascular system.

These are most frequently encountered in the settingof high-grade arterial stenoses 89:; to


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(ercussion is used to assess for gaseous distention of the bowel, free intra-abdominal air, degree of ascites, and6or presence of peritonealinflammation.

+yperresonance, commonly termed tympany to percussion, ischaracteristic of underlying gas-filled loops of bowel. 'n the setting of bowelobstruction or ileus, this tympany is heard throughout all but the right

upper quadrant, where the liver lies beneath the abdominal all.

'f locali&ed dullness to percussion is identified anywhere other than theright upper quadrant, an abdominal mass displacing the bowel should beconsidered.

>hen liver dullness is lost and resonance is uniform throughout, freeintraabdominal air should be suspected. This air rises and collects beneath

the anterior abdominal wall when the patient is in a supine position.


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Ascites is detected by looking for fluctuance of theabdominal cavity. A fluid wave or ripple can be generated bya quick firm compression of the lateral abdomen. Theresulting wave should then travel across the abdominal wall.

Movement of adipose tissue in the obese abdomen can bemistaken for a fluid wave. *alse-positive eaminations can

be reduced by first pressing the ulnar surface of theeaminer3s open palm into the midline soft tissue of theabdominal wall to minimi&e any movement of the fattytissue while generating the wave with the opposite hand.


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The ma2or step in the abdominal eamination ispalpation.

(alpation typically provides more information than anyother component of the abdominal eamination

reveals the severity and eact location of the abdominalpain,

can further confirm the presence of peritonitis andidentify organomegaly or an abnormal mass lesion.


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(ain, when focal, suggests an early or well-locali&ed diseaseprocess,

whereas diffuse pain on palpation is present with etensiveinflammation or a late presentation.

'f pain is diffuse, careful investigation should be carried out todetermine where the pain is greatest.

/ven in the setting of etreme contamination from perforatedpeptic ulcers or colonic diverticula, the site of maimaltenderness often indicates the underlying source.


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Numerous unique physical findings have come to beassociated with specific disease conditions and are welldescribed as eamination signs


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A digital rectal eamination needs to be performed inall patients with acute abdominal pain, checking for thepresence of a mass, pelvic pain, or intraluminal blood.

A pelvic eamination should be included for all women

when evaluating pain located below the umbilicus. ynecologic and adneal processes are best

characteri&ed by a thorough speculum and bimanualevaluation.

b t t di


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aboratory tudies


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'maging tudies

(l i di h


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(lain radiographs

?pright chest radiographs can detect as little as @ m of air in2ectedinto the peritoneal cavity.

ateral decubitus abdominal radiographs can also detectpneumoperitoneum effectively in patients who cannot stand0 aslittle as = to @: m of gas may be detected with this technique.

These studies are particularly helpful for patients suspected ofhaving a perforated duodenal ulcer, because approimately 9=; ofthese patients will have a large enough pneumoperitoneum to be

visible


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(lain films also show abnormal calcifications.

Approimately =; of appendicoliths, @:; of gallstones,and


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?pright and supine abdominal radiographs are helpful in identifyinggastric outlet obstruction, and obstruction of the proimal, mid, ordistal small bowel.

They can also aid in determining whether a small bowel obstructionis complete or partial by the presence or absence of gas in the colon.

4olonic gas can be differentiated from small intestinal gas by thepresence of haustral markings caused by the taenia coli present inthe colonic wall. An obstructed colon appears as distended bowelwith haustral markings


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(lain films can also suggest volvulus of the cecumorsigmoid colon.

4ecal volvulus is identified by a distended loop of colon in

a comma shape, with the concavity facing inferiorly and tothe right.

igmoid volvulus characteristically has the appearance of abent inner tube, with its ape in the right upper quadrant


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Abdominal ultrasonography


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Abdominal ultrasonography

etremely accurate for detecting gallstones and assessinggallbladder wall thickness and presence of fluid around thegallbladder

't is also helpful for determining the diameter of theetrahepatic and intrahepatic bile ducts.

Abdominal and transvaginal ultrasonography can aid in thedetection of abnormalities of the ovaries, adnea, and uterus.

?ltrasound can also detect intraperitoneal fluid.


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The presence of abnormal amounts of intestinal air inmost patients with an acute abdomen limits the abilityof ultrasonography to evaluate the pancreas or other

abdominal organs.

4T scans


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4T scans

As 4T has become more widely available and less likely to behindered by abdominal air it is becoming the secondaryimaging modality of choice in the patient with an acuteabdomen, following plain abdominal radiography.

Many of the most common causes of the acute abdomen are

readily identified by 4T scanning, as are their complications.

/amples include acute appendicitis, acute pancreatitis andcomplications

5iagnostic aparoscopy


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5iagnostic aparoscopy

(urported advantages include a high sensitivity andspecificity, the ability to treat a number of theconditions causing an acute abdomen laparoscopically,and decreased morbidity and mortality, length of stay,and overall hospital costs.

5iagnostic accuracy is high0 the accuracy ranges from


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(/)'T#N/A A%A/

peritoneal lavage can provide information that suggests pathologyrequiring surgical intervention.

The lavage can be performed under local anesthesia at the patient3sbedside.

A small incision is made in the midline ad2acent to the umbilicus anddissection is carried down to the peritoneal cavity.

A small catheter or '% tubing is inserted and @::: m of saline isinfused. A sample of fluid is allowed to siphon back out into theempty saline bag and is then analysed for cellular or biochemicalanomalies.

This technique can provide sensitive evidence of hemorrhage orinfection, as well as some types of solid or hollow organ in2ury


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A#)'T+M 'N T+/ A4?T/ A!5#M/N


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A#)'T+M 'N T+/ A4?T/ A!5#M/N


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