1. Acute Abdomen: Medical or
Surgical

2. Introduction:
 The term “Acute Abdomen” denotes any
sudden, disorder whose chief manifestation is in the
abdominal area.
 Evaluation of acute abdomen must be efficient and
should lead to an accurate diagnosis early in the
presentation.
 So that the treatment of patients who are seriously ill
is not delayed and patients with self limited disorder
are not over treated.

3. The Epidemiology of Acute
Abdominal Pain
 5-10% of all patients comes to hospital with
acute abdomen.
 Among them 14-40% patients need surgical
intervention.
 So prompt diagnosis is important to prevent
morbidity and mortality.

4. Medical causes:
Metabolic/Haematologic :
 1)Familial metabolic : Acute intermittent
porphyria, Haemochromatosis.
 2)Endocrine: Diabetic ketoacidosis, Addisonian crisis.
 3)Haematologic: Sickle cell crisis, Leukaemia, Acute
haemolytic state.
Inflammatory condition:
 Infections : Enteric infections, spontaneous bacterial
peritonitis, Hepatitis, AIDS related disorders, Mumps.

5.  Non infectious: Acute rheumatic fever, SLE
,Henoch Schoenlein purpura , Inflammatory bowel
disease, Pancreatitis.
 Drugs: Heavy metal poisoning (lead ,mercury
,Arsenic , Copper) NSAIDS, Anticoagulants, narcotic
, steroid withdrawal, snake bite , black widow spider
bite.

6. Referred : Extraperitoneal
causes:
 Pulmonary: Pnemonia ,Pulmonary embolism
Pleurisy.
 Cardiac: Acute MI, Pericarditis.
 Urologic: Pyelonephritis , Renal infarct, Cystitis,
Prostatis.
 Neurological / spinal : Multiple sclerosis, Tabes dorsalis, Herpes
zoster ,Abdominal migraine.

7. Surgical causes:
 Hemorrhage: Solid organ trauma ,Leaking or ruptured arterial
aneurysm, Ruptured ectopic Pregnancy ,Intestinal
ulcers, Hemorrhagic Pancreatitis, Spontaneous rupture of
spleen.
 Infection: Appendicitis, Cholecystitis, Meckel’s
diverticulitis, Hepatic abscess, Psoas abscess.
 Perforation: Perforated gastrointestinal ulcer, Perforated
gastrointestinal cancer.
 Blockage: Adhesion induction small, large bowel
obstruction, Sigmoid volvulus, Cecal volvulus, Gastrointestinal
malignancy , Intussusception.
 Ischemia: Mesentric thrombosis/embolism, testicular
torsion, Ischemic colitis, Ovarian torsion, Strangulated
hernia.

8. Approach:
 Approach to a patient with an Acute abdomen must be
orderly.
An Acute Abdomen must be suspected even if the patient has
only or atypical complaints.
 The history and physical examination should suggest the
probable causes and guide the choice of initial diagnostic
studies.

9. The History
 An accurate history is the essential foundation for the
diagnosis of abdominal pain. This requires time, patience, and
skill.
The way patients tell their story is as important as the story
itself.
 Any additional questions should be short, specific, and direct
and must be in language the patient understands.
 Negative findings are always as useful as positive ones.
 Unnecessary or irrelevant facts can be misleading and will
always add to the difficulties in analysis.

10.  Pain is the most comman and predominant presenting feature of
an acute abdomen ,careful consideration of the location , mode
of onset and progression and character of pain .
 Pain
 When?Where? How?
 Abrupt, gradual
 Character
 Sharp, burning, steady,
 intermittent
 Referral?
 Previous occurrence?

11. Three Types of Abdominal Pain
 Visceral Pain
 Somatic (Parietal) Pain
 Referred Pain

12.  Visceral Pain
 Within the muscular walls
of hollow organs and the
capsules of solid organs.
 Stimulated primarily by
stretching, distension, and
excessive contractions.
 Characteristically deep,
dull, aching or cramping,
and poorly localized.
 Usually felt in the midline,
unaccompanied by
tenderness.

13.  Somatic (Parietal) Pain
 Characteristically sharper, aggravated by
stimulation of the parietal peritoneum with
movement, coughing, or walking.
 True parietal pain indicates surgical cause of
abdominal pain.

14.  Referred Pain
 Pain felt a site other than
that of the primary
noxious stimulus.
 Occurs in an area
supplied by the same
neurosegment as the
involved organ.
 Most visceral pain is of
this type.
 Usually intense and
most often secondary to
an inflammatory lesion.

15. Other Symptoms Associated :
 Vomiting. Distension of abdomen.
 Fever : High grade with or without chills. Loss of appetite
 Jaundice
 Hematochezia or Hematemesis
 Frequency and urgency of urine
 Diarrhea.
 Constipation
 Obstipation

16. Relevant aspects :
 Gynecological history.
 Drug history.
 Family history.
 Travel history.
 Psycho social history.
Personal history.
Occupational exposure
Operation history

17. PHYSICAL EXAMINATION
 The patient’s general appearance and
vital
signs can help narrow
the differential diagnosis.
 Overall appearance:
 ( Facial expression, pallor,
and degree of agitation,
Detail
examination of heart , lungs and
skin)
 Walking and recumbent.
 Vital signs
 Temperature
 Tachycardia
 Hypotension

18. General Observation:
 Fairly reliable indicator of the severity of the
clinical situation.
 The writhing of the patients with visceral pain
,contrasts with the rigidly motionless bearing of
those with parietal pain.
 Diminished responsiveness or altered sensorium
often precedes imminent cardiopulmonary
collapse.

19. Differential Diagnosis :RUQ
Pain:
 Investigations:
 Xray:
Upright chest
Upright and supine abdominal.
Ultrasound.
ECG
 Complete Blood count.
 Urinalysis.
 Amylase, Creatinine, BUN,
Electrolytes.

21. RLQ
 Investigations
 Urinalysis (to exclude
obvious urinary causes)
 Pregnancy test( female of
childbearing age)
 Ultrasound
 Complete blood count
 Stool test.

23. Gynecologic causes of LQ Pain:

24. DD of LUQ and Epigastric:
 Investigations
 Upright chest XR
 Upright and supine
abdominal XR
 Ultrasound.
 ECG.
 Complete blood
counts
 Amylase and lipase .

25. Periumblical:
 Investigations
 CBC.
 Ultrasound.
 Amylase and lipase.
 Erect and supine
abdominal XR
 Stool tests

26. LLQ:
 Pregnancy test(female of
childbearing age)
 Urinalysis
 Ultrasound
 Complete blood count
 Upright and supine
abdominal XR
 CT scan( if diverticular
disease is suspected)

27.  Rectal examination :
 The right wall may be tender in pelvic type appendicitis, and often
tenderness is elicited in the rectovesical pouch in perforated peptic
ulcer.
 In intussusception the gloved finger to be smeared with mucus and
blood.
 The bulging of the anterior wall of the rectum with tenderness is
significant of a pelvic abscess.
 Vaginal examination:
 Purulent discharge and tenderness in both fornices are suggestive of
Acute Salpingitis.
 In Ruptured Ectopic Gestataion the cervix feels softer and any
movement of cervix will initiate pain.

28. Special signs:
sign Description condition
Aaron Pain or pressure in epigastrium or anterior
chest with persistent firm pressure applied to
Mc Burney point
Acute appendicitis
Blumberg Transient abdominal wall rebound tenderness Peritoneal inflammation
Carnett Loss of abdominal tenderness when
abdominal wall muscles are contracted
Intra abdominal source of a
abdominal pain
Charcot Intermittent Right upper abdominal pain
,Jaundice , Fever.
choledocholithiasis

29. Special signs:
Claybrook Accentuation of breath and cardiac
sounds through abdominal wall .
Ruptured
abdominal viscus
Courvoisier Palpable gall bladder in presence of
jaundice
Periampullary
tumor
Cullen Periumbilical bruising Haemo peritoneum
Fothergill Abdominal wall mass that does not cross
midline and remains palpable when rectus
contracted
Rectus muscle
hematomas
GreyTurner Local area of discoloration around
umbilicus and flanks
Acute hemorrhagic
pancreatitis

30. Special Signs
Kehr Left shoulder pain when
supine and pressure placed
on left upper abdomen
Hemoperitoneum
(especially from splenic
origin)
Murphy Pain caused by inspiration
while applying pressure to
right upper abdomen
Acute cholecystitis
Obturator Flexion and external rotation
of Right thigh while supine
creates hypogastric pain
Pelvic abscess or
inflammatory mass in pelvis
Rovsing Pain in Mc Burney’s point
when compressing the left
lower abdomen
Acute appendicitis

31. Approach TO Acute Care:
 Airway: Is the patient able to maintain an
airway?
Risk for aspiration of vomit or oral secretions.
 Breathing : how effectively is the patient
breathing? Rapid and shallow , use of
accessory muscles.
 Circulation: Is the patient is in shock?, is there
any evidence of active bleeding.

32. Immediate Treatment of the Acute
Abdomen
Start large bore IV with either saline or lactated Ringer’s
Solution.
Provide pain relief by IV Analgesics NSAIDS,Opioids,H2 receptor
blocker and PPI.
Provide other symptomatic relief (e.g., antiemetics, antispasmodics).
Nasogastric tube if vomiting or concerned about obstruction.
Foley catheter to follow hydration status and to obtain Urinalysis.
Antibiotic administration if suspicious of inflammation Or Perforation.
Careful follow-up with frequent re examination (by the same examiner,
when possible)
Definitive therapy or procedure will vary with diagnosis