How to approach acute abdomen?

1. ACUTE ABDOMEN
Dr. MUHAMMED MUNEER MBBS MS DNB
ASST. PROFESSOR DEPT. OF GENERAL SURGERY
GOV'T TD MEDICAL COLLEGE ALLAPPUZHA.

2. 20 yrs. man referred to surgery casualty with h/o diffuse abdominal pain & diarrhea for 1 day.
h/o abdominal pain 1 month back. He was febrile, abdomen was soft & tenderness in all quadrants.
no rebound or guarding.

3. Assessment inv & diagnostic investigations
Raised CRP and ESR
Free fluid on USG

6. Paul Valery
“To see is to forget the name the thing one sees”

7. QUESTION
ACUTE ABDOMEN ? Characterized by any sudden, spontaneous, non-traumatic, severe
abdominal pain of <24 hrs. duration.
Requires rapid & specific diagnosis, as several conditions need emergency operation
Any delay in diagnosis & treatment may adversely affect outcome.

8. COMMON CAUSES OF ACUTE ABDOMEN

9. MEDICAL CAUSES OF ACUTE ABDOMEN

10. DIAGNOSIS OF ACUTE ABDOMEN
History
Abdominal pain & other symptoms associated.
Past medical / Surgical history
Gynaecological history
Drug history
Family history
Travel history
Physical examination
Laboratory investigation
Imaging studies
Diagnostic Lap/OGD/Colonoscopy

11. ABDOMEN PAIN
Pain is the most common & predominant presenting feature.
Careful consideration of the -
Locations
Severity
Mode of onset & progression
The Character of the pain will suggest a list of diagnoses.
Visceral
Parietal
Referred & shifting pain
What kind of pain is it?

12. VISCERAL PAIN
Distension
Inflammation
Ischemia
Malignant infiltration of sensory nerves
Slow in onset, dull, poorly localised
Felt in the midline -B/L sensory supply to the spinal
cord.

13. PARIETAL PAIN
Direct irritation of parietal peritoneum by
Pus
Bile
Blood
Urine
GI secretions.
More A/c sharper, better localised pain.
U/L sensory supply to the spinal cordT6 L1 areas

14. REFERRED PAIN
Referred pain
Extension of the pain from original site to another site with persisting pain at the original site.
Spreading or Shifting pain
Origin of the pain at one site, shift to another site where pain at the initial side disappear
Typical site of various abdominal pain

15. REFERRED PAIN LOCATIONS

16. CHARACTER OF PAIN
Colicky pain -sharp intermittent, gripping pain
• Obstruction to a hollow organ (Hepatobiliary, bowel, ureteric, fallopian tube)
Constant burning pain
• F/o peritonitis
Severe agonising pain
• Characteristics of A/c pancreatitis
Throbbing pain - S/o inflammation (Cholecystitis)
Changing in character of pain – ie. colicky pain sometimes change into constant pain
• indicate strangulation

17. Characteristics of vomitus with abdomen pain
Bilious green
Intestinal obstruction, malrotation or sepsis
Coffee ground
Gastritis, gastric ulcer, esophagitis
Fresh blood
Esophagitis. Gastritis, gastric or duodenal ulcer, mallory-weiss centre
Food or stomach content
Gastroenteritis, early SBO
Feculent
Late intestinal content.

18. Other symptoms assoc. with Abdominal pain
Constipation :Suggest mechanical bowel obstruction
Diarrhoea : Pelvic abscess
Blood Stained stool : Ischemic colitis, IBD
Fever : Marker of inflammation
Anorexia
Hematemesis
Hematochezia or Malena : LGI bleed or colonic Ischemia
Hematuria : Urolithiasis or cystitis, UTI

19. PAST MEDICAL HISTORY
1. Pulmonary TB
2. Cardiac disease AF
3. APD
4. Biliary colic & Pancreatitis
5. IBD
6. Abdominal trauma: Delayed splenic bleeding
PAST SURGICAL HISTORY
1. Previous abdominal surgery
2. Mode of operation –
Laparoscopic, Open, Endovascular
3. Operative notes & pathology reports should be
obtained & reviewed

20. Other relevant aspects of the History
GYNAECOLOGICAL HISTORY
1. Menstrual history
- Ectopic pregnancy
- Mittelschmerz (Ruptured ovarian follicle )
- Endometriosis
2. H/o Vaginal d/d or dysmenorrhea may
denote PID
NSAID, Anticoagulant,
OCP,Corticosteroids
Hereditary pancreatitis
Amoebic liver abscess , Hydatid cyst
Malarial spleen , Tuberculosis
Salmonella typhi
Dysentery

21. PHYSICAL EXAMINATION
1. Appearance
Hippocratic facie’s of dehydration
2. Attitude
3. Vitals pulse
BP, RR, Temperature, Dehydration, SPO2
Anaemia, Cyanosis, Jaundice

22. ABDOMINAL EXAMINATION
INSPECTION
Abdominal contour
Respiratory movement
Peristaltic movement
Visible swelling
Hernial orifices
Scrotum
Renal angle
Skin condition
PALPATION
Tenderness
Rebound
Guarding
Rigidity
Distension
Lump
Hernia site

23. SPECIAL SIGN
4 signs : Helpful in deciding ..
is this an Acute abdomen?
Pointing test / pointing sign
Cough test
Rebound tenderness/ Release sign/ Blumberg sign
Bed shaking test/ Bapats sign
Alders sign:
Shifting tenderness helpful to differentiate b/w Appendicitis with Uterine origin tenderness

24. IMPORTANCE SIGN
Murphy’s sign : A/c cholecystitis
Kehr’s sign- Splendid rupture
Mc-burneys sign- Appendicitis
Iliopsoas sign – Appendicitis
Rovsin sign- Appendicitis
Grey turners sign- Hemoperitoneum
Chandelier sign- PID
Dance sign – Intussusception ( Empty RLQ & mass RUQ)

25. OTHER EXAMINATION
Percussion
Shifting dullness - Presence of free fluid
Obliteration of liver dullness – Pneumoperitoneum
Auscultation
Hyper peristalsis (early)
Silent abdomen (late)
Rectal examination
Vaginal examination
Tenderness on PR / PV (pelvic peritonitis )
Blood stain, malena

26. what kind of tests should you order ?
what you are looking for!
DIFFERENTIAL DIAGNOSIS
IT’S HUGE!
Use History & Physical exam to narrow it down..
R/o life-threatening pathology
Provisional diagnosis lead investigation..

27. ASSESSMENT & DIAGNOSTIC INVESTIGATION
BLOOD INVESTIGATION:
CBC – Hb TC Neutrophil count ( Ectopic, UGI, LGI Bleed, widal)
ESR
CRP
PLC ( IgM Lepto Dengu ) ( CLD?)
PBS
BLOOD C&S ( Cholangitis Pyelonephritis Sepsis)
Blood group
S. Electrolytes- Na+, K+ , Ca2+ ( DKA, Hyperparathyroidism) P04
RBS (DKA)
WBC & CRP Combination NPV 92.3%
Gronroos & gronroos et al
Ortega- Deballon et al
TRIPPLE SCREEN of WBC CRP & NEUTROPHIL
Mohammed et al NPV 81%
Yang et al – WBC < 10500 P < 75%, Normal CRP-
Sensitivity 99.2%

28. LFT
• Bilirubin- TB, DB (obstructive J)
• OT/PT ( Hepatitis)
• S. Albumin (CLD)
• ALP
S. amylase , S. lipase
PT INR aPTT
S Gastrin ( OGD USG Correlation)
RFT- Blood Urea , S. Creat.
Screening
TSH T4- Toxicity
Beta HCG

29. URE
RBC – Urolithiasis/ UTI
Pus cell- Urolithiasis / UTI/ TB
Sugar (DKA)
Albumin (CKD)
Crystals
Urinary 5-HIAA (as an early marker of Appendicitis)
Dipstick test for bilirubin & ketones
UPT
ABG- Lactate, Metabolic acidosis (mesenteric ischemia)
ECG
• AF/ NSR
• Ischemic change
• Chamber abnormality ( mesenteric ischemia)
• Electrolyte abnormality
25% Appendicitis -hematuria, pyuria & albuminuria
Urinalysis abnormal in 19-40%
.

30. IMAGING STUDIES
X-ray chest :
Free gas under diaphragm
Lower lobe consolidation
Elevated hemidiaphragm
Pleural effusion
X-ray chest is more sensitive than abdominal x-ray for Pneumoperitoneum
1ml air produce pneumo in errect CXR
5 to 10 ml air pick up in lateral decubitus position (after 10 minutes)

31. ABDOMINAL X-RAY
Multiple air fluid level
3, 6, 9, rules (3cm 6cm 9cm)
String of pearls sign
Step ladder pattern
Pneumoperitoneum
Thumb print sign
Calculus
Calcification ( pancreatic )
Pneumatosis intestinalis
Intra-peritoneal and retroperitoneal collection
Radio opaque
90% renal stone
10% gall stone
5% appendicolith

32. Multiple air fluid level
Large bowel obstruction

33. COFFEE BEAN sign in
SIGMOID VOLVULUS

34. Thumb-printing Sign
(Signifying Bowel wall oedema and thickening)
Step ladder pattern

35. Calcification ( pancreatic )Staghorn Calculus

36. Gas in the Portal Vein Pneumatosis Intestinalis
(Gas in the wall of small bowel)

37. .
CT shows distended small bowel loops that are not seen
on x-ray abdomen because they are filled with fluid only
& do not contain intraluminal air
Plain x- ray -showing no abnormalities

38. ULTRASONOGRAPHY
Inflammatory conditions, Stone disease (KUB, GB)
Good for diagnosing AAA (not for ruptured AAA )
Good for pelvic pathology, Free fluid collection
Most useful in pregnant patients (no radiation)
Distinguish from inflammatory & infectious processes
Evaluation for flow through the Mesentric vesssels.
Obesity, Following previous surgery, Ascites
Gaseous distension of bowel

39. CT SCAN
…Among pts those do not already have clear indications for laparotomy or laparoscopy
Provides excellent diagnostic accuracy.
Unknown diagnosis?
Intractable abdominal pain (infection or vascular lesion ?)
Plain CT- Free air, Renal colic, Ruptured AAA, Bowel obstruction
Contrast study -Abscess, Infection, Inflammation, unknown cause
MRI - most often used when unable to obtain CT due to contrast issue
1.children's and elderly
2.Obese
3.Critically ill patients
4.Immunocompromised pt.

40. Gas in Mesenteric
Vein
Gas in Bowel wall
(Pneumatosis intestinalis)
CECT abdomen

41. RADIOLOGY
Two-step radiological approach of an acute abdomen.
1. Confirm or exclude the most common disease
2. Screen for general signs of pathology by systematically screening the whole abdomen.

42. Inflamed fat
Hyperechoic space & non-compressible at USG
Fat-stranding at CT
Points out where & what the problem is.
As a rule, the organ or structure in the centre or nearest to the inflamed fat is the cause of the
inflammation.
inflamed fat at sonography
normal abdominal or subcutaneous fat
Omental infarction
Plain CT of fatty
tissue with
slightly increased
density
(arrowheads), in
the RUQ. Compare
this to normal
low-density S/C
fat

43. Bowel wall thickening
Indicates inflammation or Tumor
Extensive differential diagnosis.
Small bowel thickening indicates regional inflammation as small bowel tumors (carcinoid, lymphoma,
gist) are rare.
Local colonic wall thickening a carcinoma is a prime concern.
Diffuse colonic thickening seen in colitis.

44. ileus
Pathologic distention of bowel loops by an Obstruction or Paralysis.
Firstly determine which parts of the bowel is affected: small bowel, large bowel, or both.
Look for normal non-distended bowel loops - if present, strongly suggest an Obstructive cause.
intussusception
Ileus without any normal bowel loops strongly suggests a Paralytic cause

45. SBO4%
Diagnosis is made when you see dilated & collapsed small bowel loops.
Identify its cause & location.
Adhesion SBO has a smooth transition from dilated to collapsed small-bowel loops
Small bowel faeces sign
• Seen at the zone of transition, help to identify the cause of the obstruction.
• Defined as Gas & particulate material within a dilated small-bowel loop that simulates the appearance of
faeces.
.

46. Free fluid /Ascites
Normally do not have a detectable amount of free intra-peritoneal fluid
The presence of ascites is a nonspecific sign of abdominal pathology, indicating that 'something
is wrong'.
USG-guided diagnostic puncture of the ascites
• Sterile reactive fluid
• Pus
• Blood
• Urine
• Bile.

47. Free air
Presence of free intraperitoneal air is proof of bowel perforation, & indicates a surgical emergency.
2 frequent causes:
- Perforation of a gastric ulcer or colonic diverticulitis
Free air is usually not seen in perforated appendicitis.
Examine the images in lung setting for better detection of free gas .
Intraperitoneal air in a patient suspected of having appendicitis

48. ROLE OF ENDOSCOPY
OGD- Urgent ERCP may be indicated in cases of suspected cholangitis.
- Mx of PUD Bleed.
Sigmoidoscopy- to reducing a Sigmoid volvulus
Colonoscopy to locate the source of bleeding in cases of lower GI bleed

49. ROLE OF LAPAROSCOPY
Laparoscopy is a Therapeutic as well as Diagnostic modality
In cases of unclear diagnosis it guide surgical planning & avoid unwanted laparotomy
In young women it may distinguish a non surgical problem from Appendicitis
• Ruptured graffian follicle
• PID
• Tubo-ovarian disease

50. DIFFERENTIAL DIAGNOSIS
A complete list of all possible causes of an A/c abdomen is of little use in daily practice
Examples of frequent causes of A/c abdominal pain
Appendicitis &
Mesentric lymphadenitis
Diverticulitis
Bacterial ileocecitis
PID
Urolithiasis
Appendicitis mimickers

51. Appendicitis
Classic presentation
Peri-umbilical pain - localizes to RIF
Anorexia, nausea, vomiting
Only in <50% patients
Retrocecal - pain in the flank
A pelvic appendix - supra-pubic pain, dysuria
Males may have pain in the testicles
Findings-
Depends on duration of symptoms
Rebound, guarding, rigidity
Tenderness on PR
Psoas sign
Obturator sign
Fever (a late finding)

52. DIAGNOSTIC SCORING SYSTEM
MANTRELS SCORE ( ALVARADO )
Score of 3 – incidence 3.6%
4 - 6 32%
7 - 10 78%
FENYO- LINDBERG SCORE
Cut off point -26 or less – Exclusion
-26 to 0 – monitoring
0 or more – operation
FENYO SCORE
Cut off <11 monitoring >11 operation
RIPASA SCORE
APPY SCORE STRATA
ESKELINEN SCORE
<50 Exclusion 57 Monitoring >57 Operation

53. Appendicitis.
Normal appendix is surrounded by homogeneous non-inflamed fat, is compressible & often contains
intraluminal gas.
USG & CT - a blind-ending non-peristaltic tubular structure
The appendix (arrows) is fluid-filled & distended with peri-appendiceal fat-stranding

54. APPENDIX MIMICKERS
Mesenteric adenitis
Bacterial ileocecitis
Epiploic appendagitis
Omental infarction
Right-sided colonic diverticulitis
Crohns disease
Gynecologic conditions
Urolithiasis
Rectus sheath hematoma

55. MESENTERIC LYMPHADENITIS.
Benign self-limiting inflammation of right mesenteric lymph nodes without an identifiable
underlying inflammatory process
MC in children than in adults..
• Key finding: lymphadenopathy with a normal appendix & normal mesenteric fat.
On the left a CT of mesenteric lymphadenitis in a child suspected of appendicitis

56. BACTERIAL ILEOCECITIS
Infectious Enterocolitis cause mild symptoms resembling a common viral gastroenteritis
Mimic Appendicitis especially in bacterial ileocecitis caused by yersinia, campylobacter, or
salmonella.
key finding: ileocecal wall thickening without inflamed fat, adenopathy, normal appendix
USG typically shows sub-mucosal wall thickening (arrowheads) of the terminal ileum & cecum without inflammation of the
surrounding fat.

57. DIVERTICULITIS
Right-sided colonic diverticulitis mimic appendicitis or cholecystitis
In contrast to left, right-sided colonic diverticula are true diverticula (colonic wall containing all
layers )- Essentially benign selflimiting character
CT shows an inflamed cecal diverticulum (arrowhead) with regional colonic wall thickening.
Right-sided diverticulitis
A hypoechoic thickened diverticulum is surrounded by
hyperechoic inflamed fat (arrows).

58. PELVIC INFLAMMATORY DISEASE
PID is a common mimicker of both of appendicitis & diverticulitis.
TVS depicts an inhomogeneous enlarged inflamed ovary.
Enlarged adnexa due to salphingitis

59. Epiploic Appendagitis
Small adipose protrusions from the serosal surface of the colon
May undergo torsion & secondary inflammation causing focal abdominal pain that simulates
appendicitis
Self-limiting disease
key finding: inflamed fatty mass adjacent to the colon with characteristic ring sign (CT & USG)
.

60. Urolithiasis
Small stone in right ureter (arrow) causing right flank pain.
Problem with HUN
EMPHYSEMATOUS PYELONEPHRITIS

61. RUPTURED ANEURYSM
Most AAA rupture into the left (Left RP fluid collection )
Mimic sigmoid diverticulitis or renal colic due to the hematoma
Classic triad of hypotension, a pulsating mass and back pain.
USG is a quick & convenient modality
It is much less sensitive & specific for the diagnosis, than a CT
A normal USG does not rule out this entity .

62. PANCREATITIS
Generalized peritonitis need laparotomy (regardless of cause – except A/c pancreatitis)
Get a Lipase level
CT depicts fat-stranding (arrowheads) surrounding the primary focus of the inflammation: the pancreas.

63. CHOLECYSTITIS
GB is non-compressible (hydropic) & causes an impression in the anterior abdominal wall
(arrowheads).
CT –GB enlarged, edematous, thickening of its wall , & regional fat-stranding can be found.
EMPHYSEMATOUS CHOLECYSTITIS

65. when to refer?

68. Acute abdomen require an urgent therapeutic decision.
C/f of A/c abdomen is often nonspecific & because of d/d.
Normal findings in pt who need emergency surgery (Appendicitis) & may be abnormal in pt
without a surgical disease ( Salphingitis).
Always screen the whole abdomen for general signs of pathology radiologicaly
Laboratory findings (TC, ESR, CRP) are equally non-conclusive
Challenging

69. A plain x ray abdominal has a limited value , may falsely reassure the clinician.
USG & CT helps in a rapid triage of patients.
Mx may vary from emergency surgery to reassurance
Misdiagnosis result in delayed necessary treatment or unnecessary surgery.
Surgery should not be delayed for time consuming tests when an indication for surgery is
clear,
Generalized peritonitis on examination (regardless of cause - except A/c pancreatitis)
Perforation (on Chest X-RAY)
Complicated hernia -Irreducible and tender hernia (risk of strangulation)
Take home message