Acute Abdomen

Hani Albrahim ,MD

Head of the EMS Unit
Department of Emergency Medicine
Which one has the highest
mortality rate ?
 Ruptured AAA
 Perforated peptic ulcer
 Mesenteric ischemia
 Bowel obstruction
Which one has the highest
mortality rate ?
 Ruptured AAA
 Perforated peptic ulcer
 Mesenteric ischemia
 Bowel obstruction
Pain is out of proportion
is a characteristic feature of:

 Mesenteric ischemia
 Ruptured AAA
 Perforated peptic ulcer
 Intestinal obstruction
Pain is out of proportion
is a characteristic feature of:

 Mesenteric ischemia
 Ruptured AAA
 Perforated peptic ulcer
 Intestinal obstruction
 Is the most common presenting surgical
emergency. It has been estimated that at least
50% of general surgical admissions are
emergencies and 50% of them present with
acute abdominal pain.
 ‘Acute abdomen’ is a term used to encompass a
spectrum of surgical, medical and gynecological
conditions, ranging from the trivial to the life-
threatening, which require hospital admission,
investigation and treatment.
 The acute abdomen may be defined generally as
an intra-abdominal process causing severe pain
requiring admission to hospital, and which has
not been previously investigated or treated and
may need surgical intervention.
 The mortality rate varies with age, being the
highest at the extremes of age.
 The highest mortality rates are associated with
laparotomy for unresectable cancer, ruptured
abdominal aortic aneurysm and perforated peptic
ulcer.
 Most common causes in any population will vary
according to age, sex and race, as well as genetic
and environmental factors.
 Causes-
A. Gastrointestinal-

1-Gut 2-Liver and biliary tract

Acute appendicitis cholecystitis
Intestinal obstruction cholangitis
Perforated peptic ulcer Hepatitis
Diverticulitis 3-Pancreas
Inflammatory bowel disease Acute pancreatitis
4-Spleen
Splenic infarct and spontaneous
rupture
 Causes-
B. Urinary tract D. Abdominal wall conditions
Cystitis Rectus sheath haematoma
Acute pyelonephritis
Ureteric colic E. Peritoneum
Acute retention Primary peritonitis
Secondary peritonitis
C. Vascular
Ruptured aortic aneurysm
Mesenteric embolus
Mesenteric venous thrombosis
Ischemic colitis
Causes-
F. Retroperitoneal
Hemorrhage e.g anticoagulants

G. Gynecological
Torsion of ovarian cyst
Ruptured ovarian cyst
Fibroid denegeration
Ovarian infarction
Pelvic endometriosis
Endometriosis
Causes-
H. Extra-abdominal causes
Lobar pneumonia
MI
Sickle cell crisis
Uremia
DKA
Addison’s disease
Management
 History
 Physical examination
 Management
Characteristics of abdominal pain

• Site
• Time and mode of onset
• Severity
• Nature/Character
• Progression
• Radiation
• Duration
• Cessation
• Exacerbating/relieving factors
• Associated symptoms
 Symptoms--Pain

Onset
Sudden: perforation of bowel.
Slow insidious onset: inflammation of visceral peritoneum

Severity
Patient asked to rate pain from 1-10
Ureteric colic is one of worst pains

Character
Aching-dull pain poorly localized
Burning- peptic ulcer symptoms
Stabbing-ureteric colic
Gripping-smooth muscle spasm e.g. intestinal obstruction worse
by movement .
 Symptoms--Pain
Progression
-Constant e.g. peptic ulcer
-Colicky e.g. seconds(bowel), minutes(ureteric colic) or
tens of minutes (gallbladder)
Radiation of the pain
Back: duodenal ulcer, pancreatitis, aortic aneurysm
Scapula: gall bladder
Sacroiliac region: ovary
Loin to groin: ureteric colic
Groin: testicular torsion
Cessation-
Abrupt ending- colicky pains
Resolving slowly-inflammatory pain, biliary pain

Exacerbating/relieving factors-
Movement/Rest-inflammatory conditions
Food- peptic ulcers
History
History
Past history
previous surgery
trauma
any medical diseases
Drug history
corticosteroid: mask pain
anti-coagulant: intra-mural hematoma
NSAIDS: gastritis, peptic ulcer
Family history
colon cancer
IBD
Physical Examination

General appearance
-Patient is lying motionless
acute appendicitis, peritonitis

-Rolling in bed
ureteric colic, intestinal colic

-Bending forward
chronic pancreatitis
Physical Examination
Vital signs
Temp.
low grade: appendicitis, acute cholycystitis
high grade: abscess

General examination-
Conjuctival pallor
cyanosis
jaundice
Signs of dehydation
lymphadenopathy
Physical Examination
Cardio-pulmonary examination
-MI
-basal pneumonia
-pleural effusion
Physical Examination
Abdomen
*Inspection
*Palpation
*Percussion
*Auscultation
Physical Examination
Inspection
-movement with respiration
-distension, peristalsis, mass, scars and any obvious
cough impulse at hernia site

Palpation
*Superficial palpation
-tenderness, rebound tenderness, guarding, rigidity,
masses, hernial orifices
*Deep palpation
-organomegaly
Physical Examination
Percussion
-Tympanic note: intestinal obstruction
-Dullness over bladder: acute retention
Auscultation
-Silent abdomen: peritonitis
-Increase bowel sound: intestinal obstruction
Investigation
• CBC
• Urea, electrolyte, creatinine, glucose
• LFT
• Lipase
• Urinalysis
• CXR
• AXR
• CT SCAN
• U/S
• Angiography
• Pregnancy test
Treatment

1. Relieve the pain

2. IV fluids and nasogastric suction
3. Antibiotics
4. Surgery if indicated
 Case #1
 24 yo healthy M with one day hx of abdominal pain.
Pain was generalized at first, now worse in right lower
abd & radiates to his right groin. He has vomited twice
today. Denies any diarrhea, fevers, dysuria or other
complaints. No appetite today.
 PMHx: negative
 PSurgHx: negative
 Meds: none
 Physical exam:
 T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100%
room air
 Uncomfortable appearing, slightly pale
 Abdomen: soft, non-distended, tender to palpation
in RLQ with mild guarding; hypoactive bowel
sounds
 Genital exam: normal

 What is your differential diagnosis and what

do you do next?
 Appendicitis
 Classic presentation
• Periumbilical pain
• Anorexia, nausea, vomiting
• Pain localizes to RLQ
• Occurs only in ½ to 2/3 of patients
 26% of appendices are retrocecal and cause pain in the
flank; 4% are in the RUQ
 A pelvic appendix can cause suprapubic pain, dysuria
 Males may have pain in the testicles
 Urinalysis abnormal in 19-40%
 CBC is not sensitive or specific
 CT scan
 Pericecal inflammation, abscess,
periappendiceal phlegmon, fluid collection,
localized fat stranding
 Appendicitis: CT findings

Cecum

Abscess, fat
stranding
 Appendicitis

 Diagnosis  Treatment
• WBC • NPO
• Clinical appendicitis • IVFs
• Maybe appendicitis - CT scan • Preoperative antibiotics
• Not likely appendicitis – – decrease the incidence
observe for 6-12 hours or re- of postoperative wound
examination in 12 hrs infections
• Analgesia
 Case #2

 68 yo F with 2 days of LLQ abd pain,

diarrhea, fevers/chills, nausea; vomited once
at home.
 PMHx: HTN, diverticulosis
 PSurgHx: negative
 Meds: HCTZ
 Case #2 Exam

 T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99%

room air
 Gen: uncomfortable appearing, slightly pale
 CV/Pulmonary: normal heart and lung exam, no LE
edema, normal pulses
 Abd: soft, moderately TTP LLQ
 Rectal: normal tone, guiac neg brown stool

 What is your differential diagnosis & what next?

 Diverticulitis

 Risk factors  Physical Exam

• Diverticula • Low-grade fever
• Increasing age • Localized
 Clinical features tenderness
• Steady, deep discomfort • Rebound and
in LLQ guarding
• Change in bowel habits • Left-sided pain on
rectal exam
• Urinary symptoms
• Occult blood
• Tenesmus
• Peritoneal signs
• Paralytic ileus
• SBO
 Diverticulitis

 Diagnosis
• CT scan (IV and oral contrast)
• Pericolic fat stranding
• Diverticula
• Thickened bowel wall
• Peridiverticular abscess
• Leukocytosis present in only 36% of patients
 Treatment
• Fluids
• Correct electrolyte abnormalities
• NPO
• Abx: gentamicin AND metronidazole OR
clindamycin OR levaquin/flagyl
• For outpatients (non-toxic)
• liquid diet x 48 hours
• cipro and flagyl
Case #3

 46 yo M with hx of alcohol abuse with 3

days of severe upper abd pain, vomiting,
subjective fevers.
 Med Hx: negative
 Surg Hx: negative
 Meds: none; Allergies: NKDA
 Case #3 Exam
Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95%
room air
 General: ill-appearing, appears in pain
 CV: tachycardic, normal heart sounds, pulses normal
 Lungs: clear
 Abdomen: mildly distended, moderately TTP epigastric,
+voluntary guarding
 Rectal: heme neg stool

 What is your differential diagnosis & what next?

 Pancreatitis
 Risk Factors
• Alcohol
• Gallstones
• Drugs
• Amiodarone, antivirals, diuretics, NSAIDs
• Severe hyperlipidemia
• Idiopathic
 Clinical Features
• Epigastric pain
• Radiates to back
• Severe
• N/V
 Physical Findings
• Low-grade fevers
• Tachycardia, hypotension
• Respiratory symptoms
• Atelectasis
• Pleural effusion
• Peritonitis – a late finding
• Ileus
• Cullen sign*
• Bluish discoloration around the umbilicus
• Grey Turner sign*
• Bluish discoloration of the flanks
 Pancreatitis
 Diagnosis
 Lipase
• Elevated more than 2 times normal
• Sensitivity and specificity >90%
 Amylase
• Nonspecific
 CT scan
• Insensitive in early or mild disease
• NOT necessary to diagnose pancreatitis
• Useful to evaluate for complications
 Treatment
• NPO
• IV fluid resuscitation
• NGT if severe, persistent nausea
• No antibiotics unless severe disease
• E coli, Klebsiella, enterococci, staphylococci,
pseudomonas
• Imipenem or cipro with metronidazole
• Mild disease, tolerating oral fluids
• Discharge on liquid diet
• Follow up in 24-48 hours
• All others, admit
 Case #4
 72 yo M with hx of CAD on aspirin and Plavix
with several days of dull upper abd pain and
now with worsening pain “in entire abdomen”
today. Some relief with food until today, now
worse after eating lunch.
 Med Hx: CAD, HTN, CHF
 Surg Hx: appendectomy
 Meds: Aspirin, Plavix, Metoprolol, Lasix
 Social hx: smokes 1ppd, denies alcohol or drug
use, lives alone
 Case #4 Exam
 T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96%
room air
 General: elderly, thin male, ill-appearing
 CV: normal
 Lungs: clear
 Abd: mildly distended and diffusely tender to
palpation, +rebound and guarding
 Rectal: blood-streaked heme + brown stool

 What is your differential diagnosis & what

next?
 Peptic Ulcer Disease
 Risk Factors  Physical Findings
• H. pylori • Epigastric tenderness
• NSAIDs • Severe, generalized pain
may indicate perforation
• Smoking with peritonitis
• Hereditary • Occult or gross blood per
rectum or NGT if bleeding
 Clinical Features
• Burning epigastric pain
• Sharp, dull, achy, or
“empty” or “hungry” feeling
• Relieved by milk, food, or
antacids
• Awakens the patient at night
• Nausea, retrosternal pain
and belching are NOT
related to PUD
 Peptic Ulcer Disease

 Diagnosis  Treatment
• Empiric treatment
• Rectal exam for occult
• Avoid tobacco, NSAIDs,
blood aspirin
• CBC • PPI or H2 blocker
• LFTs • Immediate referral to GI if:
• >45 years
• Definitive diagnosis is
by EGD or upper GI • Weight loss
barium study • Long h/o symptoms
• Anemia
• Persistent anorexia or
vomiting
• GIB
Here is your patient’s x-ray….
Perforated Peptic Ulcer

 Abrupt onset of severe epigastric pain followed

by peritonitis
 IV, oxygen, monitor
 CBC, T&C, Lipase
 Acute abdominal x-ray series
 Lack of free air does NOT rule out perforation
 Broad-spectrum antibiotics
 Surgical consultation
 Case #5

 35 yo healthy F to ED c/o nausea and vomiting

since yesterday along with generalized
abdominal pain. No fevers/chills, +anorexia.
Last stool 2 days ago.
 Med Hx: negative
 Surg Hx: s/p hysterectomy (for fibroids)
 Social Hx: denies alcohol, tobacco or drug use
 Case #5 Exam
 T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat: 97%
room air
 General: mildly obese female, vomiting
 CV: normal
 Lungs: clear
 Abd: moderately distended, mild TTP diffusely,
hypoactive bowel sounds, no rebound or guarding

 What is your differential and what next?

Upright abd x-ray
 Bowel Obstruction

 Mechanical or nonmechanical causes  Physical Findings

1 - Adhesions from previous surgery • Distention
2 - Groin hernia incarceration
• Tympany

 • Absent, high pitched or

Clinical Features
tinkling bowel sound or
•Crampy, intermittent pain “rushes”
•Periumbilical or diffuse • Abdominal tenderness:
•Inability to have BM or flatus diffuse, localized, or minimal
•N/V
•Abdominal bloating
•Sensation of fullness, anorexia
 Bowel Obstruction
 Diagnosis  Treatment
• CBC and electrolytes • Fluid
• Electrolyte abnormalities
• NGT
• WBC >20,000 suggests bowel
necrosis, abscess or peritonitis • Analgesia
• Abdominal x-ray series • Surgical consult
• Flat, upright, and chest x-ray • OR for complete obstruction
• Air-fluid levels, dilated loops of
bowel • Peri-operative
antibiotics
• Lack of gas in distal bowel and
rectum
• CT scan
• Identify cause of obstruction
• Delineate partial from complete
obstruction
 Case #6
 48 yo obese F with one day hx of upper abd
pain after eating, does not radiate, is
intermittent cramping pain, +N/V, no diarrhea,
subjective fevers. No prior similar symptoms.
 Med hx: denies
 Surg hx: denies
 No meds or allergies
 Social hx: no alcohol, tobacco or drug use
Case #6 Exam

 T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat: 100%

room air
 General: moderately obese, no acute distress
 CV: normal
 Lungs: clear
 Abd: moderately TTP RUQ, +Murphy’s sign, non-
distended, normal bowel sounds

 What is your differential and what next?

 Cholecystitis
 Clinical Features  Physical Findings
• RUQ or epigastric pain • Epigastric or RUQ pain
• Radiation to the back or • Murphy’s sign
shoulders • Patient appears ill
• Dull and achy → sharp and • Peritoneal signs suggest
localized perforation
• N/V/anorexia
• Fever, chills
 Cholecystitis
 Diagnosis
• CBC, LFTs, Lipase
• Elevated alkaline phosphatase
• Elevated lipase suggests gallstone
pancreatitis
• RUQ US
• Thicken gallbladder wall
• Pericholecystic fluid
• Gallstones or sludge
• Sonographic murphy sign
• HIDA scan
• more sensitive & specific than US
 Treatment
• Surgical consult
• IV fluids
• Correct electrolyte abnormalities
• Analgesia
• Antibiotics
• NGT if intractable vomiting
 Case #7
 34 yo healthy M with 4 hour hx of sudden onset
left flank pain, +nausea/vomiting; no prior hx of
similar symptoms; no fevers/chills. +difficulty
urinating, no hematuria. Feels like has to urinate
but cannot.
 PMHx: neg
 Surg Hx: neg
 Meds: none, Allergies: NKDA
 Case #7 Exam

 T: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99% room air
 General: writhing around on stretcher in pain, +diaphoretic
 CV: tachycardic, heart sounds normal
 Lungs: clear
 Abd: soft; non-tender
 Back: mild left CVA tenderness
 Genital exam: normal
 Neuro exam: normal

 What is your differential diagnosis and what next?

 Renal Colic

 Clinical Features  Physical Findings

• Acute onset of severe, • non tender or mild
dull, achy visceral pain tenderness to
• Flank pain palpation
• Radiates to abdomen or • Anxious, unable to
groin including testicles sit still
• N/V and sometimes
diaphoresis
• Fever is unusual
Renal Colic
 Diagnosis
 Urinalysis
• RBCs
• WBCs suggest infection
 CBC
• If infection suspected
 BUN/Creatinine
• In older patients
• If patient has single kidney
• If severe obstruction is suspected
 CT scan
 Treatment
 IV fluid boluses
 Analgesia
• Narcotics
• NSAIDS
 Follow up with urology in 1-2 weeks
 If stone > 5mm, consider admission and urology
consult
 If toxic appearing or infection found
• IV antibiotics
• Urologic consult
Thank You