AcuteAcute AbdomenAbdomen

Prof.DrProf.Dr. Serdar . Serdar YYüüceyarceyarGeneral General SurgerySurgery

NNontraumaticontraumatic disorder whose chief manifestation is disorder whose chief manifestation is pain in the pain in the abdomabdomen,en, urgent operation may be urgent operation may be necessary. necessary. SStarts suddenly tarts suddenly andand patientspatients maymay present to a hospital present to a hospital within 7 or 10 days . within 7 or 10 days . SSymptomsymptoms arise from disease within the abdominal arise from disease within the abdominal cavity itself , but occasionally they originate cavity itself , but occasionally they originate elsewhere. elsewhere.

DDiseaseisease maymay bebe lifelife-- threatening and attemptsthreatening and attempts to reach a to reach a diagnosis must diagnosis must be be rapidrapid forfor thethe immediate treatment . immediate treatment . CCommonlyommonly there is time to take a history , to examine the there is time to take a history , to examine the patient , and to organize the investigations ....patient , and to organize the investigations ....Some patients require early surgery . Some patients require early surgery . The approach to a patient with an acute abdomen must be The approach to a patient with an acute abdomen must be orderly and thorough . orderly and thorough . The history and physical examination should suggest to the The history and physical examination should suggest to the probable causes and guide the choice of diagnostic studies .probable causes and guide the choice of diagnostic studies .

AbdominalAbdominal Anatomy Anatomy Variations Variations

individualindividualAgeAgepostureposturerespirationrespirationdiseasediseaseprevious surgeryprevious surgery

TheThe abdominal surface is best divided into six areasabdominal surface is best divided into six areas by by a transverse line going through the a transverse line going through the umblicusumblicus and and longitudinal lines running through the tip of the longitudinal lines running through the tip of the ninth rib on each side ninth rib on each side

HistoryHistory

Abdominal pain :Abdominal pain :Pain is usually the predominant and presenting feature of an Pain is usually the predominant and presenting feature of an acute abdomen acute abdomen A A -- Location of pain:Location of pain:VisceralVisceral PainPain

The embryological development of the abdomen is relevant in twoThe embryological development of the abdomen is relevant in tworespects .respects .

The intestine and all its associated organs ( liver , pancreas )The intestine and all its associated organs ( liver , pancreas ) develop initially develop initially as midline structures . as midline structures . VisVisceralceral pain is felt in the midline and also because of pain is felt in the midline and also because of the bilateral sensory supply to the spinal cord . the bilateral sensory supply to the spinal cord . The gut also has a segmental origin The gut also has a segmental origin

( correlates with the vascular supply ) ( correlates with the vascular supply ) Foregut Foregut ------------------ epigastricepigastric pain pain MidgutMidgut -------------------- umblicalumblical area ( pain ) area ( pain ) Hindgut Hindgut ------------------ HipogastricHipogastric pain pain

Visceral sensationVisceral sensation is mediated by afferent C fibers located is mediated by afferent C fibers located in the walls of hollow viscera and in the capsule of solid orgin the walls of hollow viscera and in the capsule of solid organs ans . . Visceral painVisceral pain is elicited either by distension , by inflammation is elicited either by distension , by inflammation or ischemia stimulating the receptor neurons , or by direct or ischemia stimulating the receptor neurons , or by direct involvement ( involvement ( egeg , malignant infiltration ) of sensory nerves . , malignant infiltration ) of sensory nerves . The centrally perceived sensation is generally slow in onset ,The centrally perceived sensation is generally slow in onset ,dull , poorly localized , and protracted . dull , poorly localized , and protracted . IIncreasedncreased wall tension due to luminal distension or forceful wall tension due to luminal distension or forceful smooth muscle contraction ( colic ) leads to diffuse deepsmooth muscle contraction ( colic ) leads to diffuse deep--seated pain felt in the midseated pain felt in the midlineline

Parietal Pain Parietal Pain is mediated by both C and A delta nerve fibers is mediated by both C and A delta nerve fibers TThe parietal peritoneum is innervated by somatic nerves .he parietal peritoneum is innervated by somatic nerves .

more acute ,more acute ,sharper , sharper , better localized pain sensation . better localized pain sensation .

Direct irritation by pus , bile , urine or gastrointestinal Direct irritation by pus , bile , urine or gastrointestinal secretions is associated with more exact localization of painsecretions is associated with more exact localization of pain . . The The cutaneouscutaneous distribution of P P corresponds to the T6 distribution of P P corresponds to the T6 --L1 areas , P P is more easily localized than visceral paiL1 areas , P P is more easily localized than visceral pain n because the somatic afferent fibers are directed to only onbecause the somatic afferent fibers are directed to only one e side of the nervous system .side of the nervous system .

ParietalParietal PainPain is accurately localized and is is accurately localized and is accompanied by a reflex contraction of the abdominal accompanied by a reflex contraction of the abdominal wall muscle wall muscle ( ( musclemuscle rigidityrigidity ))..

Two examples ;Two examples ;psoaspsoas spasm from acute appendicitis ,spasm from acute appendicitis ,scoliosis concave to the side of intrascoliosis concave to the side of intra--abdabd . inflammation. inflammation

Inflammation confined to the pelvis may not be Inflammation confined to the pelvis may not be accompanied by anterior abdominal muscle spasm accompanied by anterior abdominal muscle spasm and this may cause clinical confusion . and this may cause clinical confusion .

Abdominal pain may be referred or may shift . Abdominal pain may be referred or may shift . RReferredeferred pain pain isis ( usually ( usually cutaneouscutaneous ) ) thethe sensation sensation perceived at a site distant from the site of a primary stimuluperceived at a site distant from the site of a primary stimulus s ..

-- C4 mediated pain C4 mediated pain -- KehrKehr sign sign -- phrenicphrenic nerve nerve -- { the irritation of { the irritation of diaphragm by air , peritoneal fluid , mass or also pleurisy anddiaphragm by air , peritoneal fluid , mass or also pleurisy and basal basal pneumonia } .pneumonia } .-- BiliaryBiliary pain pain ------ right scapula right scapula

Spreading or shifting painSpreading or shifting painThe site of pain at onset should be distinguished from the The site of pain at onset should be distinguished from the site at presentation .site at presentation .

( acute appendicitis , perforated peptic ulcer ) ( acute appendicitis , perforated peptic ulcer )

BB-- Mode of onset and Progression of pain Mode of onset and Progression of pain reflects the nature and severity of the inciting process.reflects the nature and severity of the inciting process.explosive ( within seconds )explosive ( within seconds )rapidly progressive ( within 1 rapidly progressive ( within 1 -- 2 hours ) 2 hours ) gradual ( over several hours ) gradual ( over several hours )

ExplosiveExplosive painpain-- excruciating generalized painexcruciating generalized pain suggests an suggests an intraabdominalintraabdominal catastrophe catastrophe

perforated perforated viscusviscusrupture of an rupture of an aneursymaneursym , , ectopicectopic pregnancy or abscesspregnancy or abscessneed for prompt resuscitation and need for prompt resuscitation and laparotomylaparotomy

RapidlyRapidly progressiveprogressiveA less dramatic clinical picture is steady mild pain ( within A less dramatic clinical picture is steady mild pain ( within 11--2 hours )2 hours )more typical of acute more typical of acute cholecystitischolecystitis , acute , acute pancreatitispancreatitis , strangulated , strangulated bowellbowell , ,

mesenteric infarction , renal or mesenteric infarction , renal or ureteralureteral colic , and proximal s. colic , and proximal s. bowellbowell obstobst..

Finally Finally , , vaguevagueabdominal discomfortabdominal discomfortunclear unclear medical or surgical problem ? medical or surgical problem ?

BBecomeecome more pronounced and steady over several hours or days more pronounced and steady over several hours or days -- this patternthis pattern alsoalso maymay reflect a slowly developing condition or the body's reflect a slowly developing condition or the body's defensive efforts to cordon off an acute process. defensive efforts to cordon off an acute process.

acute appendicitisacute appendicitisincarcerated herniaincarcerated hernialow small bowel and large bowel low small bowel and large bowel obstobst ..uncomplicated peptic uncomplicated peptic ulsuls. dis. . dis. walled of walled of perfperf. ( . ( viscvisc. ) . ) some genitourinary and gynecologic conditionssome genitourinary and gynecologic conditions

C C -- Character of pain :Character of pain :Nature , severity , periodicity Nature , severity , periodicity

Steady pain Steady pain ------ most common most common Sharp superficial Sharp superficial costantcostant pain perforated ulcer , ruptured appendixpain perforated ulcer , ruptured appendixThe gripping , mounting pain The gripping , mounting pain ---- small bowel small bowel obstobst. . Disquieting and bearable pain may be originated by small conDisquieting and bearable pain may be originated by small conduits problems ( Bile duct , duits problems ( Bile duct , uterine tube , uterine tube , uretersureters ) ) " " biliarybiliary colic " is a misnomer colic " is a misnomer -- because do not have peristaltic movements . because do not have peristaltic movements . " aching discomfort " ulcer pain" aching discomfort " ulcer pain" stabbing , breathtaking " acute " stabbing , breathtaking " acute pancreatitispancreatitis and mesenteric infarction and mesenteric infarction " searing " pain " searing " pain -- ruptured aortic aneurysm ruptured aortic aneurysm Agonizing pain denotes serious or advanced disease Agonizing pain denotes serious or advanced disease ColicyColicy pain is usually promptly alleviated by analgesics .pain is usually promptly alleviated by analgesics .

Ischemic pain due to strangulated Ischemic pain due to strangulated bowellbowell or mesenteric thrombosis is only or mesenteric thrombosis is only sligthlysligthlyassuaged even by narcotics . assuaged even by narcotics . Gas stoppage sign is due to reflex Gas stoppage sign is due to reflex ileusileus induced by an inflammatory lesion walled off induced by an inflammatory lesion walled off from the free peritoneal cavity , as in from the free peritoneal cavity , as in retrocecalretrocecal appendicitis .appendicitis .

Other symptoms associated with abdominal pain :Other symptoms associated with abdominal pain :AA-- Vomiting :Vomiting :

" Pain in the acute surgical abdomen usually precedes vomiting" Pain in the acute surgical abdomen usually precedes vomiting , whereas the , whereas the reverse holds true in medical conditions ."reverse holds true in medical conditions ."absence of bile absence of bile bile bile -- stained stained feculentfeculent

B B -- Constipation Constipation

Reflex Reflex ileusileus is often induced by visceral afferent fibers stimulating effis often induced by visceral afferent fibers stimulating efferent erent fibers of the sympathetic autonomic nervous system ( fibers of the sympathetic autonomic nervous system ( splanchnicsplanchnic nerves ) to nerves ) to reduce intestinal reduce intestinal peristaltisperistaltis..ObstipationObstipation " the absence of passage of both stool and flatus "" the absence of passage of both stool and flatus "

C C -- Diarrhea :Diarrhea :Copious watery Copious watery -- gastroenteritis and other medical gastroenteritis and other medical causes of an acute abdomen.causes of an acute abdomen.Blood Blood -- stained diarrhea stained diarrhea -- ulcerative colitis , bacillary ulcerative colitis , bacillary or amebic dysentery , ischemic colitis or amebic dysentery , ischemic colitis

D D -- SpesificSpesific gastrointestinal symptoms:gastrointestinal symptoms:Jaundice Jaundice HematocheziaHematocheziaHematemesisHematemesis

Other Relevant Aspects of History Other Relevant Aspects of History A A -- Menstrual history Menstrual history

ectopicectopic pregnancypregnancyMittelschmerzMittelschmerz ( ruptured ovarian follicle ) ( ruptured ovarian follicle ) endometriosis endometriosis

BB-- Drug History Drug History Anticoagulant ( Anticoagulant ( hematomashematomas or bleeding )or bleeding )Oral contraceptive ( Hepatic adenomas , mesenteric venous infaOral contraceptive ( Hepatic adenomas , mesenteric venous infarction )rction )Corticosteroids Corticosteroids -- may masks the clinical signs may masks the clinical signs

C C -- Family history Family history D D -- Travel history Travel history

Amebic diseases , Amebic diseases , tuberculosis, tuberculosis, HydatidHydatid disease , disease , MalariasisMalariasis , , salmonellosissalmonellosis

Physical examination Physical examination 11-- General observation : General observation :

The writhing patients The writhing patients -- intestinal or intestinal or ureteralureteral coliccolicrigidly motionless patients rigidly motionless patients ------ acute appendicitis , generalized peritonitisacute appendicitis , generalized peritonitis

22-- Systemic signs : Systemic signs : Extreme pallor Extreme pallor hypothermia hypothermia TachycardiaTachycardia -- intraabdominalintraabdominal hemorhagehemorhage ( aortic ( aortic aneuaneu. , . , ectopicectopic pregpreg.).)tachypneatachypneasweatingsweating

33-- Fever :Fever :Low grade Low grade -- diverticulitisdiverticulitis , , cholecystitischolecystitis , appendicitis, appendicitisHigh fever High fever -- Acute Acute salpingitissalpingitisDisorientation or extreme lethargy , very high fever Disorientation or extreme lethargy , very high fever -------- septic shock ( septic shock ( advanadvan

cedced peritonitis , acute peritonitis , acute cholangitischolangitis , , pyelonephritispyelonephritis

44-- Examination of the acute abdomen Examination of the acute abdomen aa-- inspection :inspection :

" The abdomen should be carefully inspected before palpation"" The abdomen should be carefully inspected before palpation"distention distention surgical scar surgical scar ScaphoidScaphoid -- contracted abdomen contracted abdomen visible peristalsis visible peristalsis soft doughy fullness " paralytic soft doughy fullness " paralytic ileusileus or mesenteric thrombosis " or mesenteric thrombosis "

bb-- Auscultation :Auscultation :" auscultation of the abdomen should also precede palpation "" auscultation of the abdomen should also precede palpation "

cc-- Coughing to elicit pain :Coughing to elicit pain :dd-- Percussion : Percussion :

Tenderness Tenderness Free air under the Free air under the diaphragmadiaphragma ( absence of Liver dullness ) ( absence of Liver dullness )

e e -- Palpation : Palpation : Guarding Guarding ------ Voluntary spasm , involuntary spasm Voluntary spasm , involuntary spasm Tenderness Tenderness ------ perhaps the most important findingperhaps the most important finding

first by onefirst by one-- or two or two -- finger finger beginingbegining away from the area of cough tenderness and gradually advanciaway from the area of cough tenderness and gradually advancing toward it . ng toward it .

--well demarcated in a. well demarcated in a. cholecystitischolecystitis , a. appendicitis and , a. appendicitis and diverticulitisdiverticulitis

--diffuse tenderness without guarding in a. gastroenteritis diffuse tenderness without guarding in a. gastroenteritis ReboundRebound tendernesstendernessCarnettCarnett ' s test ( tenderness ' s test ( tenderness intraabdominalintraabdominal or abdominal wallor abdominal wall ))Hyperesthesia ( localized peritonitis , but more prominent hHyperesthesia ( localized peritonitis , but more prominent herpes zoster erpes zoster ororspinal root compression )spinal root compression )Murphy ' s signMurphy ' s sign

Abdominal Masses Abdominal Masses ((palpationpalpation ))Superficial Superficial -- Distended gallbladder , Distended gallbladder , appendicealappendiceal abscess abscess Deeper Deeper -------- often partially walled off by overlying often partially walled off by overlying omentumomentum and small and small bowellbowell . . FothergillFothergill’’s sign an s sign an intraabdominalintraabdominal mass or tenderness that disappears when the mass or tenderness that disappears when the rectusrectusmuscles are contracted by arising the head . muscles are contracted by arising the head .

indirectly found indirectly found ileopsoasileopsoas signsignobturatorobturator sign sign

Punch tenderness ( hepatic , Punch tenderness ( hepatic , splenicsplenic and and subphrenicsubphrenic or also a. or also a. cholecystitischolecystitis , a. , a. hepatitis , hepatitis , splenicsplenic infarct )infarct )CostovertebralCostovertebral angle tenderness ( a. angle tenderness ( a. pyelonephritispyelonephritis ) )

f f -- Inguinal and femoral ringsInguinal and femoral rings ; male genitalia ; male genitalia g g -- Rectal examinationRectal examination ; must always be performed ; must always be performed

Tenderness , masses , stool Tenderness , masses , stool colourcolourh h -- Pelvic examinationPelvic examination : :

Investigative studies :Investigative studies :History and physical examination provide the diagnosis in twoHistory and physical examination provide the diagnosis in two--third ofthird of the the cases cases Laboratory investigation Laboratory investigation

A A -- Blood Studies :Blood Studies :Hemoglobin Hemoglobin HematocritHematocritWhite blood cell White blood cell

marked marked leucocytosisleucocytosis > 13.000 / L is indicative of serious infection .> 13.000 / L is indicative of serious infection .moderate L , commonly encountered in medical as well as surgicmoderate L , commonly encountered in medical as well as surgical al inflaminflam. conditions. . conditions. Low WBC < 8.000 / L Low WBC < 8.000 / L -------- mesenteric adenitis and non mesenteric adenitis and non spesificspesific abdabd. pain . pain

CroosCroos matchingmatchingSerum electrolyteSerum electrolyteUrea Urea ““in shockin shock,,copious vomiting and copious vomiting and diarrhea,tensediarrhea,tenseCreatinineCreatinine abdabd and distentionand distention””

Arterial Blood gas determination Arterial Blood gas determination ( ( shockshock ))Serum amylase Serum amylase -- pancreatitispancreatitis

-- Strangulated / ischemic Strangulated / ischemic bowellbowell-- Twisted ovarian cyst Twisted ovarian cyst -- Perforated ulcer Perforated ulcer

Cloudy ( Cloudy ( lactescentlactescent ) serum ) serum pancreatitispancreatitis ??Liver function tests ( serum Liver function tests ( serum bilirubinbilirubin , alkaline , alkaline phosphatasephosphatase , AST , ALT , AST , ALT

, albumin , globulin ) , albumin , globulin ) ------ surgical hepatic disease surgical hepatic disease Clotting studies : ( platelet counts , , PT , PTT ) Clotting studies : ( platelet counts , , PT , PTT ) Peripheral blood smear Peripheral blood smear ------ hematologichematologic abnormality ( cirrhosis ,abnormality ( cirrhosis ,

petechiaepetechiae , etc. ) , etc. ) Erythrocyte sedimentation rate ; not importantErythrocyte sedimentation rate ; not important

B B -- Urine tests : Urine tests : Dark urine or high gravity Dark urine or high gravity ------ dehydration dehydration , , porphyriaporphyriaHyperbilirubinemiaHyperbilirubinemiaHematuriaHematuriapyuriapyuriaDipstick testing ( albumin , Dipstick testing ( albumin , bilirubinbilirubin , glucose and , glucose and ketonesketones ))

C C -- Stool tests :Stool tests :occult fecal blood occult fecal blood Warm stool smear for bacteria , ova and animal parasites Warm stool smear for bacteria , ova and animal parasites amebic amebic trophozoitestrophozoitesStool samples for culture in gastroenteritis , dysentery or Stool samples for culture in gastroenteritis , dysentery or cholera cholera

IMAGING STUDIES :IMAGING STUDIES :A A -- Plain chest X Plain chest X -- Ray studies :Ray studies :

SupradiaphragmaticSupradiaphragmatic conditions that simulate an acute abdomen ( conditions that simulate an acute abdomen ( basal pneumonia or ruptured esophagus ) basal pneumonia or ruptured esophagus ) Elevated Elevated hemidiaphragmhemidiaphragm or pleural effusionor pleural effusion----attention to attention to subphrenicsubphrenicinflammatory lesions .inflammatory lesions .

B B -- Plain Abdominal X Plain Abdominal X -- Ray Studies : Ray Studies : intestinal obstructionintestinal obstructionperforated perforated viscusviscusrenal renal -- ureteralureteral calculicalculiacute acute cholecystitischolecystitis

OtherOther findingsfindings in in PlainPlain XX--rayrayfree or abnormal gas pattern free or abnormal gas pattern -- under diaphragm under diaphragm Massive Massive pneumoperitoneumpneumoperitoneum -- colonic perforation colonic perforation BiliaryBiliary tree air tree air -- biliarybiliary enteric communication enteric communication choledochoduodenalcholedochoduodenal fistula fistula -- gallstone gallstone ileusileusAir in the portal venous system Air in the portal venous system -- phylephlebitisphylephlebitisGaseous distention Gaseous distention ---- bowellbowell obstruction obstruction airair--fluid levels fluid levels right lower quadrant right lower quadrant ileusileus -- acute appendicitis acute appendicitis " thumbprint " on the colonic wall " thumbprint " on the colonic wall -- ischemic colitisischemic colitisObliteration of the Obliteration of the psoaspsoas muscle margins muscle margins --retroperitoneal diseaseretroperitoneal disease

C C -- AngiographyAngiography ( contraindicated in unstable patients )( contraindicated in unstable patients )intestinal ischemia intestinal ischemia ruptured liver adenoma or carcinoma ruptured liver adenoma or carcinoma aneursymaneursym ( ( splenicsplenic artery or others )artery or others )

D D -- Contrast X Contrast X -- Ray studies Ray studies suspected perforation of the esophagus or suspected perforation of the esophagus or gastroduodenalgastroduodenal area without area without pneumoperitoneumpneumoperitoneum ------ with water soluble contrast media ( gastro with water soluble contrast media ( gastro --grafingrafin ---- megluminemeglumine diatriodiatriozzate )ate )Barium enema Barium enema -- diagnosis large diagnosis large bowellbowell obstruction or reduce sigmoid obstruction or reduce sigmoid volvulusvolvulus or or intususseptionintususseption . . Emergency IVPEmergency IVP-------- seldom in seldom in nontraumaticnontraumatic eventsevents

E E -- UltrasonographyUltrasonography and CT Scan : and CT Scan : useful in pregnant patient useful in pregnant patient 80 % sensitivity in acute appendicitis 80 % sensitivity in acute appendicitis pancreatic or pancreatic or retropancreaticretropancreatic lesion lesion Acute Acute diverticulitisdiverticulitisIntramural Intramural bowellbowell or venous gas or venous gas ------ bowellbowell infarction infarction

F F -- Radionuclide scans : Radionuclide scans : Liver Liver -- splennsplenn scans ,scans ,HIDA scans HIDA scans Gallium scans ( intra abdominal abscess ) Gallium scans ( intra abdominal abscess ) TecTec-- PertechnetatePertechnetate scans scans -- ectopicectopic gastric mucosa in gastric mucosa in MeckelMeckel div. div.

ENDOSCOPY ENDOSCOPY ProctosigmoidoscopyProctosigmoidoscopyColonoscopy Colonoscopy GastroduodenoscopyGastroduodenoscopy and ERCP and ERCP

PARACENTESIS PARACENTESIS Aspiration of blood , bile or Aspiration of blood , bile or bowellbowell contenscontensinfected infected ascitesascites -------- spontaneous peritonitis , spontaneous peritonitis , TBcTBc peritonitis , peritonitis , chylouschylous

ascitesascitesCuldocentesisCuldocentesis

LAPAROSCOPY LAPAROSCOPY ruptured ruptured graffiangraffian follicle follicle pelvic pelvic inflaminflam. etc. . etc. in critically ill patients in critically ill patients

ReferencesReferences::11--BoeyBoey JH. JH. AcuteAcute Abdomen. Abdomen. InIn, , WayWay LW (Ed) LW (Ed) CurrentCurrentSurgicalSurgical DiagnosisDiagnosis & & TreatmentTreatment. . NinthNinthEditionEdition..AppletonAppleton&&LangeLange . 1991; 430. 1991; 430--441.441.22--BoeyBoey JH,JH,DohertyDoherty GM. GM. TheThe AcuteAcute Abdomen. Abdomen. InIn, , WayWay LW , LW , DohertyDoherty GM. ( GM. ( EdsEds). ). CurrentCurrent SurgicalSurgical DiagnosisDiagnosis & & TreatmentTreatment. . EleventhEleventh EditionEdition. . McMc GrawGraw--HillHill companiescompanies. 2003 . 2003 ; 503; 503--516.516.3-Britton J. The Acute Abdomen. (In) Morris PJ,Malt RA. Oxford Textbook of Surgery. First Edition , Volume One, Oxford UniversityPress inc. , 1994 ; 1375-96.