ACUTE ABDOMEN

OTJE HUDAJA
FK UKM
2007

ACUTE ABDOMEN
ANY NON-TRAUMATIC DISORDER OF
ACUTE ONSET IN WHICH THE
SYMPTOMS ARE PREDOMINATLY
ABDOMINAL AND FOR WHICH IN SOME
CASE URGENT SURGERY MAY BE
INDICATED. PROMPT DIAGNOSIS IST
ESSENTIAL
A CAREFUL HISTORY AND
EXAMINATIONS WILL INDICATE THE
CAUSE OF MOST ACUTE ABDOMEN

ACUTE ABDOMEN
IN

PRACTICE IT REPRESENTS A
SPECTRUM OF PROBLEMS RANGING
FROM SUDDEN ONSET OF SEVERE
ABDOMINAL PAIN WITH LIFETHREATENING UNDERLAYING CAUSE
TO MINOR ABDOMINAL SYMPTOMS
OF LENGTHY DURATION

ACUTE ABDOMEN

THE SEVERE CAUSES WHICH NEED URGENT

SURGERY (e.g. RUPTERED AORTIC
ANEURYSM, PERFORATED DIVERTICULITIS)
SEVERE ANDOMINAL PAIN THAT DOES NOT
NEED REQUIERE SURGERY (BILIARY COLIC,
URETERIC COLIC, PANCREATITIS)
CONDITIONS WHICH DO NOT NEED
URGENT INVESTIGATIONS AND TREATMENT
(GASTROENTERITIS, CONSTIPATION)

HISTORY

AGE.
MESENTERIC ADENITIS IN CHILDREN,
DIVERTICULITIS IN THE OLDER PATIENT
PAIN.
- TIME AND MODE OF ONSET,
e.g. SUDDEN, GRADUAL
- CHARACTER. DULL, VAGUE, CRAMPING,
SHARP, BURNING
- SEVERITY

HISTORY

PAIN
- CONSTANCY. COUNTINUOUS PAIN,
INTERMITTENT OF INTESTINAL COLIC
- LOCATION. WHERE DID IT START,
HAS IT MOVED?
- RADIATION. LOIN TO GROIN IN UTERIC
COLIC
- EFFECT OF RESPIRATION. MOVEMENT,
FOOD, DEFAECATION, MICTURITION,
MENSTRUATION

HISTORY

VOMITING.
- DID VOMITING PRECEDE THE PAIN
- FREQUENCY
- CHARACTER, e.g. BILE, FAECULENT,
BLOOD, COFFE GROUNDS
DEFAECATION.
- ABSOLUTE CONSPTIPATION WITH COLICKY
ABDOMINAL PAIN, DISTENSION AND
VOMITING (SUGGESTS INTESTINAL OBSTRUCTION)
- DIARRHOEA.: FREQUENCY, CONSISTENCY OF STOOL,
BLOOD, MUCUS, PUS

HISTORY
FEVER. ANY RIGORS
PAST HISTORY.
- PAST SURGERY, e.g. ADHESIONS MAY
CAUSE INTESTINAL OBSTRUCTION
- RECENT TRAUMA, e.g. DELAYED
RUPTURE OF SPLEEN
- MENSTRUAL HISTORY, e.g. ECTOPIC
PREGNANCY, MITTELSCHMERZ

EXAMINATIONS

GENERAL
- IS THE PATIENT LYING COMFORTABLY?
- IS THE PATIENT LYING STILL BUT IN PAIN?
- IS THE PATIENT WRITHING IN AGONY, e.g.
URETERIC OR BILLIARY COLIC?
- IS THE PATIENT FLUSHED SUGGESTING PYREXIA?
PULSE, TEMPERATURE, RESPIRATION
CERVICAL LYMPHADENOPATHY (MESENTERIC
ADENITIS)
CHEST (REFFERED PAIN FROM LOBAR
PNEUMONIA)

EXAMINATIONS OF THE
ABDOMEN

INSPECTION. FROM ARCUS COSTARUM

GENITAL. MOVES OF RESPIRATION, SCAR,
DISTENDED, DARMKONTUR,
DARMSTEIFUNG, PAIN ON COUGHING,
HERNIAL ORIFICES (GROIN, SCROTUM),
ANY OBVIOUS MASSES, e.g. PULSALTILE
MASS TO SUGGEST AORTIC ANEURYSM
AUSCULTATION. TAKE YOUR TIME (30-6O
S), INTESTINAL OBSTRUCTION : HIGHPITCHED TINKLING BOWEL SOUNDS
(METALIC SOUND), BORBORYGMUS

EXAMINATIONS OF THE
ABDOMEN
PERCUSSION.

- TYMPANIC NOTE WITH DISTENTION

DUE TO INTESTINAL OBSTRUCTION
- DULLNESS OVER BLADDER DUE TO
ACUTE RETENTION
- PAIN BY PERITONITIS, CAVE : DONT
DO THE OTHER EXAMINATIONS

EXAMINATIONS OF THE
ABDOMEN

PALPATION
- PATIENT RELAXED, LYING FLAT, WITH ARMS BY SIDE
- BE GENTLE AND START AS FAR FROM THE
PAINFUL SITE AS POSSIBLE
- CHECK FOR GUARDING AND RIGIDITY.
- REBOUND TENDERNESS IS UNPLEASENT FOR
PATIENT AND IS RARELY HELPFUL
- CHECK THE HERNIAL ORIFICES
- CHECK FOR MASSES, e.g. APPENDIX MASS,
PULSATILE
EXPANSILE MASS OF AORTIC ANEURYSM

RECTAL EXAMINATION
AS

IMPORTANT AS THE ABDOMINAL

EXAMINATION
IN THE LEFT LATERAL POSITION
INSERT THE FINGER POSTERIORLY INTO
THE SACRAL HOLLOW
MOVE THE FINGER AROUND IN THE ARC
OF A CIRCLE UNTIL IT IMPINGES ON THE
PERITONEUM OF THE RETROVESICAL
OR RETROUTERINE POUCH

RECTAL EXAMINATION
IF

THE PATIENT HAS PAIN, THIS IS A

SIGN OF PERITONITIS IN THE MOST
DEPENDENT PART OF THE PELVIS
THE CORRECT ANNOTATION OF A
POSITIVE RECTAL EXAMINATION
SHOULD BE TENDER ANTERIORLY
TENDER HIGH UP IN THE RIGHT IS
INAPPROPIATE

RECTAL EXAMINATION
THERE

SEEMS TO BE A MISCONCEPTION
AMONG MEDICAL STUDENTS THAT YOU
FEELING THE AREA OF THE APPENDIX.
YOU ARE FEELING FOR TENDERNESS
DUE TO INFLAMMATION OF THE PELVIC
PERITONEUM CAUSED BY INFECTED
EXUDATES DRAINING TO THE MOST
DEPENDENT PART OF THE PELVIS, i.e.
THE RETROVESICAL OR RETROUTERINE
POUCH

REMEMBER
SITE OF ABDOMINAL PAIN IN RELATION TO
ANATOMY
WHAT IS MOST COMMONS IN THE SITE OF
ABDOMINAL PAIN
EXAMINATIONS :
- BE GENTLE AND START FROM NON
INVASIVE
EXAMINATION (IN TEXT BOOK : INSPECTION,
PALPATION, PERCUSSION, AUSCULTATION)
- START AS FAR FROM THE PAINFUL SITE
AS POSSIBLE

PROF.SAEGESSER

A DIRTY FINGER IS BETTER

THAN A BAD REPUTATION
THEREFORE
DONT FORGET TO DO THE
RECTAL EXAMINATION

INVESTIGATIONS

WCC (WHITE CELL COUNT) RAISED WITH A

NEUTROPHIL LEUKOCYTOSIS
UREA, ELECTROLYTES
LIVER FUNCTION TESTS
AMYLASE,
HIGH AMYLASE (PANCREATITIS)
MILDLY RAISED AMYLASE (PERFORATED
VISCUS, INTESTINAL
OBSTRUCTION/ISCHAEMIA)

INVESTIGATIONS

CHEST X RAY.
- EXCLUDE REFFERED LESIONS
- GAS UNDER DIAPHRAGM (FREE AIR)
ABDOMINAL X RAY.
DISTENDED BOWEL WITH AIR/FLUID LEVELS,
GALLSTONES, CALCIFICIED AORTA
(ANEURYSM), AIR IN BILIARY TREE
PLAIN X RAY (KIDNEY URETER BLADDER/ BNO)
INTRA VENOUS UROGRAPHY (IVU, IVP)
ANGIOGRAPHY. HAEMORRHAGE, EMBOLUS,
THROMBOSIS

INVESTIGATIONS
ULTRA

SOUND SCAN
COMPUTERIZED TOMOGRAPHY
MAGNETIC RESONANCE IMAGING
ENDOSCOPY
LAPAROSCOPIC

CAUSES OF ACUTE
ABDOMEN

GUT
- ACUTE APPENDICITIS
- INTESTINAL OBSTRUCTION
- PERFORATED PEPTIC ULCER
- ACUTE EXECERBATION OF PEPTIC ULCER
- MESENTERIC ADENITIS
- DIVERTICULITIS
- MECKELS DIVERTICULITIS

CAUSES OF ACUTE
ABDOMEN

LIVER AND BILLIARY TRACT

- CHOLECYSTITIS
- CHOLANGITIS
- HEPATITIS
- BILIARY COLIC
URINARY TRACT
- CYSTITIS
- ACUTE PYELONEPHRITIS
- URETERIC COLIC
- ACUTE RETENTION

CAUSES OF ACUTE
ABDOMEN
GYNAECOLOGICAL

- RUPTERED ECTOPIC PREGNANCY

- TORSION OF OVARIAN CYST
- RUPTERED OVARIAN CYST
- SALPINGITIS
- SEVERE DYSMENORRHOEA
- MITTELSCHMERZ
- ENDOMETRIOSIS

CAUSES OF ACUTE
ABDOMEN
VASCULAR

- RUPTERED AORTIC ANEURYSM

- MESENTERIC EMBOLUS
- MESENTERIC VENOUS THROMBOSIS
- ISCHAEMIC COLITIS
- ACUTE AORTIC DISSECTION

CAUSES OF ACUTE
ABDOMEN
PERITONEUM
- PRIMARY PERITONITIS
- SECONDARY PERITONITIS
ABDOMINAL WALL
RECTUS SHEATH HAEMATOMA
RETROPERITONEAL
HAEMORRHAGE, e.g.
ANTICOAGULANTS

SITE OF ABDOMINAL PAIN IN

RELATION TO SUSPECTED
PATHOLOGY

WHOLE ABDOMEN
- GENERALIZIED PERITONITIS
- MESENTERIC INFARCTION
RIGHT UPPER QUARDAN
- ACUTE CHOLECYSTITIS
- CHOLANGITIS
- HEPATITIS
- PEPTIC ULCERATION

SITE OF ABDOMINAL PAIN

LEFT UPPER QUARDAN

- PEPTIC ULCERATION
- PANCREATITIS
- SPLENIC INFARCT
RIGHT LOWER QUARDAN
- APPENDICITIS
- OVARIAN CYST
- ECTOPIC PREGNANCY
- PELVIC INFLAMMATORY DISEASE

SITE OF ABDOMINAL PAIN

RIGHT LOWER QUARDAN

- URETERIC COLIC
- RECTUS SHEATH HAEMATOMA
- RIGHT-SIDED LOBAR PNEUMONIA
LEFT LOWER QUARDAN
- SIGMOID DEVERTICULAR DISEASE
- OVARIAN CYST
- ECTOPIC PREGNANCY
- PELVIC INFLAMMATORY DISEASE

SITE OF ABDOMINAL PAIN

LEFT LOWER QUARDAN

- URETERIC COLIC
- RECTUS SHEATH HAEMATOMA
- LEFT-SIDED LOBAR PNEUMONIA
RADIATING PAIN
BACK
- PEPTIC ULCER, PANCREATITIS, ACUTE
AORTIC DISEASE
GROIN
- URETERIC COLIC, TESTICULAR TORSION

MEDICAL CAUSES OF ACUTE

ABDOMINAL PAIN
OCCASIONALLY,

CERTAIN MEDICAL
CONDITIONS MAY CAUSE ACUTE
ABDOMINAL PAIN
REFERRED PAIN. DEGENERATIVE
DISEASE OF THORACIC SPINE,
HERPES ZOSTER, LOBAR
PNEUMONIA, PLEURISY, MI
HAEMATOLOGICAL. THIS MAY BE DUE
TO SICKLE CELL CRISIS

MEDICAL CAUSES
INFECTIVE

AND INFLAMMATORY
TABES DORSALIS, HENOCHSCHOENLEIN PURPURA
ENDOCRINE AND METABOLIC
URAEMIA, HYPERCALCAEMIA,
DIABETIC KETOACIDOSIS, ADDISONS
DISEASE, ACUTE INTERMITTENT
PORPHYRIA