The

 Acute  Abdomen  

Jason Smith MD DMI FRCS(Gen.Surg)

Consultant Surgeon

Mr Jason Smith - Consultant Surgeon

 Acute  Abdomen  

General  name  for  presence  of  signs,  

symptoms  of  inflamma4on  of  peritoneum  

Mr Jason Smith - Consultant Surgeon

The  problems  of  a  surgeon  
  If  I  operate  and  the  problem  is  not  surgical,  pa4ent  
exposed  to  unnecessary  risk,  anesthe4c,  etc.  
  Risks  greater  with  concomitant  illness,  older  age  

  If  I  do  not  operate  and  problem  is  surgical,  pa4ent  at  

risk  because  of  wrong  therapy.  
  Again  the  older  pa4ent  is  under  greater  burden.  

  Risk-­‐Predic4on  Algorithms  

Mr Jason Smith - Consultant Surgeon

Probably  needs  an  operation  
  Acute  pain  
  Sep4c  &  toxic  
  Board-­‐like  abdomen  
  Absent  bowel  sounds  
  WBC  25,000  
  Free  air  under  diaphragm  

Mr Jason Smith - Consultant Surgeon

Probably  doesn’t  need  an  operation  
  Trivial  pain  
  Robust  appearance  
  SoM  abdomen  with  no  guarding  
  Normal  bowel  sounds  
  Normal  WBC/CRP  

Mr Jason Smith - Consultant Surgeon

Abdominal  Anatomy  
  Organs  can  be  classified  as:    
  Hollow  
  Solid  
  Major  vascular  

Mr Jason Smith - Consultant Surgeon

Solid  Organs  
  Liver  
  Spleen  
  Kidney  
  Pancreas  

When solid organs are

injured, they bleed heavily
and cause shock

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  –  Initial  Views  
  Does  the  pa4ent  look  ill,  sep4c  or  shocked?  
  Call  for  help!  
  Are  they  lying  s4ll    
  (peritoni4s,  shock),    
  or  rolling  around  in  agony      
  (colic)?  
  Assess  and  manage  Airway,  Breathing  and  Circula4on  as  a  
priority  (as  per  ALS/ATLS).  

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  –  Initial  Views  
  As  per  ATLS,  Mx  occurs  at  the  same  4me  as  assessment  &  
diagnosis  
  Large  bore  venflon  –  large  vein  
  Oxygen  
  Analgesia  (limited)  
  “Am  I  out  of  my  depth?”  
  “Do  I  have  enough  help?”  
  Documenta4on!!  
  Safety  -­‐  you  

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  -­‐  History  
  Where  do  you  hurt?  
  Know  loca4ons  of  major  organs  
  But  realize  abdominal  pain  
loca4ons  do  not  correlate  well  
with  source  

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  -­‐  History  
  What  does  pain  feel  like?  
  Steady  pain  -­‐  inflammatory  
process  
  Crampy  pain  -­‐  obstruc4ve  process  
  Sharp  –  peritoneal  irrita4on  
  Dull  –  peritoneal  stretching  

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  -­‐  History  
  Was  onset  of  pain  gradual  
or  sudden?  
  Sudden  =  perfora4on,  
hemorrhage,  infarct  
  Gradual  =  peritoneal  
irriga4on,  hollow  organ  
distension  

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  -­‐  History  
  Does  pain  radiate  (travel)  anywhere?  
  Right  shoulder,  angle  of  right  scapula  =  gall  bladder  
  Around  flank  to  groin  =  kidney,  ureter  
  Into  middle  of  back  =  pancreas,  duodenum  

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  -­‐  History  
  Dura4on?  
  <6  hour  dura4on  =  ?  surgical  significance  
  Nausea,  vomi4ng?  Bloody?  “Coffee  Grounds”?  

Any blood in GI tract =

Emergency until proven otherwise

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  -­‐  History  
  Change  in  urinary  habits?    Urine  appearance?  
  Change  in  bowel  habits?    Appearance  of  bowel  
movements?  Melena?  

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  -­‐  History  
  Regardless  of  underlying  cause  vomi4ng  or  diarrhea  can  
be  a  problem  because  of  associated  volume  loss  

Everybody has pancreatitis until proven

otherwise

Mr Jason Smith - Consultant Surgeon

Patient  Assessment  -­‐  History  
  Females  
  Last  menstrual  period?    
  Abnormal  bleeding?    

In females, abdominal pain =

Gynaeproblemuntil proven otherwise

In females, abdominal pain = Pregnant

until proven otherwise

Mr Jason Smith - Consultant Surgeon

Physical  Exam  
  General  Appearance  
  Lies  perfectly  s4ll    inflamma4on,  peritoni4s  
  Restless,  writhing    obstruc4on  
  Abdominal  distension?  
  Ecchymosis  around  umbilicus,  flanks?  

Mr Jason Smith - Consultant Surgeon

Physical  Exam  

  Vital  signs  
  Tachycardia  ?  Early  shock  (more  important  than  BP)  
  Rapid  shallow  breathing  peritoni4s  

Young / Old patients have different

responses to fluid loss

Mr Jason Smith - Consultant Surgeon

Physical  Exam  
  Palpate  each  quadrant  
  Work  toward  area  of  pain  
  Warmhands,  gentle  approach!  
  Pa4ent  on  back,  knee  bent  (helps  relax)  
  Use  child’s  own  hand  
  Note  tenderness,  rigidity,  involuntary  guarding,  voluntary  
guarding  (steth-­‐test),  masses  

Mr Jason Smith - Consultant Surgeon

Physical  Exam  
  Bowel  Sounds  
  Listen  1  minute  in  each  quadrant  
  Listen  before  feeling  
  Absent  bowel  sounds    ileus,  peritoni4s,  shock  

Auscultating bowel sounds has no value in

trauma patients

Auscultating bowel sounds in reality is a

waste of time in the acute phase

Mr Jason Smith - Consultant Surgeon

Management  
  Airway  
  High  flow  O2  
  An4cipate  vomi4ng,  appropriate  clothing,  bowel  
  An4cipate  hypovolemia  –  hence  large  bore  cannulae  
  Nothing  by  mouth,  un4l  DDx  established  
  Limited  analgesics  

Mr Jason Smith - Consultant Surgeon

Management  
  In  adults  >  30,  consider  possibility  of  referred  cardiac  
pain.  
  In  females,  consider  possible  gynaeproblem,  
especially  tubal  ectopic  pregnancy  

Mr Jason Smith - Consultant Surgeon

Acute  Abdomen  -­‐  Investigations  
  Urinalysis  
  FBC,  U&E  
  Plain  AXR  
  (CT)  

Mr Jason Smith - Consultant Surgeon

The  WCC  in  570  patients  
Diagnosis            Sensi+vity  %        Specificity  %  
Appendici4s  (↑)      91    21  
Cholecys44s  (↑)      78    11  
Obstruc4on  (↑)      56    8  
Gastroenteri4s  (N)      49    11  
Other  Non-­‐surgical  (N)    62    82  

Predic4ve  value  of  ↑  WCC  for  surgical  condi4on  29%  

Predic4ve  value  of  ↓  WCC  for  non-­‐surgical  cond                93%  

Mr Jason Smith - Consultant Surgeon

Sensitivity  of  plain  AXR-­‐  249  Patients  
             %  Abnormal  
Appendici4s          48  
Cholecys44s          64  
Pancrea44s          60  
Intes4nal  Obstruc4on      98  
Perforated  Ulcer        60  

Mr Jason Smith - Consultant Surgeon

Frequency  of  Diagnoses  in  1000  Patients  

Unknown    41%    Cholecys4s              4%  

Urinary  Tract    9%    Intes4nal  Obst        2.5%  
Gastroenteri4s      7%    Cons4pa4on              2%  
PID          7%    Misc                7%  

80%!!

Mr Jason Smith - Consultant Surgeon

Appendiscitis  
Age Young > old
Dx correct in 50%
Several episodes
Sx Central dull to RIF sharp
N&V
Off food
Si Pain, foetor
WCC, CRP – waste of time

Ix Exclude gynae problems

Mx Fluid balance
Antibiotics
Laparoscopy or open

Mr Jason Smith - Consultant Surgeon

Stomach/duodenum – Perforation  
Age Young men & alcohol
Older anyone & drugs

Sx Pain, generalised, sharp, upper

Rigidity

Si Peritonism
Shock +/- sepsis

Ix Air under diaphragm

CT better

Mx Fluid resus – most important

Laparotomy & oversew / patch
Conservative?

Mr Jason Smith - Consultant Surgeon

Age Young men & alcohol
Older anyone & drugs

Sx Haematemesis +/- Melena

Si Shock
Rockall score
Wilson Index
Ix OGD
(mesenteric angiogram)

Mx Fluid resus – most important

OGD inject
Laparotomy & underun

Mr Jason Smith - Consultant Surgeon

Age Fat, female, forty, fertile
Common in Asians

Sx Colicky upper abdo pain

(stools/urine), Courvoisier's sign
N&V
Si Palpable GB
Jaundice

Ix USS +/- CT
(Must exclude Ca Pancreas)

Mx Conservative
Lifestyle adjustment / lipids
Lap Chole

Mr Jason Smith - Consultant Surgeon

Age Overweight, women > men
Hx Gallstones

Sx Acute sharp RUQ pain rad to back,

shoulder
N&V
Si Pyrexia +/- Rigors, tachcardia
Jaundice

Ix Bloods
USS +/- CT

Mx Antibiotics (met) – 20% are infected

Analgesia
Lap Chole (acutely)

Mr Jason Smith - Consultant Surgeon

Cholangitis  
Age As for previous

Sx Acute sharp RUQ pain rad to back,

shoulder
N&V
Si Pyrexia +/- Rigors
Jaundice
(Charcot’s Triad)
Ix Bloods
USS +/- CT
(medical emergency)
Mx Antibiotics (inc met)
ERCP / PTC
Lap Chole

Mr Jason Smith - Consultant Surgeon

Acute  Pancreatitis  
Age Any age, predom younger with alcohol
& older with gallstones

Sx Constant pain, N&V++

Shock

Si Pyrexia
(Peritonism)
(Jaundice)
Ix Bloods (amylase & CRP)
USS +/- CT
(medical emergency)
Mx Supportive & complex
(surgery)

Mr Jason Smith - Consultant Surgeon

Meckel’s  Diverticulum  
Age Rare, often found incidently

Sx Rectal bleeding
Sx similar to appendiscitis

Si

Ix Radioisotope scan

Mx Remove only if symptomatic

Mr Jason Smith - Consultant Surgeon

Small  bowel  obstruction  
Age All ages, depends on underlying cause
5-10% of all admissions

Sx Colicky general pain

Vomiting early/late
‘constipation’
Si Distended resonant abdomen
‘tinkling’ bowel sounds
shock
Ix CT

Mx Fluid balance
Conservative vs Operative

Mr Jason Smith - Consultant Surgeon

Mesenteric  Ischaemia  
Age 50% embolic, 25% atheroma,
10% venous
90% mortality
Sx Incredibly difficult to diagnose
Severe central pain
Pain out of proportion to findings
Si WCC, acidosis, lactate

Ix Laparotomy

Mx Embolectomy, grafting, resection

Open & close

Mr Jason Smith - Consultant Surgeon

Acute  Diverticulitis  
Age 10% at 40yrs
60% by 80yrs
Sx common in middle age/elderly
Sx Usually LIF pain
+/- constipation +/- rectal bleeding

Si Tenderness
Fever, tachycardia
Raised WCC & CRP
Ix Ba enema / flexi
CT

Mx Antibiotics, lifestyle
2 strikes and its out!

Mr Jason Smith - Consultant Surgeon

Lower  GI  Bleed  
Age Age determines likely cause

Sx BR / DR rectal bleeding

Si Shock
Wilson Index

Ix Flexi / colonoscopy / angiogram

Mx Fluid balance & Mx of shock then

underlying cause

Mr Jason Smith - Consultant Surgeon

Perforated  colon  
Age Age determines likely cause
Don’t overlook iatrogenic & self
induced causes
Sx Peritonism
Tachycardia

Si Shock
Generalised tenderness, boardlike

Ix WCC, CRP
CT

Mx Resuscitate
Laparotomy +/- stoma

Mr Jason Smith - Consultant Surgeon

Acute  Severe  Colitis  
Age Young 20-35, women > men

Sx Bloody diarrhoea , mucus urgency ++

Generalised abdo pain

Si Shock
Anaemic, WCC up

Ix Flexi / colonoscopy
Plain films

Mx Fluid balance & Mx of shock

Steroids, cyclosporin
Joint Mx with physicians

Mr Jason Smith - Consultant Surgeon

Acute  Abdominal  Pain  
Non-­‐surgical  Emergencies  
  Mesenteric  Adeni4s  
  Acute  Enteric  Infec4ons  
  Acute  Enteric  Poisonings  
  Inflammatory  Bowel  Disease  
  Pancrea44s  (usually)  

11/98 44 medslides.com
Mr Jason Smith - Consultant Surgeon
Acute  Abdominal  Pain  
Metabolic  Causes  
  Diabe4c  Ketoacidosis  
  Heavy  Metal  Poisoning  
  Acute  Porphyria  
  Sickle  Cell  Crisis  

11/98 45 medslides.com
Mr Jason Smith - Consultant Surgeon