The Acute Abdomen

by :

Andreas Andrianto
Airlangga School of Medicine/Dr Sutomo Hospital

Definition
Acute abdomen describes clinical condition as result of emergency situations intra abdominal with pain as main symptom

Table 1. Sensory innervations of intra abdominal structures

Structure
Middle part of Diaphragm Edge of diaphragm, stomach, pancreas, gall bladder, intestine Appendix,proximal colon

Nerve
Phrenicus Plexus celiac Plexus mesentericus

Level
C 3-5 Th 6-9 Th 10-11

Distal colon, rectum, kidney, urethra & testis

Vesica urinary, recto sigmoid

Splanchnic caudal

Th 11-L 1
S 2-4

Figure 1. Innervations of diaphragm and shoulder

Referred Pain

Shifting Pain

Figure 2.Referred pain and shifting pain in the acute abdomen

Abrupt, excruciating pain

IMA Colic billier Perforated ulcer Ruptured aneurysm

Rapid onset of severe, constant pain

Acute pancreatitis

Mesenteric thrombosis, strangulated bowel

Colic ureter

Ectopic pregnancy

Gradual, steady pain

Acute cholecystitis, acute cholangitis, acute hepatitis Appendicitis, salpingitis

Intermittent, colicky pain with free interval

Early pancreatitis (rare) Small bowel obstruction

IBD

Colic billier

Figure 3. The location and character of the pain are useful in the differential diagnosis of the acute abdomen

Extra abdominal conditions that causes abdominal pain These may rarely present as referred abdominal pain. The most important to remember : pneumonia (especially lower lobe), Myocardial Infarction. Those diseases tend to be Medical diseases and surgery is not generally indicated

Table 2. Physical findings with various causes of acute abdomen

Conditions
Perforated viscous

Helpful sign
Scaphoid (early), tense abdomen, diminished bowel sound (late), loss of liver dullness, guarding or rigidity
Motionless, absent bowel sound (late), rebound tenderness, guarding Tender mass, special sign (Murphy's, obturator or psoas) Distention, visible peristaltis (late), hyperperistaltis (early) or quiet abdomen (late), diffuse pain, hernia (some) Distention, minimal bowel sound

Peritonitis Inflamed mass or abscess Intestinal obstruction

Paralytic ileus

Ischemic or strangulated bowel

Bleeding

Not distended (until late), severe pain, rectal bleeding (some)

Pallor, shock, distention, pulsatile (aneurysm)

Figure 3. Causes of shock in patients with acute abdomen

Consideration of Surgery Intervention

Decision of surgery intervention on acute abdomen depends on correct diagnosis. If we got difficulties to make decision, we should observe patient closely. Meanwhile patient must fasting, apply naso gastric tube and IV line

Table 3. Indications for urgent operations in patients with acute abdomen

Physical findings Involuntary guarding or rigidity, especially if spreading Increasing or severe localized tenderness Tense or progressive distention Tender or abdominal or rectal mass with high fever or hypotension Rectal bleeding with shock or acidosis Radiologic findings Pneumoperitoneum Gross or progressive bowel distention Free extravasations of contrast material Space occupying lesion on scan, with fever Mesenteric occlusion on angiography

Summary
Acute abdomen is serious surgical emergency requiring the surgeon to combine the result of the history and physical examination with properly selected laboratory and radiographic studies Correct preoperative diagnosis will usually lead to a successful operation