Acute Abdomen

Preseptor:
dr. Liza Nursanty, SpB, Mkes,
FINACS
Presentan :
Harum Binar .M
12100113016

Acute abdomen difined generally as an

intraabdominal process causing severe pain
and often requiring surgical intervention.

4 quadrant
Right Upper Quadrant
Right Lower Quadrant
Left Upper Quadrant
Right Lower Quadrant

1.
2.
3.
4.
5.

Right hypocondrium
Epigastric
Left hypocondrium
Right Lumbar
Regio umbilical

6.
7.
8.
9.

Left lumbal
Right inguinal
Suprapubic
Left inguinal

Acute abdominal pain is a common physical

complaint and prompted more than 7 million
emergency departement visits last year in the
united states.

ASSESMENT
Well elicited history
Proper physical
examination
Investigations are usually carried out :
only to support the diagnosis.
or to narrow down the differential diagnoses.

History
History of Present illness
Family History
Past Medical history
History of drugs taken or Medication
eg. ingestion of certain toxic drugs or
Alcohol intake

Free Peritoneal Air

This plain abdominal radiograph of a 55-year-old woman presenting with

features of intestinal obstruction shows dilated loops of the small bowel
associated with thickened edematous valvulae conniventes and a strangulated
left inguinal hernia (arrow).

PAIN
The Most Important Symptom

History of pain should include:

1.Onset
2.Severity
3.Type of pain
4.Radiation of Pain
5.Change in nature of Pain
6.Associated bowel or urinary symptoms
7.Aggravating or relieving factors

(i) Onset of Pain

Sudden onset pain which wakes the
patient from sleep
eg. perforation or strangulation of bowel
Slow insidious Onset
a. Inflammation of visceral peritoneum.
b. Contained process such as
evolving abscess.
Crampy or colicky pain
Biliary colic, Ureteric colic or
Intestinal colic

(ii) Progression of Pain

Progression from:
Dull, aching, poorly localized character
To:
Sharp, constant & better localized pain
indicates involvement of Parietal peritoneum

(iii) Associated Bowel Symptoms

CONSTIPATION
a. Progressive intestinal obstruction from a
neoplasm or inflammatory bowel disease
b. Paralytic Ileus
c. Post Operative
d. Obstructed groin hernia

(iv) Associated Bowel Symptoms

DIARRHOEA
Diarrhoea with pain is mainly medical.
The following are the exceptions :
a.Obstructed Richter's Hernia
b.Gall Stone ileus
c.Superior mesenteric vascular occlusion
d.Intestinal Obstruction associated with
pelvic abscess
e.Spurious diarrhea in chronic faecal
impaction

DRUG HISTORY
Corticosteroids mask pain
Anticoagulants can lead to an intramural
haematoma of the gut causing obstruction
Oral Contraceptives - rupture of hepatic
adenomas
NSAIDs - erosive gastritis & peptic ulcers

NAUSEA & VOMITING

i. Frequency of vomiting
ii. Character of vomiting:
projectile, non-projectile or self-induced
iii. Nature of vomiting:
a. Bilious vomiting of small bowel
obstruction
b. Non-bilious vomiting in obstruction
proximal to ampulla of vater
c. Faeculent vomiting in distal small gut
obstruction, large bowel obstruction ,
strangulation

NAUSEA & VOMITING

Pain first, followed by Vomiting is usually
surgical.
The vomiting is due to reflex
pylorospasm
Nausea & vomiting first , followed by pain
is usually due to a medical condition
Vomiting is very prominent in
a.Mallory-Weiss syndrome.
b.Boerhaave syndrome(trans- mural
esophageal tear)
c.Acute gastritis

ANOREXIA
Anorexia or decreased appetite with pain is
usually seen in Acute appendicitis

Urinary Symptoms with Pain

Ureteric colic
Cystitis

FEVER & CHILLS/RIGORS

Amoebic Liver Abscess
Pygenic Liver Abscess
Perinephric Abscess
Intra-abdominal pus collection

OTHER HISTORY
Past Surgical history: previous operationsleading to adhesions
Past Medical history: Sickle cell disease,
Diabetes or Cancer or Renal failure
Menstrual History in females
(i) Missed period- ectopic pregnancy
(ii) Mid of period-ovulation pain (Mittelschmerz)
(iii) With heavy periods- endometriosis
Family history of colon cancer, any other
malignancy or inflammatory bowel disease

Physical Examination
General Appearance
a.Anxious Patient lying motionless:
(i) Acute appendicitis
(ii) Peritonitis
b.Rolling in bed & restless:
(i) Ureteric Colic
(ii) Intestinal colic
c.Writhing in Pain:
Mesenteric Ischemia
d. Bending Forward:
Chronic Pancreatitis

Physical Examination (contd.)

e. Jaundiced:
CBD obstruction
f. Dehydrated
(i) Peritonitis
(ii) Small Bowel obstruction
g. Vital Charting
Temperature, Pulse, BP, Respiratory rate
Ruptured AAA or ectopic pregnancy can
lead to
- Pallor
- Hypotension
- Tachycardia
- Tachypnea

Physical Examination (contd.)

h.

Low grade temp. is seen with

- Appendicitis
- Acute cholecystitis
i. High grade temp. is seen with
- Salpingitis
- Abscess
j. Very High Grade Temp.with increasing
lethargy
seen in imminent septic shock
- Peritonitis
- Acute cholangitis
- Pyonephrosis

Systemic Examination
Cardiopulmonary examination
Check for:
- Possible MI
- Basal Pneumonia
- Pleural Effusion

Per Abdomen:
Inspection
- Scaphoid or flat in peptic ulcer
- Distended in ascites or intestinal obstruction
- Visible peristalsis in a thin or malnourished
Patient (with obstruction)

Systemic Examination
Erythema or discolouration
a. Peri-umbilical - Cullen sign
b. Inguinal Fox sign
c. Flanks - Grey Turner sign
Seen in Hemorrhagic pancreatitis
or any other cause of haemoperitoneum
Any Visible masses
Any visible cough impulse at hernia site

Systemic Examination
Per abdomen:
Palpation
Be gentle
Start away from site of pathology then towards
Check for Hernia sites
Tenderness
Rebound tenderness
Guarding- involuntary spasm of muscles
during palpation
Rigidity- when abdominal muscles are tense &
board-like. Indicates peritonitis.

Systemic Examination
Local Right Iliac Fossa tenderness :
a. Acute appendicitis
b. Acute Salpingitis in females
c. Amoebiasis of Caecum
Low grade, poorly localized tenderness :
Intestinal Obstruction
Tenderness out of proportion to examination:
a. Mesenteric Ischemia
b. Acute Pancreatitis
Flank Tenderness:
a. Perinephric Abscess
b. Retrocaecal Appendicitis

Systemic Examination
Rovsings Sign in Acute Appendicitis
Obturator Sign in Pelvic Appendicitis
Psoas Sign
- Retrocaecal appendicitis
- Crohns Disease
- Perinephric Abscess
Murphy's sign in Acute Cholecystitis
Thumping tenderness over lower ribs in
inflammation of
- Diaphragm
- Liver or spleen

Systemic Examination
Pulsatile Abdominal Mass with Hypotension
Leaking AAA
Cutaneous Hyperaesthesia indicates
involvement of Parietal Peritoneum
Per Rectal Examination:
- tenderness
- induration
- mass (Blummers shelf)
- frank blood

Systemic Examination
Per Vaginal Examination
- Bleeding
- Discharge
- Cervical motion tenderness
- Adnexal masses or tenderness
- Uterine Size or Contour

INVESTIGATIONS
Complete Blood Count with differential
C-reactive protein estimation
Electrolyte ,Blood Urea , Creatinine
Urine dipstick
Amylase or Lipase
Liver Function Test

INVESTIGATIONS
Radiology
Upright X ray chest for
-

Basal Pneumonia
Ruptured Oesophagus
Elevated Hemi diaphragm
Free Gas under diaphragm

Abdominal X ray film

-

Air-Fluid Levels
Stones
Ascites
Eggshell calcification in AAA
Air in Biliary tree.
Obliteration of Psoas Shadow in retro- peritoneal
disease
- Right lower quadrant sentinel loop in acute
appendicitis

INVESTIGATIONS
Other Investigations
-USG
-CT abdomen for AAA, Pancreatic disease, or
ureteric colic (non- Contrast)
-IVU
-Mesenteric Angiography for
-Ischaemia, Haemorrhage