Acute Abdomen

Presented by – Dr. Deepankar Srigyan

Under guidance of – Prof. Alekseev Gennadii Ivanovich

MOSCOW 2010
Visceral
Somatic
Referred
 Visceral pain
 Stretching of peritoneum or organ capsules by
distension or edema
 Diffuse
 Poorly localized
 May be perceived at remote locations related
to organ’s sensory innervation
 Somatic pain
 Inflammation of parietal peritoneum or
diaphragm
 Sharp
 Well-localized
 Referred pain
 Perceived at distance from diseased organ
 Pneumonia
 Acute myocardial infarction
 Male genitourinary problems
 Gastrointestinal Causes:
Peritonitis
Pancreatitis
Early Appendicitis
Mesenteric Adenitis
Gastroenteritis
Colitis
Intestinal Obstruction
 Hematologic Causes:
Leukemia
Sickle Cell Crisis
 Vascular Causes:
Mesenteric Thrombosis
Abdominal Aortic Aneurysm
Splenic artery aneurysm
Mesenteric Artery aneurysm
 Gastrointestinal Causes:
 Cholecystitis or Cholelithiasis
 Pericarditis
 Gastritis or Peptic Ulcer Disease
 Pancreatitis
 Vascular Causes:
 Myocardial Infarction
 Aortic Dissection
 Mesenteric Ischemia
Gastrointestinal Causes:
Gastritis
Pancreatitis
Miscellaneous Causes:
Splenic enlargement, splenic rupture, splenic
infarction, aneurysm
Renal pain
Cardiopulmonary Causes:
Myocardial Ischemia
Pneumonia
Empyema
Acute Pelvic Pain Causes
Gastrointestinal Causes:
Gall Bladder or Billiary Tract Disease
Hepatitis
Hepatic Abscess
Hepatomegaly due to Congestive Heart Failure
Peptic Ulcer
Pancreatitis
Retrocecal Appendicitis
Miscellaneous Causes:
Renal pain
Pneumonia
Empyema
Gastrointestinal Causes:
 Intestinal Obstruction
 Constipation
 Diverticulitis
Vascular Causes:
 Leaking aortic aneurysm
Genitourinary Causes:
 Acute Pelvic Pain Causes
 Ovarian Cyst or torsion
 Ureteral Calculus (Nephrolithiasis)
 Renal pain
 Seminal vesiculitis
Miscellaneous Causes:
 Psoas abscess
 Abdominal wall hematoma
 Gastrointestinal Causes:
 Appendicitis (pain over McBurney's Point)
 Intestinal Obstruction
 Regional Enteritis
 Diverticulitis
 Genitourinary Causes:
 Acute Pelvic Pain Causes
 Ovarian Cyst or torsion
 Ureteral Calculus (Nephrolithiasis)
 Renal pain
 Seminal vesiculitis
 Miscellaneous Causes:
 Leaking Abdominal Aortic Aneurysm
 Abdominal wall hematoma
 Inflammation of distal esophagus
 Usually from gastric reflux, hiatal hernia

 Signs and Symptoms

 Substernal burning pain, usually epigastric
 Worsened by supine position
 Usually without bleeding
 Often temporarily relieved by nitroglycerin
 Inflammation of stomach, intestine
 May lead to bleeding, ulcers
 Causes
  acid secretion
 Chronic alcohol abuse
 Biliary reflux
 Medications (Aspirin, NSAIDs)
 Infection
 Signs and Symptoms
 Epigastric pain, usually burning
 Tenderness
 Nausea, vomiting
 Diarrhea
 Possible bleeding
 Long-term mucosal changes or permanent
damage
 Due primarily to microbial infections
(bacterial, viral, protozoal)
 Fecal-oral transmission
 More common in underdeveloped countries
 Nausea, vomiting, fever, diarrhea,
abdominal pain, cramping, anorexia,
lethargy
 Inflammation of pancreas in which enzymes auto-digest gland.
 Causes include:
 Alcohol (80% of cases)
 Gallstones obstructing ducts
 Elevated serum triglycerides
 Trauma
 Viral, bacterial infections
 Signs and Symptoms
 Mid-epigastric pain radiating to back
 Often worsened by food, alcohol
 Bluish flank discoloration (Grey-Turner Sign)
 Bluish periumbilical discoloration (Cullen’s Sign)
 Nausea, vomiting
 Fever
 Gall bladder inflammation, usually secondary to
gallstones (90% of cases).
 Risk factors
 Five ‘F’s: Fat, Fertile, Febrile, Fortyish, Females
 Heredity, diet, contraceptive pills use
 Signs and Symptoms
 Sudden pain, often severe, cramping
 Right upper quadrant, radiating to right shoulder
 Point tenderness under right costal margin (Murphy’s sign)
 Nausea, vomiting
 Often associated with fatty food intake
 History of similar episodes in past
 Inflammation of vermiform appendix.
 Usually secondary to obstruction by fecalith.
 May occur in older persons secondary to
atherosclerosis of appendiceal artery and
ischemic necrosis.
 Signs and Symptoms
 Classic: Periumbilical pain  RLQ pain/cramping
 Nausea, vomiting, anorexia
 Low-grade fever
 Pain intensifies, localizes resulting in guarding
 Patient on right side with right knee, hip flexed
 Signs and Symptoms
 McBurney’s Sign: Pain on palpation of RLQ
 Aaron’s Sign: Epigastric pain on palpation of
RLQ
 Rovsing’s Sign: Pain in LLQ on palpation of
RLQ
 Psoas Sign: Pain when patient:
Extends right leg while lying on left side
Flexes legs while supine
 Signs and Symptoms
 Unusual appendix position may lead to atypical
presentations
Back pain
LLQ pain
“Cystitis”
 Rupture: Temporary pain relief followed by peritonitis
 Blockage of intestine
 Common Causes
 Adhesions (usually secondary to surgery)
 Hernias
 Neoplasms
 Volvulus
 Intussuception
 Impaction
 Pathophysiology
 Fluid, gas, air collect near obstruction site
 Bowel distends, impeding blood flow/ halting
absorption
 Water, electrolytes collect in bowel lumen leading
to hypovolemia
 Bacteria form gas above obstruction further
worsening distension
 Distension extends proximally
 Necrosis, perforation may occur
 Signs and Symptoms
 Severe, intermittent, “crampy” pain
 High-pitched, “tinkling” bowel sounds
 Abdominal distension
 History of decreased frequency of bowel
movements, semi-liquid stool, pencil-thin
stools
 Nausea, vomiting
 ? Feces in vomitus
 Protrusion of abdominal contents into groin
(inguinal) or through diaphragm (hiatal)
 Often secondary to  intra-abdominal pressure
(cough, lift, strain)
 May progress to ischemic bowel (strangulated
hernia)
 Signs and Symptoms
 Pain  by abdominal pressure
 Past history
 Inguinal hernia may be palpable as
mass in groin or scrotum
 Idiopathic inflammatory bowel disease
 Occurs anywhere from mouth to rectum
 35-45%: small intestine; 40%: colon
 Hereditary
 High risk groups
 White females
 Jews
 Persons under frequent stress
 Pathophysiology
 Mucosa of GI tract becomes inflamed
 Granulomas form, invade submucosa
 Muscular layer of bowel become fibrotic,
hypertrophied
 Increased risk develops for
Obstruction
Perforation
Hemorrhage
 Idiopathic inflammatory bowel disease
 Chronic ulcers develop in mucosal layer of colon
 Spread to submucosal layer uncommon
 75% of cases involve rectum (proctitis) or
rectosigmoid portion of large intestine
 Inflammation can spread through entire large
intestine (pancolitis)
 Severity of signs, symptoms depends on extent
 Classic presentation
 Crampy abdominal pain
 Nausea, vomiting
 Blood diarrhea or stool containing mucus
 Ischemic damage with perforation may occur
 Diverticulitis

 Diverticula
 Pouches in colon wall
 Typically in older
persons
 Usually asymptomatic
 Related to diets with
inadequate fiber
 Diverticula trap feces, become inflamed
 Occasionally result in bright red rectal
bleeding
 Rupture may cause peritonitis, sepsis
 Signs and Symptoms
 Usually left-sided pain
 May localize to LLQ (“left-sided
appendicitis”)
 Alternating constipation, diarrhea
 Bright red blood in stool
 Small masses of veins in anus, rectum
 Most frequently develop when patients are in
age of 30s or 40s; common past 50
 Most are idiopathic, can be associated with
pregnancy, portal hypertension
 Cause bright red bleeding, pain on defecation
 May become infected, inflamed
 Inflammation of abdominal cavity lining
 Signs and Symptoms
 Generalized pain, tenderness
 Abdominal rigidity
 Nausea, vomiting
 Absent bowel sounds
 Patient resistant to movement
 Positive Blumberg's sign
 Helicobacter Pylori
 Nonsteroidal Anti-inflammatory Drug (NSAID)
 Tobacco Smoking
 Stress
 Caffeine
 Alcohol
Established Risk Factors Possible Risk Factors
 Age over 60 years Questionable Risk
Factors
 previous peptic ulcer  NSAIDs-related
disease dyspepsia
 Cigarette smoking
 Previous upper GI  Duration of NSAIDs
bleeding use
 Concomitant  Alcohol consumption
 Helicobacter pylori
corticosteroid therapy infection
 high-dose and multiple  Rheumatoid arthritis
NSAIDs use
 Concomitant
anticoagulant use or
coagulopathy
 Chronic major organ
impairment (e.g.,
cardiovascular disease)
 Duodenal Ulcers  Gastric Ulcers
20 to 50 years old > 50 years old
High stress Work at jobs
occupations requiring physical
Genetic predisposition activity
Pain when stomach is Pain after eating or
empty when stomach is full
Pain at night Usually no pain at
night
Men are affected 3-4x more than women.
Damage to mucosa Acid and pepsinogen
with alcohol abuse, release with chronic Infection with
smoking, use of vagal response to Helicobacter Pylori
aspirin and NSAIDs increased stress

Damaged mucosal barrier

Imbalance of aggressive and

defensive factor

Low of mucosal cells; Low

quality of mucous; Lesstight
juntion between cells
 Infection gives increased
gastrin and decreased
somatostation production

Erosive gastritis inflammation

>> decreased acid and intrinsic
factor

Mucosal ulcerations, possible

bleeding and scarring

Severe Ulcerations:
A damage mucosa could not
secrete enough mucus to act as Signs and Symptoms:
a barrier against gastric acid  Epigastric pain
 Hematemesis
 Dsypepsia
 Pyrosis
Symptoms of gastric ulcer disease:

 epigastric pain after meal or during meal

 upper dyspeptic syndrome – loss of
appetite, nausea, vomiting, flatulence
 vomiting brings relief
 reduced nutrition
 loss of weight
Symptoms of duodenal ulcer
disease:

epigastric pain 2 hours after meal or on a

empty stomach or during night
pyrosis
good nutrition
obstipation
seasonal dependence (spring, autumn)
Complications of peptic ulcers:

 Bleeding
 Perforation
 Penetration
 Pylero-duodenal stenosis
 Malignization
NONPHARMACOLOGIC TREATMENT
 Life style modifications
 Patients with PUD should eliminate or reduce psychological stress,
cigarette smoking, and the use of Nonselective NSAIDs (including
aspirin). If possible, alternative agents such as acetaminophen, a
nonacetylated salicylate (e.g., salsalate), or a COX-2 selective
inhibitor should be used for pain relief.
 Although there is no need for a special diet, patients should avoid
foods and beverages that cause dyspepsia or exacerbate ulcer
symptoms (e.g. spicy foods, caffeine, and alcohol).

PHARMACOLOGIC TREATMENT
 acid-antisecretory agents,
 mucosal protective agents,
 agents that promote healing through eradication of H pylori.44
 Medicines for peptic ulcer disease
Drug type/mechanism Examples Dose
Acid-suppressing drugs
Antacids Maalox, Tums, 100-140 mg 1
Gaviscon and 3 h after
meals

H2 receptor antagonists Cimetidine, 800 mg/d

Ranitidine, 300 mg/d
Famotidine 40 mg/d
Proton pump inhibitors Omeprazole, 20 mg/d
Lansoprazole, 30 mg/d
Rabeprasole 20 mg/d 45
Drug type/mechanism Examples Dose

Mucosal protective agents

Sucralfate Sucralfate 1 g qid

Prostaglandine analoque Misoprostol 200 mg qid

Bismuth-containing Bismuth
compounds subsalicylate
(BSS)
46
 Omeprasol 20 mg twice daily or Ranitidine 400 mg
twice daily.
 Bismuth subcitrate (De-Nol) two tablets four times
daily.
 Tetracyclin 500 mg four times daily.
 Metronidazol 250 mg four times daily.
 The most common triple therapy :
• Omeprasol (lanzoprazol) 20 mg bid
• Clarithromycin 500 mg bid
• Amoxicillin 1 g bid for 14 days.
Gastrointestinal Hemorrhage
Intra-abdominal Hemorrhage
 Dilated veins in esophageal wall
 Occur secondary to hepatic cirrhosis, common in
alcohol abusers
 Obstruction of hepatic portal blood flow results
in dilation, thinning of esophageal veins
 Portal hypertension
 Hepatic scarring slows blood flow
 Blood backs up in portal circulation
 Pressure rises
 Vessels in portal circulation become distended
 Signs and Symptoms
 Hematemesis (usually bright red)
 Nausea, vomiting
 Evidence of hypovolemia
 Melena (uncommon)
 Mallory-Weiss Syndrome

 Longitudinal tears at
gastroesophageal junction
 Occur as result of
prolonged, forceful
vomiting, retching
 Common in alcoholics
 May be complicated by
presence of esophageal
varices
 Localized dilation due to weakening of aortic wall
 Usually older patient with history of hypertension,
atherosclerosis
 May occur in younger patients secondary to
 Trauma
 Marfan’s syndrome
 Signs and Symptoms
 Unilateral lower quadrant pain; low back or leg pain
 May be described as tearing or ripping
 Pulsatile palpable mass usually above umbilicus
 Diminished pulses in lower extremities
 Unexplained syncope
 Evidence of hypovolemic shock
 Ectopic Pregnancy

 Any pregnancy that takes

place outside of uterine
cavity
 Most common location is
in Fallopian tube
 Pregnancy outgrows
tube, tube wall ruptures
 Hemorrhage into pelvic
cavity occurs
 Suspect in females of child-bearing age with:
 Abdominal pain, or
 Unexplained shock
 When was last normal menstrual period?

Ectopic pregnancy does

NOT necessarily cause
missed period
 Where do you have pain?
 Try to point with one finger
 What does pain feel like?
 Steady pain = Inflammatory process
 Cramping pain = Obstructive process
 Onset of pain?
 Sudden = Perforation or vascular occlusion
 Gradual = Peritoneal irritation, distension of
hollow organ
 Does pain travel anywhere?
 Gallbladder = Angle of right scapula
 Pancreas = Straight through to back
 Kidney/ureter = Around flank to groin
 Heart = epigastrium, neck/jaw, shoulders, upper
arms
 Spleen = Left scapula, shoulder
 Abdominal Aortic Aneurysm = low back radiating
to one or both legs
 How long have you been paining?
 >6 hours = increased probability of surgical
significance
 Nausea, vomiting
 How much, How long?
Consider possible hypovolemia
 Blood, coffee grounds?
Any blood in GI tract = emergency until
proven otherwise
 Urine
 Change in urinary habits?
Frequency
Urgency
 Color?
 Odor?
 Bowel movements
 Change in bowel habits? Color? Odor?
Bright red blood
Melena = black, tarry, foul-smelling stool
Dark stool
Suspect bleeding
Other causes possible (iron or bismuth
containing materials)
 Last normal menstrual period?
 Abnormal bleeding?
 In females, lower abdominal pain = GYN
problem until proven otherwise
 In females of child-bearing age, lower
abdominal pain = ectopic pregnancy until
proven otherwise
 Position and General Appearance
 Still, refusing to move = Inflammation,
peritonitis
 Extremely restless = Obstruction
 Gross appearance of abdomen
 Distended
 Discolored
 Consider possible third spacing of fluids
 Vital signs
 Tachycardia = more important sign of volume
loss than falling BP
 Rapid, shallow breathing = possible
peritonitis
 Consider performing “tilt” test
 Bowel sounds
 Auscultate BEFORE palpating
 One minute in each abdominal quadrant
 Absent sounds = possible peritonitis, shock
 High-pitched, tinkling sounds = possible
bowel obstruction
 Palpation
 Palpate each quadrant
 Palpate area of pain LAST
 Do NOT check rebound tenderness in
prehospital setting
 ALL abdominal tenderness significant until
proven otherwise
 for the diagnosis of rectal tumors and other forms of cancer;
 for the diagnosis of prostatic disorders, notably tumors and benign prostatic
hyperplasia;
 for the diagnosis of appendicitis or other examples of an acute abdomen
(i.e. acute abdominal symptoms indicating a serious underlying disease);
 for the estimation of the tonicity of the anal sphincter, which may be useful
in case of fecal incontinence or neurologic diseases, including traumatic
spinal cord injuries;
 in females, for gynecological palpations of internal organs
 for examination of the hardness and color of the feces (ie. in cases of
constipation, and fecal impaction);
 prior to a colonoscopy or proctoscopy.
 to evaluate hemorrhoids
 In newborns to exclude imperforate anus
 Oxygen therapy; keep airway clear
 Intravenous opioids
 Keep patient from losing body heat
 Position of comfort
 Monitor vital signs
 Monitor ECG

Consider possible MI with pain

referred to abdomen in patients
>30 years old

 Keep patient Nil Per Os

 Analgesia controversial
 Demerol is preferred narcotic analgesic