Acute Abdomen

"Acute abdomen"
definition
It is an acute intra-abdominal condition of
abrupt onset, usually associated with pain
due to inflammation, perforation,
obstruction, infarction, or rupture of
abdominal organs, that may require
emergency surgical intervention.
According to Sabiston Textbook
of Surgery:
“The term acute abdomen refers to signs
and symptoms of abdominal pain and
tenderness, a clinical presentation that
often requires emergency surgical
therapy.”
 The BIG Question
Does this patient require an emergency
surgical exploration?
 Therefore
It is more important recognize a
surgical abdomen then to identify
the exact cause of abdominal
pain.
 Types of Abdominal Pain

• Visceral Pain.
• Somatic (Parietal) Pain
• Referred Pain
 Major Categories of Acute
Abdomen
• Inflammation
• Perforation
• Obstruction
• Congenital problem
• Bleeding or rupture of vessels or
tumor
• Ischemia or Infarction
 Clinical approach
• A complete & correctly taken history & physical
examination is the most essential part of work up.
• All features of pain MUST be defined
• Adequate examination of abdomen requires proper
exposure.
• Never forget a Rectal examination!
• Remember that in up to 1/3rd of cases Presentation can
be atypical
• Pain perception and the muscular response to peritoneal
irritation may be altered at extreems of age in the elder
patients & young children.
 Special considerations in children
• Majority of cases of acute abdominal pain are benign
• A child is often unable to describe pain, this requires patience,
persistence & persuasion by the physician.
• A careful & thoughtful clinical examination assumes greater
importance.
• A crying un cooperative child must be pacified ( with
analgesics & sedative if needed)
• In the acute surgical abdomen, pain generally precedes
vomiting, while the reverse is true in ‘medical’ conditions.
• If the diagnosis is not clear after the initial evaluation, repeated
physical examination by the same physician often is useful.
Causes of Acute Abdominal Pain in
Children
• Gastrointestinal
• Genitourinary causes
• Extra abdominal (referred pain)
• Miscellaneous
Acute Abdominal Pain in Patients
Under and Over Age 50
Under 50 (6317 cases), % Over 50 (2406 cases), %
Nonspecific abd. pain 39.5 Cholecystitis 20.5
Appendicitis 32.5 Nonspecific abd. Pain 15.7
Cholecystitis 6.3 Appendicitis 15.2
Obstruction 2.5 Obstruction 12.5
Pancreatitis 1.6 Pancreatitis 7.3
Diverticular disease <0.1 Diverticular disease 5.5
Cancer <0.1 Cancer 4.1
Hernia <0.1 Hernia 3.1
Vascular <0.1 Vascular 2.3

(Telfer et al., 1988; Scand J Gastroenterol)

Causes of acute abdomen specific
to children
• Necrotizing entero colitis
• Malrotation & midgut volvulous
• Neonatal intestinal perforation
• Infantile intususseption
Necrotizing Entero colitis (NEC)
• Classical picture is
• A premature newborn ( may be near term)
• Has been given oral feed,
• May have had a hypoxic episode
• Develops abd. Distention, vomiting often
bilious,
• septic toxic features.
• May have bloody diarrhea
 NEC Management
• NPO, N/G suction
• correction & maintainence of fluid &
electrolytes / TPN
• I/V Antibiotics
• Surgery, if features of intestinal perforation
( free gas in abdomen)
 Malrotation & Volvulous
• May present at any age from newborn to late
childhood, but mostly within first month
• Bilious vomiting may be the only complain. With
no findings on physical examination until
volvulous occurs.
• With volvulous there is abdominal pain, vomiting
& abdominal distension, may be blood in stools
• Symptoms may be recurrent.
 Intussusception
• Classically 3-12 month baby
• Intermittent abdominal pain, draws up legs, with
irritability
• Quite intervals may be lethargic
• Stools with mucous & blood with little or no
faecal matter (Current jelly stools).
• Vomiting ,may be bilious
• Palpable sausage shaped mass around
umbilicus
• May be palpable on rectal examination
 Intussusception investigations &
Treatment
• Classic clinical picture with sausage
shaped lump is almost 100 % accurate.
• US “Target sign” or “pseudo kidney sign”
• If doubt than careful contrast enema
• Early cases can be diagnosed & treated
with air contrast/ Ba enema, by pneumatic/
Hydrostatic reduction.
• Late cases, toxic patient = Surgery