INTRODUCTION
Is the most common presenting surgical emergency. It has been estimated that at least 50% of general surgical admissions are emergencies and 50% of them present with acute abdominal pain.
Studies have shown a 30-day mortality of 4% among patients admitted with acute abdomen. So, it represents a significant part of the general surgical workload. The aim is to differentiate serious causes from less serious causes of acute abdominal pain.
• ‘Acute abdomen’ is a term used to encompass a spectrum of surgical, medical and gynecological conditions, ranging from the trivial to the life-threatening, which require hospital admission, investigation and treatment.
• The acute abdomen may be defined generally as an intra-abdominal process causing severe pain requiring admission to hospital, and which has not been previously investigated or treated and may need surgical intervention.
• The mortality rate varies with age, being the highest at the extremes of age.
• The highest mortality rates are associated with laparotomy for unresectable cancer, ruptured abdominal aortic aneurysm and perforated peptic ulcer.
• Most common causes in any population will vary according to age, sex and race, as well as genetic and environmental factors.
Causes-
A. Gastrointestinal-
1-Gut
Acute appendicitis
Intestinal obstruction
Perforated peptic ulcer
Diverticulitis
Inflammatory bowel disease
Acute exacerbation of peptic ulcer
Gastroenteritis
Mesensteric adenitis
Meckel’s diverticulitis
2-Liver and biliary tract
cholecystitis
cholangitis
Hepatitis
biliary colic
3-Pancreas
Acute pancreatitis
4-Spleen
Splenic infarct and spontaneous rupture
Causes-
B. Urinary tract
Cystitis
Acute pyelonephritis
Ureteric colic
Acute retention
C. Vascular
Ruptured aortic aneurysm
Mesenteric embolus
Mesenteric venous thrombosis
Ischemic colitis
Acute aortic dissection
D. Abdominal wall conditions
Rectus sheath haematoma
E. Peritoneum
Primary peritonitis
Secondary peritonitis
F. Retroperitoneal
Hemorrhage e.g anticoagulants
G. Gynecological
Torsion of ovarian cyst
Ruptured ovarian cyst
Fibroid denegeration
Ovarian infarction
Salpingitis
Pelvic endometriosis
Severe dysmenorrhea
Endometriosis
H. Extra-abdominal causes
Lobar pneumonia
Pleurisy
MI
Sickle cell crisis
Uremia
Hypercalcemia
DKA
Addison’s disease
Acute intermitent porphyria
Classification with age
Children
Gastroenteritis
Mesentric adenitis
Meckel’s diverticulitis
Intussusception
Henoch-schonlein purpura
Adult
Regional enteritis
Ureteric colic
Perforated ulcer
Testicular torsion
Pancreatitis
Relation of pain to embryology
• Intestine and its outgrowths (the liver, biliary system and pancreas)-> midline.
• Irritation of foregut structures
• (oesophagus to the second part of the duodenum)
• ->epigastric area.
• Midgut structures
• (the second part of the duodenum to the splenic
• flexure) ->umbilicus.
• Hindgut structures (the splenic flexure to the rectum)->
• hypogastrium.
Management
• History
• Physical examination
• Management
• History-
– Biodata
Age:
• Mesenteric adenitis in children
• Diverticulitis in elderly
Gender
Characteristics of abdominal pain
• Site
• Time and mode of onset
• Severity
• Nature/Character
• Progression
• Radiation
• Duration
• Cessation
• Exacerbating/relieving factors
• Associated symptoms
Site-pain
Whole abdomen
Peritonitis or mesentric infarction
Right upper quadrant
Acute cholycystitis
Cholangitis
Hepatitis
Peptic ulceration
Left upper quadrant
Peptic ulceration
Pancreatitis
Splenic infarct
Right lower quadrant
Appendicitis
Ovarian cyst Ectopic pregnancy PID Right ureteric colic
Left lower quadrant
Sigmoid diverticular disease
Ovarian cyst
Ectopic pregnancy
PID
Left ureteric colic
Symptoms--Pain
Onset
sudden: perforation of bowel, smooth muscle colic
slow insidious onset: inflammation of visceral peritoneum
Severity
Patient asked to rate pain from 1-10
Ureteric colic is one of worst pains
Character
Aching-dull pain poorly localised
Burning- peptic ulcer symptoms
Stabbing-ureteric colic
Gripping-smooth muscle spasm e.g. intestinal obstruction worse by movement ; wringing of cloth
Progression
-Constant e.g. peptic ulcer
-Colicky e.g. seconds(bowel), minutes(ureteric colic) or tens of minutes (gallbladder
-may change character completely from dull poorly localized pain to sharp pain indicates involvement of parietal peritoneum e.g.appendicitis
Radiation of the pain
Back: duodenal ulcer, pancreatitis, aortic aneurysm
Scapula: gall bladder
Sacroiliac region: ovary
Loin to groin: ureteric colic
Groin: testicular torsion
Cessation-
abrupt ending- colicky pains
resolving slowly-inflammatory pain, biliary pain
Exacerbating/relieving factors-
Movement/Rest-inflammatory conditions
Food- peptic ulcers
Past history
previous surgery
trauma
any medical diseases
Drug history
corticosteroid: mask pain
anti-coagulant: intra-mural hematoma
NSAIDS: gastritis, peptic ulcer
Family history
colon cancer
IBD
Intestinal obstruction
• One of the common cause of acute abdomen
• May lead to high morbidity and mortality if not treated correctly
It can be classified into two types:
Dynamic (mechanical)
Adynamic
Dynamic
1.Intraluminal: impacted faeces, foreign bodies, gallstones
2.Intramural: tumours, inflammatory strictures, congenital atresia
3.Extramural: adhesion, hernias, volvulus, intussusception, tumours
*also can be divided into:
1. Small bowel obstruction (SBO)
-high ->early perfuse vomiting
rapid dehydration
-low->predominant pain, and central distention
Vomiting delayed
air-fluid levels seen on AXR
2. Large bowel obstruction (LBO)
early pronounced distension, mild pain
vomiting, dehydration late
e.g. -carcinoma
-diverticulitis or volvulus
Adynamic
1.Paralytic ileus (peristalsis is absent)
2.Peristalsis is present in a non-propulsive form e.g. mesentric vascular occlusion
Obstruction can be-
Simple: blockage without interfering with vascular supply
Strangulation: significant impairment of blood supply most commonly associated with hernia, volvulus, intussusception and vascular occlusion
-surgical emergency
Closed loop obstruction: bowel is obstructed at both the proximal and distal end)
Pathophysiology
Irrespective of etiology or acuteness of onset:
Proximal to obstruction
Increased fluid secretion abdominal distention
Accumulation of gas abdominal distention
Increased intraluminal pressure
Decreased reabsorption with time and flaccidity to prevent vascular damage from high pressure
Vomiting
Dehydration
Dilatation of bowel
Reflex contraction of smooth muscle colicky pain
Increased peristalsis to overcome obstruction increased bowel sounds
If obstruction not overcome bowel atony
Distal to obstruction: nothing is passed & bowel collapse constipation
Symptoms
The four cardinal features of intestinal obstruction:
-abdominal pain
-vomiting
-distension
-constipation
Vary according to:-
location of obstruction
age of obstruction
underlying pathology
intestinal ischemia
Abdominal pain
colicky in nature, around the umbilicus in SBO while in the lower abdomen in LBO
if it becomes continuous, think about perforation or strangulation
Vomiting
-starts early in SBO and late in LBO
-vomitus starts with clear color then becomes thick, brown and foul ( faeculent)
-more with lower or complete obstruction
-diarrhea may be present with partial obstruction
Distension
-more with lower obstruction
Constipation
-more with lower or complete obstruction
-diarrhea may be present with partial obstruction
-either absolute (no feces or flatus)<-cardinal in absolute IO
or relative (flatus passed)
Distension
-more with lower obstruction
In strangulation:
• severe constant abdominal pain
• distended abdomen
• fever
• tachycardia
• tender abdomen
Clinical examination:
General examination-
Vital signs
Signs of dehydration –tachycardia, hypotension
dry mucus membrane, decreased skin turgor, decreased urine output
Inspection
distension, scars, peristalsis, masses, hernial orifices
Palpation
tenderness, masses, rigidity
Percussion tympanitic abdomen
Auscultation
high pitched bowel sound or silent abdomen
*Examine rectum for mass, blood, feces or it may be empty in case of complete obstruction
Investigations
• CBC- WBC (neutrophilia-strangulation)
• Hb
• U&E
• Plain AXR
• Sigmoidoscopy (carcinoma, volvulus)
• Double Contrast x-ray ( complete or incomplete)
• CT abdomen
Normal Gas Pattern
AXR
Stomach
Always
Small Bowel
Two or three loops of non-distended bowel
Normal diameter = 2.5 cm
Large Bowel
In rectum or sigmoid – almost always
Normal Fluid Levels
Stomach
Always (except supine film)
Small Bowel
Two or three levels possible
Large Bowel
None normally
Treatment
• Three main measures-
- GI drainage
- F&E replacement
- Relief of obstruction, usually surgical
Treatment
• Some cases will settle by using this conservative regimen, other need surgical intervention.
• Surgery should be delayed till resuscitation is complete unless signs of strangulation and evidence of acute or closed-loop obstruction.
• Cases that show reasons for delay should be monitored continuously for 72 hours in hope of spontaneous resolution e.g. adhesions with radiological findings but no pain or tenderness
• “The sun should not both rise and set” in cases of unrelieved obstruction.
Indication for surgery:
- failure of conservative management
- tender, irreducible hernia
-strangulation
Type of surgery depends upon the nature of the cause.
Laprotomy is usually done
Decompression of obstruction ( by repair of hernia, complete lysis of adhesion)
Surgical treatment
*Once obstruction relieved, the bowel is inspected for viability, and if non-viable, resection is required.
Indication of non-viability
1.absent peristalsis
2.loss of normal shine
3.loss of pulsation in mesentry
3.green or black color of bowel
• If in doubt of viability, bowel is wrapped in hot packs for 10 minutes with increased oxygen and reassessed for viability.
• Sometimes a second look laprotomy is required in 24-48 hours e.g. multiple ischemic areas.
• Right sided large bowel lesion is treated by right hemicolectomy with covering colostomy
