ACUTE ABDOMEN

DR. D.VINDHYA

Dept of Emergency & Critical Care Medicine,

Vinayaka Mission Medical College & Hospital,

Salem

• Visceral pain

– Distension, inflammation or ischemia in hollow viscous &

solid organs

– Localisation depends on the embryologic origin of the

organ:

• Foregut to epigastrium

• Midgut to umbilicus

• Hindgut to the hypogastric region

• Parietal pain-

is localised to the dermatome

above the site of the

stimulus.

• Referred pain

– produces symptoms, not

signs e.g. tenderness

Abdominal topography

HISTORY

• Site

• Nature & character

• Duration

• Intensity

• Precipitating & relieving factors

• Associated symptoms

• Previous episodes of AP

• Investigations

• Chronic disease

• Immunosuppression

• Medications (NSAIDs)

• surgeries

Generalised abdominal pain

• Perforation• AAA• Acute pancreatitis• DM• Bilateral pleurisy

Central abdominal pain

• Early appendicitis

• SBO

• Acute gastritis

• Acute pancreatitis

• Ruptured AAA

• Mesenteric thrombosis

Epigastric pain

• DU / GU

• Oesophagitis

• Acute pancreatitis

• AAA

RUQ pain

• Gallbladder disease

• DU

• Acute pancreatitis

• Pneumonia

• Sub phrenic abscess

Differential diagnosis of RUQ pain

LUQ pain

• GU

• Pneumonia

• Acute pancreatitis

• Spontaneous splenic

rupture

• Acute perinephritis

• Sub phrenic abscess

Differential diagnosis of LUQ & epigastric pain

CONDITION CLUES

Splenic rupture h/o trauma or splenic disease

Fractured ribs h/o trauma, gross deformity, extreme tenderness on palpation

pancreatitis h/o alcohol consumption, past h/o, labs

Gastritis, peptic ulcer disease Recurrent relationship to posture or meals

Supra pubic pain

• Acute urinary retention

• UTIs

• Cystitis

• PID

• Ectopic pregnancy

• Diverticulitis

RIF pain

• Acute appendicitis

• Mesenteric adenitis

• DU perf, Diverticulitis

• PID, Salpingitis

• Ureteric colic

• Meckel’s diverticulum

• Ectopic pregnancy

• Crohn’s disease

• Biliary colic (low-lying gall bladder)

Differential diagnosis of RLQ pain CONDITIONS CLUES

Mesentric adenitis Fever, inconstant signs

Rt renal colic Colic pain ,haematuria

Rt.testis torsion Tender swollen testis

Crohns disease Recurrent h/o diarrhoea, colicky pain, wt loss

Gynecological causes of RLQ pain CONDITION CLUES

Ruptured follicle Fever, cervical discharge

Torsion ovary Midcycle, sudden onset

Ruptured ectopic pregnancy Severe pain, shock, missed periods

PID sever pain, foul smelling discharge, dyspareunia

LIF pain

• Diverticulitis

• Constipation

• IBS

• PID

• Rectal Ca

• UC

• Ectopic pregnancy

Differential diagnosis of LLQ pain CONDITIONS CLUES

Diverticular disease Elderly patient recurrent

Acute urinary retention Palpable bladder, difficulty in passing urine

Urinary tract infection Dysuria, frequency

Inflammatory bowel disease Recurrent attacks, diarrhoea

Large bowel obstruction Colicky pain, constipation

Ischemic bowel disease Rectal bleeding, pain out of proportion to examination

Systemic examination

• Inspection-

- Flat, reduced movements in peptic ulcer perforation

- Distended in ascites or intestinal obstruction

- Visible peristalsis in a thin or malnourished patient (with

obstruction)

GREY TURNER’S SIGN

RETROPERITONEAL HEMORRAGE

• Discoloration of the flank

CULLEN’S SIGNRETROPERITONEAL HEMORRAGE

• Bluish periumbilical

discoloration

Palpation

• Check for Hernia sites

• Tenderness

• Rebound tenderness

• Guarding- involuntary spasm of muscles

during palpation

• Rigidity- when abdominal muscles are tense & board-like.

Indicates peritonitis. Do not miss tetanus!

MC BURNEY’S SIGN ACUTE APPENDICITIS

• Tenderness located 2/3

distance from

anterior iliac spine to

umbilicus on right side

ILIO PSOAS SIGNACUTE APPENDICITIS

• Hyperextension of right

hip causing abdominal

pain ( retrocecal)

OBTURATOR SIGN ACUTE APPENDICITIS

• Internal rotation of

flexed right hip causing

abdominal pain (pelvic)

MURPHY’S SIGNAcute cholecystitis

• Abrupt interruption of

inspiration on palpation

of right upper quadrant

ROVSING’S SIGN Acute appendicitis

• Right lower quadrant

pain with palpation of

the left lower quadrantPain in the RLQ

Palpation of LLQ

KEHR’S SIGN

• Severe left shoulder

pain

• Splenic rupture

Ectopic pregnancy

rupture

CHANDELIER’S SIGNPELVIC INFLAMMATORY DISEASE

• Manipulation of cervix

causes patient to lift

buttocks off table

• Auscultation

• BS

– > 2min to confirm absent

– High pitched, hyperactive or tinkling

– Bruit in epigastrium

PR Examination:

- tenderness

- induration

- mass

- frank blood

Investigations

• CBC

• Amylase & lipase

• Erect & supine abdominal XRay

• stool & Urine analysis,

• pregnancy test, USG, CT scan

• If severe, unrelenting pain urgent surgical referral

Initial management

• Stabilise ABC

• Resuscitate the patient

• Shift for investigation only after stabilising

the pt

• Remember to reassess patient on a regular basis.

Airway management

• Pt’s SPO2 – is low or when RR IS > 35/min

• When the depth of breathing is shallow &

inadequate

• When the pt’s GCS is not adequate to

maintain a patent airway

• When the pattern of breathing is inappropriate

circulation

• Care to adequately hydrate the pt.

• If pt’s cardiac status is compromised then

CVP guided fluids should be administered.

• A careful monitoring of I/O should be maintained

Analgesia

• Adequate analgesia should be provided in the ER

• Shift the pt only when the pt is stabilised

Supine ray

• Dilated bowel loop

pattern, obstruction,

closed loop, bowel

wall edema

Chest xray

• Gas under diaphragm

IVP

To detect renal calculi,

ureteric obstruction

USG

ascitis cholecystitis

Acute pancreatitis

• CT detects acute

pancreatitis, small

bowel obstruction,

diverticulitis, abscess,

bowel infarction

CT images

Ureteric calculi • Detecting ureteric calculi ,

appendicitis

CASE DISCUSSIONS

Case 1

• A male pt aged 17yrs developed mild periumblical

discomfort not influenced by activity. Several hrs

later pain intensifies but is now localised to

RLQ.Movement becomes painful

• INVESTIGATION OF CHOICE ?

• Abdomino pelvic CT

Treatment

• Initial stabilisation

• Early appendicectomy within 4-12 hrs of initial

presentation

CASE 2

• A 47 yr old obese lady developed severe mid-epigastric

pain. Pain not influenced with any position or movement.

• O/E pt’s temp -100 degree, Tachycardia +, murphy’s sign

positive

• INVESTIGATIONS?

• Xray

• USG – study of choice to detect stone < 2mm

• HIDA scans – investigation of choice

Treatment

• Initial stabilisation

• cholecystectomy

• open laparoscopy

CASE 3• A 62yr old man C/O severe abdominal pain – generalised in

nature. H/O consumption of NSAIDS. He also c/o lt

shoulder pain. He feels more comfortable sitting than lying.

• O/E pt conscious ,afebrile, sweating profusely

• HR-120/min, BP-120/90 mm hg

• Abd- rigid, tenderness ,rebound tenderness & guarding

present in all quadrants .percussion –absence of liver

dullness

• What is the likely diagnosis?

• Investigations ?

Chest xray

• IMP- PERITONITIS

FOLLOWING DU

PERFORATION

• ? tetanus

Treatment

• Initial stabilisation

• Laparotomy & DU perforation closure

Case 4

• A 34y old female pt rushed to ER in shock. O/E

• HR-120/min, BP- 90/60mmhg,

• RR-26/min, SPO2-94% on RA

• CVS, RS – NAD

• ABD – LLQ tenderness +

• Next ?

• Pt’s LMP – 1&1/2 mth back – H/O

• Investigation?

• Urine HCG

• Pelvic USG

• IMP- ECTOPIC

PREGNANCY

Treatment

• Initial stabilisation

• Anti D in RH negative mother

• laparoscopic salpingostomy

Case 5

• A 23 yr old student brought to ER writhing with pain

radiating from lt lumbar to groin associated with vomiting

• Next ?

• Xray KUB ,IVP

• USG

• IMP- URETERIC COLIC

Treatment

• Initial stabilisation

• Expectant treatment

• Ureteroscopic removal

• ureterolithotomy

Case 6

• A 65 yr old male, known diabetic admitted at 9pm with h/o

abdominal pain associated with profuse sweating &

vomiting since evening 7pm O/E HR- 68/min, BP – 90/70

mmhg. What next?

• ECG done – ANTERIOR WALL MI

Management

• Initial stabilisation

• Nasal O2,Aspirin, clopilet, NTG

• Consider thrombolysis

Case 7

• A 42yr old male pt, known alcoholic presented to our ER

with H/O persistent epigastric pain improving on bending

forward & worsens with lying down .

• O/E vitals are stable except for tachycardia

• Systemic examination – NAD except for tenderness in the

epigastric region

• What is the likely diagnosis?

• What are the investigations to be

done?

• S.amylase elevated

• Xray – colon cutoff

sign

IMP- ACUTE PANCREATITIS

Management

• Initial stabilisation

• Prophylactic antibiotics

• Nutrition

• Treat the cause

Case 8

• 23 yr old female pt delivered 2 days back with c/o vomiting,

abdominal pain & constipation since the time of delivery

• Usg abdomen

shows -

• Target sign.

• Diagnosis?

• Treatment ?

Carry home message

• Our priority- ABC

• All abdominal aches need not arise from the abdomen

• Adequate hydration, adequate analgesia, appropriate

antibiotic coverage at ER

ECG

CBG ABG

THANQ