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The Acute Abdomen. Acute Abdomen Definition. Intraabdominal process causing severe pain and often requiring surgical intervention . 2 considerations Surgical or non surgical causes. General Causes. Divided into 6 broad categories Inflammatory - ie appendicitis

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Acute abdomen definition
Acute Abdomen Definition

  • Intraabdominal process causing severe pain and often requiring surgical intervention.

  • 2 considerations

    • Surgical or non surgical causes

General causes
General Causes

  • Divided into 6 broad categories

    • Inflammatory - ie appendicitis

    • Mechanical - ie acute small bowel obstruction

    • Neoplastic - ie cancer

    • Vascular - ie mesenteric vascular occulsion

    • Congenital defects - ieIntussusception

    • Traumatic - ie mesenteric bleeds due to trauma

Red flags in acute abdomens
Red Flags in Acute Abdomens

  • › Signs of impending shock

  • › Hypotension, tachycardia, tachypnea

  • › Septic appearance

  • › Confusion

  • › Signs of dehydration

  • › Rigid abdomen

  • › Absent bowel sounds

  • › Patient lying still or writhing

  • › Involuntary guarding

  • › Tenderness to percussion

  • › Hematemesis, hematochezia

  • › Abdominal pain prior to vomiting

  • › Abdominal pain localized to the periphery

  • of the abdomen or pelvis


  • Visceral

    • From abdominal viscera

    • innervated by autonomic nerve fibers

    • Responds to sensation of distention & muscular contraction

    • Poorly localized

Pathophysiology con t
Pathophysiology con’t

  • Parietal

    • From parietal peritoneum

    • Innervated by somatic nerves

    • Responds to irritation from infectious, chemical or other inflammatory processes.

    • Sharp and well localized

Pathophysiology con t1
Pathophysiology con’t

  • Referred

    • Perceived distant from source

    • Results from convergence of nerve fibers at spinal cord

    • Eg. Scapular pain due to biliary colic or groin pain due to renal colic

Abdominal p e
Abdominal P/E





Abdominal p e1
Abdominal P/E

  • Looking for

    • Distension

    • Rigidity

    • Guarding

    • Eviseration/Ecchymosis

    • Rebound tenderness

    • Rebound tenderness

    • Masses


  • Right lower quadrant pain, fever, leukocytosis, McBurney’s point localization of pain is most associated with:

    • Diverticulitis.

    • Ulcerative colitis.

    • Appendicitis.

    • Tubo-ovarian abscess.

    • Cholecystitis.

Review answer
Review - ANSWER

  • Right lower quadrant pain, fever, leukocytosis, McBurney’s point localization of pain is most associated with:

    • Diverticulitis.

    • Ulcerative colitis.

    • Appendicitis.

    • Tubo-ovarian abscess.

    • Cholecystitis.


  • A complete small bowel obstruction might be suspected in a patient with:

    • Hypoactive bowel sounds.

    • Pain out of proportion to physical exam findings.

    • Crampy abdominal pain that waxes and wanes.

    • Diarrhea.

    • A flat, rigid abdomen.

Review answer1
Review - ANSWER

  • A complete small bowel obstruction might be suspected in a patient with:

    • Hypoactive bowel sounds.

    • Pain out of proportion to physical exam findings.

    • Crampy abdominal pain that waxes and wanes.

    • Diarrhea.

    • A flat, rigid abdomen.

Liver infections
Liver Infections

Hepatic Abscess


3 major forms

- pyogenic, aerobes & anaerobes (80%)

- amebic, Entamoeba histolytica (10%)

- fungal, Candida species (10%)

Liver infections1
Liver Infections

1. Pyogenic Liver Abscess

usually gram (-) aerobic bacteria

from appendicitis or diverticulitis

ascension in biliary tree

systemic source from dental procedures


biliary instrumentation (iatrogenic)

Liver infections2
Liver Infections

1. Pyogenic Liver Abscess

fever, chills, pain, weight loss

tender liver, jaundice, hepatomegaly


CT scan

percutaneous drainage


Liver infections3
Liver Infections

2. Amebic Liver Abscess

parasitic Entamoeba histolytica

tropical climates

young men account for 90% of cases

RUQ abdominal pain

fever, chills, nausea, vomiting, anorexia,

weight loss

Liver infections4
Liver Infections

2. Amebic Liver Abscess

percutaneous drainage

amebicidal agents-paromomycin-luminal agent.

metronidazole-tissue agent

chloroquine and emetine

Liver infections5
Liver Infections

3. Fungal Liver Abscess-Hepatosplenic Candidiasis or Chronic Disseminated Candidiasis

Candida albicans

multiple abscesses


leukemia, HIV

systemic antifungal therapy (Amphotericin B)

Abdominal wall hernias
Abdominal Wall Hernias


inguinal hernia (direct or indirect)

femoral hernia

umbilical hernia

epigastric hernia

Spigelian hernia (lateral ventral hernia)

ventral / incisional hernia

Groin hernias
Groin Hernias

Inguinal Hernia (96%)

more common in men than women

indirect (80%) [Internal inguinal ring]

direct (20%) [Hesselbach’s triangle]

Femoral Hernia (4%)[medial femoral canal]

Lifetime risk of developing a groin hernia is

- 25% for men

- 5% for women

Inguinal hernia presentation
Inguinal Hernia Presentation

  • Soft non-tender mass in the groin.

  • Local burning or aching.

  • Enlargement of the mass by coughing (any maneouver that increase intra-abdominal pressure).

Inguinal hernia repair
Inguinal Hernia Repair

Indications for Elective Surgery

pain / discomfort

limits / restrictions on activity

increasing size of hernia

small risk of incarceration & strangulation


Indications for Emergency Surgery

incarceration & strangulation

Ventral hernia
Ventral Hernia

11 – 20% of laparotomies

incarceration 5 – 15%

risk of strangulation 2%

recurrence rates = 50% with tension repair

50% of incisional hernias appear in the first

6 months following laparotomy

most occur within 2 years


Clinical Presentation

intermittent, crampy, periumbilical pain

obstruction of appendiceal lumen with

a fecalith

nausea follows the pain


low grade fever

pain migrates to RLQ within 24 hrs and

changes to constant & sharp pain


Physical Examination

RLQ tenderness & localized peritonitis

Rovsing’s sign (RLQ pain with LLQ palpation)

obturator sign suggests a pelvic appendix

psoas sign suggests a retrocecal appendix

in females, must do pelvic exam to rule out adnexal mass or tenderness.

Possible Positions

of the Appendix


  • McBurney's point tenderness:1.5 to 2 inches from ASIS to the umbilicus.

  • Rovsing's sign: pain in the RLQ w/ palpation of LLQ (rt-sided local peritoneal irritation).

  • Psoas sign: (retrocecal appendix) RLQ pain with passive right hip extension.

  • Obturator sign: (pelvic appendix) RLQ pain with rt hip/knee flexion and internal rotation.


Laboratory Examination

WBC count


urine β-HCG to rule out pregnancy


Imaging Studies


- may be useful (sensitivity 80%, spec 90%)

- highly operator dependent

- useful to rule out gynecologic pathology

CT scan

- more accurate than U/S for appendicitis, sens and spec 95%.


Treatment of Nonperforated Appendicitis

laparoscopic vs open appendectomy ASAP

fluid & electrolyte imbalance usually minor

prophylactic IV antibiotics to prevent wound infection.

post-op hospital discharge 24-48 hrs


Treatment of Perforated Appendicitis

may be acutely ill

significant dehydration & electrolyte


CT scan – appendiceal abscess or phlegmon

percutaneous drainage of abscess

may choose to delay surgery for months

interval appendectomy

Vascular emergencies1
Vascular Emergencies

Mesenteric Ischemia

low blood flow to bowel

embolic event to SMA (atrial fibrillation)

thrombosis of SMA

nonocclusive mesenteric ischemia (low flow

states in critically ill patients) - vasoconstriction

Vascular emergencies2
Vascular Emergencies

Mesenteric Ischemia



CT scan with contrast


operative attempts to restore mesenteric flow

need to resect any nonviable bowel

thrombolytic therapy an option

Vascular emergencies3
Vascular Emergencies

Ruptured Abdominal Aortic Aneurysm (AAA)

common surgical emergency

many pts do not know they have an aneurysm until it ruptures

risk factors include smoking, >60 yrs, HTN, CAD, dyslipidemia, FmHx.

Vascular emergencies4
Vascular Emergencies

Clinical Presentation Ruptured AAA

acute abdominal or back pain

usually sudden onset

lightheadedness or collapse due to sudden hypotension

immediate CT scan if pt hemodynamically stable.

if unstable, diagnosis with Hx, P/E, ultrasound

Vascular emergencies5
Vascular Emergencies

Ruptured Abdominal Aortic Aneurysm (AAA)


immediate OR

laparotomy with X-clamp proximal aorta &

repair aneurysm with interposition tube graft

fluid & blood resuscitation

ICU post-op

Bifurcated Tube

Graft for

AAA Repair

Principles of the initial assessment
Principles of the Initial Assessment


Airway, Breathing, Circulation

prioritizing life-threatening injuries

assessment & resuscitation simultaneous

Abdominal trauma1
Abdominal Trauma

Purpose of Diagnostic Work-up

most important decision is to determine

whether or not the patient requires an

emergent laparotomy

Diagnosis of abdominal trauma
Diagnosis of Abdominal Trauma

history & physical exam

FAST (Focused Assessment with

Sonography for Trauma)

CT scan

DPL (diagnostic peritoneal lavage)

Diagnostic test of choice
Diagnostic Test of Choice ?


If FAST is not available, then in general:

unstable patients DPL

stable patients CT scan

Fast trauma ultrasound
FAST ( Trauma Ultrasound )




rapid assessment

can be easily repeated during work-up

accurate for the presence of intraperitoneal free fluid

can be performed by trained non-radiologist

Fast technique

Look for free fluid

in 4 places:





FAST Technique

Ct scan
CT Scan

hemodynamically stable patients only

very specific and sensitive for solid organs

quantify / grade severity of organ injury

contrast extravasation (implications)

CT scan not needed if indication for

laparotomy exists

may miss bowel injury, ruptured diaphragm


sensitive for presence of intraperitoneal


open or closed technique

positive = gross blood

red cell count > 100,000/mm3

rarely used in blunt trauma if FAST available

Approach to penetrating abdominal trauma
Approach to Penetrating Abdominal Trauma

Categorization of the anatomical site of injury:

stab wound to anterior abdomen

GSW to anterior abdomen

thoracoabdominal penetrating trauma

tangential GSW

back & flank penetrating trauma

transpelvic GSW

Stab wound to abdomen
Stab Wound to Abdomen

Anatomy (anterior abdomen)

costal margin

anterior axillary line

inguinal ligament

Stab wound to abdomen1
Stab Wound to Abdomen

Indications for laparotomy

hemodynamic instability


blood in NG, foley, rectal exam


retained stabbing implement

positive FAST or DPL (100,000 RBCs)

Management of gsw abdomen
Management of GSW abdomen


IV lines above & below diaphragm

log roll early to find all bullet wounds

plain film X-rays to localize bullets

determine need for surgery

tetanus / antibiotics

communicate with blood bank

Gsw abdomen indications for laparotomy
GSW Abdomen - Indications for Laparotomy

hemodynamic instability


path of bullet

blood in foley, NG, rectal exam



positive FAST or DPL (RBC count > 5,000)


history & physical exam of acute abdominal


diagnostic tests


surgical treatment

Red herrings
Red Herrings

Nerve root impingement

Red herrings1
Red Herrings

Herpes Zoster