Acute abdomen.
Dr.A.Y.Chary.
M.S,F.I.C.S.
Former Director of Medical Education – Govt. of A.P
Dean DR. VRK Women’s’ Medical college.
Hyderabad.
Definition.
Acute abdomen is a clinical condition of varied aetiology in which the pt. presents with an urgent episode of abdominal problem, which requires immediate evaluation and treatment, if not is associated with real morbidity and mortality.
Incidence.
50% of all surgical emergencies that come to any major hospital are due to acute abdomen. It constitutes as a major component of non traumatic emergencies. No age is bar from presentation and equally common in both sexes but the causes related to female genital system playing a major role in incidence in female pts. The presentation is atypical in extremes of age with related morbidity and mortality. Some causative factors and incidence is more to some geographical areas and it is important to note the fact while making the diagnosis.
Causes.
Diseases causing and presenting clinically as acute abdomen are varied and may differ from male to female, age wise and geographically. As abdomen is known as Pandora’s Box, some surprises are always present as causative factors. The presentation may be entirely because of a problem away from the abdomen and clinically may present as acute abdomen.
The causes can be broadly grouped into
a. Inflammatory.
b. Perforation or disruption
c. Intestinal obstruction.
d. Vascular
e. Miscellaneous.
a.inflammatory.
They account for the major cause for acute abdomen. Any organ within the abdomen which is inflamed can present as an acute abdomen. The common conditions are –
Acute appendicitis.
Acute cholecystitis.
Pancreatitis.
Diverticulitis.
Regional ileitis.
pyelonephritis
b. perforation or disruption.
Duodenal ulcer.
Gastric ulcer.
Anastomatic ulcer.
Intestinal – typhoid, tuberculosis.
Malignancy.
Gangrenous bowel.
Their clinical mode of presentation is due to peritonitis that sets in.
c. obstruction.
Small bowel obstruction.
Large bowel obstruction.
Luminal obstruction – secondary to stones, clots, foreign bodies.
Vascular obstruction.
The obstruction can be with in the wall, in the lumen, or outside the lumen leading to kinking and obstruction. The obstruction can be mechanical or paralytic which can set in late stages of peritonitis.
d. miscellaneous.
The causes can be non surgical and away from the abdomen with typical presentation and becomes difficult to make a diagnosis correctly clinically.
Lower lobe pneumonia.
Uncontrolled diabetes.
Porphyrias.
Sickle cell disease.
Filariasis.
Hypercalcemia.
Long term usage of steroids.
Spinal problem
Testicular torsion.
Certain causes are exclusively present in female sex which are related to genital tract, like
Ruptured ectopic pregnancy.
Ruptured ovarian follicle –Mittelschmerz.
Twisted ovarian cyst.
Pelvic inflammations.
Endometriosis.
In children.
Following conditions can present as acute abdomen.
Intususception.
Non specific mesenteric adenitis.
Meckel’s diverticuliyis.
Mumps.
In elderly.
Apart from the above causes, malignancy and vascular causes may play a role in the presentation. With advancing age, obstructive urological causes like BPH may be the presenting cause.
Geographically.
Sickle cell disease is more prevalent in Middle East, worms and filariasis more common in tropical countries and developing countries and one should keep in mind these conditions while making diagnosis.
Clinically.
The presentation is always sudden, urgent and acute. In some, previous history of similar episodes may be present. A thorough elicitation of clinical history is very important for proper diagnosis and management. Following are the common symptoms with which a pt of acute abdomen presents.
a. Pain.
b. Nausea
c. Vomiting
d. Distention of abdomen.
e. Disturbed bowel motility – constipation, loose motions
f. Fever – low grade, high grade with chills and rigors.
g. Associated organ symptoms – jaundice, hematuria, chyluria
Pain.
Most common presentation. Pt. presents to the hospital because of the sudden development of pain. The severity depends upon the pathology. It could be a
“Burning” type which is classically seen with inflammatory pathology, “colicky “which is classically seen with obstruction commonly due to a calculus. The pain may get radiate to the back, towards the groin, may get referred to back, shoulder. There may be shift in the perception of pain from umbilical region to rt. Iliac fossa as classically seen with ac. Appendicitis. The pain may get aggravated in relation to natural acts like breathing, passage of urine etc. The pain usually increases in intensity as the time passes by depending upon the pathology. Sudden subsidence of the pain with no improvement in the condition may denote setting up of gangrene in a case of intestinal obstruction. The site of presence of the pain may give a rough idea about the anatomical structure involved in the pathology.
Nausea and vomiting.
Commonly associated symptoms in acute abdomen. Nausea and vomiting can be secondary to a reflex phenomenon due to inflammatory pathology or colic. Mechanical obstruction is always associated with vomiting, higher the levethe peritoneuml of obstruction, more will be vomiting. Important to note the nature of vomitus – plain fluid, bile, blood, or feculent.
If pain is first and then vomiting, it could be secondary to an inflammatory pathology. If vomiting first and then the pain, it could be secondary to any obstruction.
Distention.
Varying degree of distention of abdomen is common with intestinal obstruction and peritonitis. It may involve whole of the abdomen or localized to upper, middle or lower abdomen depending upon the level of obstruction.
Bowel symptoms.
Majority of acute abdominal conditions present with varying degrees of constipation. With intestinal obstruction the pt may present with absolute constipation. With pelvic inflammation the presentation can be with loose motions.
Other symptoms.
The pt. may present with dysura, frequency or frank hematuria with pain if the pathology is confined to urinary system. A female pt may present with shock if it is a case of ruptured ectopic pregnancy.
Examination.
A thorough clinical examination is performed to come to a provisional diagnosis. Look for jaundice, anemia and shock. Record blood pressure and temperature and pulse as basic evaluation. Expose entire abdomen and hernial orifices and look for movement with respiration of all the quadrants of abdomen, areas of tenderness, rebound tenderness, local guarding and rigidity, obliteration of liver dullness which all indicates under lying inflammation of peritoneum secondary to plain inflammation or perforation of a hollow viscus. Look for distention, visible peristalisis, exaggerated intestinal sounds all suggesting the possibility of obstruction. Look at the hernial sites and exclude any obstructed hernia. Special signs may be noted as Cullen’s sign, Grey turner’s sign with acute pancreatitis, Rovsing’s sign with acute appendicitis, Boa’s sign with acute cholecystitis. Palpate testis and the cord and exclude any torsion, inflammation of the cord. Do a vaginal examination in female and rectal examination and note for any tenderness, bulge, discharge, or blood. Examine the chest and exclude any lower lobe pneumonia, examine the spine and asses the pt’s psychological status as some pts may mimic as acute abdomen.
After clinical examination one can come to a reasonable provisional diagnosis of acute abdomen and require to be substantiated by investigations.
Investigations.
These are ordered to confirm or exclude the clinical diagnosis and should be used judiciously so as to minimize the pts’ suffering.
Radiological.
This forms the basic level of investigation and 80-90% of the cases can be diagnosed. A simple plain film gives maximum information in acute abdomen.
Plain film of the abdomen.
Single most informative investigation. Can be taken as a supine film in case of obstruction or an erect film incase of perforation. One can detect “free” gas beneath the domes of diaphragm denoting a perforation of a hollow viscus, “air fluid” levels in a case of obstruction, presence of radio opaque shadows in the region of kidney, ureter,bladder, gall bladder, pancreas. Can show volvulous of large bowel, ischemia of the bowel etc.
An x-ray chest is helpful to exclude the possibility of any lung pathology.
Contrast films.
Gastrgraffin based contrast films may demonstrate perforation, level of obstruction etc. intravenous urograms may confirm the presence of radio opaque shadows as renal, ureteric or vesical calculi. Contrast films are not ordered as a routine in emergency situation.
Scans.
These non invasive investigations are quite handy to come to a diagnosis at the earliest and help in the management.
Ultra sound scan.
Basic scan that is ordered. Helpful in identifying calculous cholecystits and urinary calculi. Its role is of paramount importance in the diagnosis of gynaec and obgy problems like ectopic pregnancy. Not of much help in the diagnosis of pancreatic and intestinal pathology.
C.T.scan
Ct scan with and without contrast gives an accurate assessment for pancreatic and intestinal pathology. Helpful tool in the management.
MRI scan.
Useful in the assessment of ischemia of the bowel and to exclude and spinal problem
Endoscopic evaluation.
An upper G.I or a lower G.I endoscopy may be required in some special situations as a diagnostic and therapeutic tool.
Laparoscopy.
Laparoscopic evaluation may be required both as diagnostic and therapeutic option in some cases of perforation, adhesive obstruction, and to diagnose pelvic pain in a female pt. This modality is being put to practice commonly in recent times.
Lab investigations.
These investigations are helpful in the diagnosis due to their altered values and also act as a basic level information about the pt. they include cbp, complete urine examination, blood sugar, urea estimations, serum creatinine, amylase, lipase levels and serum electrolytes and liver function tests, calcium estimations. A high total count and rise in neutrophil count indicates inflammatory pathology. In acute pancreatitis serum amylase and lipase levels are elevated.
The clinical picture, examination along with the investigations will give in majority of the cases a definitive diagnosis so as to fashion the treatment. There are always some vagaries attached which do not fall into classical presentation and a good clinical experience sometimes helps in solving the problem and managing it.
Management.
Once the diagnosis is made, an initial assessment of the nature of the condition is to be made. Is it a major surgical problem or a minor one has to be decided? Colic’s of various natures fall into the category of minor problem and can be managed as a day care. Majority of the presentations require to be admitted to surgical observation come treatment wards.
Colic’s are managed by giving antispasmodics parenterally and starting i.v fluids and sedating the pt. Biliary colic with associated block of the cbd may require endoscopic sphincterotomy and extraction of the stone from cbd. An appropriate antibiotic coverage is mandatory. Ureteric stones with colic are managed with stenting and extraction of the stone. Once the colic subsides further evaluation for the cause and subsequent management is planned.
All the pts who require surgery or intensive care management are hospitalized and following protocol is followed in preparing the pt. for surgery.
a. nil per oral
b. naso gastric tube aspiration – more important with obstructions
c. Correction of shock and fluid and electrolyte and acid base imbalance.
d. Pre operative broad spectrum antibiotic.
e. Preparation of the part to be operated.
f. Grouping and typing and reserving necessary units of blood for the nature o
g. f disease status and surgery.
Surgical procedures.
Various surgical procedures are available depending upon the presentation and nature of the causative factor. The aim should be to perform optimal , necessary surgery and sometimes to bare minimal procedure to overcome the emergency situation to tide over the crisis with a view to correct the problem in totality at a second stage procedure. The well being of the pt should be the supreme concern.
Presently some of these surgical procedures are being performed laparoscopically with good results. Inflamed appendix and gallbladder are surgically removed. Perforations of hollow viscus are closed with omental patch. Sometimes intestinal perforations confined to a segment may require local resections. Adhesolysis, separation, division, untwisting of the loops, correction of internal herniation , resection and anastmosis , bypass or a colostomy, ileostomy may be required in cases of intestinal obstruction of various causes. Ruptured ectopic pregnancy is excised after stabilizing the pt. some of these conditions require thorough peritoneal lavage with saline and drainage. If the bowel happens to be gangrenous, may require to be exteriorized. The surgeon with his expertise should decide on the table what is advisable to that pt. and should be executed with all firmness.
Post operatively these pts should be managed in surgical intensive care.
Conservative management.
Some conditions like acute pancreatitis are managed conservatively and as and when an indication develops are subjected to surgery. Appendicular mass is managed conservatively and once the lump subsides interval appendectomy can be planned. Some of the of the sub acute obstructions may be managed conservatively.
Summary.
Acute abdomen is one of the commonest of presentation of surgical emergency. A detailed clinical history with thorough clinical examination with judicious use of available investigations will clinch the diagnosis in majority of the case. With a good preparation, the pts. are to be managed conservatively or by definitive surgery with a specific aim of circumventing the problem and saving the life of the pt.
Newer modalities of investigation, techniques are evolving as a good armamentarium for the surgeon.
Some of the common conditions and their presentation.
Acute appendicitis
a. Common presentation.
b. Commonly in young but no age is bar.
c. Pain around umbilicus and later shifts to rt. Iliac fossa.
d. Nausea and vomiting.
e. Mild constipation
f. Rt.iliac fossa tenderness, guarding or rebound at Mc.Burney point.
g. Leukocytosis, neutrophil leukocytosis.
h. U.s scan can diagnose and exclude other conditions.
i. Vagaries.
. Infants and children – no localization. Danger of perforation and peritonitis.
Elderly – gangrene and perforation common, high grade fever.
Obese pts – delay in diagnosis.
Pregnancy – tenderness at a higher point.
Perforation
a. sudden pain, may be associated with shock
b. Nausea and vomiting.
c. Previous history of ulcer pain.
d. Tenderness and guarding of rt. Hypochondrium
e. Obliterated liver dullness
f. Silent abdomen.
g. Diagnosis by plain erect film abdomen.
Intestinal obstruction.
a. colicky abdominal pain.
b. Vomiting
c. Abdominal distention.
d. Visible peristalisis
e. Empty rectum.
f. Disturbed fluid and electrolyte balance.
g. Plain film erect, supine, CT diagnostic.
Ectopic pregnancy.
a. H/o amenorrhea.
b. Pain lower abdomen with shock.
c. Pallor
d. Lower and pelvic examination – tenderness.
e. U.S scan diagnostic.
