APPROACH TO ACUTE

ABDOMEN

 Pain is the most common of all

abdominal symptoms.
This may be due to inflammatory,
infective or obstructive pathology.
Can arise from abdominal viscera or
be referred from a site outside the
abdomen, such as the lungs as in
pneumonia or the heart as in angina.

TYPE OF PAIN
Parietal pain
Parietal peritoneum lines the abdominal wall
Innervated by somatic nerves through spinal
nerves in distribution of overlying
dermatome:
Xiphisternum (T7)
Umbilicus (T10)
Pubis (T12)

Pain is sharply localized to the point of

inflammation of the parietal peritoneum

Skin and the muscles of

the abdominal wall :
the lateral and anterior
cutaneous branches of
the lower six intercostal
nerves
the iliohypogastric and
ilioinguinal nerve

 The central part of the diaphragmatic

peritoneum is supplied by the phrenic
nerve (C4)
pain arising in this region is referred to the
tip of the shoulder as it has the same
segmental supply.
The pain in the parietal peritoneum may
radiate to back or front along the dermatome

 When an inflamed organ touches the

parietal peritoneum:
pain is then localised to the segmental
dermatome of the abdominal wall

The pain in the parietal peritoneum

may radiate to back or front along
the dermatome

 Visceral pain
The abdominal organ and visceral
peritoneum innervated by autonomic
nervous system
This pain is transmitted via sympathetic
fibres and so is referred to the
appropriate somatic distribution of that
nerve root from T1 to L2
Deep, poorly localized and usually ass.
with sympathetic symptoms (nausea
and vomiting)

 Localization depends on embryologic

origin of the organ. The pain from:
Foregutstructures are referred to
theepigastricregion
Midgutstructures are to the periumbilicalregion
Hindgutstructures to thelower
abdomen

EMBRYLOGICAL DISTRIBUTION OF
GIT
Foregut

Esophagus
Stomach
Duodenum (1st and 2nd part)
Pancreas
Liver
Gallbladder

Midgut

Duodenum (3rd and 4th part)

Jejunum
Ileum
Ascending colon
Transverse colon
Appendix

Hindgut

Descending colon
Sigmoid colon
Rectum

CLINICAL APPLICATIONS
Referred pain appendicitis:
Initially, pain from the appendix (midgut
structure) and visceral peritoneum is
referred to theumbilical region.
As the appendix becomes inflamed and
irritates the parietal peritoneum the pain
becomes localised to theright iliac
fossa.

Most causes of abdominal pain will

involves both visceral and parietal pain
which indicates the inflammation
increases and spread

KEY POINTS IN HISTORY

Site
Onset
Radiation
Nature and character
Duration
Intensity
Precipitating and relieving factors
Associated symptoms

 Onset
Sudde Usually occur in perforation of an abdominal viscus
n
Rupture / perforation of viscous
Most common organ that perforate:
Appendix
Stomach and duodenum (from PUD)
Colon (from diverticular ds or severe constipation)
The gastrointestinal system also contains faeces, air
and a high concentration of organisms.
Trauma and ischaemia may cause perforation, leak
of contents and peritonitis.

Gradu Usually involves intra abdominal inflammatory

al
conditions
Cholecystitis, Appendicitis, Diverticulitis,
pancreatitis, mesenteric adenitis, pelvic
inflammatory disease
The pain very non specific, gradually increasing in
intensity over a period of several hours or even days

 Radiation
Pain radiated to the back (pancreatitis)
Pain initially at umbilical area then
radiated to the RIF (appendicitis)
Loin pain then radiating to ipsilateral
iliac fossa and genitalia (ureteric colic)

 Nature and character

Colick
y pain

Occur in obstruction of all viscera except gallblader

Intermittent severe pain with pain free interval
(resolves between short lived episodes)
Central colicky abdominal pain is a classical
presentation of small bowel obstruction.
The central distribution is because of the
segmental nerve supply of the mid-gut.

The pain reaches a

crescendo and then
disappears in
minutes when the
peristaltic wave
passes

Biliary
colic

Biliary colic: obstruction of gall bladder

Continous type of pain
Punctuated by acute exacerbation
Pain of biliary colic is insidious in onset, reaches the peak
in half an hour or so and does not ease off completely
between spasms

Burnin
g

Suggest PUD, GERD

Dull
aching

Pancreatitis

Stabbin Abdominal aneurysm

g
Pleuriti
c

Intensified by breathing
Suggest lung/cardiac causes

 Aggravating/relieving factors
Pain made worse by moving and
coughing: suggest peritoneal
inflammation
Patients rolls around with pain
Typical of colic (suggest obstruction of
viscus)

Leaning forward may relieve the pain

arising from retroperitoneal structures
Relieved by eating : suggest peptic ulcer

ASSOCIATED SYMPTOMS
Fever
In cholangitis, hepatitis,
liver abscess
Pyogenic: low grade
Amoebic: high grade
In appendicitis: low grade fever
Pyelonephritis
Cystitis

 Vomiting
Acute appendicitis:
vomiting follows abdominal pain
Usually ass. with nausea

Intestinal obstruction:
Repeated vomiting of large amount
early in high GI obstruction and late in
low GI obstruction

 Constipation
Absolute (no faeces or flatus): complete
bowel obstruction
More obvious in the initial phase of large
bowel obstruction than in small bowel
obstruction
Risk factor for diverticulitis

History of melena/hematemesis

 Urinary symptoms: Micturition

(strangury)
Painful and frequent attempts at
micturition passing only small quantity
each time
UTI symptoms
In bladder/ureteric stone or pelvic
appendicitis
Cystitis

OTHER HISTORIES
Personal histories:
Alcohol intake/smoking (pancreatitis)
Dietary intake which is fatty food (gallstone ds)
In females, menstrual histories important to
rule out ectopic pregnancy
High risk behaviour

Drug history:
NSAIDS leading to peptic ulcer
Opiates causing constipation

 Past history:
Previous abdominal surgery: adhesion
(intestinal obstruction)
Hx of peptic ulcer: possible of
perforation/recurrence

diagnosis of a perforated peptic ulcer is

supported by a past history of ulcer-type pain
followed by sudden
onset of upper abdominal pain

Family history:
For carcinoma and inflammatory bowel
disease

I GET SMASHED
(PANCREATITIS)
I Idiopathic
G Gallstone
E Ethanol
T trauma

S Steriods
M MUMPS
A Autoimmune
S Scorpion/Snake
H Hyperlipidemia
E ERCP
D Drugs

PHYSICAL EXAMINATION
General examination:
Pallor: due to intra-abdominal bleeding
Jaundice: CBD obstruction
Dehydrated: peritonitis, Small bowel
obstruction
Restless: colicky pain
Motionless: peritonitis (movement
exacerbates pain)
Leaning forward: suggest pancreatitis

ABDOMINAL EXAMINATION
General inspection:
See if the abdominal wall moves with
respiration.
If only the thorax moves: peritonitis

Look for abdominal distension: suggest

for intestinal obstruction, ascites or large
intra abdominal tumour
Expansile pulsation: abdominal aneurysm
Visible peristalsis: in a thin/malnourished
patient with obstruction

 Palpation:
Organomegaly
Tenderness according to the region
Guarding: contraction of the abdominal
wall muscle over the area of pain
Rebound tenderness
Suggest peritoneal inflammation

Board like rigidity (abdominal wall

rigid/tense all over)
Suggest generalised peritonitis

 Tender hepatomegaly: hepatitis

Localised tenderness + rebound
tenderness + guarding
appendicitis

 In female patient:
If mass palpable and unable to get,
must be arising from the pelvis.
If the mass can be moved in a
transverse direction, then it is likely to
be an uterine or ovarian mass
Twisted ovarian cyst: presented with
acute abdominal pain

 Percussion:
Intra abdominal fluid (ascites)
Intra abdominal gas (intestinal
obstruction/perforation)
Obliteration of liver dullness: cardinal
sign of free gas in the peritoneal cavity
Air leaking from the bowel gets trapped
between the liver and abdominal wall: loss
of hepatic dullness, a physical sign that
supports the diagnosis of perforation of a
hollow viscus.

 Auscultation:
Bowel sounds
Gurgling and high pitched (obstruction)
Absent (peritonitis/ileus)

Abdominal bruit (vascular)

SPECIFIC SIGNS
Signs

Description

Pathology

Courvoisi
er

Palpable gall bladder and

jaundice

Carcinoma of head of pancreas

Cullen

Peri umbilical bruising

Severe acute pancreatitis,

ruptured ectopic pregnancy or
trauma to the liver.
blood tracks to the umbilicus
along the ligamentum teres

Grey
turner

Bruising of flank

retroperitoneal haemorrhage
severe acute pancreatitis
leaking abdominal aortic
aneurysm

Rovsing

Right lower quadrant pain with

palpation with palpation of left
quadrant pain

Appendicitis

McBurne
y

Tenderness located 2/3 distance

from ASIS to umbilicus

Appendicitis

Murphy

Right upper quadrant tenderness

exacerbated by inspiration

Acute cholecystitis

Kehr

Severe left shoulder pain

Splenic rupture
Rupture ectopic pregnacy

BLOOD TEST
FBC:
HB : anemia
TWC: leucocytosis (inflammatory),
PLT : evidence of sepsis
BUSE
Evidence of dehydration
Vomiting and diarrhea can cause electrolyte imbalance
LFT
Suspect hepatobiliary disorders
Hepatitis: high bilirubin and transaminase
Obstructive pathology: high in ALP

Amylase
Useful marker for pancreatitis (3-4x >
normal)

PT/APTT/INR:
Look for evidence of sepsis
acute pancreatitis, Liver ds
GSH/GXM: if planned for operation/GI
bleed

Other test
UPT:
to exclude pregnancy (ectopic
pregnancy)
Urine FEME/Urine c+s
Urine diastase
Cardiac enzyme and ECG
If clinically suggestive of cardiac
cause

IMAGING
Erect CXR
Sub phrenic gas: sign of intestinal
perforation
Consolidation

 AXR supine
Dilated bowel due to intestinal obstruction
stones in the kidney (90% cases) or
gallbladder (10% cases)
not diagnostic of acute pancreatitis, but
are useful in the differential diagnosis.
Non-specific findings in pancreatitis
include a generalised or local ileus
(sentinel loop), a colon cut-off sign and a
renal halo

 Occasionally, calcified gallstones or

pancreatic calcification may be seen.
A chest radiograph may show a
pleural effusion and, in severe cases,
a diffuse alveolar interstitial
shadowing
may suggest acute respiratory
distress syndrome

 Abdominal US
Gold standard ix for hepato biliary
disorders. It can demonstrate

biliary calculi,
the size of the gall bladder,
the thickness of the gall bladder wall,
the presence of inflammation around the
gall bladder,
the presence of stones within the biliary
tree

 Ultrasound does not establish a

diagnosis of acute pancreatitis.
The swollen pancreas may be seen, but
ultrasonography should be performed
within 24 hours in all patients to detect
gallstones as a potential cause,

 gynae pathology (ectopic pregnancy,

twisted ovarian cyst)
Urinary pathology (stone,
pyelonephritis, pyonephrosis)

 CT scan abdomen
To diagnose the cause of intestinal
obstruction
Look presence of intraabdominal mass
CTis not necessary for all patients,
particularly those deemed
to have a mild attack on prognostic
criteria.

 Flexible endoscope
Flexible endoscopy is the gold standard
investigation of the upper
gastrointestinal tract.