ACUTE ABDOMEN

BY
S/N JANET KHOO
Acute Abdomen
Acute abdomen is Peritonitis

• The term acute abdomen refers to

a sudden, severe pain in the
abdomen that is less than 24 hours
in duration.
• It is in many cases an emergent
condition requiring urgent and
specific diagnosis.
• Treatment usually involves surgery.
Acute Abdomen

• Acute abdomen can be defined as

• Severe, persistent abdominal pain
• Of sudden onset that is likely to
require surgical intervention to treat
its cause.
• The pain may frequently be
associated with nausea and vomiting
, abdominal distention, fever and
signs of shock.
INDICATIONS OF AN ACUTE ABDOMEN

• Abdominal pain
• Guarding (contraction of abdominal muscles and
discomfort when the doctor presses on the
abdomen)

• Rigidity (hardness) of abdominal muscles

• Rebound tenderness (an increase in severe
pain and discomfort when the doctor abruptly
stops pressing on a localized region of the
abdomen)

• Leukocytosis (increase in white blood cell count)

Traumatic Causes

• Blunt or
• Perforating trauma
• To the stomach, bowel, spleen, liver
, or kidney
Mechanical Causes

• Small bowel obstruction secondary to

adhesions caused by previous surgeries,
intussusception, hernias, benign or
malignant neoplasms
• Large bowel obstruction caused by
colorectal cancer,
inflammatory bowel disease, volvulus,
fecal impaction or hernia
Inflammatory Causes

• Infections such as appendicitis,

cholecystitis, pancreatitis, pyelonephritis,
pelvic inflammatory disease, hepatitis,
mesenteric adenitis, or a
subdiaphragmatic abscess
• Perforation of a peptic ulcer, a
diverticulum, or the caecum
• Complications of
inflammatory bowel disease such as
Crohn's disease or ulcerative colitis
Vascular Causes

• occlusive intestinal ischemia,

usually caused by thromboembolism
of the superior mesenteric artery
DIAGNOSTIC TESTS FOR EVALUATING ABDOMINAL
PAIN
• Laboratory examinations of blood and urine specimens

• X-rays of the chest and abdomen

• Ultrasound (evaluation of abdominal organs and spaces with sound

waves)

• CT scans (x-ray technique using computer programming to provide

detailed images)

• Endoscopy (a tube passed into the mouth to inspect the upper

gastrointestinal tract or inserted into the rectum to view the lower
gastrointestinal tract)

• Angiography (dye studies exploring major blood vessels)

• Radionuclide scans (injected dyes that identify sources of intestinal

bleeding)
Differential diagnosis of Acute
Abdomen

• Causes
• Acute appendicitis.
• Acute peptic ulcer and its complications.
• Acute gall bladder pathology, such as an
impacted gallstone.
• Acute pancreatitis.
• Acute intestinal ischemia (See Section Below.)
• Diabetic Ketoacidosis.
• Acute Diverticulitis.
• Ectopic Pregnancy with tubal rupture.
Appendicitis

• Is a condition characterized by
inflammation of the appendix. While
mild cases may resolve without
treatment, most require removal of
the inflamed appendix, either by
laparotomy or laparoscopy.
Untreated, mortality is high, mainly
due to peritonitis and shock
Signs & Symptoms
• Pain starting centrally (periumbilical)
before localising to the right iliac
fossa
• Loss of appetite (anorexia) and
• Fever, although the latter isn't a
necessary symptom..
• Nausea or vomiting may or may not
occur.
Perforated appendicitis with formation
of an abscess (arrows), with
appendicolith (arrowhead) within the
abscess.
Deep gastric ulcer
PUD
• A peptic ulcer, or peptic ulcer disease
is
• an ulcer of an area of the
gastrointestinal tract
• that is usually acidic and thus extremely
painful.
• As much as 80% of ulcers are associated
with Helicobacter pylori, a spiral-shaped
bacterium that lives in the acidic
environment of the stomach
A benign gastric ulcer
Signs and symptoms
• Abdominal pain, classically epigastric with
severity relating to mealtimes, after around 3
hours of taking a meal (duodenal ulcers are
classically relieved by food, while gastric ulcers
are exacerbated by it);
• Bloating and abdominal fullness
• Nausea, and lots of vomiting
• Loss of appetite and weight loss;
• Hematemesis (vomiting of blood); this can occur
due to bleeding directly from a gastric ulcer, or
from damage to the esophagus from
severe/continuing vomiting.
• Melena (tarry, foul-smelling faeces due to
oxidized iron from hemoglobin)
• Rarely, an ulcer can lead to a gastric or duodenal
perforation. This is extremely painful and requires
Gallbladder
Gall Bladder Disease
• The gallbladder stores about 50ml of bile
• Which is released when food containing fat enters
the digestive tract
• Stimulating the secretion of cholecystokinin
(CCK).
• The bile, produced in the liver, emulsifies fats and
neutralizes acids in partly digested food.
• After being stored in the gallbladder, the bile
becomes more concentrated than when it left the
liver,
• Increasing its potency and intensifying its effect
on fats. Most digestion occurs in the duodenum.
• Acute or chronic inflammation of the
gallbladder (cholecystitis) causes
abdominal pain.
• 90% of cases of acute cholecystitis are
caused by the presence of gallstones.
• The actual inflammation is due to
secondary infection with bacteria of an
obstructed gallbladder
• With the obstruction caused by the
gallstone.
• When gallstones obstruct the
common bile duct (
choledocholithiasis)
• The patient develops jaundice and
liver cell damage.
• It can be a medical emergency,
requiring endoscopic
• Or surgical treatment such as a
cholecystectomy.
Acute Pancreatitis
Symptoms and Signs
• Severe upper abdominal pain, with
radiation through to the back
• Nausea and vomiting
• Blood pressure may be high (when pain is
prominent) or low (if internal bleeding or
dehydration has occurred)
• Abdominal tenderness is usually found
but may be less severe than expected
given the patient's degree of abdominal
pain.
• Bowel sounds may be reduced as a
reflection of the reflex bowel paralysis (i.e.
ileus) that may accompany any abdominal
 Most common causes

• A common mnemonic for the

causes of pancreatitis spells
• "I GET SMASHED",
• an allusion to heavy drinking (one
of the many causes):
• I - idiopathic
• G - gallstone.
• E - ethanol (alcohol)
• T - trauma
• S - steroids
• M - mumps (paramyxovirus (Epstein-Barr virus,
Cytomegalovirus)
• A - autoimmune disease (Polyarteritis nodosa, SLE)
• S - scorpion sting - Tityus Trinitatis - Trinidad/ snake bite
• H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and
hypothermia
• E - ERCP (Endoscopic Retrograde Cholangio-
Pancreatography - D D- drugs (steroids & sulfonamides,
azathioprine, NSAIDS,furosemide and thiazides, &
didanosine)
 Causes
• The most common cause of acute pancreatitis is gallstones.
• Excessive alcohol use is often cited as the second most
common cause of acute pancreatitis.
• Less common causes include hypertriglyceridemia (but not
hypercholesterolemia) and only when triglyceride values
exceed 1500 mg/dl (16 mmol/L),
• hypercalcemia,
• viral infection (e.g. mumps),
• trauma (to the abdomen or elsewhere in the body)
including post-ERCP (i.e. Endoscopic Retrograde
Cholangiopancreatography),
• vasculitis (i.e. inflammation of the small blood vessels
within the pancreas)
• autoimmune pancreatitis.
• Pregnancy can also cause pancreatitis, but in some cases
the development of pancreatitis is probably just a reflection
of the hypertriglyceridemia which often occurs in pregnant
women.
• Pancreas divisum, a common congenital malformation of
the pancreas may underlie some cases of recurrent
pancreatitis.
 Treatment

• 1. provision of pain relief.

• 2. provision of adequate replacement
fluids and salts (intravenously)
• 3. limitation of oral intake (with
dietary fat restriction the most
important point)
• 4. Start antibiotics with signs of
infection
Acute intestinal ischemia
• Vascular disorders are more likely to affect the
small bowel than the large bowel.
• Arterial supply to the intestines is provided by the
superior and inferior mesenteric arteries, (SMA
and IMA respectively) both of which are direct
branches of the aorta.
Acute intestinal ischemia
• The SMA supplies:
• Small bowel.
• Ascending and proximal 2/3 of the
Transverse colon.
• The IMA supplies:
• Distal 1/3 of the Transverse colon.
• Descending colon
• Sigmoid colon.
Small bowel obstruction caused by an anterior abdominal wall incisional hernia diagnosed by
CT. Image demonstrates dilated loop of small bowel going into the hernia and collapsed loop of
small bowel coming out, confirming a complete small bowel obstruction with the hernia as the

cause. Surgical skin staple and left pelvic transplant kidney are also noted on the image.
 Causes
• A thromboembolism from the left side of the
heart, such as may be generated during atrial
fibrillation, occluding the SMA.
• Nonocclusive ischemia, such as that seen in
hypotension secondary to heart failure may also
contribute, but usually results in a mucosal or
mural infarct, as contrasted with the typically
transmural infarct seen in thromboembolus of
the SMA.
• Primary mesenteric vein thromboses may also
cause ischemic acute abdomen, usually
precipitated by hypercoagulable states such as
polycythemia vera.
SIGNS & SYMPTOMS

• Diffuse abdominal pain

• Bowel distention
• Bloody diarrhea.
• Bowel sounds will be absent.
• Neutrophilic leukocytosis
• Increased serum amylase.
• Abdominal XR will show many air-
fluid levels, as well as widespread
edema.
• Acute ischemic abdomen is a surgical
emergency.
• Typically, treatment involves
removal of the region of the bowel
that has undergone infarction,
• And subsequent anastomosis of the
remaining healthy tissue.
 Diabetic ketoacidosis

• (DKA) is a life-threatening
complication in patients with
untreated diabetes mellitus
Symptoms and Signs

• Sluggish, extreme tiredness.

• Fruity smell to breath/compare to nail polish
remover, similar to peardrops.
• Extreme thirst, despite large fluid intake.
• Constant urination
• Extreme weight-loss.
• Oral Thrush may be present, or/ yeast infections
that fail to go away, this is because the normal
fungal/flora present in oral cavity/cervix in
women, the balance is upset and bacterial began
to feast on the high sugar from urine output/ dry
mouth from extreme thirst.
• Muscle wasting.
• Agitation / Irritation / Aggression / Confusion
The basic principles of DKA treatment
are:

• Rapid restoration of adequate circulation

and perfusion with isotonic intravenous
fluids
• Gradual rehydration and restoration of
depleted electrolytes (especially sodium
and potassium), even if serum levels
appear adequate
• Insulin to reverse ketosis and lower
glucose levels
• Careful monitoring to detect and treat
complications
 Diverticulitis

• A common digestive disease

particularly found in the
large intestine.
• Diverticulitis develops from
diverticulosis, which involves the
formation of pouches (diverticula) on
the outside of the colon.
• Diverticulitis results if one of these
diverticula becomes inflamed.
Diverticula (arrowheads) and inflammation
around the sigmoid colon, indicating
diverticulitis. A small, adjacent, early
abscess (open arrow) is noted.
 Causes

• Blockage of a diverticulum, possibly

by a piece of faeces or food particles,
leads to infection of the diverticulum
 Symptoms
• Abdominal pain
• Tenderness around the left side of
the lower abdomen
• Fever, nausea, vomiting, chills,
cramping, and constipation
 Treatment

• An initial episode of acute diverticulitis is usually

treated with
• Conservative medical management, including
bowel rest (ie, nothing by mouth),
• IV fluid resuscitation, and
• Broad-spectrum antibiotics which cover
anaerobic bacteria and gram-negative rods.
• Recurring acute attacks or complications, such
as peritonitis, abscess, or fistula may
• Require surgery, either immediately or on an
elective basis.
What’s this ?
 Ectopic pregnancy

• A complication of pregnancy
• In which the fertilized ovum is implanted in any
tissue other than the uterine wall.
• Most ectopic pregnancies occur in the
Fallopian tube (so-called tubal pregnancies),
• But implantation can also occur in the cervix,
ovaries, and abdomen.
• The fetus produces enzymes that allow it to
implant in varied types of tissues, and
• Thus an embryo implanted elsewhere than the
uterus can cause great tissue damage in its
efforts to reach a sufficient supply of blood.
 Causes
• The causes of ectopic pregnancy are unknown
• After fertilization of the oocyte in the peritoneal
cavity, the egg takes about nine days to
migrate down the tube to the uterine cavity at
which time it implants. Wherever the embryo
finds itself at that time, it will begin to implant.
• Some speculative specific causes or
associations:
• Smoking,
• Advanced maternal age and
• Prior tubal damage of any origin
 Symptoms
• Clinical presentation of ectopic pregnancy occurs
at a mean of 7.2 weeks after the last normal
menstrual period, with a range of 5 to 8 weeks.
• Pain and discomfort, usually mild.
• Vaginal bleeding, usually mild.
• An ectopic pregnancy is usually a failing
pregnancy and falling levels of progesterone from
the corpus luteum on the ovary cause withdrawal
bleeding.
• This can be indistinguishable from an early
miscarriage or the 'implantation bleed' of a
normal early pregnancy.
• Pain while having a bowel movement
• Patients with a late ectopic pregnancy
typically have pain and bleeding. This
bleeding will be both vaginal and internal
and has two discrete pathophysiologic
mechanisms.
• External bleeding is due to the falling
progesterone levels.
• Internal bleeding is due to hemorrhage
from the affected tube.
• More severe internal bleeding may cause:
• Lower back, abdominal, or pelvic pain.
• Shoulder pain. This is caused by free blood tracking up the
abdominal cavity, and is an ominous sign.
• There may be cramping or even tenderness on one side of
the pelvis.
• The pain is of recent onset, meaning it must be
differentiated from cyclical pelvic pain, and is often getting
worse.
• Ectopic pregnancy is noted that it can mimic symptoms of
other diseases such as appendicitis, other gastrointestinal
disorder, problems of the urinary system, as well as
pelvic inflammatory disease and other gynaecologic
problems.
 Treatment

• Nonsurgical treatment
• Early treatment of an ectopic pregnancy with the
antimetabolite methotrexate has proven to be a viable
alternative to surgical treatment[6] If administered early in
the pregnancy, methotrexate can disrupt the growth of the
developing embryo causing the cessation of pregnancy.
• Surgical treatment
• If hemorrhaging has already occurred, surgical intervention
may be necessary if there is evidence of ongoing blood
loss..
• Surgeons use laparoscopy or laparotomy to gain access to
the pelvis and can either incise the affected Fallopian and
remove only the pregnancy (salpingostomy) or remove the
affected tube with the pregnancy (salpingectomy).
Tubal Pregnancy showing a 1 month
embryo
Tubal pregnancy (6 week old
embryo)
 Acute Abdomen

• An elderly man with acute

abdominal pain
• This 75 year old man presented to
the Emergency Department with
acute abdominal pain and bloody
diarhoea. What does the plain
abdominal film show?
Crohn's colitis with toxic
megacolon
LEFT: Plain abdominal film in a patient with an acute abdomen,
showing no abnormalities.
RIGHT: Subsequent CT shows distended small bowel loops (arrowheads) that are not

seen on plain abdominal film because they are filled with fluid only and do not
contain intraluminal air.