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THE ACUTE ABDOMEN
The ‘acute abdomen’ is defined as a
sudden
onset
of
severe
abdominal pain of less than 24
hours duration. It has a large
number of possible causes and so
a structured approach is required.
The initial assessment
attempt to determine
patient has an acute
problem
that
immediate/prompt
intervention, or urgent
therapy.
should
if the
surgical
requires
surgical
medical
THE ACUTE ABDOMEN
• The ‘acute abdomen’ is defined as
a medical condition, which is
caused by acute destructive
abdominal diseases.
• These diseases have similar
symptoms.
• It is complicated by internal
bleeding or peritonitis.
• This condition requires emergency
surgical intervention
• Appendicitis
• Acute cholecystitis
• Acute pancreatitis
• Peptic ulcer disease
• Small bowel obstruction
• Diverticulitis and other
Сause of acute abdominal
pain
a group of acute destructive
abdominal diseases that have
similar symptoms and are
complicated by peritonitis or
bleeding and require surgical
intervention
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Acute appendicitis.
Acute peptic ulcer and its complications
Acute cholecystitis
Acute pancreatitis
Acute intestinal ischemia (see section below)
Acute diverticulitis
Ectopic pregnancy with tubal rupture
Ovarian torsion
Acute peritonitis (including hollow viscus perforation)
Bowel volvulus
Bowel obstruction
Abdominal aortic aneurysm
Hemoperitoneum
Ruptured spleen
Peptic ulcer disease
Other names
Peptic ulcer,
stomach ulcer, gastric ulcer,
duodenal ulcer
It should be noted that
uncomplicated stomach ulcer
does not belong to the category
of acute abdomen. Only
complications of gastric ulcer
such as bleeding, perforation,
penetration belong to the
category of acute abdomen
Symptom of free gas in the abdominal cavity
Causes of small
bowel obstruction
include:
[2]
Adhesions from previous abdominal
surgery (most common cause)
Barbed sutures
Pseudoobstruction
Hernias containing bowel
Crohn's disease causing adhesions or
inflammatory strictures
Neoplasms, benign or malignant
Intussusception
Volvulus
Superior mesenteric artery syndrome, a
compression of the duodenum by
the superior mesenteric artery and
the abdominal aorta
Ischemic strictures
Foreign
bodies (e.g. gallstones in gallstone
ileus, swallowed objects such
as expandable water toys)
Many women are not receiving the education
needed from their doctors about adhesions. Very
few women even know they have adhesions.
Upright abdominal X-ray
Abdominal X-rays
Bowel obstruction
Bowel obstruction, also
known as intestinal
obstruction, is a mechanical
or functional
obstruction intestines which
prevents the normal
movement of the products
of digestion small
bowel or large bowel. Signs
and symptoms
include abdominal
pain, vomiting, bloating
(вздутие) and not
passing gas. Mechanical
obstruction is the cause of
about 5 to 15% of cases
of severe abdominal pain of
sudden onset requiring
admission to hospital.
Upright
abdominal Xray
demonstrating
a small bowel
obstruction.
Note multiple
air fluid levels.
Diverticulitis
Other names
Colonic diverticulitis Section of large bowel (sigmoid colon) showing
multiple pouches (diverticula). The diverticula appear on either side of the longitudinal muscle
bundle (taenium) which runs horizontally across the specimen in an arc.
Specialty General surgery
Symptoms
Abdominal pain, fever, nausea, diarrhea, constipation, blood in the stool
Complications
Abscess, fistula, bowel perforation
Ectopic pregnancy
Other names EP, eccyesis,
extrauterine pregnancy, EUP, tubal
pregnancy (when in fallopian tube)
Laparoscopic view, looking down at the
uterus (marked by blue arrows). In the left
Fallopian tube there is an ectopic
pregnancy and bleeding (marked by red
arrows). The right tube is normal.
Specialty Obstetrics and gynecology
Symptoms
Abdominal pain,
vaginal bleeding[1]
Risk factors
Pelvic inflammatory
disease, tobacco smoking, prior tubal
surgery, history of infertility, use of
assisted reproductive technology[2]
Diagnostic method Blood tests for
human chorionic gonadotropin (hCG),
ultrasound[1]
Differential diagnosis Miscarriage,
ovarian torsion, acute appendicitis
Treatment Methotrexate, surgery
Prognosis Mortality 0.2% (developed
world), 2% (developing world)[3]
Frequency ~1.5% of pregnancies
Ovarian torsion Other names Adnexal torsion
Arteries of the female reproductive
tract: uterine artery, ovarian artery and
vaginal arteries. (Ovary and ovarian
artery visible in upper right.)
Specialty Gynecology
Symptoms
Pelvic pain
Complications
Infertility
Usual onset
Classically sudden
Risk factors
Ovarian cysts,
ovarian enlargement, ovarian tumors,
pregnancy, tubal ligation
Diagnostic methodBased on
symptoms, ultrasound, CT scan
Differential diagnosis
Appendicitis, kidney
infection, kidney stones, ectopic
pregnancy
Treatment
Surgery
Frequency
6 per 100,000
women per year
Peritonitis
Peritonitis is an
inflammation of the
peritoneum,
accompanied not only
by local changes in the
abdominal cover, but
also by a severe general
reaction of the body
caused by intoxication,
impaired intestinal
function and vital
organs.
Peritonitis
Other namesSurgical abdomen, acute abdomen
Causes
•
•
•
•
•
•
•
Causes include:
perforation of the intestinal tract,
pancreatitis,
pelvic inflammatory disease,
stomach ulcer,
or a ruptured appendix.
Risk factors include ascites (the abnormal build-up
of fluid in the abdomen) and peritoneal
dialysis. Diagnosis is generally based
on examination, blood tests, and medical imaging.
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•
•
•
•
Physical examination
In order to clinically examine a patient with an acute abdomen, it is
necessary to:
Inspection for injuries or hematomas, hernias, other abdominal wall
defects or skin discoloration (pancreatitis). The stomach participates
in the act of breathing
Auscultation should always be performed prior to manual examination
in order to avoid provoking intestinal noises. Intestinal sounds should
be auscultated in 4 sections. Are there intestinal noises present? What
grade are they? If no noises are heard, this could indicate a paralytic
ileus.
Palpation to detect muscle rigidity, muscle guarding, peritonism
(rebound tenderness), tenderness, and ascites.
Percussion helps in the detection of ascites, and abdominal fluid.
Digital rectal examination for conditions such as palpable tumors, an
empty bowel (caused by an obstacle such as ileus or tumor) and
blood.
Key symptoms of acute abdomen
1. Abdominal pain The main manifestations of peritonitis are
acute abdominal pain, abdominal tenderness, abdominal
guarding, rigidity, which are exacerbated by moving the peritoneum,
e.g., coughing (forced cough may be used as a test), flexing one's hips, or
eliciting the Blumberg sign (meaning that pressing a hand on the
abdomen elicits less pain than releasing the hand abruptly, which will
aggravate the pain, as the peritoneum snaps back into place). Rigidity is
highly specific for diagnosing peritonitis (specificity: 76–100%). The
presence of these signs in a person is sometimes referred to as
peritonism. The localization of these manifestations depends on whether
peritonitis is localized (e.g., appendicitis or diverticulitis before
perforation), or generalized to the whole abdomen. In either case, pain
typically starts as a generalized abdominal pain (with involvement of
poorly localizing visceral innervation visceral peritoneal layer), and may
become localized later (with involvement of the somatic innervation of
the parietal peritoneal layer). Peritonitis is an example of an acute
abdomen.
Other symptoms
• Diffuse abdominal rigidity (abdominal guarding)
is often present, especially in generalized
peritonitis
• Fever
• Sinus tachycardia
• Development of ileus paralyticus (i.e., intestinal
paralysis), which also
causes nausea, vomiting and bloating
• Reduced or no passage of abdominal gas and
bowel sound
Complications
• Sequestration of fluid and electrolytes, as revealed
by decreased central venous pressure, may
cause electrolyte disturbances, as well as
significant hypovolemia, possibly leading
to shock and acute kidney failure.
• A peritoneal abscess may form (e.g., above or below
the liver, or in the lesser omentum)
• Sepsis may develop, so blood cultures should be
obtained.
• Complicated peritonitis typically involves multiple
organs.
Physical examination
In order to clinically examine a patient with an acute
abdomen, it is necessary to:
• Inspection for injuries or hematomas, hernias, other abdominal wall
defects or skin discoloration (pancreatitis). The stomach participates
in the act of breathing
• Auscultation should always be performed prior to manual examination
in order to avoid provoking intestinal noises. Intestinal sounds should
be auscultated in 4 sections. Are there intestinal noises present? What
grade are they? If no noises are heard, this could indicate a paralytic
ileus.
• Palpation to detect muscle rigidity, muscle guarding, peritonism
(rebound tenderness), tenderness, and ascites.
• Percussion helps in the detection of ascites, and abdominal fluid.
• Digital rectal examination for conditions such as palpable tumors, an
empty bowel (caused by an obstacle such as ileus or tumor) and
blood.
Physical examination
•
•
•
•
•
•
•
•
•
Abdominal signs
• Cullen
• Grey Turner
• Kehr
• Murphy
• Romberg-Howship
• Blumberg
• Markle (heel jar)
• Rovsing
Other symptoms
• Diffuse abdominal rigidity (abdominal guarding)
is often present, especially in generalized
peritonitis
• Fever
• Sinus tachycardia
• Development of ileus paralyticus (i.e., intestinal
paralysis), which also
causes nausea, vomiting and bloating
• Reduced or no passage of abdominal gas and
bowel sound
Key symptoms of acute abdomen
1. Abdominal pain The main manifestations of peritonitis are
acute abdominal pain, abdominal tenderness, abdominal
guarding, rigidity, which are exacerbated by moving the peritoneum,
e.g., coughing (forced cough may be used as a test), flexing one's hips, or
eliciting the Blumberg sign (meaning that pressing a hand on the
abdomen elicits less pain than releasing the hand abruptly, which will
aggravate the pain, as the peritoneum snaps back into place). Rigidity is
highly specific for diagnosing peritonitis (specificity: 76–100%). The
presence of these signs in a person is sometimes referred to as
peritonism. The localization of these manifestations depends on whether
peritonitis is localized (e.g., appendicitis or diverticulitis before
perforation), or generalized to the whole abdomen. In either case, pain
typically starts as a generalized abdominal pain (with involvement of
poorly localizing visceral innervation visceral peritoneal layer), and may
become localized later (with involvement of the somatic innervation of
the parietal peritoneal layer). Peritonitis is an example of an acute
treatment of acute abdomen
Treatment tactics:Peritonitis is an absolute
indication for emergency surgery.
1. Preoperative preparation:
1) antibiotic prophylaxis 60 minutes before the incision
intravenously: 1.5 g of cefuroxime,· or 1.2 g of
amoxicillin/clavulanate,· or 1.5 g of ampicillin/sulbactam;· or
cephalosporins (in the above dosage) + 500mg metronidazole
or 300 mg clindamycin - at high risk of contamination by
anaerobic bacteria;· or 1 g of vancomycin - if you are allergic
to beta-lactams or have a high risk of infection of the wound;
2) correction of dysfunctions caused by concomitant pathology;
3) nasogastric probe into the stomach to evacuate the contents of
the stomach;
4) catheterization of the bladder;
5) hygienic preparation of the surgical intervention area.
Treatment goals:
1.elimination of the source of peritonitis;
2.evacuation of pathological exudate,
sanitation and drainage of the abdominal
cavity;
3.source control (in case of abdominal
sepsis), damage control (in case of injury);
4.elimination of disorders and restoration of
the function of vital organs and systems.
Surgical intervention
With peritonitis without sepsis,
it can be performed by a
traditional and laparoscopic
method and provides for radical
elimination of the source.
Anesthetic support: general
anesthesia.
• drainage of the
abdominal cavity
with rational
placement of
drains in the
supposed places
of exudate
accumulation
(with widespread
peritonitis - in
the
subdiaphragmati
c, subhepatic
areas, left lateral
canal, pelvis);
• Options for completing the operation
adequate surgical intervention with
complete elimination of the source can be
completed by rational drainage and
suturing of the abdominal cavity. At the
appearance of the first signs of
progression of peritonitis or intra–
abdominal complications requiring
surgical correction - relaparotomy "on
demand"
Physical examination
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•
•
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Peritoneal signs
• Guarding (voluntary-involuntary-rigidity)
• Rebound
• Heel jar/heel tap
• Obturator test (pain in medial thigh with
rotation)
• • Iliopsoas test (passive extension/active
flexion)
• • Rovsing sign
• • Pain out of proportion to exam
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