Assessment and Management
of the Acute Abdomen
Yingda Li
Neurosurgery HMO
23 September 2010
Objectives
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Develop a rational approach to assessing and
managing the acute abdomen in adults
Identify red-flags on history and examination
Consolidate information previously learnt about
specific pathologies
Have a set of rules to fall back on
Familiarise with the style of questions commonly
asked in exams
Overview
Definition
 History
 Examination
 Investigations
 Management
 Multi-choice questions

Definition
Abdominal pain
 Acute onset
 Usually severe
 Requiring urgent attention

Not always surgical
 Not always intra-abdominal source

Golden Rule 1
Upper abdominal pain may be from supradiaphragmatic pathology
 Acute myocardial infarct and lower lobe
pneumonia should always be in your
differential diagnosis

History
Demographics
 Tempo
 Site and radiation
 Quality
 Associated symptoms
 Antecedent events
 Pre-morbidities
 Prior episodes
 Menstrual
 Preoperative history

Golden Rule 2
A woman of childbearing age is pregnant
till proved otherwise
 A woman of childbearing age who has
acute abdominal pain is pregnant and has a
ruptured ectopic till proved otherwise
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Golden Rule 3
Never dismiss or underestimate acute
abdominal pain in an elderly patient
 They probably have mesenteric ischaemia,
ruptured AAA, perforated diverticular
abscess or a strangulated hernia
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Golden rule 4
Vomiting is the key associated symptom
 Pain before vomiting is usually surgical
 Combination of vomiting and diarrhoea is
usually gastroenteritis, but gastroenteritis
must remain a diagnosis of exclusion

Examination
General appearance
and vital signs
Inspection and
palpation
Bedside tests
Rectal, testicular
and pelvic
Auscultation
Golden Rule 5
Vital signs are vital
 You can tell a lot just by looking at a patient
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Investigations
Diagnostic
Pancreatic enzymes, cardiac
enzymes
US, CT, MRCP
Angiography
Laparoscopy
MSU
Supportive
X-ray
LFTs
Lactate, PO4
WCC, neutrophils
pH, ketones
Associated
UEC, CMP
Preoperative
Grp and Hold
Severity and Prognosis
CRP, platelets
Clotting, albumin
CT
Criteria
Management
Resuscitative cascade
Airway, breathing, circulation
General measures
Analgesia, antiemesis
NBM, IV fluids
NGT, IDC
Serial examinations
Specific measures
Antibiotics, image-guided drainage
Open surgery, laparoscopic-assisted
ERCP
Angiographic intervention
Sigmoidoscopic decompression
What is the difference between an incarcerated vs. obstructed vs. strangulated hernia?
1.
2.
3.
4.
5.
Hepatitis serology
Upper abdominal ultrasound
Full blood examination
ERCP
Liver biopsy
What would be your clinical concern if he was febrile? What eponymous triad would
that constitute?
How would you explain the low serum bicarbonate?
A.
B.
C.
D.
E.
Erect abdominal X-ray
Full blood examination
Liver function tests
Serum lipase
Upper G.I. endoscopy
A.
B.
C.
D.
E.
CT kidney, ureter and bladder
Ultrasound renal tract
24-hour urinary calcium excretion
Plain X-ray kidney, ureter and bladder
Mid-stream urine for phase microscopy
What is phase microscopy designed to look for?
What do you think is the most likely diagnosis?
Golden rules
1.
2.
3.
4.
5.
Upper abdominal pain may be from supradiaphragmatic pathology
Woman of childbearing age is pregnant till
proved otherwise
Acute abdominal pain in elderly patients must
not be dismissed or underestimated
Vomiting is the key associated symptom
Vital signs are vital