Acute Abdomen and Appendix
Xu Xiao
M.D. Ph.D.
Department of Hepatobiliary and Pancreatic Surgery
The First Affiliated Hospital, College of Medicine, Zhejiang University
1
Part Ⅰ Acute Abdomen
2
Definition of acute abdomen
Acute abdominal pain
the patient feel pain anywhere
between chest and groin. This is
often referred to the stomach region
or belly
sudden, severe abdominal pain that
is less than 24 hours in duration
medical emergency in many cases,
requiring urgent and specific
diagnosis. Several causes need
surgical treatment
3
Classification
 Physiology of abdominal pain
Diagnosis
Differential diagnosis
Treatment
4
Classification
 Internal acute abdomen
 Refers to the existing medical disease which can induce abdominal pain
with no surgical or gynecological indications, abdominal pain can be
alleviated after existing medical disease control with the comprehensive
examination and dynamic observation
 Such as acute myocardial infarction, acute mesenteric lymphadenitis,
abdominal purpura, abdominal epilepsy, acute non-specific appendicitis
Surgical acute abdomen
 Refers to the existing abdominal pain caused by some diseases which
need surgical treatment
5
Classification of surgical acute abdomen
 Peritonitis is the most specific term
 Five types
Perforation: perforated ulcer, intestinal perforation
Parenchymatous organic rupture:
hepatorrhexis, splenic rupture
Inflammatory: acute peritonitis, appendicitis
Obstruction: intestinal obstruction
Strangulation: mesenteric thrombosis
6
The Physiology of Abdominal Pain
 Visceral Pain
The most common form of pain
Manifestation
internal organs
of
damaged
or
injured
Many forms of visceral pain are particularly
prevalent in women and are associated with
their reproductive life
period pains, labour pain or postmenopausal pelvic pain
For both men and women, pain of internal
origin is the number one reason to consult a
doctor
7
pain
The Physiology of Abdominal Pain
Parietal Pain
Corresponds to the segmental nerve
roots innervating the peritoneum
Tends to be sharper and better
localized
Caused by pneumonia; empyema;
pneumothorax; tuberculosis; neoplasm;
or the accumulation of fluid resulting
from heart, liver, or kidney disease
 Aggravated by respiration and
thoracic movements
8
The Physiology of Abdominal Pain
Referred Pain
(sometimes referred to as reflective pain)
Referred pain is a term used to
describe the phenomenon of pain
perceived at a site adjacent to or at a
distance from the site of an injury‘s
origin.
One of the best examples :
myocardial infarction (heart attack):
pain is often felt in the neck, shoulders,
and back rather than in the chest, the
site of the injury
9
surface areas of referred pain
from different visceral organs
Common Causes of Acute Abdomen
Appendicitis
Perforating gastric/duodenal ulcer
Peritonitis
Ruptured ectopic pregnancy
Bowel Perforation Ruptured or hemorrhagic ovarian cyst
Pancreatitis
Pelvic inflammatory disease
Diverticular disease Abdominal aortic aneurysm
Cholecystitis
10
Tubo-ovarian abscess
Diagnosis
History
Physical examination
Laboratory Findings
Imaging studies
Diagnostic laparoscopy
Atypical patients
11
History
Type of onset
 Sudden - rupture of viscus, mesenteric thrombosis
 Gradual - cholecystitis, appendicitis
Quality
 Dull - initial epigastric pain of appendicitis
 Sharp - renal or biliary colic or obstruction of gut
 Aching - pelvic inflammatory disease
 Pleuritic - intensified by breathing
 Lancinating - acute pancreatitis
 Tearing - dissecting aneurysm
12
History
 Intensity
 Severe - rupture of viscus or blood in the peritoneal cavity
 Moderate - RLQ appendiceal mild peptic ulcer, without
perforation
 Features
 Pulsatile - abdominal aneurysm
 Continuous - acute pancreatitis
 Frequency & duration
13
Transient pain of short duration which does not recur is
usually insignificant. The longer the duration the more likely
a surgical condition
History
 Factors which intensify or relieve pain
 Relation to meals - peptic ulcer pain relieved by food,
cholecystitis pain aggravated by fatty meal
 Posture jack-knifing - leg drawn up to decrease peritoneal
irritation in suppurative appendicitis
 Motion - any movement causes intense pain in generalized
peritonitis and the patient lies motionless
14
History
 Associated nausea and vomiting
 Nausea & vomiting - reflex, or irritative non-specific
vomiting occurs in many conditions
 Such as acute appendicitis, anorexia always occurs
and vomiting, if it occurs, usually follows abdominal pain
rather than preceding it, as in gastroenteritis
 Repeated vomiting of large amounts occurs in gut
obstruction, is often bile stained and may become fecal
15
History
 Diarrhea
 Most occur with acute gastroenteritis or food poisoning
 May also occur with appendicitis or other focal inflammatory
lesions of the gut
 Constipation or obstipation
 With complete small bowel obstruction - unrelenting
constipation (obstipation)
 Progressive constipation with carcinoma of the large bowel
 Gas stoppage with decreased or absent bowel sounds - paralytic
ileus
16
Physical Examination
 Overall appearance ( Facial expression, diaphoresis, pallor,
and degree of agitation)
 Inspection: scars, hernias, masses
 Palpation : The most critical step
 Tenderness
 Rigidity and guarding
 Board-like abdomen
 Rebounding pain
17
Physical Examination
 Auscultation
Hyperactive BS(bowel sound) , hypoactive BS or silent BS
 Percussion
 Digital examination of rectum
 A routine part of the physical
examination
 Check for problems with organs or
other structures in the pelvis and
lower belly
18
Laboratory Findings
WBC-DC (differential counting )
 The total leukocyte count and percentage of polymorph nuclear
cells are usually elevated in acute inflammatory conditions
 Whereas early in the course of intestinal obstruction there may
be no significant alterations
Urinalysis
 Blood in the urine suggest disease of the urinary tract and can
also result from an inflamed appendix lying in proximity to the
ureter or bladder
 In dehydration the specific gravity of the urine may be increased,
and the red cell and hemoglobin values
19
Laboratory Findings
 Amylase, lipase
 Serum amylase values in excess of 500 units are significant and levels
of 1500-2000 units or more are not unusual in the early stages of severe
acute pancreatitis.
 β-HCG (human chorionic gonadotrophin)
– woman of childbearing age
 Bilirubin, ALT, AST, Alkaline phosphatase
20
Imaging Studies
 Standing CXR and KUB
 Ultrasound for solid organs
 CT of abdomen for abscess, free air, vessel, tumor and
ischemia bowel
 Angiography: Especially in non-diagnostic ischemia bowel
21
Imaging Studies
Gastric ulcer
22
Imaging Studies
Urethral calculus
23
Imaging Studies
Pneumoperitoneum
24
Imaging Studies
Incomplete intestinal obstruction
25
Imaging Studies
Cholecystitis
Pancreatitis

26
Effusion
 A buildup of
fluid
Imaging Studies
Gall stone
27
Imaging Studies
Hemorrhage of large hepatocellular
carcinoma
28
TACE (Transcatheter Arterial
Chemoembolization )
Imaging Studies
Biliary ascariasis
29
Diagnostic Laparoscopy
A high sensitivity and specificity
Decreased morbidity and mortality
Decreased length of stay
Decreased overall hospital costs
30
Atypical Patients
 Pregnancy
 Acute Abdomen in the Critically Ill
 Immunocompromised Patients With Acute Abdomen
 Acute Abdomen in the Morbidly Obese
31
(1) Pregnancy
 The reasons for delayed diagnosis
 The underlying pregnancy has symptoms similar with
acute abdomen, including abdominal pains, nausea,
vomiting, and anorexia
 Pregnancy can alter the presentation of some disease
processes and make the physical examination more
challenging because of the enlarged uterus in the pelvis
 Pregnancy can alter the laboratory findings, such as
white blood cell counts
 Pregnancy can influence the doctor’s decision to
perform typical imaging studies because of concern about
radiation exposure to the developing fetus
32
(1) Pregnancy
 Most common surgical diseases seen in pregnancy
 Appendicitis
Appendicitis is the most common nonobstetric
disease requiring surgery, occurring in 1 of 1500
pregnancies
 Biliary tract disorders
Surgery for biliary disease occurs in 1 to 6 per
10,000 pregnancies. Symptoms of pain, nausea, and
anorexia are the same as in nonpregnant patients
 Bowel obstructions
Bowel obstructions are much less common,
occurring in about 1 or 2 per 4000 deliveries
33
(2)Acute Abdomen in the Critically Ill
 The reasons for delayed diagnosis

Many of the underlying diseases and treatments
encountered in the intensive care unit can predispose to
acute abdominal disease
 Critically ill patients are often unable to appreciate
symptoms to the same degree as healthy peers because
of nutritional or immune compromise, narcotic analgesia,
or antibiotic use
34
(3) Immunocompromised Patients With Acute Abdomen
 The reasons for delayed diagnosis
 Immunocompromised patients have variable presentations
with acute abdominal diseases. The variability is highly
correlated to the degree of immunosuppression
 Most common Immunocompromised Patients
 Elderly, malnourished, and diabetic patients
 Transplant recipients on routine maintenance therapy
 Cancer patients; renal failure patients
 HIV patients
35
(4) Acute Abdomen in the Morbidly Obese
 The reasons for delayed diagnosis

Alterations in the signs and symptoms of
peritonitis in the morbidly obese
 Exam findings can also be difficult to confirm
distention or intra-abdominal mass because of the
size and thickness of the abdominal wall.
 Abdominal imaging is also adversely affected
by obesity
36
Treatment for Acute Abdomen
Effective management of acute abdominal pain
involves a careful history taking, ultrasound,
electrocardiography and blood tests. Computed
tomography of abdominal organs and visceral
vessels is probably important already at the
beginning of the diagnostic work up
37
Treatment Algorithms (1)
Algorithm for the treatment of acute-onset severe, generalized abdominal pain
38
CT, computed tomography;
NL, normal study;
NG, nasogastric tube;
OR, operation
Treatment Algorithms (2)
Treatment of gradualonset severe, generalized
abdominal pain.
CT, computed tomography;
ERCP, endoscopic retrograde
cholangiopancreatography; LFTs, liver
function tests
39
Treatment Algorithms (3)
Algorithm for the
treatment of right
upper quadrant
abdominal pain
CT, computed tomography;
ERCP, endoscopic retrograde
cholangiopancreatography;
LFTs, liver function tests;
NL, normal study;
40
US, ultrasound.
Treatment Algorithms (4)
Algorithm
for
the
treatment of left upper
quadrant abdominal pain
41
CT, computed tomography
Treatment Algorithms (5)
CT, computed tomography;
Algorithm for the treatment of right
lower quadrant abdominal pain
hx, history;
42
UTI, urinary tract infection
OR, operation;
Treatment Algorithms (6)
Algorithm for the treatment of left
43lower quadrant abdominal pain
CT, computed tomography
Preparation for emergency operation
 IV access
 Antibiotic infusions
 Nasogastric tube
 Foley catheter bladder drainage
 Hydroelectrolytic equilibration
 Crossmatched blood available
44
Summary
 Acute abdomen remains a challenging part of a surgeon's
practice
 KEY: A patient with an acute abdomen is an
EMERGENCY, and it is IMPERATIVE to get a correct
diagnosis
 Although advances in imaging techniques, a careful
history and physical examination remain the most important
part of the evaluation
 Perform a laparoscopy or laparotomy for diagnosis with a
good deal of uncertainty as to the expected findings
45
Case Study
20-Year-Old Male with Abdominal Pain for 18 Hours
History
 Pain started in the Mid-Abdomen
 Constant
 Anorexia, Nausea, and Vomiting
 First Episode
 No Diarrhea, Dysuria
 Pain Now Seems Worse in the Right Lower Abdomen
46
Case Study
Physical Exam
 Lying flat, avoids moving
 Afebrile
 Abdomen tender mostly in the RLQ
 Significant guarding
 Positive Roving's Sign
47
Case Study
Lab Data
 WBC
14*109/L
 AST,ALT
Normal
 Amylase, Lipase Normal
 Urine Culture
Further Testing

CT scan
•Diagnosis?
48
Negative
49
Part Ⅱ Appendix
•Appendicitis
•Appendiceal Abscess
50
Appendicitis
 Reginald Fitz first
appendicitis in 1886
described
acute
and
chronic
 It has been recognized as one of the most common causes
of severe acute abdominal pain worldwide
 Appendicitis is a condition characterized
inflammation of the appendix Vermiform appendix
by
 All cases require removal of the inflamed appendix, either
by Laparotomy or laparoscopy.
 Untreated, mortality
peritonitis and shock
51
is
high,
mainly
because
of
Appendicitis
 Anatomy and position
 Pathophysiology
 Diagnosis
 Differential Diagnoses
 Treatment
 Outcome
52
Anatomy and position
Anatomy
 A closed-ended, narrow tube up to several inches in length that attaches
to the cecum like a worm
 The inner lining of the appendix produces a small amount of mucus that
flows through the open center of the appendix and into the cecum
 The wall of the appendix contains lymphatic tissue that is part of the
immune system for making antibodies
Position
Para-caecal
post-ileal
 The vermiform appendix has
no constant position
Pre-ileal
 The appendix is more often
found in the pelvic rather than the
retrocaecal position
retrocaecal
53
pelvic
Pathophysiology
 Acute appendicitis is thought to begin with
obstruction of the lumen
 Obstruction can result from food matter, adhesions,
or lymphoid hyperplasia
 Mucosal
secretions
continue
to
increase
intraluminal pressure
54
Pathophysiology
Acute simple appendicitis
Acute purulent appendicitis
Acute gangrenous appendicitis
55
Diagnosis
History
Physical Examination
Laboratory Studies
Radiography
Diagnostic Laparoscopy
56
History
 Primary symptom: abdominal pain
 Pain beginning in epigastrium or periumbilical area that is
vague and hard to localize
 Associated symptoms: indigestion, discomfort, flatus,
need to defecate, anorexia, nausea, vomiting
 Migration of pain from initial periumbilical to RLQ was
64% sensitive and 82% specific
 Anorexia is the most common of associated symptoms
 Vomiting is more variable, occuring in about ½ of patients
57
Physical Examination
 Findings depend on duration of illness prior to exam
 Early on patients may not have localized tenderness
 With progression there is tenderness to deep palpation over
McBurney’s point
 McBurney’s Point: just below the middle of a line connecting
the umbilicus and the ASIS （anterior superior iliac spine)
 Rectal exam: pain can be most
pronounced if the patient has
pelvic appendix
58
Physical Examination
Roving's sign
Pain in RLQ with palpation to LLQ
A sign of appendicitis. If palpation of the lower left
quadrant of a person's abdomen results in more pain in
the right lower quadrant, the patient is said to have a
positive Rovsing's sign and may have appendicitis
59
Physical Examination
 Psoas sign
Place patient in L lateral decubitus and extend R leg at
the hip. If there is pain with this movement, then the sign
is positive.
Occasionally, an inflamed appendix lies on the
Psoas muscle and the patient will lie with the right hip
flexed for pain relief.
60
Physical Examination
Obturator sign
Passively flex the R hip and knee and internally rotate the
hip. If there is increased pain then the sign is positive
If an inflamed appendix is in contact with the obturator
internus, spasm of the muscle can be
demonstrated by flexing and internally
rotating the hip. This maneuver
will cause pain in the hypogastrium
61
Laboratory Studies
 WBC
 The white blood cell count is elevated with more than 75%
neutrophils in most patients
 A completely normal leukocyte count and differential is found
in about 10% of patients with acute appendicitis
 A high white blood cell count (>20,000/mL) suggests
complicated appendicitis with either gangrene or perforation

Urinalysis
 Be helpful in excluding pyelonephritis or nephrolithiasis
 Microscopic hematuria is common in appendicitis
 Gross hematuria is uncommon and may indicate the presence of
a kidney stone
62
Radiography
 Plain abdominal radiographs
 Ultrasonography
 Computed tomography (CT)
 CT：best choice based on availability and alternative
diagnoses
 CT：greater sensitivity, accuracy, predictive value
63
CT scanning
CT scan of the abdomen or pelvis in a
patient with acute appendicitis may
reveal an appendicolith (arrow)
64
CT typically shows a distended appendix
(arrow) with diffuse wall-thickening and
periappendiceal fluid (arrowhead)
Diagnostic Laparoscopy
 A direct examination of the appendix
 A survey of the abdominal cavity for
other possible causes of pain.
 Primarily for women of childbearing
age in whom preoperative pelvic
ultrasound or CT scan
65
Diagnostic Algorithm
66
Algorithm for the evaluation and management of patients with possible acute
appendicitis based on surgical assessment of clinical probability of the diagnosis
Diagnostic Algorithm
67
Algorithm summarizing the treatment of acute appendicitis
Differential Diagnoses
 Two type : A: required surgery B: not required surgery
 Required surgery
 Perforation of gastrointestinal tract ulcer, tumor, diverticulitis
 Obstetrics and gynecologic disease: ectopic pregnancy, ovarian
torsion
 Meckel’s diverticulitis
 Tumor
 Not required surgery
 Pelvic inflammation
 Mesenteric adenitis: at exploration a normal appendix and
enlarged lymph nodes in the mesentery
 Viral &bacterial gastroenteritis
 Pneumonia, pleurisy
68
Treatment
Surgical removal of appendix is definitive treatment
Incision
 Incision over the point of maximal tenderness,generally at
McBurny point
 McBurney’s incision, tansvers skin incision , 3—6cm long
Process
 The taenia of the colon are followed to the base of the appendix
 Mesoappendix is divided between clamps and ligated
The base of appendix is divided and ligated 0.5cm from caceum
and inverted using a purse-string
Suspected case
Admit the patient to hospital for further observation 12-24hrs
69
Open Appendectomy (OA)
Anterior cecal artery
Location
of
possible
incisions for an open
appendectomy
cecum
Division of the mesoappendix
70
Open Appendectomy (OA)
B. Ligation of the base
and division of the
appendix
C. Placement of pursestring suture or Z stitch
D. Inversion of the
appendiceal stump
71
Laparoscopic Appendectomy (LA)
Location of port sites for
laparoscopic appendectomy
Division of the mesoappendix
using the harmonic scalpel
72
Laparoscopic Appendectomy (LA)
Placement of an absorbable Endoloop
encircling the base of the appendix
Division of the appendix between Endoloops
Placement of the appendix into a specimen
bag before removal of the appendix with
the umbilical port
73
Antibiotic thearpy
 The differentiation between simple appendicitis and
gangrenous appendicitis/perforated appendicitis with
peritonitis should determine the length of antibiotic
administration
Simple
appendicitis
ONLY preoperative
antibiotic prophylaxis
74
Gangrenous appendicitis
and perforated appendicitis
with peritonitis
A therapeutic
course
Appendiceal Abscess
 An abscess in the peritoneal cavity resulting from the spread of
infection in acute appendicitis, especially with perforation of the appendix.
Also called periappendiceal abscess.
 Imaging studies are useful both in confirming the diagnosis and in
evaluating the size of any abscess present
 Those patients with smaller abscesses or phlegmon and who are not
sick may be successfully managed initially with antibiotics alone.
 Patients who continue to have fever and leukocytosis after several days
of nonoperative treatment are likely to require appendectomy during the
same hospitalization, whereas those who improve promptly may be
considered for interval appendectomy
75
Diagnostic Algorithm
76
Algorithm for the management of
appendiceal abscess
Outcomes
 The mortality rate after appendectomy is less than 1%.
 Surgical site infections are the most common
complications seen after appendectomy.
 Small bowel obstruction occurs in less than 1% of
patients after appendectomy for uncomplicated
appendicitis and in 3% of patients with perforated
appendicitis who are followed for 30 years.
 The risk for infertility following appendectomy in
childhood appears to be small.
 There are rare reports of appendicocutaneous or
appendicovesical fistulas after appendectomy, typically
for perforated appendicitis.
77
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Thanks !