The ACUTE ABDOMEN
Simon Lau
Mike Bozin
 The Acute Abdomen: an acute change in the condition of the
intra abdominal organs
 Usually related to inflammation or infection
 Demands IMMEDIATE and accurate diagnosis
(but this does not always correlate with the need for an operation)
Abdominal Pain
 One of the most frequent presentations to EDs
 Most are self limiting
 Some are not!
Case 1
 27yo female presents with 1d of abdominal pain
 Associated with:
 Anorexia
 Nausea, no vomiting
 Some diarrhoea
Visceral vs Parietal
 Visceral Pain:
 Related to stretching of the
walls of hollow viscera, or the
capsules of solid ones
 Dull
 Poorly localised but usually
central
Visceral vs Parietal Pain
 Parietal Pain
 Origin anywhere in the abdominal wall from the skin to the
parietal peritoneum
 Intense
 Well localised
 Transition from Visceral to Parietal
 Initial visceral pain irritates parietal peritoneum, causing
parietal pain wherever they are in contact
Cont Case 1
 Abdominal Pain:
 Initially midline/umbilical
 Over 24/24 transitioned to the RIF
 Severe, constant
Applied Anatomy
 What anatomical structures reside in the Right Iliac Fossa? (in
a girl)
The Right Iliac Fossa
 Caecum
 Appendix
 Ileocaecal junction/valve
 Right Ovary/Fallopian tube
 Right Ureter
Examination
 HR110 BP95/70 O2: 98% 4LNP RR20 T37.8⁰C
 Abdo Ex:
 RIF tenderness
 Percussion tenderness
 Rovsing Sign
 PR: nil blood, nil melena
Investigations
 FBE: 120/15.2/214 neut 11.2
 UEC: 140/4.3 Cr 64 eGFR >90
 INR: 1.0
 β-HCG: neg
 Urinalysis: NAD
 Imaging???
DDx?
Acute Appendicitis
 Inflammation of the appendix, usually secondary to
obstruction of the appendiceal lumen
 Alvarado Score
 Complications of untreated appendicitis?
 Perforation and peritonitis
 Appendiceal abscess
Other DDx’s
 GIT:




Diverticulitis
Bowel obstruction
Volvulus/strangulation
Cx of hernias
 Gynaecological:
 Ectopic pregnancy
 Adnexal torsion
 Urological:
 Pyelonephritis
 Renal stones
 Testicular torsion
 Vascular:
 Ischaemic colitis
Case 2
 46yo male presents with 12hrs of worsening abdominal pain
 Moderate in severity
 Initially colicky but now constant
 Located in the RUQ with radiation to the tip of the right
shoulder
 Associated with nausea and vomiting and fevers
Applied Anatomy
 What structures are found in the RUQ?
The Right Upper Quadrant
 Liver
 Gall Bladder
 Biliary Tree
 Pancreas
 Stomach
 Duodenum
 Right kidney
Examination
 HR: 115 BP: 120/70 RR: 19 O2: 99% 2L NP T: 38.1⁰C
 Abdo Ex:
 Tender RUQ with some (voluntary) guarding
 Murphy’s sign positive
Investigations
 FBE: 123/13.9/285 neut 10.2
 UEC: normal
 LFTs: bilirubin, GGT and ALP elevated
 Imaging??
DDx?
Cholecystitis
 Inflammation of the gallbladder, most commonly from
obstruction of the cystic duct
 Cf with choleduocholithiasis and cholangitis and biliary colic
Cont Cholecystitis
 Imaging: US Abdo or CT
A/P
 Treatment
 IV resus
 Analgesia
 Abx
 Laproscopic
cholecystectomy
Other DDx’s?
 Hepatobiliary:
 Choleduocholithiasis
 Cholangitis
 Pancreatitis
 GIT:
 Perforated peptic/duodenal ulcer
 Gastritis/GORD
 Urological:
 Pyelonephritis
 Renal stones
Case 3
 87yo male presents to the ED with sudden onset abdominal
pain
 Severe and constant
 Initially developed in the LIF but quickly became widespread
 Associated with one large passage of bloody diarrhoea
Cont Case 3
 PMHx:
 IHD – AMI 2yrs ago with PCI
 T2DM – OHG only
 AF – warfarinised recently
 PVD – Fem-Pop Bypass Graft 4yrs ago
 Nil history of abdominal surgery
 Meds:
 Warfarin, β-blocker, ACE-I, metformin, aspirin, statin
 Active smoker 4-5 cigarettes per day, 40+ PYH
Examination
 HR: 130, BP: 90/60, O2: 99% 2LNP, RR: 17, T: 37.9⁰C
 Looks flat/sick. Unwilling to move much. Drowsy
 Abdo Ex:
 Abdominal guarding and rigidity
Investigations
 FBE: 75/15.2/246 neut 11.2
 UEC: 150/3.2 Cr 265 eGFR 30 (baseline Cr 125)
 LFTs: normal
 Coags: INR 1.6
 ABG: pH 7.29 pCO2 29 HCO3 19 lactate 5.2
 AXR: dilated oedematous bowel loops
DDx? Use Applied Anatomy!
 Descending and Sigmoid
Colon
 Ureter
 Left Ovary/Fallopian Tube
Treatment:
 IV resuscitation
 Blood Cultures and Abx
 NGT, IDC
 Vit K (IV) to reverse INR
 Consent for urgent laparotomy + washout +/- proceed (eg
Hartman’s).
 Consider need for intraoperative Angiogram
Hartman’s Procedure
Lets go back to Case 1
 27yo female presents with 1d of abdominal pain
 Abdominal Pain:
 Initially midline/umbilical
 Over 24/24 transitioned to the RIF
 Severe, constant
 Further Hx:





LMP 8 weeks ago
No PV bleding
Smoker
Hx of chlamydia
Previous laparoscopic surgery for endometriosis
O/E
 Pain 2/10 after 10mg morphine IV
 Obs: HR110 BP95/70 O2: 98% 4LNP RR20 T37.8⁰C
 Abdominal examination as above
 What else do you need to do?
 ALL FEMALE PATIENTS OF REPRODUCTIVE AGE ARE
PREGNANT UNTIL PROVEN OTHERWISE - b-HCG!
 Speculum examination and bimanual examination
O&G Differentials
Obstetric
Non-Obstetric
Gynaecological
Early Pregnancy
- Ectopic pregnancy
- Miscarriage
Late Pregnancy
- Placental abruption
- Uterine rupture
- Labour / PPROM
- Braxton-Hicks
- HELLP
- Acute fatty liver
- Choramnionitis
- Symphysis pubis
dysfunction
- Round ligament pain
- Fibroid degeneration
-
- Ovarian torsion
- PID
- Ruptured ovarian
cyst
- Endometriosis
- Adenomyosis
- Mittelschmertz
Appendicitis
Pyelonephritis
UTI
GORD
Constipation
Pancreatitis
Renal colic
Cholecystitis
Bowel obstruction
Diverticulitis
IBD
Trauma / Assault
Medical causes
(pneumonia, DKA)
ACUTE ABDOMEN
+
POSITIVE PREGNANCY
=
ECTOPIC
until proven otherwise..
Risk factors for Ectopic pregnancy
 Smoking
 Clomiphene
 IUD
 PID
 Previous ectopic pregnancy
 Adhesions
 Pelvic and tubal surgery
 Endometriosis
 Pelvic masses
 Chromosomal abnormalities
Investigation
 Cultures: urine B-HCG
 Bloods: FBE, UEC, LFT, G+H, COAG, Serum B-HCG,
Serum progesterone
 Serum B-HCG >1500 I/U should see gestational sac
 Serum B-HCG > 10,000 should see heart beat
 Serum B-HCG should double every 48 hours
 Imaging: Transvaginal ultrasound
 Scopic: Diagnostic laparoscopy
FIRST RESUSCITATITE, then..
IF PATIENT IS UNSTABLE DESPITE
RESUSITATION URGENT
LAPAROTOMY IS INDICATED
Management
Medical:
 ONLY if fulfill criteria
 Methotrexate
 Anti-D if mum Rh-ve
 Follow up
 Contraception for 3 months as methotrexate teratogenic!
Surgical:
 Anti-D if mum Rh-ve
 Diagnostic Laparoscopy if patient is haemodynamically stable
 Laparotomy if patient unstable
 Salpingectomy or Salpingotomy
Management
Ovarian Torsion
 Torsion of ovary on its vascular, tubal and ligamentous pedicle (adnexal
torsion)
 Results in ischaemia and eventual infarction if not relieved
 GYNAECOLOGICAL EMERGENCY
 Risk factors:
 Ovarian mass
 Cyst
 More common in reproductive age
 Sudden onset lower quadrant visceral pain
 Radiate to flank or inner thigh
 N+V
 Can sometimes develop slowly
 Tender lower quadrant
 Adnexal tenderness on bimanual examination +/- palpable mass
Investigation and Management
 B-HCG to rule out ectopic pregnancy!
 WCC – tubo-ovarian abscess
 Urinalysis
 Doppler Ultrasound
 >50% sensitivity for torsion, but arterial flow does not rule out
 Absence of arterial flow high predictive value
 Laparoscopy / laparotomy +/- salpingo-oophorectomy
Ovarian Torsion
Other Differentials NOT TO MISS
 ΑAA
 Testicular torsion
 AMI
 Lower lobe pneumonia
Questions???