Acute Abdomen

Acute Abdomen General name for presence of signs, symptoms of inflammation of peritoneum (abdominal lining)

Anatomic Landmarks Divided in quadrants Anatomic: RUQ, LUQ, RLQ, LLQ Epigastrium Umbilical Suprapubic (hypogastrium)

Pain Visceral pain is caused by distension, inflammation or ischemia in hollow viscous and solid organs. Parietal pain is localized to the dermatome above the site of stimulus and is initially unilateral.

Pain Referred pain produces symptoms, but not signs Usually lateralized Patterns of pain are based on embryologic sharing of dermatomes

Multiple Faces of Pain Pain can be characterized as: Sharp Stabbing Burning Heavy Diffuse Dull

Diagnosis History Characterization of pain Location? Duration? Other symptoms Nausea, vomiting? Bloody?

Inspection Description of abdominal habitus Scars, wounds, erythema scaphoid, Flat Rotund Scars, wounds, erythema Anatomic Confines

Auscultation Listen with stethoscope Quantitative Qualitative Not necessary in all quadrants Quantitative Absent Decreased Hyperactive Qualitative Normal Borbyrigmy Obstructive Bruits

Percussion Abdomen Liver Span Bladder, Uterus Tympanitic gas Dull fluid Liver Span mid clavicular line by convention Bladder, Uterus Rising out of the pelvis Percussion is also a very sensitive sign of peritonitis

Palpation Prepare the patient warn them make them comfortable take tension off the abdominal wall Pillow or bend the knees Expose the entire abdomen Xiphoid to pubis

Palpation Note the patient’s attitude (physically and emotionally) Watch their eyes as you touch them After percussion: Softly at first Deeper LUQ-RUQ note liver edge Then LLQ-RUQ

Laboratory Studies Complete blood count Urinalysis Serum amylase and lipase Liver function studies HCG Serum electrolytes

Imaging Tests X rays Flat and upright abdominal films (the most common first step) Air Calcific densities (stones, eggshell) Mechanical obstruction / ileus

Imaging Tests Ultrasonography CT scan Specific organ studies IVP HIDA Angiography

Imaging Tests CT: 15-20% false negative for acute perforation Poor study for gallstones Contrast obscures kidney stones

Undergo Operation Signs of peritonitis Increasing localized abdominal tenderness Abdominal pain with signs of sepsis Acute intestinal ischemia Certain radiographic findings

Appendicitis Usually due to obstruction with fecalith Appendix becomes swollen, inflamed gangrene, possible perforation

Appendicitis Pain begins periumbilical; moves to RLQ Nausea, vomiting, anorexia Patient lies on side; right hip, knee flexed Pain may not localize to RLQ if appendix in odd location Sudden relief of pain : possible perforation

Duodenal Ulcer Disease Steady, well-localized epigastric pain “Burning”, “gnawing”, “aching” Increased by coffee, stress, spicy food, smoking Decreased by alkaline food, antacids

Duodenal Ulcer Disease May cause massive GI bleed Perforation = intense, steady pain, pt lies still, rigid abdomen

Kidney Stone Mineral deposits form in kidney, move to ureter Often associated with history of recent UTI Severe flank pain radiates to groin, scrotum Nausea, vomiting, hematuria Extreme restlessness

Abdominal Aortic Aneurysm Localized weakness of blood vessel wall with dilation (like bubble on tire) Pulsating mass in abdomen Can cause lower back pain Rupture shock, exsanguination

Cholecystitis Inflammation of gall bladder Commonly associated with gall stones More common in 30 to 50 year old females Nausea, vomiting; RUQ pain, tenderness; fever Attacks triggered by ingestion of fatty foods

Bowel Obstruction Blockage of inside of intestine Interrupts normal flow of contents Causes include adhesions, hernias, fecal impactions, tumors Crampy abdominal pain; nausea, vomiting (often of fecal matter); abdominal distension

Gynecologic Disease A common cause A thorough history Complete pelvic and rectal exam Plain films of the abdomen Pelvic ultrasound

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