1. 1

2. Introduction
Complaints related to abdominal pain comprise between 7- 9 % of all visits to the ED.
Of those, the most common discharge diagnosis is Abdominal Pain NOS.
Although most abdominal pain is non-emergent and self-limited in nature, attention must be paid to not miss medical and/or surgical emergencies.
Abdominal pain NOS approximately 40-50% of all discharging diagnosis
With the advancement of imaging in aiding the laboratory and physical exam we have been able to quickly determine the difference between surgical and non-surgical causes of patients pain. As a result admission rates for observation of abdominal pain have fallen.
SOCIAL WORKER FATHER.

3. Important Factors
Patients rarely present with the classical signs/symptoms of acute abdominal pain.
Three important factors to consider are age, gender, and co-morbidities.
In some studies as few as 30% of appendicitis presents as the classic periumbilical pain to RLQ with anorexia, fever and increased WBC. KATZ PT With R sided diverticular disease.
For example, childbearing women, the elderly, and children may all present with the same diagnosis in different ways.

4. Definition
The term acute abdomen refers to a sudden, severe abdominal pain that is less than 24 hours in duration. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need surgical treatment.
Don’t forget about the chronic pain that has acutely worsened. 4

5. Basic Principles
Proper evaluation and management requires one to recognize:
1. Does this patient need surgery?
2. Is it emergent, urgent, or can wait?
In other words, is the patient unstable or stable?
Remember medical causes of abd pain

6. 50-65% inaccurate initial diagnosis
In children
Acute appendicitis
UTI
Mesenteric adenitis GE
Constipation
> 100 causes exist
NSAP (34%)
Acute appendicitis (28%)
Acute chlecystitis (10%)
SBO (4%)
Perforated PU (3%)
Pancreatitis (3%)
Diverticular disease (2%)
Others (13%)
50-65% inaccurate initial diagnosis
50% of surgical admissions are emergencies, and of those 50% present with acute abdomen. 6

7. Types of Pain
Visceral Pain: caused by stretching of fibers innervating the walls of hollow organs or capsules of solid organs, described as cramp or dull pain
Parietal Pain: caused by irritation of fibers that innervate the parietal peritoneum, pain is more sharp and localized
Referred Pain: pain at a location distant to the diseased organ based on embryological origin
A patient’s description of the pain is vital in assessing the problem.
Examples of types of pain  Early appendicitis or diverticulitis is a visceral pain  dull pain in RLQ or LLQ respectively. Once perforation occurs in either that switches to a parietal pain  sharp unremitting pain worse with movement and ultimately leads to rigidity and rebound tenderness of peritonitis.
Referred pain classically is described as diaphragmatic irritation causing referred pain to the shoulder due both being serviced by C4.

8. Visceral pain

9. Parietal pain Referred pain
Is localised to the dermatome above the site of the stimulus.
Character:
sharp and localized pain.
somatic nerve distribution (T7-L2, umbilicus at T12). The exception to this is the diaphragmatic portion, which is supplied centrally by the phrenic nerve (C3-C5), and peripherally by the lower six intercostal and subcostal nerves.
sensitive to mechanical stimuli (stretching, pinprick , pinch), heat, electrical shock, chemical stimulus, infection-inflammation.
Referred pain
It’s pain perceived distant from its source and results from convergence of nerve fibers at the spinal cord.
produces symptoms, not signs e.g. tenderness

10. Causes of Acute Abdomen
Surgical
Gynecological
Medical

11. Think Broad categories for DDx surgical Causes
Inflammation
Obstruction
Ischemia
Perforation (any of above can end here)
Offended organ becomes distended
Lymphatic/venous obstruction due to ↑ pressure
Arterial pressure exceeded → ischemia
Prolonged ischemia → perforation

12. Inflammation versus Obstruction
Organ
Lesion
Stomach
Gastric Ulcer
Duodenal Ulcer
Biliary Tract
Acute cholecystitis
Acute cholangitis
Pancreas
Acute, recurrent, or chronic pancreatitis
Small Intestine
Crohn’s disease
Meckel’s diverticulum
Large Intestine
Appendicitis
Diverticulitis
Location
Lesion
Small Bowel Obstruction
Adhesions
Hernia
Cancer
Crohn’s disease
Gallstone ileus
Intussusception
Volvulus
Large Bowel
Obstruction
Malignancy
Volvulus: cecal or sigmoid
Diverticulitis
Biliary colic
Ureteric colic
Acute retention

13. Ischemia versus Perforation
Acute mesenteric ischemia
Usually acute occlusion of the SMA from thrombus or embolism
Chronic mesenteric ischemia
Typically smoker, vasculopathy with severe atherosclerotic vessel disease
Ischemic colitis
Torsion of a viscus
Perforated PU
Perforated diverticular disease
Perforated appendix
Acute chlolecystitis with Perforation
Ruptured AAA
Perforated bladder

14. GYN Causes Organ Lesion Ovary Fallopian tube Uterus Torsion of ovary
Ruptured graafian follicle
Tubo-ovarian abscess (TOA)
Fallopian tube
Ectopic pregnancy
Acute salpingitis
Pyosalpinx
Uterus
Uterine rupture
Endometritis

15. Non-Surgical (Medical) Causes
System
Disease
Cardiac
Myocardial infarx
Acute pericarditis
Endocrine
Diab ketoacidosis
Addisonian crisis
Pulmonary
Pneumonia
Pulmonary infarx PE
Metabolic
Acute porphyria
Mediterranean fever
Hyperlipidemia GI
Acute pancreatitis
Gastroenteritis
Acute hepatitis
Musculo- skeletal
Rectus muscle hematoma GU
Pyelonephritis
CNS
PNS
Tabes dorsalis (syph)
Nerve root compression
Vascular
Aortic dissection
Hematological
Sickle cell crisis

16. Generalized AP Perforation Mesenteric ischemia AAA Acute pancreatitis16

17. Central AP Early appendicitis SBO Acute pancreatitis Ruptured AAA
Mesenteric thrombosis
Acute gastritis 17

18. Epigastric pain DU / GU Oesophagitis Acute pancreatitis AAA
Recurrent, relationship to meals,
relationship to posture
Oesophagitis
Acute pancreatitis
History of alcohol consumption, history of similar event, elevated labs
AAA 18

19. RUQ pain Acute cholecystitis DU Acute pancreatitis
Recurrent attacks, tender over gall bladder area DU
Acute pancreatitis
Retrocecal appendicitis
Shift of pain, tenderness
R L Pneumonia
Fever, tachypnea, bronchial breathing
Subphrenic abscess 19

20. LUQ pain Pneumonia Acute pancreatitis Splenic rupture Splenic abscess
Acute perinephritis
Subphrenic abscess 20

21. RIF pain Acute appendicitis Mesenteric adenitis (young) Perf DU
Shift of pain, anorexia, localized tenderness
Mesenteric adenitis (young)
Fever, inconstant signs
Perf DU
Diverticulitis
Salpingitis
Ureteric colic
Colicky pain, hematuria
Meckel’s diverticulum
Ectopic pregnancy
Crohn’s disease
Biliary colic (low-lying GB) 21

22. LIF pain Diverticulitis Constipation IBS PID Rectal Ca UC
Ectopic pregnancy 22

23. Suprapubic pain Acute urinary retention UTI Cystitis PID
Palpable bladder, difficulty passing urine
UTI
Cystitis
PID
Ectopic pregnancy
Diverticulitis 23

24. Loin pain
Muscle strain
UTIs
Renal stones
Pyelonephritis 24

26. Approach to Acute Abdomen
Take a proper Hx and Ex, do not work to the diagnosis given to you by the referring doctor.
History is THE MOST IMPORTANT part of the diagnostic process:
Location , onset, nature , severity, radiation, aggravating or relieving factors, associated symptoms
A good medical history
A good social history, including alcohol, drugs, domestic abuse, stressors, etc.
Family history is important (IBD, cancers, etc)
MEDICATION INVENTORY

27. Was onset of pain gradual or sudden?
CLUES in Hx.
Was onset of pain gradual or sudden?
Sudden perforation, hemorrhage, infarct
Gradual inflammation, peritoneal irrigation, hollow organ distension
What does nature of pain?
Steady pain inflammatory process
Colicky pain Biliary colic ,obstruction
Stabbing AAA
Does pain radiate anywhere?
Right shoulder, angle of right scapula GB
Around flank to groin kidney, ureter
In Females ?
Last menstrual period?
Abnormal bleeding? 27

28. Progression of Pain

29. Associated symptoms
Fever
Genitourinary
Gynaecological
Vascular 29

30. PMSH Previous episodes of AP Investigations Operations Chronic disease
Medications (NSAIDs) 30

31. Physical examination
Administration of analgesics prior to surgical consultation does not obscure the diagnosis, but improves accuracy.
Observation
Bending Forward: Chronic Pancreatitis
Jaundiced: CBD obstruction
Dehydrated: Peritonitis, SBO 31

32. Inspection Not move with respiration in peritonitis
Scaphoid or flat in peptic ulcer
Distended in ascites or intestinal obstruction
Visible peristalsis in a thin or obstruction
Scars : relevant previous illness or adhesions
Hernia : intestinal obstraction 32

33. Palpation Check for Hernia sites Tenderness Rebound tenderness.
Guarding.
Rigidity.
Rebound tenderness, considered the clinical indicator of peritonitis, has a high (25%) false -ve rate
Rigidity, referred tenderness & cough pain are sufficient evidence for peritonitis 33

34. Local Right Iliac Fossa tenderness:
Acute appendicitis
Acute Salpingitis in females
Low grade, poorly localized tenderness:
Intestinal Obstruction
Tenderness out of proportion to examination:
Mesenteric Ischemia
Acute Pancreatitis
Flank Tenderness:
Perinephric Abscess
Retrocaecal Appendicitis 34

35. Cullen's sign Kehr's sign McBurney's sign Murphy's sign Iliopsoas sign
Important Signs in Patients with Abdominal Pain
Sign
Finding
Association
Cullen's sign
Bluish periumbilical discoloration
Retroperitoneal haemorrhage
Kehr's sign
referd left shoulder pain
Splenic rupture Ectopic pregnancy rupture
McBurney's sign
Tenderness located 2/3 distance from anterior iliac spine to umbilicus on right side
Appendicitis
Murphy's sign
Abrupt interruption of inspiration on palpation of right upper quadrant
Acute cholecystitis
Iliopsoas sign
Hyperextension of right hip causing abdominal pain
Obturator's sign
Internal rotation of flexed right hip causing abdominal pain
Grey-Turner's
Discoloration of the flank
Retroperitoneal hemorrhage
Chandelier sign
Manipulation of cervix causes patient to lift buttocks off table
PID
Rovsing's sign
Right lower quadrant pain with palpation of the left lower quadrant 35

36. Percussion Resonance : intestinal obstruction
Loss of liver dullness: gastrointestinal perforation
Dullness : free fluid , full bladder
Shifting dullness : free fluid

37. Auscultation NR Bowel sounds 5-30/min > 2min to confirm absent
High pitched, hyperactive or tinkling
caused by powerful peristaltic action , partial obstruction , abdominal cramping
Hypoactive bowel sounds
indicates Peritonitis , non-mechanical obstruction , Inflammation , gangrene
Bruit in epigastrium indicates AAA 37

38. Systemic Examination PR Examination: Tenderness Induration Mass
Frank blood 38

39. Systemic Examination PV Examination Bleeding Discharge
Cervical motion tenderness
Adnexal masses or tenderness
Uterine Size or Contour 39

40. Investigations Beware of misleading by investigations Blood tests
CBC (Hb & WBC) & U&E
Amylase (Pancreatitis) but remember 20% have NR values
LFTs
CRP & ESR (inflammatory markers)
ABG
Serum calcium (Abnormal GI motility PU, Pancreatitis)
Clotting (acute pancreatitis, sepsis, DIC, liver disease)
Blood glucose
ECG 40

41. CBC has a limited clinical utility
Attention to the WBC as a screening test only if substantially elevated.
25% of patients with elevated WBC do not have different outcomes from those with a normal WBC.
CBC has a limited clinical utility
In RLQ pain to rule in or rule out Acute Appendicitis
wbc count (n>70%)
< 8, very unlikely
8,000-10, unlikely
10, equivocal
12,000-15,000 suggestive
15,000-20,000 highly suggestive
>20, probably ruptured 41

43. B. Urinalysis Cheap Simple & available test
High yield when results fit with the clinical scenario
Pregnancy test 43

44. C. Radiology Erect CXR Supine AXR USS IVU (renal/ureteric colic)
Biliary trees , Mass , fluid , Retroperitoneal organs
Ultrasound in Acute Appendicitis +!?
IVU (renal/ureteric colic)
CT scan
Similar benefit as in U/S but
more time consumed , more accurate
more expensive
more risk
Causes of free sub-diaphragmatic gas
Perforation of viscus
Gas-forming infection
Pleuroperitoneal fisula
Iatrogenic
Interposition of bowel b/t liver & diaphragm 44

45. Plain X-rays have limited utility in the evaluation of AAP
Low diagnostic yield
High incidence of misleading incidental findings
Lack of impact on management
Exception: Bowel obstruction or perforation 45

46. Labs & Imaging Test Reason Test Reason CBC w diff ABG Amylase LFT UA
Left shift can be very telling
ABG
N/V, acidosis, dehydration
Amylase
Pancreatitis, perf DU, bowel ischemia
LFT
Jaundice,
hepatitis UA
GU- UTI, stone, hematuria
Beta-hCG
Ectopic
Test
Reason
KUB
Flat & Upright
SBO/LBO, free air, stones
Ultrasound
Chol’y, jaundice
GYN pathology
CT scan
Diagnostic
accuracy
Anatomic dx
Case not straight forward

47. Findings in plain X-ray abdomen
in case of Biliary disease :
radioopaque shadow for stone
pneumobilia
calcification of porcelain gallbladder
In case of pancreatic disease :
calcification in chronic pancreatitis
sentinel loop : dilatation of a segment of large or small intestine, indicative of localised ileus from nearby inflammation.
In case of appendicitis:
Fecalith: a hard stony mass of feces
Phlebolith : is a small local, usually rounded, calcification within a vein
Abscent of psoas muscle shadow

48. calcification of porcelain gallbladder

49. Pneumoperitoneum

50. Intestinal obstruction
Findings in plain X-ray abdomen
Intestinal obstruction
SBO
Erect
(air fluid level)
Step ladder
Central
Small
multiple
Supine
(dilatation of bowel)
>3cm
plicae circulares
LBO
Peripheral
Large
Few
> 5cm in sigmoid
> 10 cm in cecum
Peripheral haustration

53. ultrasound . Hepatobiliray tree(stones,mass,thickining of the wall)
*pancreases
*kidney
*pelvic organ
*intrabdominal fluid collection

54. Gall stone\ appendicolith

55. CT scan .
Helpful in case of abdominal pain without clear etiology better in evaluation of abdominal aortic aneurysm.
5.helical CT_scan
Provide rapid cost effective diagnostic tool.

56. CT scan
What is the diagnosis?
Acute appendicitis

57. Acute pancreatitis

58. D. Laparoscopy Early diagnostic laparoscopy may result in:
accurate,
prompt,
efficient management of AAP
Reduces the rate of unnecessary laparotomy
Increases the diagnostic accuracy
May be a key to solving the diagnostic dilemma of NSAP. 58

64. Immediate Treatment of the Acute Abdomen
Start large bore IV with either saline or lactated Ringer’s solution
IV pain medication
Nasogastric tube if vomiting or concerned about obstruction.
Foley catheter to follow hydration status and to obtain urinalysis.
Antibiotic administration if suspicious of inflammation or perforation.
Definitive therapy or procedure will vary with diagnosis.
Reassess patient on a regular basis.
لانسى عبارة لا تعتمدعلى تشخيص اللي قبلك 64

65. Decision to operate Tenderness w/ rebound, involuntary guarding
Proper management requires a timely decision about the need for surgical operation.
Peritonitis
Tenderness w/ rebound, involuntary guarding
Severe / unrelenting pain
“Unstable” (hemodynamically, or septic)
Tachycardic, hypotensive, white count
Intestinal ischemia, including strangulation
Pneumoperitoneum
Complete or “high grade” obstruction

66. Appendicitis +/- perforation Diverticulitis +/- perforation
Take Home Massage
Careful history (pain, other GI symptoms)
Remember DDx in broad categories
Narrow DDx based on hx, exam, labs, imaging
Always perform ABC, Resuscitate before Dx
If patient’s sick or “toxic”, get to OR (surgical emergency)
Ideally, resuscitate patients before going to the OR
Don’t forget GYN/medical causes, special situations
For acute abdomen, think of these commonly (below)
Perf DU
Appendicitis +/- perforation
Diverticulitis +/- perforation
Bowel obstruction
Cholecystitis
Ischemic or perf bowel
Ruptured aneurysm
Acute pancreatitis