Acute Abdomen
Content
Acute Abdomen YIN Detao MD Department of General Surgery, the First Affiliated Hospital of ZhengZhou University
Term TheThe termterm acute \ue000 acuteabdomen abdomendenotes denotesany any
sudden nontraumatic disorder whose chief manifestation is in the abdomina area and for which urgent operation may be necessary.
The approach to a patient with acute abdomen must be orderly and thorough. Acute abdomen must be suspected even if the patient has only mild or atypical complaints. The history and physical examination should suggest the probable causes and guide the choice of diagnostic studies.
HISTORY . . HISTORY (
). Abdominal Pain Abdominal Pain
Pain is is usually Pain usually the thepredominant predominantand and presenting feature of acute abdomen.
1. Location of Pain:
Visceral pain pain is distention, Visceral is elicited elicitedeither eitherbyby distention, inflammation, or ischemia stimulating the receptor neurons or by direct involvement of sensory nerves. The centrally centrally perceived generally slow The perceived sensation sensationis is generally slo onset, dull, poorly localized, and protracted. Parieta pain is responsible for the transmission of more acute, sharper, better-localized pain sensation. So parietal parietal pain easily localized thanthan viscera So pain isismore more easily localized vi pain.
Abdomen pain pain may or or may Abdomen maybe bereferred referred shift to sites far removed from the primarily affected organs.
The term termreferred paindenotes referred pain denotes The noxious sensations perceived at a site distant from the site of a strong prima stimulus.
Pain may may be thethe shoulder Pain bereferred referredtoto shoulde from lesions such as pleurisy or basal pneumonia, especially in young patients. Although more more often Although often perceived perceivedinintheth right scapular region, referred biliary pain may mimic angina pectoris if it is felt in the epigastric or left shoulder areas.
Spreading or or shifting Spreading shifting pain pain parallels parallelsth course of the underlying condition. Beginning classically classically in Beginning in the theepigastric epigastric or periumbilical region, the incipient visceral pain of acute appendicitis late shift to become sharper parietal pain i the right lower quadrant.
The location location of only as as The of pain painserves serves only rough guide to the diagnosis and typical descriptions are reported in on two-thirds of cases.
2.Mode of onset and progression of pain:
The mode mode of pain reflects the The ofonset onsetof of pain reflects nature and severity of the inciting process. Onset may be explosive (within seconds), rapidly progressive (within1-2 hours), or gradual (over several hours).
less dramatic AA less dramatic clinical clinicalpicture pictureis is steady mild pain becoming intensely centered in a well-defined area within 1-2 hours, especially in acute cholecystitis, acute pancreatitis, strangulated bowel, renal or ureteral colic, etc.
3. Character of pain:
The nature, nature, severity, of The severity,and andperiodicity periodicity pain provide useful clues to the underlying cause. Steady pain pain is Steady is most mostcommon. common.
Agonizing pain pain denotes Agonizing denotes serious seriousororadvanced advanc disease. Colicky pain is usually promptly alleviated by analgesics. Nonspecific abdominal abdominal pain Nonspecific pain isisusually usuallymild, mild but mild pain may also be found with perforated ulcers or mild acute pancreatitis Past episodes episodes of factors thatthat Past ofpain painand and factors aggravate or relieve pain should be noted.
( ). Other symptoms Other symptoms associated with abdominal pain
1.
Vomiting:
Pain in in acute Pain acute surgical surgicalabdomen abdomenusually usually precedes vomiting;in medical conditions the reverse is true.
Severe incontrollable incontrollable retching Severe retching provides provides temporary pain relief a moderate attacks of pancreatitis. The absence of bile in th vomitus is a feature of pyloric stenosis.
2.
Constipation:
Constipation itself itself is Constipation is hardly hardlyan anabsolute absolu indicator of intestinal obstruction. However, obstipation obstipation strongly However, strongly suggests suggest mechanical bowel obstruction if there i progressive painful abdominal distentio or repeated vomiting.
3.
Diarrhea:
Blood-stained diarrhea diarrhea suggests Blood-stained suggests ulcerative colitis, crohn’s disease, or bacillary or amebic dysentery.
4.
Specific symptoms Specific gastrointestinal gastrointestinal symptoms
These are are extremely present. These extremely helpful helpfulif if present Jaundice suggests hepatobiliary disorders; hematuria, ureteral colic or cysititis.
( ). Other relevant Other relevant aspects of history
1.
Menstrual history:
The menstrual history is crucial diagnosis of ectopic pregnancy endometriosis.
a
2.
Drug history:
The drug drug history only The history isisimportant importantnot not on in perioperative management but also because it may offer a diagnostic clue.
3.
Family history:
The family family history The history often oftenprovides providesthethe best information about medical causes of acute abdomen.
4.
Travel history:
AA travel raise the the travelhistory historymay may raise possibility of amebic liver abscess, malarial spleen, tuberculosis, etc.
examination Physical examination . . Physical
1.
General observation:
General observation observation affords General affords aafairly fairly reliable indication of the severity of th clinical situation.
2.
Systemic signs:
Systemic signs signs usually Systemic usually accompany accompany rapidly progressive or advanced disorders associated with acute abdomen. Extreme pallor, pallor, tachycardia, Extreme tachycardia, tachypnea, and sweating suggest major intra-abdominal hemorrhage.
3.
Fever:
Low-grade fever fever is Low-grade is common commoninin inflammatory conditions such as acute cholecystitis, and appendicitis.
High fever fever with High with lower lowerabdominal abdominal tenderness in a young woman without signs of systemic illness suggests acute salpingitis.
4.
Examination of abdomen
Inspection of of abdomen: Inspection abdomen:
The abdomen should be carefully inspected before palpation.
Auscultation of of abdomen: Auscultation abdomen:
Auscultation of the abdomen should also precede palpation. An abdomen that is silent except for infrequent tink or squeaky sounds marks late bowel obstruction or diffuse peritonitis.
Percussion of of abdomen: Percussion abdomen: With a perforated viscus, free air accumulating under the diaphragm may efface normal liver dullness.
Palpation of of abdomen: Palpation abdomen:
Palpation is performed with the patient resting in a comfortable supine position. position If there is voluntary spasm, the muscle will be felt to relax when the patient inhales deeply through the mouth.
Tenderness that that connotes Tenderness connotes localized localizedperitonea peritone inflammation is perhaps the most important finding in patients with acute abdomen. Compared with with the pain, Compared the degree degreeofof pain, unexpectedly little and only poorly localized tenderness is elicited in uncomplicated hollo viscus obstruction.
5.
Abdominal masses
Abdominal masses are usually detected by deep palpation.
Superficial lesions lesions such distended Superficial such as asa a distende gallbladder or appendiceal abscess are often tender and have discrete borders. Deeper masses masses may adherent to the Deeper maybebe adherent to posterior or lateral abdominal wall. As a a result, areare ill-defined, As result, their theirborders borders ill-defin and only dull pain may be elicited by palpation.
Diagnostic imaging . Diagnosticimaging
The role role of thethe The of the theradiologist radiologistin in evaluation of the patient with an acute abdomen has evolved greatly in the past decade. Moreover, CT CT and Moreover, and ultrasonography ultrasonography play an increasing role in the evaluation of this complex, emergent clinical problem.
Treatment . Treatment
1. Nonoperative treatment: General supportive supportive therapy; General therapy; Antibiotics. Antibiotics.
2.
Operative treatment:
If the nonoperative treatment is inefficient, then we need operation.
Term TheThe termterm acute \ue000 acuteabdomen abdomendenotes denotesany any
sudden nontraumatic disorder whose chief manifestation is in the abdomina area and for which urgent operation may be necessary.
The approach to a patient with acute abdomen must be orderly and thorough. Acute abdomen must be suspected even if the patient has only mild or atypical complaints. The history and physical examination should suggest the probable causes and guide the choice of diagnostic studies.
HISTORY . . HISTORY (
). Abdominal Pain Abdominal Pain
Pain is is usually Pain usually the thepredominant predominantand and presenting feature of acute abdomen.
1. Location of Pain:
Visceral pain pain is distention, Visceral is elicited elicitedeither eitherbyby distention, inflammation, or ischemia stimulating the receptor neurons or by direct involvement of sensory nerves. The centrally centrally perceived generally slow The perceived sensation sensationis is generally slo onset, dull, poorly localized, and protracted. Parieta pain is responsible for the transmission of more acute, sharper, better-localized pain sensation. So parietal parietal pain easily localized thanthan viscera So pain isismore more easily localized vi pain.
Abdomen pain pain may or or may Abdomen maybe bereferred referred shift to sites far removed from the primarily affected organs.
The term termreferred paindenotes referred pain denotes The noxious sensations perceived at a site distant from the site of a strong prima stimulus.
Pain may may be thethe shoulder Pain bereferred referredtoto shoulde from lesions such as pleurisy or basal pneumonia, especially in young patients. Although more more often Although often perceived perceivedinintheth right scapular region, referred biliary pain may mimic angina pectoris if it is felt in the epigastric or left shoulder areas.
Spreading or or shifting Spreading shifting pain pain parallels parallelsth course of the underlying condition. Beginning classically classically in Beginning in the theepigastric epigastric or periumbilical region, the incipient visceral pain of acute appendicitis late shift to become sharper parietal pain i the right lower quadrant.
The location location of only as as The of pain painserves serves only rough guide to the diagnosis and typical descriptions are reported in on two-thirds of cases.
2.Mode of onset and progression of pain:
The mode mode of pain reflects the The ofonset onsetof of pain reflects nature and severity of the inciting process. Onset may be explosive (within seconds), rapidly progressive (within1-2 hours), or gradual (over several hours).
less dramatic AA less dramatic clinical clinicalpicture pictureis is steady mild pain becoming intensely centered in a well-defined area within 1-2 hours, especially in acute cholecystitis, acute pancreatitis, strangulated bowel, renal or ureteral colic, etc.
3. Character of pain:
The nature, nature, severity, of The severity,and andperiodicity periodicity pain provide useful clues to the underlying cause. Steady pain pain is Steady is most mostcommon. common.
Agonizing pain pain denotes Agonizing denotes serious seriousororadvanced advanc disease. Colicky pain is usually promptly alleviated by analgesics. Nonspecific abdominal abdominal pain Nonspecific pain isisusually usuallymild, mild but mild pain may also be found with perforated ulcers or mild acute pancreatitis Past episodes episodes of factors thatthat Past ofpain painand and factors aggravate or relieve pain should be noted.
( ). Other symptoms Other symptoms associated with abdominal pain
1.
Vomiting:
Pain in in acute Pain acute surgical surgicalabdomen abdomenusually usually precedes vomiting;in medical conditions the reverse is true.
Severe incontrollable incontrollable retching Severe retching provides provides temporary pain relief a moderate attacks of pancreatitis. The absence of bile in th vomitus is a feature of pyloric stenosis.
2.
Constipation:
Constipation itself itself is Constipation is hardly hardlyan anabsolute absolu indicator of intestinal obstruction. However, obstipation obstipation strongly However, strongly suggests suggest mechanical bowel obstruction if there i progressive painful abdominal distentio or repeated vomiting.
3.
Diarrhea:
Blood-stained diarrhea diarrhea suggests Blood-stained suggests ulcerative colitis, crohn’s disease, or bacillary or amebic dysentery.
4.
Specific symptoms Specific gastrointestinal gastrointestinal symptoms
These are are extremely present. These extremely helpful helpfulif if present Jaundice suggests hepatobiliary disorders; hematuria, ureteral colic or cysititis.
( ). Other relevant Other relevant aspects of history
1.
Menstrual history:
The menstrual history is crucial diagnosis of ectopic pregnancy endometriosis.
a
2.
Drug history:
The drug drug history only The history isisimportant importantnot not on in perioperative management but also because it may offer a diagnostic clue.
3.
Family history:
The family family history The history often oftenprovides providesthethe best information about medical causes of acute abdomen.
4.
Travel history:
AA travel raise the the travelhistory historymay may raise possibility of amebic liver abscess, malarial spleen, tuberculosis, etc.
examination Physical examination . . Physical
1.
General observation:
General observation observation affords General affords aafairly fairly reliable indication of the severity of th clinical situation.
2.
Systemic signs:
Systemic signs signs usually Systemic usually accompany accompany rapidly progressive or advanced disorders associated with acute abdomen. Extreme pallor, pallor, tachycardia, Extreme tachycardia, tachypnea, and sweating suggest major intra-abdominal hemorrhage.
3.
Fever:
Low-grade fever fever is Low-grade is common commoninin inflammatory conditions such as acute cholecystitis, and appendicitis.
High fever fever with High with lower lowerabdominal abdominal tenderness in a young woman without signs of systemic illness suggests acute salpingitis.
4.
Examination of abdomen
Inspection of of abdomen: Inspection abdomen:
The abdomen should be carefully inspected before palpation.
Auscultation of of abdomen: Auscultation abdomen:
Auscultation of the abdomen should also precede palpation. An abdomen that is silent except for infrequent tink or squeaky sounds marks late bowel obstruction or diffuse peritonitis.
Percussion of of abdomen: Percussion abdomen: With a perforated viscus, free air accumulating under the diaphragm may efface normal liver dullness.
Palpation of of abdomen: Palpation abdomen:
Palpation is performed with the patient resting in a comfortable supine position. position If there is voluntary spasm, the muscle will be felt to relax when the patient inhales deeply through the mouth.
Tenderness that that connotes Tenderness connotes localized localizedperitonea peritone inflammation is perhaps the most important finding in patients with acute abdomen. Compared with with the pain, Compared the degree degreeofof pain, unexpectedly little and only poorly localized tenderness is elicited in uncomplicated hollo viscus obstruction.
5.
Abdominal masses
Abdominal masses are usually detected by deep palpation.
Superficial lesions lesions such distended Superficial such as asa a distende gallbladder or appendiceal abscess are often tender and have discrete borders. Deeper masses masses may adherent to the Deeper maybebe adherent to posterior or lateral abdominal wall. As a a result, areare ill-defined, As result, their theirborders borders ill-defin and only dull pain may be elicited by palpation.
Diagnostic imaging . Diagnosticimaging
The role role of thethe The of the theradiologist radiologistin in evaluation of the patient with an acute abdomen has evolved greatly in the past decade. Moreover, CT CT and Moreover, and ultrasonography ultrasonography play an increasing role in the evaluation of this complex, emergent clinical problem.
Treatment . Treatment
1. Nonoperative treatment: General supportive supportive therapy; General therapy; Antibiotics. Antibiotics.
2.
Operative treatment:
If the nonoperative treatment is inefficient, then we need operation.
