| What is acute abdomen? | ● Acute abdominal pain is a sudden, spontaneous, non-traumatic, severe
abdominal pain, with less than 24 hours of onset before the presentation
of the patient to the ER. It’s the most frequent cause of presentation of
patients to the ER.
● The delay in the diagnosis and management (treatment): ↑ increases the
morbidity and mortality.
● Atypical presentation of abdominal pain in:
- Elderly: either they don’t feel properly the pain, or it could be a shifting
of the pain, or redundant intestines (they aren’t in their normal
position), with a possible history of surgery.
- Immunocompromised: they don’t feel properly the pain
- Pregnant women
- Obese patients
- Patients with previous surgery: change in the anatomy of the abdomen
- Diabetic patients |
| What is difference between acute abdoment and surgical abdomen? | Acute abdomen is not always surgical abdomen (needs surgery) |
| What is the visceral pain of acute abdomen? | V Mediated by afferent C fibers within the wall of hollow organs (intestine, colon, common bile duct…) and capsule of solid organs (liver, spleen, pancreas…).
● Elicited by: distention, inflammation, ischemia, contraction of smooth muscles (colic) or by direct involvement of sensory nerves.
● This pain is slow in onset, centrally perceived sensation, diffuse, poorly localized and protracted.
Stimulation of C fibers → signals to the medullary center of pain →sensation of pain. |
| How is visceral pain? | This pain is diffuse because of 2 reasons:
- Multiple organs will be innervated by the same C fibers, so the medullary center will not be able to well localize the pain.
- Bilateral sensory supply to the spinal cord by these fibers → pain not well localized.
o There are 2 explanations for this process:
In embryology, the abdominal buds of multiple organs are covered by the visceral peritoneum and the parietal peritoneum.
⮚ The visceral peritoneum is in contact with the organs (colon, liver, etc.).
⮚ The parietal peritoneum covers the abdominal wall.
Hence, the visceral peritoneum covering the organs originating from the same bud is the reason why they’re innervated by the same nerve: the liver, the colon, the spleen and other organs could all refer to one nerve in the CNS
Visceral fibers come from the cervical spine to S4 (very extensive), which is why pain is less localized and more confusing. |
| What is parietal pain in acute abdomen? | ● With parietal peritoneum, the pain is more localized; the innervation
involves only one side.
● In parietal pain, we have 2 types of fibers involved: C-fibers and A-delta
fibers.
● Parietal innervation is ensured by roots T6 to L1 |
| What is referred pain in acute abdomen? | Pain distant from site of affected organ.
E.g. patient feels pain from his cardiac infarct in his abdomen; other thoracic pain etiologies: pneumonia, pleurisy, pleural effusion, all could cause abdominal pain.
● Distorted central perception of the site of pain due to confluence of afferent fibers from disparate areas in the posterior horn of the spinal cord.
● Pain starts as a vague visceral pain and later on becomes more localized. That is due to the inflammation reaching the parietal peritoneum; the patient then becomes more able to pin-point the site of the organ.
E.g. In appendicitis, pain starts as peri-umbilical or epigastric when it is still visceral, and later on becomes more localized at the right iliac fossa at McBurney’s point due to irritation of the parietal peritoneum at that level. |
| What are sensory levels associated w/ visceral structures? | . |
| How is abdominal cavity divided? | ❖Abdominal cavity divisions:
The abdominal cavity is
divided into 4 regions:
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
And 3 regions in the middle:
- Epigastric region
- Umbilical or central region
- Hypogastric region |
| What is SOCRATES description of pain? | - S: Site of onset of the pain
- O: Onset of the pain
- C: Character of pain
- R: Irradiation
E.g. a patient with umbilical pain extending to his back ? think pancreatitis.
- A: Associated symptoms and signs (Nausea, vomiting, fever, diarrhea)
- T: Time
Duration for which the pain persisted (minutes, hours, or more)
- E: Exacerbating and relieving factors
E.g. a patient presenting with acute abdominal pain; flexion forward relieves it ? think pancreatitis.
E.g. Patient present for long-term abdominal pain that is relieved by eating ? think peptic ulcer.
- S: Severity on a scale of 1 to 10 |
| How is mode of onset and progression of abdominal pain assessed? | ● How did it start (and where) reflects the nature and severity of the
underlying process:
- Strong, mild then increasing with time, etc.
- Whether for seconds or minutes or hours.
● Explosive (seconds), rapidly progressive (1-2hrs), gradual (4-6hrs)
● Unheralded (not expected)
● Excruciating generalized pain suggests intra-abdominal catastrophe. |
| What is differential of a pain : lasts seconds then disappears, starts explosive and increases with time (gunshot), pain increasing and more localized right hypochondrium/right iliac fossa, pain started 5-6 hours ago increasing intenstiy and pain like shi 3m yt5zz3? | seconds then disappear: colic
Explosive increase with time like gunshot: intestinal/duodenal/gastric perforation
increasing becoming in right iliac fossa: appendicitis/cholecystitis
pain started 5-5 hours ago: occlusion
5azze2: aortic aneurysm rupture |
| How are characters of pain described and their differential? | ● Aching discomfort: "eende shi aam ydeye2ne aa beb l me3de", epigastric malaise, abdominal malaise ? think of ulcer pain.
● Stabbing breathing pain: "Bhes shi la2etne aa beb me3dte ate3le nafase" ? acute pancreatitis or mesenteric ischemia.
● Gripping mounting pain: "ken waja3 khafif w aam yzid" ? think bowel obstruction.
● Tearing pain: "shi aam ykhaze2ne w heses hale aam mout" ? (acute) aortic aneurysm rupture
Agnoizing pain: 3m ymawwetne, peritonitis serious
Ischemic pain: mesenteric ischemia/infarction
Gas stoppage sign: cant pass gas if he passes he relieves, intestinal occlusion/ ileus |
| How is vomiting associated with abdominal pain? | ● Stimulation of afferant C fibers which go all the way to the vomitingcenters of the medulla and from there the efferent fibers innervate theintestine, causing a decrease in peristalsis which causes ileus or aggravation of peristaltis which causes vomiting.
● The pain of acute surgical abdomen mainly precedes vomiting, so patients feel acute pain followed by nausea and vomiting. However, in medical causes (non-abdominal), patients feel nausea and they vomit before the pain.
● We also need to check for blood in vomit which can be caused by a high digestive hemorrhage due to ulcers or esophageal varices (because of liver cirrhosis)...
● Check for bile as well: If no bile then we need to think of pyloric stenosis or gastric outlet obstruction or occlusion of biliary duct |
| What causes occlusion of biliary duct? | ► From gallstones closing the duct and this usually comes with severe acute pain, nausea, fever, and vomiting with no bile in vomit ? think angiocholitis, there’s something obstructing the liver ducts.
► Chronic abdominal pain with weight loss and vomiting without bile in vomiting ? think periampullary tumor, tumor obstructing the common bile duct or the pancreatic duct |
| 25 years old patient with acute very severe pain in the umbilical or periumbilical or epigastric region, ballash mthl darbit sikeen, then the pain shifts to the right iliac fossa and after several hours he develops abdominal guarding | (Could be appendicitis or) Valentino syndrome (rare): gastric or duodenal peptic ulcer perforation, so the gastric juice will go to right iliac fossa and causes pain. |
| What are types of bowel obstruction? | - Proximal occlusion: repeated vomiting (kteer 2rab mn ba3don l2n ma fi wa2t yjam3o), very small quantity which at first contains bile then becomes “mthl l ra8we”.
- Distal occlusion: (e.g. in ilium or in colon) scattered (spaced) vomiting (b3ad 3n ba3don) with large quantity and it may have a fecaloid smell |
| How is constipation associated w/abdominal pain? | ● Every inflammatory reaction in the abdomen can provoke reflex ileus: sympathetic ANS (splanchnic nerves) stimulate efferent fibers to reduce peristalsis and provoke ileus and hypoperistalsis can be detect it by auscultation ? seen in generalized or localized peritonitis.
● Obstipation: complete inability to pass gas or stools ? think mechanical obstruction: tumor, strangulation… |
| How is diarrhea associated w/abdominal pain? | Watery diarrhea ? gastroenteritis.
● Blood stained diarrhea ? IBD, dysentery, ischemic colitis, intestinal infarction, bacillary infection.
⮚ Bloody with mucus (glairosanguinolante) ? inflammatory bowel disease (IBD),
⮚ Bloody associated with fever and pain ? dysentery,
⮚ Bloody ? ischemic colitis or intestinal infarction,
⮚ Bloody with mucus ? pseudomembranous colitis (inflammation of the large intestine due to an overgrowth of Clostridioides difficile bacteria; this infection is a common cause of diarrhea after a prolonged antibiotic usage), we have a risk of intestinal perforation |
| How is significant weight loss associated w/abdominal pain? | ⮚ Without pain ? think of cancer.
⮚ With pain (postprandial pain, 1-2 hours after eating) ? think of:
- Stone (usually 1 hour postprandial),
- Hepatic insufficiency,
- Pancreatic insufficiency (in the absence of exocrine secretions),
- Mesenteric vascular insufficiency, mainly in elderly (in the
presence of vascular stenosis, when the chyme reaches the
intestine in order to be digested, the pain crisis begins and lasts 1-2 hours until the end of digestion; in some cases, diarrhea can occur due to the maldigestion of food). |
| Where does pt w/mesenteric vascular insuffeciency feel pain? | In general, he feels a pain in all the abdomen, especially an
epigastric and central pain. This condition affects mainly people with cardiac problems, atherosclerosis, old age and also the smokers |
| How is jaundice associated w/abdominal pain? | If the jaundice is associated with pain and fever ? we must think about:
- Infectious hepatitis,
- Cholangitis or angiocholitis: an inflammation of the common bile duct due to an obstruction by calculi that originate from the gallbladder.
These calculi can’t cross the ampulla of Vater (they can’t go to the duodenum), but they can go to the pancreas causing pancreatitis |
| How is hematochezia associated w/abdominal pain? | ⮚ It is rectorrhagia where there is passage of fresh blood through the anus.
⮚ It could be mild or severe:
- If it is mild ? it could be due to hemorrhoids, rectal ulcer, or inflammatory bowel disease.
- If it is more moderate and massive ? it could be due to
diverticulosis (where there is erosion of the artery in the
diverticula at the base of the colon causing this passage of fresh blood from anus).
- If it is severe (blood clot in the stools) ? it could be huge tumor, vascular ectasia (or telangiectasia), or a huge ulcer |
| How is hematemesis assocaited w/abdominal pain? | The causes of hematemesis ? think about:
- Esophageal ulcer,
- Peptic ulcer disease in the stomach or duodenum,
- Esophageal varices due to liver cirrhosis (upper gastrointestinal bleeding) |
| A patient comes with an acute abdominal pain and states that
during the last 24 hours, he vomited several times. In the beginning, his vomiting included gastro-duodenal secretions, but, in the last 2 times, he vomited blood. What is the diagnosis? | ? Mallory-Weiss syndrome (MWS). It is characterized by ulcerations of the lower esophagus leading to hematemesis. It is caused by a long-term and forceful multiple vomiting, which tears and lacerates the mucosa of the lower esophagus (post vomiting causing esophageal and upper GI tract ulcers) |
| If a patient had been vomiting and had severe epigastric pain and then (7ass mthl shi fa23 bi baton) suffered from acute abdominal pain along with severe dyspnea and desaturation (had drop in oxygen).What is the possible diagnosis? | ? Boerhaave syndrome (it is esophageal perforation post vomiting,rupture of the esophagus causing mediastinitis).
Note: aortic aneurysm can cause similar symptoms but in addition it causes hypotension, tachycardia, tachyarrhythmia, and pallor. |
| How are melena blood clots associated w/abdominal pain? | ● Melena blood clots:
⮚ There is passage of black blood, and not fresh blood, from the anus.
⮚ The acid of the stomach causes the metabolism of the hemoglobin in the blood (only the heme remains), thus making it melena. |
| What is Treitz ligament? | . |
| How is past medical hx taken for acute abdomen? | If the patient has cardiac problems and:
- He is taking anticoagulants or antiplatelet ? he has a greater risk to have hemorrhage in the stomach.
- He is taking anti-arrhythmias ? these increase the risk of having emboli in the stomach (mesenteric emboli and ischemia).
● If the patient has respiratory problems and he is taking corticoids or anti-inflammatory drugs ? he has a greater risk to develop peptic ulcers.
● If the patient has liver problems ? he may have esophageal or abdominal varices, collateral circulation, or caput medusa.
● If the patient is having chemotherapy ? this lowers the platelets (more risk to have hemorrhage) and the leukocytes (more risk to have primaryor secondary peritonitis) |
| How is past surgical hx taken in acute abdomen? | ● Due to a previous surgery or even laparoscopy ? the patient may have more risk of intestinal adherence and occlusion.
● If the patient had endovascular surgeriesfor cardiac or abdominal stent placement ? he may have a risk of mesenteric ischemia |
| How is OBGYN hx in acute abdomen? | ● For those who are sexually active or in age of pregnancy ? we investigate for sexual reactive disease.
● If she has ovarian cysts we have to ask about pain onset: did she experience pain before? Or is it the first time? Or is this pain associated with the monthly cycle? ? Mittelschmerz syndrome: acute abdominal or pelvic pain at the time of ovulation due to rupture of follicle.
● We also look for menstrual delay. |
| Case: Female admitted to ER with menstrual delay, acute abdominal pain with hypotension. | ? Ectopic pregnancy rupture. Recommended test is beta HCG to confirm pregnancy. BUT if the female is admitted after more than 24 hours of pregnancy, the fetus has already died, so beta HCG will be negative but still ectopic pregnancy should be included in our differential. |
| How is medication, travel and family hx in acute abdomen? | 4. Medication History:
If the patient is taking anticoagulants, chemotherapy…
5. Family History:
If the patient has family history of:
- Cancer
- Mediterranean fever (repetitive episodes of acute abdominal pain)
6. Travel History:
● Take travel history for the past 3 months.
● Travel history could be an indication of amebic infection, hydatid cysts,
malaria, TB, salmonella. |
| Case: Patient with severe abdominal pain in the left hypochondrium, hypotension, tachycardia and a travel history to Africa 3 months ago. What is you diagnosis? | ? Spontaneous splenic rupture due to malaria (spontaneous splenic rupture also can happen due to mononucleosis (AIDS patients)). |
| How is abdominal trauma hx? | ● Ask for abdominal trauma history 1 month ago.
● If the patient had abdominal trauma ? risk of delayed splenic rupture (laceration of spleen); some patients would have splenic rupture even after 2 months following an abdominal trauma |
| How is physical exam of acute abdomen? | ● It should always be a complete physical examination: from head to toes.
● Physical exam of the abdomen in supine position.
● Always end the physical exam with rectal touch = digital rectal exam (DRE) because there are many anal or rectal etiologies leading to acute abdominal pain.
We should inspect the general status of the patient (calm, agitated, disoriented.
pain moving this is peritonitis if agitated w/tachy then sepsis
● Vital signs should be investigated: blood pressure, pulse, temperature…
● Fever:- Constant low grade fever ? inflammatory condition.
- High grade fever ? infection of ducts. |
| Case: Fever 38-38.5 with onset of pain 5-6 hours ago: epigastric or para-umbilical pain then right hypochondrial pain | Cholecystitis |
| Case: If there is 38 fever with right hypochondrial pain and after 48 hours the fever raises to 39-40 | ? think about complication for cholecystitis:
gangrenous cholecystitis with fistula or peritonitis or other thing
Note: Pancreatitis usually causes no fever unless it’s complicated withabscess.
Note: hepatitis usually causes fever higher than 38.5, usually above 39.
Note: When temperature rises above 39-40 we have to think about a more complicated state like peritonitis, sepsis… |
| Why do we auscultate abdomen before palpation? | We do auscultation to hear peristalsis (bowel movement). If we do auscultation and the patient has ileus, we won’t hear the bowel movement; however, if we palpate first we may mobilize the liquid and the gas present in the intestine and they produce sound that it is heard as peristalsis leading to false diagnosis.
That is why we go step by step as mentioned previously. (Observation, Auscultation, Percussion, Palpation) |
| How is insepction in acute abdomen? | ► In inspection, we check if the patient did any surgery, if there is any umbilical hernia or hernia at site of incision, or any sign on abdominal wall: if there is collateral circulation or caput medusa, ballooned or not, scaphoid (l abdomen mfa5at la jowwa)…
► In inspection, we check the inguinal area: if there is “mass m5an2a ma 3am tfoot” ? we think of incarceration or strangulation of the hernia which is a common cause of acute abdomen |
| Case: If the patient has acute abdominal pain with ballooned abdomen and suddenly the inflation is released and the abdomen turned scaphoid | ? we think of perforation or if there is a descended hernia. |
| Case: If we look at the patient’s abdomen and we found ecchymosis and edema in the periumbilical region and ecchymosis in the lumbar region | ? pancreatitis where there is hemorrhage with necrosis of the pancreas that extend to the retroperitoneal area at the flank region (giving Grey Turner sign) and to the abdomen at the greater omentum (it also give ecchymosis).
Note: Ecchymosis = mthl wa7ad mekil darbe wbyazra2 jismo.
- Ecchymosis in the periumbilical region called Cullen sign.
- Ecchymosis in the lumbar region called Grey Turner sign. |
| How is auscultation in acute abdomen? | In auscultation, we need to check if bowel movement is present or not:
- In case of hyperperistalsis with acute abdominal pain ? think of a mechanical obstruction: tumor, internal hernia, strangulation...
- In case of bowel movement absence ? think of ileus: either due to a peritonitis or a medical cause (e.g. severe hypokalemia). |
| How is percussion in acute abdomen? | ► In percussion, check for dullness and tympanic sounds.
► In a normal abdomen:
- Feel dullness: above liver and at the spleen
- Feel tympanic sounds: in the remaining abdomen areas (contain gas). |
| Case: If have an acute distended abdomen with only tympanic sounds no dullness | � think of a perforation (leakage of gas into the
abdomen). |
| Case: If an old patient comes with an acute pain in the middle
Hypogastric region and below within the last 24 hours, rigid abdomen and complaining of a prostate problem (he is not able to urinate well) | think of urinary retention (treatment: urinary catheterization). |
| What are other exams done before abdominal palpation? | ● Inguinal rings and genitals:
- To check for hernias, ask the patient to stand up and do a valsalva maneuver: only then can detect a hernia.
- Check genital organs for necrosis, abscess… since, sometimes, a pelvic problem can be the cause of an acute abdominal pain.
● DRE (Digital Rectal Exam): to make sure no tumor or blood inside the rectum, or thrombotic hemorrhoids.
● Pelvic / Perineal examination: examine if there’s perianal abscess, thrombotic hemorrhoids, Maladie de Fournier - Fournier Gangrene:
necrosis of the perianal/genital area where there’s usually dissemination of the necrosis intra-abdominally (mortality rate 80-90%) (Treatment: wide-excision surgery). |
| How is palpabtion of acute abdoment? | ►Start by examining the least painful region before moving on to the most painful region.
►Start palpating using 2-3 fingers since some patients are more sensitive than others.
► Tenderness upon palpation should be specified: localized or diffuse, rebound tenderness or tenderness on palpating.
► Rebound tenderness is the tenderness that occurs upon sudden release of pressure (fingers of the physician) on the abdomen ? sign of irritation of the parietal peritoneum.
► Guarding: (abdominal guarding most likely needs surgery)
- Voluntary: abdominal muscles contract upon palpation.
- Involuntary: contraction present even before touching the abdomen ?sign of major inflammation inside the
abdomen (e.g. peritonitis) |
| Case: Patient having appendicitis: McBurney +,
Rovsing’s sign +, Psoas sign +, Obturator sign +, so
all the signs of an appendicitis are positive. But
upon doing blood tests and scan, we find out that
the patient is normal | Nevertheless, we should operate the appendicitis because, in this case, the diagnosis is clinical. In other words, even if the blood tests and imagery are negative, the case should be surgically treated ? acute appendicitis is a clinical diagnosis. |
| What are Mcburny and Rovsing's signs? | ► McBurney investigation: done at McBurney’s point in the right iliac fossa; junction between lateral one third and medial 2 thirds of the line joining ASIS with the umbilicus.
Deep palpation on this point ? positive indication for tenderness in case of appendicitis.
► Rovsing’s sign: rebound tenderness on deep palpation of left iliac fossa followed by sudden release of pressure ? deep pain is felt in right iliac fossa in case of appendicitis. |
| What is psoas sign? | . |
| What is obturator sign and murphy's sign? | ► Obturator sign: done with internal rotation of leg while flexion of thigh ? pain in case of appendicitis.
► Murphy’s sign: deep palpation of upper right hypochondrium with deep breath ? if patient can’t take a deep breath then it’s a positive sign for acute cholecystitis |
| What is Carnett's sign? | . |
| How is mesenteric ischemia and renal colic on PE of acute abdomen? | ► During physical exam, if patient complains of severe abdominal pain but no tenderness was detected (severe abdominal pain out of proportion of physical exam) ? think of mesenteric ischemia
► Renal colic:
- Renal colic + calculus can cause ileus, pain, distension.
- Renal colic causes abdominal contraction on its side, so only one side and not bilateral. So renal colic of left side get renal contraction at left side.
- Pain irradiates in renal colic, it starts in dorsal region and radiate to genital organs (testes) |
| What are Blood tests done in acute abdomen? | CBC (leukocytosis/penia/shifts)
Urea creatinine (renal function, contrast CI in renal failure)
Electrolytes (hypokalemia risk for ileus)
Glycemia (ketoacidosis)
LFT (hepatitis and obstruction)
Amylase Lipase (pancraetiits)
Procalcitonin (bacterial sepsis only)
Coagulation test (PT, PTT should be >60%)
Beta hCG (risk for ectopic pregnancy) |
| What are lab tests other than blood done in acute abdomen? | 2. Urinalysis:
It’s done if there’s:
- Infection,
- Calculus,
,رمل بالبول Oxalate -
- Acute pyelonephritis (very high WBC count with fever and acute abdominal pain).
3. Stool analysis |
| What is use of CXR in acute abdomen? | ● Simple radiology imaging done for any acute abdominal pain: chest X-ray upright position (while standing).
● If there’s pneumonia, pleural effusion, pericardial effusion all may cause acute abdominal pain on the same side.
● It is ordered upright to check if there’s free air under the diaphragm in the peritoneum. So diagnostic test of pneumoperitoneum, if we are searching for an intestinal perforation is chest x-ray upright not KUB upright because Chest X-ray upright shows diaphragm and the air accumulated under it.
Upright CXR is for perforation dx |
| Case: If a Patient comes with acute abdominal pain and we’re suspecting intestinal, duodenal or gastric perforation meaning that we are looking for pneumoperitoneum, and we asked for chest X-ray upright but we didn’t see free air under the diaphragm, what do we do next? | - Left lateral decubitus X-ray: We let the patient lie on his left side and we do an X-ray. It is on the left and not right side because if he lies on his right side the air of the stomach remains high so we don’t know if the air is from the stomach or peritoneum, while in the left position the air accumulates above the liver or intestine so it shows easily.
- If were also suspecting intestinal perforation and we did both chest X-ray upright and left lateral decubitus and free air didn’t appear, we can do scan to see free air (if there’s a scan because some hospitals don’t have one).
- If can’t do scan, we then do a test that assures us of whether we have perforation or not: We put an angi-tube (nasogastric tube)
NOTE endoscopy is CI |
| How is use of upright KUB in acute abdomen? | ● First test done to search for intestinal occlusion or ileus.
● KUB upright shows us air fluid level in the intestine if there is occlusion.
Note: air fluid level is a pattern that shows on x-ray due to both fluid and gas collection. Air rises above fluid and there’s a flat surface at the “air-fluid” interface.
● How do we know if the occlusion is in the small intestine or colon?
We do so by 3 markers:
a. In SI (small intestine) we have complete circular folds while in colon we have semi-circular folds (do not complete the circumference),
b. SI is in central region of abdomen while colon is in lateral region.
c. Air fluid level in SI is larger than high (more width than height) while it is the opposite for colon (higher than wide). |
| How can acute abdomen be fecalith? | Acute abdominal pain might be fecalith: feces are very hard, accumulate and cause obstruction of the lumen of the appendix and occlusions.
Other differential diagnosis: mesenteric adenitis in young: tonsillitis, adenitis, cervical ganglia and acute abdominal pain in the right iliac fossa. |
| How is use of abdominal US in acute abdomen? | ● For acute cholecystitis: shows us liver, spleen and kidneys.
● Appearance in ultrasound: thickening of the wall of gallbladder >1cm ingeneral or we see periparietal edema (behind the gallbladder between it and the liver). If there is air in the biliary tract: fistula with intestine.
If still nothing shows:
go for CT |
| How is CT in acute abdomen? | ● First asked without contrast to see the urinary tract (primarily): ureter and kidney, of if there is a mass or something like that.
● If we want to see if there is an abscess, inflammation, tumour… We ask for one with contrast, IV contrast (the contrast takes abscess form):
shows us if we have appendicitis with peri appendicular inflammation for example. If there is abscess the contrast takes the form of the abscess. Also shows tumor.
● We do scan with oral contrast if we suspect stenosis (some occlusion) or suspect perforation (contrast has to be hydrosoluble if not it might cause irritation of the peritoneum and lead to peritonitis). |
| How is CT angio in acute abdomen? | ● If there is suspicion of active bleeding (GI bleeding that we don't know where).
● Angiography or Angio-CT scan are at the same time:
- Diagnostic: to see if there is mesenteric thrombosis, emboli, or bleeding. If there is a place that is bleeding, we can close it or if there is stenosis, we can put a stent.
- Treatment: if there is a suspicion of bleeding and we want to do angiography or angio-CT scan or angio-MRI, keep in mind that we have to do it before we do a CT-scan with oral contrast because if we do a CT-scan with oral contrast, we will not be able to see anything with the angiography. (For example to see mesenteric ischemia) |
| How is use of GI contrasti X ray in acute abdomen? | replaced by CT contrast oral, sus of fistula or perforation or stenosis in small intestine
Drink contast then image 2-6 hours
Also could do barium enema (through rectum see colon sees tumor, fistula, perforation or diverticulitis |
| How is the use of radio-nuclide scan (scintigraphy)? | Liver-spleen scan (LFT)
HIDA-scan (cholecystitis, occlusion of cholecystits so gall bladder doesnt appear)
Tc sulfur colloid scan (in digestive hemorrhage)
Tc-pertechnitate scan (ectopic gastric mucosa, meckel's diverticulum) |
| What are endoscopic measures taken in acute abdomen? | 1. Gastroscopy:
In case of digestive hemorrhage. In the upper GI stenosis or occlusion in the stomach or duodenum, we do gastroscopy (in this case it is diagnostic+ if there is an ulcer with bleeding, we can treat it by cauterization by injection of adrenaline).
2. Lower GI Endoscopy (Proctosigmoidoscopy):
If there is a tumor in the rectum, we cannot see from above so this technique will give us a diagnosis if there is a tumor, ulcer… and at the same time if there is a sigmoid volvulus, it can make a reduction, so it will treat the sigmoid volvulus.
3. (ERCP):
We use it in 2 cases:
a. Angiocholitis that caused by a lithiasis inside the choledoch (common bile duct). The stone can’t pass so we do this to remove it.
b. Pancreatitis (caused by calculus) |
| How is use of paracenthesis in acute abdomen? | ● We draw fluid from inside the peritoneum using a needle. It’s rarely used, and usually done in the left iliac fossa at Rovsing’s point.
● In normal people, there are 20-50 cc of fluid in the peritoneum, and this fluid's role is lubrication to prevent friction in the intestine.
● This exam is done in case there's suspicion of perforation, hemorrhage, bile fistula...
● We get a +ve parancethesis if we get bile or blood mixed with the fluid.
● This exam is rarely done nowadays. |
| How is use of laparoscopy in acute abdomen? | See appendicitis or cholecystectomy |
| What are common causes of acute abdomen? | . |
| What are conditions w/diagnostic uncertainty? | ● Every person that comes with an acute abdominal pain of more than 6 hours ? we should rule out a surgical abdomen & the patient needs further investigation.
● Acute abdominal pain with uncertain diagnosis, and we have done everything and nothing showed ? we think about acute appendicitis (esp. retrocecal) or bowel obstruction (in case of Richter hernia or obturator hernia).
● In young women ? we think about PID, ovarian cyst rupture, ovarian torsion, salpingitis, or ectopic pregnancy.
● In case of Richter hernia (a part of the antimesenteric intestinal membrane enters the hernia and becomes incarcerated, this can cause strangulation, necrosis, perforation, and it doesn't show on exam due to absence of air fluid level), obturator hernia, proximal bowel obstruction, closed loop obstruction: absence of air fluid level.
● Elderly ? ischemia or cancer. |
| What are medical causes of acute abdomen? | a. Diabetic
b.Adrenal insufficiency
c. Purpura
d. Sickle cell crisis
e. MI
f. Narcotic withdrawal
g. Poisoning |
| How is periop management of acute abdomen? | We prepare the patient for surgery:
a. Give IV line,
b.Resuscitation perfusion,
c. Give analgesic (morphine, perfalgan, anti-inflammatory drugs),
d.Antibiotics (only if there are infectious causes),
e. NG tube (if there is intestinal occlusion or obstruction),
f. Foley catheter always (to see the diuresis of the patient). |
| What are indications for urgent surgery in acute abdomen? | A. Physical Findings:
a. Abdominal guarding and increasing rigidity
b. Localized tenderness with signs of peritonitis
c. Tender abdomen or rectal mass with high fever (there's an abscess)
d. Rectal bleeding with shock and acidosis
e. Septicemia with nothing showing , marked leukocytosis, mental changes,abdominal pain
f. Abdominal pain and bleeding (Hematocrit decreases)
g. Suspected ischemia (patient comes with abdominal pain and rectorrhagia)
h. Deterioration on conservative treatment |
| What are radio indications for urgent surgery? | a. Bowel distention with obstruction, if diameter of cecum is more than 10 cm, this is a bad prognosis with risk of perforation
b. Free extravasation of contrast inside the peritoneum
c. Space-occupying lesion on scan(bigmass) , with fever
d. Mesenteric occlusion on angiography (artery should be opened via laparotomy or else, mesenteric infarction will occur)
e. Pneumoperitoneum (free air inside the peritoneum)
C. Endoscopic findings:
Perforated or uncontrollable bleeding |
