Acute Abdomen Conditions Overview

Acute Abdomen

• A group of conditions that require emergency treatment and intervention.
• Peritonitis is the inflammation of the peritoneum, a membrane that lines the abdominal cavity.
• Causes include:
  • Inflammatory: Acute appendicitis, acute diverticulitis, acute pancreatitis, acute cholecystitis.
  • Perforation: Perforated peptic ulcer, ruptured aortic aneurysm, perforated bowel, perforated bladder.
  • Ischemia/Other: Acute bowel ischemia, mesenteric ischemia, torsion, intussusception, gynecological emergencies.
• Recognising an acute abdomen is essential for timely and appropriate interventions.
• Resuscitation and medical treatment are crucial for improving outcomes (morbidity and mortality).
• Triage plays a significant role in the timely assessment and treatment of patients with acute abdomen.
• Many patients require surgery, but others benefit from conservative management.

History Taking

• Understanding pain is crucial:
  • Onset: Sudden onset suggests perforation, gradual onset usually indicates inflammation.
  • Character: Colicky pain typically indicates obstruction, constant pain often suggests inflammation.
  • Location: Pain can be localised to specific areas or radiate.
  • Referral: Certain pain patterns can indicate specific diagnoses.
• SOCRATES Mnemonic: Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating or Relieving factors, Severity.
• Nature/ Character of Pain:
  • Colicky pain: Obstruction of a muscular viscus
  • Constant pain: Inflammation.
  • Pain exacerbated by movement or coughing: Parietal peritoneum involved (peritonitis)
  • Constant sudden onset pain: Typical of perforation

Radiation of pain

• Pain can radiate to different locations:
  • Right shoulder: Gallbladder (Collin's sign)
  • Around flank to groin: Kidney/ureter
  • Appendix pain: Starts centrally, then moves to the right lower quadrant (RIF)
  • Back: Aortic aneurysm (AAA), peptic ulcer disease (PUD), pancreatitis.
  • Pain in the back or flank in a male > 50: Should be considered AAA until proven otherwise.

Presenting Complaints

• Anorexia, nausea, and vomiting:
  • Blood in the first vomit: May indicate Mallory-Weiss tear.
• Changes in bowel habits: Diarrhea, constipation, or melaena (dark, tarry stools) may be signs of bleeding.
• Changes in urinary habits: Alteration in urine appearance, smell, or frequency may indicate urinary tract infection or other issues.

Medical History

• Past Medical History: Any previous medical, surgical history, or abdominal operations.
• Menstrual History: Last menstrual period, regularity, oral contraceptive use, or abnormal bleeding.
• Drug History: Medications, allergies.
• Family History: Genetic predisposition to conditions.
• Social History: Occupation, accommodation, smoking, alcohol consumption drug use.
• Systems Review: Thorough review of all systems.

Physical Examination

• Vital signs: Heart rate, blood pressure, respiratory rate, temperature, oxygen saturation, urinary output.
• ABCDE: Airway, breathing, circulation, disability, exposure.
• Inspection: Note any incisions, scars, or movement.
• Palpation:
  • Superficial: Tenderness, guarding, rebound tenderness, rigidity.
  • Deep: Masses, liver, spleen, aortic aneurysm.
• Percussion: Assess organs or fluid.
• Auscultation: Bowel sounds, ileus, enteritis.
• Groin: Palpate the groins and external genitalia.
• Rectal examination:

Workup

• Bedside investigations: History and Examination.
• Laboratory investigations: FBC (complete blood count), C-reactive protein (CRP), ABG/VBG (arterial/venous blood gas), urine dipstick, beta HCG, glucose check, kidney function tests, electrolytes, liver function tests, serum amylase/lipase, coagulation profile.
• Imaging: Erect chest X-ray, abdominal X-ray (erect and supine), abdominal ultrasound, CT abdomen and pelvis, MRI abdomen and pelvis, ERCP (endoscopic retrograde cholangiopancreatography), interventional radiology.

Universal Management Plan

• Admit: Hospitalization.
• ABCDE: Airway, breathing, circulation, disability, exposure.
• Oxygen: If in doubt, until blood gases are available.
• IV Fluids: 100 ml/hour until fluid losses are known.
• Intake/Output Chart: Monitor fluid intake and output, consider urinary catheterization.
• Analgesia: Opioids usually necessary but use with caution.
• Anti-emetics: For nausea and vomiting.
• Antibiotics: If unsure, consider co-amoxiclav (broad-spectrum antibiotic).
• NPO (Nothing by Mouth): With or without nasogastric tube if vomiting.
• Type and Screen: If surgery is a possibility.
• DVT Prophylaxis: Always.

Acute Cholecystitis

• Inflammation of the gallbladder.
• Commonly associated with gallstones.
• Symptoms: Right upper quadrant (RUQ) pain, nausea, vomiting, tenderness, guarding, fever, and Murphy's sign (pain on palpation of the RUQ).

Gallbladder

• No inflammation: Surgery is relatively easy and safe.
• Inflammation (1-3 days): Surgery is more difficult but usually safe.
• Inflammation (4-6 days): Surgery can become more difficult and dangerous.
• Inflammation (6 days to 6 weeks): Surgery is very difficult and dangerous.
• Inflammation (3 months): Surgery becomes straightforward and safe again.

Pancreatitis

• Causes: Alcohol and gallstones.
• Symptoms: Constant epigastric pain, band-like, radiating to the back. Pain is relieved by bending forward, nausea, vomiting, and abdominal tenderness.
• Complications: Systemic Organ Failure, local - necrosis, abscess, fluid collections.
• Prognosis: Prognostic score (PANCREAS): PaO2 < 60 mmHg, Age > 55 years, Neutrophils > 15x10ꝰ, Calcium < 2 mmol/l, Raised Urea > 16 mmol/l, Enzyme (LDH) > 600 units/l, Albumin < 32 mmol/l, Sugar > 10 mmol/l. More than 3 positive criteria indicate severe pancreatitis.

Peptic Ulcer Disease (PUD)

• Symptoms: Epigastric pain - Relieved by eating (duodenal ulcer), Precipitated by food (gastric ulcer). Pain described as burning, gnawing, or aching. Pain may worsen with coffee, stress, spicy food, and smoking. Pain improved by alkaline food, antacids, and milk.
• Complications: GI bleed and perforation.
• Perforation: Intense, steady pain, patient lies still, rigid abdomen.

Appendicitis

• Inflammation of the appendix.
• Usually caused by blockage of the appendix by a faecolith (hardened stool).
• Symptoms: Pain begins in the periumbilical area and moves to the RIF, anorexia, nausea, vomiting, tenderness, guarding, rebound tenderness in the RIF, low-grade pyrexia.

Bowel Obstruction

• Causes: Adhesions, herniae, impactions, tumours.
• Symptoms: Abdominal pain (crampy), abdominal distension, vomiting, nausea, constipation, increased bowel sounds (mechanical obstruction), decreased bowel sounds (ileus).
• Imaging: Plain films (erect & supine abdomen), CT abdomen.

Abdominal Aortic Aneurysm (AAA)

• Localized weakness of the blood vessel wall with dilation.
• Symptoms: Pulsating mass in the abdomen, lower back pain.
• Complications: Rupture, shock, significant mortality.
• Management: Open or endovascular repair.

Kidney Stone

• Mineral deposits form in the kidney and may move to the ureter.
• Symptoms: Severe flank pain that radiates to the groin and scrotum (loin to groin), nausea, vomiting, hematuria (blood in the urine), extreme restlessness.

Summary

• Recognize: Whether a patient has an acute abdomen.

• Construct: A differential diagnosis, including surgical and medical causes.

• Plan: Appropriate investigations.

• Management: Follow ABCDE principles.

• This introduction to the acute abdomen encourages further exploration of this important topic.

This quiz covers the essential concepts related to acute abdomen conditions that necessitate emergency treatment. Topics include causes such as peritonitis, inflammatory conditions, and the importance of recognizing symptoms for timely intervention. Understanding triage and treatment options is also discussed.