ACUTE ABDOMEN

Surgery (Dr. Penserga)

Acute Abdomen
February 18, 2008

- symptoms of intra-abdominal diseases best o localizes pain to site of stimulus

treated with surgery - Visceral peritoneum stimulation
- episodes of severe abdominal pain after o nonlocalized pain
caused by intra-abdominal condition o epigastric, periumbilical, shoulder,
requiring emergency treatment suprapubic
- continuous pain without relief (1d/<12H)
needs surgery  Gradual periumbilical pain
- appendicitis, diverticulitis, inflammatory
- pain diseases
- anorexia, nausea and vomiting
- beginning of inflammation  stim visceral
- changes in bowel habits
peritoneum, has not touched parietal
- fever, chills peritoneum
PAIN
- most common symptom
 Sudden, severe pain
- perforation of hollow viscus
- not all pain needs surgical treatment
- stomach, perforated ulcer, int
NON-SPECIFIC SYMPTOMS
- not all acute abdomen is surgical  ↑ pain intensity
- ischemic bowel disease
- Pancreatitis
- continuous, ↑ intensity, cannot be relieved
o don’t need to operate , only if there
are complications
o can develop hemorrhage  spread  Pain initially localized  generalized
- perforated ulcer
and affect portal vein  “bangungot”
- because acid sealed byomentum  abscess
disease proximal to duodenum (foregut  cannot contain  rupture  spread
derivative)
 Colicky, crampy (on/off)
stimulates celiac axis - hollow viscus obstruction
- pain not off totally
EPIGASTRIC PAIN int obstructed (tendency of bowel to push)
(duodenal ulcer, gastric ulcer)
hyperperistaltic in area proximal
disease in cecum, appendix (midgut derivative)
hyperactivity sounds and pain
stimulates afferent nerve accompanying IMA - ureteral stone: constant movement proximal
to obstruction/pain
PERIUMBILICALPAIN
*Appendicitis: visceral pain  umbi  stim parietal peritoneum ANOREXIA, NAUSEA AND VOMITING
 RLQ - commonly when abdomen is surgical
o pain  vomiting
disease in distal colon
o ex. appendicitis
- also seen in nonsurgical
stimulate afferent nerve accompanying IMA
o vomiting  pain
SUPRAPUBIC PAIN o ex. Gastroenteritis (not absolute)

phrenic nerve + C3-5 afferent fibers CHANGES IN BOWEL HABITS/CHARACTERISTIC

accompanying phrenic arteries OF STOOL
- blood in stool
innervates diaphragm and peritoneum on its o inflammation, infectious (amoebiasis,
underside mucoid and blood), ischemic process
- absence of flatus/bowel movement
stimulation of diaphragm o complete int. obstruction
o occurs hours before there is absence
SHOULDER PAIN of flatus after int. obstruction 
(referred pain) RESIDUAL

- Pariteal peritoneum stimulation FEVER, CHILLS

SOLID and 2B 1 of 4
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- contain typical patterns o jaundice, dehydration, disorientation

- appendicitis = cholangitis
o early: no fever
o non-ruptured: ↓ fever  Abdominal findings
o ruptured: ↑ fever - Inspection
- cholangitis o Abdominal distention
o biliary tree, stones obstructs bile flow  intra-peritoneal cavity
 stress  bacteria (pus) problem
o 3 common symptoms o Rigidity
 pain  muscle spasms
 fever  involuntary muscle guarding
 perforated peptic ulcer:
SPECIFIC SYMPTOMS “board-like” rigidity
 jaundice o Scaphoid abdomen
- Hx is important  sdaphragmatic hernia
o previous surgery o Bulges, protrusion, hernias
o previous episodes of similar pain  inguinal area
o previous illness
- Px movement/posture
*Surgery  inflamed condition  adhesions

HISTORY - Auscultation
- prior surgery o Silent abdomen
- adhesions  obstructions  Gangrene, diffuse peritonitis,
- surgery for malignancy  possible late obstruction
recurrence 
- organ removal  eliminates organ as o Peristaltic rush synchronous with pain
possible cause of disease  Obstruction
- status of prior surgery: success remnant  Metallic high-pitch sound
(hypersensitivity)
PATIENT MOVEMENT/POSTURE
 Very still, minimal movement - Palpation
- peritonitis o Tenderness - pain on palpation
- visceral to somatic pain o Direct, rebound, referred
o Direct
 Frequent changes of position  visceral stimulation
- hollow viscus spasm, obstruction o Rebound
- biliary, ureteral, stones, spasms  Parietal stimulation
 inflamed peritonitis
PREVIOUS ILLNESSES o Rovsing sign – referred sign (opposite
side)
- Urinary tract
o Muscle guarding:
o dysuria, hematuria
voluntary/involuntary
o Presence of masses
- Reproductive tract in female
o LMP, PID, dysmenorrheal  Which quadrant  due to
o PID mimics acute appendicitis organ involved
 no surgery
- Percussion
o Tenderness, pt of max
- CV conditions
o Atrial fibrillation o Tympany (sabi nya tempani daw
o Embolus wahaha)
 free-air in peritoneum
- DM (pneumoperitoneum)
o Uncontrolled sugar  uncontrolled  abdominal distention
infection
 Rectal findings
- DRE localize area of tenderness
PHYSICAL FINDING o Acute appendicitis
 Non-abdominal findings  Pain on the same side
- give due to the cause  Rt. Pararectal tenderness
o change in vital signs - Blood in the stool
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o Hemorrhoids, malignancy, o Perforation + typhoid ileitis (fever 2-3

inflammatory weeks, Peyer’s patch)
- Mass o Ruptured diverticulitis
- Malignancy, inflammatory abscesses  Small and large bowel
 Outpouching (Meckel’s
 Genital findings diverticulum)
- Scrotal mass, tenderness o Appendicitis
o Hernia, strangulated o Intestinal obstruction
o Intra-abdominal abscess - GB
 There is communication o Hydrops
between abdomen and scrotal  GB pear-shaped stone blocks
sac the opening
 Pus: scrotal hernia  ↑ mucus production, ↑ size
(distention)
 Gynecologic findings o develops infection (pus): Empyema
- Cervical tenderness o Perforated GB
o PID
 Important because  Ruptured solid organs
- Pelvic mass - ruptured spleen, liver
o Inflammatory disease with abscess o check for vital signs
 Tubo-ovarian o blood is irritant
 Pelvic  same in PID and ectopic
pregnancy
- pancreas
COMMON SIGNS IN ACUTE ABDOMEN o pancreatic trauma, acute pancreatitis
 Kidney punch - pyelonephritis o blood or chemical (pancreatic juice)
 Iliopsoas sign - appendicitis is irritant in the later phase
 Obturator sign - hernia, appendicitis o presence of bacteria/ food can
 Murphy’s sign - cholecystitis activate pancreatic juice  irritation
 Cough tenderness - max. pt of tenderness
 Ecchymosis - trauma, pancreatitis,  Inflammatory conditions
aneurysm - hollow and solid organs
o appendicitis
ACUTE NON-SURGICAL ABDOMEN  N&Vepiperiumbiparietal
- lower lobe pneumonia (mistaken for RLQ)
cholecystitis) ,MI (epigastric pain), DKA, cholecystitis
hepatitis, uremia  mimics duodenitis, gastritis;
- polyserositis, RF, Pb poisoning RUQ back
- hx and high index of suspicion differentiated liver abscess
from surgical abdomen  ↑grade fever
Guide in Approach o diverticulitis
- detailed and systematic evaluation
 colon
- common diagnosis more likely
 SI: distal ileum mimics
- if unclear, watchful observation
appendicitis
o pelvic (reproductive) organs
COMMON ACUTE SURGICAL ABDOMEN o mesenteric adenitis (surgical?)
 Esophageal, gastric, int perforation  LN enlarged (viral)
- Esophagus  Near appendix
o Perforation  instruments, caustic  RLQ pain and tenderness
ingestions  Mimic appendicitis
o Mediastinum: mediastinitis
 On/off pain
o Below diaphragm: peritonitis
o Pancreatitis (surgical?)
o Acid  coagulation (delayed
 Not, tx medically
perforation)
o Alkali  liquefaction  inc. damage  Ischemic condition
- Gastric and duodenum - mesenteric thrombosis
o Perforated PUD
o clogged vessels  no blood supply
- Intestines
o surgical
 Surgery– Acute Abdomen by Dr Penserga Page 4 of 4

- torsions, strangulation
o BV is compromised

BOTTOM LINE QUESTION: Do we need to do

surgery?
- Yes
o Appendicitis
o Int. obstruction
 Partial – NGT first
 Complete
- No
o Pancreatitis
o Mesenteric adenitis
o Duodenitis
o Gastritis

EQUIVOCAL SITUATION
- watchful observation
o tenderness
o guarding
o ↑intensity of pain
- op vs non op
- (-) finding vs disastrous finding
- risk and benefit for operating
- risk and benefit for not operating

SHORT QUIZ:
1. appendicitisperiumbilical - VISCERAL
2. appendicitisRLQ - PERITONEAL
3. guarding in peritonitis - “BOARD-LIKE”
RIGIDITY
4. Murphy’s sign - CHOLECYSTITIS
5. continuous pain in eary obs - FALSE
6. continuous pain in late obs - TRUE
7. cannot be reduced -
INCARCERATED HERNIA
8. BV compromised -
STRANGULATED HERNIA
9. empyema: pus in GB - TRUE
10. spreading periton: locgen -TRUE
Yey! Sana ito na ang last trans na gagawin ko…for this school
year hehe.

Anong meron ang taong

happy?

sana wala naman mag-ppirate ng trans na to diba kse andito ang

pic ko. please lang DO NOT disseminate! (bumagsak sana kung
sino man ang magbibigay ng walang permiso ko! Curse ito haha)