General Surgery

1. Dr Mohammad Asghar khan

2. What is Acute Abdomen?

3. ACUTE ABDOMEN
It is characterized by any sudden, spontaneous,
nontraumatic, severe abdominal pain of less
than 24 hours (or less than 72 hours) duration.

4. The primary symptom of the "acute abdomen" is
–Abdominal pain

5. Abdominal pain may be :
1. Visceral pain
2. Parietal Pain
3. Referred / shifting pain

6. Visceral Pain
• Caused by distention, contraction or stretching
of hollow and solid organs.
• Mostly midline (epigastrium ,periumbilical ,
hypogastrium) usually from distention of a
hollow viscus.
• Vary froma steadyacheorvaguediscomfortto
excruciating orcolicky pain.
• Occurs early and is poorly localized.

8. Parietal (Somatic pain)
• Direct irritation of parietal peritoneum by pus, bile,
urine, or GI secretions.
• More acute, sharper, better localized pain.
• Account for physical examination findings of tenderness to
palpation, guarding and rigidity.
• The cutaneous distribution of parietal pain corresponds to
the T6- L1 areas( i.e. it is Dermatomal in origin).

10. Referred Pain
• Referred pain is the pain felt at a site away from
the pathological organ.
• Pathophysilogically the reason behind referred
pain is Shared central pathways for afferent
neurons from different locations.

12. Causes of Acute Abdomen
Divided into different categories
• Surgical
• Gynecological / Obstetrical
• Medical
• Non-specific

13. A) Surgical causes:
• Inflammation
• Perforation
• Obstruction
• Strangulation
• Ischemia
• Torsion
• Abdominal wall

14. 1) Inflammation
• Acute appendicitis
• Acute pancreatitis
• Acute cholecystitis
• Meckel’s diverticulitis

15. 2) Perforation
• Peptic ulcer perforation (DU>GU)
• Typhoid ulcer perforation
• Ruptured aortic aneurysm
• Gall bladder perforation

16. 3) Obstruction
• Intestinal obstruction
• Ureteric obstruction
/colic
• Biliary obstruction
/colic
4) Strangulation
• Strangulated hernia
• Intussusception
• Volvulus

17. 5) Ischemia
• Mesenteric thrombosis
6) Torsion
• Testicular torsion
7) Abdominal wall
• Rectus sheath hematoma
• Abdominal wall abscess

18. B) Gynae & Obs:
• Ruptured ectopic pregnancy
• Acute salpingitis/ acute PID
• Twisted ovarian cyst
• Endometriosis
• Mittelschmerz
• Uterine perforation due to septic
induced abortion

19. Endocrine
and
metabloic
Hematological Referred pain Inflammatory Toxin & Drug
Uremia Sickle cell crisis MI Herpes Zoster Lead poisoning
Diabetic crisis Acute Leukemia Pneumonia Systemic Lupus
Erythematous
Narcotic
withdrawal
Addisonian crisis Other dyscrasias Pleurisy Rheumatic fever
Porphyria's Pneumothorax Poly Arteritis
Nodosa
Empyema, etc Henoch
Schonlein
Purpura
C) MEDICAL CAUSES

20. D) Non-specific Abdominal Pain (NSAP):
It is defined as ,”acute abdominal pain of under
7 day’s duration, and for which there is no diagnosis
after examination and baseline investigations”.
It comprises of a spectrum of undiagnosed
Conditions, both somatic and functional and
remains a “Diagnosis of Exclusion”.

21. Common Causes
• In patients above fifty years of age the top three reasons for
acute abdominal pain are: Biliary Tract Disease (21%,)
NSAP (16%) and Bowel Obstruction (12%).
• In patients under fifty years of age the top three reasons for
acute abdominal pain are: NSAP (40%,) Appendicitis
(32%,) and Biliary Tract Disease (13%).

22. DIAGNOSIS OF ACUTE ABDOMEN
A) History
• Abdominal pain & Other Symptoms Associated with it
• Past medical / Past Surgical history
• Gynecological history
• Medication history
• Travel history
B) Physical Examination
C) Laboratory Investigation
D) Imaging studies
E) Diagnostic Laparoscopy(if required)

23. PAIN:
• Site: Localized or Diffuse
• Onset: Sudden or Gradual
• Character: Constant/Intermittent/colicky
• Relieving factors : relieved by sitting forward
-pancreatitis
• Aggravating factors : if worsened by movement/coughing
-peritonitis
• Radiation
• Severity

25. Pain character and Diagnostic clues

26. Associated symptoms
• Vomiting and the nature of vomitus
-Undigested food/bile - upper GI pathology or obstruction
-Feculent vomiting - lower GI obstruction
• Hematemesis or melena
• Stool/urine color, urinary symptoms
• Bowel Habits - diarrhoea, constipation and ability to pass
flatus
• Fever/rigors
• Recent weight loss

27. Past Medical/Surgical History
● Past Abdominal surgery : Can beresponsible forcurrent Bowel
obstructiondue to adhesions.
● Cardiovascular disease, hypertension oratrial fibrillation:
Mesenteric ischemiaor AAA.
● Cirrhosis and ascites : Spontaneousbacterial peritonitis

28. Medication History:
NSAIDS or aspirin, Anticoagulants or antiplatelet
drugs, OCP, Corticosteroid or Immunosuppressive
drugs.
Travel History :
To Typhoid or Malaria Endemic area etc.

29. Gynecological History:
1. The menstrual history is crucial to the diagnosis of
ectopic pregnancy, Mittelschmerz (due to a ruptured
ovarian follicle) and endometriosis.
2. A history of vaginal discharge or dysmenorrhea may
denote pelvic inflammatory disease.
In females, abdominal pain =
GYN problem until proven otherwise

30. PHYSICAL EXAMINATION
1. Appearance
2.Attitude
• Patients with visceral pain are unable to
lie still.
• Patients with peritonitis like to stay
immobile.
3.Vitals:
Pulse, BP, Respiratory rate, Temp.
4.Pallor , cyanosis, Jaundice, dehydration

31. Hippocratic facies( Occurs in late generalized peritonitis due to
circulatory failure with sunken eyes, dry tongue, thready pulse and
drawn and anxious face)

32. Abdominal Examination
Look, Listen andFeel
● Inspection
● Auscultation
● Percussion
● Palpation

33. Inspection: Whatshould you look ?
● Distention or a swelling
● Masses
● Bruising( Cullen’s sign, grey turner sign)
● Scars from prior surgeries
● Cutaneous signs of portal hypertension.
● Visible pulsations or peristalsis

34. A Lump due to strangulated
Hernia
Caput Medusa

36. Auscultation: What should you listen?
1.Absentordiminished bowel sounds providelittle
usefulclinicalinformation.
2.High-pitched or tinkling sounds can be
associated with SBO, especially in the presence of
abdominal distention.
3.Low-pitched and less frequent bowel sounds are
classically associated with large bowel obstruction
4.Bruits :indicate the presence of an AAA in an
elderly patient.

37. Percussion
• Distinguishing between distention caused
by air or fluid.
• Shifting dullness or a fluid wave suggests
ascites.

38. Palpation - How to start with ?
• Ask the patient to point with one finger to the
location of greatest discomfort.
• Palpation should be performed systematically,
involving all of the 9 regions of abdomen.
• Observe the patient's facial expressions for signs
of pain during palpation
• Pulsatile mass suggestive of AAA.

39. Guarding
• Involuntary: Reflex spasm of the
abdominal wall musculature in
response to palpation or underlying
peritoneal irritation.
• Voluntary: In response to the
physician's cold hands, fear, anxiety,
or being ticklish.
• Involuntary guarding, which has
greater clinical significance, is more
likely to occur with surgical illness and
is not relieved by physician
encouragement.
Rebound Tenderness
• Elicited by slow, gentle, deep
palpation of an area of tenderness
followed by abrupt withdrawal of
the examiner's hand.
• Hallmark of surgical disease.

40. Guarding Rebound Tenderness

45. Rovsing sign

46. Genital Examination
• Every male with
abdominal pain should
have a genital
examination.
• The groin should be
inspected and palpated
for hernias, which may
be the cause of an acute
bowel obstruction.
• The external genitalia
and scrotum should
also carefully be
evaluated for any
tenderness, masses, or
abnormalities.

47. Rectal Examination
• Necessary component of
the evaluation of
patients with abdominal
pain. Helps in the
assessment of:
• Prostate and Perirectal
disease
• Stool impactions
• Rectal foreign bodies
• Gastrointestinal (GI)
bleeding

48. LABORATORY INVESTIGATION
A. Blood Studies:
• Full Blood Count and TLC
• S.Electrolytes and Urea-Creatinine
• ABG’s (for any metabolic derangement)
• Serum Lactate(Raised in ischemic bowel)
• Lipase and Amylase( For pancreatitis, lipase is more
sensitive and specific than amylase)
• Liver function tests if hepato-biliary disease is suspected
• Beta HCG (women of childbearing age.)

49. LABORATORY INVESTIGATION Contd
• Cardiac Enzymes / Troponin and ECG (In all elderly
patients with Acute Abdominal pain to rule out M.I)
B. Urine Tests:
• Routine Exam & Microscopic Exam to see
hematuria, pyuria
• Dipstick Test - (for albumin, bilirubin,
glucose and ketones)

50. Imaging studies
Plain films : What should you look for ?
1. Dilated loops of large or small bowel
2. Air-fluid levels
3. Abnormal calcifications (abdominal aorta, urinary tract(90% renal
stone), gallbladder [15 % gall stone ], or appendix (5% appendicolith )
4. Air in abnormal locations (free air under the diaphragm, air in the portal
vein, bowel wall, or between loops of gut)
Note: - 1 ml air in peritoneum can be detected in upright CXR.
- 5-10 ml air in peritoneum is required to be visible in lateral
decubitus position (after 10 minutes).

52. Plain film Abdomen: Dilated Bowel loops , Air
fluid levels

53. Abnormal Calcifications

54. ULTRASOUND
• Extremely accurate for gallstones & assessing gallbladder
wall thickness & presence of fluid around gallbladder.
• Swollen, non compressible appendix >7 mm in diameter
can be easily diagnosed with ultrasound.
• Can detect free intraperitoneal fluid and ruptured AAA.
• For detecting Ectopic pregnancy transvaginal approach is
superior to transabdominal approach.

55. USG- Gallbladder

56. Ultrasound : Inflamed Appendix Ectopic gestation

57. USG Abdomen : Free fluid
Ruptured AAA

58. CT Abdomen
• Modality of choice for undifferentiated abdominal pain
that require imaging.
• CT is useful for determining the diagnosis (and in
many cases, the clinical severity)
● Renal colic
● Bowel obstruction
● Bowel perforation
● Bowel ischemia
● Solid organ injury
● AAA
● Pancreatitis
● Intra-abdominal abscess
● Diverticulitis

59. Small bowel infarction A/W mesenteric venous
thrombosis Note the low density thrombosed SMV (solid
arrow) & incidental gallstones(open arrow)

61. ROLE OF LAPAROSCOPY IN ACUTE ABDOMEN
• Laparoscopy is a therapeutic as well as diagnostic modality
• In cases of unclear diagnosis, it guide surgical planning and
avoid unneeded laparotomies.
• In young women, it may distinguish a nonsurgical problem
(ruptured graafian follicle, pelvic inflammatory disease,
tubo-ovarian disease) from appendicitis.

62. Management
The main goals of treatment are

63. ● Physiologic stabilization and Preparation for surgical
intervention when warranted:
• NPO
• Volume Repletion
• Pain Relief
• Control of Emesis(if present)
• Antibiotics

64. Volume repletion: Facts
1. Crystalloids are the initial fluids of choice in both children
and adults.
2. Rate of repletion is determined by the patient's degree of
dehydration, cardiovascular status and response to initial
therapy
3. In Life-threatening hemodynamic collapse, blood products
may be the initial resuscitation fluid.

65. General Treatment
Pain Relief : facts
• There is a notion that Narcotics mask sign/symptoms and
mislead diagnosis, However there is No clear evidence
supporting this notion instead it may aid in the diagnosis of
surgical disease.
• In the acute setting, pain relief is typically achieved with IV
titration of opioid analgesics such as morphine sulfate or
fentanyl
• Ketorolac is not recommended for treatment of
undifferentiated abdominal pain as it may increase
bleeding times.

66. General Treatment
Antibiotic : Facts
1. Abdominal infections are often polymicrobial and
necessitate coverage for enteric Gram-negatives, Gram-
positives and anaerobic bacteria.
2. The specific regimen must take into account the patient's
presentation, comorbid conditions, and local bacterial drug
sensitivities and drug-resistance patterns.

67. General Treatment

68. Scenarios

69. In working up a patient with acute abdominal
pain, which of the following etiologies is
LEAST likely to represent an immediate
life threat?
a. Myocardial infarction
b. Splenic rupture
c. Abdominal Aortic Aneurysm
d. Perforated duodenal ulcer
e. Ruptured ectopic pregnancy

70. Answer D
• When approaching a patient with acute abdominal pain, the
clinician must consider conditions that can be an immediate
threat to the patient’s life.
• Splenic rupture, ruptured ectopic pregnancy, and AAA can all
be associated with massive bleeding and rapid decline.
• Extra abdominal conditions that present with abdominal pain
such as MI can also be life threatening.
• Perforated duodenal ulcer are serious but almost never result in
significant hemorrhage, and thus are not usually an
immediate threat to life.

71. All of the following are TRUE regarding the evaluation ofa
patient with acute abdominal pain EXCEPT
a. the onset, location, and severity of pain are useful
differentiating factors
b. the most important physical examination modality
is palpation
c. the WBC may be normal even in inflammatory
conditions such as appendicitis
d. ultrasonography is a valuable imaging tool
increasingly available
e. analgesic medications should be withheld until a
surgeon evaluates the patient because they may obscure
the diagnosis.

72. Answer E
• The onset, severity, location, and character of pain and
the presence of associated symptoms guide work-up and
treatment.
• Although a complete Physical Examination is necessary,
palpation of the abdominal is the most important modality
for diagnosis.
• Lab tests are useful adjuncts, but the limitations of a CBC
must be recognized.
• Helpful imaging modalities include standard X-Ray, U/S,
barium contrast studies, and CT
• IV opiate analgesia is humane and may actually assistin
diagnosis by facilitating Physical Exam in a patient who
could otherwise not tolerate it.

73. What is the most common cause of large
bowel obstruction?
a. adhesions
b. incarcerated hernia
c. Diverticulitis
d. Neoplasm
e. Sigmoid volvulus

74. Answer D
• The MC cause of colonic obstruction is neoplasm
• 2nd MC = diverticulitis, followed by sigmoid volvulus
• MC SBO = surgical adhesions
• 2nd MC SBO = hernias and primary small bowel lesions

75. A 40 y/o female with known gallstones presents with colicky RUQ
pain and vomiting. She has a history of similar episodes that
usually resolve after 3-4 hrs.
Vitals: BP 110/60, P 78, R/R 16, T 98.4*F.
On Physical Exam: mildly tender RUQ without signs of
peritonitis.
Which of the following would be LEAST appropriate in her ED
management?
a. IV fluids
b. Pain control with opiate analgesics
c. pain control with ketorolac
d. antiemetic administration
e. immediate surgical intervention

76. Answer E
• Pts with uncomplicated symptomatic cholelithiasis do not
require immediate surgical intervention.
• ED intervention is geared toward pain relief and correction
of volume deficits
• Pain control can be achieved with administration of
opiates or ketorolac
• Antiemetic's and gastric decompression with an NGT
may be necessary for treatment of protracted vomiting.
• If the pt’s symptoms resolve within 4-6 hrs and she
toleratesoral fluids, D/C home along with out-patient
follow-up is appropriate

77. A pt with suspected cholelithiasis presents
to the ED. What is the initial imaging
study of choice?
a. abdominal plain film
b. abdominal ultrasound
c. abdominal CT
d. Radionuclide scan (HIDA)
e. Barium contrast radiography

78. Answer B
• U/S has emerged as a valuable tool for certainconditions in the ED.
• Plain film is a poor imaging choice to detectgallstones (only 15%), but is
useful in evaluating obstruction or suspected perforation.
• CT is the diagnostic tool of choice for manyabdominal conditions including
pancreatitis, some trauma, and selected AAA, but is more costly and
invasive than U/Sfor evaluating gallstones.
• HIDA scan is a useful adjunct if U/S results are inconclusive or
acalculous cholecystitis is suspected.
• Barium studies are useful for imaging in someGI conditions, especially
suspected intussusception, but not for evaluation of Gall Bladder.

79. A 28 y/o man has complaints of intermittent,
colicky, periumbilical, and lower-quadrant pain
for 24 hours. The patient complains of nausea
and decreased appetite. He is afebrile. Which of
the following is the most likely diagnosis?
a. acute appendicitis
b. acute pancreatitis
c. Pyelonephritis
d. gastroenteritis
e. peptic ulcer disease

80. Answer D
• The pain pattern is most consistent with a diagnosis of
gastroenteritis.
• Acute appendicitis typically causes periumbilical pain that migrates to
the RLQ
• Pain of Acute pancreatitis radiates to the back or shoulder
• Pain of Pyelonephritis is from “loin to groin”
• Pain of Peptic ulcer Disease is typically located in the epigastrium

81. A 7 y/o boy presents with c/o flank pain, fever,
frequency, dysuria, and hematuria for 1 day.
The Urinalysis shows >10 WBC’s per high-
powered field, RBC’s, and WBC casts. Of the
following, the most likely diagnosis is:
a. pyelonephritis
b. acute cystitis
c. urethritis
d. renal calculi
e. urinary incontinence

82. Answer A
• Pyelonephritis is an infection of the renal parenchyma,
accompanied by systemic symptoms such as fever, N/V and
association with WBC casts in the urine.
• In pediatric male patient, its occurrence would warrant
additional evaluation to rule out anatomic abnormalities in
the urinary tract

83. A 27 y/o woman with amenorrhea is seen for vaginal bleeding
and abdominal pain. An ectopic pregnancyis suspected.
Which of the following would support the suspicion?
a. enlarged boggy uterus
b. ruptured fetal membranes
c. adnexal mass
d. weak fetal heart beat
e. painless profuse bleeding

84. Answer C
Classic features of an ectopic pregnancy are
abdominal pain, bleeding, and adnexal mass in a
pregnant woman

85. ● Donotrestrictthediagnosissolely bythelocationof the pain.
● Donotuse thepresenceorabsenceof fevertodistinguish between
surgicaland medical causes of abdominal pain.
● TheWBC countisof littleclinical valueinthepatientwith
possibleappendicitis.
● Any woman with childbearing potential and abdominal pain
has an ectopic pregnancy until her pregnancy test comes back
negative.
Pearls

86. ● Pain medicationsreducepainand sufferingwithout
compromising diagnosticaccuracy
● Anelderlypatientwithabdominal pain has ahigh likelihood
of surgicaldisease.
● Obtainan ECG inall older patientsand thosewithcardiac risk
factors presenting withabdominalpain
● The use of abdominal ultrasound or CT may help evaluate patients
over the age of 50 with unexplained abdominal or flank pain for the
presence ofAAA.
Pearls