Acute Abdomen

General name for presence of signs, symptoms of inflammation of peritoneum (abdominal lining)


History



• Where do you hurt?
– Know locations of major organs
– But realize abdominal pain locations do not correlate well with source


• What does pain feel like?
– Steady pain - inflammatory process
– Crampy pain - obstructive process


• Was onset of pain gradual or sudden?
– Sudden = perforation, hemorrhage, infarct
– Gradual = peritoneal irrigation, hollow organ distension


• Does pain radiate (travel) anywhere?
– Right shoulder, angle of right scapula = gall bladder
– Around flank to groin = kidney, ureter


• Duration?
– > 6 hour duration = ? surgical significance
• Nausea, vomiting? Bloody? “Coffee Grounds”?


• Change in urinary habits? Urine appearance?
• Change in bowel habits? Appearance of bowel movements? Melena?


• Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss


• Females
– Last menstrual period?
– Abnormal bleeding? 

Physical Exam
• General Appearance
– Lies perfectly still  inflammation, peritonitis
– Restless, writhing  obstruction
• Abdominal distension?
• Ecchymosis around umbilicus, flanks?


• Vital signs
– Tachycardia ? Early shock (more important than BP)
– Rapid shallow breathing peritonitis


• Palpate each quadrant
– Work toward area of pain
– Warm hands
– Patient on back, knee bent (if possible)
– Note tenderness, rigidity, involuntary guarding,voluntary guarding, masses


• Bowel Sounds
– Listen 1 minute in each quadrant
– Listen before feeling
– Absent bowel sounds  ileus, peritonitis, shock


Management
• Airway
• High concentration O2
• Anticipate vomiting
• Anticipate hypovolemia
• Nothing by mouth
• No analgesics, sedatives


• In adults > 30, consider possibility of referred cardiac pain.
• In females, consider possible gyn problem, especially tubal ectopic pregnancy


Appendicitis
• Usually due to obstruction with fecalith
• Appendix becomes swollen, inflamed gangrene, possible perforation


• Pain begins periumbilical; moves to RLQ
• Nausea, vomiting, anorexia
• Patient lies on side; right hip, knee flexed
• Pain may not localize to RLQ if appendix in odd location
• Sudden relief of pain = possible perforation


Duodenal Ulcer Disease
• Steady, well-localized epigastric pain
• “Burning”, “gnawing”, “aching”
• Increased by coffee, stress, spicy food, smoking
• Decreased by alkaline food, antacids


• May cause massive GI bleed
• Perforation = intense, steady pain, pt lies still, rigid abdomen
Kidney Stone
• Mineral deposits form in kidney, move to ureter
• Often associated with history of recent UTI
• Severe flank pain radiates to groin, scrotum
• Nausea, vomiting, hematuria
• Extreme restlessness
Abdominal Aortic Aneurysm
• Localized weakness of blood vessel wall with dilation (like bubble on tire)
• Pulsating mass in abdomen
• Can cause lower back pain
• Rupture shock, exsanguination
Pancreatitis
• Inflammation of pancreas
• Triggered by ingestion of EtOH; large amounts of fatty foods
• Nausea, vomiting; abdominal tenderness; pain radiating from upper abdomen straight through to back
• Signs, symptoms of hypovolemic shock
Cholecystitis
• Inflammation of gall bladder
• Commonly associated with gall stones
• More common in 30 to 50 year old females
• Nausea, vomiting; RUQ pain, tenderness; fever
• Attacks triggered by ingestion of fatty foods
Bowel Obstruction
• Blockage of inside of intestine
• Interrupts normal flow of contents
• Causes include adhesions, hernias, fecal impactions, tumors
• Crampy abdominal pain; nausea, vomiting (often of fecal matter); abdominal distension
Esophageal Varices
• Dilated veins in lower part of esophagus
• Common in EtOH abusers, patients with liver disease
• Produce massive upper GI bleeds