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Acute Abdomen

Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways that may be caused by inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, infection, perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis, ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage, or obstruction. The location of the pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, its characteristics, and associated symptoms (e.g., jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice) are important tools that help narrow the differential diagnosis. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship will typically have severe tenderness with associated rigidity Rigidity Continuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity. Megacolon and rebound tenderness. Laboratory evaluation will demonstrate leukocytosis Leukocytosis A transient increase in the number of leukocytes in a body fluid. West Nile Virus, acidosis Acidosis A pathologic condition of acid accumulation or depletion of base in the body. The two main types are respiratory acidosis and metabolic acidosis, due to metabolic acid build up. Respiratory Acidosis, and in some cases, abnormal hepatic function tests. Imaging helps narrow the differential diagnosis; first-line imaging is always an upright chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests to evaluate for pneumoperitoneum Pneumoperitoneum A condition with trapped gas or air in the peritoneal cavity, usually secondary to perforation of the internal organs such as the lung and the gastrointestinal tract, or to recent surgery. Pneumoperitoneum may be purposely introduced to aid radiological examination. Perforated Viscus. The treatment and prognosis Prognosis A prediction of the probable outcome of a disease based on a individual's condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas of acute abdomen strongly depend on the underlying cause, but the vast majority of these cases constitute a surgical emergency with associated morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status and mortality Mortality All deaths reported in a given population. Measures of Health Status.

Last updated: 26 Jan, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Acute abdomen is the constellation of signs and symptoms associated with severe abdominal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and peritonitis Peritonitis Inflammation of the peritoneum lining the abdominal cavity as the result of infectious, autoimmune, or chemical processes. Primary peritonitis is due to infection of the peritoneal cavity via hematogenous or lymphatic spread and without intra-abdominal source. Secondary peritonitis arises from the abdominal cavity itself through rupture or abscess of intra-abdominal organs. Penetrating Abdominal Injury that frequently requires emergency surgical intervention.

Epidemiology

  • Abdominal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, in general, comprises 5%–10% of ED visits.
  • About one-third of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship > 65 years old with abdominal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways will require surgical intervention.
  • Acute abdomen:
    • Young individuals: Appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis is the most common cause.
    • Older individuals with acute abdomen most commonly have:
      • Biliary disease
      • Bowel obstruction Bowel obstruction Any impairment, arrest, or reversal of the normal flow of intestinal contents toward the anal canal. Ascaris/Ascariasis
      • Intestinal ischemia Intestinal ischemia Intestinal ischemia occurs when perfusion fails to meet the demands of the intestines, resulting in ischemic tissue injury that can be life-threatening if bowel necrosis and/or perforation occurs. Symptoms can range from mild indigestion or diarrhea to severe abdominal pain. Intestinal Ischemia
      • Diverticulitis Diverticulitis Inflammation of a diverticulum or diverticula. Diverticular Disease

Etiology

Nonsurgical causes of acute abdomen:

  • Endocrine/metabolic causes:
    • Acute intermittent porphyria Acute intermittent porphyria An autosomal dominant porphyria that is due to a deficiency of hydroxymethylbilane synthase in the liver, the third enzyme in the 8-enzyme biosynthetic pathway of heme. Clinical features are recurrent and life-threatening neurologic disturbances, abdominal pain, and elevated level of aminolevulinic acid and porphobilinogen in the urine. Porphyrias
    • Hereditary Mediterranean fever Mediterranean fever Brucellosis (also known as undulant fever, mediterranean fever, or malta fever) is a zoonotic infection that spreads predominantly through ingestion of unpasteurized dairy products or direct contact with infected animal products. Clinical manifestations include fever, arthralgias, malaise, lymphadenopathy, and hepatosplenomegaly. Brucella/Brucellosis
    • Uremia Uremia A clinical syndrome associated with the retention of renal waste products or uremic toxins in the blood. It is usually the result of renal insufficiency. Most uremic toxins are end products of protein or nitrogen catabolism, such as urea or creatinine. Severe uremia can lead to multiple organ dysfunctions with a constellation of symptoms. Acute Kidney Injury
    • Diabetic ketoacidosis Diabetic ketoacidosis A life-threatening complication of diabetes mellitus, primarily of type 1 diabetes mellitus with severe insulin deficiency and extreme hyperglycemia. It is characterized by ketosis; dehydration; and depressed consciousness leading to coma. Hyperglycemic Crises
  • Hematologic causes:
    • Sickle cell crisis
    • Acute leukemia
  • Toxins and drugs:

Surgical causes of acute abdomen:

  • Hemorrhage:
    • Trauma
    • Ruptured aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Thoracic Aortic Aneurysms
    • Hemorrhagic pancreatitis Pancreatitis Inflammation of the pancreas. Pancreatitis is classified as acute unless there are computed tomographic or endoscopic retrograde cholangiopancreatographic findings of chronic pancreatitis. The two most common forms of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis. Acute Pancreatitis (usually does not require surgical intervention initially)
    • Mallory–Weiss tear
    • Ruptured ectopic pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Infection:
    • Appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis
    • Diverticulitis Diverticulitis Inflammation of a diverticulum or diverticula. Diverticular Disease
    • Hepatic abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
    • Meckel diverticulitis Diverticulitis Inflammation of a diverticulum or diverticula. Diverticular Disease
  • Perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis:
  • Obstruction:
    • Small- or large-bowel obstruction due to adhesions or malignancy Malignancy Hemothorax
    • Volvulus Volvulus A volvulus is the twisting or axial rotation of a portion of the bowel around its mesentery. The most common site of volvulus in adults is the colon; most frequently the sigmoid volvulus. Patients typically present with symptoms of bowel obstruction such as abdominal pain, distension, vomiting, and constipation/obstipation. Volvulus
    • Incarcerated hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias
    • Intussusception Intussusception Intussusception occurs when a part of the intestine (intussusceptum) telescopes into another part (intussuscipiens) of the intestine. The condition can cause obstruction and, if untreated, progress to bowel ischemia. Intussusception is most common in the pediatric population, but is occasionally encountered in adults. Intussusception
  • Ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage:
    • Mesenteric thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus or embolism
    • Ovarian torsion Ovarian torsion Ovarian torsion is a clinical emergency in which the ovaries (with or without the fallopian tubes) twist along their axis, leading to partial or complete obstruction of their blood supply. Ovarian torsion is also called adnexal or tubo-ovarian torsion, especially if a fallopian tube is also involved. Ovarian Torsion
    • Ischemic colitis Ischemic colitis Inflammation of the colon due to colonic ischemia resulting from alterations in systemic circulation or local vasculature. Large Bowel Obstruction
    • Testicular torsion Testicular torsion Testicular torsion is the sudden rotation of the testicle, specifically the spermatic cord, around its axis in the inguinal canal or below. The acute rotation results in compromised blood flow to and from the testicle, which puts the testicle at risk for necrosis. Testicular Torsion
    • Strangulated hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias

Anatomy

Boundaries of the abdominal cavity

  • Superiorly: diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy
  • Inferiorly: pelvic inlet Pelvic inlet Pelvis: Anatomy
  • Anteriorly: abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen muscles and lower ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy
  • Posteriorly: ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy, spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy, and paraspinal muscles

External anatomy

For descriptive purposes, the abdomen can be divided into 4 quadrants or 9 regions.

Quadrants:

Divided into 4 quadrants by 2 perpendicular lines crossing at the umbilicus:

Right upper quadrant Right upper quadrant Anterior Abdominal Wall: Anatomy (RUQ):
  • Right lobe of the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy
  • Gallbladder Gallbladder The gallbladder is a pear-shaped sac, located directly beneath the liver, that sits on top of the superior part of the duodenum. The primary functions of the gallbladder include concentrating and storing up to 50 mL of bile. Gallbladder and Biliary Tract: Anatomy
  • Pylorus Pylorus The region between the sharp indentation at the lower third of the stomach (incisura angularis) and the junction of the pylorus with the duodenum. Pyloric antral glands contain mucus-secreting cells and gastrin-secreting endocrine cells (g cells). Stomach: Anatomy of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy
  • First 3 parts of the duodenum Duodenum The shortest and widest portion of the small intestine adjacent to the pylorus of the stomach. It is named for having the length equal to about the width of 12 fingers. Small Intestine: Anatomy
  • Head of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas: Anatomy
  • Right kidney
  • Right adrenal gland
  • Distal ascending colon Ascending colon The segment of large intestine between the cecum and the transverse colon. It passes cephalad from the cecum to the caudal surface of the right lobe of the liver where it bends sharply to the left, forming the right colic flexure. Colon, Cecum, and Appendix: Anatomy
  • Hepatic flexure of the colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy
  • Right half of the transverse colon Transverse colon The segment of large intestine between ascending colon and descending colon. It passes from the right colic flexure across the abdomen, then turns sharply at the left colonic flexure into the descending colon. Colon, Cecum, and Appendix: Anatomy
Left upper quadrant Left upper quadrant Anterior Abdominal Wall: Anatomy (LUQ):
  • Left lobe of the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy
  • Spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: Anatomy
  • Stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy
  • Jejunum Jejunum The middle portion of the small intestine, between duodenum and ileum. It represents about 2/5 of the remaining portion of the small intestine below duodenum. Small Intestine: Anatomy
  • Proximal ileum Ileum The distal and narrowest portion of the small intestine, between the jejunum and the ileocecal valve of the large intestine. Small Intestine: Anatomy
  • Body and the tail of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas: Anatomy
  • Left kidney
  • Left adrenal gland
  • Left half of the transverse colon Transverse colon The segment of large intestine between ascending colon and descending colon. It passes from the right colic flexure across the abdomen, then turns sharply at the left colonic flexure into the descending colon. Colon, Cecum, and Appendix: Anatomy
  • Splenic flexure Splenic flexure Small Intestine: Anatomy of the colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy
  • Superior part of the descending colon Descending colon The segment of large intestine between transverse colon and the sigmoid colon. Colon, Cecum, and Appendix: Anatomy
Right lower quadrant Right lower quadrant Anterior Abdominal Wall: Anatomy (RLQ):
  • Majority of the ileum Ileum The distal and narrowest portion of the small intestine, between the jejunum and the ileocecal valve of the large intestine. Small Intestine: Anatomy
  • Cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy and appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy
  • Proximal ascending colon Ascending colon The segment of large intestine between the cecum and the transverse colon. It passes cephalad from the cecum to the caudal surface of the right lobe of the liver where it bends sharply to the left, forming the right colic flexure. Colon, Cecum, and Appendix: Anatomy
  • Proximal right ureter
  • Right ovary
  • Right uterine tube
  • Right half of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy
  • Right half of the urinary bladder Urinary Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters (ureter), and is held there until urination. Urinary Tract: Anatomy
Left lower quadrant Left Lower quadrant Anterior Abdominal Wall: Anatomy (LLQ):
  • Distal descending colon Descending colon The segment of large intestine between transverse colon and the sigmoid colon. Colon, Cecum, and Appendix: Anatomy
  • Sigmoid Sigmoid A segment of the colon between the rectum and the descending colon. Volvulus colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy
  • Left ureter
  • Left ovary
  • Left uterine tube
  • Left half of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy
  • Left half of the urinary bladder Urinary Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters (ureter), and is held there until urination. Urinary Tract: Anatomy

Regions:

The abdomen can be divided into regions with 4 lines:

  • 2 transverse lines:
    • Subcostal line: through the 10th costal cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology
    • Intertubercular line: connects the tubercles of the iliac crests
  • 2 vertical lines: right and left midclavicular lines
Right hypochondriac region Epigastric region Epigastric region Anterior Abdominal Wall: Anatomy Left hypochondriac region
Right lumbar region Lumbar region Spinal Cord: Anatomy Umbilical region Umbilical Region Surgical Anatomy of the Abdomen Left lumbar region Lumbar region Spinal Cord: Anatomy
Right iliac region Hypogastric region Left iliac region
Abdominal quadrant regions

Abdominal quadrant regions:
There are (a) 9 abdominal regions and (b) 4 abdominal quadrants in the peritoneal cavity Peritoneal Cavity The space enclosed by the peritoneum. It is divided into two portions, the greater sac and the lesser sac or omental bursa, which lies behind the stomach. The two sacs are connected by the foramen of winslow, or epiploic foramen. Peritoneum: Anatomy.

Image: “Abdominal quadrant regions” by OpenStax. License: CC BY 3.0, edited by Lecturio.

Internal anatomy

Relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship of intra-abdominal organs to peritoneal cavity Peritoneal Cavity The space enclosed by the peritoneum. It is divided into two portions, the greater sac and the lesser sac or omental bursa, which lies behind the stomach. The two sacs are connected by the foramen of winslow, or epiploic foramen. Peritoneum: Anatomy:

  • Intraperitoneal Intraperitoneal Peritoneum: Anatomy:
    • Stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy and small intestine Small intestine The small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum. Small Intestine: Anatomy
    • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy
    • Spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: Anatomy
    • Transverse colon Transverse colon The segment of large intestine between ascending colon and descending colon. It passes from the right colic flexure across the abdomen, then turns sharply at the left colonic flexure into the descending colon. Colon, Cecum, and Appendix: Anatomy
    • Duodenal bulb and pancreatic tail
  • Extraperitoneal: bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess
  • Retroperitoneal Retroperitoneal Peritoneum: Anatomy organs can be grouped in the SAD PUCKER mnemonic:
    • Suprarenal glands 
    • Aorta and inferior vena cava Inferior vena cava The venous trunk which receives blood from the lower extremities and from the pelvic and abdominal organs. Mediastinum and Great Vessels: Anatomy
    • Duodenum (except the 1st part)
    • Pancreas (except the tail)
    • Ureters
    • Colon (descending and ascending)
    • Kidneys
    • Esophagus
    • Rectum

Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and innervation patterns

  • Visceral innervation: 
    • Innervation of internal organs
    • Senses the distention of a hollow viscus (e.g., stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach: Anatomy, intestines)
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways:
      • Vague and poorly localized 
      • Epigastric, periumbilical, or hypogastric in location
  • Parietal Parietal One of a pair of irregularly shaped quadrilateral bones situated between the frontal bone and occipital bone, which together form the sides of the cranium. Skull: Anatomy innervation:
    • Segmental nerves that innervate the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy
    • Transmit the pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways from peritoneal irritation usually secondary to inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation or internal bleeding
    • Sharper and more localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • Referred pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways:
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways perceived at a site different from the source of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Secondary to innervation of different sites by the same nerve roots
    • Classic example: diaphragmatic irritation perceived as shoulder pain Shoulder Pain Acute shoulder injuries are a common reason for visits to primary care physicians and EDs. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Acute Shoulder Pain due to both structures being innervated by C3–C5 roots

Clinical Presentation

The hallmark of acute abdomen is acute onset of severe abdominal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways that may or may not be associated with other symptoms. A detailed history and physical exam should be performed to determine the correct course of action.

History

  • Description of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways:
    • Onset
    • Location
    • Duration
    • Description
    • Radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma
    • Severity
    • Aggravating or alleviating factors: Peritonitis Peritonitis Inflammation of the peritoneum lining the abdominal cavity as the result of infectious, autoimmune, or chemical processes. Primary peritonitis is due to infection of the peritoneal cavity via hematogenous or lymphatic spread and without intra-abdominal source. Secondary peritonitis arises from the abdominal cavity itself through rupture or abscess of intra-abdominal organs. Penetrating Abdominal Injury is classically exacerbated by movement.
  • Associated symptoms:
    • Nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics
    • Vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
    • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
    • Melena Melena The black, tarry, foul-smelling feces that contain degraded blood. Gastrointestinal Bleeding or hematochezia Hematochezia Gastrointestinal Bleeding
    • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Past history:
    • Previous similar episodes
    • Underlying medical conditions
    • Preceding trauma (car accident, assault)
    • Prior abdominal surgeries
    • Recent travel, toxic exposures, food poisoning Food poisoning Acute illnesses, usually affecting the gastrointestinal tract, brought on by consuming contaminated food or beverages. Most of these diseases are infectious, caused by a variety of bacteria, viruses, or parasites that can be foodborne. Sometimes the diseases are caused by harmful toxins from the microbes or other chemicals present in the food. Especially in the latter case, the condition is often called food poisoning. Clostridia

Physical examination

  • Exam should always start with visual inspection Inspection Dermatologic Examination to note things such as: 
    • Jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice
    • Pallor
    • Work of breathing Work of breathing Respiratory muscle contraction during inhalation. The work is accomplished in three phases: lung compliance work, that required to expand the lungs against its elastic forces; tissue resistance work, that required to overcome the viscosity of the lung and chest wall structures; and airway resistance work, that required to overcome airway resistance during the movement of air into the lungs. Work of breathing does not refer to expiration, which is entirely a passive process caused by elastic recoil of the lung and chest cage. Pulmonary Examination
    • Patient’s behavior:
      • Trying to lie still
      • Grimacing 
  • A full set of vital signs should be obtained and constitutional signs noted:
    • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
    • Tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
    • Tachypnea Tachypnea Increased respiratory rate. Pulmonary Examination
    • Altered mental status Altered Mental Status Sepsis in Children
  • A thorough abdominal exam should be completed:
    • Inspection Inspection Dermatologic Examination:
      • Distention
      • Bruising (Cullen or Grey–Turner sign: hemorrhagic pancreatitis Pancreatitis Inflammation of the pancreas. Pancreatitis is classified as acute unless there are computed tomographic or endoscopic retrograde cholangiopancreatographic findings of chronic pancreatitis. The two most common forms of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis. Acute Pancreatitis)
      • Bulging, skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions discoloration (would suggest strangulated hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias)
    • Percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination
      • Tympanic (bowel distention or pneumoperitoneum Pneumoperitoneum A condition with trapped gas or air in the peritoneal cavity, usually secondary to perforation of the internal organs such as the lung and the gastrointestinal tract, or to recent surgery. Pneumoperitoneum may be purposely introduced to aid radiological examination. Perforated Viscus)
      •  Dull ( ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites or blood)
    • Auscultation: 
    • Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination
      • Typically, diffuse tenderness in all quadrants
      • Can have more pronounced tenderness in one site, which could help narrow the diagnosis
    • Peritoneal signs:
      • Rebound tenderness: Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is suddenly worse when manual pressure is removed.
      • Guarding: involuntary or voluntary contraction of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen
      • Rigidity Rigidity Continuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity. Megacolon: constant involuntary abdominal muscle contraction

Diagnosis

Laboratory studies

  • CBC:
  • Basic metabolic panel Basic Metabolic Panel Primary vs Secondary Headaches: ↑ BUN and creatinine 
  • Amylase Amylase A group of amylolytic enzymes that cleave starch, glycogen, and related alpha-1, 4-glucans. Digestion and Absorption and lipase Lipase An enzyme of the hydrolase class that catalyzes the reaction of triacylglycerol and water to yield diacylglycerol and a fatty acid anion. It is produced by glands on the tongue and by the pancreas and initiates the digestion of dietary fats. Malabsorption and Maldigestion: ↑ in cases of pancreatitis Pancreatitis Inflammation of the pancreas. Pancreatitis is classified as acute unless there are computed tomographic or endoscopic retrograde cholangiopancreatographic findings of chronic pancreatitis. The two most common forms of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis. Acute Pancreatitis
  • Hepatic function panel:
    •  ↑ or normal total and direct bilirubin Direct bilirubin Liver Function Tests
    •  ↑ or normal liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body’s constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes
  • Lactate: high levels indicative of sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock/hypoperfusion
  • Urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children: to rule out urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infection
  • Infectious Infectious Febrile Infant stool panel
  • Blood cultures Cultures Klebsiella

Imaging studies

  • X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests:
    • Upright chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests:
      • First-line imaging in evaluating a patient with abdominal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways to rule out perforated viscus Perforated Viscus Perforated viscus or GI perforation represents a condition in which the integrity of the GI wall is lost with subsequent leakage of enteric contents into the peritoneal cavity, resulting in peritonitis. The causes of perforated viscus include trauma, bowel ischemia, infections, or ulcerative conditions, all of which ultimately lead to a full-thickness disruption of the intestinal wall. Perforated Viscus
      • Can identify as little as 1 mL of intra-abdominal free air
      • Can also reveal significant gastric dilation
    • Lateral decubitus abdominal film:
      • Can detect 5–10 mL of intra-abdominal free air
      • Identifies dilated loops of bowel, air fluid levels Air Fluid Levels Imaging of the Intestines, and volvulus Volvulus A volvulus is the twisting or axial rotation of a portion of the bowel around its mesentery. The most common site of volvulus in adults is the colon; most frequently the sigmoid volvulus. Patients typically present with symptoms of bowel obstruction such as abdominal pain, distension, vomiting, and constipation/obstipation. Volvulus
  • Abdominal ultrasonography:
  • CT scan:
    • Second-line test after plain films
    • IV contrast and oral contrast (if tolerating oral intake)
    • Very specific for intra-abdominal pathology:
      • Perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis: free air
      • Bowel obstruction Bowel obstruction Any impairment, arrest, or reversal of the normal flow of intestinal contents toward the anal canal. Ascaris/Ascariasis with dilated loops of bowel and air fluid levels Air Fluid Levels Imaging of the Intestines
      • Bowel ischemia Bowel ischemia Mesenteric ischemia is a rare, life-threatening condition caused by inadequate blood flow through the mesenteric vessels, which results in ischemia and necrosis of the intestinal wall. Mesenteric ischemia can be either acute or chronic. Mesenteric Ischemia with pneumatosis, enhancing intestinal walls and portal venous gas Portal Venous Gas Imaging of the Intestines
      • Intra-abdominal hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception: with IV contrast can identify a vascular source
A chest radiograph demonstrating pneumoperitoneum

Upright chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests showing pneumoperitoneum Pneumoperitoneum A condition with trapped gas or air in the peritoneal cavity, usually secondary to perforation of the internal organs such as the lung and the gastrointestinal tract, or to recent surgery. Pneumoperitoneum may be purposely introduced to aid radiological examination. Perforated Viscus (arrows)

Image: “A chest radiograph demonstrating pneumoperitoneum Pneumoperitoneum A condition with trapped gas or air in the peritoneal cavity, usually secondary to perforation of the internal organs such as the lung and the gastrointestinal tract, or to recent surgery. Pneumoperitoneum may be purposely introduced to aid radiological examination. Perforated Viscus” by Manabu Kaneko et al AL Amyloidosis. License: CC BY 4.0

Management

Acute abdomen is a surgical emergency or urgency in the vast majority of cases. The initial evaluation should determine the cases that do not require surgical treatment.

Initial management

Resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome:

  • The first step should always be resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome of the patient.
  • Obtain reliable large-bore IV access.
  • Fluid bolus of 30 mL/kg for hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension and tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children
  • Electrolyte correction
  • Airway Airway ABCDE Assessment protection/mechanical ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing for impaired mental status or respiratory distress
  • Broad-spectrum Broad-Spectrum Fluoroquinolones IV antibiotics can be administered empirically.
  • Pain management Pain Management Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Pain Management

Evaluation:

  • Thorough history and physical exam 
  • Obtain labs, including CBC, basic metabolic panel Basic Metabolic Panel Primary vs Secondary Headaches, lactate, hepatic function panel.
  • Early blood cultures Cultures Klebsiella
  • Imaging:
    • In the majority of cases, there is at least time to obtain an upright chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests to evaluate for free air.
    • Free air on imaging is an indication for immediate surgical intervention.
    • Without evidence of free air in a stable patient, there is time to obtain a CT scan.

Operative management

Surgical treatment is usually needed unless a nonsurgical cause has been established. If surgical intervention is warranted, there are two approaches:

  • Diagnostic laparoscopy Diagnostic Laparoscopy Laparotomy and Laparoscopy:
    • Minimally invasive approach using a laparoscope Laparoscope Endoscopes for examining the abdominal and pelvic organs in the peritoneal cavity. Laparotomy and Laparoscopy to explore the abdomen
    • Most helpful in triaging the abdomen and deciding whether an open approach is needed
    • Sometimes, a definitive intervention can be performed laparoscopically.
    • Technically limited in difficult-to-access areas and complex surgical repairs
    • Should be avoided in cases of significantly dilated bowel owing to risk of perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis with port insertion and laparoscopic instruments
    • Should not be performed in cases in which diagnosis is clear and open intervention will definitely be required
  • Exploratory laparotomy Exploratory Laparotomy Laparotomy and Laparoscopy:
    • Open surgical approach, typically through a midline incision
    • Allows for visual and tactile examination of all the abdominal quadrants and their contents
    • Approach of choice in cases of gross abdominal contamination with bile Bile An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts; cholesterol; and electrolytes. It aids digestion of fats in the duodenum. Gallbladder and Biliary Tract: Anatomy or enteric contents
    • Allows for repair of the source of contamination as well as irrigation of the abdominal cavity

References

  1. Squires, R. A., Postier, R. G. (2012). In Mattox, K. L., Evers, B. M., Beauchamp, R. D., Townsend, C. M. (Eds.), Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 19th ed. pp. 1141–1159.
  2. Penner, R. M., Fishman, M. B. (2020). Evaluation of the adult with abdominal pain. In Kunins L. (Ed.), UpToDate. Retrieved April 4, 2021, from https://www.uptodate.com/contents/evaluation-of-the-adult-with-abdominal-pain
  3. Cahalane, M. J. (2019). Overview of gastrointestinal tract perforation. In Chen, W. (Ed.), UpToDate. Retrieved April 4, 2021, from https://www.uptodate.com/contents/overview-of-gastrointestinal-tract-perforation
  4. Bordejanou, L., Yeh, D. D. (2020). Management of small bowel obstruction in adults. In Chen, W. (Ed.), UpToDate. Retrieved April 4, 2021, from https://www.uptodate.com/contents/management-of-small-bowel-obstruction-in-adults
  5. Daley, B. J. (2019). Peritonitis and abdominal sepsis. In Roy, P. K. (Ed.), Medscape. Retrieved April 6, 2021, from https://emedicine.medscape.com/article/180234-overview#a2

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