Acute Abdomen

Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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, ischemia, or obstruction. The location of the pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, 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 will typically have severe tenderness with associated rigidity and rebound tenderness. Laboratory evaluation will demonstrate leukocytosis, 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 to evaluate for pneumoperitoneum. The treatment and prognosis of acute abdomen strongly depend on the underlying cause, but the vast majority of these cases constitute a surgical emergency with associated morbidity and mortality.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Acute abdomen is the constellation of signs and symptoms associated with severe abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and peritonitis that frequently requires emergency surgical intervention.

Epidemiology

  • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, in general, comprises 5%–10% of ED visits.
  • About ⅓ of patients > 65 years old with abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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
      • 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

Etiology

Nonsurgical causes of acute abdomen:

  • Endocrine/metabolic causes:
    • Acute intermittent porphyria
    • Hereditary Mediterranean 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
    • Uremia
    • Diabetic ketoacidosis Diabetic ketoacidosis Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are serious, acute complications of diabetes mellitus. Diabetic ketoacidosis is characterized by hyperglycemia and ketoacidosis due to an absolute insulin deficiency. Hyperglycemic Crises
  • Hematologic causes:
    • Sickle cell crisis
    • Acute leukemia
  • Toxins and drugs:
    • Lead poisoning
    • Narcotic withdrawal
    • Black widow spider poisoning

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. Extremity and Visceral Aneurysms
    • Hemorrhagic pancreatitis (usually does not require surgical intervention initially)
    • Mallory–Weiss tear
    • Ruptured ectopic pregnancy Ectopic pregnancy Ectopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity. The main cause is disruption of the normal anatomy of the fallopian tube. Ectopic Pregnancy
  • 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
    • Hepatic abscess
    • Meckel diverticulitis
  • Perforation:
    • Perforated gastric ulcer
    • Perforated diverticulum
    • Perforated tumor
    • Boerhaave syndrome
  • Obstruction:
    • Small- or large-bowel obstruction due to adhesions or malignancy
    • 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
    • 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:
    • Mesenteric thrombosis 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
    • 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

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
  • Inferiorly: pelvic inlet
  • Anteriorly: abdominal wall muscles and lower ribs
  • Posteriorly: ribs, spine, 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 (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
  • 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
  • Pylorus 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
  • First 3 parts of the duodenum
  • 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
  • Right kidney
  • Right adrenal gland
  • Distal ascending 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
  • 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
  • Right half of the transverse 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
Left upper quadrant (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
  • Spleen
  • Stomach
  • Jejunum
  • Proximal ileum
  • 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
  • Left kidney
  • Left adrenal gland
  • Left half of the transverse 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
  • Splenic 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
  • Superior part of the descending 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
Right lower quadrant (RLQ):
  • Majority of the ileum
  • Cecum and appendix
  • Proximal ascending 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
  • Proximal right ureter
  • Right ovary
  • Right uterine tube
  • Right half of the uterus
  • Right half of the urinary bladder
Left lower quadrant (LLQ):
  • Distal descending 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
  • Sigmoid 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
  • Left ureter
  • Left ovary
  • Left uterine tube
  • Left half of the uterus
  • Left half of the urinary bladder

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
    • Intertubercular line: connects the tubercles of the iliac crests
  • 2 vertical lines: right and left midclavicular lines
Right hypochondriac region Epigastric region Left hypochondriac region
Right lumbar region Umbilical region Left lumbar region
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.

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

Internal anatomy

Relationship of intra-abdominal organs to peritoneal cavity:

  • Intraperitoneal:
    • Stomach 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
    • Liver
    • Spleen
    • Transverse 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
    • Duodenal bulb and pancreatic tail
  • Extraperitoneal: bladder
  • Retroperitoneal organs can be grouped in the SAD PUCKER mnemonic:
    • Suprarenal glands 
    • Aorta and inferior vena cava
    • Duodenum (except the 1st part)
    • Pancreas (except the tail)
    • Ureters
    • Colon (descending and ascending)
    • Kidneys
    • Esophagus
    • Rectum

Pain 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, intestines)
    • Pain:
      • Vague and poorly localized 
      • Epigastric, periumbilical, or hypogastric in location
  • Parietal 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 and Retroperitoneum
    • Transmit the pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Referred pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain:
    • Pain perceived at a site different from the source of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain:
    • Onset
    • Location
    • Duration
    • Description
    • Radiation
    • Severity
    • Aggravating or alleviating factors: Peritonitis is classically exacerbated by movement.
  • Associated symptoms:
    • Nausea
    • Vomiting
    • Diarrhea
    • Melena or hematochezia
    • Fever
  • Past history:
    • Previous similar episodes
    • Underlying medical conditions
    • Preceding trauma (car accident, assault)
    • Prior abdominal surgeries
    • Recent travel, toxic exposures, food poisoning

Physical examination

  • Exam should always start with visual inspection to note things such as: 
    • Jaundice
    • Pallor
    • Work of breathing
    • Patient’s behavior:
      • Trying to lie still
      • Grimacing 
  • A full set of vital signs should be obtained and constitutional signs noted:
    • Fever
    • Tachycardia
    • 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
    • Altered mental status
  • A thorough abdominal exam should be completed:
    • Inspection:
      • Distention
      • Bruising (Cullen or Grey–Turner sign: hemorrhagic 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. Structure and Function of the Skin discoloration (would suggest strangulated hernia)
    • Percussion: 
      • Tympanic (bowel distention or pneumoperitoneum)
      •  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: 
      • Typically, acute abdomen will be associated with hypoactive or absent bowel sounds.
      • Can have hyperactive bowel sounds in cases of high-grade bowel obstruction
    • Palpation: 
      • 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 is suddenly worse when manual pressure is removed.
      • Guarding: involuntary or voluntary contraction of the abdominal wall
      • Rigidity: constant involuntary abdominal muscle contraction

Diagnosis

Laboratory studies

  • CBC:
    • ↑ WBCs
    • ↓ or  ↑ hemoglobin (bleeding versus hemoconcentration due to dehydration)
  • Basic metabolic panel: ↑ BUN and creatinine 
  • Amylase and lipase: ↑ in cases of pancreatitis
  • Hepatic function panel:
    •  ↑ or normal total and direct bilirubin
    •  ↑ 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 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 Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock/hypoperfusion
  • Urinalysis: 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 infection
  • Infectious stool panel
  • Blood cultures

Imaging studies

  • X-ray:
    • Upright chest X-ray:
      • First-line imaging in evaluating a patient with abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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, and volvulus
  • Abdominal ultrasonography:
    • Right upper quadrant:
      • 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 pathology
      • Hepatic pathology
      • Evaluate for free fluid
    • Right lower quadrant:
      • Appendiceal pathology
      • Ovarian and adnexal pathology
  • CT scan:
    • Second-line test after plain films
    • IV contrast and oral contrast (if tolerating oral intake)
    • Very specific for intra-abdominal pathology:
      • Perforation: free air
      • Bowel obstruction with dilated loops of bowel and air fluid levels
      • Bowel ischemia with pneumatosis, enhancing intestinal walls and portal venous gas
      • Intra-abdominal hematoma: with IV contrast can identify a vascular source
A chest radiograph demonstrating pneumoperitoneum

Upright chest X-ray showing pneumoperitoneum (arrows)

Image: “A chest radiograph demonstrating pneumoperitoneum” by Manabu Kaneko et al. 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:

  • The first step should always be resuscitation of the patient.
  • Obtain reliable large-bore IV access.
  • Fluid bolus of 30 mL/kg for hypotension and tachycardia
  • Electrolyte correction
  • Airway protection/mechanical ventilation for impaired mental status or respiratory distress
  • Broad-spectrum 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, lactate, hepatic function panel.
  • Early blood cultures
  • Imaging:
    • In the majority of cases, there is at least time to obtain an upright chest X-ray 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 Laparoscopy Laparoscopy is surgical exploration and interventions performed through small incisions with a camera and long instruments. Laparotomy and Laparoscopy:
    • Minimally invasive approach using a laparoscope 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 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 Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. 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 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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