9.
Acute Abdomen
Definition
Acute abdomen is a condition where the patient experiences moderate to severe
abdominal pain of less than 24h duration
Has many causes and only after a thorough history taking and complete PE aided by
laboratory and radiologic examination, can a physician differentiate those conditions
needing surgical vs medical management
Pathogenesis
Depends on the particular disease entity but abdominal pain is divided into
neuroanatomic categories: visceral, somatic , and referred.
VISCERAL PAIN SOMATIC PAIN REFERRED PAIN
PAIN TRANSMISSION Unmyelinated C fibers Myelinated A-δ fibers Interplay b/w 2 fibers
CHARACTER Dull, crampy, gnawing, Sharp, sudden, well Felt in areas distant
midline, difficult to localize localized pain from the diseased organ
MECHANISM Obstruction, ischemia, or Irritation of Visceral and somatic
inflammation can cause myelinated fibers that afferent neurons from a
stretching of unmyelinated innervate the parietal different anatomic
fibers that innervate the walls peritoneum. region converge on 2nd
or capsules of organs. order neurons on the
The pain can be spinal cord at the same
Visceral afferent nerves localized to the spinal segment.
follow a segmental dermatome
distribution and is therefore superficial to the site For example, ureteral
localized by the sensory of the pain stimulus. obstruction presents
cortex to an approximate with ipsilateral testicular
spinal cord level. pain. Pain is always
Intraperitoneal organs are perceived on the same
innervated bilaterally and the side as the involved
stimuli are sent to both sides organ because it is not
of the spinal cord causing mediated fibers that
intraperitoneal visceral to be provide bilateral
felt midline innervation of the cord
Probable etiologies depending on the Location of Pain
DIFFUSE PAIN: (DEGGSA) DKA, Early appendicitis, Gastroenteritis, Generalized peritonitis, Small
bowel obstruction, abdominal aortic aneurysm dissected or ruptured
RUQ pain (gallbladder, bileduct, liver) Biliary LUQ pain (Stomach, Heart, pancreas)
colic, Cholangitis, Cholecystitis, Hepatits, Peptic ulcer disease complicated, Gastritis,
Hepatic congestion Hepatic abscess, MI MI, Pancreatitis, Splenic rupture
RLQ pain (appendix, cecum, small LLQ pain
instestines, ascending colon, adnexa, Same + sigmoid CA, colorectal CA except
testicles, ureter) Appendicitis, Cecal without acute AP and meckel’s diverticulum
diverticulitis/carcinoma, Incarcerated,
strangulated hernia, meckel’s diverticulum,
colon CA, diverticultis, acute mesenteric
ischemia ureteral calculi, ectopic pregnancy,
PID, testicular torsion, ovarian torsion,
endometriosis
DISCUSS ACUTE CHOLANGITIS, ACUTE APPENDICITIS or MECHANICAL INTESTINAL
OBSTRUCTION
Additional DDX:
Acute cholecystitis
Definition: Is the inflammation of the gallbladder secondary to gallstone disease.
Less often, acute cholecystitis develop without gallstones( acalculous
cholecystitis)
Clinical manifestation: Characterized by a triad of RUQ PAIN, FEVER AND
LEUKOCYTOSIS accompanied by gallbladder inflammation
RUQ pain described as - “biliary colic”- steady, severe, prolonged (greater than 4
to 6 hours) radiating to the right shoulder, scapula or back precipitated by fatty
food ingestion 1 hour before
Associated symptoms fever, nausea, vomiting and anorexia
Physical examination:+ RUQ tenderness and + Murphy’s sign ( hook fingers
deeply beneath the right costal margin while the patient takes a deep breath,
+mid inspiratory arrest
Laboratory findings: leukocytosis shift to the left
Imaging: Ultrasound- + sonographic murphy’s sign, edema(double wall sign,
gallstone, gallbladder thickening >3mm, distented GB lumen > 4mm,
Pericholecystic fluid collection, Impacted stone in cystic duct
If diagnosis is uncertain after utz the Gold standard test is : Cholescintigraphy
(Hepatobiliary IminoDiAcetic scan)- radioactive chemical technecium 99m
given via IV removed from blood via liver and secreted into bile goes to
gallbladder and bile ducts and a gamma camera sense the radioactivity. If no
cystic blockage it will go to gall bladder. + result non visualization of the
gallbladder
CT SCAN- to rule out complications
Management- Admit to hospital give supportive care:
IV hydration
Correction of electrolyte imbalance
Pain control- NSAID Ketorolac 30mg/tab for biliary colic
and inflammation– watch out for renal insufficiency or
Opiods Morphine, Meperidine – leads to sphincter of Oddi
contraction
IV antibiotics- important since cholecytitis is commonly
accompanied with secondary infections of gallbladder.
Guidelines suggest routinely administering antibiotics to
all patients diagnosed with acute cholecystitis until
gallbladder is removed. Cover for klebsiella,
ecoli,enterococci, pseudomonas, bacteroides, clostridium
(keep bc)
o Ampicillin/Sulbactam
o Piperacillin/tazobactam
o Ertapenem
o Ciprofloxacin + Metronidazole
o Cefepime
Mainstay of treatment: Cholecystectomy unless poor surgical candidate
perofrom non operative management first with antibiotics
o EMERGENCY CHOLECYSTECTOMY- for complicated acute
cholecystitis since it may be fatal!!!
Complications: gangrenous cholecystitis (gangrene of the bldder wall) leading to
sepsis , gallbladder perforation leading to peritonitis, emphysematous
cholecystitis (cause by gas forming organism) leading to abdominal crepitus, and
gallstone ileus leading to bowel obstruction
Prognosis: Uncomplicated acutecholecystitis has an excellent prognosis. Most
have complete remission within 1-4 days however 25-30 % will require surgery.
Once with complications- less favorable
Mortality rate of calculous cholecystitis- 4%, Acalculous
cholecystitis- 10 to 50%. In acalculous cholecystitis plus
perforation 50 to 60%
