General Surgery [ACUTE ABDOMEN]
Categorization of Abdominal Pain
Obstruction is usually colicky (comes and goes) with contraction Peritoneal Signs
of the obstructed lumen. The pain is localized - generally near the 1) Abdominal Pain
area of the affected organ (gallbladder, kidney). The patient will 2) Involuntary Guarding SURGERY!
squirm to try to find comfort, but will find none. If there are signs 3) Rebound
of peritoneal irritation (though there are often none) they will be
localized. Systemic Findings of Inflammation
1) Fever
Perforation presents with a sudden onset of abdominal pain that 2) Leukocytosis
is both vague and persistent. It is severe. This person will lay 3) Tachycardia
motionless in fear that any movement will slosh fluid around and
aggravate their pain. There will be obvious peritoneal signs. For more information on “Acute Abdomen” aka
“Abdominal Pain for Surgery” check out the associated GI
Inflammation has a crescendo abdominal pain that becomes content
constant and is localized - as is the peritoneal pain. Inflammation
causes systemic findings: fever + leukocytosis.
Ischemia of visceral organs causes necrosis. This presents with a
sudden onset abdominal pain that is out of proportion to the
physical exam. There are no signs of peritoneal irritation; there
may be bloody stool if the gut is affected. Look for the old guy
whose status is post MI (shock) or with Afib (arterial emboli).
Intervene early rather than later.
Management
If the acute abdomen is more than just abdominal pain, in that
there are peritoneal findings, the only option is Ex-Lap.
Finding the correct cause isn’t necessary, but testing is often done.
An upright X-ray will demonstrate free air under the
diaphragm and a CT scan can likely give the correct diagnosis.
Before cutting get the usual tests to rule out mimickers of Acute
Abdomen pain and identify risk factors for surgery: CXR (lower
lobe pneumonia), EKG (MI), and Amylase/Lipase (pancreatitis).
Finally, if the patient is at risk for spontaneous bacterial
peritonitis (larger amount of ascites), a paracentesis may be done
in conjunction with treatment against the bacteria. All other
causes of abdominal pain are covered in their respective sections.
Type Timing Pain Peritoneal Timing Patient Dx Tx Examples
Perforation Sudden Severe Generalized Constant Motionless Upright KUB Ex-Lap Duodenal Ulcer,
Onset Chicken Bone,
Iatrogenic
Obstruction Sudden Severe Localized Colicky Moving U/S or CT Variable Cholecystitis,
Onset Around scan Ureteral Stone,
Ectopic Pregnancy
Inflammation Crescendo Severe Localized Constant @ Fever + U/S or CT Variable Diverticulitis
maximum Leukocytosis scan Appendicitis
intensity Pancreatitis
Salpingitis
Cholecystitis
Ischemia Sudden Severe out of Generalized Constant Bloody Arteriogram, Ex-Lap Mesenteric
Onset proportion to Diarrhea, s/p Colonoscopy Ischemia
physical MI or Afib
exam
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