AA=a sudden, severe abdominal pain of unclear etiology. Most patients are found to have self limited conditions. A subset of patients have a serious… [601423]

Acute Abdominal
syndrome
Dr.Lucian Palli
Surgery Department
USMF

Acute Abdomen
AA=a sudden, severe  abdominal pain  of
unclear etiology.
Most patients are found to have self
limited conditions.
A subset of patients have a serious
intraabdominal disease that requires
urgent surgical or medical intervention.
Early diagnosis is the key to outcome
improvement.

Abdominal Anatomy

Abdominal Pain
Acute abdominal pain is the hallmark of an
acute abdomen
It may originate from any organ in the
abdominal cavity
Understanding the mechanisms of pain
production and the physiology of pain
perception allows a more accurate diagnostic

Abdominal Cauze s
Gastrointestinal:
 ApendicitaApendicita
 Ulcer perforativUlcer perforativ
 Obstrucție intestinalăObstrucție intestinală
 Perforație intestinalăPerforație intestinală
 Ischemia intestinalăIschemia intestinală
 Diverticulita colonicăDiverticulita colonică
 Inflamația diverticulului MeckelInflamația diverticulului Meckel
 Afecțiuni inflamatorii a Afecțiuni inflamatorii a
intestinuluiintestinului
Pancreatic, Biliar y, Hepatic și
Splenic:
 Pancreatita acutăPancreatita acută
 Colecistita acutăColecistita acută
 Abces hepaticAbces hepatic
 Tumor hepatic rupt sau Tumor hepatic rupt sau
hemoragichemoragic
 Hepatita acutăHepatita acută
 Colangită acutăColangită acută
 Ruptura de splinăRuptura de splină Urological:
 Calculi ureteraliCalculi ureterali
 PielonefritaPielonefrita
Retroperitoneal:
 Anevrism de aortăAnevrism de aortă
 Hemoragie Hemoragie
retroperitonealăretroperitoneală

Ginecologic al :
 Chist ovarian eruptChist ovarian erupt
 Torsiune de ovarTorsiune de ovar
 Sarcina ectopicăSarcina ectopică
 Salpingita acută Salpingita acută , ,
PiosalpinxPiosalpinx
 EndometritaEndometrita
 Ruptura de uterRuptura de uter
abdominal wall :
 Hematoma mușchilor Hematoma mușchilor
recți abdominalirecți abdominali
 Hernii strangulateHernii strangulate

Extraabdominal Causes AA
Toracic:
 Infarct de miocardInfarct de miocard
 Pericardita acutăPericardita acută
 Pneumonia lobului bazalPneumonia lobului bazal
 PneumotoraxPneumotorax
 Infarct pulmonarInfarct pulmonar
Hematologic al :
 Leucemia acutăLeucemia acută
Neurologic al :
 Herpes zosterHerpes zoster
 Tabes dorsalisTabes dorsalis
 Compresia radiculilor nervoșiCompresia radiculilor nervoșiMetabolic:
 Cetoacidoza diabeticăCetoacidoza diabetică
 Criza AddisonianăCriza Addisoniană
 Porfiria acutăPorfiria acută
 HiperlipoproteinemiaHiperlipoproteinemia
Toxines:
 Intoxicație cu plumbIntoxicație cu plumb
 Revenire după narcoticeRevenire după narcotice

CLASIFICAREA AA
Abdomen acut
Abdomen acut
traumaticAbdomen acut
netraumatic
Abdomen acut
medicalAbdomen acut
falsAbdomen acut
medico-
chirurgicalAbdomen acut
chirurgical

Abdominal Pain
Pain may be visceral, somatic or referred
Visceral pain is characterized by dullness, poor
localization, cramping, burning or gnawing
Visceral pain is mediated by autonomic
(sympathetic and parasympathetic) nerves
The pain location corresponds to the involved
organs dermatomes.

Aprofundarea diagnosticului
în AAC
I.I. Diagnostic deDiagnostic de
sindromsindrom
 PeritoniticPeritonitic
 OclusivOclusiv
 HemoragicHemoragic
 Torsiune de organTorsiune de organ
II. Diagnostic deII. Diagnostic de
boalăboală
 Ulcer perforatUlcer perforat
 Volvus de sigmoid etcVolvus de sigmoid etc..AAC
Diagnostic de sindrom
Diagnostic de boală

Nozologii frecvente AAC

Etiology
Gastrointestinal –
Appendicitis
Perforated Ulcer
Intestinal Perforation
Intestinal Obstruction
Intestinal Ischemia
Diverticulitis
Pancreas,Liver,Gallblader&
Spleen –
Acute Pancreatitis
Acute Cholycystitis
Acute Cholangitis
Acute Hepatitis
Hepatic Tumor
Hepatic Abscess
Spleenic Rupture
Gynecology –
Uterine Rupture
Ovarian Cyst Rupture
Ovarian Torsion
Acute Salpingitis
Endometritis
Urologic Diseases –
Urolithiasis
Pyelonephritis
Retroperitoneal –
Aortic Aneurysm
Retroperitoneal Hemorrhage
Abdominal wall –
Strangulated Hernia
Abdominal muscles
Hematoma.

NB! Evoluția durerii
În evoluția durerii există uneori În evoluția durerii există uneori acalmii acalmii
înșelătoare, înșelătoare, periculoase, realizate prin periculoase, realizate prin
următoarele mecanismeurmătoarele mecanisme: :
a. a. Spontane:
– – acoperirea perforației prin epiploon, acoperirea perforației prin epiploon,
viscereviscere; ;
– – analgezic endogene analgezic endogene (endorfine(endorfine ))
– – necroza organuluinecroza organului. .
 b. b. Provocate:
– – administrarea anticipată de antibiotice, administrarea anticipată de antibiotice,
antialgice antialgice (constituie o greșeală regretabilă (constituie o greșeală regretabilă
atât timp cât lipsește diagnosticulatât timp cât lipsește diagnosticul););
– – tratamente cu corticosteroizi — tratamente cu corticosteroizi — perforația perforația
poate fi însoțită de durere minimăpoate fi însoțită de durere minimă..

Appendicitis
Usually due to
obstruction with
fecalith
Appendix becomes
swollen, inflamed->
gangrene-> possible
perforation

Appendicitis
Pain begins periumbilical, then moves to RLQ
Nausea, vomiting, anorexia, fever (signs of intoxication,
infection)
The patient lies on a side; right hip and knee are flexed
Pain may not be localized in the RLQ if appendix has
uncommon location
Sudden relief of pain = possible perforation (..!)

Bowel Obstruction
Intestine blockage from the inside
Normal flow of contents interruption
Causes include: adhesions, hernias,
fecal impact, tumors
Cramping abdominal pain, nausea,
vomiting (often of fecal matter),
abdominal distension;

Bowel Obstruction

Acute Cholecystitis
The most common symptom: Biliary colic
Pain may radiate to the right shoulder or
scapula
The pain is colicky and it is associated with
nausea and vomiting
Murphy’s sign/acute abdomen
Ultrasound/HIDA/DISIDA Scans

Acute Cholecystitis

Diverticulitis
Pouches become
blocked and infected
with fecal matter
causing inflammation.
Pain, perforation,
severe peritonitis.

Diverticulitis

Peptic Ulcer Disease
 Steady, well-localized
epigastric or LUQ pain
 Described as a
“burning”, “gnawing”,
“aching”
 Increased by coffee,
stress, spicy food,
smoking
 Decreased by alkaline
food, antacids

Peptic Ulcer Disease
Erosion of the lining of the stomach,
duodenum, or esophagus
May cause massive GI bleed
Patient lies very still, complaining of intense,
steady pain, rigid abdomen at the exam,
suspect perforation.

Perforated Ulcer
Chest x-rays may show segmental atelectasis, pleural
effusions and an elevated left hemidiaphragm;
KUB may show the “sentinel loop” and psoas shadow loss;
CT scan with double contrast will show pancreatic edema,
retroperitoneal inflammation, and pancreatic necrosis areas.

Perforated Ulcer

Ectopic Pregnancy
Fertilized egg is
implanted outside
the uterus.
Growth causes
rupture-> massive
bleeding.
Patient c/o of
severe RLQ or LLQ
pain with radiation.

Esophageal Varices
Dilated veins in lower
part of the esophagus
Common in EtOH
abusers, patients with
liver disease
Produce massive
upper GI bleeds

Gastroesophageal Reflux
Also known as
GERD
Signs and
symptoms can
mimic cardiac pain.
Onset is usually
after eating.
Typically resolved
with medication.

Inguinal Hernia
Protrusion of the
intestine through the
inguinal canal;
Usually identified by
abnormal mass in
lower quadrant, with
or without pain;
Strangulation can
lead to necrosis.

Kidney Stone
Mineral deposits are
formed in kidney,then
move in the ureter;
Often associated with
recent UTI history;
Severe flank pain
radiates to groin,
scrotum;
Nausea, vomiting,
hematuria;
Extreme restlessness.

Acute Pancreatitis
Acute onset;
Abdomen tenderness, but rarely there are
true peritoneal signs;
Grey Turner’s sign, Cullen’s sign and Fox’s
sign are infrequently seen;
Serum amylase and lipase are the
biochemical hallmarks;
Ranson’s criteria is used to torture surgical
housestaff – APACHE Score.

Acute Pancreatitis

Pelvic Inflammatory Disease
Inflammation of
the fallopian
tubes and tissues
of the pelvis;
Typically lower
abdominal or
pelvic pain,
nausea, vomiting
occur.

Splenic Trauma
Blunt force trauma is
typical MOI.
Signs and symptoms
may not develop in first
24 hours.
Pain usually in LUQ but
may be present
atypically in other
quadrants.

Signs and Symptoms
Local/diffuse
abdominal pain or
tenderness
Abdominal Guarding
Rapid, shallow
breathing
Referred pain
Rebound tendernessAnorexia, nausea,
vomiting
Abdominal distension
Constipation or bloody
stool
Tachycardia
Hypotension
Fever

History
Where does it hurt?
Know locations of major organs
But realize abdominal pain locations do
not correlate well with the source

History (2 )
Was the pain onset gradual or sudden?
Gradual = peritoneal irritation or hollow organ
distension
Sudden = perforation, hemorrhage, infarct
What does the pain feel like?
Steady pain – inflammatory process
Crampy pain – obstructive process

History (3 )
Does the pain radiate (travel) anywhere?
Right shoulder, angle of right scapula =
gallbladder, liver, spleen
Around flank to groin = kidney, ureter

Referred Pain Locations

History (4 )
Duration?
Nausea, vomiting? Bloody? (Coffee grounds
emesis?)
Change in urinary habits? Urine appearance?
Change in bowel habits? Melena (Dark, tarry
stools?)
Regular food/water intake?

History (5 )
Females:
Last menstrual period?
Abnormal bleeding?
In females, abdominal pain =
GYN problem until proven otherwise

Physical Exam
General Appearance
Lies perfectly still suspect
inflammation, peritonitis
Restless, writhing suspect
obstruction
Abdominal distension?
Ecchymosis around umbilicus, on flanks?
Obvious bleeding noted?

Physical Exam (2 )
Vital signs
Tachycardia  ? Early shock
(more important than BP)
Rapid shallow breathing 
peritonitis
Postural changes may indicate
internal bleeding
Signs of shock?

Physical Exam (3 )
Palpate each
quadrant
Going towards painfull area
Warm hands
Patient on back, knee bent
(if possible)
Note tenderness, rigidity,
guarding, masses

Special Considerations
In adults > 30 , consider possibility of referred
cardiac pain .
In females, consider possible gyn problem,
especially tubal ectopic pregnancy
Geriatric patients may present with atypical signs
and symptoms
Never underestimate trauma injury

Laborator y
 Global analysis of blood
 Global analysis of urine,
 biochemical blood test,
 coagulogram.
Determinarea α-amilazeiDeterminarea α-amilazei and and
EElectrolitlectrolit eses

Imaging
Bedside films vs. In Department-
 CXR – free air, effusions.
 Abdominal films – colonic volvulus, obstruction,
stones, pneumobilia.
 US – biliary system.
 CT – little use in 1st post-op week for abscess.
 Angiography – mesenteric ischemia, GI bleeds.
Endoscopy – UGI bleed, colonic ischemia.

Laparoscop y
 High High diagnosticdiagnostic accurancy accurancy
 Low Low Risc Risc (complica(complica tions tions
3,6%3,6%))
● Vizualizarea directă a organelor intraabdominaleVizualizarea directă a organelor intraabdominale
● Mărirea imaginiiMărirea imaginii
● Posibilitatea completării cu unele măsuri curativePosibilitatea completării cu unele măsuri curative

General rules
 Forbiden Forbiden administraadministra tion oftion of : :
 opioideopioidess
 antibioticantibiotic ss
 corticosteroizcorticosteroiz dsds
 purgativepurgative ss ..
● Bolnavul este îndrumat în serviciu chirurgical cîtBolnavul este îndrumat în serviciu chirurgical cît
mai rapid posibilmai rapid posibil
● Rezultatele depind de precocitatea intervențieiRezultatele depind de precocitatea intervenției
chirurgicalechirurgicale
● Nu există abdomenul acut chirurgical „depășit” careNu există abdomenul acut chirurgical „depășit” care
să impună abținerea de la intervenția de urgență.să impună abținerea de la intervenția de urgență.

When to Operate ?
Peritonitis
Tenderness w/ rebound, involuntary guarding
Severe / unrelenting pain
“Unstable” (hemodynamically, or septic)
Tachycardic, hypotensive, white count
Intestinal ischemia, including strangulation
Pneumoperitoneum
Complete or “high grade” obstruction

Medicine is my lawful wife and literature is my mistress; when I get
tired of one, I spend the night with the other. 
-Anton Chekhov