Acute Abdomen : Case Discussions

Adianto Nugroho
Consultant Digestive Surgeon
adiyusuf97@gmail.com

Acute Abdomen refers to abdominal pain of short duration that requires a

decision regarding whether an urgent intervention is necessary. Instead of consider
the 50 or so “most likely” causes of acute abdominal pain from the list, tries to
identify a clinical pattern and to decide on a course of action from a limited menu of
management options.

Course of Action
Clinical Pattern
1. Immediate Operation
1. Abdominal Pain and Shock 2. Preoperative preparation, then
2. Generalized Peritonitis operation
3. Localized Peritonitis 3. Conservative treatment
4. Intestinal Obstruction (active observation, IV fluids,
5. Waste Basket antibiotics)
6. Gynecological 4. Discharge home
7. Trauma

Abdominal Pain and Shock

Most dramatic, but fortunately least common

Pale, diaphoretic in severe abdominal pain, with hypotension

Most common:
o ruptured ectopic pregnancy
o ruptured abdominal aortic aneurysm

Management: immediate surgery

Generalized Peritonitis

Diffuse severe abdominal pain in sick and toxic patient

Pitfalls: geriatric, “rough and deep palpation”

Most common
o perforated ulcer
o colonic perforation
o perforated appen- dicitis

Management: preoperative preparation, then operation

Important exception: acute pancreatitis (measure amylase and lipase)

1
Localized Peritonitis

The clinical signs are confined to one quadrant of the abdomen

Most common:
o acute appendicitis (right lower)
o acute cholecystitis (righ upper)
o acute diverticulitis (left lower)

Peritonitis confined to the left upper quadrant (LUQ) is uncommon, making
this quadrant the “silent one.”

Management: not in a hurry, mostly preoperative preparation then operation,
or conservative

Intestinal Obstruction

Vomiting and colicky pain are more characteristic of small bowel obstruction,
whereas constipation and gross distension are typical of colonic obstruction.

However, the distinction between these two kinds of obstruction usually
hinges on the plain abdominal X-ray.

Missed groin hernia sometimes are the sole cause of intestinal obstruction

Management: conservative treatment OR operative treatment after adequate
preparation

Waste Basket (“non specific abdominal pain” or “medical”)

Non specific abdominal pain is a type of acute abdominal pain that is severe
enough to bring a patient to seek medical attention, but all physical
examination as well as diagnostic work up (may include CT scan) are
negative, and the pain is self limiting.

Two most important medical causes is myocardial infarction and diabetic
ketoacidosis

Summary
Acute abdomen is a surgical emergency, Early recognition of specific clinical
pattern is essential in the diagnosis of acute abdomen, which will mandate the
appropriate treatment. Early and appropriate pain relief for patients with acute
abdominal pain is humane, does not adversely affect diagnostic acumen or clinical
decision making, and should be considered part of the initial management of every
such patient.