6 Abdomen Agudo

45 CHAPTER
Acute Abdomen
Ronald Squires, Steven N. Carter, Russell G. Postier
OUTLINE
Anatomy and Physiology Diagnostic Laparoscopy
History Differential Diagnosis
Physical Examination Preparation for Emergency Operation
Laboratory Studies Atypical Patients
Imaging Studies Algorithms in the Acute Abdomen
Intra-abdominal Pressure Monitoring Summary
The term acute abdomen refers to signs and symptoms of abdomi- imaging studies, although usually needed, are directed by the
nal pain and tenderness, a clinical presentation that often requires findings on history and physical examination.
emergency surgical therapy. This challenging clinical scenario
requires a thorough and expeditious workup to determine the
need for operative intervention and to initiate appropriate therapy. ANATOMY AND PHYSIOLOGY
Many diseases, some of which are not surgical or even intra-
abdominal,1 can produce acute abdominal pain and tenderness. Abdominal pain is conveniently divided into visceral and parietal
Therefore, every attempt should be made to make a correct diag- components. Visceral pain tends to be vague and poorly localized
nosis so that the chosen therapy, often a laparoscopy or laparot- to the epigastrium, periumbilical region, or hypogastrium,
omy, is appropriate. Despite improvements in laboratory and depending on its origin from the primitive foregut, midgut, or
imaging studies, history and physical examination remain the hindgut (Fig. 45-1). It is usually the result of distention of a
mainstays of determining the correct diagnosis and initiating hollow viscus. Parietal pain corresponds to the segmental nerve
proper and timely therapy. roots innervating the peritoneum and tends to be sharper and
The diagnoses associated with an acute abdomen vary accord- better localized. Referred pain is pain perceived at a site distant
ing to age and gender.2 Appendicitis is more common in the from the source of stimulus. For example, irritation of the dia-
young, whereas biliary disease, bowel obstruction, intestinal isch- phragm may produce pain in the shoulder. Common referred pain
emia and infarction, and diverticulitis are more common in the sites and their accompanying sources are listed in Box 45-3.
elderly. Most of these diagnoses result from infection, obstruction, Determining whether the pain is visceral, parietal, or referred is
ischemia, or perforation. important and can usually be done with a careful history.
Nonsurgical causes of an acute abdomen can be divided into Introduction of bacteria or irritating chemicals into the peri-
three categories: endocrine and metabolic, hematologic, and toneal cavity can cause an outpouring of fluid from the peritoneal
toxins or drugs (Box 45-1).3 Endocrine and metabolic causes membrane. The peritoneum responds to inflammation by
include uremia, diabetic crisis, addisonian crisis, acute intermit- increased blood flow, increased permeability, and the formation
tent porphyria, acute hyperlipoproteinemia, and hereditary Medi- of a fibrinous exudate on its surface. The bowel also develops
terranean fever. Hematologic disorders are sickle cell crisis, acute local or generalized paralysis. The fibrinous surface and decreased
leukemia, and other blood dyscrasias. Toxins and drugs causing intestinal movement cause adherence between the bowel and
an acute abdomen include lead and other heavy metal poisoning, omentum or abdominal wall and help to localize inflammation.
narcotic withdrawal, and black widow spider poisoning. It is As a result, an abscess may produce sharply localized pain with
important to keep these possibilities in mind when evaluating a normal bowel sounds and gastrointestinal function, whereas a
patient with acute abdominal pain (Box 45-1). diffuse process, such as a perforated duodenal ulcer, produces
Because of the potential surgical nature of the acute abdomen, generalized abdominal pain with a quiet abdomen. Peritonitis
an expeditious workup is necessary (Box 45-2). The workup pro- may affect the entire abdominal cavity or a portion of the visceral
ceeds in the usual order of history, physical examination, and or parietal peritoneum.
laboratory and imaging studies. Whereas imaging studies have Peritonitis is peritoneal inflammation from any cause. It is
increased the accuracy with which the correct diagnosis can be usually recognized on physical examination by severe tenderness
made, the most important part of the evaluation remains a thor- to palpation, with or without rebound tenderness, and guarding.
ough history and careful physical examination. Laboratory and Peritonitis is usually secondary to an inflammatory insult, most
1120
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CHAPTER 45 Acute Abdomen 1121
BOX 45-1 Nonsurgical Causes of the BOX 45-2 Surgical Acute Abdominal
Acute Abdomen Conditions
Endocrine and Metabolic Causes Hemorrhage
Uremia Solid organ trauma
Diabetic crisis Leaking or ruptured arterial aneurysm
Addisonian crisis Ruptured ectopic pregnancy
Acute intermittent porphyria Bleeding gastrointestinal diverticulum
Hereditary Mediterranean fever Arteriovenous malformation of gastrointestinal tract
Intestinal ulceration
Hematologic Causes Aortoduodenal fistula after aortic vascular graft
Sickle cell crisis Hemorrhagic pancreatitis
Acute leukemia Mallory-Weiss syndrome
Other blood dyscrasias Spontaneous rupture of spleen
Toxins and Drugs Infection

Lead poisoning Appendicitis
Other heavy metal poisoning Cholecystitis
Narcotic withdrawal Meckel’s diverticulitis
Black widow spider poisoning Hepatic abscess
Diverticular abscess
Psoas abscess
often gram-negative infections with enteric organisms or anaer-
Perforation
obes. It can result from noninfectious inflammation, a common
Perforated gastrointestinal ulcer
example being pancreatitis. Primary peritonitis occurs more com-
Perforated gastrointestinal cancer
monly in children and is most often due to pneumococcus or
Boerhaave syndrome
hemolytic streptococcus.4 Adults with end-stage renal disease on
Perforated diverticulum
peritoneal dialysis can develop infections of their peritoneal fluid,
with the most common organisms being gram-positive cocci. Blockage
Adults with ascites and cirrhosis can develop primary peritonitis, Adhesion induction small or large bowel obstruction
and in these cases the organisms are usually Escherichia coli and Sigmoid volvulus
Klebsiella. Cecal volvulus
Incarcerated hernias
Inflammatory bowel disease
HISTORY Gastrointestinal malignant neoplasm
Intussusception
A detailed and organized history is essential to formulating an
accurate differential diagnosis and subsequent treatment regimen. Ischemia
Modern advancements in imaging cannot and will never replace Buerger disease
the need for a skilled clinician’s careful history and bedside exami- Mesenteric thrombosis or embolism
nation. The history must focus not only on the investigation of Ovarian torsion
the pain complaints but also on past problems and associated Ischemic colitis
symptoms as well. Questions should be open ended whenever Testicular torsion
possible and structured to disclose the onset, character, location, Strangulated hernias
duration, radiation, and chronology of the pain experienced. It is
tempting to ask a question such as, Is the pain sharp? or Does
eating make it worse? This specific yes or no style can speed up
the history taking by not allowing the patient to narrate, but it worsens during several hours is typical of conditions of progressive
stands to miss vital details and potentially to skew the responses. inflammation or infection, such as cholecystitis, colitis, and bowel
A much better questioning style would be, How does the pain obstruction. The history of progressive worsening versus intermit-
feel to you? or Does anything make the pain better or worse? tent episodes of pain can help differentiate infectious processes
Often, additional information can be gained by observing how that worsen with time compared with the spasmodic colicky pain
the patient describes the pain that is experienced. Pain identified associated with bowel obstruction, biliary colic from cystic duct
with one finger is often much more localized and typical of parietal obstruction, or genitourinary obstruction (Figs. 45-2 to 45-4).
innervation or peritoneal inflammation compared with an area of Equally important as the character of the pain is its location and
discomfort illustrated with the palm of the hand, which is more radiation. Tissue injury or inflammation can trigger both visceral
typical of the visceral discomfort of bowel or solid organ disease. and somatic pain. Solid organ visceral pain in the abdomen is
The intensity and severity of the pain are related to the underly- generalized in the quadrant of the involved organ, such as liver
ing tissue damage. Sudden onset of excruciating pain suggests pain across the right upper quadrant of the abdomen. Small bowel
conditions such as intestinal perforation and arterial embolization pain is perceived as poorly localized periumbilical pain, whereas
with ischemia, although other conditions, such as biliary colic, colon pain is centered between the umbilicus and the pubic sym-
can be manifested suddenly as well. Pain that develops and physis. As inflammation expands to involve the peritoneal surface,
1122 SECTION X Abdomen
SEGMENTAL
VISCUS NERVES PLEXUSES
INNERVATIONS
C1
2
3
4
Esophagus, 5
6 Sup. cardiac*
trachea, bronchi Vagus 7
8 Middle cardiac
T1 Inf. cardiac
Heart and
aortic arch T1-T3 or 2
Cardiac
T4 3 Thoracic cardiac Pulmonary*
4
Stomach T5-T7
5
Biliary tract T6-T8 6
7
Small intestine T8-T10 8
9
Kidney T10-L1 10 Maj. splanchnic
Celiac
Colon T10-L1 11 Min. splanchnic and
12 adrenal*
Least splanchnic
Uterine fundus T10-L1 Renal
L1
2 Spermatic*
3 Ovarian*
4
Uterine cervix 5 Preaortic
Inf. mesenteric
Bladder S2-S4 S1 Sup. hypogastric
2 Sacral
Bladder*
Rectum Parasympathetic Prostate*
3
Bladder Uterus
4 Cervix
5 Rectum
* No known sensory fibers in sympathetic rami.

FIGURE 45-1 Sensory innervation of the viscera. (From White JC, Sweet WH: Pain and the neurosurgeon,
Springfield, Ill, 1969, Charles C Thomas, p 526.)
parietal nerve fibers from the spine allow focal and intense sensa-
tion. This combination of innervation is responsible for the classic
diffuse periumbilical pain of early appendicitis that later shifts to
become an intense focal pain in the right lower abdomen at
BOX 45-3 Locations of Referred Pain McBurney point. If clinicians focus on the character of the current
and Its Causes pain and do not thoroughly investigate its onset and progression,
they will miss these strong historical clues (Figs. 45-5 and 45-6).
Right Shoulder Pain may also extend well beyond the diseased site. The liver
Liver shares some of its innervation with the diaphragm and may create
Gallbladder referred pain to the right shoulder from the C3-C5 nerve roots.
Right hemidiaphragm Genitourinary pain is another source of pain that commonly has
a radiating pattern. Symptoms are primarily in the flank region
Left Shoulder
originating from the splanchnic nerves of T11-L1, but pain often
Heart
radiates to the scrotum or labia through the hypogastric plexus of
Tail of pancreas
S2-S4.
Spleen
Activities that exacerbate or relieve the pain are also important.
Left hemidiaphragm
Eating will often worsen the pain of bowel obstruction, biliary
Scrotum and Testicles colic, pancreatitis, diverticulitis, or bowel perforation. Food can
Ureter provide relief from the pain of nonperforated peptic ulcer disease
or gastritis. Clinicians will often recognize that they are evaluating
Cholecystitis
Hepatitis Pancreatitis Perforated
ulcer
Ureteral colic
Appendicitis (may be
constant)
Ruptured
Diverticulitis
aortic
Tubo-ovarian
aneurysm
abscess or
ectopic
pregnancy
FIGURE 45-2 Character of pain: gradual, progressive pain. FIGURE 45-4 Character of pain: sudden, severe pain.
Biliary colic
Perforated
ulcer
Ureteral colic
Pyelonephritis,
(kidney stones)
renal or
Small bowel ureteral colic
obstruction
Colonic
obstruction
FIGURE 45-3 Character of pain: colicky, crampy, intermittent pain. FIGURE 45-5 Referred pain. Solid circles are primary or most intense
sites of pain.
peritonitis during the history. Patients with peritoneal inflamma- of significant abdominal pain in many medical conditions,
tion will avoid any activity that stretches or jostles the abdomen. whereas the pain of an acute surgical abdomen is manifested first
They describe worsening of the pain with any sudden body move- and stimulates vomiting through medullary efferent fibers that are
ment and will realize that there is less pain if their knees are flexed. triggered by the visceral afferent pain fibers. Constipation or obsti-
The car ride to the hospital can be agonizing, with the patient pation can be a result of either mechanical obstruction or decreased
feeling every bump along the way. peristalsis. It may represent the primary problem and require laxa-
Associated symptoms can be important clues to the diagnosis. tives and prokinetic agents or merely be a symptom of an underly-
Nausea, vomiting, constipation, diarrhea, pruritus, melena, hema- ing condition. A careful history should include whether the
tochezia, and hematuria can all be helpful symptoms if they are patient is continuing to pass any gas or stool from the rectum. A
present and recognized. Vomiting may occur because of severe complete obstruction is more likely to be associated with subse-
abdominal pain of any cause or as a result of mechanical bowel quent bowel ischemia or perforation related to either massive
obstruction or ileus. Vomiting is more likely to precede the onset distention or a closed loop of small bowel that can occur. Diarrhea
population ages. These drugs may be the cause of gastrointestinal

bleeds, retroperitoneal hemorrhages, or rectus sheath hematomas.
They also can complicate the preoperative preparation of the
patient and be the cause of substantial morbidity if their use goes
unrecognized. Finally, recreational drugs can play a role in patients
with an acute abdomen. Chronic alcoholism is strongly associated
with coagulopathy and portal hypertension from liver impair-
ment. Cocaine and methamphetamine can create an intense vaso-
Pancreatitis spastic reaction that can cause life-threatening hypertension as
Cholecystitis well as cardiac and intestinal ischemia.
The gynecologic health, and specifically the menstrual history,
is crucial in evaluation of lower abdominal pain in a young
woman. The likelihood of ectopic pregnancy, pelvic inflammatory
disease, mittelschmerz, or severe endometriosis is heavily influ-
enced by the details of the gynecologic history.
Very little has changed in the technique or goals of history
Appendicitis
taking since Zachary Cope first published his classic paper on the
diagnosis of acute abdominal pain in 1921.5 An exception is the
application of computers to the “art” of history taking, which has
been extensively studied in Europe.6-10 Data were collected by
physicians on detailed standardized forms during history and
physical examinations and entered into computers programmed
FIGURE 45-6 Referred pain. Solid circles are primary or most intense with a medical database of diseases and their associated signs and
sites of pain. symptoms. The computer-generated diagnosis based on mathe-
matical probabilities was as much as 20% more accurate than
physicians left to their own methods. Statistically significant
improvement was identified in timely laparotomy, shortened hos-
is associated with several medical causes of acute abdomen, includ- pital stays, and reduced need for surgery and hospitalization.6
ing infectious enteritis, inflammatory bowel disease, and parasitic However, statistically significant improvement in accuracy and
contamination. Bloody diarrhea can be seen in these conditions efficiency has been realized without computer assistance if similar
as well as in colonic ischemia. standardized forms are used for data collection. This has also been
The past medical history can potentially be more helpful than observed in the settings of trauma and critical care.
any other single part of the patient’s evaluation. Previous illnesses
or diagnoses can greatly increase or decrease the likelihood of
certain conditions that would otherwise not be highly considered. PHYSICAL EXAMINATION
Patients may, for example, report that the current pain is very
similar to the kidney stone passage they experienced a decade An organized and thoughtful physical examination is critical to
prior. On the other hand, a prior history of appendectomy, pelvic the development of an accurate differential diagnosis and the
inflammatory disease, or cholecystectomy can significantly shape subsequent treatment algorithm. Despite newer technologies
the differential diagnosis. During the abdominal examination, all including high-resolution computed tomography (CT) scanning,
scars on the abdomen should be accounted for by the medical ultrasound, and magnetic resonance imaging (MRI), the physical
history obtained. examination remains a key part of a patient’s evaluation and must
A history of medications as well as the gynecologic history of not be minimized. A skilled clinician will be able to develop a
female patients is also important. Medications can both create narrow and accurate differential diagnosis in most of his or her
acute abdominal conditions and mask their symptoms. Although patients at the conclusion of the history and physical examination.
a thorough discussion of the impact of all medications is beyond Laboratory and imaging studies can then be used to further
the scope of this chapter, several common drug classes deserve confirm the suspicions, to reorder the proposed differential diag-
mention. High-dose narcotic use can interfere with bowel activity nosis, or, less commonly, to suggest unusual possibilities not yet
and lead to obstipation and obstruction. Narcotics also can con- considered.
tribute to spasm of the sphincter of Oddi and exacerbate biliary The physical examination should always begin with a general
or pancreatic pain. Clearly, they also may suppress pain sensation inspection of the patient to be followed by inspection of the
and alter mental status, which can impair the ability to accurately abdomen itself. Patients with peritoneal irritation will experience
diagnose the condition. Nonsteroidal anti-inflammatory agents worsened pain with any activity that moves or stretches the peri-
are associated with an increased risk of upper gastrointestinal toneum. These patients will typically lie very still in the bed
inflammation and perforation, whereas steroid medications can during the evaluation and often maintain flexion of their knees
block protective gastric mucus production by chief cells and and hips to reduce tension on the anterior abdominal wall. Disease
reduce the inflammatory reaction to infection, including advanced states that cause pain without peritoneal irritation, such as isch-
peritonitis. Immunosuppressant agents as a class both increase a emic bowel or ureteral or biliary colic, typically cause patients to
patient’s risk of acquiring a variety of bacterial or viral illnesses continually shift and fidget in bed while trying to find a position
and also blunt the inflammatory response, diminishing the pain that lessens their discomfort (Fig. 45-7). Other important clues,
that is present and the overall physiologic response. Anticoagu- such as pallor, cyanosis, and diaphoresis, may be observed during
lants are much more prevalent in our emergency patients as the the general inspection as well.
upper quadrant, an abdominal mass displacing the bowel should

be considered. When liver dullness is lost and resonance is uniform
throughout, free intra-abdominal air should be suspected. This air
rises and collects beneath the anterior abdominal wall when the
patient is in a supine position. Ascites is detected by looking for
fluctuance of the abdominal cavity. A fluid wave or ripple can be
generated by a quick firm compression of the lateral abdomen.
Stomach
The resulting wave should then travel across the abdominal wall.
Gallbladder Pancreas Movement of adipose tissue in the obese abdomen can be mis-
taken for a fluid wave. False-positive examinations can be reduced
by first pressing the ulnar surface of the examiner’s open palm into
the midline soft tissue of the abdominal wall to minimize any
movement of the fatty tissue while generating the wave with the
Small bowel
Renal opposite hand.
Peritonitis is also assessed by percussion. Older, traditional
writings teach a technique of deep compression of the abdominal
Colon wall followed by abrupt release. This practice is excruciating in
Uterine
the setting of peritoneal inflammation and can create significant
discomfort even in its absence. More sensitive and reliable methods
can and should be used. Firmly tapping the iliac crest, the flank,
or the heel of an extended leg will jar the abdominal viscera and
elicit characteristic pain when peritonitis is present.
FIGURE 45-7 Common locations for visceral pain. The final major step in the abdominal examination is palpa-
tion. Palpation typically provides more information than any
Abdominal inspection should address the contour of the other single component of the abdominal examination. In addi-
abdomen, including whether it appears distended or scaphoid and tion to revealing the severity and exact location of the abdominal
whether a localized mass effect is observed. Special attention pain, palpation can further confirm the presence of peritonitis as
should be paid to all scars present; if they are surgical in nature, well as identify organomegaly or an abnormal mass lesion. Palpa-
they should correlate with the past surgical history provided. tion should always begin gently and away from the reported area
Fascial hernias may be suspected and can be confirmed during of pain. If considerable pain is induced at the outset of palpation,
palpation of the abdominal wall. Evidence of erythema or edema the patient is likely to voluntarily guard and continue to do so,
of skin may suggest cellulitis of the abdominal wall; ecchymosis limiting the information obtained. Involuntary guarding, or
is sometimes observed with deeper necrotizing infections of the abdominal wall muscle spasm, is a sign of peritonitis and must be
fascia or abdominal structures, such as the pancreas. distinguished from voluntary guarding. To accomplish this, the
Auscultation can provide useful information about the gastro- examiner applies consistent pressure to the abdominal wall away
intestinal tract and the vascular system. Bowel sounds are typically from the point of maximal pain while asking the patient to take
evaluated for their quantity and quality. A quiet abdomen suggests a slow, deep breath. In the setting of voluntary guarding, the
an ileus, whereas hyperactive bowel sounds are found in enteritis abdominal muscles will relax during the act of inspiration; if
and early ischemic intestine. The pitch and pattern of the sounds guarding is involuntary, they remain spastic and tense.
are also considered. Mechanical bowel obstruction is characterized Pain, when focal, suggests an early or well-localized disease
by high-pitched tinkling sounds that tend to come in rushes and process; diffuse pain on palpation is present with extensive inflam-
are associated with pain. Far-away echoing sounds are often mation or late presentations. If pain is diffuse, careful investiga-
present when significant luminal distention exists. Bruits heard tion should be carried out to determine where the pain is greatest.
within the abdomen reflect turbulent blood flow within the vas- Even in the setting of extreme contamination from perforated
cular system. These are most frequently encountered in the setting peptic ulcers or colonic diverticula, the site of maximal tenderness
of high-grade arterial stenoses of 70% to 95% but can also be often points to the underlying source.
heard if an arteriovenous fistula is present. The clinician can also Numerous unique physical findings have come to be associated
subtly test for the location and degree of pain during the ausculta- with specific disease conditions and are well described as examina-
tory examination by varying the position and amount of pressure tion “signs” (Table 45-1). Murphy sign of acute cholecystitis
applied with the stethoscope. These data can then be compared results when inspiration during palpation of the right upper quad-
with the findings during palpation and evaluated for consistency. rant results in sudden worsening of pain because of descent of the
Even though few patients will intentionally try to deceive the liver and gallbladder toward the examiner’s hand. Several signs
physician, some may exaggerate their pain complaints so as not help to localize the site of underlying peritonitis, including the
to be disregarded or taken lightly. obturator sign, the psoas sign, and Rovsing sign. Others, such as
Percussion is used to assess for gaseous distention of the bowel, Fothergill sign and Carnett sign, help distinguish intra-abdominal
free intra-abdominal air, degree of ascites, or presence of perito- disease from that of the abdominal wall.
neal inflammation. Hyperresonance, commonly referred to as Digital rectal examination needs to be performed in all patients
tympany to percussion, is characteristic of underlying gas-filled with acute abdominal pain, checking for the presence of a mass,
loops of bowel. In the setting of bowel obstruction or ileus, this pelvic pain, or intraluminal blood. A pelvic examination should
tympany is heard throughout all but the right upper quadrant be included in all women in evaluating pain located below the
where the liver lies beneath the abdominal wall. If localized dull- umbilicus. Gynecologic and adnexal processes are best character-
ness to percussion is identified anywhere other than the right ized by a thorough speculum and bimanual evaluation.
TABLE 45-1 Abdominal Examination Signs

Aaron sign Pain or pressure in epigastrium or anterior chest with persistent firm pressure Acute appendicitis
applied to McBurney point
Bassler sign Sharp pain created by compressing appendix between abdominal wall and iliacus Chronic appendicitis
Blumberg sign Transient abdominal wall rebound tenderness Peritoneal inflammation
Carnett sign Loss of abdominal tenderness when abdominal wall muscles are contracted Intra-abdominal source of abdominal pain
Chandelier sign Extreme lower abdominal and pelvic pain with movement of cervix Pelvic inflammatory disease
Charcot sign Intermittent right upper abdominal pain, jaundice, and fever Choledocholithiasis
Claybrook sign Accentuation of breath and cardiac sounds through abdominal wall Ruptured abdominal viscus
Courvoisier sign Palpable gallbladder in presence of jaundice Periampullary tumor
Cruveilhier sign Varicose veins at umbilicus (caput medusae) Portal hypertension
Cullen sign Periumbilical bruising Hemoperitoneum
Danforth sign Shoulder pain on inspiration Hemoperitoneum
Fothergill sign Abdominal wall mass that does not cross midline and remains palpable when Rectus muscle hematomas
rectus is contracted
Grey Turner sign Local areas of discoloration around umbilicus and flanks Acute hemorrhagic pancreatitis
Iliopsoas sign Elevation and extension of leg against resistance create pain Appendicitis with retrocecal abscess
Kehr sign Left shoulder pain when supine and pressure placed on left upper abdomen Hemoperitoneum (especially from splenic origin)
Mannkopf sign Increased pulse when painful abdomen is palpated Absent if malingering
Murphy sign Pain caused by inspiration while applying pressure to right upper abdomen Acute cholecystitis
Obturator sign Flexion with external rotation of right thigh while supine creates hypogastric pain Pelvic abscess or inflammatory mass in pelvis
Ransohoff sign Yellow discoloration of umbilical region Ruptured common bile duct
Rovsing sign Pain at McBurney point when compressing the left lower abdomen Acute appendicitis
ten Horn sign Pain caused by gentle traction of right testicle Acute appendicitis
LABORATORY STUDIES BOX 45-4 Helpful Laboratory Studies in

A number of laboratory studies are considered routine in the the Acute Abdomen
evaluation of a patient with an acute abdomen (Box 45-4). They Hemoglobin
help confirm that inflammation or an infection is present and also White blood cell count with differential
aid in the elimination of some of the most common nonsurgical Electrolyte, blood urea nitrogen, and creatinine concentrations
conditions. A complete blood count with differential is valuable Urinalysis
as most but not all patients with an acute abdomen will have Urine human chorionic gonadotropin
either a leukocytosis or bandemia. Serum electrolyte, blood urea Amylase and lipase levels
nitrogen, and creatinine measurements will assist in evaluating the Total and direct bilirubin concentration
effect of such factors as vomiting and third space fluid losses. In Alkaline phosphatase
addition, they may suggest an endocrine or metabolic diagnosis Serum aminotransferase
as the cause of the patient’s problem. Serum amylase and lipase Serum lactate levels
determinations may suggest pancreatitis as the cause of the Stool for ova and parasites
abdominal pain, but levels can also be elevated in other disorders, C. difficile culture and toxin assay
such as small bowel infarction and duodenal ulcer perforation.
Normal serum amylase and lipase levels do not exclude pancre-
atitis as a possible diagnosis because of the effects of chronic
inflammation on enzyme production and timing factors. Liver including an operation if indicated.11 Stool testing for occult
function tests including total and direct bilirubin, serum amino- blood can be helpful in the evaluation of these patients but is
transferase, and alkaline phosphatase are helpful in evaluating nonspecific. Stool for ova and parasite evaluation as well as culture
potential biliary tract causes of acute abdominal pain. Lactate and toxin assay for Clostridium difficile can be helpful if diarrhea
levels and arterial blood gas determinations can be helpful in is a component of the patient’s presentation.
diagnosis of intestinal ischemia or infarction. Urine testing, such
as urinalysis, is helpful in the diagnosis of bacterial cystitis, pyelo-
nephritis, and certain endocrine abnormalities, such as diabetes IMAGING STUDIES
and renal parenchymal disease. Urine culture, although it can
confirm a suspected urinary tract infection and direct antibiotic Improvements in imaging techniques, especially multidetector
therapy, is not available in time to be helpful in the evaluation of CT scans, have revolutionized the diagnosis of the acute abdomen.
an acute abdomen. Urinary measurements of human chorionic The most difficult diagnostic dilemmas of the past, appendicitis
gonadotropin can either suggest pregnancy as a confounding in young women and ischemic bowel in the elderly, can now be
factor in the patient’s presentation or aid in decision making about diagnosed with much greater certainty and speed (Figs. 45-8 and
therapy. The fetus of a pregnant patient with an acute abdomen 45-9).12-14 This has resulted in more rapid operative correction of
is best protected by providing the best care to the mother, the problem with less morbidity and mortality. Despite its
A B
FIGURE 45-8 Appendicitis. A, CT scan of uncomplicated appendicitis. A thick-walled, distended, retroce-
cal appendix (arrow) is seen with inflammatory change in the surrounding fat. B, CT scan of complicated
appendicitis. A retrocecal appendiceal abscess (A) with an associated phlegmon posteriorly found in a 3-week
postpartum, obese woman. Inflammatory change extends through the flank musculature into the subcutane-
ous fat (arrow).
A B
FIGURE 45-9 Small bowel infarction associated with mesenteric venous thrombosis. A, Note the low-
density thrombosed superior mesenteric vein (solid arrow) and incidental gallstones (open arrow). B, Thicken-
ing of proximal small bowel wall (arrow) coincided with several feet of infarcting small bowel at time of
operation.
usefulness, CT is not the only imaging technique available and is aortic aneurysms, visceral artery aneurysm, and atherosclerosis in
also not the first step in imaging for most patients. In addition, visceral vessels.
none of the imaging techniques take the place of a careful history Upright and supine abdominal radiographs are helpful in iden-
and physical examination. tifying gastric outlet obstruction and obstruction of the proximal,
Plain radiographs continue to play a role in imaging in patients mid, or distal small bowel. They can also aid in determining
with acute abdominal pain. Upright chest radiographs can detect whether a small bowel obstruction is complete or partial by the
as little as 1 mL of air injected into the peritoneal cavity. Lateral presence or absence of gas in the colon. Colonic gas can be dif-
decubitus abdominal radiographs can also detect pneumoperito- ferentiated from small intestinal gas by the presence of haustral
neum effectively in patients who cannot stand. As little as 5 to markings from the taeniae coli in the colonic wall. Obstructed
10 mL of gas may be detected with this technique.15 These studies colon appears as distended bowel with haustral markings (Fig.
are particularly helpful in patients suspected of having a perfo- 45-11). Associated distention of small bowel may also be present,
rated duodenal ulcer as about 75% of these patients will have a especially if the ileocecal valve is incompetent. Plain films can also
large enough pneumoperitoneum to be visible (Fig. 45-10).16 This suggest volvulus of either the cecum or sigmoid colon. Cecal
obviates the need for further evaluation in most patients, allowing volvulus is identified by a distended loop of colon in a comma
laparotomy with little delay. shape with the concavity facing inferiorly and to the right. Sigmoid
Plain films also show abnormal calcifications. Approximately volvulus characteristically has the appearance of a bent inner tube
5% of appendicoliths, 10% of gallstones, and 90% of renal stones with its apex in the right upper quadrant (Fig. 45-12).
contain sufficient amounts of calcium to be radiopaque. Pancre- Abdominal ultrasonography is extremely accurate in detecting
atic calcifications seen in many patients with chronic pancreatitis gallstones and in assessing gallbladder wall thickness and the
are visible on plain films, as are the calcifications in abdominal presence of fluid around the gallbladder.17 It is also good at
FIGURE 45-10 Upright chest radiograph depicting moderate-sized

pneumoperitoneum consistent with perforation of abdominal viscus.
FIGURE 45-12 Upright abdominal radiograph in a patient with a
sigmoid colon volvulus. Note the characteristic appearance of a bent
inner tube with its apex in the right upper quadrant.
to the value of ultrasonography in the diagnosis of diseases that

are manifested as an acute abdomen. Ultrasound has been found
to be clinically inferior to CT scanning for the diagnosis of appen-
dicitis.18 In addition, ultrasound images are more difficult for
most surgeons to interpret than are plain radiographs and CT
images. Many hospitals have radiologic technologists available at
all times to perform CT, but this is often not the case with ultra-
sonography. As CT has become more widely available and less
likely to be hindered by abdominal air, it is becoming the second-
ary imaging modality of choice in the patient with an acute
abdomen, following plain abdominal radiographs.
A number of studies have demonstrated the accuracy and
utility of CT of the abdomen and pelvis in the evaluation of acute
abdominal pain.12-14 Many of the most common causes of the
acute abdomen are readily identified by CT scanning, as are their
complications. A notable example is appendicitis. Plain films and
even barium enemas add little to the diagnosis of appendicitis;
FIGURE 45-11 Upright abdominal radiograph in a patient with an however, a well-performed CT scan is highly accurate in this
obstructing sigmoid adenocarcinoma. Note the haustral markings on disease. Prior experience suggested that optimal CT imaging for
the dilated transverse colon that distinguished this from small
appendicitis should include intravenous, oral, and rectal contrast
intestine.
agents. Most recently, a large retrospective review of more than
9000 patients from 56 hospitals representing both urban and rural
determining the diameter of the extrahepatic and intrahepatic bile practices found no added diagnostic accuracy with the addition
ducts. Its usefulness in detecting common bile duct stones is of enteral contrast material. Operative findings correlated with the
limited. Abdominal and transvaginal ultrasonography can aid in CT observations 90% of the time whether or not enteral contrast
the detection of abnormalities of the ovaries, adnexa, and uterus. material was used.19
Ultrasound can also detect intraperitoneal fluid. The presence of It is equally important that an experienced radiologist, accus-
abnormal amounts of intestinal air in most patients with an acute tomed to reading abdominal CT scans, interpret the study to
abdomen limits the ability of ultrasonography to evaluate the maximize the sensitivity and specificity of the examination. A
pancreas or other abdominal organs. There are important limits prospective study from The Netherlands illustrated the variability
of CT interpretation in the diagnosis of appendicitis. Three can be significant distracters that compromise an otherwise careful
blinded groups of radiologists read CT scans of patients suspected history and physical examination. In addition, many patients suf-
of having appendicitis. All patients then underwent exploratory fering a blunt abdominal trauma will have altered mental states
laparoscopy; 83% of patients were found to have appendicitis at from coexisting closed head injuries or from intoxicating sub-
surgery. Radiology group A was made up of radiology residents stances. When a bowel injury is suspected, optimal CT scanning
on call and trained in CT interpretation. Group B were on-call uses both oral and intravenous contrast agents. Zissin and col-
staff radiologists. Group C was represented by expert abdominal leagues17 reported an overall sensitivity of 64%, specificity of
radiologists. For group A, B, and C radiologists, the sensitivity of 97%, and accuracy of 82% when diagnosing small bowel injury
CT scanning for the diagnosis of acute appendicitis was 81%, after blunt trauma using dual contrast CT scanning. Keys to the
88%, and 95%, respectively; the specificity was 94%, 94%, and diagnosis include bowel wall thickening, any gas outside the
100%; and the negative predictive value was 50%, 68%, and lumen of the intestine, or a moderate to large amount of intra-
81%. Differences between groups A and C were statistically sig- peritoneal fluid without visible solid abdominal organ injury.
nificant.14 CT is also excellent in differentiating mechanical small
bowel obstruction from paralytic ileus and can usually identify
the transition point in mechanical obstruction (Fig. 45-13). Some INTRA-ABDOMINAL PRESSURE MONITORING
of the most difficult diagnostic dilemmas, including acute intes-
tinal ischemia and bowel injury after blunt abdominal trauma, An elevated intra-abdominal pressure can be a symptom of an
can often be identified by this method. acute abdominal process or it can be the cause of the process.
Traumatic small bowel injuries can be a challenging clinical Abnormally increased intra-abdominal pressures diminish the
diagnosis. Associated abdominal wall, pelvic, or spinous injuries blood flow to abdominal organs and decrease venous return to
the heart while increasing venous stasis. Increased pressure in the
abdomen can also press upward on the diaphragm, thereby
increasing peak inspiratory pressures and decreasing ventilatory
efficiency. Risk of esophageal reflux and pulmonary aspiration has
also been associated with abdominal hypertension. It is important
to consider the possibility of abdominal hypertension in any
patient who presents with a rigid or significantly distended
abdomen.
Normal intra-abdominal pressure is considered to be 5 to
7 mm Hg for a relaxed individual of average body build lying in
a supine position. Obesity and elevation of the head of the bed
can increase the normal resting abdominal pressure. Morbid
obesity has been shown to increase “normal pressures” by 4 to
8 mm Hg; elevating the head of the bed to 30 degrees raises the
pressure by 5 mm Hg on average.20 Pressures are most commonly
measured through the bladder by pressure transducer attached to
a Foley catheter. Pressure readings are obtained at the end-
expiration after instillation of 50 mL of saline into an otherwise
empty bladder. Abnormally elevated pressures are those above
11 mm Hg and are graded 1 to 4 by severity (Table 45-2).
Abdominal hypertension grades 1 and 2 can most always be
treated adequately with medical interventions focusing on main-
taining euvolemia, gut decompression with nasogastric tubes or
laxatives and enemas, withholding of enteral feedings, catheter
aspiration of ascitic fluid, abdominal wall relaxation, and judi-
FIGURE 45-13 CT scan of a patient with a partial small bowel obstruc- cious use of hypotonic intravenous fluids. Grades 3 and 4 often
tion. Note the presence of dilated small bowel and decompressed small require surgical decompression by laparotomy with open packing
bowel. The decompressed bowel contains air, indicating a partial of the abdomen if the severe hypertension and organ dysfunction
obstruction. do not respond promptly to aggressive medical intervention.
TABLE 45-2 Abdominal Hypertension

MESENTERIC PRESSURE CO CVP PIP GFR PERFUSION TREATMENT
Normal pressure 5-7 mm Hg ↔ ↔ ↔ ↔ ↔ None
Grade 1 hypertension 12-15 mm Hg ↔ ↔/↑ ↔/↑ ↓ ↓ Maintain euvolemia
Grade 2 hypertension 16-20 mm Hg ↓ ↑* ↑ ↓ ↓ Nonsurgical decompression
Grade 3 hypertension 21-25 mm Hg ↓↓ ↑↑* ↑↑ ↓↓ ↓↓ Surgical decompression
Grade 4 hypertension >25 mm Hg ↓↓↓ ↑↑* ↑↑ ↓↓↓ ↓↓↓ Surgical decompression; reexplore
CO, cardiac output; CVP, central venous pressure; GFR, glomerular filtration rate; PIP, peak inspiratory pressure.
*Misleadingly elevated and not reflective of intravascular volume.
DIAGNOSTIC LAPAROSCOPY BOX 45-5 Findings Associated With

Surgical Disease in the Setting of Acute
A number of studies have confirmed the utility of diagnostic lapa-
roscopy in patients with acute abdominal pain.21-23 The purported Abdominal Pain
advantages include high sensitivity and specificity, ability to treat Physical Examination and Laboratory Findings
a number of the conditions causing an acute abdomen laparo- Abdominal compartment pressures >30 mm Hg
scopically, decreased morbidity and mortality, decreased length of Worsening distention after gastric decompression
stay, and decreased overall hospital costs. It may be particularly Involuntary guarding or rebound tenderness
helpful in the critically ill, intensive care patient, especially if a Gastrointestinal hemorrhage requiring >4 units of blood without stabilization
laparotomy can be avoided.24 Diagnostic accuracy is high, and Unexplained systemic sepsis
reports show the accuracy ranges between 90% and 100%, with Signs of hypoperfusion (acidosis, pain out of proportion to examination find-
the primary limitation being recognition of retroperitoneal pro- ings, rising liver function test results)
cesses. This compares favorably with other diagnostic studies
showing superiority to peritoneal lavage, CT scanning, or ultra- Radiographic Findings
sound of the abdomen.25 Because of advances in equipment and Massive dilation of intestine
increased availability, this technique is being used with greater Progressive dilation of stationary loop of intestine (sentinel loop)
frequency in these patients. Pneumoperitoneum
Extravasation of contrast material from bowel lumen
Vascular occlusion on angiography
Fat stranding or thickened bowel wall with systemic sepsis
DIFFERENTIAL DIAGNOSIS
The differential diagnosis for acute abdominal pain is extensive. Diagnostic Peritoneal Lavage (1000 mL)
Conditions range from the mild and self-limited to the rapidly >250 white blood cells per milliliter of aspirate
progressive and fatal. All patients must therefore be seen and evalu- >300,000 red blood cells per milliliter of aspirate
ated immediately on presentation and reassessed at frequent inter- Bilirubin level higher than plasma level (bile leak) within aspirate
vals for changes in condition. Although many “acute abdomen” Presence of particulate matter (stool)
diagnoses will require surgical intervention for resolution, it is Creatinine level higher than plasma level in aspirate (urine leak)
important to keep in mind that many causes of acute abdominal
pain are medical in etiology (see Figs. 45-2 and 45-4).26 Develop-
ment of the differential diagnosis begins during the history and is Although the goal of every surgeon is to make the correct
further clarified during the physical examination. Refinements are diagnosis preoperatively and to have planned the best possible
then made with the assistance of laboratory analysis and imaging surgical procedure before entering the operating suite, it must be
studies so that typically, one or two diagnoses rise above the rest. emphasized that a clear diagnosis will not be able to be developed
To be successful, this process requires a comprehensive knowledge in every patient. Surgeons must always be willing to accept uncer-
of the medical and surgical conditions that create acute abdominal tainty and commit to abdominal exploration when examination
pain to allow individual disease features to be matched to patient findings warrant. Laboratory and imaging studies, although
demographics, symptoms, and signs. helpful, should never replace the bedside clinical judgment of an
Certain physical examination, laboratory, and radiographic experienced surgeon. Patients are far more likely to be seriously
findings are highly correlated with surgical disease (Box 45-5). At or fatally harmed by delay of surgical treatment to perform con-
times, some patients will be too unstable to undergo comprehen- firmatory tests than by misdiagnoses discovered at operation.
sive evaluations that require transportation to other departments, Laparoscopy has proved to be a valuable tool when the diagnosis
such as radiology. In this setting, peritoneal lavage can provide is unclear. The presence of surgical disease can be confirmed in all
information suggesting pathologic processes requiring surgical but the most hostile abdominal environments, and as the sur-
intervention. The lavage can be performed under local anesthesia geon’s experience grows, more and more conditions are able to be
at the patient’s bedside. A small incision is made in the midline treated laparoscopically as well. Even when conversion to open
adjacent to the umbilicus, and dissection is carried down to the technique is required, laparoscopic evaluation facilitates more
peritoneal cavity. A small catheter or intravenous tubing is accurate positioning of the laparotomy incision, thereby reducing
inserted, and 1000 mL of saline is infused. A sample of fluid is its length.
then allowed to siphon back out into the empty saline bag and
is then analyzed for cellular or biochemical anomalies. This tech-
nique can provide sensitive evidence of hemorrhage or infection PREPARATION FOR EMERGENCY OPERATION
as well as of some types of solid or hollow organ injury.
Patients having emergency or life-threatening surgical disease Patients with an acute abdomen vary greatly in their overall state
are taken for immediate laparotomy; urgent diagnoses allow time of health at the time the decision to operate is made. Regardless
for stabilization, hydration, and preoperative preparation as of the patient’s severity of illness, all patients require some
needed. The remaining acute abdominal patients are grouped as degree of preoperative preparation. Intravenous access should be
those with surgical conditions that sometimes require surgery, obtained and any fluid or electrolyte abnormalities corrected.
those with medical diseases, and those who as yet remain unclear. Nearly all patients will require antibiotic infusions. The bacteria
Hospitalized patients who do not go urgently to the operating common in acute abdominal emergencies are gram-negative
room must be reassessed frequently and preferably by the same enteric organisms and anaerobes. Infusions of antibiotics to cover
examiner to recognize potentially serious changes in condition that these organisms should be begun once a presumptive diagnosis is
alter the diagnosis or suggest development of complications. made. Patients with generalized paralytic ileus or vomiting benefit
from nasogastric tube placement to decrease the likelihood of

vomiting and aspiration. Foley catheter bladder drainage to assess
urine output, a measure of adequacy of fluid resuscitation, is
indicated in most patients. Preoperative urine output of 0.5 mL/
kg/hr, systolic blood pressure of at least 100 mm Hg, and a pulse
rate of 100 beats/min or less are indicative of an adequate intra-
vascular volume. A common electrolyte abnormality requiring
correction is hypokalemia. Preoperative acidosis may respond to
fluid repletion and intravenous bicarbonate infusion. Acidosis due
to intestinal ischemia or infarction may be refractory to preopera- 8 mo
tive therapy. Placement of a central venous catheter may facilitate 7 mo
resuscitation and allow accelerated correction of potassium con-
6 mo Umbilicus
centration. Significant anemia is uncommon, and preoperative
blood transfusions are usually unnecessary. However, most patients 5 mo
should have blood typed and crossmatched and available at opera- 4 mo
tion. There is an inherent uncertainty in the operation that will 3 mo
be required in these patients, and having crossmatched blood McBurney’s
available avoids transfusion delay if unexpected intraoperative point
events occur. The need for preoperative stabilization of patients
must be weighed against the increased morbidity and mortality
associated with a delay in the treatment of some of the surgical
diseases that are manifested as an acute abdomen. The underlying
nature of the disease process, such as infarcted bowel, may require FIGURE 45-14 Location of maternal normal appendix during fetal
surgical correction before stabilization of the patient’s vital signs gestation.
and restoration of acid-base balance can occur. Resuscitation
should be viewed as an ongoing process and continued after the
surgery is completed. Deciding when the maximum benefit of radiation exposure to the developing fetus. The lack of radiologic
preoperative therapy in these patients has been achieved requires information can take a physician out of his or her diagnostic
good surgical judgment. routine and cause extra emphasis to be placed on other modalities,
such as vital signs and laboratory studies, which can confuse or
ATYPICAL PATIENTS underestimate the existing condition. Finally, physicians naturally
tend to be more conservative in treating pregnant patients. First
Pregnancy trimester miscarriage rates from nonobstetric surgeries have been
Acute abdominal pain in the pregnant patient creates several reported to be as high as 38%, but most reports place the surgical
unique diagnostic and therapeutic challenges. Special emphasis miscarriage rate similar to spontaneous first trimester miscarriage
must be placed on the possibility of gynecologic and surgical rates of 8% to 16%.27 Without controls, it is unclear if some of
diseases when acute abdominal pain develops during pregnancy the increased miscarriage rates noted are secondary to the disease
because of their frequency and morbidity if left unrecognized. or the surgery itself. Surgery has not been associated with increased
Laparoscopy has had a major impact on the diagnosis and treat- stillbirths and congenital abnormalities.28 Abdominal surgery has
ment of the gravid woman with acute abdominal pain and is now been associated with an increased incidence of preterm labor in
routinely employed for many clinical situations. Although case both the second and third trimesters of pregnancy, with the
reports of fetal demise after laparoscopic surgery continue to be highest incidence in the third trimester. It is thought that preterm
reported, its safety has been considered equal or superior to an labor is less in the second trimester because of less uterine manipu-
open surgical approach in all trimesters of pregnancy.27,28 A retro- lation. Intraoperative care during pregnancy is focused on optimal
spective study and meta-analysis did call into question the safety care of the mother. If the fetus is previable, fetal heart tones should
of laparoscopic appendectomy compared with laparotomy, high- be measured before and after the surgery. If the fetus is viable,
lighting the need for more research into this area.29,30 The greatest fetal heart sounds should be measured throughout the surgery
threat facing the pregnant patient with acute abdominal pain is with a provider capable of performing an emergent cesarean
the potential for delayed diagnosis. Delays in receiving surgical section readily available.33
treatment have proved far more morbid than the operations them- Appendicitis is the most common nonobstetric disease requir-
selves.11,31 Delays occur for several reasons. Many times, symp- ing surgery, occurring in 1/1500 pregnancies.29,33 Its symptoms
toms are attributed to the underlying pregnancy, including typically consist of right lateral abdominal pain, nausea, and
abdominal pains, nausea, vomiting, and anorexia. Pregnancy can anorexia, yet “typical” presentations account for only 50% to 60%
also alter the presentation of some disease processes and make the of cases.34 Fever is uncommon unless the appendix is perforated
physical examination more challenging because of the enlarged with abdominal sepsis. Symptoms are sometimes attributed to the
uterus in the pelvis. The appendix rises out of the pelvis to within underlying pregnancy, and a high index of suspicion must be
a few centimeters of the right anterolateral costal margin late in maintained. Laboratory studies can also be misleading. Leukocy-
the third trimester (Fig. 45-14).32 Laboratory studies such as white tosis as high as 16,000 cells/µL is common in pregnancy, and
blood cell counts and other chemistries are also altered in preg- labor can increase the count to 21,000 cells/µL. Many authors
nancy, making recognition of disease more difficult. In addition, have suggested that a neutrophil shift of more than 80% is sug-
physicians may hesitate to perform typical imaging studies, such gestive of an acute inflammatory process such as appendicitis, yet
as plain abdominal films or CT scans, because of concern over others have observed that only 75% of patients with proven
TABLE 45-3 Modified Alvarado Scoring The second and third most common surgical diseases seen in
pregnancy are biliary tract disorders and bowel obstructions.
System for Appendicitis
Surgery for biliary disease occurs in 1 to 6/10,000 pregnancies.38
FEATURE SCORE Symptoms of pain, nausea, and anorexia are the same as in non-
Symptoms pregnant patients. Even though the elevated estrogen levels should
Right iliac fossa pain 1 be more lithogenic, the incidence of disease is similar to that in
Nausea/vomiting 1 nongravid women.28 With few exceptions, the evaluation and
Anorexia 1 treatment during pregnancy are similar to the evaluation and
treatment of all patients with biliary disease. Ultrasound is the
Signs diagnostic test of choice. Alkaline phosphatase is elevated second-
Right iliac fossa tenderness 2 ary to elevated estrogen, and normal values must be adjusted.
Fever 1 Laparoscopic cholecystectomy is the preferred technique for
Rebound tenderness 1 cholecystectomy.28,38,39 Many studies have suggested laparoscopic
cholecystectomy for all symptomatic disease secondary to high
Tests antepartum and postpartum recurrence and complications regard-
WBC ≥ 10,000 2 less of trimester.28,38 Still, most surgeons try to treat simple biliary
Left shift of neutrophils 1 colic with conservative management in the first and third trimes-
Score ≥ 7 Surgery is recommended ters and plan elective laparoscopic cholecystectomy for the second
trimester or the postpartum period to minimize fetal risk.38 Gall-
From Brown MA, Birchard KR, Semelka RC: Magnetic resonance
stone pancreatitis and acute cholecystitis should be managed more
evaluation of pregnant patients with acute abdominal pain. Semin
Ultrasound CT MR 26:206–211, 2005.
carefully. Gallstone pancreatitis has been associated with fetal loss
as high as 60%. If a woman does not respond quickly to conserva-
tive treatment with hydration, bowel rest, analgesia, and judicious
use of antibiotics, further evaluation should be performed as
appendicitis had a shift, whereas as many as 50% of patients with surgery may be indicated.
a shift and pain were found to have a normal appendix.11,30 Bowel obstructions are much less common, occurring in
Scoring systems have been advocated that assign numerical scores approximately 1 to 2/4000 pregnancies; the underlying cause is
to certain symptoms, signs, and laboratory values to predict the adhesions in two thirds of cases. Volvulus is the second most
likelihood of appendicitis. Although systems such as the Modified common cause, occurring in 25% of cases compared with only
Alvarado Scoring System (Table 45-3) help predict the need for 4% of the nonpregnant population.30 Signs and symptoms are
surgical intervention, they have not been validated in a model of typical but must not be attributed to “morning sickness.” Colicky
pregnancy.34 Ultrasound has been relied on as the first imaging abdominal pain with rapid abdominal distention should key the
tool in many centers. Graded compression ultrasound has been clinician to the diagnosis. Three periods during gestation are
shown to have a sensitivity of 86% in the nonpregnant patient.29 associated with an increased risk of obstruction and correlate with
In a case series of 42 pregnant women with suspected appendicitis, rapid changes in uterine size.30 The first is from 16 to 20 weeks
graded compression ultrasound was found to be 100% sensitive, when the uterus grows beyond the pelvis; the second is from 32
96% specific, and 98% accurate.35 Three women were excluded to 36 weeks when the fetal head descends; and the third is in the
from the analysis because of a technically inadequate examination early postpartum period. The evaluation should be the same as
due to advanced gestational age (>35 weeks). Helical CT scanning for any patient, and there should be no hesitation to obtain
has been established as a valuable tool for evaluation of the non- abdominal radiographs if the situation warrants. As with other
pregnant patient and shows promise as a second-line study in acute inflammatory processes in the abdomen, the maternal and
pregnancy. Compared with traditional CT scans, helical CT can fetal morbidity is most affected by delayed definitive treatment.
provide a much faster study with radiation exposures of approxi-
mately 300 mrad to the fetus.29 MRI now plays an important role Pediatrics
in the diagnosis as well. MRI is not only capable of demonstrating Strategies for diagnosis of the acute abdomen in the pediatric
the normal appendix, but it can also recognize an enlarged appen- population are the same as for adults. Appendicitis remains one
dix, periappendiceal fluid, and inflammation.36 The sensitivity of the primary causes of the acute abdomen in this age group.
and specificity reported in a retrospective review of 148 patients Although bowel obstructions and gallstone disease are seen, these
suspected of having acute appendicitis were 100% and 93%, entities are far less frequent than in adults. Intussusception should
respectively.37 be maintained in the differential diagnosis, especially for those
The added difficulties in evaluating the pregnant patient with younger than 3 years. Gastroenteritis, perforations from foreign
right lower quadrant abdominal pain have resulted in a signifi- body ingestion, food poisoning, Meckel’s diverticulitis, and C.
cantly higher negative appendectomy rate compared with non- difficile colitis are also potential causes. Presentations and exami-
pregnant peers in the past. Although this diagnostic error rate nation findings are similar to those of adult patients. The primary
would be unacceptable in a typical young healthy woman, it is challenge to making the correct diagnosis lies in obtaining an
widely accepted because of the fetal mortality suffered when accurate history. Children will often be poor historians because of
appendicitis progresses to perforation before surgery. Perioperative age, fear, or their general ability to describe their experience. A
fetal loss associated with appendectomy for early appendicitis is thorough history must therefore be also obtained from the child’s
3% to 5%, whereas it climbs to more than 20% in the setting of parents as well. Diagnostic testing choices as well as treatments
perforation.31 With modern imaging, especially MRI, negative may be influenced by the age of the patient. Clinicians may be
appendectomies have decreased without an associated increase in less inclined to perform studies that deliver ionizing radiation to
perforations.36,37 young children. A retrospective study of 1228 children
with suspected appendicitis evaluated the use of ultrasound as a transplant recipients having received high-dose therapy for rejec-
first-line tool, with CT scanning used as an adjunct for equivocal tion in the past 2 months, cancer patients on chemotherapy
studies.40 This study showed that CT scanning was avoided in especially with neutropenia, and HIV patients with CD4 counts
more than half of patients while maintaining a negative appen- below 200/mm3. These patients present very late in their course,
dectomy rate of 8.1%. Finally, there is a growing experience in often with little or no pain, no fever, and vague constitutional
treating early appendicitis nonoperatively with antibiotics. A symptoms followed by an overwhelming systemic collapse.
recent prospective nonrandomized study of 77 children with Pseudomembranous colitis has traditionally been associated
appendicitis found the immediate and 30-day success rates of with recent broad-spectrum antibiotic use, although it is increas-
nonoperative treatment to be 93% and 90%. Of the three patients ingly seen in immunocompromised patients with diseases such as
who failed to respond to medical management, none progressed lymphoma, leukemia, and AIDS. Clinical manifestations com-
to perforated or complicated appendicitis. Children in the medi- monly include diarrhea, dehydration, abdominal pain, fever, and
cally managed group were found to return to school 2 days sooner, leukocytosis, yet immunocompromised patients may fail to exhibit
had 14 fewer disability days, but incurred an 18-hour longer many of these findings because of their inability to mount a normal
hospitalization on average.41 inflammatory response. Imaging studies such as CT of the
abdomen become increasingly important in making early, accurate
Acute Abdomen in the Critically Ill diagnoses when presentations are atypical. CT scans are useful in
The critically ill patient with a potential acute abdomen is a dif- patients with complicated colitis without obvious operative indica-
ficult challenge for intensivists and surgeons alike. Many of the tions. CT scans are useful to evaluate for megacolon, ileus, ascites,
underlying diseases and treatments encountered in the intensive perforation, and colon wall thickening (Table 45-4).45 These find-
care unit can predispose to acute abdominal disease. At the same ings, when present, can greatly assist the clinician with forming
time, unrecognized abdominal illness can be responsible for the diagnosis of colitis. However, up to 14% of patients with
patients lingering in a critical state. Critically ill patients are often proven pseudomembranous colitis will have had normal findings
unable to appreciate symptoms to the same degree as healthy peers on CT examination, and therefore the diagnosis should not be
because of nutritional or immune compromise, narcotic analgesia, ruled out solely on the basis of a negative scan. Early surgical
or antibiotic use. Many of these patients have an altered mental consultation has been shown to decrease mortality.46
status or are intubated and cannot provide detailed information In addition, these patients may suffer from atypical infections,
to their providers. including peritoneal tuberculosis, fungal infections including
Cardiopulmonary bypass has been associated with several acute aspergillus, endemic mycoses, and a variety of viral infections
abdominal illnesses. Mesenteric ischemia, paralytic ileus, Ogilvie including cytomegalovirus and Epstein-Barr virus (Box 45-6).
syndrome, stress peptic ulceration, acute acalculous cholecystitis, When an abdominal infection does occur, it is less likely to be
and acute pancreatitis have all been linked to the low-flow state walled off as a localized infection because of the lack of inflam-
of cardiopulmonary bypass, and incidence appears tied to the matory reaction. All severely immunocompromised patients
length of the cardiac procedure.42,43 Vasoactive medications and require prompt and thorough evaluation for any persistent
ventilator support have also been linked to hypoperfusion and abdominal complaints. All patients requiring hospitalization
similar abdominal processes. When an acute abdominal complica- should receive a surgical consult to aid in timely diagnosis and
tion occurs in an intensive care unit patient, it has a dramatic treatment. High-resolution CT scanning can be of great benefit
effect on outcome. Intensivists should maintain a high index of in these patients, but a low threshold for laparoscopy or laparot-
suspicion for the development of intra-abdominal disease and omy should be maintained for those with equivocal diagnostic test
consult with surgeons early to maximize recovery potential. Sur- results and persistent symptoms that remain unexplained.
geons must then work to exclude the possibility of abdominal
disease using all of the methods described in this chapter as well Acute Abdomen in the Morbidly Obese
as bedside ultrasound, paracentesis, or mini-laparoscopy so that Morbid obesity creates numerous challenges to the accurate diag-
early surgical intervention can be appropriately undertaken.44 nosis of acute abdominal processes. Many authors describe altera-
tions in the signs and symptoms of peritonitis in the morbidly
Immunocompromised Patients With Acute Abdomen
Immunocompromised patients have variable presentations with
TABLE 45-4 Frequency of Common
acute abdominal diseases. The variability is highly correlated to
the degree of immunosuppression. There is no reliable test for CT Scan Observations in
determining the degree of immunosuppression experienced by a Pseudomembranous Colitis
given patient, so estimates are made by associations with certain CT FINDINGS FREQUENCY (%)
disease states or medications. Mild to moderate compromise is
Bowel wall thickening (>4 mm) 86
experienced by the elderly, the malnourished, diabetics, transplant
Pancolic distribution 46
recipients on routine maintenance therapy, cancer patients, renal
Pericolic stranding 45
failure patients, and HIV patients with CD4 counts above 200/
Ascites 38
mm3. Although patients in this group have the same types of ill-
Nodular or polypoid wall thickening 38
nesses and infections as their immunocompetent peers, they still
Mucosal enhancement 18
can present in an atypical fashion. Abdominal pain and systemic
signs and symptoms are often tied to the development of inflam- Bowel dilation 14
mation. These patients may not be able to mount a full inflam- Accordion sign 14
matory response and therefore may experience less abdominal From Tsiotos GG, Mullany CJ, Zietlow S, et al: Abdominal
pain, have delayed development of fever, and have a blunted complications following cardiac surgery. Am J Surg 167:553–557,
leukocytosis. Severely compromised patients typically include 1994.
obese.47-49 Findings of overt peritonitis are often late and usually findings can also be difficult to interpret. Severe abdominal pain
ominous, leading to sepsis, organ failure, and death.47 Abdominal is not common, and less specific findings, such as tachycardia,
sepsis is a much more subtle diagnosis in this population and tachypnea, pleural effusion, and fever, may be the primary obser-
may be associated only with symptoms such as malaise, shoulder vation.49 Appreciation of distention or intra-abdominal mass is
pain, hiccups, or shortness of breath.48 Physical examination also difficult because of the size and thickness of the abdominal
wall.
BOX 45-6 Causes of Acute Abdominal Abdominal imaging is also adversely affected by obesity. Plain
Pain in the Immunocompromised Patient abdominal radiographs can require multiple images to view the
entire abdomen, and clarity is reduced. CT and MRI scanning
Opportunistic Infections
may be impossible to perform as a patient’s girth or weight exceeds
Endemic mycoses (coccidioidomycosis, blastomycosis, histoplasmosis)
the size of the scanning aperture or the weight limit of the mecha-
Tuberculin peritonitis
nized bed. In these settings, a high index of suspicion and low
Aspergillosis
threshold for surgical exploration must be maintained. Laparos-
Neutropenic colitis (typhlitis)
copy is a valuable tool in these patients.
Pseudomembranous colitis
Cytomegalovirus colitis, gastritis, esophagitis, nephritis
Epstein-Barr virus
Hepatic abscesses (fungal or pyogenic) ALGORITHMS IN THE ACUTE ABDOMEN
Iatrogenic Conditions Algorithms can aid in the diagnosis of the patient with an acute
Graft-versus-host disease with hepatitis or enteritis abdomen. As stated earlier, computer-assisted diagnosis has been
Peptic ulcer or perforation from steroid use shown to be more accurate than clinical judgment alone in a
Pancreatitis caused by steroids or azathioprine number of acute abdominal disease states. Algorithms are the basis
Hepatic veno-occlusive disease (secondary to primary immunodeficiency or for computer diagnosis and can be useful in making clinical deci-
chemotherapy) sions. The algorithms presented in Figures 45-15 to 45-20 are
Nephrolithiasis caused by indinavir treatment of HIV helpful in acute abdomen patients and can allow both a focused
workup and expeditious therapy.
History and physical
Acute onset
No peritoneal signs Peritoneal signs
Acidosis, ↑lactate Abdominal x-ray
CT Pneumoperitoneum No pneumoperitoneum
Arterial NL Mesenteric
ischemia Consider angio venous
thrombosis OR Water-soluble contrast swallow
or
OR Angio Anticoagulation Leak, Contained No leak

not contained leak
OR OR NG + CT
antibiotics
FIGURE 45-15 Algorithm for the treatment of acute-onset severe, generalized abdominal pain. CT, com-
puted tomography; NG, nasogastric tube; NL, normal study; OR, operation.
History and physical SUMMARY

Evaluation and management of the patient with acute abdominal
pain remain a challenging part of a surgeon’s practice. Whereas
Gradual onset
advances in imaging techniques, use of algorithms, and computer
assistance have improved the diagnostic accuracy for the condi-
tions causing the acute abdomen, a careful history and physical
Amylase, lipase, LFTs
examination remain the most important part of the evaluation.
Even with these tools at hand, the surgeon must often make the
decision to perform a laparoscopy or laparotomy with a good deal
Pancreatitis Fever, abnormal of uncertainty as to the expected findings. Increased morbidity
LFTs, cholangitis and mortality associated with a delay in the treatment of many of
the surgical causes of the acute abdomen argue for an aggressive
and expeditious surgical approach.
Evaluate severity Antibiotics, ? ERCP
Common Pitfalls
Shock, • Failure to thoroughly examine and document findings
Mild Moderate Severe
respiratory failure • Failure to perform a rectal or vaginal examination when
appropriate
Supportive Consider CT No shock • Failure to evaluate for hernias, including the scrotal region
treatment
Consider
• Failure to conduct a pregnancy test or to consider pregnancy
peritoneal lavage in the diagnosis
CT • Failure to reassess the patient frequently while developing a
FIGURE 45-16 Algorithm for the treatment of gradual-onset severe,
differential diagnosis
generalized abdominal pain. CT, computed tomography; ERCP, endo- • Failure to reconsider an established diagnosis when the clinical
scopic retrograde cholangiopancreatography; LFTs, liver function tests. situation changes
• Failure to recognize immune compromise and to appreciate its
masking effect on the historical and examination findings
• Allowing a normal laboratory value to dissuade a diagnosis
when there is cause for clinical concern
• Failure to consult colleagues when appropriate
LFTs, amylase, lipase
• Failure to take age- and situation-specific diagnoses into
consideration
• Failure to make specific and concrete follow-up arrangements
NL ↑ LFTs, NL amylase, lipase when monitoring a clinical situation on an outpatient basis
• Hesitancy to go to the operating room without a firm diagnosis
when the clinical situation suggests surgical disease
US US
SELECTED REFERENCES
Gallstones NL Dilated bile ducts NL bile ducts Ahmad TA, Shelbaya E, Razek SA, et al: Experience of laparo-
scopic management in 100 patients with acute abdomen. Hepa-
togastroenterology 48:733–736, 2001.
Laparoscopy CT
CT vs. ERCP CT
A description of the usefulness of laparoscopy in a large
Directed therapy series of patients with acute abdomen. A good review of
Directed therapy Directed therapy this important diagnostic and therapeutic tool.
FIGURE 45-17 Algorithm for the treatment of right upper quadrant
abdominal pain. CT, computed tomography; ERCP, endoscopic retro- Cademartiri F, Raaijmaker RHJM, Kuiper JW, et al: Multi-
grade cholangiopancreatography; LFTs, liver function tests; NL, normal detector row CT angiography in patients with abdominal angina.
study; US, ultrasound. Radiographics 24:969–984, 2004.
A good review of the computed tomographic characteristics

of acute mesenteric ischemia. This outlines the radiographic
findings that have greatly assisted in the diagnosis of this
otherwise difficult condition.
CT
Graff LG, Robinson D: Abdominal pain and emergency depart-
ment evaluation. Emerg Med Clin North Am 19:123–136, 2001.
CT-directed therapy
Good review of the spectrum of patients presenting with
FIGURE 45-18 Algorithm for the treatment of left upper quadrant
acute abdominal pain.
abdominal pain. CT, computed tomography.
Female Male
Gynecologic hx, ? UTI, ? appendicitis Presentation Equivocal presentation

consistent with
appendicitis
CT OR CT
Appendicitis No appendicitis Laparotomy CT-directed therapy

vs. laparoscopy
Laparoscopy/laparotomy CT-directed therapy
FIGURE 45-19 Algorithm for the treatment of right lower quadrant abdominal pain. CT, computed tomog-
raphy; hx, history; OR, operation; UTI, urinary tract infection.
Peritonitis No peritonitis
CT Diverticulitis Equivocal
Contained abscess Perforation Antibiotics CT
Antibiotics + Laparotomy CT-directed therapy

percutaneous drainage
Elective resection
FIGURE 45-20 Algorithm for the treatment of left lower quadrant abdominal pain. CT, computed
tomography.
Macari M, Balthazar EJ: The acute right lower quadrant: CT

This is a classic monograph stressing the importance of
evaluation. Radiol Clin North Am 41:1117–1136, 2003.
history and physical examination in the diagnosis of the
acute abdomen. Nearly all diseases manifesting as an acute
A modern discussion of the role of computed tomography
abdomen are presented. A must read for the surgical
in the evaluation of patients with right lower quadrant
resident.
abdominal pain.
Silen W: Cope’s early diagnosis of the acute abdomen, ed 21, New Steinheber FU: Medical conditions mimicking the acute surgical
York, 2005, Oxford University Press. abdomen. Med Clin North Am 57:1559–1567, 1973.
20. De Keulenaer BL, De Waele JJ, Powell B, et al: What is

This classic article nicely reviews the various medical condi-
normal intra-abdominal pressure and how is it affected by
tions that can be manifested as an acute abdomen. It is well
positioning, body mass and positive end-expiratory pressure?
written and remains pertinent to the evaluation of these
Intensive Care Med 35:969–976, 2009.
patients.
21. Ahmad TA, Shelbaya E, Razek SA, et al: Experience of lapa-
roscopic management in 100 patients with acute abdomen.
Hepatogastroenterology 48:733–736, 2001.
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New York, 2005, Oxford University Press. 27. de Bakker JK, Dijksman LM, Donkervoort SC: Safety and
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1990. 28. Pearl J, Price R, Richardson W, et al: Guidelines for diagno-
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45 CHAPTER

Toxins and Drugs Infection

* No known sensory fibers in sympathetic rami.

population ages. These drugs may be the cause of gastrointestinal

upper quadrant, an abdominal mass displacing the bowel should

TABLE 45-1 Abdominal Examination Signs

LABORATORY STUDIES BOX 45-4 Helpful Laboratory Studies in

FIGURE 45-10 Upright chest radiograph depicting moderate-sized

to the value of ultrasonography in the diagnosis of diseases that

TABLE 45-2 Abdominal Hypertension

DIAGNOSTIC LAPAROSCOPY BOX 45-5 Findings Associated With

from nasogastric tube placement to decrease the likelihood of

History and physical

No peritoneal signs Peritoneal signs

Acidosis, ↑lactate Abdominal x-ray

OR Angio Anticoagulation Leak, Contained No leak

History and physical SUMMARY

A good review of the computed tomographic characteristics

History and physical

Gynecologic hx, ? UTI, ? appendicitis Presentation Equivocal presentation

Appendicitis No appendicitis Laparotomy CT-directed therapy

Laparoscopy/laparotomy CT-directed therapy

History and physical

Contained abscess Perforation Antibiotics CT

Antibiotics + Laparotomy CT-directed therapy

Macari M, Balthazar EJ: The acute right lower quadrant: CT

20. De Keulenaer BL, De Waele JJ, Powell B, et al: What is

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