Acute Abdomen

What is meant by the term acute abdomen ? 

  • The classic definition refers to the sudden onset of severe abdominal pain of unclear cause. 
  • Acute abdomen refers to any abdominal condition that requires prompt diagnosis.
  • Often acute abdomen is equated with inflammation of the peritoneum or peritonitis, but they are not identical.
  • Although many cases may ultimately require surgical intervention, it is not inherently implied by the term.

What elements of a patient’s history are most important?

  • Age
  • Location of pain (what quadrant)
  • Character (sharp, stabbing, dull, burning)
  • Onset and duration
  • Past surgical history and medical comorbidities

Which disorders are associated with specific age groups?

  • Neonates: intussusception, appendicitis, Meckel’s diverticulitis, mesenteric adenitis, midgut volvulus, malrotation, hypertrophic pyloric stenosis, small bowel atresia
  • Adults: cholecystitis, diverticulitis, gynecologic disorders, peptic ulcer disease (PUD), incarcerated hernia, ruptured spleen, renal or biliary stones, pancreatitis, small bowel obstruction
  • Older adults: diverticulitis, colon cancer (perforation), appendicitis, aortic aneurysm, colonic (cecal or sigmoid) and small bowel volvulus, mesenteric ischemia

Pain in each of these locations is often associated with which disorders?

  • Right upper quadrant: biliary tract disease, hepatitis, PUD, pneumonia
  • Right flank: hepatitis, pyelonephritis, appendicitis
  • Right lower quadrant: appendicitis (late), ectopic pregnancy, incarcerated inguinal hernia, rectus sheath hematoma, ovarian torsion, pelvic inflammatory disease, ruptured ovarian cyst, Meckel’s diverticulitis, Crohn’s disease
  • Epigastrium: pancreatitis, PUD, cardiac disease, esophageal disease
  • Central abdomen: bowel obstruction, bowel ischemia, midgut volvulus, appendicitis (early)
  • Left upper quadrant: splenic rupture or infarct, PUD, pneumonia, leaking abdominal aortic aneurysm
  • Left lower quadrant: diverticulitis, incarcerated inguinal hernia, ovarian torsion, pelvic inflammatory disease, colon cancer (perforated)

What associated problems can help to pinpoint the diagnosis? 

  • A complete medical, surgical, and family history are essential. For example, in premenopausal women, pelvic inflammatory disease and pregnancy-related issues must be screened as part of the initial assessment.
  • Risk factors will often narrow a wide differential, such as chronic nonsteroidal antiinflammatory drug use in a patient with epigastric pain (peptic ulcer), or history of inflammatory bowel disease in a patient with obstipation and right lower quadrant pain (Crohn’s ileocecal stricture).
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