Acute abdomen
Encyclopedia
The term acute abdomen refers to a sudden, severe abdominal pain
of unclear etiology
that is less than 24 hours in duration. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need surgical treatment
.
. While this is not entirely incorrect, peritonitis is the more specific term, referring to inflammation of the peritoneum
. It manifests on physical examination
as rebound tenderness
, or pain upon removal of pressure rather than application of pressure to the abdomen. Peritonitis may result from several of the above diseases, notably appendicitis
and pancreatitis
.
The Superior Mesenteric Artery supplies:
The Inferior Mesenteric Artery supplies:
Of note, the splenic flexure
, or the junction between the transverse and descending colon, is supplied by the most distal portions of both the Inferior Mesenteric Artery and Superior Mesenteric Artery, and is thus referred to medically as a Watershed area
, or an area especially vulnerable to ischemia during periods of systemic hypoperfusion, such as in shock.
Acute abdomen of the ischemic variety is usually due to:
Clinically, patients present with diffuse abdominal pain, bowel distention, and bloody diarrhea. On physical exam, bowel sounds will be absent. Laboratory tests reveal a neutrophilic leukocytosis, sometimes with a left shift, and increased serum amylase. Abdominal radiography will show many air-fluid levels, as well as widespread edema.
Acute ischemic abdomen is a surgical emergency. Typically, treatment involves removal of the region of the bowel that has undergone infarction
, and subsequent anastomosis
of the remaining healthy tissue.
and / or a CT scan. These tests can provide a differential diagnosis between simple and complex pathologies. It can also provide evidence to the doctor whether surgical intervention is necessary.
Patients will also most likely receive a complete blood count
(or full blood count in the U.K.), looking for characteristic findings such as neutrophilia
in appendicitis
.
Traditionally, the use of opiates or other painkillers in patients with an acute abdomen has been discouraged before the clinical examination, because these would alter the examination. However, the scientific literature does not reveal any negative results from these alterations.
Abdominal pain
Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...
of unclear etiology
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
that is less than 24 hours in duration. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need surgical treatment
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
.
Causes
The differential diagnoses of acute abdomen include but are not limited to:- Acute appendicitisAppendicitisAppendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to...
. - Acute peptic ulcerPeptic ulcerA peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm...
and its complications. - Acute cholecystitisCholecystitis-Signs and symptoms:Cholecystitis usually presents as a pain in the right upper quadrant. This is known as biliary colic. This is initially intermittent, but later usually presents as a constant, severe pain. During the initial stages, the pain may be felt in an area totally separate from the site...
. - Acute pancreatitisPancreatitisPancreatitis is inflammation of the pancreas. It occurs when pancreatic enzymes that digest food are activated in the pancreas instead of the small intestine. It may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years...
. - Acute intestinal ischemiaIschemiaIn medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
(See Section Below.) - Diabetic KetoacidosisDiabetic ketoacidosisDiabetic ketoacidosis is a potentially life-threatening complication in patients with diabetes mellitus. It happens predominantly in those with type 1 diabetes, but it can occur in those with type 2 diabetes under certain circumstances...
. - Acute DiverticulitisDiverticulitisDiverticulitis is a common digestive disease particularly found in the large intestine. Diverticulitis develops from diverticulosis, which involves the formation of pouches on the outside of the colon...
. - Ectopic PregnancyEctopic pregnancyAn ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...
with tubal rupture. - Acute peritonitisPeritonitisPeritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...
. ( including hollow viscus perforation) - Acute ureteric colic.
- Bowel volvulusVolvulusA volvulus is a bowel obstruction with a loop of bowel whose nose has abnormally twisted on itself.-Types:* Volvulus Neonatorum.* Volvulus Small Intestine.* Volvulus Caecum.* Volvulus Sigmoid Colon .* Gastric volvulus....
. - Acute pyelonephritisPyelonephritisPyelonephritis is an ascending urinary tract infection that has reached the pyelum or pelvis of the kidney. It is a form of nephritis that is also referred to as pyelitis...
. - Adrenal crisis.
- Biliary colic
Peritonitis
Acute abdomen is occasionally used synonymously with peritonitisPeritonitis
Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...
. While this is not entirely incorrect, peritonitis is the more specific term, referring to inflammation of the peritoneum
Peritoneum
The peritoneum is the serous membrane that forms the lining of the abdominal cavity or the coelom — it covers most of the intra-abdominal organs — in amniotes and some invertebrates...
. It manifests on physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
as rebound tenderness
Rebound tenderness
Rebound tenderness is a clinical sign that a doctor or other health care provider may detect in physical examination of a patient's abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen...
, or pain upon removal of pressure rather than application of pressure to the abdomen. Peritonitis may result from several of the above diseases, notably appendicitis
Appendicitis
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to...
and pancreatitis
Pancreatitis
Pancreatitis is inflammation of the pancreas. It occurs when pancreatic enzymes that digest food are activated in the pancreas instead of the small intestine. It may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years...
.
Ischemic Acute Abdomen
Vascular disorders are more likely to affect the small bowel than the large bowel. Arterial supply to the intestines is provided by the superior and inferior mesenteric arteries, (SMA and IMA respectively) both of which are direct branches of the aorta.The Superior Mesenteric Artery supplies:
- Small bowel.
- AscendingAscending colonThe ascending colon is smaller in caliber than the cecum.It passes upward, from its commencement at the cecum, opposite the colic valve, to the under surface of the right lobe of the liver, on the right of the gall-bladder, where it is lodged in a shallow depression, the colic impression; here it...
and proximal 2/3 of the Transverse colonTransverse colonThe transverse colon, the longest and most movable part of the colon, passes with a downward convexity from the right hypochondrium region across the abdomen, opposite the confines of the epigastric and umbilical zones, into the left hypochondrium region, where it curves sharply on itself beneath...
.
The Inferior Mesenteric Artery supplies:
- Distal 1/3 of the Transverse colonTransverse colonThe transverse colon, the longest and most movable part of the colon, passes with a downward convexity from the right hypochondrium region across the abdomen, opposite the confines of the epigastric and umbilical zones, into the left hypochondrium region, where it curves sharply on itself beneath...
. - Descending colonDescending colonThe descending colon of humans passes downward through the left hypochondrium and lumbar regions, along the lateral border of the left kidney....
- Sigmoid colonSigmoid colonThe sigmoid colon is the part of the large intestine that is closest to the rectum and anus. It forms a loop that averages about 40 cm...
.
Of note, the splenic flexure
Splenic flexure
The splenic flexure is a sharp bend between the transverse and the descending colon in the left upper quadrant of humans. The left colic flexure is near the spleen, and hence called the splenic flexure. There are two colic flexures in the transverse colon — the other being the hepatic...
, or the junction between the transverse and descending colon, is supplied by the most distal portions of both the Inferior Mesenteric Artery and Superior Mesenteric Artery, and is thus referred to medically as a Watershed area
Watershed area (medical)
Watershed area is the medical term referring to regions of the body that receive dual blood supply from the most distal branches of two large arteries, such as the splenic flexure of the large intestine....
, or an area especially vulnerable to ischemia during periods of systemic hypoperfusion, such as in shock.
Acute abdomen of the ischemic variety is usually due to:
- A thromboembolism from the left side of the heart, such as may be generated during atrial fibrillationAtrial fibrillationAtrial fibrillation is the most common cardiac arrhythmia . It is a common cause of irregular heart beat, identified clinically by taking a pulse. Chaotic electrical activity in the two upper chambers of the heart result in the muscle fibrillating , instead of achieving coordinated contraction...
, occluding the SMA. - Nonocclusive ischemia, such as that seen in hypotension secondary to heart failure may also contribute, but usually results in a mucosal or mural infarct, as contrasted with the typically transmural infarct seen in thromboembolus of the SMA.
- Primary mesenteric vein thromboses may also cause ischemic acute abdomen, usually precipitated by hypercoagulable states such as polycythemia vera.
Clinically, patients present with diffuse abdominal pain, bowel distention, and bloody diarrhea. On physical exam, bowel sounds will be absent. Laboratory tests reveal a neutrophilic leukocytosis, sometimes with a left shift, and increased serum amylase. Abdominal radiography will show many air-fluid levels, as well as widespread edema.
Acute ischemic abdomen is a surgical emergency. Typically, treatment involves removal of the region of the bowel that has undergone infarction
Infarction
In medicine, infarction refers to tissue death that is caused by a local lack of oxygen due to obstruction of the tissue's blood supply. The resulting lesion is referred to as an infarct.-Causes:...
, and subsequent anastomosis
Anastomosis
An anastomosis is the reconnection of two streams that previously branched out, such as blood vessels or leaf veins. The term is used in medicine, biology, mycology and geology....
of the remaining healthy tissue.
Workup
Patients presenting to A&E or the ER with severe abdominal pain will almost always have an Abdominal x-rayAbdominal x-ray
An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB .-Diagnostic Tool:...
and / or a CT scan. These tests can provide a differential diagnosis between simple and complex pathologies. It can also provide evidence to the doctor whether surgical intervention is necessary.
Patients will also most likely receive a complete blood count
Complete blood count
A complete blood count , also known as full blood count or full blood exam or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood...
(or full blood count in the U.K.), looking for characteristic findings such as neutrophilia
Neutrophilia
Neutrophilia is a condition where a person has a high number of neutrophil granulocytes in their blood.-Causes:...
in appendicitis
Appendicitis
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to...
.
Traditionally, the use of opiates or other painkillers in patients with an acute abdomen has been discouraged before the clinical examination, because these would alter the examination. However, the scientific literature does not reveal any negative results from these alterations.