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Acute abdomen:
Classification of acute abdomen
based on the etiology |
Presentation | Symptoms | Signs | Lab findings | Preferred diagnostic test | Additional findings | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Fever | Jaundice | Nausea/
Vomiting |
Diarrhea | Constipation | Abdominal
Pain Location |
General
Appearance |
Bowel Sounds | Abdominal tenderness | Shifting dullness | Rigidity | Rebound tenderness | Shock | |||||||
Superficial | Deep | ||||||||||||||||||
Common causes of peritonitis | Primary peritonitis | Spontaneous bacterial peritonitis | ✔ | ✔/✘ | ✔/✘ | ✘ | ✘ | diffuse | lies supine motionless
tense abdomen due to ascites |
diminished | ✔ | ✘ | ✔ | ✘ | ✘ | Ascitic fluid PMN>250cells/mm3
Single organism on culture of the ascitic fluid |
ascitic fluid PMN count | Altered mental status usually seen. | |
Inflammatory disorders and perforations causing Secondary peritonitis | Perforated gastro-duodenal ulcers | ✔ | ✘ | ✔ | ✘ | ✘ | right upper quadrant | Scaphoid, tense abdomen | ✘ | ✔ | ✘ | ✘ | ✔ | ✔ | Fulfillment of 2/3 runyon's criteria:
glucose < 50mg/dl total protein > 1g/dl LDH ascites > normal LDH serum |
upright chest x-ray, CT scan | |||
Acute cholangitis | ✔ | ✔ | ✘ | ✘ | ✘ | Right upper quadrant | Toxic look | normal | ✘ | ✘ | ✘ | ✘ | ✘ | Ultrasound, CT, ERCP, MRCP, PTC | Charcot triad ( RUQ pain, jaundice,fever)
Reynold pentad ( RUQ pain, jaundice,fever, confusion,shock) | ||||
Acute cholecystitis | ✔ | ✔ | ✘ | ✘ | Right upper quadrant or epigastrium may radiate to the right shoulder or back | ✔ right upper abdomen | ✘ | ✘ | ✘ | ✘ | Ultrasound | Murphy's sign (pain on inspiration causing a cessation of breathing) may be present | |||||||
Acute pancreatitis | ✔ | ✔ | midepigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side with a band-like radiation to the back | ✔epigastrium | ✘ | ✘ | ✘ | ✘ | Serum amylase/lipase | CT scan | |||||||||
Acute appendicitis | ✔ | ✘ | ✘ | vague periumbilical initially that eventually localises to right lower quadrant | ✔right lower quadrant | CT scan, ultrasound | |||||||||||||
Acute diverticulitis | ✔ | ✘ | ✔ | ✔/✘ | ✔/✘ | Left lower quadrant pain | ✔left lower quadrant | CT scan | leukocytosis | ||||||||||
Acute salpingitis | ✔ | ||||||||||||||||||
Hollow Viscous Obstruction | small Intestinal obstruction | ✔ | periumbilical and crampy, with paroxysms of pain occurring every 4-5minutes.Pain progresses from crampy to constant and more severe indicating impending strangulation | Dissension of the abdomen | Flat and upright film, CT scan | ||||||||||||||
Volvulus | ✔ | ✔ in sigmoid volvulus | steady pain, with a superimposed colicky component | ||||||||||||||||
Biliary Colic | ✔ | right upper quadrant | CT scan | hepatomegaly and a palpable gallbladder(courvoisier sign) pancreatic head tumor | |||||||||||||||
Renal Colic | colicky and radiates to the flank or groin | Hematuria | |||||||||||||||||
Vascular disorders | Ischemic | Mesenteric ischemia | ✔ | severe periumbilical pain out of proportion to physical examination findings | Soft duffy fullness | Severe pain out of proportion to examination | increased lactic acid and leukocytosis | Abdominal x-ray, CT Angiogram, MRI | |||||||||||
Acute ischemic colitis | CT scan,
Colonoscopy |
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Hemorrhagic | Ruptured abdominal aortic aneurysm | ✘ | ✘ | ✘ | ✘ | ✘ | variable depending on the location of the rupture(proximal or distal aorta) | toxic | normal | ✘ | ✘ | ✘ | ✘ | ✘ | ✔ | White blood cell count, fibrinogen, D-dimer, troponin T, N-terminal pro-brain natriuretic peptide, and high-sensitivity C-reactive protein | abdominal ultrasound and computed tomography (CT) of abdomen are most useful | patients presenting with abdominal/back/flank pain, hypotension, pulsatile mass should undergo emergency surgery. cullen sign(bruising around the umbilicus) | |
Intraabdominal or Retroperitoneal hemorrhage | Grey turner sign(bruising in the flank) | ||||||||||||||||||
Gynecologic Causes | Ovarian Cyst Complications | Torsion | ✔ | lower abdominal pain | |||||||||||||||
Rupture | focal,unilateral lower abdominal pain accompanied by light vaginal bleeding | measurement of human chorionic gonadotropin and alpha-fetoprotein | transvaginal ultrasonography | ||||||||||||||||
Ruptured Ectopic Pregnancy | ✘ | ✘ | ✔/✘ | ✘ | ✘ | lower abdominal quadrant and pelvis | toxic look | normal | ✘ | ✘ | ✘ | ✘ | ✘ | urine b-hcg +, | transvaginal ultrasonography and serial testing of hCG | Amenorrhea and vaginal bleeding. |