Acute abdomen

An acute abdomen refers to a sudden, severe abdominal pain.^[1] It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need surgical treatment.

Causes

The differential diagnoses of acute abdomen include but are not limited to:

1. Acute appendicitis
2. Acute peptic ulcer and its complications
3. Acute cholecystitis
4. Acute pancreatitis
5. Acute intestinal ischemia (see section below)
6. Acute diverticulitis
7. Ectopic pregnancy with tubal rupture
8. Ovarian torsion
9. Acute peritonitis (including hollow viscus perforation)
10. Acute ureteric colic
11. Bowel volvulus
12. Acute pyelonephritis
13. Adrenal crisis
14. Biliary colic
15. Abdominal aortic aneurysm
16. Familial Mediterranean fever
17. Hemoperitoneum
18. Ruptured spleen
19. Kidney stone
20. Sickle cell anaemia

Peritonitis

Acute abdomen is occasionally used synonymously with peritonitis. 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 more than on application of pressure to the abdomen. Peritonitis may result from several of the above diseases, notably appendicitis and pancreatitis. While rebound tenderness is commonly associated with peritonitis, the most specific finding is rigidity.

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:

1. Small bowel
2. Ascending and proximal two-thirds of the transverse colon

The inferior mesenteric artery supplies:

1. Distal one-third of the transverse colon
2. Descending colon
3. Sigmoid colon

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:

1. A thromboembolism from the left side of the heart, such as may be generated during atrial fibrillation, occluding the SMA.
2. 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.
3. 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, and subsequent anastomosis of the remaining healthy tissue.

Workup

Stable patients presenting to A&E (accident and emergency department) or ER (emergency room) with severe abdominal pain will almost always have an abdominal x-ray and/or a CT scan. These tests can provide a differential diagnosis between simple and complex pathologies. However, in the unstable patient, fluid resuscitation and a FAST-ultrasound are done first, and if the latter is positive for free fluid, straight to surgery. They may 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.^[2][3]

References