Acute abdomen

Intra-abdominal pathological process, of recent onset, that presents with pain, systemic repercussions and requires rapid diagnosis and treatment.

Generalities

The interpretation of the signs and symptoms of abdominal origin is difficult and requires solid knowledge and vast experience of the attending physician. All abdominal pain warrants a good medical history and an adequate physical examination. The evolution of pain is an important data and for this reason analgesics and antibiotics should be avoided before establishing the behavior to be followed.

The acute abdomen is not always surgical; however, lengthy diagnostic procedures that can delay surgical resolution should be avoided. There are extra-abdominal processes that can simulate an acute abdomen.

Causes

There are a wide variety of both intra-abdominal and extra-abdominal pathologies that can cause or simulate an acute abdomen.

Pain of intra-abdominal origin originate in the peritoneum , intestinal hollow viscera, solid viscera, mesentery, or pelvic organs. They can be due to inflammation, obstruction or acute distention and vascular disorders, generally of the ischemic type.

The extra-abdominal causes are usually of coronary origin, inflammation of the peripheral nerves and pleural irritation.

Symptoms

There are a large number of symptoms associated with an acute abdomen, which depend on the disease that causes the abdominal pain. In general, the symptoms that patients most commonly report are:

• Abdominal pain : it is the predominant symptom and sufficient time must be devoted to it during the preparation of the medical history.
• Nausea and vomiting : The chronology of nausea and vomiting in relation to the appearance of pain is important because they are usually secondary when it comes to an intra-abdominal entity due to stimulation of the medullary centers by afferent visceral fibers; in an extra-abdominal condition, the opposite occurs. The characteristics of vomiting can be helpful in distinguishing the possible level of involvement when intestinal obstruction is suspected. The presence of blood (hematemesis) should also be documented.
• Constipation : It is not easy to differentiate constipation from intestinal obstruction, where there would be no flatus, with decreased peristalsis due to a reflex ileus, caused by stimulation of the sympathetic autonomic system through the visceral afferent fibers of the splanchnic nerves, which can be caused by any intra-abdominal entity. In this case, it is very important to note if there is progressive painful abdominal distention and frequent vomiting, which would mean intestinal obstruction.
• Diarrhea : Severe watery diarrhea is characteristic of gastroenteritis and other medical causes of acute abdomen. The presence of blood may be due to inflammatory bowel disease or amoebic dysentery or ischemic colitis.

Types of Abdominal Pain

• Visceral Pain.-It is of a poorly defined character, poorly located:

a) Medial. Peritoneal viscera involvement. b) Lateral: It involves retroperitoneal viscera.

• Somatic Pain.-It is that pain that follows the path of the cerebrospinal fibers between D6 and L1, which extend through the parietal peritoneum and the root of the mesentery. Well-localized acute, which is located in relation to the affected viscus, is aggravated by movement and is accompanied by muscle contracture.
• Referred Pain.- It is produced by compromise of the descending nerve branches of C3 and C4, stimulating the peritoneal surface of the diaphragm. Example: Pain in the upper angle of the right scapula in acute cholecystitis. Interscapular pain in a process of pancreatitis.

Pathologies that can cause an acute abdomen

Intra-abdominal conditions that require immediate surgery

1. Complicated acute appendicitis (abscess or perforation)
2. Bowel obstruction with strangulation
3. Hollow Viscus Perforation:
   1. Perforated peptic ulcer .
   2. Diverticular perforation of the colon.
   3. Terminal ileum perforation.
   4. Cecum drilling.
   5. Sigmoid secondary to malignant tumor
4. Complicated acute cholecystitis (pyocholecyst, emphysematous in diabetics)
5. Dissecting abdominal aortic aneurysm
6. Mesenteric thrombosis
7. Gynecological:
   1. Twisted ovarian cyst .
   2. E Ectopic Contraindicated in pregnancy broken
8. Testicular torsion
9. Severe acute pancreatitis (necrotic-haemorrhagic)

Abdominal conditions that do not require surgery

1. Uncomplicated acid-peptic disease
2. Liver diseases:
   1. Acute hepatitis .
   2. Uncomplicated liver abscess .
3. Intestinal conditions ( gastroenteritis , terminal ileitis, food poisoning)
4. Urinary tract infection, nephroureteral colic
5. Gynecological conditions:
   1. Acute pelvic inflammatory disease.
   2. Ovulation pain or breakthrough pain.
6. Spontaneous primary peritonitis (in cirrhotics).
7. Intramural hemorrhage of the large intestine secondary to anticoagulants
8. Uncommon causes:
   1. Mediterranean fever.
   2. Abdominal epilepsy .
   3. Porphyria .
   4. Lead poisoning .
   5. Vasculitis .

Extra-abdominal conditions simulating an acute abdomen

1. Acute myocardial infarction .
2. Acute pericarditis.
3. Passive congestion of the liver.
4. Pneumonia .
5. Diabetic cetoacidosis.
6. Acute adrenal insufficiency.
7. Hematological:
   1. Sickle cell anemia.
   2. Henoch – Schönlein purple.

Research

We consider the following as minimal and essential auxiliary examinations, due to their valuable support for diagnosis and because their processing can be carried out in all first-level healthcare centers:

1. Hemogram, hemoglobin and hematocrit: They are basic, because if there is an increase in leukocytes with an increase in filling, it will indicate a left deviation, orienting us towards an infectious process If the hemoglobin and hematocrit are below their normal values ​​and if there is a history of abdominal trauma in the anamnesis in the patient, we will be facing a picture of intra-abdominal hemorrhage.
2. Urine test: It is very valuable to rule out urinary tract infection, especially in women, because urinary infections are more frequent in them.
3. Dosage of amylase and lipase in blood: They must be done quickly and if these results come out with high levels we will be facing the diagnosis of pancreatitis, then we will immediately act with the treatment and thus reduce the morbidity and mortality in the patient.
4. Ultrasound and Tomography: They are very useful to define the different pathological processes that may be causing abdominal pain.
5. Peritoneal Wash: With saline solution (paracentecis) in case of blunt abdominal trauma. Although it is true that this procedure is classic, it is not without diagnostic value in blunt abdominal trauma, due to its practicality and speed in its handling. Especially in cases of false negatives, the laboratory will be asked to analyze the peritoneal lavage fluid and if the result is 100,000 / mm3 of erythrocytes or greater than this value, it will make a decision on surgical intervention.
6. Plain abdominal radiography: Unprepared abdominal radiography provides valuable information; For a patient with an acute abdomen, three events are required:

• Standing frontal abdomen plate.- It allows to see eventually air-fluid levels.

• Frontal abdomen plate in supine position.- In addition, frontal plate can be obtained in right or left lateral decubitus with horizontal ray. It allows the air to be seen upwards and the liquid in the sloping areas, for example: aerobilia in gallstone ileus due to cholecystoduodenal fistula.
• Plate of the abdomen in prone position.- The air is displaced towards the lateral zones and to the rectal ampulla.
• In addition to the abdominal film, the standing frontal chest film is also useful, with which we will demonstrate a possible pneumoperitoneum, we will identify a pneumopathy of basal location, which causes abdominal symptoms or, conversely, the pulmonary manifestation of a subdiaphragmatic pathology .

Preoperative and post-operative care

The preoperative and postoperative care of abdominal surgery must be the same as those performed in a preoperative and general postoperative one, adding to them those cares that derive from the doctor’s indications, according to the abdominal surgical conduct. (from the inflammatory region, to the inguinal region and the upper middle third of both thighs) insisting on the correct disinfection of the area.