event. If the patient has had abdominal surgery, intraabdominal adhesions become a consideration. Alcohol abuse may suggest pancreatitis or gallstone disease.
TABLE 13-1 Diagnostic Considerations in the Acute Abdomen* | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The Acute Abdomen
The Acute Abdomen
The term acute abdomen evokes an image of a patient suffering from sudden, severe abdominal pain, perhaps accompanied by vomiting, attentively surrounded by physicians and surgeons who are earnestly deciding whether to take the patient to the operating room. Indeed, many instances of acute abdomen are surgical emergencies. However, the differential diagnosis is extensive, and the management of an acute abdomen varies according to the diagnosis.
I. DIFFERENTIAL DIAGNOSIS.
The differential diagnosis in a patient with an acute abdomen may be broad or narrow, depending on the clinical signs and symptoms. For example, a 12-year-old boy whose generalized abdominal pain has intensified and become localized to the right lower quadrant very likely has acute appendicitis, but acute Crohn’s disease and mesenteric lymphadenitis must also be considered. On the other hand, severe midabdominal pain in a 65-year-old man with ascites may indicate spontaneous bacterial peritonitis, intestinal ischemia, a perforated ulcer, or a leaking aortic aneurysm, among other possibilities.
A partial list of the diagnostic considerations for an acute abdomen is found in Table 13-1.
II. CLINICAL PRESENTATION
A. History
1. Pain
a. Types. Abdominal pain is an invariable feature of an acute abdomen and presents as one or a combination of three types.
i. Visceral pain develops from stretching or distending of an abdominal viscus or from inflammation. The pain is diffuse and poorly localized. It generally has a gnawing, burning, or cramping quality.
ii. Somatic pain arises from the abdominal wall, the parietal peritoneum, the root of the mesentery, or the diaphragm. It is more intense and better localized than visceral pain.
iii. Referred pain is felt at a site distant from the source of the pain but shares the same dermatome or neurosegment. Referred pain is usually sharp and well localized; thus, it resembles somatic pain.
b. The onset of pain may be instantaneous, or the pain may develop over minutes or even hours. Sudden severe pain characterizes such events as a perforated ulcer, a ruptured viscus, a ruptured ectopic pregnancy, a spontaneous pneumothorax, or a dissecting aortic aneurysm. On the other hand, more gradual development of pain is typical of acute pancreatitis, acute cholecystitis, intestinal obstruction, bowel perforation, diverticulitis, and intraabdominal abscess.
2. Vomiting
usually accompanies an acute abdomen to a variable degree. A clinical rule is that pain precedes vomiting in disorders requiring surgical treatment, whereas vomiting precedes pain in medically treated disorders. Vomiting can be persistent, as with intestinal obstruction. Long-standing obstruction may result in feculent vomiting due to the proximal growth of colonic bacterial flora. Vomiting of bloody material suggests that the bleeding lesion is above the ligament of Treitz.
3. Other historical aspects.
A history of a known disorder, such as pancreatitis or peptic ulcer, makes that diagnosis more likely as the cause of the current
event. If the patient has had abdominal surgery, intraabdominal adhesions become a consideration. Alcohol abuse may suggest pancreatitis or gallstone disease.
event. If the patient has had abdominal surgery, intraabdominal adhesions become a consideration. Alcohol abuse may suggest pancreatitis or gallstone disease.
