Acute Abdomen

• • and appendix (T9 & T10) around the umbilicus, whereas in case of colon (T11 & 12, L1 & 2) in the hypogastrium. The diaphragm is supplied by the phrenic nerve (C3, 4 & 5 of which the main supply comes from the fourth). The cutaneous nerves from the same segments are concerned in supplying the skin over the shoulder as also the upper part of the front of the chest through the supraclavicular nerves (C3 & 4). Any irritation on the undersurface of the diaphragm either by gastric contents or blood or bile (after operation on the biliary tract) or inflammatory exudate may give rise to referred pain to the corresponding shoulder. In suspected cases the foot-end of the bed may be raised by about 18 inches to allow the exudates to gravitate down towards the undersurface of the diaphragm which will obviously initiate pain on the corresponding shoulder. In renal colic, pain is referred from the loin to the groin, testis and inner side of the thigh, ie. the distribution of the genito-femoral nerve(L1 & 2). The same segments supply the ureter also. In biliary colic the pain radiates from the right hypochondrium to inferior angle of the right scapula since the gallbladder is supplied by the 7th to 9th thoracic segments. In passing, it must be emphasised that the segmental nerve supply as has been referred to in this section is the sympathetic supply of the viscus. Of course the same viscus also receives the parasympathetic supply mostly from the vagus (the sole exception being the hindgut and the bladder which receive the sacral sympathetic supply). Similarly irritation of the parietal pleura as may occur in pleurisy, haemothorax or pneumothorax may initiate referred pain to the abdominal wall as may mimic acute abdominal conditions.Character of pain-

    • • Colicky pain- It is a sharp intermittent griping pain which comes on suddenly and disappears suddenly. It indicates obstruction to a hollow organ- either bowel obstruction (intestinal colic) or obstruction of the common bile duct with a stone (biliary colic) or obstruction of the renal pelvis or ureter with a stone (renal or ureteric colic).

      • Constant burning pain- is a feature of peritonitis and often seen in perforated peptic ulcer.

      • Severe agonising pain- is very much characteristic of acute pancreatitis or of torsion.

      • Throbbing pain- is suggestive of inflammation, eg. hepatitis or cholecystitis.

        • • • Change in character of the pain is sometimes noticed. Colicky pain of acute intestinal obstruction may change into constant burning type which indicates strangulation. Diminution of pain is not always a happy symptom. In acute appendicitis it may indicate perforation of an obstructive gangrenous appendix. In 2nd stage (stage of irritation) of peptic perforation, pain diminishes in intensity although the disease is continuing. This is due to the fact that the peritoneal exudate dilutes the irritant gastric content.

• • • Effect of pressure on pain- In colics pressure gives relief but in inflammatory conditions it aggravates the pain.

    • Relation of the pain to jolting, walking, respiration & micturition- In amoebic hepatitis, cholecystitis and appendicitis the aggravates during walking and jolting. Ureteric colic sometimes gets worse by jolting. In diaphragmatic pleurisy pain is aggravated during deep inspiration and coughing. Pain during the act of micturition or 'strangury' is frequently met with in ureteric colic, pelvic appendicitis or even pelvic abscess.

    • What makes the pain better or worse?- In case of peritonitis, pain is slightly relieved if the patient lies still. If he rolls about the pain becomes worse. In case of pain due to diaphragmatic irritation either due to inflammatory exudate or due to blood from injury to the liver or spleen deep inspiration will aggravate the pain. In case of hiatus hernia and reflux oesophagitis, stooping will make the pain worse.

    • How is the pain relieved?- Vomiting sometimes relieves the pain in peptic ulcer. In colics vomiting temporarily relieves the pain which reappears immediately. In acute pancreatitis the pain is relieved to a certain extent by sitting up from the recumbent position. Application of local pressure relieves colicky pain (biliary ureteric or intestinal).

• Vomiting-

  • • Character of the act- The vomiting may be projectile ie. involuntary forceful ejection of a large quantity of vomitus in high intestinal obstruction, toxic enteritis etc. In case of peptic ulcer perforation or general peritonitis the vomiting is quite regurgitation of mouthfuls.

    • Vomitus- In intestinal obstruction at first the stomach contents, next the duodenal contents (bilious) and lastly the intestinal contents (faeculent) are voided. True faecal vomiting is not common. It is also seen in gastrocolic fistula. In case of biliary colic the vomiting is usually bilious. In case of peptic ulcer the vomitus is nothing but gastric contents. In late cases of peritonitis the vomitus becomes dark brown, faeculent being mixed with altered blood. This type of vomitus is also seen in uraemia.

    • Frequency and quantity- Vomiting is constant, frequent and profuse in acute intestinal obstruction and acute pancreatitis. In peptic ulcer vomiting is periodical. In perforation of a peptic ulcer vomiting is not a diagnostic feature. It may be once or twice during the first stage, it is more or less absent in the second stage and may reappear in the last stage with the characteristic vomitus of diffuse peritonitis. Similarly in acute appendicitis it may or may not be present. But nausea is more often complained of. Both nausea and vomiting are the characteristic complaints in pre-or post-ileal appendicitis.

    • Its relationship with pain- Pain precedes vomiting in acute appendicitis, acute pancreatitis, peptic ulcer, biliary and renal colics. In high intestinal obstruction, vomiting appears almost simultaneously with the pain. In obstruction of the lower end of the ileum vomiting may not occur in the beginning but follows after a few hours; in large bowel obstruction vomiting is absent or is a late feature. Vomiting relieves pain in case of peptic ulcer but in colics it relieves pain temporarily so that it reappears immediately.

• • Bowel habit- Absolute constipation ie. arrest of both faeces and flatus is the usual accompaniment of intestinal obstruction and peritonitis. A history of one motion in the beginning of intestinal obstruction is not unusual. In acute appendicitis history of constipation is often received. In pelvic appendicitis or pelvic abscess, irritation of the rectum may lead to 'Tenesmus', ie. ineffectual straining at stool with passage of mucus and blood. In children features of intestinal obstruction accompanied by passage of mucus and blood per anum is suggestive of acute intussusception. In mesenteric thrombosis, blood and putrid stool may be noticed. Diarrhoea occurs in acute ulcerative colitis, regional ileitis and acute enteritis.

  • Micturition- 'Strangury', ie. painful and frequent attempts at micturition passing only a small quantity each time is often come across in case of stone impacted in the lower end of the ureter and stone in the bladder. In inflammatory conditions in the neighbourhood of the bladder and ureter, such as retrocaecal appendicitis, pelvic appendicitis and pelvic peritonitis, they may give rise to the same condition. Even retrocaecal appendicitis lying in very close proximity to the ureter, may lead to haematuria which may mislead the clinician.

PERSONAL HISTORY- In women the menstrual history is very important and should never be missed. A history of missed period is often present in rupture of ectopic gestation. If a patient presents with symptoms very much similar to acute appendicitis in the middle of her menstrual period one should suspect ruptured follicular (lutein) cyst. Smoking and alcoholic habits should always be enquired into.

PAST HISTORY-

• • In perforation of peptic ulcer previous history of ulcer pain may be elicited, even there may be history of haematemesis and melaena.

  • In suspected cases of acute appendicitis, biliary and renal colics, history of previous attacks may be presented which the patient may consider to bear no relation with the present illness.

  • In intestinal obstruction one may get a history of previous abdominal operation.

  • In acute cholecystitis there may be a past history of biliary colic, high rise of temperature and jaundice.

PHYSICAL EXAMINATION

GENERAL SURVEY-

• • Appearance- In 'acute abdomen' the patient usually presents a peculiar facial expression- 'abdominal facies', which helps the clinician to discriminate an abdominal from an extra-abdominal case. In terminal stage of peritonitis, the typical 'facies Hippocratica' can be observed. An anxious look, bright eyes, pinched face and cold sweat on the surface are the features of this type of facies, which once seen will never be forgotten. The facies of dehydration is also typical and consists of sunken eyes, drawn checks and dry tongue. The peculiar lividity or blueness (cyanosis) of the face is a feature which is characteristic, though not often found, in acute haemorrhagic pancreatitis. Extreme pallor and gasping respiration in a woman of child bearing age should arouse suspicion of ruptured tubal gestation.

  • Attitude- In colic the patient is either tossing on the bed, doubbled up or rolls in agony seeking in vain a position of comfort. In peritonitis the patient remains quiet because movements will only increase the pain. Only in the last stage of peritonitis and post-operative peritonitis the patient becomes highly excitable which is evidenced by throwing of bed clothes, tossing of the head, grumbling, ineffective of the hands and feet etc. nothing seems to give him comfort.

  • Pulse- In the early stage of many acute abdominal conditions eg. acute intestinal obstruction, acute haemorrhagic pancreatitis, perforation of peptic ulcer, the pulse remain normal in rate, volume and tension. But it is said to be a good diagnostic guide in acute appendicitis. Sometimes the patient who cannot locate the abdominal pain properly, probably the pulse plays an important role, so far as the diagnosis of acute appendicitis is concerned. In internal haemorrhage pulse becomes immediately rapid. In peptic perforation the pulse may become normal in the early stage but with the spread of peritontis the pulse begins to quicken and becomes small in volume. In acute intestinal obstruction though the pulse remains normal in the beginning but with the advent of dehydration the volume and tension fall and its rate increases with no tendency to return to normal.

  • Respiration- Barring internal haemorrhage and late cases of peritonitis, the respiration rate may seldom be high in acute abdominal conditions. If the temperature becomes high, the respiration rate will be proportionately increased. Increased rate with movements of alae nasi should direct one's attention to the thorax as the seat of the disease. Referred pain in the abdomen is quite common in lobar pneumonia, basal pleurisy etc.

  • Temperature- In infective conditions the temperature will be raised. This rise of temperature varies from condition to condition. This may be quite high in case of acute appendicitis particularly in children, in acute cholecystitis it is raised to a moderate degree, whereas in acute pancreatitis or in acute diverticulitis the temperature may not be raised that much. But it must be remembered that rise of temperature is never an early sign, it occurs late in the disease, eg. in acute appendicitis pain comes first followed by vomiting, and fever comes last of all (Murphy's syndrome).

  • Tongue- It is supposed to be an index of the state of the digestive system. Note whether it is dry or moist, coated or not. A dry tongue indicates dehydration. A dry and brown tongue signifies toxaemia. Even in the early stage of appendicitis, it may be dry and thinly coated, as the patient might have vomited a good quantity.

  • Anaemia, Cyanosis & Jaundice-