Physical exam of an acute surgical abdomen. Using detailed descriptions of pain along with onset and physical exam tests including peritoneal signs and more advanced physical exam maneuvers in order to formulate a diagnosis and severity of illness.

1. The Acute Abdomen
Samuel Hamner Gay
UMMC School of Medicine
Surgical Clerkship

2. The Acute Abdomen
• Sudden nontraumatic disorder of the abdomen for
which urgent operation may be necessary
• Goal of acute abdomen H/P:
– Diagnose or at least and most importantly determine if
the acute abdomen is a life-threatening surgical
emergency or indolent medical condition

3. The most common causes of the Acute
Abdomen
For adults:
• Appendicitis
• Bowel obstruction
• Acute vascular condition
• Cancer
• Cholecystitis
For children:
• Appendicitis (1/3)
• Nonspecific abdominal pain (2/3)

4. Other causes of the Acute Abdomen
• Can be caused by disorders within organs
outside the abdominal cavity:
– lower lobe pneumonia, inferior MI, bursitis and
hip joint disorders, thoracic radiculopathy, and a
variety of pelvic disorders

5. Abdominal Pain
Visceral pain
• Afferent C fibers innervating walls of
hollow organs or capsules of solid
organs
• Stimulated by distention,
inflammation, ischemia
• Generally dull, poorly localized, mild
to moderate pain
• Most often felt in midline
• Pt constantly moving
• Not aggravated by coughing
• Its usually the first type of pain felt in
an AA
• May be more indicative of a medical
condition
Parietal pain
• Afferent C and A delta fibers
innervating the parietal peritoneum
• Stimulated by pus, bile, urine, GI
secretions
• A delta fibers are responsible for the
more acute, sharper, localized severe
pain
• Pt doesn’t want to move
• Aggravated by coughing/breathing
• Rectus muscle rigidity (aka Guarding)
• May be more indicative of a surgical
acute abdomen

6. Visceral Pain

7. Colic Pain
• Type of visceral pain
• Defined as pain with pain-free intervals reflecting
intermittent peristalsis
• Sharp or dull intermittent pain
– Sharp colicky pain: ureters or uterine tube obstruction
– Dull colicky pain: bowel obstruction
• Caused by the obstruction of a visceral conduit like the
intestine, ureters, uterine tubes
• “Biliary colic” is not colicky pain
– The gallbladder and bile duct, in contrast to the intestine and
ureters, do not have peristaltic movements

8. Referred Pain
• Type of parietal pain
• Due to the confluence of afferent fibers w/in
the posterior horn that innervate separate
cutaneous areas
• Example: Shoulder pain
– Subdiaphragmatic irritation by air and/or blood in
peritoneal fluid is referred to the shoulder via C4
mediated phrenic nerve

9. Shifting Pain
• Pain that changes location overtime,
paralleling the coarse of the underlining
condition
• Example: Acute Appendicitis
– Begins with visceral pain within the peri-umbilical
area followed by parietal pain within the RLQ

10. Referred and Shifting Pain

11. Location, onset, and character of pain

12. Abdominal Pain
Sharp, superficial, constant pain is most
likely caused by which of the following?
a)
b)
c)
d)
Small bowel obstruction
Large bowel obstruction
Perforated ulcer
Kidney stone

13. Abdominal Pain
Intermittent, vague, deep-seated, dull
crescendo pain is most likely due to which
of the following?
a)
b)
c)
d)
Kidney stone
Small bowel obstruction
Ruptured appendix
Ruptured ovarian cyst

14. Abdominal Pain
Unbearably intense, sharp, intermittent
pain is most likely due to which of the
following?
a)
b)
c)
d)
Cholecystitis
Large bowel obstruction
Ruptured ectopic pregnancy
Non-ruptured ectopic pregnancy

15. Abdominal Pain
No pain w/ a vague feeling of abdominal
fullness that feels like it could be relieved
by a bowel movement is most likely caused
by which of the following?
a)
b)
c)
d)
Cholecystitis
Pancreatitis
SBO
Retrocecal appendicitis

16. Gas Stoppage Sign
• Abdominal fullness that feels as though it
could be relieved by a bowel movement
• Sign of reflex ileus caused by inflammatory
process
– Most commonly retrocecal or retroileal
appendicitis

17. Vomiting
• Did the vomiting occur before or after the onset of
pain?
– Pain before vomiting: surgical condition
– Vomiting before pain: medical condition
• Did the vomiting come before or after nausea?
– Prolonged nausea before vomiting may be an indication
for LBO

18. Vomiting
• Appearance helps indicate the location of an
obstruction
• What does it look like?
– Green – SBO
– No green – Pyloric Stenosis
– Feculent material – LBO

19. Constipation
Constipation
• Constipation is the absence of
passage of stool
• Post-surgical constipation is
most likely reflex ileus induced
by visceral afferent fibers
stimulating efferent splanchnic
nerves
• Not an indicator of intestinal
obstruction
Obstipation
• Absence of passage of both stool
and gas
• Strongly suggest bowel
obstruction, especially if there is
painful abdominal distention or
repeated vomiting

20. Diarrhea
• Usually an indicator of a medical cause of an
acute abdomen:
– Non-blood-stained diarrhea:
• Gastroenteritis
– Blood-stained diarrhea:
• dysentery, ulcerative colitis, Crohn’s disease
• SURGICAL CAUSE OF BLOOD STAINED DIARRHEA =
ISCHEMIC COLITIS

21. Bloody Diarrhea and RUQ pain w/ a Hx of Travel

22. Other Specific Symptoms
•
•
•
•
•
•
•
Jaundice
Hematemesis
Melena
Hematochezia
Rectorrhagia
Hematuria
Passage of blood clots

23. Other relevant aspects of the History
• Gynecological Hx
– Menstrual Hx
• Drug Hx
– Anticoagulants – retroperitoneal and intramural duodenal
and jejunal hematomas
– Oral contraceptives – mesenteric venous infarction and
benign hepatic adenomas
– Corticosteroids – mask signs of advanced peritonitis
– Crack smoking – pyloric perforation
• Family Hx
• Travel Hx
• Surgical Hx

24. Physical Exam
• General observation
• Systemic signs
– Tachycardia and diaphoresis
– Fever
• Low-grade
– Inflammatory conditions (polyarthritis nodosa, UC, Crohn’s)
• High grade
– Severe infections
• Abdominal exam

25. Abdominal exam
•
•
•
•
•
•
Inspection
Auscultation
Cough Tenderness
Percussion
Guarding or rigidity
Palpation
–
–
–
–
Light palpation
Deep palpation
Rebound tenderness
Punch tenderness
• Costal area
• Costovertebral area
• Special tests/signs
• Rectal and pelvic examination

26. Inspection
•
•
•
•
Distention – SBO, LBO, or Ileus
Scaphoid – Perforated Ulcer
Cullen Sign – Intraperitoneal Hemorrhage
Grey Turner Sign - Intraperitoneal Hemorrhage

27. Auscultation
• Mostly useless due to the many variant noises of
any given abdominal disorder
• Strong peristaltic rushes synchronous w/ colic = Early SBO
• Silent abdomen = LATE SBO
• High-pitched hyperperistaltic sounds = enteritis

28. Cough Tenderness
• Tests for presence and severity of parietal pain
• Important preliminary test if pt is in severe
abdominal pain

29. Percussion
• Assess size of liver
• Test for shifting dullness
• Test for midline tympany

30. Palpation
• Begin away from area of pain
• Test for Guarding
– Voluntary spasm
– Involuntary spasm
• only caused by peritoneal inflammation and, for
unknown reasons, renal colic
• Parietal pain is aggravated by touch, therefore
this most be performed gently and slowly

31. Special Tests/Signs
•
•
•
•
Carnett’s Sign
Murphy’s Sign
Psoas Sign
Obturator Sign

33. Pelvic Examination
• Crucial in women with
– discharge, dysmenorrhea, menorrhagia, or LLQ
pain
• Young women w/ an acute abdomen have the
highest risk for an incorrect diagnosis

34. Investigative Studies
• H/P provides the diagnosis in 2/3 of acute
abdomen cases

36. Which of the following is the best method
of confirming a perforated peptic ulcer?
a)
b)
c)
d)
e)
Barium swallow
Leukocytosis
Upper endoscopy
Upright abdominal radiograph
Colonoscopy

37. Which of the following is the best test to
diagnose cholecystitis?
a)
b)
c)
d)
e)
Abdominal radiograph
Ultrasound of abdomen
Dimethyl iminodiacetic acid (HIDA) scan
MRI of abdomen
Upper endoscopy

38. Pancreatitis
• Severe abdominal pain that radiates to back,
accompanied by vomiting
• The addition of peritoneal signs and Cullen
sign
– Necrotizing pancreatitis
• Cloudy (lactescent) serum in a pt w/
abdominal pain
– Pancreatitis even if serum amylase is normal

42. Specific findings in chest and
abdominal X-rays
• Small and large bowel dilation w/ diffuse gas pattern w/ air
outlining the rectal ampulla is suggestive of Paralytic Ileus
• Dilated small bowel loops w/ air-fluid levels along w/
absence or minimal colonic gas is suggestive of SBO
• Distended Cecum w/ small bowel dilation and absence of
air within the rectum is suggestive of LBO
• Free gas under the hemidiaphragm is suggestive of
Perforated Peptic Ulcer

45. Summary
• The variety of acute abdominal presentations and the
frequency at which they present atypically can make a
diagnosis challenging
• The H/P is the most valuable tool that a physician can use
when managing an acute abdomen workup, yet interpretive
studies can help establish a diagnosis, especially in atypical
presentations
• The ability to recognize a life-threatening acute abdomen is a
vital skill that can be done using one’s knowledge of
abdominal pain and other acute abdominal symptoms