The "acute abdomen" refers to a patient who suddenly becomes unwell, presenting with a painful abdomen. It is a presentation all medical students and foundation doctors should know about, as it is the most common emergency presentation in surgery. The abdomen includes a number of organs of which any could be responsible for the pain. The way to approach these patients is no different to any other; a relevant history and a focussed examination will guide you in the right direction with your management.
Common causes of abdominal pain
Thinking outside the box...
Some medical conditions can also masquerade as an acute abdomen, a few to watch out for are shown below.
Areas of the abdomen
Shown in the diagram are the areas of the abdomen, and the most likely underlying pathology.
Taking a relevant history is always the first step. Having a structure is a good idea, as it means you won't get lost. You will need to know what sections are particularly significant to the presentation, in order to gather relevant information, and so that you don't waste any time!
Knowing typical presentations of common causes of abdominal pain will help to keep you on track, and remind you of anything you might have forgotten. A few of these are shown in the list on the right.
It is worth remembering that you are more likely to see strange presentations of the common causes than text book presentations of rare diseases.
Shown on the left is a break down of the history structure, and the relevant areas that should be covered for an acute abdomen.
History of presenting complaint
Past medical and surgical history
From the history you should already have formulated differential diagnoses. The examination will then allow you to narrow it down further to guide any investigations.
Always start at the point furthest away from the pain. The aim of palpation is to find the area specifically involved with the pain. Guarding is a response of the muscle tensing in the immediate area of the pain. Peritonitis will feel rigid, from contraction of the abdominal muscles.
Useful for distinguishing the character of any lumps and bumps. It may also produce rebound tenderness.
High pitched, or tinkling, bowel sounds indicate an obstruction. The absence of them could indicate peritonitis or an ileus.
Genitalia, Hernial orifices and Rectal examination
Full examination of these areas would be carried out on patients with an acute abdomen. Be sure to mention you would ideally like to perform these examinations in the OSCEs.
The next steps of management should be guided by your history and examination. Investigations should be specific to your patient and their presentation, not just a generic set of procedures.
Urine can be tested with a dipstick, if anything abnormal is seen then a sample shoud be sent for microscopy and culture.
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