Acute abdomen

English: acute abdomen, surgical abdomen

Synonyms

acute abdominal acute = sudden onset, of short duration, vs. chronic; abdomen = abdominal cavity, abdominal cavity An acute abdomen is a sudden onset of increasingly severe diseases of the abdominal cavity. It is usually accompanied by severe, suddenly beginning abdominal pain. Without appropriate treatment, they endanger the patient’s vital parameters.

The acute abdomen itself is not a disease in itself, but a reaction of the body to changes that threaten it vital (life-threatening). An acute abdomen represents an emergency. However, the acute abdomen is not an independent clinical picture, but rather a reaction of the body to changes that appear to be acutely life-threatening.

The cause of the acute abdomen can be a large number of events. These range from appendicitis, through perforation of hollow organs (gastrointestinal tract), to bleeding after traumas (accidents). Inflammations are also possible.

The dangerous thing about the acute abdomen is that an inflammation of the abdominal cavity and peritoneum can develop, which is difficult to control and quickly leads to blood poisoning with organ failure. The main symptoms include pain, nausea and vomiting. When diagnosing “acute abdomen”, in addition to the symptoms offered by the patient, imaging is of utmost importance.

Ultrasound and X-rays are among the most important procedures here. For example, fluid or air in the abdomen can be diagnosed. If so-called free fluid is seen, it could be blood; so-called free air makes a perforation (piercing) of a hollow organ likely.

There are no precautionary measures for the prevention of the acute abdomen. One should avoid the underlying disease. The most important symptom of the acute abdomen is pain.

If this occurs suddenly and is extremely severe, it occurs in the case of perforations (rupture, e.g. stomach rupture/rectal rupture). In the case of colicky pain that runs in wave-like waves, an obstruction (e.g. ileus = intestinal obstruction) should be considered. Furthermore, the patients suffer from

  • Fever
  • Nausea
  • Vomiting
  • Diarrhoea
  • Constipation and
  • Pain,

An “acute abdomen” represents a clinical emergency and requires immediate diagnosis and appropriate therapy when the cause is identified.

The complications that can arise are almost as varied as the possible causes of an acute abdomen. They are therefore very difficult to formulate in general terms. Basically, inflammation of various abdominal organs, for example appendicitis or inflammation of the bowel, can lead to perforation of the organ.

This means that a hole is formed in the wall of the organ. This can lead to the escape of toxic substances as well as bacteria that cause peritonitis, an inflammation of the peritoneum or blood poisoning. Other clinical pictures, such as the acute inflammation of the pancreas, pancreatitis, can also lead to blood poisoning (sepsis) or shock with failure of the circulation.

Intestinal obstruction (ileus) can also occur as a complication of other clinical pictures leading to the working diagnosis of an acute abdomen. These include inflammation of the gall bladder (acute cholecystitis), appendix (appendicitis) or peritonitis. The list of complications is very long, so it is very important to act quickly and clarify the cause of an “acute abdomen” at an early stage.

Some complications, such as sepsis or shock, can become life-threatening within a short time. Basically, inflammation of various abdominal organs, such as appendicitis or inflammation of the intestine, can lead to perforation of the organ. This means that a hole is formed in the wall of the organ.

This can lead to the escape of toxic substances as well as bacteria that cause peritonitis, an inflammation of the peritoneum or blood poisoning. Other clinical pictures, such as the acute inflammation of the pancreas, pancreatitis, can also lead to blood poisoning (sepsis) or shock with failure of the circulation. Intestinal obstruction (ileus) can also occur as a complication of other clinical pictures leading to the working diagnosis of an acute abdomen.

These include inflammation of the gall bladder (acute cholecystitis), appendix (appendicitis) or peritonitis. The list of complications is very long, so it is very important to act quickly and clarify the cause of an “acute abdomen” at an early stage. Some complications, such as sepsis or shock, can become life-threatening within a short time.

The causes of an acute abdomen are manifold. In order to keep a certain overview, one can distinguish between pathological changes which are localized in the intraperitoneal, retroperitoneal and extraperitoneal space. Organs that are covered by the peritoneum, such as the stomach, liver, spleen and some other organs are located intraperitoneally.

The space behind them is called retroperitoneal space. All other localisations are called extraperitoneal, which means outside the intraperitoneal space. With the help of these terms, a certain systematic approach to the causes of the acute abdomen can be brought into play.

Furthermore, certain clinical pictures are more typical for a younger patient and others are more typical for an older patient. Important causes of an acute abdomen in younger patients, which are located in the intraperitoneal space, are In older people, appendicitis as the cause of an acute abdomen usually plays a minor role, as it is more common in children, adolescents and young adults. In older people, diverticulitis (inflammation of protrusions of the intestinal wall) or a mesenteric infarction (acute closure of an intestinal vessel) can cause an acute abdomen.

Furthermore, the following causes can occur in both younger and older people:

  • Appendicitis (acute appendicitis, colloquially known as appendicitis),
  • A (gastro)enteritis (inflammation of the stomach and intestines),
  • Cholecystitis (inflammation of the gall bladder)
  • And in women, pelvic inflammatory disease (inflammation of the fallopian tubes, ovaries and surrounding tissues)
  • Ulcus ventriculi (stomach ulcer),
  • Duodenal ulcer,
  • An ulcer perforation (perforation of the wall of a hollow organ, caused by an ulcer),
  • An incarcerated hernia,
  • A bleed,
  • A bowel obstruction (ileus),
  • Traumas as they can occur in the context of accidents
  • Gynaecological diseases, such as pregnancy outside the uterine cavity (extrauterine pregnancy) or ovarian torsion (rotation of the ovary)

Important causes of an acute abdomen that are located in the retroperitoneal space are Causes of acute abdominal distress located extraperitoneally It is generally said that extraperitoneal causes cause a “pseudo-acute abdomen”, because they only simulate the symptoms of an acute abdomen. In addition to the classification of causes shown here, the causes can also be classified according to the “quadrant scheme”. Here the abdomen is divided into four quadrants, so that the following regions are obtained: Depending on the localization of the pain, the physician can assume pathological changes in organs that are in the area of the pain by his anatomical knowledge.

In summary, it can be said that an acute abdomen is caused by one of the following diseases in more than 90% of cases:

  • Pancreatitis (inflammation of the pancreas),
  • Urological diseases, such as renal colic, ureteral colic or cystitis (inflammation of the bladder)
  • Diseases that originate from the lymph vessel system
  • Or also diseases in the area of the vessels, such as a mesenteric infarction or a mesenteric vein thrombosis. – Diseases of the heart, such as a heart attack (here mainly a posterior wall infarction),
  • Diseases of the lungs, such as pneumonia,
  • Intoxications (poisoning) and
  • Metabolic diseases: An example of a metabolic disease would be diabetic ketoacidosis with high blood sugar levels and hyperacidity of the blood. The reason for this is a lack of insulin.

This severe metabolic disorder can cause pseudoperitonitis, which has taken its name from the similarity of symptoms to peritonitis. – right upper abdomen,

  • Left upper abdomen,
  • Right lower abdomen
  • And left lower abdomen. – an appendicitis (inflammation of the appendix),
  • An acute inflammation of the gall bladder (cholecystitis),
  • An acute inflammation of the pancreas (pancreatitis)
  • An inflammation of protrusions of the intestinal wall (diverticulitis),
  • A perforation of the intestinal wall through an ulcer of the stomach or duodenum (ulcer perforation),
  • A bowel obstruction (ileus)
  • And renal colic.

An ileus is a disturbance of the intestinal passage due to an intestinal obstruction or paralysis of the bowel. The symptoms may vary depending on the cause of the ileus. For example, tumours in the intestine can cause obstruction.

Paralysis of the bowel, on the other hand, can be caused by diabetes mellitus or by inflammation in the abdominal cavity, for example in the course of appendicitis. In general, ileus is a more diffuse form of abdominal pain. These are pains that are distributed throughout the entire abdominal cavity and are not concentrated in a specific area.

Furthermore, vomiting of stool may occur. This is called a “misery”. Stool and wind may also be present.

X-ray and ultrasound as well as the examination of the abdomen with a stethoscope are suitable as quick diagnostics. In case of a mechanical closure of the intestine, an emergency operation is usually performed to quickly restore intestinal passage. Otherwise, there is a risk of infarcts in the abdomen, blood poisoning and other complications.

An acute abdomen is always an emergency situation in which the diagnosis should be made as soon as possible. Often, however, this is already possible with a few precise questions to the patient and certain aids. Above all, the patient interview (anamnesis) is decisive, where the following points should be particularly addressed:

  • Pain localisation and the radiation of the pain,
  • Intensity of pain,
  • Pain character (for example dull or colicky),
  • Start of pain
  • Course of pain

Colicky pain can be an indication of gallstones, an intestinal obstruction or even a ureteral stone.

Pain that increases continuously indicates an inflammation, for example of the appendix (appendicitis), the gall bladder (cholecystitis), protrusions of the intestinal wall, so-called diverticulitis or pancreas (pancreatitis). In addition, accompanying symptoms such as nausea and vomiting, diarrhoea or stool retention, loss of appetite, fever should also be addressed. Menstruation should also be discussed in women.

In addition, women should be asked about medications they have taken, previous operations and any episodes with the same symptoms that have already occurred. The doctor then carries out a physical examination in which the patient’s abdomen should be looked at (inspection), listened to (auscultation), tapped (percussion) and palpated (palpation). In addition, the general condition of the patient should also be assessed, because things like posture or skin colour can also give further clues as to the cause of the acute abdomen.

Finally, a digital-rectal examination, i.e. the examination of the rectum, is an indispensable part of the procedure. Subsequently, blood is taken from the affected person, which is examined, for example, for elevated inflammation values (C-reactive protein [CRP]) and white blood cells (leukocytes). In addition to the patient interview and the clinical examination, imaging procedures can also provide important information about the cause of the symptoms:

  • Ultrasound: The most important imaging procedure is ultrasound (sonography), as it can be performed quickly and is available almost everywhere nowadays.

Here, for example, it can be quickly determined whether free fluid is present in the abdominal cavity. An increased accumulation of fluid in the free abdominal cavity is indicative of ascites, colloquially known as abdominal dropsy. In addition, the internal organs, such as the liver, can also be assessed more precisely with the help of ultrasound.

However, the diagnosis with ultrasound can be problematic in obese patients or patients with excessive gas accumulation in the digestive tract (meteorism). – Standard diagnostics is also an X-ray of the thorax and abdomen (abdominal x-ray). – Only in children is the abdominal radiograph usually omitted in order to reduce the radiation exposure.

While the abdomen is being x-rayed, the patient is positioned in a standing or lying position, depending on his condition. In the abdominal radiograph, when the patient is lying on his or her left side, the abdominal cavity is particularly free of air, which indicates that the intestine or an air-containing hollow organ such as the gall bladder has been perforated. In addition, an intestinal obstruction (ileus) can also be diagnosed.

The diagnosis of an intestinal obstruction is particularly successful when the patient is in a right-sided position. If one wants to determine whether the digestive tract is continuous or whether a perforation is present, an X-ray can be taken after administration of a water-soluble contrast medium. An x-ray of the chest (chest X-ray) can also provide important information and should therefore be carried out.

For example, a fracture of a deep-lying rib can lead to a rupture of the liver or spleen. – Nowadays, multi-slice computed tomography (MS-CT) with its short examination time also plays an important role. A disadvantage here is the higher radiation exposure.

  • A peritoneal lavage as a diagnostic tool takes a back seat due to the options mentioned above. Another reason is that in many cases it may not be performed due to certain circumstances, such as adhesions or pregnancy. In the course of abdominal lavage, a puncture of the abdominal cavity is performed in the midline below the navel.

Now a solution at body temperature can be introduced into the abdominal cavity, which finally runs back into the outside bottle. Here the irrigation fluid can be assessed. It should be clear and colourless.

  • Endoscopy is very important for diagnosis and therapy. Not only can it be used to determine the cause of an acute abdomen, but depending on the reason, a therapy can also be carried out directly. – If a problem is suspected in the area of the blood vessels, the doctor can arrange for a radiological imaging (angiography) of these.

If necessary, the problem can also be corrected directly by angiography. Depending on the localisation of the pain, various causes can be considered. The classification is made in quadrants.

For example, if pain (especially) in the right upper abdomen, the following illnesses are possible: If the left upper abdomen is affected, the following illnesses can be the trigger: In the right and left lower abdomen, the following diseases are mainly

  • Diseases affecting the liver and/or gallbladderGall stonesGallenblasentzündungGestauteal liver
  • Gallstones
  • Gall bladder inflammation
  • Congested liver
  • Gallstones
  • Gall bladder inflammation
  • Congested liver
  • Diseases affecting the kidneyKidney stonesStasis/inflamed kidneys but also lungs or intestines can be affected
  • Kidney stones
  • Congested / inflamed kidney
  • But lungs or intestines can also be affected
  • Kidney stones
  • Congested / inflamed kidney
  • But lungs or intestines can also be affected
  • Also here liver, lung and intestine
  • In addition, spleen and pancreasMalic infarction, ruptured spleenMilz painPancreatitis
  • Splenic infarction, ruptured spleen
  • Splenic pain
  • Pancreatitis Bauchspeicheldrüsenentzu
  • Splenic infarction, ruptured spleen
  • Splenic pain
  • Pancreatitis ̈ndung
  • Intestinal diseases and
  • Diseases in the urogenital system under consideration

Depending on the cause of the acute abdomen, the therapy is also directed in a certain direction. The aim is to restore the functionality of the affected organ systems (prevent organ failure) and ensure the survival of the patient. It is possible that a reduction in quality of life must be expected.

General measures such as volume replacement (blood and/or fluid) and the insertion of a gastric tube can be taken first. The administration of oxygen is also one of the immediate measures. All vital parameters (blood pressure, heart rate and respiratory rate, oxygen content in the blood) must be monitored and possibly directed into physiological channels. Normally surgery is performed in the presence of an acute abdomen. The administration of antibiotics is also one of the treatment options.

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  1. Acute abdomen
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