Health Tips and Tricks

The term acute abdomen describes a syndrome of sudden abdominal pain with accompanying symptoms and signs that focus attention on the abdominal region. It is clinically useful to limit discussion to cases in which the pain has been present for less than 24 hours. Associated symptoms such as nausea, vomiting, constipation, diarrhea, anorexia, abdominal distention, and fever often are present and sometimes are confusing. Although operative therapy is not required for all cases of acute abdomen, unwarranted operative delay can have serious, potentially fatal consequences. Successful management is based on a careful initial assessment that incorporates history taking and physical examination; delineation of clinical priorities; and concurrent resuscitation, diagnosis, and therapy.
Treatment of patients with acute abdominal processes differs in a fundamental way from care delivered to patients with long-term problems. The potential for pathologic processes to be rapidly progressive and for
serious adverse consequences to result from therapeutic delay places a time constraint on diagnosis and treatment. An accurate diagnosis should lead promptly to specific therapy. A complete and accurate history and physical examination are the most important requirements for success.
The treating physician should first focus on the nature and timing of the abdominal pain. The pattern of onset and the progression of pain provide valuable clues to the cause. The pain associated with perforation of a duodenal ulcer or rupture of an abdominal aortic aneurysm is incapacitating, begins suddenly, and quickly reaches peak intensity. Because the onset of pain is so dramatic, patients may be able to provide detailed information about the time of onset or their activities at that moment. In contrast, pain associated with appendicitis increases over a period of one to several hours. Similarly, pain caused by acute cholecystitis increases over hours before reaching a steady intensity. The duration of painful symptoms is important. Biliary colic typically lasts for several hours before rapidly resolving, presumably as a result of dislodgment of the offending stone from the cystic duct. Pain caused by acute pancreatitis is unrelenting. Patients with mechanical obstruction of the small intestine initially may feel remarkably well between episodes of intense and debilitating colic.
The physical examination should be conducted in a systematic and unhurried manner. A complete abdominal examination requires unhindered visualization of the area between the nipples and the midthigh, anteriorly and posteriorly. The examination begins with observation of the patient’s expression and behavior. A patient with serious intraperitoneal abnormalities usually has an anxious, pale face. Sweating, dilated pupils, and shallow breathing are common. In the presence of chemical or bacterial contamination of the peritoneum, the patient tends to lie immobile to minimize movement of inflamed viscera against the parietal peritoneum. Knees may be flexed, the abdomen scaphoid, breathing shallow. Inhaling deeply or coughing aggravates the pain. With ureteral colic or mesenteric ischemia, by contrast, the patient may appear restless with frequent changes in posture in an attempt to relieve discomfort. During inspection, the location of all surgical scars, masses, external hernias, and stomas is determined.
Auscultation precedes abdominal palpation. All four quadrants are auscultated for tone and quantity of bowel sounds and the presence of vascular bruits. Bowel sounds are considered to be absent only if no tones are heard over a 2-minute period of auscultation.
Next the abdomen is palpated. To determine areas of tenderness and the vigor with which palpation may be pursued, it is useful first to ask the patient to demonstrate the point of maximal discomfort. Palpation begins in the abdominal quadrant farthest from the area of suspected pathologic change. Gentle pressure to elicit tenderness and muscular resistance ensues. Progressively deeper palpation is attempted to delineate masses. Intentional efforts to reproduce abdominal pain by means of deep palpation and rapid release of pressure, termed rebound tenderness, are not helpful and should not be attempted. Production of rebound tenderness provides no information that is not available through gentle examination, causes the patient to guard voluntarily, and eliminates the possibility of meaningful serial abdominal examinations. The best evidence of a localized inflammatory process is demonstration of point tenderness, caused by movement of parietal peritoneum against the inflamed surface of a diseased viscus. Point tenderness is sought by means of palpation in the area of maximal discomfort but also may be elicited by means of grasping the patient’s hips and gently rocking the pelvis; the movement of inflamed peritoneum is presumed to cause pain. A stethoscope may be used to palpate the abdominal quadrants.
Every patient must undergo a digital rectal examination. If an inflamed appendix lies deep within the pelvis, point tenderness may sometimes be elicited only by means of palpation through the right rectal wall. Stool is tested for guaiac positivity. For female patients, manual and speculum vaginal examinations are required; vaginal secretions are obtained for Gram stain and culture. All external stomas, wounds, and fistulas are explored digitally.