Makindo Medical Notes

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

⚠️ Pain may be absent or muted in certain high-risk groups — elderly patients, those on long-term steroids, diabetics, and the very frail. Always think: is the patient moribund/in extremis? If so → follow ABC, call for senior/surgical help early, gain IV access, give oxygen, start IV crystalloids, provide analgesia, and send urgent bloods (including lactate, FBC, U&E, amylase, and cross-match if haemorrhage is suspected). 👉 If shocked with bleeding → get 2 wide-bore lines, activate major haemorrhage protocol, consider urgent O negative blood. 👉 If septic → IV antibiotics + fluids without delay.

📖 Acute Abdomen – Key Principles

• Sudden onset severe abdominal pain (<24h) → always assume potentially lethal pathology until proven otherwise
• Expert assessment + early surgical involvement crucial
• Pain localisation often follows embryological origin:
  • 🌐 Foregut → Epigastrium
  • 🌐 Midgut → Peri-umbilical
  • 🌐 Hindgut → Below umbilicus

🧠 Pathophysiological Background

• Parietal peritoneum richly innervated → inflammation causes localised pain, guarding & rigidity
• Visceral pain → poorly localised, dull (e.g. appendicitis starts peri-umbilical)
• When parietal peritoneum becomes involved → pain localises (e.g. appendicitis to RIF at McBurney’s point)
• Always examine hernial orifices to exclude strangulated hernia

🔎 Common Causes of Acute Abdominal Pain

🧾 Additional Diagnostic Pearls

• 📉 Silent abdomen + rigidity → peritonitis → surgical emergency
• 🧪 Amylase 3× ULN → pancreatitis (but can rise in perforation, ectopic, DKA)
• 📍 Pain radiation clues:
  • Shoulder → diaphragmatic irritation
  • Back → AAA or pancreatitis
  • Periumbilical → appendicitis (early)
• 🚺 All women of child-bearing age → pregnancy test mandatory

🧰 Investigations

• Bloods: FBC, U&E, CRP, LFTs, Ca, glucose, amylase/lipase, group & save
• Urine dip ± culture; urine pregnancy test
• ECG – exclude ACS
• Imaging: AXR (limited), CXR (free air, pneumonia), CT abdo (most useful), USS (biliary/gyne)
• Blood cultures if sepsis suspected
• Special: CT angiography (mesenteric ischaemia), porphobilinogen (acute porphyria)

🫁 Causes of Free Sub-diaphragmatic Gas on AXR

• Perforated viscus (peptic ulcer, diverticulitis, appendix)
• Gas-forming infection
• Iatrogenic (post-laparoscopy)
• Pleuroperitoneal fistula

• Stabilise → ABC, O2, IV access, fluids, catheter, NG tube if obstruction
• 3L/day crystalloids minimum in pancreatitis/obstruction
• Correct electrolytes, insulin infusion if DKA
• Early antibiotics if sepsis or perforation suspected
• Urgent senior surgical review
• CT abdo for diagnosis, laparotomy if peritonitis/rupture
• DVT prophylaxis unless contraindicated

🔪 Surgical Management

• Do not delay surgery except for resuscitation
• Broad-spectrum IV antibiotics (e.g. Tazocin ± Gentamicin ± Metronidazole)
• Remove infarcted/perforated tissue
• Repair perforations, drain abscesses, lavage peritoneum
• Massive haemorrhage protocol if bleeding