Acute Abdomen

• Sudden onset of abdominal pain
• Generally associated with:
  • Severe progressive problems that require medical attention
  • Peritonitis will usually develop if the acute abdomen is not treated - can be fatal

Physiology of the Abdomen

• Solid and hollow (GI, Genital, Urinary) organs
• Parietal Peritoneum - lines abdominal cavity
• Visceral Peritoneum - lines the organs
• Small amount of Peritoneal fluid to bathe/lubricate organs
• Peritonitis- Foreign material can cause irritation
• Retroperitoneal - behind the peritoneal:
• Kidneys, Ovaries, Pancreas

• Parietal peritoneum - supplied by spinal cord nerves that supply skin of abdomen
• Perceives same types of sensations (pain, touch, pressure, heat, and cold)
• Can easily:
  • identify
  • Localize a point of irritation

• Supplied by the autonomic nervous system
• Less able to localize sensation (patient can't localize or describe pain)
• Stimulated when distention or contraction of the hollow abdominal organs activates the stretch receptors
• Often interpreted as colic - severe intermittent cramping pain
• Referred Pain - Perceived art a distant point on the surface of the body (shoulder, back, or deep)

• Referred pain is result of - connections between the body's 2 separate nervous systems
• Somatic Nervous System - spinal cord supplies sensory nerves to the skin and muscles
• Autonomic Nervous System 
  • Controls abdominal organs and blood vessels

• The nerves connecting these 2 systems cause the stimulation of the autonomic nerves to be perceived as stimulation of the spinal sensory nerves
• Eg. Acute cholecytticis - inflammation of the gall bladder may cause pain in the right shoulder because the autonomic nerves serving the gall bladder lie near the spinal cord at the same autonomic level as the spinal sensory nerves that supply the skin of the shoulder

Causes of Abdominal Pain

Solid Organs

• Liver
• Spleen
• Pancreas
• Kidneys
• Ovaries
• Adrenal Glands

• Gall Bladder
• Stomach
• Small Intestine
• Large Intestine
• Bladder
• Bile Duct
• Appendix
• Rectum
• Fallopian Tubes
• Uterous

Causes of Abdominal Pain

• Visceral Peritoneum usually irritated 1st:
  • Early abdominal pain tends to be vague and poorly localized
• Perietal Peritomeum becomes irritated:
  • Pain becomes more severe and more specifically located

Causes of Abdominal Pain

Digestive System

• Ulcers (erosions of the stomach or the duodenum) - most common due to overactivity of digestive juices
• Perforation of at ulcer causes severe peritonitis and acute abdomen
• Gall Bladder - storage pouch for digestive juices and waste from the liver
• Gall Stones - can form and block the outlet from the Gall Bladder = pain
• Cholecystitis = severe inflammation of the Gall Bladder (blockage doesn't pass)

• Pancreas - Retroperitoneal - pain referred to the back
• Forms digestive juices
• Produces Insulin
• Pancreatitis - inflammation of the pancreas
• Caused by:
  • Blocking Gall Stone 
  • Alcohol Abuse
  • Other Diseases

• Appendix - a small recess in the large intestine
• Inflammation or Infection frequent cause of Acute Abdomen

Diverticulitis - Inflammation of small pouches in the Large Intestine

Pouches can become blocked and infected leading to:

Pain

Perforation

Severe Peritonitis

• Kidneys - stones form from materials normally passed in urine
• If a stone passes - sever pain = Renal Cholic
• Frequently associated with blood in the urine
• Kidney Infections - severe pain - often in the flank
• Often quite ill with a high fever

• Cystitis - Bladder Infection - more common in women
• Lower abdominal pain

• Always consider that a women with lower abdominal pain and tenderness may have a problem related to the ovaries, Fallopian Tubes, or Uterus
• Mittelschmerz (associated with the release of an egg from the ovary)- common lower abdominal pain - short lived

• Infection of the Fallopian Tubes and surrounding tissues of the Pelvis
• Causes acute pain and tenderness in the lower abdomen may be intense and cause High fever
• Promptly transport
• Ectopic Pregnancy - abrupt abdominal pain & massive internal hemorage
• Hypovolemic Shock - Immediate Transport

Other Organ Systems

• Aorta - lies immediately behind the peritoneum on the spinal column 
• Older - walls become thin - aneurysm
• Pulsating mass may be felt in the abdomen
• Rarely associated with symptoms - occurs slowly
• If Aneurysm ruptures - massive hemorrhaging & Acute peritoneal irritation
• Severe Back Pain or pressure of blood on the back
• Bleeding - profound shock
• Handle patient gently

Pneumonia

• Esp. in the lower parts of the lung may cause:
• Ileus & Abdominal Pain
• Problem lies in an adjacent body cavity, but the intense inflammatory response can effect the abdomen

Hernia

• A protrusion of an organ or tissue through a hole in the body wall, covering its normal site
• Every organ can herniate in certain circumstances
• Can occur as a result of:
  • A Congenital Defect (around the umbilicus)
  • A surgical Wound that has failed to heal properly
  • Natural weakness of an area, such as the groin
• Do not always produce a mass or lump that the patient is aware of

• Reducible Hernia - May disappear back where it belongs
• Incarcerated Hernia - can't be pushed back
• Strangulation can occur
• Contents become compresses - compromises the blood supply
• Serious medical Emergency - Surgery

• A clear statement that a mass was reducible, but no longer is
• Pain at the hernia site
• Tenderness when the hernia is palpated
• Red or Blue skin discoloration over the hernia

Signs & Symptoms of Acute Abdomen

• Pain and Tenderness - most common
• May be sharp or difussed
• Localized pain - clue to problem organ
• Peritonitis typically causes ileus (paralysis of the muscular contractions that normally propel material through the intestine)
• Retained gas and feces cause abdominal Distention

• Nothing can pass so patient throws up (emesis)
• Almost always associated with:
• Nausea & vomiting (in that order)
• Look at patient's abdomen to gauge the degree of distention
• Distention begins shortly after muscular contractions of the bowel have ceased
• Pulse and BP may change significantly, or not at all

• Anorexia - loss of hunger or appetite
• Non- Specific Symptom
• Almost universal complaint in GI or abdominal issues
• Peritonitis - loss of body fluid into the body cavity
• Usually results from abnormal shifts of fluid from the blood stream into body tissues
• Fluid shift decreases the volume of circulating blood = decreased BP or Shock

• Shock = the inadequate perfusion due to the collapse of the Cardio-Vascular system
• Patient may have normal vital signs or may present with:
  • Tachycardia
  • Hypotension
• Fever may or may not be present

• Tenderness of abdominal muscles over the irritated area
• Muscles may become rigid (involuntary effort to protect the abdomen)
• Guarding - board-like muscle spasm
• Can be seen with major problems such as:
  • Perforated Ulcer
  • Pancreatitis

• Observe position patient finds most comfortable - provides a clue as the what hurts
• EG.
• Appendicitis - pull up right knee
• Pancreatitis - lie curled up on 1 side

General Impression

• LOC - AVPU
• Chief Complaint
• ABCs
• Circulation - for major bleeding
• Pulse rate and quality (condition) - may indicate shock - high flow Oxygen, elevating legs 6 - 12"
• Keep patient warm

• Transport decision 
• Quickly:
  • Patients who have problems with their airways
  • Problems with any ABC
  • Problems with pulse & Perfusion
  • Suspected Internal Bleeding
  • Poor General Impression (esp. pediatric and geriatric)

• Local or diffused abdominal pain or tenderness
• Quiet patient who is guarding the abdomen
• Patients in shock
• Rapid and Shallow Breathing
• Referred (distant) pain
• Anorexia
• Nausea
• Vomiting
• Tense, often distended, abdomen
• Constipation or bloody diarhea
• Tachycardia
• Hypotention
• Fever
• Rebound Tenderness (tender when pressure is applied, very painful when pressure is released)

SAMPLE History

• OPQRST
• Notice patient position
• Question about any recent trauma
• Have they ingested a substance?
• Give patient nothing by mouth

Focused Physical Exam

Steps 1-4

• Explain what I am going to do to the patient
• Place patient in supine position - legs drawn up and flexed at the knees (relax abdominal muscles)
• Determine if patient is restless or quiet, or motion causes pain, distention or abnormality is present
• Palpate the 4 quadrants gently to determine if it is tense, guarded, or soft (suspected quadrant last)

• Determine if patient can relax the abdominal wall on command
• Determine if the abdomen is tender when palpated
• Don't prolong
• Be very gentle

Baseline Vital Signs

• Monitor for adequate ventilation and shock
• High Respiratory rate with normal Pulse and BP = patient may not be able to ventilate well due to pain
• High Respiratory Rate and High Pulse Rate with signs of shock, such as pallor and diaphoresis = sepsis or hypovolemic shock
• BP - last vital sign to go
• Shock is severe - hypotensive

Interventions

• Oxygen:
  • Alterations in breathing
  • Nausea
• Proper Positioning

Detailed Physical Exam

• Detailed History
• Should not delay transport
• Reassess every 5 mins. - unstable
• Reassess every 15 mins. - stable (may deteriorate rapidly)
• Position - usually on the side