Moshe Schein
“For the abdominal surgeon it is a familiar experience to sit, ready scrubbed and gowned, in a corner of the quiet theatre, with the clock pointing midnight. …In a few minutes the patient will be wheeled in and another emergency laparotomy will commence. This is the culmination of a process which began a few hours previously with the surgeon meeting with and examining the patient, reaching a diagnosis, and making a plan of action.” (Peter F. Jones)
“The general rule can be laid down that the majority of severe abdominal pains which ensue in patients who have been previously fairy well, and which last as long as six hours, are caused by conditions of surgical import.”
(Zachary Cope, 1881–1974)
Simply stated, the term acute abdomen refers to abdominal pain of short duration that requires a decision regarding whether an urgent intervention is neces- sary. This clinical problem is the most common cause for you to be called to provide a surgical consultation in the emergency room, and serves as a convenient gateway for a discussion of the approach to abdominal surgical emergencies.
The Problem
Most major textbooks contain a long list of possible causes for acute ab- dominal pain,often enumerating 20–30 “most common”etiologies.These “big lists”
usually go from perforated peptic ulcer down to such esoteric causes as porphyria and black widow spider bites. The lists are popular with medical students, but totally useless for practical guys like you.
The experienced surgeon called upon to consult a patient with acute ab- dominal pain in the emergency room (ER) in the middle of the night simply does not work this way. He or she does not consider the 50 or so “most likely” causes of acute abdominal pain from the list and does not attempt to rule them out one by one.Instead, the smart surgical resident tries to identify a clinical pattern, and to decide upon a course of action from a limited menu of management options.
Below we will demonstrate how the multiple etiologies for acute abdominal pain actually converge into a small number of easily recognizable clinical patterns. Once recognized, each of these patterns dictates a specific course of action.
* Asher Hirshberg, MD contributed to this chapter in the 1st edition of the book.
The Acute Abdomen: Clinical Patterns and Management Menus The Management Options
Seeing a patient with an acute abdomen in the ER you have only the four possible management options listed in Table 3.1. The last option (discharge) deserves some consideration. Many patients with acute abdominal pain undergo a clinical examination and a limited workup – which today in some centers may include even a CT scan – only to be labeled as “non-specific abdominal pain”
(NSAP), and then discharged. NSAP is a clinical entity, albeit an ill-defined one. It is a type of acute abdominal pain that is severe enough to bring a patient to seek medical attention (> Fig 3.1). The patient’s physical examination and diagnostic workup are negative, and the pain is self-limiting and usually does not recur.
It is important to keep in mind that in an ER setting, more than half the patients presenting with acute abdominal pain have NSAP, with acute appendicitis, acute
Table 3.1. Management options
Immediate operation (“surgery now”)
Pre-operative preparation and operation (“surgery tomorrow morning”) Conservative treatment (active observation, intravenous fluids, antibiotics, etc.) Discharge home
Fig. 3.1. “Which of them has an ‘acute abdomen’?”
cholecystitis and “gynecological causes”, the commonest “specific” conditions.
But the exact pathology you see depends of course on your geographical location and pattern of practice. Just remember that patients discharged home labeled with the diagnosis of NSAP have an increased probability of a subsequent diag- nosis of abdominal cancer. Therefore, referral for elective investigations may be indicated.
The Clinical Patterns
The acute abdomen usually presents as one of five distinct and well-defined clinical patterns stated in Table 3.2. Two additional patterns (trauma and gyne- cological) are addressed elsewhere in this volume. Occasionally a mixed picture of obstruction/inflammation may present. Each of these clinical patterns dictates a specific management option from the menu. Your task is to identify the specific pattern in order to know how to proceed.
Abdominal Pain and Shock
This is the most dramatic and least common clinical pattern of the acute abdomen. The patient typically presents pale and diaphoretic, in severe abdominal pain and with hypotension, the so-called abdominal apoplexy. The two most com- mon etiologies of this clinical pattern are a ruptured abdominal aortic aneurysm and a ruptured ectopic pregnancy (> Chaps. 37 and 31). Here the only management option is immediate surgery-now. No time should be wasted on “preparations” and on ancillary investigations. Losing a patient with abdominal apoplexy in the CT scanner is a cardinal, and unfortunately not too rare, sin. Note that other abdominal emergencies may also present with abdominal pain and shock due to fluid loss into the “third space”.This is not uncommon in patients with intestinal obstruction
(> Chap 21), acute mesenteric ischemia (> Chap. 23), or severe acute pancreatitis
(> Chap. 18) – particularly if neglected or superimposed on a marginal or pre-
morbid cardiovascular system.
Table 3.2. Clinical patterns
Abdominal pain and shock Generalized peritonitis
Localized peritonitis (confined to one quadrant of the abdomen) Intestinal obstruction
“Medical” illness
Generalized Peritonitis
The clinical picture of generalized peritonitis consists of diffuse severe ab- dominal pain in a patient who looks sick and toxic.The patient typically lies motion- less, and has an extremely tender abdomen with “peritoneal signs” consisting of board-like rigidity, rebound-tenderness, and voluntary defense-guarding. Surpris- ingly enough, less experienced clinicians occasionally miss the diagnosis entirely.
This is especially common in the geriatric patient who may have weak abdominal musculature or may not exhibit the classical peritoneal signs. The most common error in the physical examination of a patient with acute abdominal pain is rough and “deep” palpation of the abdomen, which may elicit severe tenderness even in a patient without any abdominal pathology.Palpation of the abdomen should be very gentle, and should not hurt the patient. The umbilicus is the shallowest part of the abdominal wall where the peritoneum almost touches the skin.Thus one of the most effective maneuvers in the physical examination of a patient suspected of having peritonitis is gentle palpation in the umbilical groove, where tenderness is very obvious. We appreciate that at this stage of your surgical career you do not need a detailed lecture on the examination of the acute abdomen. Forgive us, however, for emphasizing that the absence of rebound tenderness means nothing and that a good way to elicit peritoneal irritation is by asking the patient to cough, shaking (gently) his bed, or by very gentle percussion of the abdomen.
The three most common causes of generalized peritonitis in adults are a perforated ulcer(> Chap. 17), colonic perforation (> Chap. 26), and perforated appendicitis(> Chap. 28). The management of a patient with diffuse peritonitis is pre-operative preparation and operation (surgery tonight). The patient should be taken to the operating room only after adequate pre-operative preparation as outlined in > Chap. 6.
The only important exception to this management option is the patient with acute pancreatitis. While most patients with acute pancreatitis present with mild epigastric tenderness, the occasional patient may present with a clinical picture mimicking diffuse peritonitis (> Chap. 18). As a precaution against misdiagnosing these patients, it is good practice always to measure the serum amylase in any patient presenting with significant abdominal symptoms (> Chap. 4).An (unneces- sary) exploratory laparotomy in a patient suffering from acute severe pancreatitis may lead to disaster.Remember: God put the pancreas in the back because he did not want surgeons messing with it.
Localized Peritonitis
In the patient with localized peritonitis, the clinical signs are confined to one quadrant of the abdomen. In the right lower quadrant (RLQ) the most common cause of localized peritonitis is acute appendicitis (> Chap. 28). In the right upper quadrant (RUQ) it is acute cholecystitis (> Chap. 19), and in the left lower quadrant (LLQ) it is acute diverticulitis (> Chap. 26). Peritonitis confined to the left upper quadrant (LUQ) is uncommon, making this quadrant the “silent one”.
As a general rule, localized peritonitis is often not an indication for a surgery- tonight policy. Instead, when the diagnosis is uncertain, it may initially be treated conservatively. The patient is admitted to the surgical floor, given intravenous anti- biotics (e.g., if the diagnosis of acute cholecystitis or diverticulitis is entertained) and hydration, and is actively observed by means of serial physical exams.Time is a superb diagnostician; when you return to the patient’s bedside after a few hours you may find all the previously missing clues.
The exception to this rule is, of course, a tender RLQ, for which the working diagnosis is acute appendicitis, and appendectomy may therefore be indicated.
However, if there is a palpable mass in the RLQ, the working diagnosis is an
“appendiceal phlegmon” for which an appropriate initial management would be conservative (> Chap. 28). In young women RLQ signs may be gynecological in origin, and continued conservative management may also be appropriate in this situation (> Chap. 31).
The management of acute cholecystitis varies among surgeons. While past experience taught us that most of these patients would respond to antibiotics,
“modern” surgeons prefer to operate early on a “hot” gallbladder – usually the next morning or whenever operating room schedule permits (> Chap. 19).
Intestinal Obstruction
The clinical pattern of intestinal obstruction consists of central, colicky abdominal pain, distension, constipation and vomiting.
As a general rule the earlier and more pronounced the vomiting, the more proximal the site of obstruction is likely to be; the more marked the distension, the more distal the site of obstruction. Thus, vomiting and colicky pain are more characteristic of small bowel obstruction, whereas constipation and gross disten- sion are typical of colonic obstruction. However, the distinction between these two kinds of obstruction usually hinges on the plain abdominal X-ray. There are two management options for these patients: conservative treatment, or operative treat- ment after adequate preparation. The major problem with intestinal obstruction is not in making the diagnosis but in deciding on the appropriate course of action.
If the patient has a history of previous abdominal surgery and presents with small bowel obstruction but without signs of peritonitis, the working diagnosis is
“simple”adhesive small bowel obstruction.The initial management of these patients is conservative, with intravenous fluids and nasogastric tube decompression. If the obstruction is complete (e.g., no gas in the colon above the peritoneal reflection of the rectum), the chances of spontaneous resolution are small and some surgeons would opt for an operative intervention. In the presence of clinical peritonitis, fever, and elevated white blood cell count, the indication for laparotomy is clear-cut
(> see Chap. 21).
There are three classical pitfalls with small bowel obstruction:
The obese elderly lady with no previous surgical history who presents with small bowel obstruction, where an incarcerated femoral hernia can easily be missed if not specifically sought
The elderly patient with a “simple” adhesive small bowel obstruction who improves on conservative treatment and is discharged only to come back lat- er with a large tumor mass in the right colon
The elderly lady whose “partial”small bowel obstruction “resolves and recurs”
intermittently and is finally diagnosed as gallstone ileus
The patient with a history of previous gastric surgery who presents with inter- mittent episodes of obstruction originating from a bezoar in the terminal ileum
Unlike small bowel obstruction, colon obstruction is always an indication for surgery – “tonight or tomorrow” but usually “tomorrow”. A plain abdominal X-ray cannot make the diagnosis where functional colonic pseudo-obstruction (Ogilvie’s syndrome) or chronic megacolon cannot reliably be distinguished from a mechan- ical obstruction. Thus, these patients usually undergo either fiberoptic colonoscopy or a contrast enema to clinch the diagnosis. The management option for these patients is operation after adequate preparation (> Chap. 25).
Important Medical Causes
While there is a large number of non-surgical causes that may result in acute abdominal pain,two must be kept constantly in your mind: inferior wall myocardial infarction and diabetic ketoacidosis. A negative laparotomy for porphyria or even basal pneumonia is an unfortunate surgical (and medicolegal) occurrence, but inadvertently operating on a patient with an undiagnosed inferior wall MI or diabetic ketoacidosis may well be a lethal mistake that should be avoided at all costs.
Wherever you practice you may be exposed to a growing number of HIV- positive patients suffering from AIDS, who are susceptible to a large number of abdominal conditions, which can produce or mimic an “acute abdomen”. In
> Chap. 33 we will tell you how to deal with these patients, most of them being best treated without an operation.
Conclusion
The multiple etiologies of the acute abdomen converge to five distinct and well-defined clinical patterns, each of which is associated with a specific manage- ment option. You should be familiar with these patterns and with the various management options.You should also keep in mind the classical pitfalls inherent in this common surgical condition in order to avoid gross errors in the surgical care of such patients.After all, you already have enough cases to present at the morbidity and mortality (M & M) meeting, don’t you? (> Chap. 52).
“It is as much an intellectual exercise to tackle the problems of belly ache as to work on the human genome.” (Hugh Dudley)
Who Should Look After the “Acute Abdomen” and Where?
Everybody’s business is nobody’s business
The majority of patients suspected of having an acute abdomen or other abdominal emergency do not require an operation. Nevertheless, it is you – the surgeon – who should take, or be granted, the leadership in assessing, excluding or treating this condition, or at least, play a major role in leading the managing team.
To emphasize how crucial this issue is, we dedicate an entire section of this chapter to it – although its scope would fit into a paragraph.
Unfortunately, in “real life”, surgeons are often denied the primary respon- sibility.Too often we see patients with mesenteric ischemia (> Chap.23) rotting away in medical wards,the surgeon being consulted “to evaluate the abdomen”,only when the bowel – and, subsequently, the patient – has died. A characteristic scenario is a patient with an abdominal surgical emergency, admitted under the care of non-sur- geons who undertake a series of unnecessary, potentially harmful and expensive di- agnostic and therapeutic procedures. Typically, internists, gastroenterologists, infectious-disease specialists and radiologists are involved,each prescribing his own wisdom in isolation (> Fig. 3.2). When, finally, the surgeon is called in, he finds the condition difficult to diagnose, partially treated or maltreated. Eventually, the indicated operation is performed, but too late and thus carries a higher morbidity and mortality. The etiology of such chaos is not entirely clear. Motives of power, ego and financial considerations are surely involved.
The team approach to the acutely ill surgical patient should not be discarded.
The team, however, should be led and co-ordinated by a general surgeon. He is the one who knows the abdomen from within and without. He is the one qualified to call in consultants from other specialties, to order valuable tests, to veto those that are superfluous and wasteful.And,above all,he is the one who will eventually decide that enough is enough and the patient needs to be taken to the operating room.
When you decided to become a general surgeon you became the captain of the ship, navigating the deep ocean of the abdomen. Do not abandon your ship while the storm rages on!
Continuity of care is a sine qua non in the optimal care of the acute abdomen as the clinical picture, which may change rapidly, is a major determinant in the choice of therapy and its timing. Such patients need to be frequently re-assessed by the same clinician who should be a surgeon. Any deviation from this may be hazardous to the patient; this is our personal experience and that which is repeated ad nauseum in the literature. But why should we be re-inventing the wheel? Why don’t we learn? The place for the patient with an acute abdominal condition in on the surgical floor, surgical intensive-care unit (ICU), or in the operating room and under the care of a surgeon – yourself! Don’t duck your responsibilities!
Only 10 or 20 years ago, when we were residents, an “acute abdomen” and clinical evidence of peritonitis mandated an operation. Today we are smarter.
Judicious usage of diagnostic modalities (see Chap. 4) and better understanding of the natural history of various disease processes allow us to decrease mortality and
Fig. 3.2. “Who is responsible?”
morbidity by being less invasive and more selective and, in general, to achieve more by doing less harm.
The key for the “best” outcome of the acute abdomen is:
Operate only when necessary, and do the minimum possible
Do not delay a necessary operation, and do the maximum when indicated
Advice:When you finish this book go and buy yourself Cope’s Early Diagnosis of the Acute Abdomen. Zachary Cope, who died in 1974, published the first edition of his book in 1921.The current edition is the twentieth! You cannot be a real general surgeon without reading this book. Or can you?
