ACUTE ABDOMEN
Acute abdomen means is the term applied to any abdominal emergency need for urgent relif since an immediate operation is often necessary
what are the differential diagnosis of acute abdomen
we can classified it to
1-Colics as intestinal renal biliary appendicular pancreatic
2-Acute inflammation as acute appendicitis cholecystitis panctreatitis diverticulitis regional ileits enteroclotis pyelitis salpingitis non specific mesenteric lymphadenitis iliac adenitis
Perforations -3
As perforated peptic ulcer typhoid ulcer
4-Peritonitis
Either primary or secondary
5-Intestinal obstruction
Like simple occlusion strangulation paralytic ileus
6-Internal haemorrhage
As ruptured spleen ectopic pregnancy ovarian cyst or aneurysm
7-Torsion as twisted ovarian cyst torsion of omentum
8- Referred pain as chest spine
Now will be discuss the pain in details because it is very important which can lead you to proper and rapid diagnosis as we see now the pain is usually the first and most important symptoms we should investigated it as follow 1- onest of the pain you should note the exact time of the onset and whether the trouble started during sleep as in acute appendicitis after meal perforated peptic ulcer in the middle of the day as colics follow some special exertion as in strangulated hernia also we should be asked about the mode of the onset whether sudden as in haemorrhage or perforation or gradual as in
inflammation 2- site of the pain we ask the patient to point out to the exact site of the pain if the pain is diffuse or deep seated he will not be able to located it and he use the whole hand to indicate the affected region of the abdomen but in localized types of pain he will locate the exact spot with one finger but we most remember that the site of the pain dos not always indicated affection of the subjacent organ as in acute appendicitis the pain usually starts in the region of umbilicus and later shift to the right iliac fossa this is due to the fact that the nerve supply of the appendix and the umbilical region both arise from the tenth dorsal segment of the cord at first the inflammation confined to the appendix and the pain referred to the umbilical region called (visceral pain) but later on the peritoneum is involved and the pain felt over the site of the lesion itself called (parietal pain) but lesions of the stomach duodenum gall bladder and upper part of small intestine the initial pain will be felt in the upper abdomen and those in the caecum colon rectum in the lower abdomen in case of diaphragmatic pleurisy,basal pneumonia and coronary thrombosis pain is referred to the upper abdomen and may causes great confusion in the diagnosis because it is may lead to fetal mistake because patient may come with myocardial infarction and he treated as just gastritis 3- characters of the pain we note whether the pain is sharp or dull and whether it is persistent or spasmodic or intermittent pain as in colics sharp stabbing pain as in peritonitis dull aching or throbbing as in inflammation 4- course of the pain we ask about any changes in the characters as in intestinal obstruction the intermittent colicky pain changes into constant burring pain with the onset of peritonitis it is very important to remember that diminution of the pain is not always sign of improvement like in appendictis it may be perforated also in perforated peptic ulcer due to dilution of the irritant gastric contents by the peritoneal exudate called (lucid interval)5-we must note the effect of various factors on the intensity of the pain as in colics we see movement heat and local pressure give some relief but in acute inflammation movement aggravates the pain and the patient cannot tolerate anything touch his abdomen in case of diaphragmatic pleurisy there is increased when the patient take deep breath pain during micturition may be due to cystitis ureteric stone or pelvic peritonitis pain temporary relif by vomiting as in gastric lesions passage of faeces or flatus or change in position as in pancreatitis and the patient more comfortable when sitting up than when lying on his back 6- we should note any change in the position of the pain in acute abdomen the pain may remain localized to particular region or may shift spread radiate or be referred to other area as we see shifting of the pain as in acute appendicitis spreading of the pain as in perforative peritonitis radiating pain where it is shoots from the original focus toward other parts sharing the same nerve supply as in renal colic where the pain shoots from the lion to the groin and inner side of the thigh by genito-femoral nerve in biliary colic it radiates from right hypochondrium to the lower angle of the right scapula by seventh to ninth thoracic segments referred pain is felt somewhere else than the reall site of the lesion as the initial pain of intestinal lesions which is felt in the middline of the abdomen and the referred shoulder pain due to diaphragmatic irritation the phrenic and supraclavicular nerves both arise from the fourth cervical segment
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