Recognizing an acute abdomen

Do you know when to refer your patient with an acute abdomen for urgent treament? In this video, from our Abdominal Examination Essentials course, you'll learn the three key signs of an acute abdomen, critical symptoms that require urgent referral, and underlying conditions that lead to this painful situation.

Performing a great abdominal exam is a vital aspect of clinical practice. In this course, you’ll learn special techniques for evaluating the abdomen and how to correlate exam findings with relevant anatomy. You’ll learn the differential diagnoses associated with different regions of the abdomen and confidently refer symptomatic patients for further testing or therapeutic interventions.

Severe acute abdominal pain with an abrupt onset less than 24 hours, is known as acute abdomen. This is often associated with fever, tachycardia, hypotension, and, or hypoxia. The initial assessment should be quick and accurate to determine if immediate surgical intervention is needed. The pain felt in an acute abdomen is caused from peritonitis, inflammation of the peritoneal.

Peritonitis can be caused by several conditions, including perforated peptic ulcer, small or large bowel obstruction or perforation, diverticular disease, or inflammatory bowel disease. The peritonitis is extremely painful, and the patient will likely present with specific symptoms, such as a rigid abdomen, guarding and, or rebound tenderness.

A rigid abdomen is involuntary stiffness of the abdominal wall muscles, the patient cannot forcibly relax the muscles. The second is guarding, which is tensing of the abdominal muscles, that can be either voluntary or involuntary, and tends to be generalized over the entire abdomen. Voluntary guarding is a conscious contraction of the abdominal wall in anticipation of an exam that will cause pain.

Involuntary guarding is a reflex contraction of the abdominal muscles upon palpation, due to localized peritoneal inflammation. The muscle often remains in spasm throughout the respiratory cycle. It is similar to rigidity, except it is associated with palpation, whereas rigidity is not. In order to differentiate between voluntary and involuntary guarding, pay attention to the patient's nonverbal clues during conversation, while palpating the abdomen.

Demonstrated here is voluntary guarding. The patient is having a conscience contraction of the abdominal wall, in anticipation of the physician laying hands on their abdomen. The third symptom is rebound tenderness, or Blumberg sign, which is tenderness with sudden withdrawal of manual pressure. This causes more pain than the actual application of pressure.

Deeply palpate a section of the abdomen, hold it down for five seconds, then rapidly release the pressure. Ask which caused more pain. If the patient experienced more pain when you release the pressure, that is a positive rebound tenderness test. Some acute abdominal conditions, such as bleeding, require urgent surgical consultation.

The source of massive blood loss can be a ruptured AAA, abdominal aortic aneurysm, gastrointestinal bleed, or bleeding peptic ulcer, trauma, or bleeding diverticular disease. Any of these can require greater than four to six units of packed red blood cells in a 24 hour period. This large blood loss is often associated with hemodynamic instability, and these patients often present with hypotension and tachycardia.

The patient is pale, cool and clammy on exam. Another urgent condition is a perforated viscous, such as bowel perforation. Bowel contents leak into the abdomen, which is extremely irritating to the peritoneal cavity. These patients present with tachycardia, hypotension, and fever. Ischemic bowel is also an urgent condition.

These patients tend to have abdominal pain out of proportion to what is found on the exam. The pain is diffuse and constant. They may present with hypotension or hypertension, a rigid abdomen and tachycardia.