Chapter 17. The acute abdomen
Abdominal emergencies usually present with acute abdominal pain in association with other symptoms and signs. The causes range from life-threatening conditions that require immediate resuscitation and laparotomy to those that require more conservative management.
Diagnosis may be difficult, consequently the paramedic should concentrate instead on assessing the severity of the patient’s condition and on managing it appropriately. In particular, it is important to detect patients who require immediate resuscitation and urgent transfer.
Pain is the major symptom of abdominal emergencies. It also has characteristics that can provide a clue to the underlying problem.
Irritation of the diaphragm, e.g. by blood, may produce pain referred to the shoulder-tip on the same side (due to shared innervations). A ruptured ectopic pregnancy may produce referred shoulder-tip pain.
• History
• Pain
• Vomiting
• Bleeding (haematemesis or per rectum)
• Altered bowel habit
• Shock
• Abdominal distension.
• Where is the pain?
• What type of pain is it (i.e. inflammatory, colicky or ischaemic)?
• Does the pain move?
• What makes the pain better?
• What makes the pain worse?
• How long has the pain been present?
• How rapid was the onset of pain?
• Have you had this pain before? If so, what happened?
• Patient can localise the area of tenderness precisely (early)
• Coughing precipitates abdominal pain in the area of tenderness (early)
• There is rebound tenderness in the painful area (intermediate)
• Reluctance to move (aggravates the pain)
• No abdominal movement with expansion of the chest on inspiration (late)
• Generalised rigidity of the abdominal wall (very late)
• Pyrexia.
Vomiting and GI haemorrhage
• Vomiting may accompany severe pain or be directly caused by the abdominal disease. It is a common presentation in most acute abdominal conditions
• Intestinal obstruction is one of the causes of vomiting
• Vomiting blood indicates disease of the upper gastrointestinal tract Unaltered, bright red blood (haematemesis) suggests an oesophageal lesion, whereas altered blood, resembling ‘coffee grounds,’ due to partial digestion, indicates a gastric or duodenal site
• Upper gastrointestinal bleeding can also give rise to melaena, altered blood being lost as sticky, black, ‘tarry’ stools with a characteristic smell
• Bleeding from the lower gastrointestinal tract is seen as altered blood if the lesion is in the proximal part of the large bowel (e.g. caecal or small bowel carcinoma) or as bright red blood if it lies more distally (e.g. haemorrhoids or rectal carcinoma)
• Patients will need intravenous fluids to treat dehydration or replace blood loss.
• Acute gastrointestinal bleeding
• Ruptured abdominal aortic aneurysm
• Trauma leading to abdominal vessels or organs being torn or ruptured
• Intestinal obstruction
• Mesenteric infarction
• Continuous vomiting or diarrhoea without fluid replacement
• Ectopic pregnancy (ruptured).
Common abdominal emergencies
Stomach and proximal duodenum
Diseases of the upper GI tract (e.g. gastritis and duodenitis, peptic ulcer disease) commonly present with:
• Epigastric or retrosternal inflammatory pain
• Mild epigastric tenderness
• Nausea
• Haematemesis (less common).
Gastroenteritis (most commonly due to ‘food poisoning’) presents with:
• Mild to severe, colicky abdominal pain (poorly localised)
• Vomiting, especially initially
• Diarrhoea
• Dehydration
• Raised temperature
• Diffuse, mild abdominal tenderness
• Guarding and rebound tenderness (rare).
Severe tenderness with localised signs of peritonitis (guarding and rigidity) suggests that the bowel may have perforated. If this is left untreated, the area of tenderness and pain increases as more of the gastric contents leak into the peritoneal cavity. Ultimately the patient will become shocked and critically ill and may die from overwhelming septic shock.
Biliary tract obstruction
Biliary tract obstruction (biliary colic) is caused by gallstones in the biliary tract. Epigastric colicky pain (may be provoked by eating fatty meals):
• Nausea
• Vomiting and belching
• Jaundice (rare).
Secondary infection is common in the stagnant bile trapped in the biliary tree proximal to the obstruction resulting in the symptoms and signs of acute cholecystitis (gall bladder inflammation).
Gall bladder inflammation (acute cholecystitis) can occur without stones in the biliary tract and presents with:
• Acute right upper quadrant pain (referred to the scapula) and tenderness
• Nausea
• Vomiting
• Anorexia
• Fever.
Intestines
Colic from small and large bowel obstruction is usually localised to the periumbilical and hypogastric regions, respectively.
The frequency of vomiting and dehydration as an early associated feature increases with the more proximal location of the intestinal obstruction.
Appendicitis
Appendicitis is usually associated with poor appetite, vomiting and a mild pyrexia. As with all inflammatory conditions, if it is left untreated the patient’s condition will become more pyrexial and toxic as infection and necrosis develop.
Pancreas
Patients with pancreatitis have epigastric tenderness and severe inflammatory pain, which may radiate to the back. The most common causes are gallstones and alcohol abuse.
In order to gain some relief, the patients will either sit and lean forward or lie curled up on their side. Nausea and vomiting are common. Severe cases are associated with dehydration and a major metabolic disturbance.
Bruising of the flanks and abdomen indicates a more fulminant presentation with internal haemorrhage.
Begin IV fluid replacement and give opiate analgesia.
Kidneys and ureters
Obstruction in the kidneys or ureters from renal calculi presents as severe pain localised to the posterior aspect of the flank (renal angle). Pain may radiate to the groin (‘loin to groin pain’). Severe pain is commonly associated with vomiting and may be associated with urinary symptoms.
Give analgesia and antiemetics as appropriate.
Blood vessels
Aortic aneurysm
Aortic aneurysms develop progressively with age and enlargement may be relatively painless until catastrophic haemorrhage occurs following rupture or dissection.
Ruptured aneurysms present with collapse, sweating and abdominal ischaemic pain which may radiate through to the back. An abdominal pulsatile mass may be palpable.
Ruptured aortic aneurysm
Resuscitate the patient with 250 mL boluses of crystalloid fluid, titrated to the radial pulse. Excess fluid administration may make the bleeding worse.
• Collapse
• Sweating
• Abdominal pain: can be referred to the back or even the left flank
• Abdominal tenderness
• Abdominal pulsatile mass
• Respiratory and circulatory compromise
• Vomiting – RARE
• Haematemesis – RARE
• Lower limb pain and neurological deficit – VERY UNCOMMON.
Mesenteric artery embolus
Mesenteric artery embolism has a sudden onset. Initially there is colicky abdominal pain, which after about 1 hour becomes unrelenting and poorly localised.
With subsequent progression localised peritonitis and dehydration develop, the latter being due to impaired absorption, vomiting and fluid becoming trapped in the atonic bowel.
Later, when the bowel wall becomes gangrenous and necrotic, generalized peritonitis and septic shock occur.
Genital tract
Pelvic inflammatory disease
This is a blanket term used to cover inflammation of the female upper genital tract and the adjacent peritoneum and bowel, usually from bacterial infection.
Usually there are also signs of infection such as pyrexia, tachycardia and occasionally rigors. The lower abdomen may be tender.
Ectopic pregnancy
Ectopic pregnancy occurs when a fertilised ovum becomes implanted outside the uterus. These patients require immediate resuscitation and urgent transfer to hospital so that haemostasis can be achieved surgically. This must not be delayed.
Before rupture
• Lower abdominal pain
• Tenderness and guarding
• Amenorrhoea ‘fainting’ feelings
• Irregular vaginal bleeding.
After rupture
• Bleeding
• Pain in the iliac fossa or hypogastrium
• Generalised tenderness and guarding
• Shoulder tip pain can occur (when there is much free intraperitoneal blood and the patient has been lying with her head down).
Ovarian cyst torsion
Ovarian cyst torsion presents as sudden onset of recurrent colicky pain in the ipsilateral iliac fossa. Nausea and vomiting are common associated features. In addition, the abdominal wall overlying the torsion is tender and may be rigid during the attacks.
Testicular torsion
Twisting of the testis on its cord causes intense ischaemic pain localised in the testis. Usually there is localised tenderness and vomiting (which may be the sole presenting feature), but no significant swelling. These patients require urgent surgery to salvage the testis and must be transferred immediately to hospital.
Hernias
HERNIA: a protrusion of an organ or tissue out of the body cavity in which it normally lies.
