The Acute Abdomen

In his "Diagnosis of the Acute Abdomen in Rhyme," Zachary Cope (alias Zeta) wrote,

"The “big” four I mention whom you must watch well

More clearly, the site of their author to tell

Come right off the tongue in a simple refrain—

Distension, rigidity, vomiting, pain."

--silly, but so right!

 

The "big 4" warning signals for peritonitis (AKA, "the acute abdomen"):

1. Abdominal distention,
2. musculoskeletal rigidity ("guarding"),
3. vomiting, and
4. pain.

Add to this rebound tenderness, and it doesn't really matter what the cause is; it is a time-urgent surgical emergency, and rapid transport is indicated. Such a patient cannot be helped by you or anyone else until he or she is at an appropriate surgical receiving facility!

 

GUARDING:

Musculoskeletal rigidity is involuntary guarding, a condition of the musculature itself in response to peritonitis; voluntary guarding is when a patient grabs your hand to keep you from touching him or her out of fear you'll cause pain. Voluntary guarding can be normal in squeamish, ticklish, or pediatric patients.

The acute abdomen is a sudden and severe abdominal pain or discomfort requiring urgent and specific assessment and diagnosis. In pediatric patients, vomiting/diarrhea can quickly deteriorate into hypovolemia.

With the diverse organ systems of liver/gallbladder, pancreas/digestion/intestines, reproduction, and urine collection all surrounded by a very sensitive layer of trigger-edge surveillance called the peritoneum, the acute abdomen is the body's response to a major disruption in the peritoneal cavity:

• Bleeding,
• pus,
• rupture, and
• malignancy can all present this way.

 

Assessment of the Acute Abdomen

Assessment techniques of the acute abdomen include inspection and palpation.

Normal findings during inspection and palpation are a soft and non-tender abdomen in all four quadrants and normal bowel sounds.

Abnormal findings during inspection and palpation are

• nausea, vomiting, or diarrhea (with further classification as “excessive;” special attention is given to the presence of blood in emesis or stool),
• pain to any specific area/quadrant with or without palpation,
• signs of shock,
• fever,
• guarding,
• rebound tenderness, and
• absent or high-pitched (rushes) bowel sounds.

 

GI Bleeding vs. the Acute Abdomen

Although GI bleeding seen in hematemesis or hematochezia/melena may represent an acute situation, if there is no blood in the actual abdomen and the integrity of the intestines is intact, it is NOT, technically, an "acute abdomen."

This means that an upper GI bleeding emergency--while still a true emergency--is different from an acute abdomen.

In the field, this distinction is not important, as both require transport.

Specific acute abdominal conditions may include signs and symptoms of gastrointestinal (GI) bleeding. GI bleeding can be caused by many different things, including but not limited to ulcerative diseases, esophageal varices, hemorrhoids, anal fissures, liver diseases, infectious disorders, peritonitis, gastroenteritis, irritable bowel syndrome, inflammatory bowel disease, bowel obstruction, hernias, rectal foreign body obstruction, rectal abscess, and mesenteric ischemia.

Assessment findings and symptoms specific to UPPER GI bleeding include bloody vomit (the color is red--fresh or active; or looks like coffee grounds--old or chronic) and/or black and described as “tarry” (chronic--melena). Melena is a significant finding to recognize and essential to understand in that the majority of melena cases (about 90%) start in the first part of the small intestine. However, it's important to note that melena can also originate from other sources, such as the oropharynx or nasopharynx, small bowel, or colon. Even small amounts of blood loss, as little as 50 mL, can result in the appearance of melena. 

Assessment findings and symptoms specific to LOWER GI bleeds include blood in the stool (the color is red (acute--hematochezia). Older blood is deoxygenated, giving it its dark color; blood that is recently bled still has its hemoglobin intact, giving it its red color.

Signs of shock such as hypotension, tachycardia, and pale cool skin may accompany any type of bleed--GI or otherwise.

 

Management of the Acute Abdomen

General management for patients with acute or progressive abdominal pain includes

• verifying scene safety,
• donning personal protective equipment,
• verifying and supporting the ABCs: a patent airway, assuring adequate respiration and ventilation and assessing and managing for adequate circulation. Additionally,
• providing emotional support as part of delivering adequate care.

In geriatric patients, abdominal pain may be related to a heart attack.

Management of specific acute abdominal conditions, besides transport, should always include

• Standard body substance isolation (BSI) and other personal protection equipment (PPE) if needed.
• Airway patency--a priority and must be maintained, often requiring suctioning.
• Oxygenation and ventilation must be adequate and may require administration of oxygen and assistance with ventilation if indicated.
• Proper positioning may relieve some abdominal pain, but this is a comfort measure and no substitute for transport.