Acute abdomen

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

## Overview

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Acute abdomen refers to a sudden, severe pain in the abdomen that is less than 24 hours in duration. It is in many cases an emergency condition requiring urgent and specific diagnosis, and the treatment usually involves surgery.

## Classification

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### Peritonitis

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Acute abdomen is occasionally used synonymously with peritonitis. This is not incorrect; however, peritonitis is the more specific term, referring to inflammation of the peritoneum. It is diagnosed on physical examination as rebound tenderness, or pain upon removal of pressure rather than application of pressure to the abdomen. Peritonitis may result from several diseases, notably appendicitis and pancreatitis.

### Ischemic Acute abdomen

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Vascular disorders are more likely to affect the small bowel than the large bowel. Arterial supply to the intestines is provided by the superior and inferior mesenteric arteries, (SMA and IMA respectively) both of which are direct branches of the aorta.

The superior mesenteric artery supplies:

1. Small bowel
2. Ascending and proximal 2/3 of the transverse colon

The inferior mesenteric artery supplies:

1. Distal 1/3 of the transverse colon
2. Descending colon
3. Sigmoid colon

Of note, the splenic flexure, or the junction between the transverse and descending colon, is supplied by the most distal portions of both the inferior mesenteric artery and superior mesenteric artery. It is referred to medically as a watershed area, or an area especially vulnerable to ischemia during periods of systemic hypoperfusion, such as in shock (medical).

Acute abdomen of the ischemic variety is usually due to:

1. A thromboembolism from the left side of the heart, such as may be generated during atrial fibrillation, occluding the SMA.
2. Nonocclusive ischemia, such as that seen in hypotension secondary to heart failure may also contribute, but usually results in a mucosal or mural infarct, as contrasted with the typically transmural infarct seen in thromboembolus of the SMA.
3. Primary mesenteric vein thromboses may also cause ischemic acute abdomen, usually precipitated by hypercoagulable states such as polycythemia vera.

## Causes

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### Life Threatening Causes

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### Common Causes

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* Acute appendicitis
* Acute peptic ulcer and its complications
* Acute cholecystitis
* Acute pancreatitis
* Acute intestinal ischemia
* Diabetic ketoacidosis
* Acute diverticulitis
* Ectopic pregnancy with tubal rupture
* Acute peritonitis
* Bowel perforation with free air or bowel contents in the abdominal cavity
* Acute ureteral colic
* Bowel volvulus

### Causes by Organ System

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Cardiovascular | No underlying causes

|

Chemical/Poisoning | No underlying causes
Dental | No underlying causes
Dermatologic | No underlying causes
Drug Side Effect | Clomifene
Ear Nose Throat | No underlying causes
Endocrine | No underlying causes
Environmental | No underlying causes
Gastroenterologic | No underlying causes
Genetic | No underlying causes
Hematologic | No underlying causes
Iatrogenic | No underlying causes
Infectious Disease | No underlying causes
Musculoskeletal/Orthopedic | No underlying causes
Neurologic | No underlying causes
Nutritional/Metabolic | No underlying causes
Obstetric/Gynecologic | No underlying causes
Oncologic | No underlying causes
Ophthalmologic | No underlying causes
Overdose/Toxicity | No underlying causes
Psychiatric | No underlying causes
Pulmonary | No underlying causes
Renal/Electrolyte | No underlying causes
Rheumatology/Immunology/Allergy | No underlying causes
Sexual | No underlying causes
Trauma | No underlying causes
Urologic | No underlying causes
Miscellaneous | No underlying causes

### Causes in Alphabetical Order

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## Diagnosis

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### History and Symptoms

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Patients with an Ischemic type of acute abdomen present with symptoms of:

* Diffuse abdominal pain
* Bowel distension
* Bloody diarrhea

### Physical Examination

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#### Abdomen

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In cases of ischemic acute abdomen, bowel sounds will be absent.

### Laboratory Findings

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In cases of ischemic acute abdomen, laboratory tests reveal:

* Neutrophilic leukocytosis, sometimes with a left shift assessed through a complete blood count
* Increased serum amylase.

### CT

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A CT scan can provide a differential diagnosis between simple and complex pathologies causing the Acute abdomen. The scan can also provide evidence to the doctor whether surgical intervention is necessary.

### Other Imaging Findings

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In cases of ischemic acute abdomen, abdominal radiography will show many air-fluid levels, as well as widespread edema.

## Treatment

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### Surgery

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Acute ischemic abdomen is a surgical emergency. Typically, treatment involves removal of the region of the bowel that has undergone infarction, and subsequent anastomosis of the remaining healthy tissue.

## References

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