Abdominal emergency
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abdominal emergency classification overview surgical causes 2024
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Abdominal Emergency - Overview & Classification
Definition
An abdominal emergency (the "acute abdomen") refers to any condition causing sudden, severe abdominal pain that may require urgent - often surgical - intervention. It is one of the most challenging presentations in emergency and surgical practice, as it encompasses a wide spectrum from benign self-limiting conditions to immediately life-threatening pathologies.
"One of the most challenging and rewarding aspects of the general surgeon's duties is the management of patients with abdominal emergencies. Many of these conditions are life-threatening and develop without warning in previously healthy individuals." - Pye's Surgical Handicraft, 22nd Ed.
Classification
A. Intra-abdominal Causes
1. Inflammatory / Infective
| Condition | Key Features |
|---|---|
| Acute appendicitis | Periumbilical pain shifting to RIF; McBurney's point tenderness; Rovsing's sign; rebound tenderness |
| Acute cholecystitis | RUQ pain, Murphy's sign, fever, jaundice if stone in CBD |
| Acute pancreatitis | Epigastric pain radiating to back, serum amylase/lipase raised |
| Acute diverticulitis | LIF pain, fever, altered bowel habits (left-sided "appendicitis") |
| Acute salpingitis / PID | Lower abdominal pain in females, cervical excitation tenderness |
| Amoebic liver abscess | RUQ pain, fever, diaphragmatic irritation |
| Acute mesenteric lymphadenitis | Mimics appendicitis, esp. in children |
| Peritonitis (primary/secondary) | Generalised rigidity, board-like abdomen |
2. Perforations
- Perforated peptic ulcer (gastric or duodenal) - sudden onset epigastric pain, peritonism, free gas under diaphragm on erect CXR
- Perforated typhoid ulcer
- Perforated diverticulum
- Perforated carcinoma of colon
- Perforated ulcerative colitis
3. Intestinal Obstruction
(a) Mechanical:
- In the lumen: Gallstone ileus, roundworm bolus, faecolith, swallowed foreign bodies
- In the wall: Tubercular stricture, intussusception, colorectal carcinoma
- Outside the wall: Adhesions/bands, volvulus (sigmoid/caecal), external herniae (inguinal, femoral, incisional), internal herniae
(b) Functional (Paralytic Ileus): Post-operative, peritonitis, metabolic
(c) Neurogenic: Hirschsprung's disease (in children/neonates)
(d) Vascular (Strangulation): Mesenteric artery embolism/thrombosis - most lethal form; bowel ischaemia/gangrene
Clinical tetrad: colicky pain + vomiting + distension + absolute constipation (no flatus or faeces)
4. Haemorrhage / Vascular Catastrophes
- Ruptured ectopic pregnancy - most common cause of haemoperitoneum in females of reproductive age; shock out of proportion to pain; +ve urine/serum bHCG
- Ruptured aortic aneurysm (AAA) - triad of sudden severe back/abdominal pain, pulsatile mass, hypotensive shock; requires immediate vascular intervention
- Aortic dissection extending to abdomen
- Ruptured lutein (corpus luteum) cyst
- Spontaneous splenic rupture (malaria, infectious mononucleosis)
- Mesenteric vessel occlusion
5. Torsion / Mechanical Accidents
- Twisted ovarian cyst / adnexal torsion - sudden onset, nausea, pelvic tenderness; ovarian Doppler shows absent perfusion
- Torsion of omentum or mesentery
- Torsion of uterine fibroid
6. Colics
- Biliary colic: RUQ, radiates to right shoulder tip
- Ureteric/renal colic: Loin-to-groin, writhing in agony, haematuria
- Appendicular colic
- Intestinal colic
B. Extra-abdominal Causes
(Important "medical causes" that mimic acute abdomen)
| Category | Examples |
|---|---|
| Thoracic | Basal pneumonia, pleuritis, spontaneous pneumothorax, pericarditis, acute MI/angina (inferior STEMI mimics epigastric pain) |
| Parietal/Abdominal wall | Cellulitis, gas gangrene, rectus sheath haematoma, torn inferior epigastric artery |
| Retroperitoneal | Leaking aortic aneurysm, retroperitoneal haematoma, pyelitis, Dietl's crisis |
| Spinal/Neural | Pott's disease, herpes zoster (pre-rash), intercostal neuralgia, tabes dorsalis (gastric crisis) |
| Metabolic/Systemic | Diabetic ketoacidosis, Addisonian crisis, uraemia, acute porphyria, sickle cell crisis, lead poisoning, haemophilia |
| Infections | Malaria, typhoid fever |
Special Populations
Children
Common causes:
- Acute appendicitis (most common surgical emergency in children)
- Intussusception (telescoping of bowel - "redcurrant jelly" stool)
- Intestinal obstruction (roundworms, Meckel's diverticulum, congenital bands)
- Non-specific mesenteric lymphadenitis
- Meckel's diverticulitis
- Primary peritonitis (usually pneumococcal)
Females
Always consider:
- Ruptured ectopic pregnancy (life-threatening haemorrhage)
- Ruptured/haemorrhagic ovarian cyst
- Adnexal torsion
- Acute salpingitis / tubo-ovarian abscess
- Torsion/degeneration of uterine fibroid
Elderly
- Presentations are often atypical and blunted
- Higher rates of ischaemic colitis, perforated malignancy, sigmoid volvulus
- Ruptured AAA must always be considered
Life-Threatening Priorities (Must Not Miss)
| Condition | Clue | Action |
|---|---|---|
| Ruptured AAA | Pulsatile mass + shock | Immediate vascular surgery |
| Ruptured ectopic pregnancy | Shock + +ve bHCG | Emergency laparotomy |
| Mesenteric ischaemia | Pain out of proportion to signs, AF | Urgent CT angiography |
| Perforated viscus | Free air on CXR, peritonism | Emergency laparotomy |
| Strangulated bowel | Obstruction + fever + localised tenderness | Urgent surgery |
| Acute pancreatitis (severe) | Epigastric pain, SIRS | ITU, CT severity scoring |
Approach to Assessment
- End-of-bed assessment - is the patient critically ill? A-E approach if unstable
- History - onset (sudden vs gradual), character, radiation, aggravating/relieving factors, associated symptoms (vomiting, fever, change in bowel habit, urinary symptoms, LMP)
- Examination - vital signs, inspection (distension, guarding), palpation (tenderness, rigidity, rebound, masses), percussion, auscultation (bowel sounds)
- Investigations:
- Bloods: FBC, U&E, amylase/lipase, LFTs, CRP, lactate, bHCG (females)
- Urine dipstick + MSU
- Erect CXR (free gas), AXR (obstruction pattern)
- CT abdomen/pelvis with contrast - investigation of choice for most acute presentations
- Ultrasound (biliary, pelvic, AAA)
The TeachMeSurgery guide to the acute abdomen notes: "In cases where the patient is in extremis and not stable enough for imaging, if there is strong clinical suspicion of intra-abdominal pathology amenable to surgical intervention, immediate exploration in theatre may be warranted."
On analgesia: The historical myth that analgesia masks the diagnosis and should be withheld is now debunked. A patient who is not in pain is more easily assessable and safely transportable for imaging. - Medscape, 2024
Sources: S Das - A Manual on Clinical Surgery, 13th Ed. | Bailey and Love's Short Practice of Surgery, 28th Ed. | Pye's Surgical Handicraft, 22nd Ed.
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