Table of contents · 7 sections
Acute abdomen is a collective clinical term encompassing emergency abdominal diseases and injuries requiring urgent surgical care. Correct differential diagnosis of the "acute abdomen" is one of the core skills for a physician of any specialty, upon which the patient's life depends.
Definition and classification of causes
Causes of acute abdomen are divided into three groups:
| Group | Mechanism | Examples |
|---|---|---|
| Inflammatory | Infection, autoimmune inflammation | Appendicitis, cholecystitis, pancreatitis, diverticulitis, peritonitis |
| Perforative | Loss of integrity of a hollow organ | Gastric/duodenal ulcer perforation, bowel perforation |
| Obstructive and ischemic | Disruption of passage or blood supply | Intestinal obstruction, incarcerated hernia, mesenteric thrombosis, volvulus |
Separately, gynecological causes (ectopic pregnancy, ovarian apoplexy, cyst torsion) and urological causes (renal colic, testicular torsion) are distinguished.
Key symptoms and diagnostics
Classical triad of the acute abdomen:
- Abdominal pain — the main symptom. Character, localization, and radiation indicate the cause
- Muscle rigidity of the anterior abdominal wall (defence musculaire) — a sign of peritoneal irritation
- Disrupted peristalsis — enhanced (mechanical obstruction) or weakened/absent (paresis, peritonitis)
Crucial peritoneal signs:
- Blumberg's sign — pain intensifies upon sudden withdrawal of the hand from the abdomen (peritoneal irritation)
- Rovsing's sign — pain in the right iliac fossa upon pressure in the left (appendicitis)
- Murphy's sign — inspiratory arrest during palpation at the gallbladder point (cholecystitis)
- Mayo-Robson's sign — pain in the left costovertebral angle (pancreatitis)
- Hochenegg's sign — gaping anus, balloon-like ampulla of the rectum (sigmoid volvulus)
Differential diagnosis by pain localization
| Localization | Most probable causes |
|---|---|
| Right upper quadrant | Acute cholecystitis, hepatitis, subphrenic abscess |
| Epigastrium | Ulcer perforation, acute pancreatitis, myocardial infarction (abdominal form!) |
| Right iliac fossa | Acute appendicitis, mesenteric lymphadenitis, Crohn's disease, right-sided renal colic |
| Left iliac fossa | Sigmoid diverticulitis, sigmoid volvulus, left-sided renal colic |
| Umbilical region | Early appendicitis (visceral pain), small bowel obstruction, mesenteric ischemia |
| Diffuse pain | Generalized peritonitis, intestinal obstruction (late stage), mesenteric thrombosis |
Examination algorithm
- Inspection and palpation — visual signs (distension, asymmetry), guarding, peritoneal signs
- Laboratory tests — CBC (leukocytosis, left shift), amylase/lipase (pancreatitis), hCG in women of reproductive age
- Plain abdominal radiography — free gas under the diaphragm dome (perforation), air-fluid levels/Kloiber's cups (obstruction)
- Abdominal ultrasound — free fluid, gallstones, appendix >6 mm, aortic aneurysm
- Contrast-enhanced CT — gold standard for an unclear clinical picture
- Diagnostic laparoscopy — when doubts persist
Management: when to operate?
Absolute indications for emergency surgery:
- Hollow organ perforation (free gas on X-ray)
- Ongoing intra-abdominal bleeding
- Incarcerated hernia
- Mesenteric thrombosis (bowel necrosis)
- Generalized purulent peritonitis
For uncomplicated appendicitis, cholecystitis, pancreatitis — surgery within the next 24–72 hours after stabilization. Destructive pancreatitis is initially managed conservatively in the ICU.
Mistakes that must not be made
- Prescribing analgesics before surgical examination — "masks" the clinical picture (although modern protocols allow pain relief, the classical principle is important for the exam)
- Ectopic pregnancy not ruled out — hCG is mandatory in all women of childbearing age with abdominal pain
- Abdominal form of myocardial infarction — ECG for epigastric pain!
- Mesenchymal ischemia — "pain out of proportion to findings" (severe pain with a soft abdomen in the early stages)
Frequently asked questions
How to distinguish surgical acute abdomen from non-surgical?
Key signs of surgical pathology: peritoneal signs (Shchetkin-Blumberg sign), progressive pain, impaired passage (vomiting, delayed stool and gas), free gas or fluid on X-ray/ultrasound, leukocytosis with a shift. Non-surgical causes (diabetic abdominal crisis, porphyria, renal colic) usually do not present with muscle defense and peritoneal signs.
Why does pain start in the epigastrium in appendicitis?
This is due to dual innervation: initial visceral pain (via Th10 sympathetic fibers) is projected to the periumbilical/epigastric region. When the inflammation reaches the parietal peritoneum, the pain "migrates" to the right iliac region (somatic pain via Th11-L1). This phenomenon is Kocher-Volkovich sign.
Study surgery through interactive lessons on the platform. Related topics: peptic ulcer disease, pathophysiology of inflammation, tissue necrosis. Use clinical calculators to assess severity.