Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Stomac and duodenum
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
Assessent and Diagnosis

Referred abdominal pain

Gastrointestinal obstruction, perforation and strangulation are important conditions which usually present with abdominal pain, although pain may also be referred. The location of referred abdominal pain is based on the embryological origin of the affected organ, while the location of peritoneal irritation depends on the anatomical position of the diseased organ. In cases where the diagnosis is not clear, repeated physical examination at frequent intervals will often clarify the need for surgery. It is prudent to seek a second opinion to assist in an equivocal case.

Surgical exploration

The treatment of many acute abdominal conditions includes surgical abdominal exploration. Use laparotomy to expose the abdominal organs and confirm the diagnosis. The patient’s history and physical examination should suggest the diagnosis and help determine the site of incision.

Avoid performing a laparotomy for pancreatitis. If surgery is indicated, do not avoid it in vulnerable patients including the young, old or pregnant. The foetus is best protected by providing the mother with optimum care. Use the midline incision which is simple, does not cause much bleeding, can be performed rapidly, closed quickly and extended easily. The midline laparotomy incision is described in Unit 6: Laparotomy and Abdominal Trauma. The gridiron incision for appendectomy is described on page 7–11 and the groin incision for hernia in Unit 8: Abdominal Wall Hernia. The surgical practitioner at the district hospital who can perform these three incisions can successfully manage most acute abdominal conditions.

Peritoneal irritation

Peritoneal irritation can be localized or generalized. Findings that are important indications for surgery, are:

:: Abdominal tenderness, suggesting inflammation of an underlying organ
:: Rebound abdominal tenderness elicited by percussion, which confirms peritoneal irritation
:: Involuntary contraction of the abdominal wall, a sign of peritoneal irritation, which presents as local guarding or generalized rigidity.

Physical examination

The history and physical examination are crucial to determine the most likely causes of an acute abdomen. The precise location of abdominal pain and tenderness helps the practitioner to make a differential diagnosis. Although there are many acute abdominal conditions, only a few causes are common at any facility. Inflammatory bowel disease and colonic cancers are unusual at the district hospital while trauma, hernia and bowel obstruction are common. Become familiar with the patterns in your locality.

When doing a physical examination:

:: Determine the vital signs
– Rapid respiration may indicate pneumonia
– Tachycardia and hypotension indicate patient decompensation
– Temperature is elevated in gastrointestinal perforation and normal in gastrointestinal obstruction
:: Look for abdominal distension
– Percuss to differentiate gas from liquid
:: Palpate the abdomen
– Start away from the site of tenderness
– Check for masses or tumours
– Determine the site of maximum tenderness
– Check for abdominal rigidity
:: Listen for bowel sounds
– Absence is a sign of peritonitis or ileus
– High pitched tinkling indicates obstruction
:: Always examine:
– Groin for incarcerated hernia
– Rectum for signs of trauma, abscess, obstruction
– Vagina for pelvic abscess, ectopic pregnancy, distended pouch of Douglas.

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  Kep Points  
Fore gut pain (stomach, duodenum, gall bladder) is referred to the upper abdomen

Mid gut pain (small intestine, appendix, right colon is referred to the mid abdomen

Hind gut pain (mid transverse, descending, sigmoid colon and rectum) occurs in lower abdomen

Diseased retroperitoneal organs (kidney, pancreas) may present with back pain

Ureteric pain radiates to the testicle or labia

Diaphragmatic irritation presents as shoulder tip pain.