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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:
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Abdominal
tenderness, suggesting inflammation of an underlying
organ |
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Rebound
abdominal tenderness elicited by percussion, which confirms
peritoneal irritation |
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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:
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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 |
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Look
for abdominal distension
– Percuss to differentiate gas from liquid |
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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 |
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Listen
for bowel sounds
– Absence is a sign of peritonitis or ileus
– High pitched tinkling indicates obstruction |
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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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