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The acute abdomen 

The acute abdomen
The acute abdomen

Chris Watson

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date: 25 June 2018

The term ‘acute abdomen’ is commonly used to describe abdominal pain of recent onset requiring urgent surgical assessment. Most cases of acute abdominal pain present in the community and are managed by family practitioners, with only a few presenting to a hospital. Those cases that do present to hospital are usually referred to the general surgeons. In a third of cases, no specific diagnosis is made, although many will subsequently re-present with identifiable pathology.

Only a few patients with an acute abdomen present directly to medical specialities or occur in patients already on a medical ward. These patients are often older, and the acute abdomen may present on a background of other comorbidities; hence a patient with known ischaemic heart disease who presents with upper abdominal pain from biliary colic or reflux may be misdiagnosed with cardiac chest pain. In addition, the disorders most commonly causing an acute abdomen in a medical patient differ from those occurring in the community and referred to surgeons, since the more obvious causes are likely to have been identified and referred appropriately. In elderly medical patients vascular events and intestinal obstruction due to malignancy are much more common than the appendicitis seen in the typical ‘surgical’ patient.

Management of the acute abdomen in medical patients can be extremely difficult: there is no substitute for an experienced and vigilant physician working together with a thoughtful surgeon and radiologist. The key question is, ‘Does this patient need an operation?’, a decision which depends on (1) symptoms, e.g. severe pain; (2) findings on examination, e.g. a rigid abdomen; (3) findings on investigation, e.g. subdiaphragmatic air; (4) excluding nonoperative diagnoses, e.g. pancreatitis; and (5) the presumed diagnosis, e.g. appendicitis as opposed to Crohn’s ileitis. But it must be remembered that in very sick patients it may be necessary to proceed straight to surgery without any supportive imaging.

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