What Is Acute Abdomen?

Acute Abdominalgia is one of the most common conditions in emergency patients. It is reported in the literature that about 30% of emergency patients are mainly complained of abdominal pain, and about 25% of acute abdominal pain needs urgent treatment. About 15% to 40% of people have suffered from abdominal pain, and abdominal pain caused by more serious diseases can account for more than 50% of all abdominal pains.

Basic Information

Visiting department

Emergency Department

Common causes

True visceral pain, similar to visceral pain, involving pain

Common symptoms

stomach ache

Contagious

no

Causes of Acute Abdominal Pain

According to different clinical needs, doctors have different classification methods for acute abdominal pain: for example, they are divided into inflammatory abdominal pain, perforating abdominal pain, obstructive abdominal pain, bleeding abdominal pain, and traumatic abdominal pain, etc. According to different departments, abdominal pain can be divided into surgical abdominal pain, obstetrics and gynecological abdominal pain, internal abdominal pain and pediatric abdominal pain. According to the innervation and conduction pathway of abdominal pain, it is divided into visceral abdominal pain, somatic abdominal pain and induced abdominal pain. Pre-hospital emergency treatment is divided into immediate fatal abdominal pain, delayed fatal abdominal pain and general abdominal pain.

According to the cause of the disease, acute abdominal pain can be divided into true visceral pain, similar to visceral pain and involved pain, which are described as follows:

1. true visceral pain

It refers to abdominal pain caused by pathological changes of abdominal organs (such as stomach, intestine, liver, gall, pancreas, spleen, etc.). The nerve impulse produced by the peripheral nerve receptors in the viscera at the diseased site is transmitted to the cerebral cortex, resulting in a feeling of abdominal pain. The reasons are:

(1) Caused by changes in visceral wall muscle layer tension and tube wall spasm or swelling due to visceral ischemia, inflammation, mechanical and chemical stimulation, smooth muscle spasm or strong contraction;

(2) Abdominal pain due to visceral congestion, bleeding, swelling, or substantial tissue compression caused by adjacent tissues. True visceral pain is characterized by its painful nature as dull pain or colic, blurred positioning and no local skin hypersensitivity.

2. Similar to visceral pain

Also known as parietalpain, where the abdominal wall, peritoneal wall, and mesentery are chemically stimulated (such as inflammation) and physically stimulated (such as torsion, traction) to cause impulses to be transmitted to the cerebral cortex The feeling of abdominal pain. The characteristics similar to visceral pain are acupuncture-like sharp pain, persistent pain, accurate positioning, consistent with the site of visceral lesions, and often accompanied by clear and constant local tenderness and abdominal muscle rigidity.

3. Involved in pain (referredpain)

Also known as radiation pain, it is caused by the impulse from visceral nerve fibers spreading in the spinal cord to the corresponding spinal nerve. Appears as pain in a part of the abdomen that is far from the diseased organ after being stimulated. There are two types of involved pain, one is trunk involved pain, and the other is visceral involved pain. The characteristic of the involved pain is the stimulation of a certain organ in the abdomen, but the feeling of pain occurs in another part. The part where the pain appears is a certain distance from the diseased organ. Pain in areas other than the abdomen. In addition, diseases other than the abdomen can cause induced abdominal pain, that is, pseudoabdominal pain caused by non-abdominal diseases in the abdomen. The areas involved in pain are often accompanied by hyperalgesia, muscle spasms, deep tenderness, and hyperautonomic function.

Acute abdominal pain that causes abdominal pain

True abdominal pain

(1) Acute inflammation of abdominal organs Gastritis, enteritis, cholangitis, appendicitis, hemorrhagic and necrotic enteritis, peritonitis, pelvic inflammatory disease, pyelonephritis, and mesenteric lymphadenitis.

(2) Perforation of cavity organs Perforation of stomach, duodenum and small intestine.

(3) Changes in the position of the abdominal organs or obstruction Stomach torsion, greater omentum torsion, spleen torsion, gallbladder torsion, ovarian cyst pedicle torsion, pregnancy uterine torsion, gastric mucosal prolapse, intestinal obstruction, biliary obstruction.

(4) Rupture and bleeding of abdominal organs Rupture of liver, spleen, ovary and ectopic pregnancy.

(5) Abdominal organ vascular disease Mesenteric arteriovenous, portal and hepatic vein thrombosis, splenic infarction, renal infarction, abdominal aortic aneurysm, abdominal aortic dissection, etc.

(6) Others Acute gastric mucosal lesions, gastric dilation, gastric cramps, intestinal cramps, dysmenorrhea, gallstone colic, renal colic, ureteral colic, etc.

2. Pseudo abdominal pain

(1) Chest disease Acute myocardial infarction, pericarditis, lobar pneumonia, acute pulmonary infarction, iliac pleurisy, acute right heart failure, and intercostal neuralgia.

(2) Poisoning Acute radon poisoning, lead poisoning, and tetanus.

(3) Metabolic diseases: uremia, diabetic ketosis, hypoglycemia, hyponatremia, hypocalcemia, and rhodopsinemia.

(4) Connective tissue and allergic diseases Abdominal allergic purpura, abdominal rheumatic fever, etc.

(5) Mental and neurogenic abdominal pain: abdominal epilepsy, neurotic abdominal pain, etc.

Acute abdominal pain diagnosis

The main points of the preliminary judgment of acute abdominal pain are as follows:

1. Judging by the site of abdominal pain

Except for the involved abdominal pain and metastatic pain, in general, the first place where abdominal pain occurs is mostly the location of the lesion, and there is a significant relationship between the pain site and the organs in that site (Table 1).

(1) Left upper abdominal pain is more common in acute pancreatitis, gastric perforation, left pneumonia, left subcondylar abscess, perisplenitis, left pleural disease, left renal disease, spleen disease or injury, diaphragmatic hernia or submental disease, colonic spleen curvature disease, Heart disease and other diseases.

(2) Right upper abdominal pain is more common in gallbladder, biliary diseases such as acute cholecystitis, cholelithiasis, biliary ascariasis, liver disease, duodenal ulcer or perforation, right subphrenic abscess, right lower pneumonia, right pleurisy, right kidney Stones, right pyelonephritis, pyelonesis and pus, right half colon disease, etc.

(3) Middle and upper abdomen More common in gastric cramps, acute gastritis, upper gastrointestinal ulcer or perforation, hiatal hernia, acute pancreatitis, angina pectoris, acute myocardial infarction, and the beginning of acute appendicitis.

(4) Abdominal pain in the mid-abdomen (periumbilical) is seen in acute gastroenteritis, enteritis, cramps, obstruction, intestinal ascariasis, peritonitis, onset of acute appendicitis, diabetic ketoacidosis, hematopoietic organ disease, food poisoning, and certain poison Or abdominal pain caused by toxins (lead, thallium, drugs such as pesticides, arsenic, hydride, etc.).

(5) Middle and lower abdominal pain are more common in cystitis, urinary retention, ectopic pregnancy, ovarian cyst pedicle torsion, dysmenorrhea, pelvic inflammatory disease or pelvic abscess, rectal diseases, and some sigmoid colon diseases.

(6) Right lower abdominal pain is found in diseases such as appendicitis, enteritis, intestinal tuberculosis, tumors, intestinal lymphadenitis, right ureteral stones, female right pelvic inflammatory disease, ruptured ovarian follicles, right inguinal hernia and other diseases.

(7) Left and right mid-abdominal pain Rising, descending colon diseases such as tumors, tuberculosis, high appendicitis, kidney disease, ureter diseases such as stones.

(8) Left lower abdominal pain is more common in gastrointestinal bleeding, left fallopian tube disease, left ovarian disease, sigmoid torsion, inguinal hernia, bacillary dysentery, colon amoebiasis, colon cancer, left ureteral stones, left appendicitis, Ovarian follicle rupture and other diseases.

(9) Total abdominal pain can be seen in generalized (diffuse) peritonitis caused by tuberculosis, cavity organ perforation, acute hemorrhagic necrotizing pancreatitis, visceral rupture and bleeding.

2. Judging by the pathogenesis and nature of abdominal pain

(1) Visceral abdominal pain is also referred to as medical abdominal pain. Pain impulses mainly come from excessive tension, contraction, extension, and expansion of smooth muscles. Pain is mostly intermittent. Symmetrical pain with the midline of the abdomen as the axis is diffuse and non-fixed. Tenderness points, often accompanied by nausea, vomiting, sweating and other autonomic reflexes. This kind of abdominal pain generally does not require urgent surgical treatment, and is seen in the early manifestations of diseases such as acute gastritis, peptic ulcer, acute appendicitis, and acute pancreatitis.

(2) Somatic abdominal pain It is also called surgical topical written abdominal pain. It is characterized by a clear location of abdominal pain, a fixed tenderness point, and abdominal pain is a continuous knife-like pain or colic. Abdominal signs include tenderness, rebound pain, and abdominal wall muscle health (also known as abdominal muscle tension, that is, a state of protective rigidity in the abdominal muscles), as well as disappearance of abdominal breathing and forced posture. Found in various acute abdomen.

(3) Involved abdominal pain, also known as radiation pain or diffuse pain, is caused by a short circuit between the afferent neurons of the two parts due to the increased degree of visceral abdominal pain. It is characterized by unclear abdominal pain, no tenderness or no fixed tenderness points, such as acute upper abdominal pain in acute myocardial infarction, acute cholecystitis, shoulder pain in gallstones, and back pain in renal colic.

3. Judging by the different characteristics of abdominal pain

(1) Onset of disease Onset of rapid onset and rapid progress of disease are more common in perforation of cavity organs, intra-abdominal bleeding, intestinal torsion, mesenteric vascular occlusion, and aneurysm rupture. Slow onset is common in milder medical and systemic diseases.

(2) Duration of pain Persistent abdominal pain is seen in inflammation, such as acute suppurative appendicitis, acute suppurative cholecystitis, etc .; Persistent abdominal pain accompanied by paroxysmal aggravation is a characteristic of the coexistence of lesions such as abdominal inflammation and cavity organ perforation.

(3) Patient Position Patients with kidney stones, gallstones, and biliary ascariasis were mostly turned, while patients with acute peritonitis showed forced posture.

(4) Symptom sequence: First onset of fever and vomiting, abdominal pain is usually a medical disease, abdominal pain first, followed by fever, and abdominal pain lasting for more than 6 hours, most of them may be surgical acute abdomen.

(5) Radiation: The pain of pancreatitis often radiates to the left lower back; the perforation of gastric and duodenal ulcers is radiated to the shoulder due to the stimulation of the ventral surface of the diaphragm; Rectal pain often radiates to the lumbosacral region; ureteral stone colic often radiates to the perineum or inner thigh.

4. Acute abdominal pain-related syndromes (Table 2)

(1) Peritoneal irritation syndrome manifested as abdominal tenderness, rebound pain and abdominal wall muscle health. Acute abdominal pain with peritoneal irritation group is common in acute abdomen. The abdominal wall muscle guard is also called increased abdominal muscle tone, which can be divided into two types: localized and diffuse (extensive). It is one of the most common and clinically significant signs in patients undergoing abdominal examination. In the elderly and obese people, it is often difficult to know the true condition of the patient's abdominal wall by conventional methods because of the thick abdominal fat. At this time, deep pressure palpation should be carefully examined to avoid missed diagnosis.

(2) Intestinal obstruction group manifested as vomiting, bloating, abdominal pain, cessation of defecation and exhaustion of bowel sounds, or disappearance of bowel sounds, which are common in gastrointestinal obstructive diseases.

(3) Internal hemorrhage group manifests as thirst, pale, cold sweats, rapid heartbeat, shortness of breath, decreased blood pressure, etc. It is common in closed gastrointestinal bleeding caused by massive bleeding in the digestive tract and trauma.

(4) Inflammatory syndrome, or systemic inflammatory response syndrome, manifests as an increase in body temperature> 38 ° C or a decrease of 90 beats / min; shortness of breath> 20 beats / min; an increase in white blood cell count> 12 × 10 / L, common For primary or secondary infection-associated abdominal diseases, such as cholangitis, appendicitis, hemorrhagic and necrotic enteritis, peritonitis, and pelvic inflammatory disease.

(5) Gastrointestinal syndrome: manifested as acid reflux, belching, nausea, vomiting, hiccups, bloating, diarrhea, cessation of defecation and exhaustion, greasy food, jaundice, changes in stool characteristics, etc., common in digestive diseases, sometimes Accompanied manifestations of acute abdomen.

5. Out-of-hospital clinical features of common acute abdomen

(1) Acute appendicitis: Metastatic right lower quadrant pain; a fixed tenderness area in the right lower quadrant; different degrees of peritoneal irritation; Roche's sign (indirect tenderness), psoas major sign, and obturator sign positive.

(2) Acute cholecystitis often has a history of eating greasy foods or full meals; the onset is more rapid, and the onset is more frequent at night; paroxysmal colic in the right upper or middle abdomen is later converted to persistent pain with paroxysmal hyperplasia, Pain can be radiated to the right shoulder and right chest and back; it can be associated with chills, fever, nausea, vomiting, and jaundice in a few patients; right upper quadrant tenderness, muscle tension and rebound pain, sometimes touching the tender gallbladder; Muphy's sign is positive.

(3) Acute pancreatitis often occurs after a full meal or drinking; onset is rapid; mostly left and mid-abdominal left-left continuous knife-cut severe pain, accompanied by exacerbation of paroxysmal pain, which can be banded and left or Radiation on both sides of the lower back; nausea, vomiting and bloating; mild upper abdominal and left upper quadrant peritoneal irritation signs; acute hemorrhagic necrotizing pancreatitis may have shock, mainly manifested as irritability, cold sweat, thirst, cold limbs, Fine pulse, shallow breathing, decreased blood pressure, and oliguria.

(4) Sudden onset of cavity organ perforation ; severe persistent abdominal pain, forced posture; nausea, vomiting and other gastrointestinal disorders; peritoneal irritation syndrome from local to whole abdomen, "plate-shaped abdomen" may appear in severe cases Mobile dullness in the abdominal cavity; weakening or disappearing of bowel sounds; disappearance of lung and liver in percussion; prone to concurrent shock (lower blood pressure, faster pulse, reduced pulse pressure, cold sweats, cold limbs, etc.).

(5) Acute intestinal obstruction Paroxysmal colic; vomiting, abdominal distension; stop defecation and exhaust; intestinal type, peristaltic wave; hyperactive bowel sounds, sound of air over water.

(6) History of trauma to liver and spleen rupture, history of direct or indirect blunt violent injury to abdomen; persistent severe abdominal pain, radiation to right shoulder (liver rupture) or spread to left shoulder and lower abdomen (rupture of spleen); peritoneal irritation sign Internal bleeding symptoms; percussion mobile dullness.

(7) Ectopic pregnancy rupture Menopause women of the right age; tearing pain in one side of the lower abdomen; vaginal bleeding; obvious tenderness in the lower abdomen but rebound pain, but no obvious muscle health; percussion mobile dullness; syncope and internal bleeding signs may be present.

6. Clinical characteristics of abdominal pain in common medical diseases

(1) Most cases of large leaf pneumonia occur in winter and early spring; before the onset of abdominal pain, most patients have symptoms of upper respiratory tract infection; rapid onset, chills, high fever (body temperature rises quickly to 39-40 ° C), chills, Muscle pain, chest pain, cough, and deep breathing increased throughout the body; upper abdominal tenderness was widespread but deep pressure did not worsen, and there was no rebound pain; bowel sounds were normal; white blood cell counts were mostly between 20 and 30 × 10 / L.

(2) Acute onset of acute myocardial infarction ; patients are mostly over 40 years of age; severe persistent pain in the upper abdomen, but tenderness is not obvious; severe chest tightness and dyspnea; often accompanied by sweating, nausea, vomiting, abdominal distension and hiccup; No peritoneal irritation sign; may be associated with arrhythmia, hypotension, shock; characteristic changes in electrocardiogram; portable myocardial marker test was positive.

(3) Aortic dissections are mostly men over 40 years of age; they have a history of hypertension and arteriosclerosis; sudden onset; persistent abdomen-like tears that often spread upward or downward along the aorta; shock manifestations but sometimes Blood pressure does not decrease; blood pressure and pulse of both upper limbs may be inconsistent.

(4) Acute gastroenteritis often has a history of unclean food such as cold eating and long storage time; it develops within a few hours after eating and manifests as upper abdominal discomfort and gastrointestinal symptoms. People who are caused by salmonella infection often have fever; often accompanied by fever Diarrhea, watery stools; mild tenderness in the upper abdomen or around the umbilicus, but no fixed tenderness points and rebound pain; hyperactive bowel sounds.

(5) Acute gastric dilatation usually occurs 1 to 2 hours after overeating; sudden upper abdominal or peri-umbilical pain with vomiting; abdominal distension, drum sounds on percussion; no abdominal muscle tension and hyperactive bowel sounds.

(6) Intestinal tsutsugamushi infection rate is higher in areas with poor sanitary conditions; more men than women; history of tsutsugamushi infection (history of deworming, etc.); paroxysmal colic in the upper abdomen or around the umbilicus, or It has a knife-like sensation or drill-like pain, and children can play freely when relieved. When they are seized, they are restless, bend their body, hold their belly, crawl and roll, and sweat all over the body; Muscle tension may occur during concurrent infections. It is often accompanied by vomiting and usually occurs after abdominal pain; sometimes it can also cause fever.

Table 1 Etiology and location judgment of abdominal pain

Table 2 Key points for determining the symptoms and characteristics of abdominal pain

Acute abdominal pain treatment

The basic idea of pre-hospital emergency classification and on-site diagnosis and treatment of acute abdominal pain is mainly around the particularity of on-site self-rescue and emergency treatment. Acute abdominal pain can be divided into the following three categories:

1. Immediate fatal abdominal pain

It refers to abdominal pain that may pose a life threat to patients in a short period of time. Such patients appear to have abdominal pain, but they are not actually caused by abdominal disease, but caused by cardiovascular disease. Therefore, they are also called cardiovascular abdominal pain. The disease is severe coronary syndrome, especially acute myocardial infarction, aortic dissection and severe pulmonary infarction. Patients with this type of abdominal pain may experience sudden cardiac arrest (usually ventricular fibrillation), which may lead to sudden death.

The treatment strategy for this type of patients is: patients should immediately rest on the spot, take a comfortable position (can be in a supine, semi-recumbent or sitting position), relax the body as much as possible, and avoid stress and fear. At the same time immediately call the 120 emergency phone to call an ambulance, go through the on-site first aid, and then go to the hospital under ECG monitoring. Before the arrival of the ambulance, blood pressure and pulse can be measured. Those with blood pressure not lower than usual can take nitroglycerin drugs. Note: Never go to the hospital yourself. This is because in the case of a sudden heart attack, patients may have malignant arrhythmias at any time and cause sudden death. Therefore, any factor that increases the work of the heart may worsen the condition. Such tragedies have occurred many times in the past.

2. Delay fatal abdominal pain

Although this kind of abdominal pain has rapid onset and rapid development, it will not endanger the patient's life in a short time (usually several hours), but the patient must go to the hospital as soon as possible to get the correct diagnosis and treatment. Delayed diagnosis will bring patients Serious harm. Common diseases are acute abdomen and so on. The earlier the treatment of patients with this type of disease, the better the effect, and the later the treatment, the condition may suddenly worsen, or even get out of control, resulting in patient death.

AcuteAbdomen is an acute disease group in which abdominal organs are the main lesions and clinically needs urgent treatment, especially surgical emergency treatment. This type of disease accounts for a large proportion of severe abdominal pain diseases, which is characterized by rapid onset, high incidence, many common diseases, and high mortality. The literature reports that the disease accounts for 5% to 10% of patients in general hospitals, about 10% to 25% in emergency departments, and a comprehensive mortality rate of about 0.5% to 5%. Special attention should be paid to critical acute abdomen, which is mainly represented by acute hemorrhagic necrotizing pancreatitis, acute suppurative cholangitis, abdominal hemorrhage (rupture of abdominal tumors and abdominal aortic aneurysms, traumatic liver and spleen rupture, etc.), and the entire small intestine. Reverse it and so on. Such patients have rapid onset, fierce onset, rapid disease changes, high mortality, and sometimes die without a clear diagnosis. Therefore, pre-hospital rescuers should pay special attention to this kind of acute abdomen, and be able to identify them as soon as possible, and send suspects to the hospital as soon as possible to avoid delays in time.

3. General abdominal pain

It refers to the abdominal pain that excludes the above two cases, and the disease will not basically pose a life threat to the patient for a considerable period of time. So whether patients go to the hospital or call an ambulance depends on the specific situation.

In short, the main principle of pre-hospital emergency treatment for patients with acute abdominal pain is to screen patients with abdominal pain according to the above classification. First, we must exclude immediate fatal abdominal pain. Such diseases can sometimes be expressed as acute abdominal pain, and patients have cardiac arrest at any time. There is also the danger of sudden death. Therefore, the first step in pre-hospital emergency treatment is to conduct relevant examinations around the above diseases. For example, after calling an ambulance, an adult patient should use an electrocardiogram as a routine examination for acute abdominal pain. Emergency treatment and preventive measures.

After excluding the first case, the second step of the screening work is to distinguish whether the patient has delayed fatal abdominal pain, that is, whether the patient is acute abdominal disease, or general medical abdominal pain or functional abdominal pain. The identification methods that can be referred to before admission are: The positive signs of patients with general abdominal pain are not obvious. For example, if there is no fixed tenderness point in the abdomen, there is no abdominal wall muscle guard on palpation and the "eye-closing sign" appears, that is, the patient closes his eyes to show pain during palpation. Abdominal pain caused by organic diseases is often widened with fear when palpated. In addition, distracting the patient during palpation can also identify the nature and extent of abdominal pain. For example, you can press the abdomen while chatting with the patient, and if the patient still has obvious abdominal tenderness when the attention is diverted. Mostly explained is organic abdominal pain. In most cases, acute abdomen requires emergency surgery, so the patient should be sent to the hospital for further examination as soon as possible, without too much delay before the hospital. Sometimes symptomatic treatments such as spasmolysis, fluid replacement, acupuncture, and hot compress can be used to relieve the patient as appropriate. Symptoms, alleviate the patient's pain, and avoid the application of powerful painkillers (such as morphine, duolidine, qiangtongding, etc.) before diagnosis, so as not to cover up the disease and delay the diagnosis. For general abdominal pain, measures such as local observation and treatment are taken as appropriate.