Acute abdomin ayman abdelmofeed

Acute Acute AbdomenAbdomen

By

Ayman M. AbdelmofeedLecturer of General &Plastic Surgery

"An acute abdomen" denotes any sudden, spontaneous, nontraumatic disorder whose chief manifestation is in the abdominal area and for which urgent operation may be necessary. Because there is frequently a progressive underlying intra-abdominal disorder, undue delay in diagnosis and treatment adversely affects outcome

DefinitionDefinition

condition characterized by severe abdominal pain which develops over a period of 8 hrs. In pt who have been previously well.

rapid and accurate diagnosis is essential for morbidity and mortality process.

‘‘severe’ abdominal painsevere’ abdominal pain acute onsetacute onset short durationshort duration urgent intervention urgent intervention

necessarynecessary

WWW.SMSO.CCWWW.SMSO.CC

EtiologyEtiology> 1000 causes exi st 2

According to

SystemPathologyarea

• Gastrointestinal tract disorders

*Nonspecif ic abdominal pain *Appendicit is *Small and large bowel obstruction *Perforated peptic ulcer Incarcerated hernia Bowel perforation Meckel's divert iculit is Boerhaave's syndrome *Divert iculit is Inflammatory bowel disorders Mallory-Weiss syndrome Gastroenterit is Acute gastrit is Mesenteric adenit is Parasit ic infections

• Liver, spleen, and bil iary tract disorders

*Acute cholecystitis Acute cholangitis Hepatic abscess Ruptured hepatic tumor Spontaneous rupture of the spleen Splenic infarct Biliary colic Acute hepatitis Pancreatic disorders *Acute pancreatitis

Urinary tract disorders *Ureteral or renal colic Acute pyelonephritis Acute cystitis Renal infarct Gynecologic disorders Ruptured ectopic pregnancy Twisted ovarian tumor Ruptured ovarian follicle cyst *Acute salpingitis Dysmenorrhea Endometrios

Vascular disorders Ruptured aortic and visceral aneurysms Acute ischemic colitis Mesenteric thrombosis Peritoneal disorders Intra-abdominal abscesses Primary peritonitis Tuberculous peritonitis

Retroperitoneal disorders Retroperitoneal hemorrhage

Structures Nervous System Pathways

Sensory Level

Liver, spleen, and central part of diaphragm

Phrenic nerve C3–5

Peripheral diaphragm, stomach, pancreas, gallbladder, and small bowel

Celiac plexus and greater splanchnic nerve

T6–9

Appendix, colon, and pelvic viscera

Mesenteric plexus and lesser splanchnic nerve

T10–11

Sigmoid colon, rectum, kidney, ureters, and testes

Lowest splanchnic nerve

T11–L1

Bladder and rectosigmoid

Hypogastric plexus

S2–4

InflammatoInflammatoryry

obstructioobstructionn

IschemicIschemic PerforationPerforation

Inflammatory Inflammatory Bowel Bowel DiseaseDiseaseAppendicitisAppendicitisDiverticulitisDiverticulitisPancreatitsPancreatitscholecystitischolecystitisCholangitisCholangitisMeckel’s Meckel’s diverticulum.diverticulum.

Intestinal Intestinal ObstructionObstructionBiliary colicBiliary colicUreteric Ureteric coliccolic

Mesenteric Mesenteric ischemiaischemiaTorsion of Torsion of viscus viscus (organ)(organ)

Peptic Peptic Ulcerative Ulcerative Disease Disease (PUD)(PUD)Diverticular Diverticular diseasediseaseAppendixAppendixToxic Toxic megacolonmegacolon

Hemorrhage

ruptured arterial aneurysm Spontaneo

us rupture of spleen

pathologypathology SurgicalSurgical

MedicalMedical gynecologicalgynecologicalMyocardial InfarctionMyocardial InfarctionGastritisGastritisGastroenteritisGastroenteritisHepatitisHepatitisUrinary Tract InfectionUrinary Tract Infection

Ectopic pregnancyEctopic pregnancyOvarian cyst torsionOvarian cyst torsionEndometriosis Endometriosis (endometrial (endometrial cells are deposited in areas outside the cells are deposited in areas outside the uterine cavity )uterine cavity )

Endocrine and Metabolic CausesUremiaDiabetic crisisAddisonian crisisAcute intermittent porphyriaHereditary Mediterranean fever

Hematologic CausesSickle cell crisisAcute leukemiaOther blood dyscrasias

Toxins and DrugsLead poisoningOther heavy metal poisoningNarcotic withdrawalBlack widow spider poisoning

Nonsurgical Causes of Acute Abdomen


Visceral painVisceral pain– Distention, inflammation or ischaemia Distention, inflammation or ischaemia

in hollow viscous & solid organsin hollow viscous & solid organs– Localisation depends on the Localisation depends on the

embryologic origin of the organ:embryologic origin of the organ: Forgut to epigastriumForgut to epigastrium Midgut to umbilicusMidgut to umbilicus Hindgut to the hypogastric regionHindgut to the hypogastric region

Parietal painParietal pain– is localised to the dermatome above is localised to the dermatome above

the site of the stimulus. the site of the stimulus.

Referred pain Referred pain – produces symptoms, not signs e.g. produces symptoms, not signs e.g.

tenderness tenderness

Common causes of abdominal pain

Abdominal Pain visceral pain :is elicited by distention, by

inflammation or ischemia stimulating the receptor neurons, or by direct involvement (e.g., malignant infiltration) of sensory nerves. The centrally perceived sensation is generally slow in onset, dull, poorly localized, and protracted

parietal pain : is mediated by both C and A delta nerve fibers, the latter being responsible for the transmission of more acute, sharper, better-localized pain sensation. Direct irritation of the somatically innervated parietal peritoneum (especially the anterior and upper parts) by pus, bile, urine, or gastrointestinal secretions leads to more precisely localized pain

Referred pain :denotes noxious (usually cutaneous) sensations perceived at a site distant from that of a strong primary stimulus. Distorted central perception of the site of pain is due to the confluence of afferent nerve fibers from widely disparate areas within the posterior horn of the spinal cord

Ref erred Produces sympt oms not si gnsBased on devel opment al embryol ogy

- Uret eral obst ruct i on →t est i cul ar pai n- Subdi aphragmat i c i rri t at i on →i psi l at eral shoul der or supracl avi cul ar pai n- Gynecol ogi c pat hol ogy back →or proxi mal l ower ext remi t y- Bi l i ary di sease ri ght →i nf rascapul ar pai n- MI epi gast ri c , neck, j aw or →upper ext remi t y pai n

Generalized APGeneralized AP PerforationPerforation AAAAAA Acute pancreatitisAcute pancreatitis DMDM Bilateral pleurisy Bilateral pleurisy

Central APCentral AP Early appendicitisEarly appendicitis SBOSBO Acute gastritisAcute gastritis Acute pancreatitisAcute pancreatitis Ruptured AAARuptured AAA Mesenteric Mesenteric

thrombosisthrombosis

Epigastric painEpigastric pain DU / GUDU / GU OesophagitisOesophagitis Acute pancreatitisAcute pancreatitis AAAAAA

RUQ painRUQ pain Gallbladder diseaseGallbladder disease DUDU Acute pancreatitis Acute pancreatitis PneumoniaPneumonia Subphrenic abscess Subphrenic abscess

RUQ painRUQ pain Gallbladder diseaseGallbladder disease DUDU Acute pancreatitis Acute pancreatitis PneumoniaPneumonia Subphrenic abscess Subphrenic abscess

Suprapubic painSuprapubic pain Acute urinary retentionAcute urinary retention UTIs UTIs Cystitis Cystitis PIDPID Ectopic pregnancy Ectopic pregnancy Diverticulitis Diverticulitis

RIF painRIF pain Acute appendicitisAcute appendicitis Mesenteric adenitis (young)Mesenteric adenitis (young) Perf DUPerf DU Diverticulitis Diverticulitis PIDPID SalpingitisSalpingitis Ureteric colic Ureteric colic Meckel’s diverticulum Meckel’s diverticulum Ectopic pregnancy Ectopic pregnancy Crohn’s diseaseCrohn’s disease Biliary colic (low-lying gall Biliary colic (low-lying gall

bladder) bladder)

Loin painLoin pain Muscle strainMuscle strain UTIsUTIs Renal stonesRenal stones PyelonephritisPyelonephritis

Acute appendicit is, constant ,progressive more severe start per umbilical move toward RIF.+ nausea, vomiting, low grade fever, anorexia &/or constipation.

Acute cholecytit is Constant moderate pain in RUQ

radiated to Rt shoulder t ip + nausea, bil ious vomitus, low grade fever & jaundice

Perforated peptic ulcer,

Sudden onset of pain in midepigastrium that spreads and is aggravated by movement; patient appears acutely i l l and is reluctant to move; rigid abdomen; grunting respiration; bowel sounds absent

Ectopic pregnancy,

Pain sudden, severe,persistent,following a missed or abnormal period, typically epigastric; associated with hypotension and tachycardia

Ovarian cystPain constant with sharp, sudden onset, usually in ipsilateral hypogastrium; may have nausea and vomiting following the pain.

Pelvic inflammatory disease. Pain at end of or after normal

menstrual period, bilateral lower quadrant pain aggravated by cervical manipulation; anorexia, nausea, and vomiting rare; possible cervical discharge; fever

Urinary stone, Pain location changes with

movement of stone, may radiate to testicle, groin of involved side, pain very severe; patient cannot get comfortable

Clinical evaluationClinical evaluation

HistoryHistory AgeAgeCertain conditions occur in certain age groupsCertain conditions occur in certain age groupsE.g.E.g. diverticulitis in elderly diverticulitis in elderly Mesenteric adenitis Mesenteric adenitis (inflammation of mesenteric lymph (inflammation of mesenteric lymph

nodes)nodes) in children in children

PainPain– OnsetOnset sudden perforationsudden perforation gradual inflammatory causesgradual inflammatory causes


sitesite

SiteSite

Cholecystitis

cholangitis

Peptic Ulcerative Disease (PUD)

Peptic Ulcerative disease (PUD)

Pancreatitis

cholecystitis

Gastric ulcer

Perforated colon

Appendicitis

Salpingitis

Ruptured. Ectopic pregnancy

Diverticulitis

Salpingitis

Tubo-ovarian abscess

History, cont…History, cont…

– NatureNature colicky obstruction (cramping pain)colicky obstruction (cramping pain) dull inflammation e.g. pancreatitis dull inflammation e.g. pancreatitis

(constant pain) (constant pain)

– RadiationRadiation to tip of the right shoulder in acuteto tip of the right shoulder in acute cholecystitis (boa’s sign)cholecystitis (boa’s sign)


– Aggravating factorsAggravating factors breathingbreathing coughing peritonitiscoughing peritonitis changing positionchanging position fatty meal cholecystitisfatty meal cholecystitis

– Relieving factorsRelieving factors lying still peritonitislying still peritonitis leaning forward pancreatitis (prayer’s signleaning forward pancreatitis (prayer’s sign passing flatus Intestinal Obstructionpassing flatus Intestinal Obstruction


– Associated factorsAssociated factors1.1. vomitingvomiting

Precedes the pain medical conditionPrecedes the pain medical condition Follows the pain surgical conditionFollows the pain surgical condition ContentsContents

– Bilious Small Bowel ObstructionBilious Small Bowel Obstruction– Nonbilious pyloric stenosisNonbilious pyloric stenosis


2. 2. Change in bowel habitsChange in bowel habits– constipationconstipation– Obstipation (constipation +no flatus)Obstipation (constipation +no flatus)– DiarrheaDiarrhea

3. 3. Anorexia (poor appetite)Anorexia (poor appetite)– e.g. appendicitise.g. appendicitis

4. 4. feverfever– Inflammatory causesInflammatory causes

Examination Examination

Note: physical signs may be less obvious Note: physical signs may be less obvious in elderly, obese patients, and those on in elderly, obese patients, and those on steroidssteroids

General examinationGeneral examination– Motionless peritonitisMotionless peritonitis– in agony colic in agony colic – Jaundice- obstructive jaundiceJaundice- obstructive jaundice– dehydrationdehydration

Examination, cont…Examination, cont… Vital signsVital signs

– PulsePulse– Respiratory rateRespiratory rate– Blood PressureBlood Pressure

High grade feverHigh grade fever Low grade feverLow grade feverAcute cholangitis Acute cholangitis (Fever,jaundice,abdominal pain due to (Fever,jaundice,abdominal pain due to bacterial proliferation superimposed on bacterial proliferation superimposed on obstruction of biliary tree due to gall obstruction of biliary tree due to gall stones)stones)

PeritonitisPeritonitis

Acute cholecystitisAcute cholecystitisAppendicitisAppendicitis

Abdominal examinationAbdominal examination InspectionInspection

What you seeWhat you see What it meansWhat it meansDistensionDistension

Rigidity Rigidity Decreased movementDecreased movementScarsScarsHerniaHerniaVisible peristalsisVisible peristalsis

Intestinal Obstruction , AscitisIntestinal Obstruction , Ascitis

PeritonitisPeritonitisPeritonitisPeritonitisAdhesionsAdhesionsIntestinal ObstructionIntestinal ObstructionIntestinal ObstructionIntestinal Obstruction

Abdominal examination, Abdominal examination, cont…cont… Palpation-(to feel)Palpation-(to feel)

signsign significancesignificanceTenderness, Tenderness, guarding,guarding,Rebound tendernessRebound tenderness

Rigidity (board like)Rigidity (board like)Pulsatile massPulsatile massSuccession splash Succession splash (splashing sound due to presence (splashing sound due to presence of air or fluid)of air or fluid)

Inflammation of parietal Inflammation of parietal peritoniumperitonium

peritonitisperitonitisAortic aneurysmAortic aneurysmGastric outlet obstructionGastric outlet obstruction

Abdominal examination, Abdominal examination, cont…cont… PercussionPercussion-(tapping on a surface)-(tapping on a surface)

signsign significancesignificanceResonanceResonanceLoss of liver dullnessLoss of liver dullnessShifting dullnessShifting dullness

Intestinal ObstructionIntestinal ObstructionPerforationPerforationAscitis, free fluidAscitis, free fluid

Abdominal examination, Abdominal examination, cont…cont…

AuscultationAuscultation

signsign significancesignificanceAbsent bowel soundsAbsent bowel soundsIncreased sound, Increased sound, Borborygmi Borborygmi (rumbling (rumbling sound caused by gas moving)sound caused by gas moving)

Bruit Bruit (Abnormal sound over (Abnormal sound over blood vessel)blood vessel)

Paralytic ileusParalytic ileus etc etcMechanical obstructionMechanical obstruction

Vascular diseaseVascular disease

Specific s ignsSpecific s ignssignsign indicationindication

Murphy’s signMurphy’s signBoa’s signBoa’s sign

Rovsing’s signRovsing’s signObturator signObturator signPsoas signPsoas sign

Grey turner & cullen’s Grey turner & cullen’s signsign

Acute cholecystitsAcute cholecystits

AppendicitisAppendicitis

Retrocecal appendicitis,Retrocecal appendicitis, Hemorrhagic Hemorrhagic pancreatitispancreatitis

Cul l en’ s s i gn

http://rds.yahoo.com/S=96062883/K=+acute+pancreatitis/v=2/l=IVI/*-http:/www.learnsurgery.com/images/greyturners.jpg

Murphy’s sign, Psoas sign –if posit ive where is the appendix? Retrocecal

Abdominal examination, Abdominal examination, cont…cont… Rectal examinationRectal examination Per vaginal examination Per vaginal examination

Digital rectal examination,Per Vaginal Examination

Aaron sign – Pain or pressure in epigastrium or anterior chest with persistent

f irm pressure applied to McBurney's point for Acute appendicit is Bassler sign

– Sharp pain created by compressing appendix between abdominal wall and il iacus for Chronic appendicit is

Blumberg's sign– Transient abdominal wall rebound tenderness Peritoneal

inflammation Carnett 's sign

– Loss of abdominal tenderness when abdominal wall muscles are contracted Intra-abdominal source of abdominal pain

Chandelier sign– Extreme lower abdominal and pelvic pain with movement of cervix

Pelvic inflammatory disease Charcot's sign

– Intermittent r ight upper abdominal pain, jaundice, and fever Choledocholithiasis

Claybrook sign– Accentuation of breath and cardiac sounds through abdominal

wall Ruptured abdominal viscus Courvoisier 's

– sign Palpable gallbladder in presence of painless jaundice Periampullary tumor

Cruveilhier sign– Varicose veins at umbil icus (caput medusae) Portal hypertension

Cullen's sign– Periumbil ical bruising Hemoperitoneum

Danforth sign– Shoulder pain on inspiration Hemoperitoneum

Fothergil l 's sign – Abdominal wall mass that does not cross midline and remains

palpable when rectus contracted Rectus muscle hematomas Grey Turner's sign

– Local areas of discoloration around umbilicus and flanks Acute hemorrhagic pancreatitis

I l iopsoas sign Elevation and extension of leg against resistance creates pain = Appendicit is with retrocecal abscess

Kehr's sign Left shoulder pain when supine and pressure placed on left upper abdomen Hemoperitoneum (especial ly from splenic origin)

Mannkopf's sign Increased pulse when painful abdomen palpated Absent i f malingering

Murphy's sign Pain caused by inspiration while applying pressure to right upper abdomen Acute cholecystit is

Obturator sign Flexion and external rotation of r ight thigh while supine creates hypogastric pain Pelvic abscess or inf lammatory mass in pelvis

Ransohoff sign Yellow discoloration of umbil ical region Ruptured common bile duct

Rovsing's sign Pain at McBurney's point when compressing the left lower abdomen Acute appendicit is

Ten Horn sign Pain caused by gentle traction of r ight testicle Acute appendicit is

InvestigationsInvestigations To assess patients condition in generalTo assess patients condition in general

1.1. Complete Blood Count (Blood Routine)Complete Blood Count (Blood Routine)2.2. Electrolytes-Na ,K ,ClElectrolytes-Na ,K ,Cl3.3. Blood Urea Nitrogen (BUN) & CreatinineBlood Urea Nitrogen (BUN) & Creatinine4.4. Arterial Blood Gas (ABG)Arterial Blood Gas (ABG)5.5. UrinalysisUrinalysis6.6. Liver Function Test (LFT)Liver Function Test (LFT)7.7. Prothrombin Time (PT)11 to 13.5 sec,PTT –25 Prothrombin Time (PT)11 to 13.5 sec,PTT –25

to 35 secto 35 sec(Partial thromboplastin time)(blood test that tells how long it (Partial thromboplastin time)(blood test that tells how long it takes for plasma to clot?)takes for plasma to clot?)

8.8. Blood grouping and cross matchingBlood grouping and cross matching

Investigations, cont…Investigations, cont…

2. 2. Serum Beta HCG Serum Beta HCG (human chorionic (human chorionic gonadotrophin hormone)gonadotrophin hormone)– In female of child bearing ageIn female of child bearing age– To rule out ectopic pregnancyTo rule out ectopic pregnancy


Specific investigationsSpecific investigationsA. Lab A. Lab 1.1. Amylase & lipase Amylase & lipase

– Lipase elevation is specific for pancreatitisLipase elevation is specific for pancreatitis– Amylase elevation confirms the diagnosis Amylase elevation confirms the diagnosis

of Pancreatitis, but also seen in:of Pancreatitis, but also seen in: Perforated viscus (Internal organs)Perforated viscus (Internal organs) Intestinal.ObstructionIntestinal.Obstruction Acute cholecystitisAcute cholecystitis


B. RadiologicalB. Radiological1.1. Chest x-rayChest x-ray

Air under the Air under the diaphragm in diaphragm in perforated viscus perforated viscus (duodenal perforation)(duodenal perforation)

Elevated diaphragm in Elevated diaphragm in abdominal distentionabdominal distention


2.2. Abdominal x-rayAbdominal x-ray air fluid levels in intestinal obstructionair fluid levels in intestinal obstruction

Stones (90% of kidney stones can be seen Stones (90% of kidney stones can be seen in x-ray and 10% can’t be seen but 10% of in x-ray and 10% can’t be seen but 10% of gallstones can be seen in x-ray but 90% gallstones can be seen in x-ray but 90% can’t be seen) why ? Calcium .can’t be seen) why ? Calcium .


Kidney stone, Gall stones


3.3. USG-Ultra sound ScanUSG-Ultra sound Scan GallstonesGallstones AppendicitisAppendicitis Ectopic pregnancyEctopic pregnancy Torsion of ovarian cystTorsion of ovarian cyst empyemaempyema

4.4. CT scanCT scan pancreatic pathologypancreatic pathology Acute aortic aneurysmAcute aortic aneurysm Severe diverticulitisSevere diverticulitis Abdominal abscessAbdominal abscess

Gall stones

Abdominal CT scan

CT scanCT scan

What i s t he di agnosi s?Acut e appendi ci t i s


5.5. Duplex scan or angiographyDuplex scan or angiography for superior mesenteric embolus orfor superior mesenteric embolus or thrombosisthrombosis

6.6. ERCP (Endoscopic retrograde ERCP (Endoscopic retrograde cholangio-pancreatography)cholangio-pancreatography)


C. ParacentesisC. Paracentesis– To assess Small Bowel Perforation in To assess Small Bowel Perforation in

ascitis ascitis – Free blood, bile, bowel contents suggest Free blood, bile, bowel contents suggest

Bowel perforation Bowel perforation

D. Endoscopy & laparoscopyD. Endoscopy & laparoscopyE. Diagnostic peritoneal lavageE. Diagnostic peritoneal lavage

Peritoneal lavage, Paracentesis


ManagementManagement

Initial management Initial management – Nil Per OralNil Per Oral– Intravenous fluids, Bolus Ringer Lactate solutionIntravenous fluids, Bolus Ringer Lactate solution– Monitor urine outputMonitor urine output– Nasogastric tubeNasogastric tube

DecompressionDecompression suctionsuction

– AnalgesiaAnalgesia PethidinePethidine

CC

Management, cont…Management, cont…

– Antibiotics Antibiotics BroadspectrumBroadspectrum In case of sepsis or peritonititsIn case of sepsis or peritonitits

Management, cont…Management, cont…

Surgical managementSurgical management– IndicationsIndications1.1. Physical findingsPhysical findings

Localized peritoneal irritation with guarding Localized peritoneal irritation with guarding or rigidityor rigidity

Spreading tendernessSpreading tenderness Tense or progressive distensionTense or progressive distension Tender abdominal or rectal mass with high Tender abdominal or rectal mass with high

fever or hypotensionfever or hypotension

Indications for surgery, Indications for surgery, cont…cont…

Rectal bleeding with shock or acidosisRectal bleeding with shock or acidosis

Equivocal (uncertain)abdominal findings with Equivocal (uncertain)abdominal findings with – Septicemia: high fever, leukocytosis, Septicemia: high fever, leukocytosis,

mental status changesmental status changes– Bleeding: shock, acidosis, falling Bleeding: shock, acidosis, falling

hematocrithematocrit– Suspected ischemia: acidosis, fever, Suspected ischemia: acidosis, fever,

tachycardiatachycardia

Indications for surgery, Indications for surgery, cont…cont…2. 2. Radiological findingsRadiological findings

Pneumoperitonium –bowel perforationPneumoperitonium –bowel perforation Gross or progressive bowel distension-bowel Gross or progressive bowel distension-bowel

obstructionobstruction Free extravasation of contrast media-bowel Free extravasation of contrast media-bowel

perforationperforation Space occupying lesion –Mass or tumorSpace occupying lesion –Mass or tumor Mesenteric occlusion-IschemiaMesenteric occlusion-Ischemia

Indications for surgery, Indications for surgery, cont…cont…3. 3. Endoscopic findingsEndoscopic findings

Perforated lesionPerforated lesion Uncontrolled bleeding lesionUncontrolled bleeding lesion

4. Paracentesis4. Paracentesis Blood Blood bilebile bowel contentsbowel contents urineurine


The Acute Abdomen: Management OptionsThe Acute Abdomen: Management Options

Emergent (‘surgery now’)Emergent (‘surgery now’) Urgent (‘surgery today’)Urgent (‘surgery today’) Semi-urgent (‘surgery tomorrow’)Semi-urgent (‘surgery tomorrow’) Non operativeNon operative


- Act i ve observat i on- Di scharge

Abdominal Pain Clinical Abdominal Pain Clinical PearlsPearls

Significant abdominal tenderness should never be attr ibuted to Signif icant abdominal tenderness should never be attr ibuted to gastroenterit isgastroenterit is

Incidence of gastroenterit is in the elderly is very lowIncidence of gastroenterit is in the elderly is very low Always perform genital examinations when lower abdominal pain Always perform genital examinations when lower abdominal pain

is present – in males is present – in males andand females, in females, in youngyoung and and oldold In older patients with renal colic symptoms, exclude AAAIn older patients with renal colic symptoms, exclude AAA Severe pain should be taken as an indicator of serious diseaseSevere pain should be taken as an indicator of serious disease Pain awakening the patient from sleep should always be Pain awakening the patient from sleep should always be

considered signficantconsidered signficant Sudden, severe pain suggests serious diseaseSudden, severe pain suggests serious disease Pain almost always precedes vomiting in surgical causes; Pain almost always precedes vomiting in surgical causes;

converse is true for most gastroenterit is and NSAPconverse is true for most gastroenterit is and NSAP Acute cholecystit is is the most common surgical emergency in Acute cholecystit is is the most common surgical emergency in

the elderlythe elderly A lack of free air on a chest xray does NOT rule out perforationA lack of free air on a chest xray does NOT rule out perforation Signs and symptoms of PUD, gastrit is, reflux and nonspecific Signs and symptoms of PUD, gastrit is, reflux and nonspecific

dyspepsia have signif icant overlapdyspepsia have signif icant overlap If the pain of bil iary col ic lasts more than 6 hours, suspect early If the pain of bil iary col ic lasts more than 6 hours, suspect early

cholecystit ischolecystit is

Acute abdomin ayman abdelmofeed

Healthcare