Acute abdomen: 4 criteria for preliminary diagnosis and algorithm of medical actions

Acute abdominal syndrome is a complex clinical and diagnostic complex caused by pathological changes occurring in the abdominal cavity and disrupting the functioning of the entire body. It is manifested by unbearable pain in the abdomen, tension in its muscular frame, intoxication phenomena and a violation of the motor-evacuation ability of the digestive tract. The syndrome requires emergency hospitalization, urgent diagnostic measures and emergency care by qualified surgeons.

Acute abdominal syndrome is a manifestation of inflammatory diseases, dyscirculatory processes, traumatic injury, intestinal obstruction and some other disorders. All of them have similar clinical manifestations: acute onset, sharp pain, plank-shaped abdominal wall, specific symptoms of muscle protection and irritation of the parietal peritoneum.

The concept of "acute abdomen" was introduced in 1940 by Henry Mondor, who wrote a book on the diagnosis of emergency conditions. He called the pathological process “a catastrophe in the abdominal cavity.” After the scientific work was published, practicing surgeons began to actively study and discuss the etiology, clinical picture, diagnosis and treatment of this syndrome.

An acute abdomen is associated with pain. But this illness is not just pain. It poses a real threat to human life. To achieve complete restoration of health, it is necessary to find out the cause of the syndrome. To do this, you should collect an anamnesis, examine the patient, and conduct radiographic, ultrasound and laparoscopic examinations. Early seeking medical help allows you to avoid such a serious complication as peritonitis - inflammation of the membrane lining the abdominal cavity from the inside. Only urgent surgical intervention performed by a qualified specialist can save the patient’s life.

Introduction and historical facts about the concept of “acute abdomen”

It is not known exactly who exactly introduced the concept of “acute abdomen” into the world medical vocabulary.
In 1940, the French surgeon Henry Mondor in his book “Emergency Diagnosis. Belly" for the first time used the phrases: "Acute abdomen" and "Abdominal catastrophe." In his works, he primarily highlighted the problem of time; the main idea of his work is that the shorter the period between the appearance of the patient’s first symptoms and the provision of emergency surgical care, the greater the chance of successful treatment and recovery.

In the early 50s of the 20th century, in the territory of the former USSR, Nikolai Samarin published the monograph “Diagnostics of Acute Abdomen”, which became widespread even in European countries. Of course, 70 - 80 years ago a surgeon could rely only on his tactile sensations, eyes, hearing and, in rare cases, radiography, so at present the work of these doctors is not entirely relevant.

In 2018, a person living in a developed country has access to hundreds of types of laboratory and instrumental research methods. However, the problem of primary diagnosis of acute abdomen still remains relevant, and achieving timely verification of the diagnosis in 100% of cases is an extremely difficult task.

General information about the disease

Acute abdomen is a complex of clinical symptoms, laboratory and instrumental research data, indicating the presence of acute damage to an organ or group of organs in the abdominal cavity, retroperitoneal space, or pelvic cavity. This diagnosis is always preliminary and exists only to refer the patient for specialized examination and treatment (surgical).

“Acute abdomen” is not a nosological unit, but a diagnosis temporarily assigned to a person, which includes many diseases.

Treatment process

First medical aid for persons with acute abdomen syndrome is as follows: the patient must be calmed, placed on his back, cold applied to the stomach and an ambulance called. The sooner the emergency room is called, the greater the chance of recovery. Patients with obvious signs of pathology are taken to surgery. Persons in critical condition are hospitalized in intensive care for anti-shock treatment. General therapeutic measures will be most effective only if you consult a doctor early.

The choice of treatment tactics and type of surgery depends on specific causative factors. If during diagnostic procedures it was determined that the pathological process is localized in the abdominal cavity, emergency surgery is performed. It is performed immediately after hospitalization or in the first 2-4 hours after examination. Emergency surgical care improves the prognosis of pathology and significantly reduces the incidence of complications. If the patient is in a state of death throes, the operation begins immediately.

All patients are prohibited from eating, drinking, smoking, taking enemas, or applying a warm heating pad to the stomach. The use of analgesics will ease pain and relieve tension from the abdominal muscles, which will blur the clinic and lead to diagnostic errors.

After making a diagnosis, the doctor, in order to at least slightly alleviate the condition of the patients, prescribes antispasmodic drugs - “No-shpu”, “Papaverine”. Before surgery, patients have their stomach washed and a catheter is inserted into a vein for infusion therapy, which allows them to compensate for blood loss, normalize CBS and determine central venous pressure. Patients are injected intravenously with a solution of glucose, electrolytes, plasma substitutes, Albumin, blood, and antibiotics.

Epidemiology of acute abdomen

Without a doubt, acute abdomen is one of the top five among all diseases in terms of incidence, along with acute coronary syndrome (myocardial infarction, unstable angina), acute cerebrovascular accident (ischemic and hemorrhagic strokes), acute trauma (road accidents, domestic trauma, burns and etc.), various infectious diseases.

In surgical practice, the acute abdomen comes first, as it includes a fairly large group of nosological units. Since statistics are kept for individual diseases, it is difficult to give an exact figure for the pathological incidence of the population with “acute abdomen”.

Etiology of acute abdominal pain

The etiology of acute abdomen, in fact, is also a classification of this pathology.

The causes of coolant development are diseases:

Diseases of the abdominal organs, manifested by acute abdominal pain

appendicitis (including its complications: perforation, bleeding, gangrene, appendiceal infiltrate, abscess);
acute intestinal obstruction (mechanical, dynamic);
acute cholecystitis - inflammation of the gallbladder and its complications: destruction, abscess, choledocholithiasis - blockage of the common bile duct with a stone;
acute perforation of a stomach or duodenal ulcer (one of the most severe pain syndromes);
thrombosis of the mesenteric vessels (blocking the lumen of the vessels supplying the intestines);
gastrointestinal bleeding of various origins (exacerbation of chronic gastric or duodenal ulcer, rupture of a malignant tumor vessel, Mallory-Weiss syndrome, esophageal varices);
peritonitis - inflammation of the peritoneum (local, diffuse, general);
strangulated hernias (inguinal, ventral);
infectious diseases (typhoid fever, viral hepatitis, etc.).

Diseases of the retroperitoneum

acute pancreatitis - inflammation of the pancreas, pancreatic necrosis (including bleeding, pseudocysts);
renal colic (pain syndrome is caused by a violation of the outflow of urine from the kidney, or its acute ischemia);
infectious diseases of the kidneys, ureters (pyelonephritis, abscesses and carbuncles of the kidneys, urethritis).

Pathology in the pelvic cavity, provoking the development of an acute abdomen

endometritis (inflammation of the uterine mucosa);
salpingitis (inflammation of the fallopian tubes);
oophoritis (inflammation of the ovaries);
proctitis and paraproctitis (inflammation of the rectum and fatty tissue around it);
varicose veins of the rectum.

Extra-abdominal pathology

radicular syndrome (compression of a large nerve root) due to a hernia or tumor of the intervertebral disc;
cardiac pathologies (myocardial infarction, dissecting aortic aneurysm, cardiac asthma);
acute diseases of the lungs and mediastinal organs (pleurisy, pneumonia, pulmonary embolism);
psychiatric diseases (pseudo-OSH).

Acute injuries

closed and open abdominal injuries (with the development of bleeding, perforation of hollow organs);
spinal cord injuries in the lumbar and sacral regions.

Etiology

The causes of acute abdomen are very diverse. Acute inflammatory processes developing in the abdominal cavity most often lead to the appearance of the syndrome. Conventionally, they are divided into several groups:

Inflammation of organs located in the abdominal cavity - the appendix, various parts of the small and large intestines, bile ducts and gallbladder, stomach, pancreas;
Perforated ulcer of the stomach or intestines with the formation of a through hole in the wall of the organ;
Termination of blood supply - embolism or thrombosis of peritoneal vessels, mesenteric ischemia, intestinal infarction or obstruction;
Intra-abdominal bleeding caused by rupture of the ovary, digestive glands, spleen, perforated ulcer, hemorrhagic gastritis;
Oncopathology - benign or malignant neoplasms in the stomach, intestines, liver;
Abdominal injuries, damage to the walls of internal organs by a foreign body;
Infectious processes - salmonellosis, dysentery, food poisoning.

structure of the gastrointestinal tract
Diseases of the pelvic organs can also be accompanied by signs of an acute abdomen, but this happens somewhat less frequently. These include:

Pathology of the female genital organs – oophoritis, salpingitis, salpingoophoritis, complicated ectopic pregnancy,
Kidney damage - purulent inflammation, infarction, colic, purulent melting of perinephric tissue, stones in the ureters,
Urological pathology – prostatitis, testicular torsion, dysuria, ischuria.

Pathologies that “simulate” acute abdomen:

Cardiac - rupture of aortic aneurysm, acute manifestation of coronary heart disease, pulmonary embolism, inflammation of the membranes of the heart - pericardium, myocardium,
Neurological – intervertebral hernia, radiculitis, myelitis, osteomyelitis, spondyloarthrosis, intercostal neuralgia,
Pulmonary - inflammation of the pleura, lungs,
Infectious – influenza, mumps, infectious mononucleosis, brucellosis, scarlet fever,
Traumatic – fractures of ribs and vertebrae, pelvic bones,
Systemic and endocrine - rheumatism, diabetes mellitus,
Oncological.

Pathogenesis and pathomorphology of acute abdomen

The development of the clinical picture of an acute abdomen is directly related to the etiological factor, that is, the disease that provokes it.

In the case of inflammatory diseases of the abdominal organs (appendicitis, cholecystitis, gastric ulcer), the main link in the pathogenesis will be direct local damage to the tissue or the entire organ: cell destruction, edema, increased arterial blood flow and impaired venous outflow, the action of inflammatory mediators (histamine, leukotrienes, thromboxanes, serotonin, interleukins, etc.) to pain receptors, which transmit information about this to the brain and spinal cord.

Non-inflammatory pathologies of the abdominal cavity (obstruction of the intestinal lumen, urinary tract, bile ducts) cause severe pain in the patient due to compression of the wall of the hollow organ and adjacent tissues. This process always leads to an increase in edema and ischemia of the organ area and, without treatment, transforms into inflammation.

Acute ischemic conditions (thrombosis of the vessels of the mesentery, stomach, spleen, etc., strangulated hernia) are a sudden complete stop of blood circulation in the affected organ. The pain syndrome is extremely pronounced due to the lack of tissue oxygenation and the accumulation of under-oxidized metabolites in them, which are harmful to living cells. These diseases are the most time-consuming for emergency surgical care, and often result in the death of parts or an entire organ and even death.

Some diseases are often hidden under the guise of abdominal disasters. Acute circulatory disorders in the chest organs (myocardial infarction, pulmonary embolism) in approximately 20% of cases are manifested by abdominal pain. Infections with fluid accumulation in the lungs (pneumonia) and irritation of the pleura (the serous lining of the lungs) also often cause abdominal pain. Such unusual manifestations of diseases of organs limited to the abdominal cavity are due to the fact that the human nervous system is united and is divided only conditionally. Extremely strong local stimulation of one nerve plexus transmits impulses to nearby ganglia, and in some cases to distant ones - this is called radiating or referred pain.

From the spinal cord to the abdominal organs, muscles and skin of the abdominal wall, large nerves and their branches pass, providing autonomic, sensory and motor innervation. Compression and damage to the spinal cord in the lumbar segments may initially manifest as abdominal pain. For example, a long-term asymptomatic benign tumor of the vertebra (osteoid osteoma) can suddenly and in a short time lead to compression of the nerve root of the spinal cord and manifest itself as renal colic, volvulus of the colon or perforated gastric ulcer.

The development of coolant fluid in acute trauma is a more favorable option for diagnosis, since a person, most often, can himself indicate the location, mechanism and type of traumatic injury. With a closed abdominal injury (without damage to the parietal peritoneum), hematomas, intestinal ruptures, bleeding from the spleen, duodenum, and others most often develop. In case of rupture of the parietal peritoneum (penetrating wounds of the abdominal cavity), the damage can be of the most varied nature: damage by foreign bodies to the intestinal wall with the development of fecal peritonitis, bleeding from the vessels of the mesentery, stomach, liver, inferior vena cava, abdominal aorta, and so on.

4.Treatment

Almost all cases of acute abdomen create absolute indications for emergency surgery. Currently, the standard of care, based on extensive statistical material, requires making and implementing a decision within a time period not exceeding six hours from the moment of the onset of diagnostically significant symptoms.

Therefore, it is worth recalling once again that in any situation and in any area, with any refusals and any dissimulation (deliberate concealment of sensations) on the part of the patient - who, before the onset of symptoms characteristic of an acute abdomen, could be as strong and healthy as he likes - as well as with any doubts among relatives, the time factor is critical, and the faster help is provided, the higher the chances of avoiding death. The question should be posed precisely in this formulation.

Symptoms. Clinical picture of acute abdomen

The symptoms of acute abdomen depend on the location of the pathological process, severity, duration, age and gender of the person, current state of health, and the presence of complications.

There are 4 main syndromes in acute abdomen.

Pain syndrome is the most important criterion

By localization

epigastrium;
mesogastrium or peri-umbilical region;
hypogastrium or suprapubic region;
right hypochondrium;
left hypochondrium;
right iliac region;
left iliac region;
right side area;
left side area.

Pain can occur in several areas at once or even throughout the entire abdomen (for example, with generalized peritonitis).

The nature

acute;
dull;
pulling;
pressing;
bursting;
constant;
coming;
associated with other factors (physical activity, mechanical pressure on the painful area, food intake, body position, etc.);
not related to other factors.

Dyspeptic syndrome

nausea;
belching;
vomiting (of eaten food, bile, mixed with blood, intestinal contents);
diarrhea (formed or unformed stool, possible impurities, changes in color, smell, presence of blood);
obstipation (constipation) - absence of stool for more than 72 hours (with preserved peristalsis, without peristalsis);
flatulence (accumulation of gases in the intestines).

Intoxication syndrome

general weakness;
increased body temperature;
adynamia;
decreased ability to work;
sweating

The development of these symptoms is associated with cytopathic factors (bacteria, viruses and their toxins, inflammatory mediators). The hypothalamus (a part of the brain) always reacts primarily, instantly increasing the temperature of a person’s body, then a cascade of immune reactions is launched in counterbalance to the infection. As a rule, the more severe the intoxication, the greater the number of infectious agents that have entered the body.

Peritoneal syndrome

Associated with irritation of the peritoneum - the serous membrane covering the walls and organs of the abdominal cavity. There are special manipulations that make it possible to identify this syndrome for sure.

Shchetkin-Blumberg symptom - deep palpation of the abdominal area with a sharp withdrawal of the palpating hand causes severe pain in the patient (this technique is the most used and important in the diagnosis of peritonitis throughout the world).

Mendel's symptom - when percussing (tapping) with fingers on the anterior abdominal wall, severe pain occurs (a symptom of peritoneal irritation, most characteristic of peritonitis with a perforated ulcer).

Frenicus symptom - when pressing with a finger in the area between the legs of the sternocleidomastoid muscle, pain appears (this is due to the branches of the phrenic nerve, which are irritated in the abdominal cavity during inflammatory processes).

Symptoms

The main manifestations of acute abdomen syndrome are pain, tension in the abdominal muscle frame and a disorder of the peristaltic activity of the digestive tract. These signs always accompany the syndrome, regardless of its underlying cause. They are combined in different variations with other secondary symptoms.

Pain syndrome occurs first. The pain has different localization and intensity. In trauma and peritonitis it is most pronounced. Diseases with severe intoxication are characterized by the wandering nature of the pain and its gradual increase. Most patients describe a stabbing, cramping, burning, debilitating pain in the abdomen. Migration of pain and its spread to neighboring organs is possible. Acute pain may alternate with periods of imaginary well-being or be accompanied by symptoms of dyspepsia - vomiting, nausea, hiccups.
The “vanka-stand up” symptom is a sign of intra-abdominal bleeding, characterized by a decrease in pain in the abdomen in a sitting position. When quickly moving from a lying to a sitting position, an attack of dizziness with loss of consciousness may develop. This is due to the movement of effusion in the abdominal cavity and irritation of pain receptors. “Phrenicus symptom” is a sign of referred pain. With its help, you can suspect acute cholecystitis or pancreatitis.
Tension of the abdominal muscles increases with the appearance of exudate, blood, and gastric contents in the abdominal cavity. These substances have an irritating effect on the parietal peritoneum, which is abundantly innervated by somatic sensory nerves.
Alternating diarrhea and constipation, bloating, severe flatulence are signs of intestinal dysfunction.
Intoxication with high fever, tachycardia, vomiting is almost always present in pathology.
With acute abdomen syndrome, sooner or later signs of anemia appear: pale skin, cold and sticky sweat, chills.
In advanced cases, shock develops, manifested by apathy, detachment, lethargy, passivity, pointed facial features with an earthy skin tone.

Clinical manifestations of acute abdominal syndrome in each specific case may differ and be supplemented by signs of the underlying disease:

Appendicitis
begins suddenly: against the background of complete well-being, pain appears, which gradually increases. It is localized first in the epigastric region - above the navel, and after some time it descends, shifting to the right, or spreads to the entire abdomen. The pain intensifies when coughing, sneezing and walking, but does not radiate to neighboring areas. It is very difficult for patients to show the painful area on themselves. By palpation, the doctor feels a spasmodic muscle on the right, and the patient feels a new attack of pain in the right side. The pain syndrome is accompanied by dyspepsia - single vomiting. Constipation occurs due to intestinal paresis.
Acute intestinal obstruction is characterized by sudden and cramping pain, the intensity and severity of which depends on the type and cause of obstruction, as well as vomiting, retention of stool and gases, tachycardia, increased pressure and body temperature, coating on the tongue, tension and asymmetry of the abdomen, “splashing noise or falling drop."
A perforated stomach ulcer manifests itself as unbearable, stabbing pain that prevents the patient from breathing normally. He occupies a forced position, which he maintains for a long time. Pain often radiates to the upper limb, neck, and shoulder girdle. Patients turn pale, become covered in cold sweat, and lie with their legs drawn up. Their heart rate increases, blood pressure decreases, and vomiting occurs.
Hepatic colic is manifested by increasing pain in the right hypochondrium, gradually spreading to the lower back, upper torso, and neck.
Pancreatitis is accompanied by girdling, shooting, boring pain, indomitable vomiting of bile that does not bring relief, flatulence, dry mouth, hiccups, nausea and belching.
Pain during renal colic occurs suddenly in the lumbar region and radiates to the lower abdomen, groin area, and genitals. It is accompanied by dyspeptic symptoms, flatulence, hypertension, tachycardia, and chills.
With myocardial infarction , severe pain behind the sternum presses, burns, squeezes, and can radiate to the arm, shoulder, back, jaw, neck, upper abdomen, thereby reminiscent of an acute abdomen. It is accompanied by fear of death, shortness of breath, pallor, and faintness.
Acute pneumonia and pleurisy are accompanied by painful sensations in the supra-umbilical region, severe chills, fever, respiratory distress, shortness of breath, migraine paroxysms, lethargy, vomiting, agitation and clouding of mind, retraction of the skin when inhaling from the inflamed area, severe cough, tachycardia.
Prostatitis is manifested by throbbing, sharp pain, concentrated in the groin and spreading to the lumbar spine, perineum, and lower limb. In this case, the urge to urinate becomes frequent and defecation becomes painful. Dysuria, sexual weakness, and depression occur.
Symptoms of intestinal infectious diseases are: cramping pain in the abdomen, decreasing after defecation, diarrhea, tenesmus, mucus, blood, pus in the feces.

Diagnosis of acute abdomen

Various methods are used to diagnose acute abdomen.

Interview and examination of the patient

The first stage begins with collecting a detailed history and complaints of the patient:

when and under what conditions the first symptoms appeared;
whether the intensity of abdominal pain increases and whether it spreads to other areas of the abdomen;
which syndrome is most pronounced (pain, dyspeptic, intoxication, etc.);
whether there have been acute diseases of the abdominal organs in the past and whether surgical interventions were performed;
the patient has pathologies of other systems (diseases of the cardiovascular system, lungs, liver, nervous system, trauma, endocrine diseases).

The inspection should always be comprehensive and detailed.

general condition of the patient - clarity of consciousness, body position (active, passive, forced), skin color, presence of gross external signs of severe damage to internal organs;
eye examination - the presence of yellowness of the sclera, hemorrhages, changes in position (may be due to a stroke), foreign bodies;
examination of the oral cavity - the color of the mucous membranes, the presence of plaque on the tongue and tonsils, blood and food debris;
measurement of the most important physical indicators - blood pressure, pulse, heart rate, respiratory rate;
palpation (palpation) of the main groups of lymph nodes (evaluate their size, density, pain, displacement when pressed; inflammatory changes in the lymph nodes usually indicate the pathology of the organs from which lymph flows into these nodes);
auscultation (listening with a phonendoscope) of the lungs, heart, large vessels, intestines;
examination and palpation of the abdomen - pay attention to the shape, symmetry, participation in breathing, the presence of protrusions of the abdominal wall. The fact of pain during palpation, the intensity of pain, its localization, and irradiation to other areas are determined. Mandatory check of specific symptoms: Shchetkin - Blumberg, Voskresensky, Sitkovsky, Mendel, Mayo - Robson, Kehr, Pasternatsky, etc.;
For women, an examination by a gynecologist is required, for men - by a proctologist (excluding inflammatory and oncological diseases of the female internal genital organs, rectum, prostate);
If you suspect an injury or exacerbation of a chronic disease of the spine, consultation with a neurologist or neurosurgeon is required.

Laboratory research

Mandatory tests

Mandatory studies for all patients:

General blood test: determination of the presence of anemia (decrease in hemoglobin level), signs of inflammation in the body - leukocytosis, acceleration of ESR.
General urine analysis: quantity and specific gravity, presence of pathological salts, erythrocytes, leukocytes, epithelium.
Biochemical blood test: assessment of kidney and liver function, determination of inflammatory proteins (fibrinogen “B”, C - reactive protein).
Analysis of blood glucose levels (assessment of pancreatic function, exclusion of acute complications of diabetes mellitus).
The Wasserman reaction is a specific test for syphilis.
Determination of blood group and Rh factor (necessary for surgery).

Specific laboratory tests

The following tests are prescribed based on a survey, examination, and physical data if a specific pathology is suspected.

Amylase, phospholipase A-2, blood trypsin - used to diagnose acute pancreatitis.
LDH (lactate dehydrogenase), troponins, D - dimer, ST2 (marker of heart failure), CPK (creatine phosphokinase) - tests to exclude or confirm myocardial infarction.
Thyroid and thyroid-stimulating hormones (T3, T4, antibodies to TPO, antibodies to TG) - if a thyrotoxic crisis is suspected.
Urine analysis for hCG in women - to exclude pregnancy.
Serological tests for antigens and antibodies to viral hepatitis (HBsAg, anti-HBs Ig, HbcAg, anti-HCv Ig, etc.).
Others (tests for adrenal hormones, tumor markers, cyto-histological studies, serological studies for the presence of various infectious agents).

Instrumental and hardware research methods

X-ray

Plain radiography of the abdominal cavity and chest is a routine diagnostic method used to diagnose the most obvious and common pathologies (not always effective).

Sight radiography is a picture of a small area of the abdominal, thoracic cavity, pelvis, etc. — used to more accurately determine morphological changes in organs and tissues.

X-ray contrast study is a method using special substances (for example, barium sulfate). The contrast is drunk by the patient, administered rectally or through a tube, or administered intravenously. Using this test, you can determine the patency of the esophagus, stomach, duodenum, small and large intestine, bile ducts, evaluate the morphological properties of organs and suspect the presence of “plus tissue”: tumors, polyps, wall hypertrophy, etc.

Mesenteric angiography is a contrast study of the patency of mesenteric vessels (diagnosis of intestinal ischemia in thrombosis of mesenteric vessels).

Computed and magnetic resonance imaging

Computed tomography is the most modern x-ray research method, which allows you to evaluate the layer-by-layer structure of tissues by taking several dozen images. The tomograph also provides a digital image of organs, bones, and joints in a 3D version (the disadvantage of this study is the high absorbed dose of X-ray radiation by humans).

Magnetic resonance imaging is an absolutely safe and informative diagnostic method. Not used routinely due to high cost. Purpose of MRI - the study is indicated only when simpler methods are ineffective. It is used more to analyze the morphological structure of internal organs, soft tissues, and joints.

Ultrasound

Ultrasound examination is used to assess the condition of the cavity (esophagus, stomach, intestines) and parenchymal (liver, kidneys, pancreas, adrenal glands, spleen, lungs, heart) organs of the thoracic and abdominal cavity.

Research using optics

FGDS (fibrogastroduodenoscopy) is an invasive research method. Using a long probe with a camera at the end, the patency and objective condition of the esophagus, stomach, and duodenum are examined (the most informative study for the diagnosis of gastrointestinal bleeding, perforated gastric or duodenal ulcers, erosive gastritis, stenosis of the cardiac and pyloric sphincters, tumors of the esophagus and stomach).

Rectomanoscopy - using a metal-plastic tube, the condition of the rectum, the presence of tumors, erosions, perforations, and bleeding are assessed.

Colonoscopy is an endoscopic examination of the sigmoid and colon (diagnosis of cancer, mechanical and dynamic intestinal obstruction, Crohn's disease, ulcerative colitis and other pathologies).

Laparoscopy and diagnostic laparotomy

Laparoscopy - a puncture of the abdominal wall is made and a hollow metal tube is inserted into the abdominal cavity, then a camera is passed through the tube and the image is displayed on the monitor (used for emergency diagnosis of appendicitis, pancreatitis, cholecystitis, etc. or when other methods are not able to verify the diagnosis of 100%).

Diagnostic laparatomy is divided into general, upper, middle, lower and their combinations. A scalpel is used to dissect the anterior abdominal wall from the xiphoid process to the symphysis pubis (to the extent necessary for diagnosis). After this, the surgeon conducts an inspection of the abdominal cavity and makes a final diagnosis (often this method ends with surgical intervention, i.e. treatment of the underlying disease).

Criteria for diagnosing “acute abdomen”

Presence of abdominal pain (of any nature).
Intoxication syndrome.
Dyspeptic syndrome.
Peritoneal syndrome (not always detected, especially in the early stages of the disease).

Diagnostic measures

Medical specialists of any profile and qualification may encounter acute abdominal syndrome in practice. Their main task is to determine the cause of the disease. This must be done quickly and correctly. Because the prognosis of the syndrome worsens over time. A leisurely approach is unacceptable here.

To help the patient and save his life, it is necessary to be able to diagnose this disorder. For this purpose there is a certain examination scheme.

Taking an anamnesis involves finding out the details of the onset of pain: when it appeared, under what circumstances, suddenly or gradually, where it is localized, whether it is accompanied by vomiting, diarrhea or other dyspeptic symptoms. An important point is the frequency and nature of stool, the color of stool. A gynecological history is collected from women: past gynecological diseases, the regularity of the menstrual cycle, and the date of the last menstruation are clarified.
A physical examination consists of examining the patient, assessing the general condition by measuring pulse, temperature, pressure, determining the shape of the abdomen, identifying scars and hernias, and the participation of the abdomen in the act of breathing. It is necessary to observe the general condition of the patient: is he excited or lethargic, passive. When examining the tongue, you should pay attention to the presence of a dry grayish coating. The patient's face is pale with drops of sweat on the forehead, with pointed features and sunken eyes.
By palpation, symptoms of peritoneal irritation are determined, neoplasms are found in the abdomen, and the location of the pain is identified. Palpation is carried out extremely carefully, trying not to press too hard, so as not to provoke a powerful painful attack. The Shchetkin-Blumberg symptom is as follows: when pressing on the abdomen and sharply removing the arm, the patient’s pain increases. This diagnostic test is always positive if there is acute inflammation or a perforated ulcer in the abdomen.
A rectal examination is carried out to detect pain when palpating the walls of the rectum. This is a sign of fluid accumulation in the pelvis. During a rectal examination, tumors and distended intestinal loops are detected. This method is especially informative when examining children.
Vaginal examination is indicated for all women with acute abdominal pain. It allows you to identify the accumulation of hemorrhagic exudate or effusion in the pelvis, pain and overhang of the vaginal vaults, and the size of the appendages. This diagnostic technique is necessary for differentiating surgical pathology of the abdominal organs and diseases of the female reproductive system.
Laboratory diagnosis reveals general signs of inflammation and anemia.
Plain radiography of the abdominal organs is considered one of the most informative diagnostic methods. On the pictures you can see free gas in the abdominal cavity, exudate, and a space-occupying formation.
X-ray contrast examination is carried out in special cases when it is impossible to determine the cause of the syndrome by other methods. A simple contrast contrast of the stomach, a selective X-ray contrast study of the celiac trunk of the aorta and its branches, the superior and inferior mesenteric arteries are performed.
Ultrasound of the abdominal organs allows you to examine their structure, identify exudate, gas, neoplasm, intussusception and other causes of acute abdomen. Ultrasound is relevant if urological or gynecological diseases are suspected. This method has become widespread due to a number of advantages: it is non-invasive, highly informative and does not require patient preparation.
In some cases, FEGDS, sigmoidoscopy and colonoscopy are additionally performed.
Laparoscopy, laparocentesis and laparotomy are performed in particularly severe cases when other methods do not allow a diagnosis of pathology to be made.

Using the methods listed above, it is possible to identify and exclude non-surgical pathology that mimics an acute abdomen. Patients with severe chronic diseases are not always allowed to undergo emergency surgery. In the presence of myocardial infarction, pneumonia, pleurisy, renal or hepatic colic, any operation can worsen the patient’s general condition and even lead to death.

Differential diagnosis

Differential diagnosis is a method of clarifying and making a final clinical diagnosis by comparing diseases with similar symptoms and using additional laboratory and instrumental research methods.

This stage is extremely important for deciding on surgical or conservative management of the patient.

A person’s life directly depends on the correct differentiation of an acute abdomen!!!

Acute appendicitis

Acute appendicitis is inflammation of the appendix of the cecum. About 20 - 30% of cases of acute abdomen. Clinically, in the early stages it manifests itself as pain in the peri-umbilical or epigastric regions, and then the pain shifts to the right iliac region, its intensity increases. Body temperature with uncomplicated appendicitis is usually normal or slightly elevated (36.6 - 37.5 ℃). Vomiting and diarrhea are observed. Positive symptoms of Voskresensky, Sitkovsky, Aaron.

With complicated appendicitis (perforation, bleeding, peritonitis), the Shchetkin-Blumberg symptom appears, pallor, lethargy, and a sharp increase in pain. Diagnosed on the basis of clinical data, inflammatory signs in general and biochemical blood tests, ultrasound and radiography of the appendix (signs of edema, accumulation of free fluid in the abdominal cavity, destructive changes in the walls of the appendix). Treatment is exclusively surgical.

Acute cholecystitis

Acute cholecystitis is inflammation of the gallbladder. Clinically manifested by pain in the right hypochondrium, epigastrium, which can radiate to the left scapular region, nausea and vomiting, yellowness of the skin and mucous membranes (not always). Acholic (light) feces and dark urine also often appear. Laboratory data of biochemical analysis - an increase in the level of total bilirubin due to the direct fraction, an increase in the level of alkaline phosphatase (a symptom of cholestasis), in a general blood test - neutrophilic leukocytosis, acceleration of ESR.

It is confirmed by x-ray and ultrasound examination (including contrast), the images reveal an enlarged gallbladder, an edematous wall (often with a double contour), and with calculous cholecystitis, stones are visible in the lumen of the bladder or common bile duct. You can also detect a spasm of the papilla of Vater (sphincter of Oddi, a muscle that regulates the flow of bile and pancreatic enzymes into the lumen of the duodenum). In doubtful cases, RCP (retrograde cholangiopancreatography is an endoscopic research method) is used. It is treated promptly.

Perforated ulcer of the stomach and duodenum

A perforated ulcer of the stomach or duodenum is an acute defect in the wall of these organs with penetration of the contents into the abdominal cavity. It is characterized by the appearance of sudden, extremely intense “dagger” pain in the epigastrium, nausea and vomiting may occur. Body temperature rises every hour from the onset of the disease. Since the contents of the gastrointestinal tract end up in the abdominal cavity, first local and then general peritonitis develops quite quickly. The Shchetkin-Blumberg symptom will be positive within 8 to 12 hours. A general blood test reveals signs of an inflammatory reaction, and sometimes anemia is observed.

Of the instrumental diagnostic methods, the most informative will be: plain radiography of the abdominal cavity (including with contrast), ultrasound, computed tomography. A typical sign of perforation in the image will be the presence of free gas and liquid in the abdominal cavity; sometimes a defect in the wall of the stomach or duodenum is determined directly. In doubtful cases, FGDS is used. Treatment is always surgical.

Acute pancreatitis

Acute pancreatitis is inflammation of the pancreas. It most often begins acutely; from the anamnestic data, the consumption of alcohol on the eve of the disease and fatty foods in large quantities is decisive. Clinically, it is manifested by girdling (circular) pain in the upper abdomen (epigastric, left hypochondrium, periumbilical region), nausea, vomiting with bile, which does not bring relief, and bloating. The temperature may be normal or decreased, and there are signs of dehydration.

For diagnosis, a biochemical blood test is used to measure the level of pancreatic amylase, lipase, trypsin, and phospholipase A2. The FA2 level indicates the volume and severity of gland damage. Instrumental methods include angiography of pancreatic vessels (with pancreatitis, tissue perfusion will be impaired), ultrasound and computed tomography reveals signs of edema or even destruction of parts of the organ. Treatment is conservative and surgical.

Acute gastrointestinal bleeding

Acute gastrointestinal bleeding is damage to the wall of the vessel(s) with bleeding into the lumen of hollow organs and the abdominal cavity. Symptoms depend on the severity of blood loss. Abdominal pain is less pronounced and may be completely absent. In some cases, for example, when bleeding from a gastric ulcer, a symptom of a sudden cessation of pain is observed, because the alkaline pH of the blood neutralizes the acidic gastric juice at the site of damage to the wall, and the irritation stops.

Bleeding is manifested by pale skin, lethargy, dizziness, cold extremities, dry mouth, decreased blood pressure, and increased heart rate. When blood leaks into the intestinal lumen, the stool becomes dark in color, and with severe bleeding, blood free from stool is completely visible. When bleeding from the esophagus, vomiting of fresh, unchanged dark scarlet blood is observed, from the stomach - vomiting of “coffee grounds” (since the acidic environment leads to blood clotting and the formation of hydrochloric acid hematin).

In a general blood test, a decrease in the level of hemoglobin and the number of red blood cells is observed (posthemorrhagic anemia). X-ray and ultrasound diagnostics reveal accumulation of blood in the pockets of the abdominal cavity, local hematomas, fluid levels along the lateral flanks, in the pouch of Douglas (between the uterus and rectum in women, between the bladder and rectum in men). When revising the abdominal cavity during laparoscopy or diagnostic laparotomy, blood from the abdominal cavity is always first drained to determine the source of bleeding, and then it is finally stopped.

These are the most common pathologies in abdominal surgery; the list of diseases for the differential diagnosis of acute abdomen is extremely extensive and can only fit in the memory of an experienced surgeon. If you experience symptoms of an acute abdomen, seek medical help immediately!

Material on the diagnosis of “acute abdomen” is presented. The main reasons for its occurrence are considered. The cardinal symptoms of acute surgical diseases of the abdominal organs are described in detail. Particular attention is paid to the interpretation of pain syndrome based on the anatomical and physiological characteristics of the innervation of internal organs and the anterior abdominal wall. Recommendations for preventing diagnostic errors are given.

Acute abdomen

The material for the diagnosis of “acute abdomen” and the main reasons for its occurrence are presented. It is detailed description of the cardinal symptoms of acute surgical diseases of abdominal organs. Particular attention is paid to the interpretation of pain at the basis of anatomical features physiological innervation of internal organs and abdominal wall. The recommendations for the prevention of diagnostic errors are given.

An analysis of lethal outcomes in acute surgical pathology of the abdominal organs shows that in most cases they are based on late admission of patients to the surgical hospital. And no matter how brilliantly the operation is performed, if it is performed at an advanced stage of the pathological process, only at the cost of “heroic” efforts does it become possible to achieve the desired result - to save the life of a seriously ill patient.

Diagnosis of acute surgical diseases at the prehospital stage has a characteristic feature - the specialist who first examines the patient is, in most cases, a non-surgical doctor. Since the time factor in emergency surgery plays a decisive role in the development of the pathological process, the qualifications of a given doctor ultimately determine the future fate of the patient.

The patient’s ability to detect symptoms of an acute surgical disease and promptly seek medical help largely depends on the level of his culture and education. Unfortunately, we have to admit the opposite phenomenon.

Often the cause of a serious complication of acute appendicitis, which is most often encountered in surgical practice, is the underestimation of the early manifestations of the disease by the patient himself. However, there are many examples where patients promptly sought medical help, but the symptoms of an “acute abdomen” were not recognized and surgical interventions were performed when the clinical picture of peritonitis was beyond doubt. There is also a number of non-surgical diseases, the manifestation of which is often accompanied by abdominal symptoms. Performing unnecessary laparotomy in such patients can aggravate the course of the underlying pathological process and lead to death. So, what is an “acute abdomen” and how to avoid mistakes in recognizing it?

“Acute abdomen” (AB) is one of the most generalized clinical syndromes that develops with traumatic injuries and acute surgical diseases of the abdominal organs and retroperitoneal space. The appearance of this symptom complex predetermines the immediate referral of the patient to a surgical hospital. Thus, the term OB should be considered not as medical jargon, but as a working hypothesis at the prehospital stage, which always requires the doctor examining the patient to take active action to clarify the nature of the disease.

The causes of coolant are numerous and can be grouped as follows:

injuries of the abdominal organs and retroperitoneal space;
acute inflammatory diseases of the abdominal organs;
perforation of hollow organs;
intra-abdominal bleeding;
acute intestinal obstruction;
acute disturbance of mesenteric circulation.

If a patient develops a symptom complex of coolant, the surgeon is asked questions that require an immediate answer:

1. Are the existing symptoms really caused by acute surgical pathology?

2. Does the patient need surgery and what is the degree of urgency?

To answer the first question, it should be remembered that, despite the variety of causes of coolant, its clinical picture is strictly delineated and determined by a number of cardinal symptoms:

1. Pain.

2. Vomiting.

3. Gas retention and lack of stool.

4. Protective muscle tension of the anterior abdominal wall.

The severity of cardinal symptoms depends on the duration of the disease, the age of the patient and the functional state of the body. The greatest difficulties arise when making a correct diagnosis in children and the elderly, pregnant women, people in a state of shock, alcohol intoxication and drug influence, patients with severe mental disorders. It is very important to clarify the chronological order and details of the occurrence of these symptoms. Since abdominal pain, as a rule, accompanies any acute disease of the abdominal organs and is the main reason for patients seeking medical help, the doctor’s attention should primarily be focused on finding out their cause, time of occurrence, nature and location.

The feeling of pain occurs involuntarily under the influence of a painful stimulus, which excites pain receptors and is processed in the diencephalon. Thus, pain is a subjective sensation of a person, which must be taken into account for its correct interpretation.

In accordance with the anatomical and physiological characteristics of the nervous system of the abdominal cavity and anterior abdominal wall, three main types of pain are distinguished:

1. Visceral pain.

2. Somatic pain.

3. Referred (referred) pain.

Receptors that perceive visceral pain are located on the visceral peritoneum, which covers the internal organs, and respond to an increase in intracavitary pressure, and not to direct irritants (burn, incision, necrosis). Pain impulses traveling along visceral afferents reach only the subcortical centers, so such pain does not have a clear localization. Depending on the affected organ, visceral pain can be approximately localized in the epigastrium, periumbilical region, lower abdomen, etc. It does not intensify when the patient’s body position changes; its intensity can be wavy or paroxysmal in nature.

An example of such pain is various colics (bilious, intestinal, appendicular, renal, etc.), which does not exclude acute surgical pathology in the initial stage of its development (acute cholecystitis, acute appendicitis, acute intestinal obstruction, acute pancreatitis, mesenteric thrombosis). The transition of cramping pain to constant may indicate a violation of blood circulation in the wall of the organ due to high intracavitary pressure. The well-known Volkovich-Kocher symptom in acute appendicitis shows how visceral pain, localized in the initial stage of the disease in the epigastric region, subsequently moves to the right iliac region. This feature is associated with the transition of the inflammatory process from the visceral peritoneum of the appendix to the parietal peritoneum of the iliac fossa. The pain that arises is called somatic . Its receptors are located in the parietal peritoneum. Since impulses traveling along somatic afferent pathways reach the cerebral cortex, these pains are always localized, are constant and increase in intensity. They intensify with changes in body position, coughing, deep breathing and walking. Due to intense pain that occurs during perforation of hollow organs, patients prefer to lie on their side with their knees brought to the chest, relaxing the muscles of the anterior abdominal wall and thereby alleviating their condition. At the moment of perforation of a stomach or duodenal ulcer, pain immediately reaches its maximum values. After some time, the intensity of somatic pain may decrease, which is associated with the peculiarities of the impact of pathological contents on the parietal peritoneum. This period of “imaginary well-being” can be misinterpreted, which leads to diagnostic errors at the prehospital stage. In this case, the doctor conducting the examination should pay attention to the appearance of symptoms in the patient indicating the development of endogenous intoxication (thirst, dry mouth, tachycardia) and intestinal paresis (nausea, vomiting, bloating, lack of stool and non-passage of flatus).

Thus, clinical signs of somatic pain, confirmed in doubtful cases by special research methods, serve as an indication for emergency surgical intervention.

Features of segmental anatomical relationships between the autonomic nervous system and spinothalamic nerves often lead to irradiation (reflection) of visceral pain. Since the same neurons in the dorsal horns of the spinal cord receive impulses coming from internal organs and from the surface of the body, the central nervous system does not always accurately differentiate the starting point of irritation. In this case, pain is projected not onto the area of the focus of the pathological process in the abdominal cavity, but onto the surface of the body, which is innervated by this spinal center. The localization of such radiating pain corresponds to the Zakharyin-Ged zones. Often the pain spreads beyond the abdomen. A typical example is the pain that appears in the shoulder girdle and the side of the neck with a perforated ulcer of the stomach or duodenum, pleurisy, hemoperitoneum, a destructive process in the gallbladder (Elecker's symptom). Due to irritation of the diaphragm by pathological contents of the abdominal cavity (intestinal contents, bile, blood), pain impulses are transmitted along the phrenic nerves to the fourth cervical segment and the areas that are innervated by the CIV. This feature forces the patient to take a position that facilitates the movement of peritoneal contents to other parts of the abdominal cavity and thereby reduces pain impulses. If there is a forcible attempt to change it, the patient again takes the original position (the “vanka-stand up” symptom). Another example of radiating pain is thoracoabdominal syndrome, which occurs due to pathology of the chest organs. Since the six lower intercostal nerves take part in the innervation of the anterior abdominal wall, lower lobe pneumonia, pleurisy, rib injuries, and pericarditis can occur with acute pain in the abdomen and tension in the abdominal muscles (thoraco-abdominal syndrome). Knowing the characteristics of radiating pain can help in making the correct diagnosis and avoiding unnecessary laparotomies.

An important feature of abdominal pain in acute surgical pathology is that it usually precedes the appearance of other symptoms (vomiting, fever, icterus of the skin and mucous membranes, flatulence and diarrhea), which over time can have independent significance.

It remains to add that intense pain involuntarily affects the autonomic innervation, which can be accompanied by tachycardia, a drop in blood pressure, increased sweating, and involuntary urination.

Vomiting is the next most common symptom of coolant. Its presence and nature often have no independent significance, except in cases of acute intestinal obstruction and gastroduodenal bleeding. Thus, with high small-intestinal obstruction, vomiting, being an early sign of the disease, is permanent and leads to rapid exhaustion of the patient. However, with low small-intestinal and large-intestinal obstruction, vomiting occurs in the later stages of the disease. The vomit is foul-smelling (“fecal vomit”) and is large in volume. Vomiting can be observed not only when the gastrointestinal tract is obstructed, but also occurs reflexively with renal colic, torsion of an ovarian cyst, acute pancreatitis, and acute cholecystitis. In acute appendicitis, vomiting is often one-time, less often repeated or repeated, but it is not indomitable. Most patients with ongoing intense bleeding from the stomach and duodenum experience vomiting of blood with clots. Characteristic vomiting is “fountain” or “mouth full”, which occurs when bleeding from varicose veins of the esophagus. Vomit the color of coffee grounds is often observed. It acquires this appearance due to the combination of hemoglobin with free hydrochloric acid to form hydrochloric acid hematin, which occurs with mild or stopped gastroduodenal bleeding.

The absence of stool and non-passage of gases is an important symptom of coolant, indicating mechanical or functional intestinal obstruction. This symptom is an early sign of colonic obstruction. It must also be remembered that with small intestinal obstruction, especially at the beginning of the disease (the first 6 hours), there may be stool and spontaneous passage of gases due to emptying of the distal intestines. The development of peritonitis leads to reflex inhibition of intestinal motor activity. However, with pelvic peritonitis, diarrhea and tenesmus may occur due to irritation of the rectal ampulla by peritoneal exudate. This feature is often observed in destructive pelvic appendicitis.

N. _ B. _ Coprostasis and non-passage of gases often accompany acute appendicitis in elderly and senile people.

The symptom of protective muscle tension (defense musculaire) clinically manifests itself due to irritation of the parietal peritoneum and occurs in parallel with somatic pain, being the result of a visceromotor reflex. Irritants of peritoneal receptors can be gastrointestinal contents, bile, urine, blood and peritoneal exudate. Impulses coming from the receptor field are transmitted to the corresponding segment of the spinal cord and from the motor neurons of its anterior horns to the muscles innervated by this segment, which enter a state of motor contraction. The protective tension of the muscles of the anterior abdominal wall causes a kind of immobilization and provides rest to the abdominal organs, creating optimal conditions for delimiting the pathological process. Assessing the clinical significance of the symptom of protective muscle tension, the famous French surgeon G. Mondor wrote: “Of all pathologies, there is hardly a more accurate, more accurate, more useful and more life-saving indicator.” The importance of this indicator for diagnosis lies in the fact that its localization mainly corresponds to the location of the diseased organ; the intensity of the muscle reaction often gives an idea of the degree of the inflammatory process. Despite its apparent simplicity, its identification will largely depend on the experience and skill of the surgeon. The severity of this symptom is determined not only by the quality of the current stimulus, but also by the place of its impact on the peritoneum. The latter is explained by the fact that not all areas of the peritoneum are equivalent as receptor fields for this reflex. Thus, a distinct defense musculaire occurs when the parietal peritoneum lining the upper and middle floors of the abdominal cavity is irritated. Protective muscle tension (PMT) is less pronounced when the peritoneum in the pelvic area is irritated. The duration of MN, which can be observed over several days, is of practical importance. This unusual duration of contraction of skeletal muscles, which easily tire under normal conditions, indicates the inclusion of special mechanisms in the implementation of mental health. Over time (after about 12 hours), a gradual weakening of muscle tension is observed, which is accompanied by increasing endogenous intoxication, metabolic and water-electrolyte disturbances characteristic of the late stages of general purulent peritonitis.

Crucial to detecting minor signs of MN is compliance with a number of methodological techniques that the doctor examining the patient must master. Pay attention to the following features:

The study should take place in a warm room.
The patient should lie calm and relaxed (as far as possible with this pathology).
Before palpation begins, you should warm your hands, ask the patient to breathe deeply into the stomach and cough. In this case, a sharp increase in pain may be observed if the inflammatory process spreads to the parietal peritoneum.
Palpation of the abdomen should begin superficially at the maximum distance from the area where the patient feels the greatest pain, gradually and methodically moving the hands to this area.
When identifying a symptom of MN, it is necessary to determine its voluntary or involuntary (true) nature. Voluntary muscle contraction, as a rule, decreases with deep inhalation and subsequent exhalation, bending the legs at the knee and hip joints (false defense musculaire).
Deep palpation should be performed at the very end of the examination to diagnose tumor formations and deeply localized sources of pain.

An intense and rapidly developing symptom of MN is observed with perforated ulcers of the stomach and duodenum. Bile and urine poured into the abdominal cavity have less effect on the parietal receptors. Blood causes the least irritation. However, in the generation and sending of impulses to the abdominal muscles, receptors not only of the parietal peritoneum, which form the main receptive field of the brainstem, take part, but also of the internal organs themselves. This feature allows us to explain a number of atypical clinical cases associated with the difficulty of diagnosing acute surgical pathology. The physiological characteristics of the body should also be taken into account. Thus, the symptom of MN is less pronounced in elderly people, in the early postpartum period, in patients in a state of collapse, toxemia, shock, or alcohol intoxication.

Other symptoms identified during examination of patients with abdominal pain can also help in diagnosing an “acute abdomen”. At the same time, you should not get too carried away in reproducing them, remembering that symptoms should not be counted, but weighed. An experienced clinician uses only a few, well-tested in practice, signs.

Symptoms of acute appendicitis

1. With a typical location of the appendix:

Bartomier-Mikhelson . Increased pain on palpation in the right iliac region with the patient positioned on the left side.

Volkovich-Kocher . The pain initially occurs in the epigastric region and only after some time is concentrated in the right iliac region.

Razdolsky. Percussion or light tapping of the abdominal wall with fingertips reveals pain in the right iliac region.

Rovzinga . With your left hand, press on the abdominal wall in the left iliac region and make a short push with your right hand in the left hypochondrium. Colon gases move proximally when pushed, causing sharp pain in the right iliac region in acute appendicitis.

Sitkovsky . Increased pain in the right iliac region when the patient lies on his left side.

Soresi . Pain in the right iliac region that occurs when coughing.

2. With a pelvic location of the appendix:

Cope (obturator muscle symptom). With the patient lying on his back, the leg is bent at the hip and knee joints at an angle of 900. When the right hip is rotated inwards, an increase in pain in the right iliac region is noted.

Rotter . A rectal examination reveals sharp pain in the right wall of the rectal ampulla.

Supolta - Seye . Taking a deep breath causes pain behind the bladder in the patient.

3. With a retrocecal location of the appendix:

Yaure - Rozanova . Pain when pressing on the area of Petite's triangle.

4. During pregnancy:

Brando . Increased pain in the right half of the abdomen when pressing on the left rib of the pregnant uterus.

Mikhelson . Increased pain in the right half of the abdomen when the patient is positioned on the right side, when the pregnant uterus presses on the inflamed appendix.

Symptoms of perforated gastric and duodenal ulcers:

Bailey (perverted thoraco-abdominal rhythm). When inhaling, the abdominal wall is drawn in simultaneously with the chest rising.

Grekova . Slowing of the pulse in the first hours after the ulcer perforates.

Dieulafoy . Sharp stabbing pain in the abdomen.

Clarke . Disappearance of “liver dullness” upon percussion.

Mondor triad. Acute stabbing pain in the abdomen, protective tension in the muscles of the anterior abdominal wall, history of ulcers.

Ratner-Wicker . Long-term persistent muscle tension in the right upper quadrant of the anterior abdominal wall with the general satisfactory condition of the patient. Characteristic for covered perforation.

Elekera (phrenicus symptom). Abdominal pain radiating to the shoulder or shoulder blade. It can also occur with intra-abdominal bleeding.

Peritoneal symptoms:

Winter . The anterior abdominal wall is not involved in the act of breathing.

Mendel . Pain that occurs when you lightly tap your fingertips on the anterior abdominal wall.

Stokes law. Widespread inflammatory processes in the abdominal cavity cause paralytic ileus.

Trendlenburg . Plank-shaped abdomen combined with contraction of the muscles supporting the testicle.

Shchetkin - Bloomberg . Increased pain when sharply tearing off the fingers of the hand palpating the anterior abdominal wall.

Symptoms of intra-abdominal bleeding:

Kulenkampf . With a soft abdomen, sharp pain upon percussion of the anterior abdominal wall.

Rozanova (symptom of “Vanka-Vstanka”). The patient lies on his left side with his thighs tucked toward his stomach. When you try to turn him over onto his back or the other side, he immediately turns over and takes his previous position. Observed when the spleen ruptures.

History and physical examination results provide up to 60-70% of the information necessary to establish the correct diagnosis. In order not to complicate the course of the pathological process and not to veil its clinical manifestations until examined by a surgeon, you should not: prescribe analgesics and antibiotics, use laxatives and cleansing enemas, wash the stomach, prescribe thermal procedures. At the prehospital stage, there is always overdiagnosis of the “acute abdomen”, which indicates the wariness of doctors in the polyclinic network and emergency medical services regarding acute surgical diseases, a lack of time and opportunity for a detailed examination of the patient. Nevertheless, the percentage of fatal diagnostic errors, when acute surgical pathology is not recognized in time, continues to remain quite high. Therefore, there is a rule according to which all patients with acute abdominal pain must be sent to a surgical hospital for urgent measures to clarify the nature of the disease. Carrying out dynamic monitoring of such patients on an outpatient basis is a serious mistake.

Currently, the arsenal of the emergency diagnostic program includes modern methods of radiological examination of the abdomen (ultrasound, CT) and video laparoscopy. This provides invaluable assistance in objectifying diagnoses of acute cholecystitis, destructive pancreatitis, appendicitis, acute gynecological pathology, and traumatic injuries to the abdomen.

Paradoxically, the use of unfounded diagnostic tests in emergency surgery increases the likelihood of false-positive results and the percentage of wasted laparotomies. However, when objective examination data can be interpreted ambiguously and the cause of acute abdominal pain remains unclear, a delay in performing laparoscopy and persistent continuation of conservative treatment should be considered a gross tactical error.

I.S. Malkov

Kazan State Medical Academy

Malkov Igor Sergeevich - Doctor of Medical Sciences, Professor, Head of the Department of Surgery

Treatment of diseases accompanied by acute abdominal pain

Therapeutic tactics for acute abdomen directly depend on the final diagnosis. Without a doubt, most pathological conditions require urgent surgical intervention, but in certain cases the disease responds well to treatment with conservative methods.

Diseases requiring urgent surgical treatment

Acute appendicitis (uncomplicated, complicated by bleeding, perforation, peritonitis) - an appendectomy is performed (removal of the appendix).
Peritonitis (local, diffuse, general) - elimination of the primary source of infection, rinsing the abdominal cavity with antiseptic solutions, installing passive drainages.
Gastrointestinal bleeding - treatment depends on the source of the bleeding. Endoscopic coagulation (cauterization with high-frequency electric current), open surgery (laparatomy, mini-laparatomy) with ligation of the vessel or end-to-end stitching are possible.
Pancreatitis (severe), pancreatic necrosis - installation of drains in the pancreas area with the constant removal of toxic substances from the body, resection of part of the gland.
Calculous cholecystitis - most often, laparoscopic cholecystectomy (removal of the gallbladder with stones through a metal hollow tube).
Ectopic pregnancy - the fertilized egg is removed laparoscopically from the fallopian tube. If this pathology is complicated by a rupture of the pipe wall, it is completely excised.
Acute complete intestinal obstruction - treatment depends on the type of obstruction (disinvagination is carried out, restoration of blood flow to a section of the intestine, removal of fecal stones, excision of tumors, polyps, a piece of dead intestine).
Many other pathologies that, without surgical treatment, lead to death (thrombosis of mesenteric vessels, perforated gastric or duodenal ulcer, splenic rupture, occlusion of large arteries, dissecting aortic aneurysm, etc.)

Diseases that can be treated conservatively

Uncomplicated pancreatitis (mild severity)

infusion therapy (drip intravenous administration of colloid and crystalloid solutions);
antienzyme therapy - administration of medications that suppress the synthesis of pancreatic enzymes;
analgesics - pain relief;
antibiotic therapy - to prevent the addition of a bacterial infection.

Exacerbation of chronic gastric ulcer, duodenal ulcer

drug therapy aimed at reducing the acidity of gastric juice (proton blockers, H - receptors);
antibiotic therapy (against Helicobacter pylori);
purpose of diet (limiting spicy, fatty, fried, etc.).

Exacerbation of chronic cholecystitis

choleretic drugs;
antispasmodics;
antibiotic therapy;
fat-restricted diet.

Partial intestinal obstruction

cleaning the intestines from contents (enemas);
treatment of the underlying disease that caused the obstruction;
analgesic therapy;
detoxification and antispasmodic therapy;
restoration of water-salt balance.

Contraindications to surgery of any type

Shock (except hemorrhagic).
Acute cerebrovascular accident (stroke).
Acute circulatory disorder in the heart muscle (infarction).
Unstable hemodynamics (arrhythmias of various types, jumps in blood pressure, heart failure).
Decreased renal function (glomerular filtration rate less than 50 ml/min).
Malignant neoplasms.
Cirrhosis of the liver.
Decompensated conditions in diabetes mellitus, COPD (chronic obstructive pulmonary disease) and other chronic diseases.
Psychiatric diseases (aggressive states, inadequate perception of reality, inability to make decisions independently).

Prevention of acute abdomen

There is no specific prevention of acute abdomen!

Dynamic observation by a family doctor and treatment of chronic diseases of the gastrointestinal tract, cardiovascular system, lungs, liver, kidneys, and genitourinary system.
Timely referral of the patient to a surgeon if symptoms of an acute abdomen occur.
Qualified differential diagnosis in the surgical department.
Adequate choice of treatment tactics (operative or conservative management of the patient).
The use of antibacterial drugs and other medications to prevent postoperative complications.