Acute abdomen

Introduction to acute abdomen Acute abdomen (acuteabdomen) refers to abrupt pathological changes in the abdominal cavity, pelvic and retroperitoneal tissues and organs, resulting in abdomen symptoms and signs, accompanied by clinical manifestations of systemic reactions, the most common is Acute abdominal pain. Acute abdomen, severe abdominal pain, tenderness, rebound tenderness, abdominal muscle tension, and even shock. Acute abdomen often means extensive lesions and serious illness. No matter what kind of disease, family members should seek immediate treatment. The diagnosis is differentiated by the doctor based on the patient's medical history and other complications. Do not give painkillers or alcohol to patients before they are rescued and diagnosed by the doctor to avoid aggravating the condition and masking the symptoms. Common acute abdomen diseases include: acute appendicitis, acute perforation of ulcer disease, acute intestinal obstruction, acute biliary infection and cholelithiasis, acute pancreatitis, abdominal trauma, urinary calculi and rupture of ectopic pregnancy. In addition, certain systemic or other systemic diseases such as hematoporphyria, hypokalemia, septicemia, spinal trauma or spinal cord disease may also have clinical manifestations similar to acute abdomen. There are three types of abdominal pain: visceral pain, peritoneal irritation, and pain (radiation pain). Characteristics of the course: acute, fast, heavy, and varied. basic knowledge The proportion of illness: 0.03% Susceptible people: no special people Mode of infection: non-infectious Complications: multiple system organ failure shock

Cause of acute abdomen

Surgical acute abdomen

1, infection and inflammation: acute appendicitis, acute cholecystitis, acute cholangitis, acute pancreatitis, acute intestinal diverticulitis, acute necrotic enteritis, Crohn disease, acute diffuse peritonitis, abdominal abscess (infraorbital, intestinal space, pelvic abscess ).

2, cavity organ perforation: gastric, duodenal ulcer perforation, gastric cancer perforation, typhoid intestinal perforation, gangrenous cholecystitis perforation, abdominal traumatic rupture of the intestine.

3, abdominal bleeding: trauma caused by liver, spleen rupture or mesenteric vascular rupture, spontaneous liver cancer rupture; abdominal or lumbar traumatic retroperitoneal hematoma.

4, obstruction: gastrointestinal tract, biliary tract, urinary tract obstruction.

5, strangulation: gastrointestinal obstruction or ovarian tumor torsion caused by blood circulation disorders, and even ischemic necrosis, often leading to peritonitis, shock.

6, vascular lesions: vascular embolism, such as atrial fibrillation, subacute bacterial endocarditis, cardiac wall thrombosis caused by mesenteric artery embolization, splenic embolism, renal embolism. Thrombosis, such as acute portal venous inflammation with mesenteric venous thrombosis. Aneurysm rupture, such as abdominal aorta, liver, kidney, spleen aneurysm rupture.

Obstetrics and gynecology

Acute attachment inflammation, acute pelvic inflammatory disease, rupture of the corpus luteum, ovarian tumor torsion, rupture of ectopic pregnancy.

Medical disease

1. Abdominal medical diseases: acute gastroenteritis, acute mesenteric lymphadenitis, acute viral hepatitis, primary peritonitis, abdominal purpura, sickle cell anemia crisis, lead poisoning, diabetes, uremia.

2, non-abdominal medical disease: due to nerve involvement in radiation-induced abdominal pain, common acute pneumonia, acute pleurisy, angina pectoris, myocardial infarction, pulmonary embolism.

3, spinal cord lesions: spinal proliferative osteoarthritis, spinal tuberculosis, tumors, injuries, spinal nerves are compressed or stimulated.

Acute abdomen prevention

The differential diagnosis of acute abdomen is not very easy. Do not drink water or eat before going to the hospital for emergency treatment. In case of gastrointestinal perforation, it is necessary to aggravate the condition. Some acute abdomen need urgent surgery. It will increase the difficulty of anesthesia after eating. Do not give painkillers, because the cause of acute abdomen diagnosis by doctors is mainly based on the location, nature, extent and progress of the pain. Once the painkillers are used, the symptoms are masked and the doctors will be diagnosed with illusions.

(1) Disease collection and information screening are the key: the changes in abdominal pain and vital signs in infants and young children are different from those in adults. Care should be taken to observe and monitor. In addition to closely observing postures, expressions, movements and emotions, They should be guided to give detailed, truthful and correct complaints to reflect the condition, and they should pay attention to their complaints about pain to obtain reliable, objective and correct medical information.

(2) observation of abdominal signs: 1 to understand the nature, location, degree of abdominal pain, sudden pain, colic, knife-like pain or gradually aggravated dull pain or pain, paroxysmal pain or persistence Sexual pain, with or without radioactivity or pain. Abdominal pain is located in the upper abdomen or lower abdomen, is the left side or the right side, is limited to a certain part or spread to the whole abdomen. Infants and young children, due to insufficiency of the myelin sheath, the cerebral cortex is low in excitability, not sensitive to various stimuli, and often manifests as generalization. Therefore, the child's sense of pain is often unclear, ambiguous, and difficult to identify. Sometimes appendicitis has formed, but there is no obvious right lower abdomen tenderness. When there is a mass in the right lower abdomen, tenderness and rebound pain, the condition has developed to a very serious degree; 2 should pay attention to observe the shape and performance of the abdomen, and observe whether abdominal breathing is observed. Exist, there is no surgical scar on the abdominal wall, the abdomen is bulged or boat-like, symmetrical, with or without intestinal or abnormal peristaltic waves, with or without peritoneal irritation, muscle tension and rebound tenderness. In this group of 7 children with intestinal obstruction, when there was abdominal distension, intestinal type or abnormal peristaltic wave in the abdominal wall, timely surgical treatment, the risk of safety.

(3) observation of vomiting and excretion: children with acute abdomen often accompanied by nausea, vomiting, abdominal distension and anal discharge of mucus and blood. Should pay attention to observe the traits and color of vomit and excrement, pay attention to whether it is paroxysmal vomiting, or persistent vomiting, jet vomiting, or reflex vomiting, observe the mode, frequency, quantity, nature, etc. of vomiting, etc. Assessment and identification of the nature of the child's condition. Under normal circumstances, the peptic ulcer bleeding is tar-like stool, the perforation of the digestive tract is bright red, the intestinal obstruction is bloody liquid, and the intussusception is jam-like. In this group of children with intestinal perforation, frequent hematemesis and stool bleeding, timely emergency surgery, and turned to safety.

Acute abdomen complications Complications, multiple system organ failure, shock

Concurrent shock, multiple organ dysfunction syndrome and multiple system organ failure, hemorrhage, acid-base balance disorders.

Acute abdomen symptoms Common symptoms Abdominal pain Abdominal wall extensive calcinosis Right abdominal pain Nausea nausea and vomiting fever with frequent urination, urine... Left abdominal pain

The card showed abdominal pain, bloating, vomiting, abnormal bowel movements, cold and sweating after the onset of the disease.

The disease develops as follows:

1. Onset of symptoms with or without prodromal symptoms, such as internal medicine acute abdomen often have fever, vomiting and then have abdominal pain, surgical acute abdomen often has abdominal pain, followed by fever. The rapid onset of abdominal pain, or immediate or subsequent symptoms, can help diagnose.

2. The site of abdominal pain is generally the initial and most obvious site of abdominal pain, often the site of the lesion. Should pay attention to the pain with or without metastasis and radiation, such as appendicitis with metastatic right lower abdominal pain, omental, ileal lesions in the initial mid-upper or umbilical cord, and later limited to the location of the lesion. Biliary tract disease often has radiation pain in the right shoulder and back. Pancreatitis often has radiation pain in the left lower back, and renal colic is radiated to the perineum.

3. Abdominal pain The peritonitis is persistently sharp, and the organ is obstructed or dilated into paroxysmal colic. The twist or rupture of the organ can cause strong cramps or persistent pain. The vascular obstruction is severe and persistent. Poisoning and metabolic abdominal pain are severe without clear orientation. The characteristics of seizures can be divided into persistence, paroxysmal and persistent pain with paroxysmal aggravation. Persistent pain mostly reflects intra-abdominal inflammation and hemorrhage. Paroxysmal abdominal pain is mostly empty organ obstruction or paralysis. Persistent pain is accompanied by Aggravation of inflammation suggests that inflammation and obstruction coexist.

4. The degree of abdominal pain can generally have pain, tingling, burning pain, knife-like pain, drill-like pain, cramps, etc., to a lesser extent. The severity of the condition cannot be judged solely by the degree of pain.

5. Induced exacerbation or alleviation factors Acute peritonitis abdominal pain is relieved in the recumbent, abdominal wall pressure or changes in body position, the patient is often happy when lead colic, biliary colic can be induced by fat meal, binge eating is the cause of acute gastric dilatation, Acute hemorrhagic necrotic enteritis is associated with unclean diet.

6. In the case of abdominal pain, such as perforation caused by perforation and rupture of the organ, the patient often adopts a lateral flexion position, which is agitated, that is, a quiet type. Biliary aphids, patients with biliary colic often turn to the opposite side, holding the abdomen, that is, noisy type. In some patients with acute pancreatitis, pain in the prone position or knee chest position can be alleviated.

Disease accompanying symptoms

1, nausea, vomiting: early is reflective, is caused by splanchnic nerve stimulation. Such as early appendicitis, perforation of gastric duodenal ulcer and so on. Because the gastrointestinal tract causes vomiting through the disorder, it is called reflux vomiting, which is generally late and heavier, such as advanced intestinal obstruction. There are also due to the absorption of toxins, stimulating the central nervous system, and vomiting in the late stage. The nature of vomit has important reference value for diagnosis.

2, stool situation: ask whether there is venting and stool, stool characteristics and color. Such as the onset of abdominal pain, stop venting, defecation, mostly mechanical intestinal obstruction. Conversely, if there is diarrhea or urgency, it may be enteritis or dysentery. Asphalt is often used for upper gastrointestinal bleeding, and intussusception should be considered in children with jam.

3, other: colic with frequent urination, urgency, dysuria or hematuria, consider more urinary tract infections or stones. Abdominal pain associated with chest tightness, cough, blood stasis or associated with arrhythmia, should consider pleural, lung inflammation or angina. With chills, high fever, can be seen in acute suppurative biliary inflammation, abdominal organ abscess, lobar pneumonia, suppurative pericarditis. With jaundice, can be seen in acute liver, biliary tract disease, pancreatic disease, acute hemolysis. With shock, common in acute intra-abdominal hemorrhage, acute obstructive suppurative biliary tract inflammation, strangulated intestinal obstruction, acute perforation of peptic ulcer, acute pancreatitis, acute myocardial infarction.

Acute abdomen examination

General examination and inspection

Pay attention to changes in consciousness, expression, posture, body temperature, pulse, respiration, and blood pressure. Whether there is dehydration, blood loss, signs of shock, sclera with or without jaundice. In general, patients with acute peritonitis have multiple lower limb flexion, restless fear, and abdominal breathing weakened. Intra-abdominal hemorrhage often has a pale complexion, weak pulse or shock. Patients with obstruction of the cavity are often uneasy. Intestinal obstruction can be seen in abdominal distension and intestinal type; see gastric type and gastric peristaltic wave suggest pyloric obstruction.

palpation

The patient should relax on the back of the knee to relax the abdominal muscles, first check from the site of the abdominal pain, and finally touch the lesion; infants should avoid crying, it is best to carry it into the mother's arms or if necessary, after the injection of appropriate amount of sedative. The palpation is shallow and deep, and there is no tenderness in all areas of the abdomen. It is very important to check the tenderness and muscle tension. The peritoneal irritation sign is generally mild, medium and heavy: 3 degrees: hand pressure to the peritoneum; The degree is pressed to the muscle layer; the severity is the pressure under the skin, the severity is also called "plate-like abdomen", often suggesting that there may be severe digestive tract perforation, strangulated intestinal obstruction or acute hemorrhagic necrotizing pancreatitis The condition of peritonitis. At the time of palpation, attention should also be paid to the liver, gallbladder, spleen and its hardness and surface traits, whether there is tenderness; whether it can be abnormal and abnormal mass or intestinal fistula.

Percussion

Focus on understanding whether there is a reduction or disappearance of the liver dullness, and there is a suggestion that there may be free gas under the armpit, which is caused by perforation of the gastrointestinal tract. There is no mobile dullness, and some suggest that there is peritoneal effusion, which may be caused by peritonitis or intra-abdominal hemorrhage. Liver area pain may have liver abscess or biliary tract infection, kidney area pain may have kidney stones.

auscultation

Mainly check the bowel sounds, water sounds and vascular murmurs. Normal bowel sounds 3 to 5 times per minute, intestinal hyperthyroidism is common in mechanical intestinal obstruction and acute gastroenteritis, high-profile, metal sound and gas over-water sound are characteristic of mechanical intestinal obstruction. Attenuation of bowel sound refers to hearing bowel sounds 1 min or more; disappearance of bowel sounds means that more than 3 min can not smell bowel, common in acute peritonitis and paralytic ileus. The sound of shaking water indicates pyloric obstruction or acute gastric dilatation. Abdominal hernia and swelling with the pulsation of the arteries, and smell of vascular murmur, suggesting abdominal aortic aneurysm.

Anorectal examination

Acute abdomen should be routinely examined to identify rectal cancer, to understand the presence or absence of pelvic abscess, posterior appendicitis, intussusception and gynecological inflammation.

Auxiliary inspection

Laboratory inspection

Including blood, urine, stool routine, blood biochemistry, electrolytes, liver, kidney function, blood, urine amylase, blood gas analysis. White blood cell count and classification can help to diagnose inflammation and its severity; hemoglobin decline may have intra-abdominal hemorrhage; platelet progressive decline, should consider the presence or absence of DIC, suggesting further examination; a large number of red blood cells in the urine suggest urinary calculi or kidney damage Increased blood urea gelatinase suggests acute pancreatitis; severe water, electrolytes and acid-base disorders suggest severe conditions; elevated blood direct bilirubin, elevated transaminase, suggesting biliary obstructive jaundice; urea nitrogen, creatinine may be primary Disease with acute renal dysfunction or uremic peritonitis.

Diagnostic abdominal puncture

Diagnostic abdominal puncture is feasible when the percussion has mobile dullness and the diagnosis is not clear. Generally choose the umbilical cord and the anterior superior iliac spine in the middle and outer 1/3 intersection point, puncture fluid turbidity or pus suggestive peritonitis or abdominal abscess, if there is gastrointestinal contents (food residue, bile, feces, etc.), suggesting digestive tract perforation Non-coagulating fluid is mostly rupture of parenchymal organs, such as traumatic liver, spleen rupture, or spontaneous rupture of liver cancer, may also puncture to retroperitoneal hematoma; pale red blood, may be strangulated intestinal obstruction, such as blood, urine, The high ascites amylase is hemorrhagic necrotizing pancreatitis. If the blood is quickly solidified by puncture, it may puncture the blood vessels of the abdominal wall or internal organs. Be careful not to puncture the puncture needle into the intestine when the intestine is inflated. Be sure to puncture the abdomen under turbidity.

Peritoneal lavage is feasible for severe abdominal distension and negative abdominal puncture, but can not rule out abdominal lesions. Such as lavage erythrocyte >100 × 109 / L or white blood cells > 0.5 × 109 / L, or amylase > 100 Somogyi U, visible blood, bile, gastrointestinal contents, or positive bacteria, suggesting abdominal cavity There are inflammation, bleeding or perforation of hollow organs.

Film degree exam

Including abdominal X-ray examination, B-ultrasound, CT, MRI and so on. Abdominal radiographs or fluoroscopy found that there is free gas under the armpit, which is helpful for diagnosing perforation of the stomach and duodenal ulcer, perforation of the small intestine or intestinal fistula. Abdominal fat line and lumbar muscle shadow blurred or disappeared suggestive of peritonitis. Acute mechanical intestinal obstruction is characterized by dilatation of the intestine above the obstruction, gas accumulation and multiple gas-liquid surfaces; paralytic intestinal obstruction is the expansion of the whole intestine (including the colon), accumulation of gas, is one of the characteristics of total peritonitis; found isolation Intestinal tube expansion with fluid surface, should consider closed intestinal obstruction. Suspected intussusception, intestinal torsion, colon tumor, X-ray photograph of barium enema in the absence of intestinal narrowing and peritonitis. Abdominal plain film found that high-density calcification helps to diagnose kidney, ureteral stones, pancreatic duct stones, pancreatitis and a small part of gallstones.

BUS has a great diagnostic value for liver, biliary tract, kidney, ureter, uterus, accessory disease and abdominal cavity with or without ascites and abscess. Ultrasound Doppler examination also contributes to the diagnosis of abdominal aortic aneurysm, arteriovenous fistula, arteriovenous thrombosis or embolism, and vascular malformations.

CT and MRI are more valuable for the diagnosis of liver, gallbladder, pancreas, spleen, kidney, abdominal occupying lesions and vascular diseases.

Diagnosis and diagnosis of acute abdomen

clinical diagnosis

The right treatment depends on the right diagnosis, and the correct diagnosis depends on a comprehensive collection of medical history data and a multi-faceted examination. Image examination is one of the clinical examination methods. With the application of the new X-ray diagnostic machine and the continuous improvement and update of the contrast technology, its status in disease diagnosis is also increasing. The same is true in the diagnosis of acute abdomen. For example, the discovery of free gas under the armpit, combined with clinical manifestations, is decisive for the diagnosis of perforation of abdominal cavity organs. The appearance of dilated intestinal effusion in the abdominal image should first consider whether there is intestinal obstruction. It is worth mentioning that imaging examination is not only an important diagnostic method, but also plays an important role in the treatment of certain acute abdomen, such as laparotomy. Therefore, to improve the level of medical staff's diagnosis and treatment, X-ray doctors and clinicians need to work closely together to achieve a high-quality diagnostic criteria.

After the clinician has examined the patient and believes that X-ray examination is required, the clinical data should be filled in the application form for reference by the radiologist. The application form should indicate the initial clinical diagnosis, the purpose of the examination, and indicate whether the patient can move or stand so that the imaging specialist can better inspect the design.

Patients with acute abdomen are prone to shock, so they should be smooth, gentle, and accurate during escorting and examination, and minimize unnecessary movement. If you experience severe shock, you should first rescue the patient with the clinician and wait until the condition improves.

General acute abdomen can be diagnosed by plain film or fluoroscopy. However, for some patients with acute or chronic disease, some special examinations (such as CT, MR, etc.) can be selected.

Routine examination of acute abdomen includes: perspective: due to some chest diseases, such as pneumonia, pleurisy, pulmonary infarction, pneumothorax, etc. may produce some symptoms similar to acute abdomen, and acute abdomen is easy to secondary to some chest changes, such as lung Bottom inflammation, linear atelectasis, changes in diaphragm position and mobility. Therefore, in the imaging examination of acute abdomen, the combined perspective of the chest and abdomen is indispensable. When examining, attention should be paid to diaphragmatic movement and heart beat. Abdominal effusion and its distribution and extent, whether there is free gas under the armpit. In patients with mechanical intestinal infarction, the peristalsis is hyperthyroidism. On the screen, the changes of the gas-liquid level in the intestine due to hyperactivity can be seen. From low to high or high to low, the lifting can be seen. Boiling water sign, combined with palpation, blood routine examination, white blood cells rise, severe infection can reach 20.0 × 10.9 / L, and even electrolyte disorders and symptoms, which will greatly help the diagnosis.

Abdominal pain identification

(1) Acute perforation of gastroduodenal ulcer: more common in young men, most of them have a history of peptic ulcer, sudden persistent upper abdominal pain, and soon spread to the whole abdomen, digestive juice stimulates the diaphragm to produce shoulder involvement Pain, sometimes the digestive juice flows to the right lower abdomen leading to peritoneal irritation of the right lower quadrant, which is easily misdiagnosed as acute appendicitis. Physical examination of total abdominal tenderness, rebound tenderness, muscle tension was plate-like, liver dullness reduced or disappeared, bowel sounds weakened or disappeared, X-ray examination showed free gas under the armpit.

(2) acute cholecystitis: often combined with gallstones, more common in women, repeated episodes of right upper quadrant, right shoulder and right back radiation, with chills, fever. Examination of the right upper peritoneal irritation, can be swollen and enlarged gallbladder, Morphy sign positive. B-ultrasound showed gallbladder enlargement, wall thickening, and gallstones often seen.

(3) acute cholangitis: recurrent episodes of right upper quadrant with chills and high fever and obstructive jaundice, severe mental disorders and shock. In the right upper abdomen, severe peritoneal irritation, and swelling of the liver or / and gallbladder. B-ultrasound bile duct dilatation, most with bile duct stones.

(4) acute pancreatitis: often after overeating or drinking, or have a history of biliary stones, mites; sudden onset of severe upper abdominal pain, paroxysmal aggravation, often to the left waist and back radiation, with nausea, Vomiting, fever. Physical examination of total abdominal tenderness, rebound tenderness, muscle tension, above the middle abdomen is heavy, and there is lumbar tenderness, bowel sounds reduce or disappear. Hematuria amylase increased. Hemorrhagic necrotizing pancreatitis, abdominal pain, abdominal distension and peritoneal irritation are severe, and abdominal wear can be used to draw hemorrhagic fluid. B-ultrasound and CT showed pancreatic enlargement, necrosis, and effusion.

(5) acute intestinal obstruction: According to the reasons can be divided into mechanical, paralytic, blood transport intestinal obstruction. Simple mechanical intestinal obstruction manifested as abdominal paroxysmal pain, vomiting, abdominal distension and cessation of anal defecation. The body showed swelling of the abdomen, showing intestinal type and peristaltic wave, intestinal hyperthyroidism, high-profile, and gas over-water. X-ray showed obstruction of the proximal intestinal fistula with a liquid-gas surface. If the condition worsens, blood circulation disorder may occur, and the disease progresses to strangulated intestinal obstruction. At this time, there is persistent severe abdominal pain, often shock, and there is peritoneal irritation, and a painful mass in the abdomen. Abdominal puncture fluid, vomit or anal discharge is a bloody fluid, and X-ray shows isolated and swollen intestinal fistula. To further identify the cause of obstruction, there should be a history of surgery should consider intestinal adhesions; intestinal obstruction after the activity progresses rapidly, may be intestinal torsion; children may be intussusception or intestinal aphids; elderly low intestinal obstruction may be colon tumors. There are other reasons such as abdominal hernia, abdominal hernia, and congenital intestinal malrotation.

(6) acute appendicitis: Sudden upper abdomen or umbilical pain, then transferred to the right lower abdomen, right lower abdomen fixed tenderness, rebound tenderness, muscle tension. Localized peritonitis or perforated diffuse peritonitis may be combined, but the sign of the right lower abdomen is still the heaviest.

Differential diagnosis

Surgical acute abdomen is an acute abdomen that may be surgically treated. It is characterized by acute abdominal pain accompanied by peritoneal irritation. Due to different treatment methods, medical diseases should be excluded first. Common medical acute abdomen is as follows:

(1) acute pneumonia and pleurisy: lower lung inflammation and pleurisy can stimulate the diaphragm, leading to pain in the upper abdomen. However, patients often have high fever, cough, difficulty breathing; abdominal tenderness is light, mostly without muscle tension and rebound tenderness, normal bowel sounds; phlegm at the lungs, weakened breath sounds, increased vocal fibrillation, audible wetness, tubular breathing Sound, or pleural friction sound. A flat chest piece is helpful for diagnosis.

(2) Myocardial infarction: A small number of patients may present with pain in the upper abdomen, and may also be associated with abdominal muscle tension. The pain is mostly located behind the sternum, under the xiphoid or in the upper abdomen, and the pain is radiated to the left upper limb. The abdominal tenderness point is not fixed and there is no rebound pain. Electrocardiogram and myocardial enzymology can confirm the diagnosis.

(3) acute gastroenteritis: more than 2 to 3 hours after entering the unclean food, mainly manifested as severe vomiting, abdominal pain, diarrhea, and more without fever. Abdominal pain is extensive, but there is no tenderness, rebound tenderness and muscle tension in the abdomen, and the bowel is active. Abdominal pain after diarrhea can be temporarily relieved, and white blood cells and pus cells can be seen under the stool.

(4) acute mesenteric lymphadenitis: more common in children and adolescents, often have a history of upper respiratory tract infection, early fever, because there are multiple lymph nodes in the end of the ileum become swollen, often have lower right abdomen pain and tenderness, but the scope is not Specifically, the tender point is not constant, and there is no muscle tension and rebound tenderness, and the increase in white blood cell count is not obvious.

(5) abdominal type allergic purpura: due to gastrointestinal allergy caused by intestinal mucosa, mesenteric or peritoneal extensive bleeding, often paroxysmal colic, location is not fixed, and often accompanied by nausea, vomiting, diarrhea or bloody stools.

(6) Primary peritonitis: more common in patients with weakened whole body, cirrhosis or uremic ascites, and immunocompromised patients. The pathogens are often circulated by blood, and hemolytic streptococcus, pneumococci and Escherichia coli are more common. The patient begins to have a fever, followed by abdominal pain, increased ascites, abdominal tenderness or rebound tenderness, but peritoneal irritation is less severe than secondary peritonitis. There are white blood cells and pus cells in the ascites puncture fluid, and the bacteria culture is positive.

(7) Diabetes: This disease may be accompanied by obvious abdominal pain, nausea and vomiting or mild muscle tension and tenderness when combined with ketoacidosis. The patient had a history of diabetes, a disturbance of consciousness, an exhaled gas with a rotten apple smell, and a laboratory test for elevated blood sugar, urine sugar, and urine ketone body.

(8) uremia: Some patients may be accompanied by abdominal pain, and have tenderness, rebound tenderness and muscle tension. The mechanism is unknown. It may be caused by metabolic waste discharge through the peritoneum to stimulate the peritoneum. The patient had a history of chronic kidney disease, abnormal urine, and a significant increase in blood BUN and Cr. Abdominal puncture can be performed if necessary, and the ascites is clear, and the routine and bacteriological examinations are negative.

(9) urinary retention: due to urethral or bladder neck lesions, such as stones, tumors, prostatic hypertrophy, urethral stricture, uterine tumor compression and other factors can cause obstructive urinary retention; or due to neurological and psychiatric disorders, such as spinal cord spasm, myelitis, Spinal cord injury, neurosis, meningoencephalitis, etc., can cause non-obstructive urinary retention. Mild urinary retention has pain in the abdomen, the lower abdomen can be swollen and swollen bladder, turbidity; severe bladder can be dilated to the upper abdomen and the bladder border is unclear. As the bladder is extremely dilated, the visceral peritoneum is stimulated to cause abdominal pain, accompanied by There are total abdominal tenderness, rebound tenderness, muscle tension, can be misdiagnosed as diffuse peritonitis, but the whole abdomen turbidity, bladder shrinkage after catheterization, abdominal pain disappeared is its characteristics.

(10) sickle cell anemia crisis: for chromosomal genetic diseases, black more common, repeated episodes of severe abdominal pain, may be associated with chest pain and bone and joint pain, rapid breathing, tachycardia, and often fever, up to 39 ° C The tenderness is mostly in the upper abdomen. The disease often incorporates cholelithiasis.

(11) Lead poisoning: Most of the right lower quadrant pain of paroxysmal recurrent episodes is easily misdiagnosed as acute appendicitis, but the abdominal signs are light and the patient has chronic lead exposure history.

Carefully ask the female patient's menstrual history, whether there is menopause, menstrual flow and leucorrhea, if necessary, please consult a gynaecologist to make a gynecological examination to confirm the diagnosis.

(1) rupture of ectopic pregnancy: more history of menopause or irregular vaginal bleeding, sudden onset of severe abdominal pain in the lower abdomen, lower abdominal tenderness, muscle tension and rebound tenderness, decreased bowel sounds, caused by blood stimulation of the peritoneum. Patients often have signs of hemorrhagic shock such as accelerated heart rate and decreased blood pressure. Abdominal and posterior iliac puncture can be used to extract non-clotting fluid, and human chorionic gonadotropin (HCG) test is positive.

(2) rupture of ovarian corpus luteum: more common in women of childbearing age, often severe abdominal pain 18 to 20 days after menstruation, with abdominal muscle tension, tenderness and rebound tenderness. Because of the small amount of blood loss, there is often no sign of acute blood loss.

(3) acute attachment inflammation and pelvic inflammatory disease: The patient has a history of sexual life, abdominal pain is located in the lower abdomen, accompanied by increased vaginal discharge and systemic infection symptoms, few nausea, vomiting, diarrhea, constipation and other gastrointestinal symptoms. Physical examination of the left or right lower abdomen tenderness, anal finger examination of the axillary tenderness, but the peritoneal irritation is less severe, rarely spread to the middle and upper abdomen.

(4) Ovarian tumors: Ovarian tumors (often cystic adenomas) can cause sudden acute left or right lower abdomen pain when they are ruptured or twisted. They are mostly persistent and may be accompanied by nausea and vomiting. Physical examination of the lower abdomen can be aching and tender mass, and there is a peritoneal irritation. The right side is easily confused with acute appendicitis or appendicitis abscess. Ultrasound helps to differentiate the diagnosis.

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