Acute abdomen

Introduction Acute abdomen is a general term for acute abdominal diseases. 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. The first site that occurs may be the primary site of the lesion.

Cause

Causes

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.

Pathogenesis

Abdominal pain is a kind of self-feeling of the body's different stimulation to the abdomen or other parts, and it is one of the warning signals that the body is attacked. Different stimuli include:

1 chemical: such as stomach, intestinal fluid, bile, urine, blood, electrolytes (K+, Na+, Ca++, etc.).

2 mechanical: abdominal trauma, hollow organ obstruction (such as stones, tumors, adhesions, etc.) caused by organ expansion stretch or smooth muscle spasm.

3 inflammatory: such as bacterial infection. Abdominal pain stimulates the pain caused by the sympathetic nerve, parasympathetic nerve, and the three nerves that innervate the peritoneum of the parietal layer. Different individual disease thresholds are different. Sensitive patients have lower thresholds, and smaller stimuli may cause more severe pain. Insensitive patients, such as older people, hypnosis, neurasthenia, etc., may also have less painful reactions.

Abdominal pain can be divided into visceral pain, parietal peritoneal pain and pain involved depending on its origin and nature.

Visceral pain

According to the innervation of the nerve plexus, the upper abdominal organs are dominated by the abdominal plexus, and the pain is in the upper abdomen, including the lower esophagus, the stomach, the upper part of the duodenum, the liver, the gallbladder and the extrahepatic bile duct, and the middle abdomen, including the distal part of the duodenum. The small intestine, ascending colon and transverse colon are innervated by the superior mesenteric plexus, and the pain is generally in the umbilical circumference; while the intestinal tube below the transverse colon is dominated by the inferior mesenteric plexus, so the pain is generally located in the lower abdomen. Visceral pain is usually dull pain, pain or cramps, because the parasympathetic nerves in the vagus nerve provoke the vomiting center of the medulla, often accompanied by nausea and vomiting.

Parietal peritoneal pain

As the somatosensory nerves distributed on the peritoneum of the parietal layer are stimulated by inflammation, mechanical and chemical, it will result in clear and accurate severe abdominal pain. When the stimulation is strong, it can cause the contraction and rigidity of the reflex abdominal muscles, leading to muscle tension, tenderness and rebound. Pain, the so-called peritoneal irritation.

Involved in pain

The pain of the organ causing pain away from the part is called pain. Such as acute cholecystitis to the right shoulder and back radiation, renal ureteral colic, to the waist and perineum, pelvic disease involved in the lumbosacral region, myocardial infarction caused pain in the left upper arm and forearm medial or upper abdominal pain, diaphragmatic muscles stimulated by inflammation can cause shoulder Pain, right lower pleurisy can cause upper right abdominal pain and so on.

an examination

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.

Differential diagnosis

1. Acute pneumonia and pleurisy

Lower lung inflammation and pleurisy can stimulate the diaphragm, causing pain in the upper abdomen. However, patients often have high fever, cough, difficulty breathing, mild abdominal tenderness, more often without muscle tension and rebound tenderness, normal bowel sounds, phlegm at the lungs, weakened breath sounds, increased tremors, 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, but 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. Patients with cardiovascular risk factors, electrocardiogram and myocardial enzymology can be diagnosed.

3. Acute gastroenteritis

More than 2 to 3 hours after entering the unclean food, the main manifestations are severe vomiting, abdominal pain, diarrhea, and more fever. Abdominal pain is extensive, but there is no tenderness, rebound tenderness and muscle tension in the abdomen, and the bowel sounds are 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 of multiple colitis at the end of the ileum, often have pain and tenderness in the right lower quadrant, but the range is not exact, the tender point is not constant, and Without muscle tension and rebound tenderness, the increase in white blood cell count was not significant.

5. Abdominal allergic purpura

Allergic to the gastrointestinal tract caused by extensive bleeding of the intestinal mucosa, mesentery or peritoneum, 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, immunocompromised patients. The pathogens are often circulated by blood, and hemolytic streptococcus, pneumococci and Escherichia coli are more common. The patient begins to have fever, followed by abdominal pain, increased peritoneal effusion, abdominal tenderness or rebound tenderness, but peritoneal irritation is less severe than secondary peritonitis. There are white blood cells and pus cells in the peritoneal effusion puncture, and the bacteria culture is positive.

7. Diabetes

When the disease is combined with ketoacidosis, it may be accompanied by obvious abdominal pain, nausea or vomiting or mild muscle tension and tenderness. 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 peritoneal effusion is clear, and the routine and bacteriological examinations are negative.

9. Urinary retention

Due to urethral or bladder neck lesions, such as stones, tumors, enlarged prostate, urethral stricture, uterine tumor compression and other factors can cause obstructive urinary retention, or due to neurological and psychiatric disorders such as spinal cord hernia, myelitis, spinal cord injury, neurosis , meningeal encephalitis, 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 people are more common, and 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, tenderness in the upper abdomen. The disease often incorporates cholelithiasis.

11. Lead poisoning

Most of the right lower quadrant pain of paroxysmal recurrent episodes, easily misdiagnosed as acute appendicitis, but the abdominal signs are light, the patient has a history of chronic lead exposure.

12. Ectopic pregnancy rupture

There are many 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, and decreased bowel sounds are 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.

13. 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.

14. Acute attachment inflammation and pelvic inflammatory disease

The patient has a history of sexual life. The abdominal pain is located in the lower abdomen, accompanied by increased vaginal discharge and symptoms of systemic infection. There are few gastrointestinal symptoms such as nausea, vomiting, diarrhea and constipation. 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.

15. Ovarian tumor

Ovarian tumors (often cystic adenomas) can cause sudden acute left or right lower abdomen pain when ruptured or reversed, mostly persistent, with 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.

16. Other situations

Certain systemic or other systemic diseases, such as hematoporphyria, hypokalemia, sepsis, spinal trauma or spinal cord disease, can also have clinical manifestations similar to acute abdomen.

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