ACUTE ABDOMEN / FREE AIR

Question 1

Symptoms

Answer 1

Pain is often acute and abrupt in onset,
starting severe and maintaining severity. The location of first pain may point to the etiology.

Question 2

Risk Factors

Answer 2

Ascertain risk factors for peptic ulcer disease (NSAID use, steroid use, H. pylori infection, chronic heartburn),
diverticular disease (LLQ pain), chronic constipation, foreign body ingestion.

Question 3

Signs

Answer 3

Assess for diffuse board-like rigidity, areas
of maximal tenderness, the vital signs are essential for identifying shock. Complete examination (cardiovascular, respiratory, abdominal) is essential for identifying the cause of diffuse peritonitis.

Question 4

Labs / Imaging

Answer 4

CBC will usually identify leukocytosis, EKG
to rule out referred cardiac pain, Blood Glucose to rule out DKA, Lipase to assess for pancreatitis, Renal function and INR for operative preparation. AXR may
demonstrate area of pathology. Upright CXR will show free air under the diaphragm (R>L). It may also reveal a lower lobe pneumonia.

Question 5

D/Dx

Answer 5

Perforated Duodenal Ulcer, Perforated
Diverticulitis, Perforated Colon Cancer, Stecoral Ulcer, Diabetic Ketoacidosis, Rectus Sheath Hematoma, Pancreatitis, Pneumonia, MI, Constipation.

Question 6

Initial Management

Answer 6

Initiate broad spectrum antibiotics, IV fluids
and NPO. Prepare the patient for emergent surgery (informed consent, EKG (if needed), book the OR, inform senior resident/staff), usually ‘exploratory laparotomy, possible bowel resection, possible stoma’.

Question 7

Common Pitfalls

Answer 7

Be certain that the cause of peritonitis is
definitely surgical before booking the OR – several medical illnesses can cause an acute abdomen. These patients can often be elderly with several co-morbidities – an urgent anesthesia consult is often required, and sometimes there should be a discussion as to whether surgery is even appropriate for the individual patient.