– the multiplicity of etiologies: more than a hundred disorders;
– the clinic sometimes incomplete, atypical or misleading: extradigestive affections, “aberrant” irradiations or variables in time;
– in general medicine, the initial clinical examination must make it possible to take the appropriate decisions (to hospitalize from the outset to calm and to see again the patient?).
CLINIC:
Recognize a vital emergency:
Look for signs of severity or poor tolerance: signs of haemorrhagic or infectious shock (pallor, sweating, running pulse, hypotension, dyspnoea, mottling, cyanosis).
In all these cases: hospitalization with EMS call for medical transport, resuscitation procedures to begin immediately (venous route, O 2 , symptomatic treatments …).
In practice, these situations are quite rare.
Observe the patient and his entourage!
The position in rifle dog is seen in acute pancreatitis, agitation in attacks of renal colic, occlusions. Movement economy is found in peritonitis. The flexed right thigh position evokes the psoïtis of retrocecal appendicitis. Attention to the sitting position, better supported than the decubitus in the thoracic pathologies.
There is a need to assess the social context (the ability of the family to monitor), especially among older people and children; hospitalization can be decided on these criteria.
The interrogation must remain an essential time:
History of known digestive pathology, surgical interventions, treatments (NSAIDs, aspirin, etc.).
Family history of cancer, metabolic diseases; field (vascular, diabetic), ethnic origin, etc.
The symptomatology must be precise: initial location of pain and mode of onset, type of pain, exacerbation or relief factors (position, vomiting …), painful irradiation, general and associated signs (fever, digestive disorders).
Take time for abdominal palpation:
Inspect (scars, arches, trauma …), auscultate (water-jet sounds, vascular murmurs).
The exploration begins with the region described as the least painful. The examination should explore the different areas of the abdomen by looking for pain, mass, defense or contracture. This examination will be followed by pelvic examinations and hernial orifice inspection. The percussion will look for an effusion, a dullness (vesical globe) or even a tympanism (visceral aortic dilation).
To examine in a complete way, not to disregard a medical cause:
– Cardiopulmonary examination: pathologies whose expression may be abdominal.
– Neurological and spinal examination: a radicular syndrome, an abnormality of reflexes of sensitivity, a pyramidal syndrome, sphincter disorders.
– At the skin level, do not let pass melanoderma, purpura, bubbles in the exposed areas, pruritus.
In women during a period of genital activity:
The abdominopelvic pain must evoke the pregnancy and its complications. In practice, the date of the last menstrual period, the contraception, the accompanying signs (fever, gynecological losses, metrorrhagia, nausea, etc.), the gynecological and obstetrical antecedents will be noted.
ADDITIONAL EXAMENS:
Useful investigations, first-line:
– Biology: NFS, VS, CRP, ionogram, glycemia, creatinine, serum calcium, transaminases, LDH, amylases. At the slightest doubt, in a woman of childbearing age, β HCG, urinary strip and Hemocultus.
– ECG at the slightest doubt (especially on vascular ground).
– Imaging: two key exams: ultrasound and CT scan.
Traditional imaging RP, ASP.
Laparoscopy is performed in case of failure of other means of non-invasive investigation.
An exploratory laparotomy can be performed urgently in front of an acute abdominal panel with rapid deterioration of the patient’s general condition and “surgical” abdomen on palpation.
ETIOLOGICAL DIAGNOSIS:
Surgical emergencies:
They are frequent and do not suffer the error. If there is a state of shock, it is most often hemorrhagic shock (ruptured GEU, organ perforation, rupture of aneurysm, mesenteric infarction ..) with the need for direct admission to the operating room. It can also be septic shock, severe pancreatitis.
In women during periods of genital activity, always consider:
– One GEU: abdominal pain + Metrorrhagia + β HCG positive + uterus void echo: the management is most often surgical.
– The torsion of an ovarian cyst, symptomatology resulting in a peritoneal reaction that can mimic an appendicular crisis. Laparoscopy takes all its interest, both diagnostically and therapeutically.
– Acute uterine or adnexal infection: endometritis that may occur after an invasive procedure (curettage, abortion …) or secondary to STD type contamination (mycoplasma, Chlamydia trachomatis, gonococcus, etc.).
– The necrobiosis of a myoma, possibly.
Do not ignore the medical etiologies at the origin of tables:
acute abdominals
– Infectious causes: atypical pneumonia, yersiniosis, pseudomembranous colitis. Sometimes noisy digestive tables of Mycoplasma pneumoniae, Q fever, typhoid, mycoplasma.
– Endocrine and metabolic causes: acute adrenal insufficiency. Diabetic ketoacidosis.
More rarely acute abdominal attacks of acute intermittent porphyria, angioneurotic edema of the periodic disease.
– Hematologic causes: think of nocturnal paroxysmal haemoglobinuria, sickle cell disease.
– Gastrointestinal vasculitis of PAN or rheumatoid purpura is exceptional but should not be operated.
– Toxic causes: lead poisoning, acute poisoning with mercury, arsenic.