ACUTE ABDOMENSurgical Emergencies 2576 Insert one or two large-bore i.v. cannulae and send blood for FBC, U&Es, LFTs,
blood sugar and lipase/amylase. Cross-match blood if haemorrhage is suspected.
Send blood cultures if pyrexial. Check an arterial or venous blood gas.
7 Commence an i.v. inf usion wit h norma l sa line.
(i) Arrange insertion of a CVP line by an experienced doctor
in older patients with pre-existing cardiac disease, to avoid
precipitating heart failure from fluid overload.
8 Catheterize the bladder. Test the urine for sugar, blood, protein, bile and
urobilinogen, and send for microscopy and culture.
(i) Perform a urinary -human chorionic gonadotrophin (hCG)
pregnancy test in females of reproductive age.
9 Perform an ECG.
10 Request plain radiology:
(i) Erect CXR or lateral decubitus abdominal film if the patient is
unable to sit upright, to look for free gas in suspected perforation.
(ii) AXR for possible bowel obstruction, volvulus or for abnormal air
such as the ‘double-wall sign’ in a perforation.
11 Arrange a focused bedside ultrasound for a suspected AAA or ectopic
pregnancy.
12 Insert a nasogastric tube if there is evidence of intestinal obstruction, ileus or
peritonitis.
13 Commence broad-spectrum antibiotics such as gentamicin 5 mg/kg,
ampicillin 1 g i.v. and metronidazole 500 mg i.v. for generalized peritonitis.
14 Refer the patient immediately to the surgical team.
STABLE PATIENT WITH AN ACUTE ABDOMEN
DIAGNOSIS AND MANAGEMENT1 Determine the onset and nature of pain:
(i) Explosive and excruciating pain: consider myocardial infarction,
ruptured aortic aneurysm, perforated viscus, and biliary or renal colic.
(ii) Rapid, severe and constant pain: consider pancreatitis,
strangulated bowel, mesenteric infarction and ectopic pregnancy.
(iii) Gradual, steady pain: consider cholecystitis, appendicitis,
diverticulitis, hepatitis and pelvic inflammatory disease (salpingitis).
(iv) Intermittent pain with crescendos: consider mechanical obstruction.
2 Ask about the location and radiation of pain:
(i) Central abdominal pain radiating to the back suggests an aortic
aneurysm or pancreatitis.
(ii) Flank pain radiating to the genitalia suggests ureteric colic, or
rarely ruptured aortic aneurysm.