Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Acute Abdomen

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In one line

·Acute abdomen is sudden, severe belly pain with signs that the belly lining is angry and inflamed — a surgical emergency until proven otherwise.

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Normal physiology

·The peritoneum is a smooth, two-layer membrane that lines the abdominal cavity (the space inside your belly) and covers most abdominal organs. The visceral peritoneum wraps the organs and senses stretch or swelling, giving dull pain that is hard to pinpoint. The parietal peritoneum lines the belly wall and has many pain nerves that give sharp, precise pain. Normally, the peritoneum is slippery like wet glass, so organs glide smoothly.

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What goes wrong

·Usually one broken thing explains all the strange findings together.

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Hallmark signs

·Severe, sharp, localized abdominal pain
·Rebound tenderness (pain worse when examiner releases pressure)
·Involuntary guarding and rigidity (board-like abdomen)
·Absent or diminished bowel sounds
·A fast heart rate (Tachycardia) (heart rate greater than 100 beats per minute)
·Low blood pressure (Hypotension) (systolic blood pressure less than 90 mmHg) in severe cases
·Nausea and vomiting
·Patient lying motionless, knees drawn up

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Red flags · escalate now

·Low blood pressure (Hypotension) (systolic BP less than 90 mmHg) or signs of shock (cold, clammy skin, confusion, weak pulse)
·Rigid, board-like abdomen with severe rebound tenderness
·Pain out of proportion to physical exam findings (suggests mesenteric starved blood flow (ischemia)—blocked blood vessels feeding the bowel)
·Rising lactate (greater than 2 to 4 mmol/L) or worsening metabolic acidosis (acid building up in the blood) (acid buildup in blood from dying tissue)
·Free air on imaging (gas outside the gut seen on X-ray or CT, suggests perforation requiring emergent surgery)

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Workup

·Complete blood count (CBC)
·Basic metabolic panel (BMP)
·Serum lactate
·Lipase
·Upright chest x-ray or left lateral decubitus abdominal x-ray
·CT scan of abdomen and pelvis with IV contrast
·Urine or serum pregnancy test (for all people with a uterus of childbearing age)
·Type and screen (blood bank preparation)

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Treatment

·IV fluids (normal saline or lactated Ringer's—1 to 2 liters rapid bolus, then continuous infusion at 125 to 200 mL per hour)
·Broad-spectrum IV antibiotics (e.g., piperacillin-tazobactam 3.375 g every 6 hours, or ceftriaxone 1 to 2 g every 24 hours plus metronidazole 500 mg every 8 hours)
·Emergency surgery or interventional radiology drainage (based on imaging and how stable the patient is)
·Pain medicine (IV opioids, e.g., morphine 2 to 4 mg IV or fentanyl 25 to 50 mcg IV, adjusted to pain level)
·NPO (nothing by mouth) and nasogastric tube if vomiting or a stalled gut (ileus) is present
·Serial abdominal exams and vital sign monitoring (check every 1 to 2 hours)
·Vasopressors (e.g., norepinephrine 0.05 to 2 mcg/kg/min IV) if blood pressure stays low despite fluid resuscitation

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NCLEX trap

·Give pain relief right away. Pain medicine does NOT erase the danger signs that tell you the belly lining is irritated — pain when you let go after pressing (rebound tenderness), a stiff belly (guarding), muscles that tighten on their own (rigidity). Pain medicine actually LETS you do a reliable exam. When someone is in severe pain, their belly muscles tighten as a reflex, so you cannot tell if real danger signs are there underneath. Current guidelines (ACEP, ACS) say early pain control improves your exam accuracy and does not hide serious findings. Always treat the pain.
·A fast heart rate in someone with sudden, severe belly pain is the body trying to keep up with serious trouble: the belly lining is inflamed (irritated and swollen), fluid or blood is leaking out of blood vessels into the belly, or a life-threatening infection is starting to spread into the blood. A fast heart rate PLUS a stiff belly or pain when you let go after pressing means a surgical emergency or shock (the body cannot keep blood pressure and oxygen delivery normal). Do not assume it is just nerves. Move fast — start IV fluids, get imaging, and call surgery.
·No belly sounds when someone has sudden, severe belly pain means the intestines have stopped moving. This is called paralytic a stalled gut (ileus) (the intestines go quiet and still). It happens because the belly lining is inflamed, or something is blocking the intestines, or the blood supply to the bowel is cut off. It is NOT a harmless stomach ache. The body shuts down the intestines to protect itself when danger is present inside the belly. Never give a laxative in acute abdomen — it can make a blockage or a hole much worse. Get imaging and call surgery.
·Touching and pressing on the belly is essential when someone has sudden, severe belly pain. A stiff belly (like pressing on a wooden board), pain when you let go after pressing (rebound tenderness), and muscles that tighten on their own (involuntary guarding) tell you the belly lining is irritated. These signs mean a surgical emergency until proven otherwise. A CT scan confirms WHAT is wrong, but it does NOT replace what you learn by touching the belly. If the belly is stiff PLUS signs of peritoneal irritation (inflamed belly lining) are there, act right now — do not wait for the scan to come back. Start IV fluids, give antibiotics if infection is suspected, call surgery, and THEN get the scan.
·Fever PLUS a stiff belly PLUS signs of shock (fast heart rate, low blood pressure, confusion, cool and damp skin) can come from many catastrophic causes: a hole in the stomach or intestine (perforated ulcer, perforated bowel), tissue dying from blocked blood supply (mesenteric starved blood flow (ischemia), volvulus), severe bleeding (ruptured aneurysm, ectopic pregnancy), or overwhelming infection (perforated appendix with abscess, necrotizing pancreatitis). Keep ALL dangerous causes in mind. If the pain is worse than what you see on exam (the belly looks okay but the patient is screaming), OR the lactate level is rising (a waste chemical that goes up when tissues are starving for oxygen), think mesenteric starved blood flow (the intestines are dying from low blood flow) until you rule it out with imaging or surgery. Time is critical — every hour of delay increases the chance of bowel death, septic shock, and death.

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