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A D V E R T I S E M E N T
A D V E R T I S E M E N T
The acute or surgical abdomen is a surgical emergency due to a major intraabdominal pathologic process. The abdominal cavity, bounded by transversalis fascia, encompasses both “intraperitoneal” and extraperitoneal structures (see surgical anatomy of the abdomen.) When the process impinges on the peritoneal space, peritoneal pain receptors are activated causing involuntary abdominal muscle guarding (parietal peritoneum) and rebound (visceral). Inflammatory mediators released by white cells in the peritoneal cavity elicit a chemotactic response from the peritoneum which sticks to the inflamed area and walls off the process as an evolutionary defense mechanism against free perforation. Steroids and other immunocompromising conditions blunt this mechanism. The surface area of the peritoneum is greater than the skin surface, so diffuse peritonitis is akin to a total body burn in its metabolic effect. Peritonitis and subsequent abscess (see pelvic abscess following appendectomy) can lead to death by multi-organ failure.
A D V E R T I S E M E N T
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The last few centimeters of the distal esophagus are intraabdominal and may cause peritonitis by iatrogenic rupture (see esophageal perforation) during endoscopy or traumatic rupture from violent vomiting on a full stomach (Boerhaave’s syndrome). Paraesophageal hernia (see paraesophageal hernia mobilization) can incarcerate and strangulate part or all of the stomach in the chest and become a surgical emergency.
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A D V E R T I S E M E N T
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Perforated gastric or duodenal ulcer leads to the most virulent peritonitis because of gastric acid spillage. As the spillage spreads over the course of a few hours, the peritoneal pain results in a rigid abdomen and an immobile patient because every movement hurts. The early tracking of spillage directed by the root of the small bowel mesentery toward the right lower quadrant can mimic appendicitis. A third of patients with perforated ulcer have no antecedent history and 50% have free air (see pneumatosis cystoides intestinalis and pneumoperitoneum) under the diaphragm on upright chest X-ray at 6 hours.
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This page was last modified on 4/28/2006.
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