Surgery: The Acute Abdomen and the Trauma Sequence
What you must know
Surgical questions reward a disciplined sequence: resuscitate, diagnose, then definitive care. The primary survey (airway with cervical spine control, breathing, circulation with haemorrhage control, disability, exposure) applies to every injured patient. In the acute abdomen, decide early which patient needs theatre: generalised peritonitis, perforation, strangulation, uncontrolled haemorrhage or hollow viscus injury. Learn the typical narrative of appendicitis, small and large bowel obstruction, perforated peptic ulcer, acute cholecystitis, pancreatitis and strangulated hernia.
Classic traps
- Analgesia does not mask the diagnosis. Give adequate pain relief; it improves comfort without changing surgical decisions.
- Small bowel obstruction: central colicky pain, bilious vomiting, constipation late. Large bowel obstruction: progressive distension, absolute constipation early, vomiting late.
- Strangulation is suggested by constant severe pain, tachycardia, fever, localised tenderness and leucocytosis. These are theatre indications, not indications for more imaging.
- Elderly and pregnant patients often lack classic findings; a soft abdomen does not exclude serious pathology.
Rule of thumb
Pain migrating from the umbilicus to the right iliac fossa with guarding in a young adult means appendicitis. Pain out of proportion to abdominal findings, especially after eating, suggests mesenteric ischaemia. Always perform a pregnancy test in any woman of reproductive age with abdominal pain, and always examine the hernial orifices in bowel obstruction.