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ACUTE ABDOMEN

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Title: ACUTE ABDOMEN


1
ACUTE ABDOMEN
  • Done by- Fatima Salim

2
INTRODUCTION
  • Is the most common presenting surgical emergency.
    It has been estimated that at least 50 of
    general surgical admissions are emergencies and
    50 of them present with acute abdominal pain.
  • Studies have shown a 30-day mortality of 4 among
    patients admitted with acute abdomen. So, it
    represents a significant part of the general
    surgical workload. The aim is to differentiate
    serious causes from less serious causes of acute
    abdominal pain.

3
INTRODUCTION
  • Acute abdomen is a term used to encompass a
    spectrum of surgical, medical and gynecological
    conditions, ranging from the trivial to the
    life-threatening, which require hospital
    admission, investigation and treatment.
  • The acute abdomen may be defined generally as an
    intra-abdominal process causing severe pain
    requiring admission to hospital, and which has
    not been previously investigated or treated and
    may need surgical intervention.

4
INTRODUCTION
  • The mortality rate varies with age, being the
    highest at the extremes of age.
  • The highest mortality rates are associated with
    laparotomy for unresectable cancer, ruptured
    abdominal aortic aneurysm and perforated peptic
    ulcer.
  • Most common causes in any population will vary
    according to age, sex and race, as well as
    genetic and environmental factors.

5
Causes-
  • A. Gastrointestinal-
  • 1-Gut
  • Acute appendicitis
  • Intestinal obstruction
  • Perforated peptic ulcer
  • Diverticulitis
  • Inflammatory bowel disease
  • Acute exacerbation of peptic ulcer
  • Gastroenteritis
  • Mesensteric adenitis
  • Meckels diverticulitis
  • 2-Liver and biliary tract
  • cholecystitis
  • cholangitis
  • Hepatitis
  • biliary colic
  • 3-Pancreas
  • Acute pancreatitis
  • 4-Spleen
  • Splenic infarct and spontaneous rupture

6
Causes-
  • B. Urinary tract
  • Cystitis
  • Acute pyelonephritis
  • Ureteric colic
  • Acute retention
  • C. Vascular
  • Ruptured aortic aneurysm
  • Mesenteric embolus
  • Mesenteric venous thrombosis
  • Ischemic colitis
  • Acute aortic dissection
  • D. Abdominal wall conditions
  • Rectus sheath haematoma
  • E. Peritoneum
  • Primary peritonitis
  • Secondary peritonitis

7
Causes-
  • F. Retroperitoneal
  • Hemorrhage e.g anticoagulants
  • G. Gynecological
  • Torsion of ovarian cyst
  • Ruptured ovarian cyst
  • Fibroid denegeration
  • Ovarian infarction
  • Salpingitis
  • Pelvic endometriosis
  • Severe dysmenorrhea
  • Endometriosis

8
Causes-
  • H. Extra-abdominal causes
  • Lobar pneumonia
  • Pleurisy
  • MI
  • Sickle cell crisis
  • Uremia
  • Hypercalcemia
  • DKA
  • Addisons disease
  • Acute intermitent porphyria

9
Classification with age
  • Children
  • Gastroenteritis
  • Mesentric adenitis
  • Meckels diverticulitis
  • Intussusception
  • Henoch-schonlein purpura
  • Adult
  • Regional enteritis
  • Ureteric colic
  • Perforated ulcer
  • Testicular torsion
  • Pancreatitis

Adult female Salpingitis Pyelonephritis
Ectopic pregnancy Elderly
Diverticulitis Intestinal obstruction
Colonic carcinoma Mesentric infarction
Aortic aneurysm
10
Relation of pain to embryology
  • Intestine and its outgrowths (the liver, biliary
    system and pancreas)-gt midline.
  • Irritation of foregut structures
  • (oesophagus to the second part of the duodenum)
  • -gtepigastric area.
  • Midgut structures
  • (the second part of the duodenum to the splenic
  • flexure) -gtumbilicus.
  • Hindgut structures (the splenic flexure to the
    rectum)-gt
  • hypogastrium.

11
Management
  • History
  • Physical examination
  • Management
  • History-
  • Biodata
  • Age
  • Mesenteric adenitis in children
  • Diverticulitis in elderly
  • Gender

12
  • Characteristics of abdominal pain
  • Site
  • Time and mode of onset
  • Severity
  • Nature/Character
  • Progression
  • Radiation
  • Duration
  • Cessation
  • Exacerbating/relieving factors
  • Associated symptoms

13
Site-pain
  • Whole abdomen
  • Peritonitis or mesentric
    infarction
  • Right upper quadrant
  • Acute cholycystitis
  • Cholangitis
  • Hepatitis
  • Peptic ulceration
  • Left upper quadrant
  • Peptic ulceration
  • Pancreatitis
  • Splenic infarct

14
  • Right lower quadrant
  • Appendicitis
  • Ovarian cyst Ectopic pregnancy PID
    Right ureteric colic
  • Left lower quadrant
  • Sigmoid diverticular disease
  • Ovarian cyst
  • Ectopic pregnancy
  • PID
  • Left ureteric colic

15
Symptoms--Pain
  • Onset
  • sudden perforation of bowel, smooth muscle
    colic
  • slow insidious onset inflammation of visceral
    peritoneum
  • Severity
  • Patient asked to rate pain from 1-10
  • Ureteric colic is one of worst pains
  • Character
  • Aching-dull pain poorly localised
  • Burning- peptic ulcer symptoms
  • Stabbing-ureteric colic
  • Gripping-smooth muscle spasm e.g. intestinal
    obstruction worse by movement wringing of cloth

16
Symptoms--Pain
  • Progression
  • -Constant e.g. peptic ulcer
  • -Colicky e.g. seconds(bowel), minutes(ureteric
    colic) or tens of minutes (gallbladder
  • -may change character completely from dull
    poorly localized pain to sharp pain indicates
    involvement of parietal peritoneum
    e.g.appendicitis
  • Radiation of the pain
  • Back duodenal ulcer, pancreatitis, aortic
    aneurysm
  • Scapula gall bladder
  • Sacroiliac region ovary
  • Loin to groin ureteric colic
  • Groin testicular torsion

17
  • Cessation-
  • abrupt ending- colicky pains
  • resolving slowly-inflammatory pain, biliary pain
  • Exacerbating/relieving factors-
  • Movement/Rest-inflammatory conditions
  • Food- peptic ulcers

18
History

19
History
  • Past history
  • previous surgery
  • trauma
  • any medical diseases
  • Drug history
  • corticosteroid mask pain
  • anti-coagulant intra-mural hematoma
  • NSAIDS gastritis, peptic ulcer
  • Family history
  • colon cancer
  • IBD

20
Physical Examination
General appearance -Patient is lying
motionless acute appendicitis, peritonitis
-Rolling in bed ureteric colic, intestinal
colic -Bending forward chronic
pancreatitis
21
Physical Examination
Vital signs Temp. low grade
appendicitis, acute cholycystitis high
grade abscess Pulse, BP,
Resp.rate General examination- Conjuctival
pallor cyanosis jaundice Signs of
dehydation Cervical lymphadenopathy -mesentric
adenitis
22
Physical Examination
Cardio-pulmonary examination -MI
-basal pneumonia -pleural
effusion
23
Physical Examination
Abdomen Inspection Palpation
Percussion Auscultation Inspection
-movement with respiration -distension,
peristalsis, mass, scars and any obvious cough
impulse at hernia site
24
Physical Examination
Palpation superficial palpation
-tenderness, rebound tenderness, guarding,
rigidity, masses, hernial orifices deep
palpation -organomegaly Percussion
-tympanic note intestinal obstruction
-dullness over bladder acute retention
25
Physical Examination
Auscultation -silent abdomen peritonitis
-increase bowel sound intestinal
obstruction Dont forget to examine rectum for
tenderness, mass, blood and vaginal examination
for discharge, tenderness( PID).
26
Investigation
  • CBC with differential (infection and
    inflammation)
  • Urea, electrolyte, creatinine, glucose (DKA)
  • LFT
  • Amylase ( high in acute pancreatitis)
  • urinalysis
  • CXR ( basal pneumonia, gas under diaphragm)
  • AXR
  • -distended bowel with air fluid level
  • -stones
  • -calcified aorta
  • -air in biliary tree

27
Investigation
  • U/S (ovarian cyst, ectopic pregnancy)
  • IVU for stones
  • Angiography (mesentric embolus or thrombosis)
  • Sickling test
  • Pregnancy test

28
Treatment
1. Relieve the pain 2. IV fluids and nasogastric
suction 3. Antibiotics in case of peritonitis or
sepsis 4. Surgery if indicated Indication for
surgery If patient has guarding or rigidity
with peritoneal irritation spreading
tenderness Progressive distension or generalized
peritonitis Shock with bleeding or sepsis Free
gas on x-ray Mesentric occlusion on
angiography Blood, pus or bile on paracentesis
29
  • Intestinal
  • Obstruction

30
Intestinal obstruction
  • One of the common cause of acute abdomen
  • May lead to high morbidity and mortality if not
    treated correctly
  • It can be classified into two types
  • Dynamic (mechanical)
  • Adynamic

31
Dynamic
  • 1.Intraluminal impacted faeces, foreign bodies,
    gallstones
  • 2.Intramural tumours, inflammatory strictures,
    congenital atresia
  • 3.Extramural adhesion, hernias, volvulus,
    intussusception, tumours

32
Dynamic
  • also can be divided into
  • 1. Small bowel obstruction (SBO)
  • -high -gtearly perfuse vomiting
  • rapid dehydration
  • -low-gtpredominant pain, and central distention
  • Vomiting delayed
  • air-fluid levels seen on AXR
  • 2. Large bowel obstruction (LBO)
  • early pronounced distension, mild pain
  • vomiting, dehydration late
  • e.g. -carcinoma
  • -diverticulitis or volvulus

33
Adynamic
  • 1.Paralytic ileus (peristalsis is absent)
  • 2.Peristalsis is present in a non-propulsive
    form e.g. mesentric vascular occlusion

34
Obstruction can be-
  • Simple blockage without interfering with
    vascular supply
  • Strangulation significant impairment of blood
    supply most commonly associated with hernia,
    volvulus, intussusception and vascular occlusion
  • -surgical emergency
  • Closed loop obstruction bowel is obstructed
    at both the proximal and distal end)

35
Pathophysiology
  • Irrespective of etiology or acuteness of onset
  • Proximal to obstruction
  • Increased fluid secretion ? abdominal distention
  • Accumulation of gas ? abdominal distention
  • Increased intraluminal pressure
  • Decreased reabsorption with time and flaccidity
    to prevent vascular damage from high pressure
  • Vomiting
  • Dehydration
  • Dilatation of bowel
  • Reflex contraction of smooth muscle ? colicky
    pain
  • Increased peristalsis to overcome obstruction ?
    increased bowel sounds
  • If obstruction not overcome ? bowel atony
  • Distal to obstruction nothing is passed bowel
    collapse ? constipation

36
Symptoms
  • The four cardinal features of intestinal
    obstruction
  • -abdominal pain
  • -vomiting
  • -distension
  • -constipation
  • Vary according to-
  • location of obstruction
  • age of obstruction
  • underlying pathology
  • intestinal ischemia

37
Symptoms
  • Abdominal pain
  • colicky in nature, around the umbilicus in
    SBO while in the lower abdomen in LBO
  • if it becomes continuous, think about
    perforation or strangulation
  • Vomiting
  • -starts early in SBO and late in LBO
  • -vomitus starts with clear color then
    becomes thick, brown and foul ( faeculent)
  • -more with lower or complete obstruction
  • -diarrhea may be present with partial
    obstruction
  • Distension
  • -more with lower obstruction

38
Symptoms
  • Constipation
  • -more with lower or complete obstruction
  • -diarrhea may be present with partial
    obstruction
  • -either absolute (no feces or flatus)lt-cardinal
    in absolute IO
  • or relative (flatus passed)
  • Distension
  • -more with lower obstruction

39
Symptoms
  • In strangulation
  • severe constant abdominal pain
  • distended abdomen
  • fever
  • tachycardia
  • tender abdomen

40
Clinical examination
  • General examination-
  • Vital signs
  • Signs of dehydration tachycardia, hypotension
  • dry mucus membrane, decreased skin turgor,
    decreased urine output
  • Inspection
  • distension, scars, peristalsis, masses, hernial
    orifices
  • Palpation
  • tenderness, masses, rigidity
  • Percussion tympanitic abdomen
  • Auscultation
  • high pitched bowel sound or silent abdomen
  • Examine rectum for mass, blood, feces or it may
    be empty in case of complete obstruction

41
Investigations
  • CBC- WBC (neutrophilia-strangulation)
  • Hb
  • UE
  • Plain AXR
  • Sigmoidoscopy (carcinoma, volvulus)
  • Double Contrast x-ray ( complete or incomplete)
  • CT abdomen

42
Normal Gas PatternAXR
  • Stomach
  • Always
  • Small Bowel
  • Two or three loops of non-distended bowel
  • Normal diameter 2.5 cm
  • Large Bowel
  • In rectum or sigmoid almost always

43
Gas in stomach
Gas in a few loops of small bowel
Gas in rectum or sigmoid
Normal Gas Pattern
44
Normal Fluid Levels
  • Stomach
  • Always (except supine film)
  • Small Bowel
  • Two or three levels possible
  • Large Bowel
  • None normally

45
Always air/fluid level in stomach
A few air/fluid levels in small bowel
Erect Abdomen
46
Large vs. Small Bowel
  • Large Bowel
  • Peripheral
  • Haustral markings don't extend from wall to wall
  • Small Bowel
  • Central
  • Valvulae extend across lumen
  • Maximum diameter of 2"

47
Abnormal Gas Patterns
  • Mechanical Obstruction
  • SBO
  • LBO
  • Functional Ileus
  • Localized (Sentinel Loops)
  • Generalized adynamic ileus

48
Mechanical SBOKey Features
  • Dilated small bowel
  • Fighting loops
  • Little gas in colon, especially rectum
  • Key disproportionate dilatation of SB

49
Small bowel obstruction
50
Mechanical LBO
  • Causes-
  • Tumor
  • Volvulus
  • Hernia
  • Diverticulitis
  • Intussusception

51
Prone
Supine
LBO
52
Mechanical LBOPitfalls
  • Incompetent ileocecal valve
  • Large bowel decompresses into small bowel
  • May look like SBO
  • Get BE or follow-up

53
Carcinoma of Sigmoid,LBO Decompressed into SB
54
Localized IleusKey Features
  • One or two persistently dilated loops of large or
    small bowel
  • Gas in rectum or sigmoid

55
Localized IleusPitfalls
  • May resemble early mechanical SBO
  • Clinical course
  • Get follow-up

56
Generalized IleusKey Features
  • Gas in dilated small bowel and large bowel to
    rectum
  • Long air-fluid levels
  • Only post-op patients have generalized ileus

57
Generalized Adynamic Ileus
Erect
Supine
58
(No Transcript)
59
Treatment
  • Three main measures-
  • - GI drainage
  • FE replacement
  • - Relief of obstruction, usually surgical

60
Treatment
Conservative -Nasogastric aspiration by Ryle
or Salem tube -IV fluids- volume varies
depending on dehydration -NPO -urinary
catheter -check temp. and pulse 2 hourly
-abdominal examination 8 hourly -Broad spectrum
antibiotics initiated early-reduce bacterial
overgrowth
61
Treatment
  • Some cases will settle by using this conservative
    regimen, other need surgical intervention.
  • Surgery should be delayed till resuscitation is
    complete unless signs of strangulation and
    evidence of acute or closed-loop obstruction.
  • Cases that show reasons for delay should be
    monitored continuously for 72 hours in hope of
    spontaneous resolution e.g. adhesions with
    radiological findings but no pain or tenderness
  • The sun should not both rise and set in cases
    of unrelieved obstruction.

62
Treatment
  • Indication for surgery
  • - failure of conservative management
  • - tender, irreducible hernia
  • -strangulation
  • Type of surgery depends upon the nature of the
    cause.
  • Laprotomy is usually done
  • Decompression of obstruction ( by repair of
    hernia, complete lysis of adhesion)

63
Surgical treatment
  • Operative decompression required-
  • if dilatation of bowel loops prevent exposure, if
    bowel wall viability is compromised, or if
    subsequent closure will be compromised.
  • Savages decompressor used within seromuscular
    purse-string suture.
  • Or large-bore NG tube maybe used for milking
    intestinal contents into stomach.

64
Surgical treatment
  • Once obstruction relieved, the bowel is
    inspected for viability, and if non-viable,
    resection is required.
  • Indication of non-viability
  • 1.absent peristalsis
  • 2.loss of normal shine
  • 3.loss of pulsation in mesentry
  • 3.green or black color of bowel

65
Surgical treatment
  • If in doubt of viability, bowel is wrapped in hot
    packs for 10 minutes with increased oxygen and
    reassessed for viability.
  • Sometimes a second look laprotomy is required in
    24-48 hours e.g. multiple ischemic areas.
  • Right sided large bowel lesion is treated by
    right hemicolectomy with covering colostomy

66
Prognosis
  • Simple small bowel obstruction has a very low
    mortality rate but increases in case of
    strangulation
  • Reaches up to 15 in case of large bowel
    obstruction mainly due to perforation

67
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