The Acute Abdomen

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The Acute Abdomen

• Raymond Yiu
• Surgery Team 3

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• Acute Life-threatening intra-abdominal conditions
• Requires Emergency admissions
• Often requires Emergency surgery

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Aetiology Abdominal Pain

• EXTRAABDOMINAL
• Cardiovascular MI
• Metabolic DKA
• Abdominal wall rectus sheath haematoma
• Neurogenic referred pain
• INTRABDOMINAL
• Imflammatory
• Traumatic
• Obstructive
• Vascular

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INTRABDOMINAL

• Imflammatory Conditions (Peritonitis)
• Localised / Generalised
• Primary / Secondary / Tertiary
• Traumatic Blunt / Penetrating Injury
• Bleeding / Peritonitis
• Obstructive Gastric/ Small / Large Bowel
• Vascular Mesenteric infarction
• Strangulated hernias
• Volvulus (small or large bowel)
• Rupture AAA
• Aortic dissection

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Imflammatory Conditions

• Peritonitis

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Peritonitis

• Bacteria
• primary/ secondary/ tertiary spontaneous
• Chemical

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Peritonitis Bacterial

• secondary majority of cases
• perforated viscus / GIT
• primary very rare
• healthy people in absence of surgery and
  trauma (children and young adult females)
• streptococcal pneumoniae/ gonococcus
• laparotomy washout antibiotics
• tertiary ICU patients
• persistent/ recurrent sepsis following
  adequate therapy of secondary peritonitis
• poor prognosis

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Spontaneous bacterial peritonitis

• Immunocompromised patients with ascites,
  cirrhosis, renal failure on CAPD, nephrotic
  syndrome
• Gram negative organisms
• E. Coli in ascites (bacterial translocation)
• Present with abdominal pain, fever, generalised
  perionitis
• Ascitic fluid tap?white cells, gm stain, culture
• Treatment by iv cephalosporins, intraperitoneal
  antibiotics (vancomycin/netelmicin for gm ve
  organisms)

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Peritonitis Chemical

• Leakage of irritant fluids ie urine, bile, acid
• leading to initial chemical peritonitis
• Later secondary infection occurs after a few
  hours
• Clinical Examples PPU, Bile leak from cystic
  duct stump post cholecystectomy

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PeritonitisClinical Features

• Abdominal pain (recent onset)
• Irritation of somatic nerves supplying parietal
  peritoneum
• Constant, sharp, aggravated by movement
• May be referred to other parts of body (eg
  shoulder-tip pain in acute cholecystitis)

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PeritonitisClinical Features

• Systemic Fever
• Tachycardia
• Leucocytosis
• Chills/rigors
• Dehydration
• Abdominal tenderness, guarding, rigidity,absent
  BS, distention (ileus)

Generalised
localised
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PeritonitisLocalisation of signs and pathology
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PeritonitisClinical Features
Pancreatitis
Liver abscess
PPU
Cholecystitis Cholangitis
Diverticultis
Meckels diverticultis Small bowel perf
Appendicitis
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Acute abdomenCommon conditionsAppendicitisCho
lecystitis
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Acute appendicitis aetiology
Obstruction of lumen by Lymphoid
hyperplasia Faecolith Parasites Cancer/ carcinoid
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Acute appendicitis Clinical Features
7 population 10-30 years Mortality rate
lt1 5 Elderly and young (delay in
diagnosis)
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Acute appendicitis

• RLQ pain
• Pain migration
• Anorexia, nausea

• RLQ tenderness
• RLQ guarding
• RLQ rebound
• Fever
• Leucocytosis (80)

Mcburneys point
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Acute appendicitis Signs
Rovsings sign Pain in RLQ on pressing
LLQ Dumphys sign Pain on coughing
Psoas sign
Obturator sign
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Acute appendicitis Signs

• Depends on where inflamed appendix is
• Retrocecal Lumbar sign Pain in right flank
• Pelvic irritate bladder dysuria
• irritate rectum diarhoea

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Acute appendicitis Ix
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Acute appendicitis
Open
Laparoscopic
Young women of child bearing age
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Acute appendicitis appendiceal mass

• Usually reflects delayed presentation
• Patient presents with mass in RLQ
• /- peritoneal signs
• Mass represents walling off of appendix by
  surrounding structures
• Rx Osler-schering regime in absence of clinical
  signs
• Conservative rx with IVF and iv antibiotics until
  sx subside (follow by colonoscopy and interval
  appendicectomy 4-6 weeks later)

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Acute Cholecystitis
Remember 4 Fs
Pigment
Calcium
Cholesterol
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Acute Cholecystitis
Chemical peritonitis initally
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Acute Cholecystitisclinical features
Short onset RUQ pain
Fever RUQ peritoneal signs Murphys signs
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Acute CholecystitisImaging
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Acute CholecystitisTreatment

• Short duration of sx (lt5days pain)
• Consider surgery (lap)
• Higher incidence of conversion
• Longer duration of sx (gt5days)
• conservative treatment by npo, iv antibiotics
• Followed by lap cholecystectomy 6-8 weeks later
• Any signs of perforation requires urgent surgery
• Interval cholecystitis
• Unfit patients
• cholecystostomy

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Intestinal Obstruction
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Aetiology

• Extramural adhesions
• hernias (int/ext)
• tumor
• Intramural tumor
• stricture (radiation/crohns/tb)
• Intraluminal Food bolus
• GS
• FB
• Faecal impaction

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Aetiology by incidence (SBO)

• Previous OT adhesions
• Virgin abdomen carcinoma, hernias

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Questions to ask?

• Site Stomach vs SB vs LB
• Presentation Acute vs Subacute
• Urgency simple mechanical vs strangulating

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Site Sx
Gastric outlet Small bowel Large bowel
Pain Epigastric Central colic Lower colic
Vomiting Early Early/late Late/none
BO/flatus Normal Normal/ none none
Distension upper General General/ localised (just LB)
Ausculatation Sucussion splash Hyperactive BS Hyperactive BS
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Site X-ray
Mainly LB dilatation (SB if competent ICV)
AXR
Large gastric bubble
Mainly SB dilatation (no LB or rectal gas)
Gastric outlet obstruction
LB obstruction
SB obstruction
Contrast enema (Watersoluble)
RT decompression OGD Oral contrast study
Virgin abdo
Previous OT
Ca caecum hernias
adhesions
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Presentation Acute vs Subacute SBO

• Acute
• short onset
• May require laparotomy if does not resolve
• Subacute
• on/off symptoms that subside but does not
  completely resolve
• Investigate (eg colonoscopy) if subside
• Repeated attacks may require laparotomy

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Simple Mechanical Obstruction
Strangulating
vs
Can wait
Cannot wait
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Simple Mechanical Obstruction
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Simple Mechanical ObstructionFemoral hernias
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Strangulating obstruction

• Vascular supply compromised
• Can occur in any type of obstruction
• Closed loop obstruction (eg volvulus, LBO with
  competent ICV)
• Intussusception
• Stangulation of mesenteric blood supply (adhesive
  band, hernias)

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Sigmoid Volvulus
Example of close loop obstruction both ends of
the bowel are blocked and air enters in a one-way
valve
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Sigmoid Volvulus
Decompression bedside sigmoidoscopy or
colonoscopy
failure
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intussusception
Usually associated with polyps acting as lead
point
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Small bowel ischemia
Prolonged strangulation from adhesion band, hernia
Small bowel volvulus
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Recognising bowel ischemia

• Awareness is the most important
• Pain out of proportion to abdominal signs
• Peritoneal signs (may be late)
• Sepsis (fever, high WCC, shock , acidosis)

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Management
Hx and exam Initial Mx Baseline Ix Special
Ix Preparation for OT
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History and Examination
Discharge Diagnosis 1972 1977
1993 Undifferentiated 41 39 25
GI causes 13 19 18
Gastroenteritis 7 12
5 Surgical GI 10 18
8 UTI 11 -- 11
Pelvic Disorder 12 --
12

Brewer, Am J Surg, 1976 Jazon, AC Scand,
1982 Powers, AJEM,

• History examination and simple lab tests have
  about a 50-60 accuracy in giving a diagnosis

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Pattern Recognition is very important !
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Pattern Recognition
Central colicky abdo pain? shifts to RLQ region
RLQ peritoneal signs Temp 38 C
Young male
appendicitis



RUQ peritoneal signs (Murphys) Temp 38 C
ElderlyObese female
Acute cholecystitis



RUQ pain
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Initial Mx
NGT
NPO
analgesia
Resuscitation IVF
Iv antibiotics
Monitoring devices
Foley (CVP)
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Baseline Laboratory testing
Blood tests Plain X-rays ECG

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WBC

• Limited utility
• WBC gt 11,000 LR 2
• lt 11,000 LR- 0.5
• WBC alone doesnt distinguish patients with
  surgical disease from non-specific abdominal pain
  

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Liver function tests

• ? Bilirubin/ALP suggestive of biliary
  obstruction
• ? Bilirubin/ ALT suggestive of hepatitis
• Normal LFT in up to 40 with acute cholecystitis
• May be deranged in all types of sepsis. Not
  specific for any disease entity

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Amylase

• ? in acute pancreatitis
• May be normal in 40 cases of pancreatitis
• Raised in other intra-abdominal conditions eg
  PPU, hyperamylassaemia, renal failure

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Urinalysis

• Pregnancy test ------gt Mandatory for all young
  females
• (ectopic)
• WBC
• UTI
• Haemuturia (RBC)
• Renal colic (LR 2 , LR- 0.3)
• Hematuria occurs in up to 30 with AAA
• Most common misdiagnosis in AAA- kidney stone

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Plain X-rays
Sensitive for free air 90-95

• Aerobilia (RPC, GS ileus)

Bowel obstruction- 70 sensitive
Renal stones 90 radio-opaque GS 10 Normal
X-rays does not exclude acute abdomen!
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Special investigations

• History examination and simple lab tests have
  about a 50-60 accuracy
• Technological advances in imaging are responsible
  for our increased accuracy in diagnosing patients
  with acute abdominal pain
• CT
• Ultrasound

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Imaging-Ultrasound
Good first line investigation for most
intra-abdominal conditons
Non-invasive, no radiation
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Imaging-Ultrasound
Biliary tract Cholecystitis Cholangitis
Appendicitis Gynaecological
conditions Ovarian cysts (rupture,
torsion) Ectopic(TVS) Urological conditions
(renal, ureteric stones, hydronephrosis)
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CT scan
High accuracy in most acute abdominal conditions

• GI
• Small/ large bowel obstruction
• Diverticulitis (hinchey grading)
• Vascular
• AAA (esp leaking)
• Aortic dissection
• Mesenteric ischemia
• Hepatobiliary
• Biliary tract (stones)
• Rupture HCC
• Pancreatitis

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Contrast Enema
LB obstruction
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Hx and exam
Baseline Ix CBC, RFT, LFT, Amylase, AXR,
CXR Initial MX
peritonitis
No peritoneal signs or equivocal
Equivocal signs
Operation
Further Ix CT/USS
Serial Examination
peritonitis
Def RX
Peritonitis or condition requiring surgery
Diagnosis
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Preoperative preparation
Informed consent IV antibiotics X-match Optimize
comorbidities Booking of emergency OT