Acute Abdomen and Appendix

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Acute Abdomen and Appendix
Xu Xiao M.D. Ph.D.
Department of Hepatobiliary and Pancreatic Surgery
The First Affiliated Hospital, College of
Medicine, Zhejiang University
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Part ? Acute Abdomen
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Definition of acute abdomen

• Acute abdominal pain
• the patient feel pain anywhere between chest and
  groin. This is often referred to the stomach
  region or belly
• sudden, severe abdominal pain that is less than
  24 hours in duration
• medical emergency in many cases, requiring urgent
  and specific diagnosis. Several causes need
  surgical treatment

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• Classification

• Physiology of abdominal pain

• Diagnosis

• Differential diagnosis

• Treatment

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 Classification

• Internal acute abdomen
• Refers to the existing medical disease which can
  induce abdominal pain with no surgical or
  gynecological indications, abdominal pain can be
  alleviated after existing medical disease control
  with the comprehensive examination and dynamic
  observation
• Such as acute myocardial infarction, acute
  mesenteric lymphadenitis, abdominal purpura,
  abdominal epilepsy, acute non-specific
  appendicitis
• Surgical acute abdomen
• Refers to the existing abdominal pain caused by
  some diseases which need surgical treatment

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 Classification of surgical acute abdomen

• Peritonitis is the most specific term
• Five types
• Perforation perforated ulcer, intestinal
  perforation
• Parenchymatous organic rupture
• hepatorrhexis, splenic rupture
• Inflammatory acute peritonitis, appendicitis
• Obstruction intestinal obstruction
• Strangulation mesenteric thrombosis

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The Physiology of Abdominal Pain

• Visceral Pain
• The most common form of pain
• Manifestation of damaged or injured internal
  organs
• Many forms of visceral pain are particularly
  prevalent in women and are associated with their
  reproductive life
• period pains, labour pain or
  postmenopausal pelvic pain
• For both men and women, pain of internal origin
  is the number one reason to consult a doctor

pain
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The Physiology of Abdominal Pain

• Parietal Pain
• Corresponds to the segmental nerve roots
  innervating the peritoneum
• Tends to be sharper and better localized
• Caused by pneumonia empyema pneumothorax
  tuberculosis neoplasm or the accumulation of
  fluid resulting from heart, liver, or kidney
  disease
• Aggravated by respiration and thoracic movements
  

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The Physiology of Abdominal Pain

• Referred Pain
• (sometimes referred to as reflective pain)
• Referred pain is a term used to describe the
  phenomenon of pain perceived at a site adjacent
  to or at a distance from the site of an injurys
  origin.
• One of the best examples
• myocardial infarction (heart attack) pain is
  often felt in the neck, shoulders, and back
  rather than in the chest, the site of the injury

surface areas of referred pain from different
visceral organs
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Common Causes of Acute Abdomen

• Appendicitis
• Peritonitis
• Bowel Perforation
• Pancreatitis
• Diverticular disease
• Cholecystitis

• Perforating gastric/duodenal ulcer
• Ruptured ectopic pregnancy
• Ruptured or hemorrhagic ovarian cyst
• Pelvic inflammatory disease
• Abdominal aortic aneurysm
• Tubo-ovarian abscess

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Diagnosis

• History
• Physical examination
• Laboratory Findings
• Imaging studies
• Diagnostic laparoscopy
• Atypical patients

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History

• Type of onset
• Sudden - rupture of viscus, mesenteric
  thrombosis
• Gradual - cholecystitis, appendicitis
• Quality
• Dull - initial epigastric pain of appendicitis
  
• Sharp - renal or biliary colic or obstruction
  of gut
• Aching - pelvic inflammatory disease
• Pleuritic - intensified by breathing
• Lancinating - acute pancreatitis
• Tearing - dissecting aneurysm

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History

• Intensity
• Severe - rupture of viscus or blood in the
  peritoneal cavity
• Moderate - RLQ appendiceal mild peptic ulcer,
  without perforation
• Features
• Pulsatile - abdominal aneurysm
• Continuous - acute pancreatitis

• Frequency duration

Transient pain of short duration which does
not recur is usually insignificant. The longer
the duration the more likely a surgical condition
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History

• Factors which intensify or relieve pain
• Relation to meals - peptic ulcer pain relieved
  by food, cholecystitis pain aggravated by fatty
  meal
• Posture jack-knifing - leg drawn up to decrease
  peritoneal irritation in suppurative appendicitis
• Motion - any movement causes intense pain in
  generalized peritonitis and the patient lies
  motionless

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History

• Associated nausea and vomiting
• Nausea vomiting - reflex, or irritative
  non-specific vomiting occurs in many conditions
• Such as acute appendicitis, anorexia always
  occurs and vomiting, if it occurs, usually
  follows abdominal pain rather than preceding it,
  as in gastroenteritis
• Repeated vomiting of large amounts occurs in
  gut obstruction, is often bile stained and may
  become fecal

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History

• Diarrhea
• Most occur with acute gastroenteritis or food
  poisoning
• May also occur with appendicitis or other focal
  inflammatory lesions of the gut
• Constipation or obstipation
• With complete small bowel obstruction -
  unrelenting constipation (obstipation)
• Progressive constipation with carcinoma of the
  large bowel
• Gas stoppage with decreased or absent bowel
  sounds - paralytic ileus

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Physical Examination

• Overall appearance ( Facial expression,
  diaphoresis, pallor, and degree of agitation)
• Inspection scars, hernias, masses

• Palpation The most critical step
• Tenderness
• Rigidity and guarding
• Board-like abdomen
• Rebounding pain

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Physical Examination

• Auscultation
• Hyperactive BS(bowel sound) , hypoactive
  BS or silent BS
• Percussion
•   Digital examination of rectum

• A routine part of the physical examination
• Check for problems with organs or other
  structures in the pelvis and lower belly

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Laboratory Findings

• WBC-DC (differential counting )
• The total leukocyte count and percentage of
  polymorph nuclear cells are usually elevated in
  acute inflammatory conditions
• Whereas early in the course of intestinal
  obstruction there may be no significant
  alterations
• Urinalysis
• Blood in the urine suggest disease of the
  urinary tract and can also result from an
  inflamed appendix lying in proximity to the
  ureter or bladder
• In dehydration the specific gravity of the urine
  may be increased, and the red cell and hemoglobin
  values

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Laboratory Findings

• Amylase, lipase
• Serum amylase values in excess of 500 units are
  significant and levels of 1500-2000 units or more
  are not unusual in the early stages of severe
  acute pancreatitis.
• ß-HCG (human chorionic gonadotrophin)
• woman of childbearing age
• Bilirubin, ALT, AST, Alkaline phosphatase

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Imaging Studies

• Standing CXR and KUB
• Ultrasound for solid organs
• CT of abdomen for abscess, free air, vessel,
  tumor and ischemia bowel
• Angiography Especially in non-diagnostic
  ischemia bowel

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Imaging Studies
Gastric ulcer
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Imaging Studies
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Imaging Studies
Pneumoperitoneum
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Imaging Studies
Incomplete intestinal obstruction
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Imaging Studies
Cholecystitis

• Pancreatitis
• Effusion
• A buildup of fluid

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Imaging Studies
Gall stone
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Imaging Studies
Hemorrhage of large hepatocellular carcinoma
TACE (Transcatheter Arterial Chemoembolization )
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Imaging Studies
Biliary ascariasis
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Diagnostic Laparoscopy

• A high sensitivity and specificity

• Decreased morbidity and mortality

• Decreased length of stay

• Decreased overall hospital costs

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Atypical Patients

• Pregnancy

• Acute Abdomen in the Critically Ill

• Immunocompromised Patients With Acute Abdomen

• Acute Abdomen in the Morbidly Obese

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(1) Pregnancy

• The reasons for delayed diagnosis

• The underlying pregnancy has symptoms similar
  with acute abdomen, including abdominal pains,
  nausea, vomiting, and anorexia
• Pregnancy can alter the presentation of some
  disease processes and make the physical
  examination more challenging because of the
  enlarged uterus in the pelvis
• Pregnancy can alter the laboratory findings,
  such as white blood cell counts
• Pregnancy can influence the doctors decision to
  perform typical imaging studies because of
  concern about radiation exposure to the
  developing fetus

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(1) Pregnancy

• Most common surgical diseases seen in pregnancy

• Appendicitis
• Appendicitis is the most common
  nonobstetric disease requiring surgery, occurring
  in 1 of 1500 pregnancies
• Biliary tract disorders
• Surgery for biliary disease occurs in 1
  to 6 per 10,000 pregnancies. Symptoms of pain,
  nausea, and anorexia are the same as in
  nonpregnant patients
• Bowel obstructions
• Bowel obstructions are much less common,
  occurring in about 1 or 2 per 4000 deliveries

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(2)Acute Abdomen in the Critically Ill

• The reasons for delayed diagnosis

• Many of the underlying diseases and treatments
  encountered in the intensive care unit can
  predispose to acute abdominal disease
• Critically ill patients are often unable to
  appreciate symptoms to the same degree as healthy
  peers because of nutritional or immune
  compromise, narcotic analgesia, or antibiotic use

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(3) Immunocompromised Patients With Acute Abdomen

• The reasons for delayed diagnosis

• Immunocompromised patients have variable
  presentations with acute abdominal diseases. The
  variability is highly correlated to the degree of
  immunosuppression

• Most common Immunocompromised Patients

• Elderly, malnourished, and diabetic patients
• Transplant recipients on routine maintenance
  therapy
• Cancer patients renal failure patients
• HIV patients

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(4) Acute Abdomen in the Morbidly Obese

• The reasons for delayed diagnosis

• Alterations in the signs and symptoms of
  peritonitis in the morbidly obese
• Exam findings can also be difficult to confirm
  distention or intra-abdominal mass because of the
  size and thickness of the abdominal wall.
• Abdominal imaging is also adversely affected by
  obesity

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Treatment for Acute Abdomen
Effective management of acute abdominal pain
involves a careful history taking, ultrasound,
electrocardiography and blood tests. Computed
tomography of abdominal organs and visceral
vessels is probably important already at the
beginning of the diagnostic work up
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Treatment Algorithms (1)
Algorithm for the treatment of acute-onset
severe, generalized abdominal pain
CT, computed tomography NG, nasogastric
tube NL, normal study OR,
operation
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Treatment Algorithms (2)
Treatment of gradual-onset severe, generalized
abdominal pain.
CT, computed tomography ERCP, endoscopic
retrograde cholangiopancreatography LFTs, liver
function tests
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Treatment Algorithms (3)
Algorithm for the treatment of right upper
quadrant abdominal pain
CT, computed tomography ERCP, endoscopic
retrograde cholangiopancreatography LFTs, liver
function tests NL, normal study US,
ultrasound.
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Treatment Algorithms (4)
Algorithm for the treatment of left upper
quadrant abdominal pain
CT, computed tomography
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Treatment Algorithms (5)
CT, computed tomography hx, history OR,
operation UTI, urinary tract infection
Algorithm for the treatment of right lower
quadrant abdominal pain
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Treatment Algorithms (6)
Algorithm for the treatment of left lower
quadrant abdominal pain
CT, computed tomography
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Preparation for emergency operation

• IV access
• Antibiotic infusions
• Nasogastric tube
• Foley catheter bladder drainage
• Hydroelectrolytic equilibration
• Crossmatched blood available

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Summary

• Acute abdomen remains a challenging part of a
  surgeon's practice
• KEY A patient with an acute abdomen is an
  EMERGENCY, and it is IMPERATIVE to get a correct
  diagnosis
• Although advances in imaging techniques, a
  careful history and physical examination remain
  the most important part of the evaluation
• Perform a laparoscopy or laparotomy for
  diagnosis with a good deal of uncertainty as to
  the expected findings

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Case Study
20-Year-Old Male with Abdominal Pain for 18
Hours

• History

• Pain started in the Mid-Abdomen
• Constant
• Anorexia, Nausea, and Vomiting
• First Episode
• No Diarrhea, Dysuria
• Pain Now Seems Worse in the Right Lower Abdomen

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Case Study

• Physical Exam

• Lying flat, avoids moving
• Afebrile
• Abdomen tender mostly in the RLQ
• Significant guarding
• Positive Roving's Sign

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Case Study

• Lab Data

• WBC 14109/L
• AST,ALT Normal
• Amylase, Lipase Normal
• Urine Culture Negative

• Further Testing

• CT scan

• Diagnosis?

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Part ? Appendix

• Appendicitis
• Appendiceal Abscess

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Appendicitis

• Reginald Fitz first described acute and chronic
  appendicitis in 1886
• It has been recognized as one of the most
  common causes of severe acute abdominal pain
  worldwide
• Appendicitis is a condition characterized by
  inflammation of the appendix Vermiform appendix
• All cases require removal of the inflamed
  appendix, either by Laparotomy or laparoscopy.
• Untreated, mortality is high, mainly because of
  peritonitis and shock

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Appendicitis

• Anatomy and position
• Pathophysiology
• Diagnosis
• Differential Diagnoses
• Treatment
• Outcome

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Anatomy and position

• Anatomy
• A closed-ended, narrow tube up to several
  inches in length that attaches to the cecum like
  a worm
• The inner lining of the appendix produces a
  small amount of mucus that flows through the open
  center of the appendix and into the cecum
• The wall of the appendix contains lymphatic
  tissue that is part of the immune system for
  making antibodies
• Position

post-ileal
Para-caecal

• The vermiform appendix has no constant position
• The appendix is more often found in the pelvic
  rather than the retrocaecal position

Pre-ileal
retrocaecal
pelvic
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Pathophysiology

• Acute appendicitis is thought to begin with
  obstruction of the lumen
• Obstruction can result from food matter,
  adhesions, or lymphoid hyperplasia
• Mucosal secretions continue to increase
  intraluminal pressure

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Pathophysiology

• Acute simple appendicitis
• Acute purulent appendicitis
• Acute gangrenous appendicitis

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Diagnosis

• History
• Physical Examination
• Laboratory Studies
• Radiography
• Diagnostic Laparoscopy

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History

• Primary symptom abdominal pain
• Pain beginning in epigastrium or periumbilical
  area that is vague and hard to localize
• Associated symptoms indigestion, discomfort,
  flatus, need to defecate, anorexia, nausea,
  vomiting
• Migration of pain from initial periumbilical
  to RLQ was 64 sensitive and 82 specific
• Anorexia is the most common of associated
  symptoms
• Vomiting is more variable, occuring in about ½
  of patients

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Physical Examination

• Findings depend on duration of illness prior to
  exam
• Early on patients may not have localized
  tenderness
• With progression there is tenderness to deep
  palpation over McBurneys point
• McBurneys Point just below the middle of a
  line connecting the umbilicus and the ASIS
  (anterior superior iliac spine)
• Rectal exam pain can be most
• pronounced if the patient has
• pelvic appendix

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Physical Examination

• Roving's sign
• Pain in RLQ with palpation to LLQ
• A sign of appendicitis. If palpation of the lower
  left quadrant of a person's abdomen results in
  more pain in the right lower quadrant, the
  patient is said to have a positive Rovsing's sign
  and may have appendicitis

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Physical Examination

• Psoas sign
• Place patient in L lateral decubitus and extend R
  leg at the hip. If there is pain with this
  movement, then the sign is positive.
• Occasionally, an inflamed appendix lies on the
  Psoas muscle and the patient will lie with the
  right hip flexed for pain relief.

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Physical Examination

• Obturator sign
• Passively flex the R hip and knee and internally
  rotate the hip. If there is increased pain then
  the sign is positive

• If an inflamed appendix is in contact with the
  obturator internus, spasm of the muscle can be
• demonstrated by flexing and internally
• rotating the hip. This maneuver
• will cause pain in the hypogastrium

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Laboratory Studies

• WBC
• The white blood cell count is elevated with
  more than 75 neutrophils in most patients
• A completely normal leukocyte count and
  differential is found in about 10 of patients
  with acute appendicitis
• A high white blood cell count (gt20,000/mL)
  suggests complicated appendicitis with either
  gangrene or perforation
• Urinalysis
• Be helpful in excluding pyelonephritis or
  nephrolithiasis
• Microscopic hematuria is common in
  appendicitis
• Gross hematuria is uncommon and may indicate
  the presence of a kidney stone

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Radiography

• Plain abdominal radiographs
• Ultrasonography
• Computed tomography (CT)

• CTbest choice based on availability and
  alternative diagnoses
• CTgreater sensitivity, accuracy, predictive
  value

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CT scanning
CT scan of the abdomen or pelvis in a patient
with acute appendicitis may reveal an
appendicolith (arrow)
CT typically shows a distended appendix (arrow)
with diffuse wall-thickening and periappendiceal
fluid (arrowhead)
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Diagnostic Laparoscopy

• A direct examination of the appendix
• A survey of the abdominal cavity for other
  possible causes of pain.
• Primarily for women of childbearing age in whom
  preoperative pelvic ultrasound or CT scan

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Diagnostic Algorithm

Algorithm for the evaluation and management of
patients with possible acute appendicitis based
on surgical assessment of clinical probability of
the diagnosis
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Diagnostic Algorithm

Algorithm summarizing the treatment of acute
appendicitis
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Differential Diagnoses

• Two type A required surgery B not
  required surgery
• Required surgery
• Perforation of gastrointestinal tract ulcer,
  tumor, diverticulitis
• Obstetrics and gynecologic disease ectopic
  pregnancy, ovarian torsion
• Meckels diverticulitis
• Tumor
• Not required surgery
• Pelvic inflammation
• Mesenteric adenitis at exploration a normal
  appendix and enlarged lymph nodes in the
  mesentery
• Viral bacterial gastroenteritis
• Pneumonia, pleurisy

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Treatment

• Surgical removal of appendix is definitive
  treatment
• Incision
• Incision over the point of maximal
  tenderness,generally at McBurny point
• McBurneys incision, tansvers skin incision ,
  36cm long
• Process
• The taenia of the colon are followed to the base
  of the appendix
• Mesoappendix is divided between clamps and
  ligated
• The base of appendix is divided and ligated 0.5cm
  from caceum and inverted using a purse-string
• Suspected case
• Admit the patient to hospital for further
  observation 12-24hrs

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Open Appendectomy (OA)
Anterior cecal artery
Location of possible incisions for an open
appendectomy
cecum
Division of the mesoappendix
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Open Appendectomy (OA)
B. Ligation of the base and division of the
appendix C. Placement of purse-string suture or
Z stitch D. Inversion of the appendiceal stump
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Laparoscopic Appendectomy (LA)
Location of port sites for laparoscopic
appendectomy
Division of the mesoappendix using the harmonic
scalpel
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Laparoscopic Appendectomy (LA)
Placement of an absorbable Endoloop encircling
the base of the appendix
Division of the appendix between Endoloops
Placement of the appendix into a specimen bag
before removal of the appendix with the umbilical
port
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Antibiotic thearpy

• The differentiation between simple appendicitis
  and gangrenous appendicitis/perforated
  appendicitis with peritonitis should determine
  the length of antibiotic administration

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Appendiceal Abscess

• An abscess in the peritoneal cavity resulting
  from the spread of infection in acute
  appendicitis, especially with perforation of the
  appendix. Also called periappendiceal abscess.
• Imaging studies are useful both in confirming
  the diagnosis and in evaluating the size of any
  abscess present
• Those patients with smaller abscesses or
  phlegmon and who are not sick may be successfully
  managed initially with antibiotics alone.
• Patients who continue to have fever and
  leukocytosis after several days of nonoperative
  treatment are likely to require appendectomy
  during the same hospitalization, whereas those
  who improve promptly may be considered for
  interval appendectomy

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Diagnostic Algorithm

Algorithm for the management of appendiceal
abscess
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Outcomes

• The mortality rate after appendectomy is less
  than 1.
• Surgical site infections are the most common
  complications seen after appendectomy.
• Small bowel obstruction occurs in less than 1
  of patients after appendectomy for uncomplicated
  appendicitis and in 3 of patients with
  perforated appendicitis who are followed for 30
  years.
• The risk for infertility following appendectomy
  in childhood appears to be small.
• There are rare reports of appendicocutaneous or
  appendicovesical fistulas after appendectomy,
  typically for perforated appendicitis.

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Thanks !