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Acute abdomen

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Acute abdomen

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  1. Acute abdomen Prof. M K Alam M S ; F R C S

  2. Learning objectives • Definition of acute abdomen • Anatomy and physiology of abdominal pain. • Pathophysiology of common causes of acute abdomen. • Symptoms and signs of acute abdomen in relation to the underlying pathology • Laboratory and imaging investigations • Initial and definitive management

  3. Definition Acute abdomen: a clinical presentation of abdominal pain and tenderness, that often requires emergency surgical therapy.

  4. Some non-surgical or non intra-abdominal diseases, can present with acute abdominal pain. • Every attempt should be made to make a correct diagnosis so that an appropriate therapy is given

  5. Anatomy and Physiology of Abdominal pain

  6. Types of abdominal pain • Visceral • Parietal

  7. Visceral pain • Vague, poorly localized • Splanchnic nerves • Usually the result of distention of a hollow viscus • Depending on the origin of the affected organ from the primitive foregut, midgut, orhindgut, the pain is localized to epigastrium, periumbilical , or hypogastrium respectively

  8. Parietal pain -Corresponds to the segmental nerve roots (somatic nervous system) innervating the peritoneum. -Sharper and better localized.

  9. Referred pain Definition:Pain perceived at a site distant from the source of stimulus. Common examples of referred pain: Gall bladder- right subscapular or shoulder Heart, tail of pancreas, spleen- left shoulder (Kehr's sign) Ureter- Scrotum and testis

  10. Pain locations (Great degree of overlap) • Right hypochondrium.- gallbladder • Left hypochondrium.- pancreas • Epigastrium.- Stomach and duodenum • Lumber- kidney • Umbilical- small bowel, caecum, retroperitoneal • Right iliac fossa- Appendix, caecum • Left iliac fossa- Sigmoid colon • Hypogastrium- Colon, urinary bladder, adenexae

  11. Pathophysiology

  12. Surgical Acute Abdominal Conditions • Infection-Appendicitis, cholecystitis • Perforation-Perforated duodenal ulcer, ileum, colon • Obstruction-Small bowel adhesions, obstructed hernia, sigmoid volvulus, carcinoma colon • Ischemia- Mesenteric ischemia (thrombosis/ embolism), strangulated hernia • Hemorrhage-Ruptured ectopic pregnancy, ruptured aneurysm, solid organ-trauma, tumour

  13. Common nonsurgical causes of Acute Abdomen • Diabetic crisis • Uremia • Hereditary Mediterranean fever • Sickle cell crisis • Acute leukemia • Myocardial ischemia

  14. Pathophysiology: Acute appendicitis • Most common general surgical emergency • Derived from the midgut • Obstruction of the lumen (fecalith, lymphoid hyperplasia, vegetable matter or seeds, parasites) - the major cause of acute appendicitis. • Obstruction contributes to bacterial overgrowth,

  15. Pathophysiology: Acute appendicitis • Continued secretion of mucus leads to intraluminal distention. • Distention produces the visceral pain sensation as periumbilical pain. • Promote a localized inflammatory process • May progress to gangrene and perforation. • Inflammation of the adjacent peritoneum- localized pain in RLQ • Perforation usually after 48 hours from the onset of symptoms

  16. Bacterial flora in appendicitis • Polymicrobial • Escherichia coli, Streptococcus viridans, and Bacteroides and Pseudomonas

  17. Perforated peptic ulcer • 5% of peptic ulcers penetrate through the duodenal wall into the peritoneal cavity • Most common site: 1st part of the duodenum, anteriorly • Produce chemical peritonitis initially. Bacterial peritonitis develops within few hours.

  18. Peritonitis • Peritonitis is peritoneal inflammation from any cause. • Introduction of bacteria or irritating chemicals into the peritoneal cavity cause peritoneal inflammation. • A localized inflammation (appendicitis) produce sharply localized pain and normal bowel sounds. • A diffuse inflammation (perforated viscus) produces generalized peritonitis causing generalized abdominal pain with a quiet abdomen (absent bowel sound).

  19. Types of peritonitis • Secondary peritonitis: more common, secondary to an inflammatory insult from within abdomen, most often gram-negative infections with enteric organisms or anaerobes. Example- perforated appendicitis • Primary peritonitis: uncommon. No intra-abdominal cause. Children: Pneumococcus or hemolytic Streptococcus. Adults: peritoneal dialysis for end-stage renal dis.(gram+vecocci), ascites and cirrhosis(Escherichia coli and Klebsiella) • Noninfectious inflammation- chemical peritonitis –pancreatitis.

  20. Small bowel obstruction • Post-operative adhesion- most common • Hernia, tumour, Crohn’s disease- other causes • Early- the intestinal contraction increases to propel contents past the obstructing point (colicky pain) • Later- the intestine becomes fatigued and dilates, contractions becoming less intense. • Bowel dilates, water and electrolytes accumulate in lumen and in the bowel wall. • Massive third-space fluid loss: dehydration and hypovolemia. • Intraluminal pressure increases in the bowel, a decrease in mucosal blood flow occurs.

  21. MesentericIschemia • Arterial: embolism, thrombosis • Venous: thrombosis • Superior mesenteric vessel distribution • Intestinal mucosal sloughing- 3 hours of onset. • Full-thickness intestinal infarction- 6 hours

  22. Symptoms & Signs in Acute abdomen

  23. Main symptom- Abdominal pain • Location: finger vs hand • Severity: Colic, ischemia (severe), inflammation- milder • Onset: Sudden in perforation, ischemia, biliary colic • Progress: Inflammation- develops and worsens over several hours - appendicitis, cholecystitis • Spasmodic: Biliary colic, or genitourinary obstruction • Radiation and shift: Cholecystitis, appendicitis • Exacerbating factors: Food worsen pain- bowel obstruction, gastric ulcer • Relieving factors: Food relieves pain- duodenal peptic ulcer disease or gastritis.

  24. Associated symptoms • Vomiting likely to precede abdominal pain in medical conditions whereas pain presents first inacute surgical abdomen. • Constipationor obstipation - mechanical obstruction or decreased peristalsis (ileus). • Diarrhea is associated with several medical causes of acute abdomen, including infectious enteritis, inflammatory bowel disease (IBD), and parasitic contamination • Bloody diarrhea- IBD, Colonic ischemia

  25. Past medical history: Passage of stone(ureteric colic), previous surgery (intestinal obstruction) • Gynecologic history: LMP (ectopic pregnancy), mid cycle pain (mittelschmerz) • Medications: Create acute abdominal conditions or mask their symptoms. NSAID (bleeding, perforation), narcotics (constipation), steroids (mask inflammation)

  26. PHYSICAL EXAMINATION(Inspection) • Inspection of the patient: • Ischemic bowel and ureteral and biliary colic- patients continually shift and fidget in bed while trying to find a position that lessens their discomfort. • Patients with peritonitis lie very still in the bed, and often maintain flexion of their knees and hips to reduce tension on the anterior abdominal wall.

  27. Inspection of the abdomen • Distension- obstruction, ileus • Restricted mobility- ?peritonitis • Scars of previous surgery • Hernias • Mass effect • Ecchymosis ? Acute pancreatitis (Cullen’s, Grey Turner’s sign)

  28. Palpation of the abdomen • Start gently, away from the area of pain. • Severity and exact location of tenderness- localized/ generalized • Involuntary guarding • Organomegaly, mass • Murphy’s sign, Rovsing’s sign, • Rebound tenderness (Blumberg’s sign)

  29. Percussion of the abdomen • Hyperresonance :distendedbowel loops • Dullness due to organomegaly or mass • Liver dullness lost- free intra-abdominal air is suspected. • Shifting dullness- free fluid • Tenderness

  30. Auscultation of the abdomen • Quiet abdomen- ileus • Hyperactive bowel sounds- enteritis, ischemic intestine • Mechanical bowel obstruction- high-pitched “tinkling” sounds that come in rushes and are associated with pain • Bruits- high-grade arterial stenosis

  31. Digital rectal examination • Performed in all patients with acute abdominal pain • Checking for mass, pelvic pain, or intraluminal blood • Pelvic examination in female

  32. Investigations

  33. Routine laboratory investigations • Hematology:WBC count, differential count, hemoglobin, platelets, red blood cells • Electrolytes, urea, creatinine • Amylase, lipase • LFTs: Bilirubin (T & D), alkaline phosphatase, aminotransferase, • Serum lactate & arterial blood gas • Urine analysis • Urine human chorionic gonadotropin • Stool for parasites

  34. WBC count: Leukocytosis in infection, ischemia • Electrolytes, blood urea nitrogen, and creatinine: Disturbed due to the effect of vomiting or third-space fluid losses • Serum amylase and lipase- acute pancreatitis, small bowel infarction or duodenal ulcer perforation • Liver function tests: Biliary tract disease, acute pancreatitis.

  35. Lactate levels and arterial blood gas: intestinal ischemia or infarction. • Urinalysis: Bacterial cystitis, pyelonephritis, diabetes. • Urinary human chorionic gonadotropin: Pregnancy - a factor in the patient's presentation or aid in decision making regarding therapy. • Stool:Fresh blood , occult blood, parasite, Cl. Difficile (toxin & culture).

  36. Imaging studies None of the imaging techniques take the place of a careful history and physical examination.

  37. Plain radiographs • Upright chest radiographs – free gas under the dome of diaphragm Perforated duodenal ulcer-75% • Lateral decubitus abdominal radiographs- pneumoperitoneum in patients who cannot stand

  38. Plain x-ray abdomen • Calcifications: renal stones 90%, chronic pancreatic, aortic aneurysms, fecalith • Supine and upright films: distension, fluid levels, gas distribution (small vs large bowel), volvulus of sigmoid colon/ cecum

  39. Abdominal ultrasonography • Gallbladder: Stone, wall thickness, fluid around gallbladder, diameter of bile ducts • Liver: Abscess, other masses • Pelvis: Ovarian, adnexal & uterine pathologies • Free fluid in peritoneum • Limited evaluation of pancreas • Limitations: Bowel gas, person dependent, difficult to interpret for most surgeons

  40. CT abdomen • Widely available. • Easier to interpret. • Imaging modality of choice in acute abdomen, following plain abdominal radiographs. • Accuracy and utility of CT abdomen and pelvis in acute abdominal pain is well established. • Most common causes of acute abdomen are readily identified by CT. • Highly accurate in acute appendicitis, mechanical bowel obstruction, intestinal ischemia.

  41. DIAGNOSTIC LAPAROSCOPY • Ability to diagnose and treat a number of the conditions causing acute abdomen • High sensitivity and specificity • Decreased morbidity and mortality, decreased length of stay, and decreased overall hospital costs • Advances in equipment and greater availability

  42. DIFFERENTIAL DIAGNOSIS • Differential diagnosis of acute abdominal pain is extensive. • Comprehensive knowledge of the medical and surgical conditions that create acute abdominal pain • Mild, self-limited illness to the rapidly progressive and fatal • Evaluated immediately upon presentation and reassessed at frequent intervals. • Many acute abdomen require surgical intervention but some abdominal pain are medical in aetiology.