The Acute Abdomen

1. The Acute Abdomen Raymond Yiu Surgery Team 3

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

3. Aetiology: Abdominal Pain • EXTRAABDOMINAL • Cardiovascular MI • Metabolic DKA • Abdominal wall rectus sheath haematoma • Neurogenic referred pain • INTRABDOMINAL • Imflammatory • Traumatic • Obstructive • Vascular

4. INTRABDOMINAL • Imflammatory Conditions (Peritonitis) Localised / Generalised Primary / Secondary / Tertiary • TraumaticBlunt / Penetrating Injury Bleeding / Peritonitis • ObstructiveGastric/ Small / Large Bowel • Vascular Mesenteric infarction Strangulated hernias Volvulus (small or large bowel) Rupture AAA Aortic dissection

5. Imflammatory Conditions Peritonitis

6. Peritonitis • Bacteria primary/ secondary/ tertiary spontaneous • Chemical

7. 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

8. 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)

9. 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

10. 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)

11. PeritonitisClinical Features • Systemic: Fever Tachycardia Leucocytosis Chills/rigors Dehydration • Abdominal: tenderness, guarding, rigidity,absent BS, distention (ileus) Generalised localised

12. PeritonitisLocalisation of signs and pathology

13. PeritonitisClinical Features Pancreatitis Liver abscess PPU Cholecystitis Cholangitis Diverticultis Meckels diverticultis Small bowel perf Appendicitis

14. Acute abdomenCommon conditionsAppendicitisCholecystitis

15. Acute appendicitis: aetiology Obstruction of lumen by: Lymphoid hyperplasia Faecolith Parasites Cancer/ carcinoid

16. Acute appendicitis: Clinical Features 7% population 10-30 years Mortality rate <1% 5% Elderly and young (delay in diagnosis)

17. RLQ pain Pain migration Anorexia, nausea RLQ tenderness RLQ guarding RLQ rebound Fever Leucocytosis (80%) Acute appendicitis Mcburneys point

18. Acute appendicitis: Signs Rovsings sign: Pain in RLQ on pressing LLQ Dumphys sign: Pain on coughing Psoas sign: Obturator sign:

19. Acute appendicitis: Signs Depends on where inflamed appendix is: Retrocecal: Lumbar sign: Pain in right flank Pelvic: irritate bladder: dysuria irritate rectum: diarhoea

20. Acute appendicitis: Ix

21. Acute appendicitis Open Laparoscopic Young women of child bearing age

22. 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)

23. Acute Cholecystitis Remember 4 ‘F’s Pigment Calcium Cholesterol

24. Acute Cholecystitis Chemical peritonitis initally

25. Acute Cholecystitisclinical features Short onset RUQ pain Fever RUQ peritoneal signs Murphys signs

26. Acute CholecystitisImaging

27. Acute CholecystitisTreatment • Short duration of sx (<5days pain) • Consider surgery (lap) • Higher incidence of conversion • Longer duration of sx (>5days) • 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

28. Intestinal Obstruction

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

30. Aetiology by incidence (SBO) • Previous OT: adhesions • “Virgin” abdomen: carcinoma, hernias

31. Questions to ask? • Site: Stomach vs SB vs LB • Presentation: Acute vs Subacute • Urgency: simple mechanical vs strangulating

32. Site: Sx

33. 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

34. 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

35. Simple Mechanical Obstruction Strangulating vs Can wait Cannot wait

36. Simple Mechanical Obstruction

37. Simple Mechanical ObstructionFemoral hernias

38. 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)

39. Sigmoid Volvulus Example of close loop obstruction: both ends of the bowel are blocked and air enters in a one-way valve

40. Sigmoid Volvulus Decompression : bedside sigmoidoscopy or colonoscopy failure

41. intussusception Usually associated with polyps acting as lead point

42. Small bowel ischemia Prolonged strangulation from adhesion band, hernia Small bowel volvulus

43. 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)

44. Management Hx and exam Initial Mx Baseline Ix Special Ix Preparation for OT

45. History and Examination DischargeDiagnosis 1972 19771993 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% History & examination and simple lab tests have about a 50-60 % accuracy in giving a diagnosis Brewer, Am J Surg, 1976; Jazon, AC Scand, 1982; Powers, AJEM,

46. Pattern Recognition is very important !

47. 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

48. Initial Mx NGT NPO analgesia Resuscitation: IVF Iv antibiotics Monitoring devices Foley (CVP)

49. Baseline Laboratory testing Blood tests Plain X-rays ECG

50. WBC Limited utility WBC > 11,000 LR+ = ~ 2 < 11,000 LR- = ~ 0.5 WBC alone doesn’t distinguish patients with surgical disease from non-specific abdominal pain