Acute Abdomen and Appendix

1. Acute Abdomenand Appendix Xu Xiao M.D. Ph.D. Department of Hepatobiliary and Pancreatic Surgery The First Affiliated Hospital, College of Medicine, Zhejiang University

2. Part Ⅰ Acute Abdomen

3. 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

4. Classification • Physiology of abdominal pain • Diagnosis • Differential diagnosis • Treatment

5.  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

6.  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

7. 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

8. 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

9. 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 injury‘s 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Laboratory Findings • Amylase, lipase • Serum amylasevalues 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. • β-HCG (human chorionic gonadotrophin) – woman of childbearing age • Bilirubin,ALT, AST, Alkaline phosphatase

21. 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

22. Imaging Studies Gastric ulcer

23. Urethral calculus Imaging Studies

24. Imaging Studies Pneumoperitoneum

25. Imaging Studies Incomplete intestinal obstruction

26. Imaging Studies Cholecystitis • Pancreatitis • Effusion • A buildup of fluid

27. Imaging Studies Gall stone

28. Imaging Studies Hemorrhage of large hepatocellular carcinoma TACE (Transcatheter Arterial Chemoembolization )

29. Imaging Studies Biliary ascariasis

30. Diagnostic Laparoscopy • A high sensitivity and specificity • Decreased morbidity and mortality • Decreased length of stay • Decreased overall hospital costs

31. Atypical Patients • Pregnancy • Acute Abdomen in the Critically Ill • Immunocompromised Patients With Acute Abdomen • Acute Abdomen in the Morbidly Obese

32. (1) Pregnancy • The reasons for delayeddiagnosis • The underlying pregnancy hassymptoms similar with acute abdomen, including abdominal pains, nausea, vomiting, and anorexia • Pregnancy canalter the presentation of some disease processes and make the physical examination more challenging because of the enlarged uterus in the pelvis • Pregnancy can alter thelaboratory findings, such as white blood cell counts • Pregnancy can influence the doctor’s decision to perform typical imaging studies because of concern about radiation exposure to the developing fetus

33. (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

34. (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

35. (3) ImmunocompromisedPatients 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

36. (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

37. 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

38. 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

39. Treatment Algorithms (2) Treatment of gradual-onset severe, generalized abdominal pain. CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; LFTs, liver function tests

40. 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.

41. Treatment Algorithms (4) Algorithm for the treatment of left upper quadrant abdominal pain CT, computed tomography

42. Treatment Algorithms (5) CT, computed tomography; hx, history; OR, operation; UTI, urinary tract infection Algorithm for the treatment of right lower quadrant abdominal pain

43. Treatment Algorithms (6) Algorithm for the treatment of left lower quadrant abdominal pain CT, computed tomography

44. Preparation for emergency operation • IV access • Antibiotic infusions • Nasogastric tube • Foley catheter bladder drainage • Hydroelectrolytic equilibration • Crossmatched blood available

45. 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

46. 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

47. Case Study • Physical Exam • Lying flat, avoids moving • Afebrile • Abdomen tender mostly in the RLQ • Significant guarding • Positive Roving's Sign

48. Case Study • Lab Data • WBC 14*109/L • AST,ALT Normal • Amylase, Lipase Normal • Urine Culture Negative • Further Testing • CT scan • Diagnosis?

50. Part ⅡAppendix • Appendicitis • Appendiceal Abscess