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Evaluation of Acute Abdomen By Dr. Conrad D’Costa, MS, DNB  (Senior House Officer) Mr.Sudhir Jain,MS,FRCS,FACS, (Specialis...
Acute Abdomen <ul><li>Challenge to Surgeons & Physicians </li></ul><ul><li>Most common cause of surgical emergency admissi...
DEFINITION <ul><li>Acute Abdomen is a term used synonymously for a condition that needs immediate surgical intervention </...
ASSESMENT <ul><li>Well elicited history </li></ul><ul><li>Proper physical examination </li></ul><ul><li>Diagnosis can be m...
Assesment(cont.) <ul><li>Investigations are usually carried out : </li></ul><ul><li>only to support the diagnosis. </li></...
History <ul><li>History of Present illness </li></ul><ul><li>Family History </li></ul><ul><li>Past Medical history </li></...
PAIN <ul><ul><li>The Most Important Symptom </li></ul></ul><ul><li>History of  pain should include: </li></ul><ul><li>1. O...
(i) Onset of Pain <ul><li>Sudden onset pain which wakes the patient from sleep </li></ul><ul><li>eg. perforation or strang...
(ii) Progression of Pain <ul><li>Progression from:  </li></ul><ul><li>Dull, aching, poorly localized character </li></ul><...
(iii) Associated Bowel Symptoms <ul><li>CONSTIPATION </li></ul><ul><li>a. Progressive intestinal obstruction </li></ul><ul...
(iv) Associated Bowel Symptoms <ul><li>DIARRHOEA </li></ul><ul><li>Diarrhoea with pain is mainly medical. </li></ul><ul><l...
DRUG HISTORY <ul><li>Corticosteroids – mask pain </li></ul><ul><li>Anticoagulants – can lead to an intramural haematoma of...
NAUSEA & VOMITING <ul><ul><li>Frequency of vomiting </li></ul></ul><ul><li>(ii)  Character of vomiting:  </li></ul><ul><li...
NAUSEA & VOMITING  <ul><li>Pain first, followed by Vomiting is usually surgical. </li></ul><ul><li>The vomiting is due to ...
Vomiting (cont.) <ul><li>Vomiting is very prominent in </li></ul><ul><li>a. Mallory-Weiss syndrome. </li></ul><ul><li>b. B...
ANOREXIA <ul><li>Anorexia or decreased appetite with pain is usually seen in Acute appendicitis </li></ul>
Urinary Symptoms with Pain <ul><li>Ureteric colic  </li></ul><ul><li>Cystitis </li></ul>
FEVER & CHILLS/RIGORS <ul><li>Amoebic Liver Abscess </li></ul><ul><li>Pygenic Liver Abscess </li></ul><ul><li>Perinephric ...
OTHER HISTORY <ul><li>Past Surgical history: previous operations- leading to adhesions </li></ul><ul><li>Past Medical hist...
Physical Examination <ul><ul><ul><li>General Appearance </li></ul></ul></ul><ul><li>a. Anxious Patient lying motionless: <...
Physical Examination (contd.) <ul><li>d. Bending Forward: </li></ul><ul><li>Chronic Pancreatitis </li></ul><ul><li>e. Jaun...
Physical Examination (contd.) <ul><ul><ul><li>Vital Charting </li></ul></ul></ul><ul><li>Temperature, Pulse, BP, Respirato...
Physical Examination (contd.) <ul><ul><ul><ul><li>Low grade temp. is seen with  </li></ul></ul></ul></ul><ul><li>- Appendi...
Systemic Examination <ul><li>Cardiopulmonary examination </li></ul><ul><li>Check for: </li></ul><ul><li>- Possible MI </li...
Systemic Examination <ul><li>Per Abdomen: </li></ul><ul><li>  Inspection </li></ul><ul><li>- Scaphoid or flat in peptic ul...
Systemic Examination <ul><li>Erythema or discolouration </li></ul><ul><li>a. Peri-umbilical - Cullen sign </li></ul><ul><l...
Systemic Examination <ul><li>Per abdomen: </li></ul><ul><li>Palpation  </li></ul><ul><li>Be gentle </li></ul><ul><li>Start...
Systemic Examination <ul><li>Local Right Iliac Fossa tenderness: </li></ul><ul><li>a. Acute appendicitis </li></ul><ul><li...
Systemic Examination <ul><li>Rovsing’s Sign in Acute Appendicitis </li></ul><ul><li>Obturator Sign in Pelvic Appendicitis ...
Systemic Examination <ul><li>Murphy's sign in Acute Cholecystitis </li></ul><ul><li>Thumping tenderness over lower ribs in...
Systemic Examination <ul><li>Pulsatile Abdominal Mass with </li></ul><ul><li>Hypotension </li></ul><ul><li>Leaking AAA </l...
Systemic Examination <ul><li>Per Rectal Examination: </li></ul><ul><li>- tenderness </li></ul><ul><li>- induration </li></...
Systemic Examination <ul><li>Per Vaginal Examination </li></ul><ul><li>- Bleeding </li></ul><ul><li>- Discharge </li></ul>...
INVESTIGATIONS <ul><li>Complete Blood Count with differential </li></ul><ul><li>C-reactive protein estimation </li></ul><u...
Radiology <ul><li>Upright X ray chest for </li></ul><ul><li>- Basal Pneumonia </li></ul><ul><li>- Ruptured Oesophagus </li...
Radiology <ul><ul><ul><ul><ul><li>Abdominal X ray film </li></ul></ul></ul></ul></ul><ul><li>Air-Fluid Levels </li></ul><u...
INVESTIGATIONS <ul><li>Other Investigations </li></ul><ul><li>- USG </li></ul><ul><li>- CT abdomen for AAA, Pancreatic dis...
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Acute Abdomine

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medical learning about how to diagnose, investigate & treat a case of acute abdomine

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Transcript of "Acute Abdomine"

  1. 1. Evaluation of Acute Abdomen By Dr. Conrad D’Costa, MS, DNB (Senior House Officer) Mr.Sudhir Jain,MS,FRCS,FACS, (Specialist Registrar Surgery) North Middlesex University Hospital,London
  2. 2. Acute Abdomen <ul><li>Challenge to Surgeons & Physicians </li></ul><ul><li>Most common cause of surgical emergency admission </li></ul><ul><li>Clinical course can vary from from minutes to hours to weeks. </li></ul><ul><li>It can be an acute exacerbation of a chronic problem e.g. Chronic Pancreatitis,Vascular Insufficiency. </li></ul>
  3. 3. DEFINITION <ul><li>Acute Abdomen is a term used synonymously for a condition that needs immediate surgical intervention </li></ul>
  4. 4. ASSESMENT <ul><li>Well elicited history </li></ul><ul><li>Proper physical examination </li></ul><ul><li>Diagnosis can be made most of the time by a good history and a proper physical examination. </li></ul>
  5. 5. Assesment(cont.) <ul><li>Investigations are usually carried out : </li></ul><ul><li>only to support the diagnosis. </li></ul><ul><li>or to narrow down the differential diagnoses. </li></ul>
  6. 6. History <ul><li>History of Present illness </li></ul><ul><li>Family History </li></ul><ul><li>Past Medical history </li></ul><ul><li>History of drugs taken or Medication eg. ingestion of certain toxic drugs or Alcohol intake </li></ul>
  7. 7. PAIN <ul><ul><li>The Most Important Symptom </li></ul></ul><ul><li>History of pain should include: </li></ul><ul><li>1. Onset </li></ul><ul><li>2. Severity </li></ul><ul><li>3. Type of pain </li></ul><ul><li>4. Radiation of Pain </li></ul><ul><li>5. Change in nature of Pain </li></ul><ul><li>6. Associated bowel or urinary symptoms </li></ul><ul><li>7. Aggravating or relieving factors </li></ul>
  8. 8. (i) Onset of Pain <ul><li>Sudden onset pain which wakes the patient from sleep </li></ul><ul><li>eg. perforation or strangulation of bowel </li></ul><ul><li>Slow insidious Onset </li></ul><ul><li>a. Inflammation of visceral peritoneum. </li></ul><ul><li>b. Contained process such as evolving abscess. </li></ul><ul><li>Crampy or colicky pain </li></ul><ul><li>Biliary colic , Ureteric colic or Intestinal colic </li></ul>
  9. 9. (ii) Progression of Pain <ul><li>Progression from: </li></ul><ul><li>Dull, aching, poorly localized character </li></ul><ul><li>To: </li></ul><ul><li>Sharp, constant & better localized pain </li></ul><ul><li>indicates involvement of Parietal peritoneum </li></ul>
  10. 10. (iii) Associated Bowel Symptoms <ul><li>CONSTIPATION </li></ul><ul><li>a. Progressive intestinal obstruction </li></ul><ul><li>from a neoplasm or inflammatory </li></ul><ul><li>bowel disease </li></ul><ul><li>b. Paralytic Ileus </li></ul><ul><li>c. Post Operative </li></ul><ul><li>d. Obstructed groin hernia </li></ul>
  11. 11. (iv) Associated Bowel Symptoms <ul><li>DIARRHOEA </li></ul><ul><li>Diarrhoea with pain is mainly medical. </li></ul><ul><li>The following are the exceptions: </li></ul><ul><li>a. Obstructed Richter's Hernia </li></ul><ul><li>b. Gall Stone ileus </li></ul><ul><li>c. Superior mesenteric vascular occlusion </li></ul><ul><li>d. Intestinal Obstruction associated with </li></ul><ul><li>pelvic abscess </li></ul><ul><li>e. Spurious diarrhea in chronic faecal </li></ul><ul><li>impaction </li></ul>
  12. 12. DRUG HISTORY <ul><li>Corticosteroids – mask pain </li></ul><ul><li>Anticoagulants – can lead to an intramural haematoma of the gut causing obstruction </li></ul><ul><li>Oral Contraceptives - rupture of hepatic adenomas </li></ul><ul><li>NSAIDs - erosive gastritis & peptic ulcers </li></ul>
  13. 13. NAUSEA & VOMITING <ul><ul><li>Frequency of vomiting </li></ul></ul><ul><li>(ii) Character of vomiting: </li></ul><ul><li>projectile, non-projectile or self-induced </li></ul><ul><li>(iii) Nature of vomiting: </li></ul><ul><li>a. Bilious vomiting of small bowel obstruction </li></ul><ul><li>b. Non-bilious vomiting in obstruction proximal to </li></ul><ul><li>ampulla of vater </li></ul><ul><li>c. Faeculent vomiting in distal small gut obstruction, </li></ul><ul><li>large bowel obstruction , strangulation </li></ul>
  14. 14. NAUSEA & VOMITING <ul><li>Pain first, followed by Vomiting is usually surgical. </li></ul><ul><li>The vomiting is due to ‘reflex pylorospasm’ </li></ul><ul><li>Nausea & vomiting first , followed by pain is usually due to a medical condition </li></ul>
  15. 15. Vomiting (cont.) <ul><li>Vomiting is very prominent in </li></ul><ul><li>a. Mallory-Weiss syndrome. </li></ul><ul><li>b. Boerhaave syndrome(trans- mural esophageal tear) </li></ul><ul><li>c. Acute gastritis </li></ul><ul><li>d. Acute pancreatitis </li></ul>
  16. 16. ANOREXIA <ul><li>Anorexia or decreased appetite with pain is usually seen in Acute appendicitis </li></ul>
  17. 17. Urinary Symptoms with Pain <ul><li>Ureteric colic </li></ul><ul><li>Cystitis </li></ul>
  18. 18. FEVER & CHILLS/RIGORS <ul><li>Amoebic Liver Abscess </li></ul><ul><li>Pygenic Liver Abscess </li></ul><ul><li>Perinephric Abscess </li></ul><ul><li>Intra-abdominal pus collection </li></ul>
  19. 19. OTHER HISTORY <ul><li>Past Surgical history: previous operations- leading to adhesions </li></ul><ul><li>Past Medical history: Sickle cell disease, Diabetes or Cancer or Renal failure </li></ul><ul><li>Menstrual History in females </li></ul><ul><li>(i) Missed period- ectopic pregnancy </li></ul><ul><li>(ii) Mid of period-ovulation pain (Mittel- schmerz) </li></ul><ul><li>(iii) With heavy periods- endometriosis </li></ul><ul><li>Family history of colon cancer, any other malignancy or inflammatory bowel disease </li></ul>
  20. 20. Physical Examination <ul><ul><ul><li>General Appearance </li></ul></ul></ul><ul><li>a. Anxious Patient lying motionless: </li></ul><ul><li>(i) Acute appendicitis </li></ul><ul><li>(ii) Peritonitis </li></ul><ul><li>b. Rolling in bed & restless: </li></ul><ul><li>(i) Ureteric Colic </li></ul><ul><li>(ii) Intestinal colic </li></ul><ul><li>c. Writhing in Pain: </li></ul><ul><li>Mesenteric Ischemia </li></ul>
  21. 21. Physical Examination (contd.) <ul><li>d. Bending Forward: </li></ul><ul><li>Chronic Pancreatitis </li></ul><ul><li>e. Jaundiced: </li></ul><ul><li>CBD obstruction </li></ul><ul><li>f. Dehydrated </li></ul><ul><li>(i) Peritonitis </li></ul><ul><li>(ii) Small Bowel obstruction </li></ul>
  22. 22. Physical Examination (contd.) <ul><ul><ul><li>Vital Charting </li></ul></ul></ul><ul><li>Temperature, Pulse, BP, Respiratory rate </li></ul><ul><li>Ruptured AAA or ectopic pregnancy can lead to </li></ul><ul><li>-Pallor </li></ul><ul><li>-Hypotension </li></ul><ul><li>-Tachycardia </li></ul><ul><li>-Tachypnea </li></ul>
  23. 23. Physical Examination (contd.) <ul><ul><ul><ul><li>Low grade temp. is seen with </li></ul></ul></ul></ul><ul><li>- Appendicitis </li></ul><ul><li>- Acute cholecystitis </li></ul><ul><ul><li>High grade temp. is seen with </li></ul></ul><ul><li>- Salpingitis </li></ul><ul><li>- Abscess </li></ul><ul><li>Very High Grade Temp.with increasing lethargy seen in imminent septic shock </li></ul><ul><li>- Peritonitis </li></ul><ul><li>- Acute cholangitis </li></ul><ul><li>- Pyonephrosis </li></ul>
  24. 24. Systemic Examination <ul><li>Cardiopulmonary examination </li></ul><ul><li>Check for: </li></ul><ul><li>- Possible MI </li></ul><ul><li>- Basal Pneumonia </li></ul><ul><li>- Pleural Effusion </li></ul>
  25. 25. Systemic Examination <ul><li>Per Abdomen: </li></ul><ul><li> Inspection </li></ul><ul><li>- Scaphoid or flat in peptic ulcer </li></ul><ul><li>- Distended in ascites or intestinal obstruction </li></ul><ul><li>- Visible peristalsis in a thin or malnourished patient (with obstruction) </li></ul>
  26. 26. Systemic Examination <ul><li>Erythema or discolouration </li></ul><ul><li>a. Peri-umbilical - Cullen sign </li></ul><ul><li>b. Inguinal – Fox sign </li></ul><ul><li>c. Flanks - Grey Turner sign </li></ul><ul><li>Seen in Hemorrhagic pancreatitis </li></ul><ul><li>or any other cause of haemoperitoneum </li></ul><ul><li>Any Visible masses </li></ul><ul><li>Any visible cough impulse at hernia site </li></ul>
  27. 27. Systemic Examination <ul><li>Per abdomen: </li></ul><ul><li>Palpation </li></ul><ul><li>Be gentle </li></ul><ul><li>Start away from site of pathology then towards </li></ul><ul><li>Check for Hernia sites </li></ul><ul><li>Tenderness </li></ul><ul><li>Rebound tenderness </li></ul><ul><li>Guarding- involuntary spasm of muscles during palpation </li></ul><ul><li>Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis. </li></ul>
  28. 28. Systemic Examination <ul><li>Local Right Iliac Fossa tenderness: </li></ul><ul><li>a. Acute appendicitis </li></ul><ul><li>b. Acute Salpingitis in females </li></ul><ul><li>c. Amoebiasis of Caecum </li></ul><ul><li>Low grade, poorly localized tenderness: </li></ul><ul><li>Intestinal Obstruction </li></ul><ul><li>Tenderness out of proportion to examination: </li></ul><ul><li>a. Mesenteric Ischemia </li></ul><ul><li>b. Acute Pancreatitis </li></ul><ul><li>Flank Tenderness: </li></ul><ul><li>a. Perinephric Abscess </li></ul><ul><li>b. Retrocaecal Appendicitis </li></ul>
  29. 29. Systemic Examination <ul><li>Rovsing’s Sign in Acute Appendicitis </li></ul><ul><li>Obturator Sign in Pelvic Appendicitis </li></ul><ul><li>Psoas Sign </li></ul><ul><li>- Retrocaecal appendicitis </li></ul><ul><li>- Crohn’s Disease </li></ul><ul><li>- Perinephric Abscess </li></ul>
  30. 30. Systemic Examination <ul><li>Murphy's sign in Acute Cholecystitis </li></ul><ul><li>Thumping tenderness over lower ribs in inflammation of </li></ul><ul><li>-Diaphragm </li></ul><ul><li>- liver or spleen </li></ul>
  31. 31. Systemic Examination <ul><li>Pulsatile Abdominal Mass with </li></ul><ul><li>Hypotension </li></ul><ul><li>Leaking AAA </li></ul><ul><li>Cutaneous Hyperaesthesia </li></ul><ul><li>indicates involvement of </li></ul><ul><li>Parietal Peritoneum </li></ul>
  32. 32. Systemic Examination <ul><li>Per Rectal Examination: </li></ul><ul><li>- tenderness </li></ul><ul><li>- induration </li></ul><ul><li>- mass (Blummer’s shelf) </li></ul><ul><li>- frank blood </li></ul>
  33. 33. Systemic Examination <ul><li>Per Vaginal Examination </li></ul><ul><li>- Bleeding </li></ul><ul><li>- Discharge </li></ul><ul><li>- Cervical motion tenderness </li></ul><ul><li>- Adnexal masses or tenderness </li></ul><ul><li>- Uterine Size or Contour </li></ul>
  34. 34. INVESTIGATIONS <ul><li>Complete Blood Count with differential </li></ul><ul><li>C-reactive protein estimation </li></ul><ul><li>Electrolyte ,Blood Urea , Creatinine </li></ul><ul><li>Urine dipstick </li></ul><ul><li>Amylase or Lipase </li></ul><ul><li>Liver Function Test </li></ul>
  35. 35. Radiology <ul><li>Upright X ray chest for </li></ul><ul><li>- Basal Pneumonia </li></ul><ul><li>- Ruptured Oesophagus </li></ul><ul><li>- Elevated Hemi diaphragm </li></ul><ul><li>- Free Gas under diaphragm </li></ul>
  36. 36. Radiology <ul><ul><ul><ul><ul><li>Abdominal X ray film </li></ul></ul></ul></ul></ul><ul><li>Air-Fluid Levels </li></ul><ul><li>Stones </li></ul><ul><li>Ascites </li></ul><ul><li>Eggshell calcification in AAA </li></ul><ul><li>Air in Biliary tree. </li></ul><ul><li>Obliteration of Psoas Shadow in retro- peritoneal disease </li></ul><ul><li>Right lower quadrant sentinel loop in acute appendicitis </li></ul>
  37. 37. INVESTIGATIONS <ul><li>Other Investigations </li></ul><ul><li>- USG </li></ul><ul><li>- CT abdomen for AAA, Pancreatic disease, or ureteric colic (non- Contrast) </li></ul><ul><li>- IVU </li></ul><ul><li>- Mesenteric Angiography for </li></ul><ul><li>Ischaemia, Haemorrhage </li></ul>
  38. 38. THANK YOU
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