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

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

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Acute Abdomine Presentation Transcript

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