The acute abdomen seminar

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  • 1. Acute Abdomen: Medical orSurgical
  • 2. Introduction: The term “Acute Abdomen” denotes anysudden, disorder whose chief manifestation is in theabdominal area. Evaluation of acute abdomen must be efficient andshould lead to an accurate diagnosis early in thepresentation. So that the treatment of patients who are seriously illis not delayed and patients with self limited disorderare not over treated.
  • 3. The Epidemiology of AcuteAbdominal Pain 5-10% of all patients comes to hospital withacute abdomen. Among them 14-40% patients need surgicalintervention. So prompt diagnosis is important to preventmorbidity and mortality.
  • 4. Medical causes:Metabolic/Haematologic : 1)Familial metabolic : Acute intermittentporphyria, Haemochromatosis. 2)Endocrine: Diabetic ketoacidosis, Addisonian crisis. 3)Haematologic: Sickle cell crisis, Leukaemia, Acutehaemolytic state.Inflammatory condition: Infections : Enteric infections, spontaneous bacterialperitonitis, Hepatitis, AIDS related disorders, Mumps.
  • 5.  Non infectious: Acute rheumatic fever, SLE,Henoch Schoenlein purpura , Inflammatory boweldisease, Pancreatitis. Drugs: Heavy metal poisoning (lead ,mercury,Arsenic , Copper) NSAIDS, Anticoagulants, narcotic, steroid withdrawal, snake bite , black widow spiderbite.
  • 6. Referred : Extraperitonealcauses: Pulmonary: Pnemonia ,Pulmonary embolismPleurisy. Cardiac: Acute MI, Pericarditis. Urologic: Pyelonephritis , Renal infarct, Cystitis,Prostatis. Neurological / spinal : Multiple sclerosis, Tabes dorsalis, Herpeszoster ,Abdominal migraine.
  • 7. Surgical causes: Hemorrhage: Solid organ trauma ,Leaking or ruptured arterialaneurysm, Ruptured ectopic Pregnancy ,Intestinalulcers, Hemorrhagic Pancreatitis, Spontaneous rupture ofspleen. Infection: Appendicitis, Cholecystitis, Meckel’sdiverticulitis, Hepatic abscess, Psoas abscess. Perforation: Perforated gastrointestinal ulcer, Perforatedgastrointestinal cancer. Blockage: Adhesion induction small, large bowelobstruction, Sigmoid volvulus, Cecal volvulus, Gastrointestinalmalignancy , Intussusception. Ischemia: Mesentric thrombosis/embolism, testiculartorsion, Ischemic colitis, Ovarian torsion, Strangulatedhernia.
  • 8. Approach: Approach to a patient with an Acute abdomen must beorderly.An Acute Abdomen must be suspected even if the patient hasonly or atypical complaints. The history and physical examination should suggest theprobable causes and guide the choice of initial diagnosticstudies.
  • 9. The History An accurate history is the essential foundation for thediagnosis of abdominal pain. This requires time, patience, andskill.The way patients tell their story is as important as the storyitself. Any additional questions should be short, specific, and directand must be in language the patient understands. Negative findings are always as useful as positive ones. Unnecessary or irrelevant facts can be misleading and willalways add to the difficulties in analysis.
  • 10.  Pain is the most comman and predominant presenting feature ofan acute abdomen ,careful consideration of the location , modeof onset and progression and character of pain . Pain When?Where? How? Abrupt, gradual Character Sharp, burning, steady, intermittent Referral? Previous occurrence?
  • 11. Three Types of Abdominal Pain Visceral Pain Somatic (Parietal) Pain Referred Pain
  • 12.  Visceral Pain Within the muscular wallsof hollow organs and thecapsules of solid organs. Stimulated primarily bystretching, distension, andexcessive contractions. Characteristically deep,dull, aching or cramping,and poorly localized. Usually felt in the midline,unaccompanied bytenderness.
  • 13.  Somatic (Parietal) Pain Characteristically sharper, aggravated bystimulation of the parietal peritoneum withmovement, coughing, or walking. True parietal pain indicates surgical cause ofabdominal pain.
  • 14.  Referred Pain Pain felt a site other thanthat of the primarynoxious stimulus. Occurs in an areasupplied by the sameneurosegment as theinvolved organ. Most visceral pain is ofthis type. Usually intense andmost often secondary toan inflammatory lesion.
  • 15. Other Symptoms Associated : Vomiting. Distension of abdomen. Fever : High grade with or without chills. Loss of appetite Jaundice Hematochezia or Hematemesis Frequency and urgency of urine Diarrhea. Constipation Obstipation
  • 16. Relevant aspects : Gynecological history. Drug history. Family history. Travel history. Psycho social history.Personal history.Occupational exposureOperation history
  • 17. PHYSICAL EXAMINATION The patient’s general appearance andvitalsigns can help narrowthe differential diagnosis. Overall appearance: ( Facial expression, pallor,and degree of agitation,Detailexamination of heart , lungs andskin) Walking and recumbent. Vital signs Temperature Tachycardia Hypotension
  • 18. General Observation: Fairly reliable indicator of the severity of theclinical situation. The writhing of the patients with visceral pain,contrasts with the rigidly motionless bearing ofthose with parietal pain. Diminished responsiveness or altered sensoriumoften precedes imminent cardiopulmonarycollapse.
  • 19. Differential Diagnosis :RUQPain: Investigations: Xray:Upright chestUpright and supine abdominal.Ultrasound.ECG Complete Blood count. Urinalysis. Amylase, Creatinine, BUN,Electrolytes.
  • 20. RLQ Investigations Urinalysis (to excludeobvious urinary causes) Pregnancy test( female ofchildbearing age) Ultrasound Complete blood count Stool test.
  • 21. Gynecologic causes of LQ Pain:
  • 22. DD of LUQ and Epigastric: Investigations Upright chest XR Upright and supineabdominal XR Ultrasound. ECG. Complete bloodcounts Amylase and lipase .
  • 23. Periumblical: Investigations CBC. Ultrasound. Amylase and lipase. Erect and supineabdominal XR Stool tests
  • 24. LLQ: Pregnancy test(female ofchildbearing age) Urinalysis Ultrasound Complete blood count Upright and supineabdominal XR CT scan( if diverticulardisease is suspected)
  • 25.  Rectal examination : The right wall may be tender in pelvic type appendicitis, and oftentenderness is elicited in the rectovesical pouch in perforated pepticulcer. In intussusception the gloved finger to be smeared with mucus andblood. The bulging of the anterior wall of the rectum with tenderness issignificant of a pelvic abscess. Vaginal examination: Purulent discharge and tenderness in both fornices are suggestive ofAcute Salpingitis. In Ruptured Ectopic Gestataion the cervix feels softer and anymovement of cervix will initiate pain.
  • 26. Special signs:sign Description conditionAaron Pain or pressure in epigastrium or anteriorchest with persistent firm pressure applied toMc Burney pointAcute appendicitisBlumberg Transient abdominal wall rebound tenderness Peritoneal inflammationCarnett Loss of abdominal tenderness whenabdominal wall muscles are contractedIntra abdominal source of aabdominal painCharcot Intermittent Right upper abdominal pain,Jaundice , Fever.choledocholithiasis
  • 27. Special signs:Claybrook Accentuation of breath and cardiacsounds through abdominal wall .Rupturedabdominal viscusCourvoisier Palpable gall bladder in presence ofjaundicePeriampullarytumorCullen Periumbilical bruising Haemo peritoneumFothergill Abdominal wall mass that does not crossmidline and remains palpable when rectuscontractedRectus musclehematomasGreyTurner Local area of discoloration aroundumbilicus and flanksAcute hemorrhagicpancreatitis
  • 28. Special SignsKehr Left shoulder pain whensupine and pressure placedon left upper abdomenHemoperitoneum(especially from splenicorigin)Murphy Pain caused by inspirationwhile applying pressure toright upper abdomenAcute cholecystitisObturator Flexion and external rotationof Right thigh while supinecreates hypogastric painPelvic abscess orinflammatory mass in pelvisRovsing Pain in Mc Burney’s pointwhen compressing the leftlower abdomenAcute appendicitis
  • 29. Approach TO Acute Care: Airway: Is the patient able to maintain anairway?Risk for aspiration of vomit or oral secretions. Breathing : how effectively is the patientbreathing? Rapid and shallow , use ofaccessory muscles. Circulation: Is the patient is in shock?, is thereany evidence of active bleeding.
  • 30. Immediate Treatment of the AcuteAbdomenStart large bore IV with either saline or lactated Ringer’sSolution.Provide pain relief by IV Analgesics NSAIDS,Opioids,H2 receptorblocker and PPI.Provide other symptomatic relief (e.g., antiemetics, antispasmodics).Nasogastric tube if vomiting or concerned about obstruction.Foley catheter to follow hydration status and to obtain Urinalysis.Antibiotic administration if suspicious of inflammation Or Perforation.Careful follow-up with frequent re examination (by the same examiner,when possible)Definitive therapy or procedure will vary with diagnosis