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Acute abdomen approach to managment-hazem

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Approach to initial assessment; resusscitation; and managment of acute abdominal pain

Approach to initial assessment; resusscitation; and managment of acute abdominal pain

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  • 1. ACUTE ABDOMEN MANAGEMENT APPROACH DR.M.HAZEM EL-FOLL FRCS-(UK) Consultant General and Laparoscopic Surgery
  • 2. Acute Abdomen Definition And Epidemiology  Undiagnosed Abdominal Pain of less than 7-10 days duration.  Abdomino-thoracic Trauma is excluded from this definition.  It accounts for 5-10% of ER visits  It accounts for 1% of all hospital admission.  Most Patients-(70-75%) Discharged after ER Evaluation.  Only 7-10% of Patients will Require Urgent Surgery for Life-Threatening Conditions.
  • 3. SURGICAL CAUSES—SURGICAL ABDOMEN MEDICAL CAUSES---NON-SURGICAL ABDOMEN Acute Abdominal pain
  • 4. Etio-Pathological Classification:- Inflammatory/Infective • Acute Cholecystitis • Liver Abscess • Acute Pancreatitis • Inflammatory Bowel Disease • Acute Appendicitis • Acute Diverticulitis • Meckle's Diverticulitis • PID-(Salpingitis)/Tubo- ovarian abscess. • UTI-Acute Pyelonephritis/Acute Cystitis Perforation • Perforated Peptic Ulcer Disease • Perforated Appendicitis/Cholecystiti s • Perforated Small Bowel • Esophageal Perforation • Perforated Colon • Aortic Dissection
  • 5. Etio-Pathological Classification Obstruction Infarction  Thrombo-embolic diseases • Acute Intestinal Ischemia • Renal Infarction • Splenic Infarction  GIT-Volvulus  Omental Torsion  Intussusception  Torsion ovarian cyst/sub-serous fibroid  Intestinal Obstruction  Biliary Colic  Renal Colic
  • 6. Etio-Pathological Classification Spontaneous intra-peritoneal bleeding Rupture AAA. Rupture visceral A.Aneurysms in mesenteric; hepatic and renal arteries. Rupture pathologically enlarged spleen Rupture Hepatic Tumor. Gynecological causes:- • Ruptured Ectopic pregnancy • Ruptured Ovarian Cyst • Ruptured Graffian's follicles( mid-cycle) • Ruptured Endometriosis.
  • 7. Medial Causes of Acute Abdominal Pain Non-Surgical Abdomen Intra-Abdominal Conditions • Gastro-Enteritis. • Infective Colitis • Mesenteric Adenitis • Typhoid Fever • UTI • Acute Viral Hepatitis • Congestive Hepatomegaly • Liver Tumors Intra-Thoracic Conditions • MI • Basal Lobar Pneumonia and Lung Abscess • Pericarditis. • Spontaneous Pneumothorax.
  • 8. Non-Surgical Abdomen Metabolic Causes • D-Ketoacidosis • Uremia • Adreno-cortical Insufficiency • Hypercalcemia • Acute Intermittent Porphyria. • Heavy Metals Poisoning Haematological Diseases • Haemolytic Crisis of Chronic Haemolytic Anaemia. • Polycythemia. • Henoch- Schonelein Purpura. • Lymphoma. • Leukemia.
  • 9. Non-Surgical Abdomen Neurological Causes  Herpes Zoster- commonly involving spinal nerves T3-L1.  Spinal cord Compression:- • Degenerative-Disc Prolapse. • Metastases.  Nerve Entrapment:- • 2-3 localised areas just medial to linea semilunaris of rectus muscle. Collagen Diseases  SLE.  Polyarteritis Nodosa. • Abdominal Pain caused by thrombosis of visceral arteries lead to Visceral infarction.
  • 10. Management Approach • (I)-Clinical Evaluation: • Accurate History and Complete Physical Examination are Essential for Diagnosis • (II)-Resuscitation and Immediate Diagnostic Tools. • (III)-Other Investigations-according to clinical progress of the patient.
  • 11. History taking
  • 12. Abdominal pain Onset; Progression of pain Duration. Site of pain: at onset, at present. Severity. • Type: intermittent colicky, sharp persistent Radiation of Pain Aggravating factors: movement, coughing, food Relieving factors: position, drug, food
  • 13. Physiology of Pain-Visceral Pain • Elicited by distention ; inflammation of the serous coat of hollow viscera and in the capsules of solid organs. • Mediated by afferent autonomic nerve fibres. • Diffuse; felt in the midline in regions related to the embryological development.
  • 14. Somatic(Parietal)Pain • Elicited by direct irritation/inflammation of the somatically innervated parietal peritoneum. • Mediated by afferent somatic nerve fibres. • localised in the dermatomes supplied by segmental nerve roots innervating the parietal peritoneum.
  • 15. Referred Pain • Pain Sensations perceived at a site distant from that of a strong primary stimulus. • Due to Confluence of afferent nerve fibers from widely disparate areas within the posterior horn of the spinal cord. This may cause distorted central perception of the site of pain.
  • 16. In Most causes of Surgical Abdominal pain • There is insidious onset of pain started diffuse; dull ach/or gripping pain. In hollow viscus obstruction; the pain is sever gripping associated with nausea; vomiting; and sweating; causing the patient to move around in bed and inability to lie still. There is no aggravating of relieving factors. • In Early Inflammatory Processes of Solid Viscera; there is diffuse dull ache pain Visceral pain.
  • 17. Progression of pain-In Inflammatory and Obstructed Causes • There is progression of pain over several hours; and change character of pain into sharp localised stabbing pain. The pain is aggevated by moving; coughing and relieved by lying still. Somatic Pain • There will be associated Abdominal localised tenderness; rebound; and involuntary muscle guarding. (Localised Peritonitis.)
  • 18. In perforation; Strangulation(Infarction);and Spontaneous Bleeding • The pain is sudden in onset with progression over minutes to 1-2 hours; into sharp localised stabbing pain. There will be Localised (Early) / or Generalised Abdominal tenderness; rebound and rigidity. • Shoulder tip and sub-scapular pain; is common due to blood/or pus in sub-phrenic space.
  • 19. In Most of Non-Surgical causes of Abdominal Pain • There will be Diffuse mild dull-ach/or vague discomfort. • Vomiting usually precedes the onset of pain; especially in metabolic causes. • There will be Diffuse; non-specific abdominal tenderness. However there will be NO Rebound tenderness and NO Muscle Guarding.
  • 20. Associated symptoms • Nausea and vomiting • Indigestion • Anorexia and weight loss • Bowel habit • Urinary Symptoms • Gynecological Symptoms
  • 21. Menstrual History-in women in Reproductive age • Sexual Activity and IUD • Amenorrhea(Missed period) • Vaginal Bleeding • Vaginal Discharge • Mid-Cycle
  • 22. Medical History • Medical Diseases; HTN ; CAD ; AF ; Vascular Diseases ;Pulmonary Diseases. • Previous Surgery. • Current Medications. • Alcohol and Smoking.
  • 23. Physical examination
  • 24. General Examination • Vital Signs: Pulse ; Temp.; BP. • Pallor ; Jaundice ; Cyanosis. • Tongue:-Dry ; Coated ; acetone smell. • Examination of Cervical LNs. • Examination of Chest and Heart.
  • 25. Abdominal Examination General Inspection • Patient is agitated; the patient moves around in bed and inability to lie still.= visceral pain. In hollow viscus obstruction and Strangulation • Patient is lying motionless in bed=Parietal pain In Localised/Generalised Peritonitis. • Patient is Drowsy with decrease responsiveness . Haemodynamic Collapse/Sepsis.
  • 26. Abdominal Examination Inspection • Patient should be exposed from nipple to mid- thigh. • Abdominal Distension. • Obvious Abdominal Swelling • Scar ; Fistula ; Sinus. • Distended Superficial Veins • Ecchymosis,Cullen”s and Gray-Turner”s Signs
  • 27. • Cullen sign Grey-Turner sign
  • 28. Palpation and Percussion Light and deep palpation. Start gently and away from reported area of pain. Palpation with pulp of fingers NOT Tips of fingers.
  • 29. Palpation/Percussion  Rebound tenderness = “Peritoneal irritation can be elicited by:- Cough tenderness = Percussion tenderness.  Involuntary Muscle guarding=Peritonitis.  Areas of maximum tenderness.  Detect Organomegaly.  Tympanatic Abdomen.= gas in bowel loops.  Shifting dullness in Ascites.
  • 30. Auscultation • High-pitch “tinkling” sound = mechanical bowel obstruction. • Hyperactive bowel sounds = Enteritis and early intestinal ischemia • No sound within 1-2 min = absent bowel sounds.
  • 31. Do Not Forget  Examination of:- • Hernial Orifices. • External Genitalia-Testis and Scrotum. • Examination of the Back of the patient.  PR and PV Examination.  Dip-stick testing of urine for sugar ; ketone ; blood ; proteins and pus cells.
  • 32. Resuscitation and Immediate Investigations
  • 33. Resuscitation • NPO • NG-Tube in intestinal obstruction and if there is persistent vomiting. • IV-Line and Start IV Fluids. • Analgesia after initial assessment should be given for pain relief. • Important:-Narcotic analgesia don't mask physical signs or obscure the diagnosis. • Start broad spectrum IV Antibiotics if Inflammatory Conditions suspected. • Correction of dehydration and electrolyte imbalance. • Urinary catheter and monitor the urine output.
  • 34. Resuscitation-In Critically Ill-Patients • Air Way and Oxygen Supplement. • Oxygen Saturation Monitoring • ABG • CV-Line ; Volume Replacement.
  • 35. Laboratory studies • CBC • Electrolytes • Blood urea nitrogen/creatinine • Amylase / lipase • Serum lactate levels • Liver function test • Pregnancy Test-In all Women in child- bearing age. • Sickling Test • Blood Group and save the serum. • ECG.
  • 36. Emergency Abdominal Ultrasonography:--  Detection of acute Cholecystitis; pancreatitis; pancreatic pseudo-cysts; liver abscess  Detection of appendicitis/ appendicular abscess; diverticular abscess; mesenteric cysts; Tubo-ovarian abscess; PID and pelvic abscess.  Useful in pregnant and young female patient (detect pelvic pathology);ovarian cysts ; sub-serous fibroid ;PID.  Diagnosis of suspected AAA.  Diagnosis of free intra-peritoneal blood/fluid.
  • 37. Contrast-enhanced CT-Scan (oral and IV Contrast) • It is the secondary imaging modality of choice in the patient with an acute abdomen, following plain abdominal radiography; as images not masked by bowel gas and most surgeons can interpret the findings more than US. • CT-Scan establishes the diagnosis of acute abdominal pain in over 95% of cases.
  • 38. Thick-walled, fluid-filled appendix with surrounding inflammation
  • 39. Large Appendicular Abscess containing gas.
  • 40. Acute Pancreatitis--An enlarged pancreas with indefinite border and infiltration of the surrounding fat-(the peri-pancreatic stranding)
  • 41. Pancreatic Necrosis-- Lack of gland enhancement following IV contrast administration is diagnostic.
  • 42. Multiple splenic abscess
  • 43. CT-IV Contrast-Small Bowel Ischemia due to Strangulation
  • 44. After the initial assessment the patients with acute abdominal pain should be categorized into: (I)Patients with immediately Life Threatening conditions :- Patients who need immediate Laparotomy ( Abdominal Crises ) (1)—Massive intra-abdominal bleeding; (Ruptured AAA. or visceral aneurysms, ruptured ectopic pregnancies, and spontaneous hepatic or splenic ruptures). (2)—Acute Intestinal Ischemia with hypovolemia and resistant acidosis. (3)-Intra-abdominal sepsis; (due to perforated viscus/or strangulation; volvulus; Intussusception; strangulated hernia ) ; with high fever; tachypnea; sweating; frank hypotension; deterioration of mental state(agitation, disorientation); indicating impending septic shock.
  • 45. Medical life threatening conditions:-  Myocardial infarction.  Spontaneous tension Pneumothorax.  D-Ketoacidosis .  Acute AD.Cortical Failure.
  • 46. (II)– Patients with Rapidly Life Threatening conditions. Patients who need; Urgent laparotomy;(with in 4-6H.)  Perforated hollow viscera.  Strangulated Bowel.  Intra-abdominal Abscesses; (Appendicular; and Diverticular); with free intra-peritoneal perforation and diffuse peritonitis.  Clinical; Laboratory; and Radiological indicators for Urgent Laparotomy:-  Increasing severe localized tenderness.  Progressive tense abdominal distention.  Spreading Involuntary muscle Rigidity.  High fever, tachycardia, confusion.  Marked Leukocytosis with left shift.  Pneumoperitoneum
  • 47. (III)-Serious conditions:-that need early planned surgery/or need early supportive treatment and close monitoring  Appendicitis/appendicular abscess; acute Cholecystitis/peri-cholecystic abscess; acute pancreatitis.  Diverticulitis/Diverticular abscess; PID /Tubo- ovarian abscess; Localised intra-abdominal or Pelvic abscess.  Small bowel obstruction.  Large bowel obstruction due to: diverticular abscess/ carcinoma
  • 48. (IV)-Less serious conditions which require conservative treatment  Biliary colic; renal colic.  Inflammatory bowel disease.  Non-specific abdominal pain.  Gastro-enteritis and infective colitis.  UTI.  Un-complicated ovarian cyst and fibroid; and endometriosis. Mid-ovulatory pain.  Un-complicated Diverticulitis.  Most of Medical causes.
  • 49. Differential Diagnosis
  • 50. Differential Diagnosis of patients with Acute Abdominal Pain Each List Represents > 90-95% of Causes in each Group) Infants less than one year old • Infantile Colic. • Gastro-enteritis. • Intussusception. • Incarcerated congenital hernia • Constipation. • UT-Infection. • Hirschsprung disease. • Volvulus neonatorum Children 1-5 years old Appendicitis. Non-specific abdominal pain Intussusception. Incarcerated congenital hernia Gastro-enteritis UT-Infection Constipation Sickle cell crisis Henoch scheneloin Purpura
  • 51. Differential Diagnosis of patients with Acute Abdominal Pain Young and middle age Adult • Appendicitis. • Acute Cholecystitis. • Acute Pancreatitis. • Non-specific abdominal pain. • Intestinal obstruction. • Active/Perforated PU. • UTI. • Diverticulitis. • Renal colic Young and middle age Women • Salpingitis-PID. • Appendicitis. • Acute Cholecystitis. • Acute Pancreatitis. • Rupture ectopic pregnancy • Rupture/Torsion Ovarian cyst. • Mid-ovulatory Pain. • UTI.
  • 52. Suppruative Appendicitis
  • 53. Meckle's Diverticulum
  • 54. Volvulus of Meckle's Diverticulum
  • 55. Torsion Ovarian Cyst
  • 56. Ruptured Ectopic Pregnancy
  • 57. Acute Cholecystitis
  • 58. Sigmoid Volvulus.
  • 59. Acute Abdominal Pain in Elderly Patients  In Elderly patients >60 years old; after exclusion of the commonest causes of Acute Abdominal Pain; as:-  Acute Cholecystitis ' Acute Pancreatitis; Acute Appendicitis; the patients should be investigated as; they may have colonic obstruction/ perforation due to Colo-rectal carcinoma; diverticular abscess  In patients >70 years old; 10% of patients with Acute Abdominal Pain will have Vascular Accident; Acute Intestinal Ischemia; or MI.
  • 60. Messages
  • 61.  Accurate History and complete clinical Examination are essential to put provisional diagnosis/or short list of DD; and to institute diagnostic tests and to decide if the patient will need urgent surgery.  It is NOT Important to make specific diagnosis but to detect Urgent and immediate Life-Threatening conditions.  The diagnosis of acute abdominal pain; particularly in early stage of presentation is often difficult and is accurate only in 45-65% of patients. So the patient should be re-examined by the same physician after resuscitation.  Define Surgical from non-surgical Abdomen. The term Acute Abdomen should never equate with the invariable need for surgery.
  • 62.  Analgesia-Make the patient pain-free.  Opioids as (Morphine and Pethidine) don't mask the physical signs or prevent accurate diagnosis.  The most common surgical diagnosis: -- acute appendicitis, followed by acute Cholecystitis, small bowel obstruction, and gynecologic disorders.  A useful rule is never to place appendicitis lower than second in the differential diagnosis of acute abdominal pain in a previously healthy person.
  • 63.  Indications of Surgical Consultation:-  (A.)-Severe Progressive Abdominal Pain.  (B.)-Involuntary Abdominal Muscles Guarding/Rigidity.  (C.)-Bile-stained or Faeculent Vomiting.  (D.)-Haemodynamically Instability(Fluid/Blood Loss)- Signs of hypoperfusion as un-explained acidosis.