2. Acute abdomen; the most common non
traumatic abdominal emergency
characterized by sudden onset of severe
abdominal pain
DDx ; Acute appendicitis
Intestinal Obstruction
Peritonitis
Perforated PUD
2
4. Visceral ( Splanchnic)
Tension, stretch, ischemia, distension
Dull poorly localized, mid line
Parietal (Somatic)
Parietal peritoneal involvement
Sharp, intense, discrete, well localized
Referred
Same as parietal, but felt remote
4
5. Nausea/vomiting
◦ Before or after pain?
Diarrhea/Bloody
◦ Before or after pain?
Constipation
Jaundice
Anorexia
History of trauma
Urinary symptoms
Cough and chest
symptoms
Alcohol intake
Associated symptoms
Gynecologic history
Past illness
Family history
Drug use
5
6. General Appearance
◦ Lies perfectly still: Inflammation, peritonitis
◦ Restless, writhing: Colic, obstruction
Vital signs
◦ Tachycardic? Early shock (Important than BP)
◦ Rapid shallow breathing: peritonitis
◦ Level of hydration
◦ Fever
6
7. Bowel Sounds(5-35 pm)
◦ Listen 1 minute in each quadrant before palpation
◦ Absent bowel sounds: ileus, peritonitis, shock
Palpate each quadrant
◦ Work toward area of pain with warm hands
◦ Patient on back and knee bent (if possible)
Tenderness/Rebound tenderness, rigidity, involuntary
guarding, voluntary guarding, masses
Point of maximal tenderness ?
7
10. Acute appendicitis is the commonest cause of
abdominal pain leading to emergency
abdominal surgery in pediatrics.
Life time risk: 8.6% for males,6.7% for females
with the highest incidence in the second and
third decades, 1.1 cases per 1000 people per
year and some familial predisposition exists.
The Pathophysiology of appendicitis is due to
a closed loop obstruction of the appendix.
◦ hyperplasia of the submucosal lymphoid follicles.
◦ Fecaliths
◦ Parasites
◦ Foreign bodies
10
11. Obstruction of the appendiceal lumen
Increasing intraluminal pressure + mucosal
edema.
Venous and lymphatic obstruction
Ischemic inflammation of the appendix.
Bacterial proliferation
Perforation will
Arterial obstruction and gangrene
Peritonitis develops.
The overall mortality ~ 0.2-0.8% is attributable
to complications of the disease..
11
12. Variations in the position of the appendix, age of
the patient, and degree of inflammation make
the clinical presentation of appendicitis
notoriously inconsistent.
◦ Periumbilical pain that shifts to the RLQ**~ 80% sensitive
◦ Anorexia, nausea, few vomit
◦ Diarrhea/Constipation
◦ Urinary symptoms
◦ Afebrile or low-grade fever.
12
13. •Tenderness
• Mc Burney’s
•Rebound tenderness
•Guarding and rigidity
•Rovsing’s sign
•Psoas sign
•Obturator sign
Cough sign
Generalized peritonitis
RLQ mass
PR tenderness or mass
Inflamed hemi
scrotum
CVA tenderness
13
15. WBC count and differential count
◦ Leukocytosis with a left shift
◦ If >18,000 indicates perforation
◦ There may be luekopenia with nuetrophil predominant
C-reactive proteins
Urinalysis
◦ Irritation of the bladder or ureters by an inflamed appendix may result in
a few WBCs in the urine;also to rule out UTI
15
16. Sensitivity = 85%, specificity = 94% in pediatric
patients in experienced hands.
◦ Specific findings can support the diagnosis.
Non-compressible dilated appendix
Transverse diameter of 6 mm or more.
Lack of peristalsis(actualy no
peristalisis in normal appendix)
Peri appendiceal phlegmon or abscess
formation.
An appendicoliths
Focal tenderness over the inflamed appendix
16
17. M =Migration of pain to the RLQ 1
A = Anorexia 1
N = Nausea and vomiting 1
T = Tenderness in RLQ 2
R = Rebound pain 1
E = Elevated temperature 1
L = Leukocytosis 2
S = Shift of WBC to the left 1
Total 10BN
17
18. Score <3; low likelyhood of appendicites
4-6;consider further imaging
>or equal to 7 operate
18
19. Patients with a classic history for appendicitis
require prompt surgical intervention.
◦ Kept NPO
◦ Administer analgesics once decision is made
◦ IV fluids and ensure adequate hydration.
◦ Antibiotics Gm-ve and anaerobic organisms such as E. coli and
Bacteroides(if necessary)
◦ Open Vs. Laparoscopy appendectomy
◦ At McBurney point oblique (one third of the distance from the
ASIS to the Umbilicus
◦ If prforation is suspected lower midline laparatomy
19
20. Appendiceal mass: Conservative treatment,
followed by elective appendectomy after 6
weeks.
Appendiceal abscess: Drain abscess, leave
appendix untouched if difficult to identify,
elective surgery after 6 weeks.
Nonsurgical treatment: may be useful when
appendectomy is not accessible or when it is
temporarily a high-risk procedure.
20
21. Perforation
Sepsis
Shock
Dehiscence
Wound infection
Bowel obstruction
Abdominal/pelvic abscess
Death (rare)
The prognosis is generally excellent
21
23. Intestinal obstruction
Small bowel 80% of obstruction
20% of acute abdomen admissions
5% of all surgical admissions
Large bowel 20% of obstruction
Ethiopia → Acute abdomen in TAH; 2000 (Berhanu K.)
i. Acute Appendicitis=52%
ii. Intestinal obstruction=26%
Small bowel= 52.3 %
Large bowel= 46.7 %
26. Large bowel obstruction
Intraluminal – Impaction or obstipation
Intramural – Colon cancer, Stricture (diverticulitis,
Inflammatory bowl disease or ischemic)
Extramural - Volvulus, Intussusception
27. Ileo-sigmoid knotting
(compound volvulus)
Dramatic
presentstion with
shock & gangrene of
bowl
4th
decade
Intussusception
Commonest site -
ileocaecal junction
Sigmoid volvulusSigmoid volvulus
SmallSmall IntestinalIntestinal volvulusvolvulus
28. Non mechanical
Paralytic Ileus
Mesenteric vascular occlusion (SMA)
Embolus
Thrombosis
Pseudo - obstruction (Ogilvie syndrome )
Theories - ↑sympathetic tone, ↓parasympathetic tone
95% - associated with medical or surgical conditions
5% - idiopathic
29. Proximal Bowel
=> Initially, increreased peristalsis
dilatation (fluid and air)
=> Later, reduction in peristaltic
strength
Flaccidity and Paralysis
Distal bowel
=> Normal Peristalsis and
absorption Empty
contracted and immobile
30. Small-Bowel Obstruction
Proximal gut is distended by swallowed
gas and fluid from GI secretions.
Copious vomiting exacerbates fluid loss
and electrolytic depletion.
Hypovolemia may be fatal.
Prolonged obstruction → Compromise of venous
blood
→ Bowel edema,
→ Localized tissue anoxia→ ischemia, necrosis,
perforation leading to peritonitis,
→ Septicemia
→Death
31. Large Bowel Obstruction
Colonic pressure ↑ and mesenteric venous flow ↓
causing oedema of wall and transudation of water and
electrolytes into lumen.
3rd space loss and dehydration and electrolyte
imbalance.
Arterial blood supply becomes jeopardized → mucosal
ulceration, full thickness necrosis and perforation.
Colonic bacteria translocation → septic complications.
32. Simple Obstruction
Mechanical block or ileus, without impairment of
blood supply of the gut .
Fluid and Electrolyte loss (ECF)
Bacterial proliferation in the pool of fluid
→ Highly infectious
N.B. Ischemic changes progressing to necrosis and
perforation may occur at site of obstruction.
33. Strangulated Obstruction
When bowl involvment is extensive hypovolemic shock
Hypoxia of intestinal mucosa (luminal hypoventilation and ↓ed
blood flow)
Decreased mucosal resistance Auto-digestion + Bacterial
invasion
Inflammation, Ulceration Bacterial and Endotoxin
translocation
Frank gangrene and perforation
Causes:Causes:
volvulusvolvulus
Hernial orificesHernial orifices
Adhesions / bandsAdhesions / bands
IntussusceptionsIntussusceptions
Closed loop obstructionClosed loop obstruction
34. Closed loop obstruction
Obstruction of a bowel
segment at both ends
Rapidity of onset of Signs &
symptoms depend on the
length of involved segment
Progression to strangulation
frequently occurs if surgical
intervention is delayed
35. C.F. vary according to
Site of the obstruction
Duration of the obstruction
Underlying pathology
Presence / absence of strangulation
36. The four cardinal features of obstruction
Dehydration → Tachycardia, Hypotension, oliguria
Features of peritonism → Strangulation or perforation
Abdominal PainAbdominal Pain
VomitingVomiting
Abdominal DistensionAbdominal Distension
Absolute ConstipationAbsolute Constipation
37. Constipation is a rule in intestinal obstruction
doesn't apply in:
Richter's hernia,
Gallstone obstruction,
Mesentric vascular occlusion,
Obstruction associated with pelvic abscess,
Partial obstruction (diarrhea may occur).
38. ◦ Severe continuous pain
◦ Tenderness with rigidity
◦ Shock
◦ Fever
◦ Tachycardia after resuscitation
Lab. →Leukocytosis
39. Clinical
Focus on:
• Distinguishing mechanical Vs ileus
• Etiology of obstruction
• High or Low
• Simple or strangulated
• Partial or complete
40. History
Cardinal features of obstruction
Age, Sex, Occupation, Address
Past Hx
abdominal/pelvic surgery
medical illnesses: TB; IBD
41. P/Examination
◦ General appearance
◦ V/S
◦ Abdomen
Surgical scars, distension, visible bowl loops,
Hernia orifices,
Guarding and tenderness,
Bowel sounds,
DRE --- masses, stool, blood
◦ Examination other systems
42. Plain abdominal X-ray
in SBO – triads of:
Dilated small bowl
(>3cm)
Air-fluid level
Paucity of air in colon
• Sensitivity = 70-80% ;
Specificity is low ~60%
DDx: ileus, colonic
obstruction
• False negative- in high
small bowl obstruction
Erect abdominal
radiograph of a
47-year-old man
Supine
abdominal
radiograph in a
57-year-old man
44. Fluid and electrolyte
◦ Deficit, maintenance, continued third space losses
NGT decompression until return of bowel function
Input / output monitoring
Antibiotics
Observation for complications
46. Management
1. Rectal tube/sigmoidoscopic decompression → for simple
sigmoid
Rectal tube should be placed in situ for 2 - 3 days
Recurrence rate of 20 -30%
1. Emergency surgery
Indications for Emergency surgery
◦ Failed rectal tube decompression
◦ Signs of bowel gangrene
47. Management
1. Rectal tube/sigmoidoscopic decompression → for simple
sigmoid
Rectal tube should be placed in situ for 2 - 3 days
Recurrence rate of 20 -30%
1. Emergency surgery
Indications for Emergency surgery
◦ Failed rectal tube decompression
◦ Signs of bowel gangrene
48. Def.
1.Primary SIV →occurs without any predisposing cause.
2.Secondary SIV → most frequently related conditions
are bands, adhesions, Meckel`s diverticulum, internal
hernia and pregnancy.
49. Obstruction may result from a single band or multiple
dense adhesions
Cause
• Postoperative
• Inflammatory
• After blunt trauma
• congenital
Develops in 5% of abdominal operations
50. Treatment
◦ Conservative: NPO, NGT, iv fluids, analgesics
◦ Success rate 90% in early adhesive obstruction and
partial obstruction
60-85% over all
51. Treatment….
3 hourly examination by the same clinician is
crucial to be alert to changes in patients
condition.
Repeat abdominal x-ray in 6 hrs.
Conservative management for up to 48 hours
is often safe
Early postoperative for the first 7 to 14 days
If strangulation suspected Immediate
operation.
52. Def.
Failure of transmission of peristaltic waves due
to neuromuscular failure
Causes
Postoperative, self-limiting→24-72 hrs.
Intra-abdominal sepsis
Reflex ileus →Retroperitoneal hemorrhage, spine or rib
fracture
Metabolic →hypokalaemia, uraemia
Clinical F.
◦ Abdominal distension
◦ Vomiting = gastric and bilious
◦ Discomfort from distension, not colicky pain
53. The term peritonitis refers to a constellation
◦ Abdominal pain
◦ Tenderness on palpation
◦ Abdominal wall muscle rigidity and
◦ Systemic signs of inflammation.
May be
◦ Primary ► Spontaneous
◦ Secondary ► Related to a pathologic process in an
organ
◦ Tertiary ► Persistent or recurrent infection after
adequate initial therapy.
◦ Localized or Generalized
53
54. 1. Direct infection
i. Via a GI perforation
ii. Via an abdominal wall breach
iii. Post operative: Drains, foreign materials
2. Local infection
i. From an inflamed organ
ii. Migration through a gut wall
iii. Via the fallopian tubes
3. Blood-stream (hematogenous)
54
55. The diagnosis of peritonitis is clinical!!!
Early ;symptoms on associated organs
Dull and poorly localized Steady, more severe,
More severe Generalized worse by moving or
breathing, the patient usually lies still
Infrequent bowel suonds
Pulse and temperature may rise
Late; generalised rigidity , distention with absent
bowel suonds due to paralytic ileus
Hypotention: cold extermity,sunken eyes,dry
tongue,irregular pulse,anxious face(Hippocrates
facies)
◦ Symptoms referable to specific organs
55
56.
Physical exam
◦ Unwell and in acute distress
◦ Tachycardia, hypotension/overt septic shock.
◦ Abdominal wall rigidity**
◦ Tenderness and rebound tenderness**
◦ Pts avoid all motion & keep their hips flexed
◦ Hypoactive/absent bowel sounds.
◦ Rectal and vaginal findings
56
57. CBC with differential
◦ Leukocytosis/leucopeni
a with left shift
Serum electrolyte
panel
BUN and creatinine
Coagulation profile
Liver function tests
Serum amylase and
lipase levels
Urinalysis (UTI)
Aerobic and
anaerobic blood
cultures
Peritoneal fluid
analysis
Intra operative fluid
analysis
57
58. Fluid resuscitation + blood transfusion
Administration of antibiotics
Oxygen
Nasogastric intubation
Urinary catheterization
Monitoring of vital signs and homodynamic data.
Analgesia
Early surgery
58
59. Surgical intervention for secondary peritonities
Antibiotics is enough for primary peritonities
Surgical intervention if the diagnosis is in
duobt
Nonoperative interventional therapies include
◦ percutaneous drainage of abscesses
◦ Percutaneous&endoscopic stent placements.
59
60. 1. Residual abscess
2. Bacterial septicemia
3. Bronchopneumonia
4. Electrolyte imbalance
5. Renal; failure
6. Bone marrow suppression
7. Multi organ failure
8. Post operative adhesion
9. Paralytic ileus
60
