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Acute Abdomen Diagnosis and Management
- 2. 20 yrs. man referred to surgery casualty with h/o diffuse abdominal pain & diarrhea for 1 day. h/o abdominal pain 1 month back. He was febrile, abdomen was soft & tenderness in all quadrants. no rebound or guarding.
- 4. QUESTION ACUTE ABDOMEN ? Characterized by any sudden, spontaneous, non- traumatic, severe abdominal pain of <24 hrs duration. Requires rapid & specific diagnosis, as several conditions need emergency operation Any delay in diagnosis & treatment may adversely affect outcome.
- 5. COMMON CAUSES OF ACUTEABDOMEN
- 6. MEDICAL CAUSES OF ACUTEABDOMEN
- 7. DIAGNOSIS: History Past medical / Surgical , Gynaecological, Drug Family ,Travel history Abdominal pain & associated symptoms Physical examination Laboratory investigation Imaging studies Diagnostic Lap/OGD/Colonoscopy
- 8. ABDOMEN PAIN Pain is the most common & predominant presentingfeature. Assessment of the patient’s pain • The classic PQRST mnemonic for a complete pain history is as follows: P3 – Positional, palliating, and provoking factors Q – Quality R3 – Region, radiation, referral S – Severity,T3 – Temporal factors (time and mode of onset, progression, previous episodes)
- 9. What kind of pain is it? Referred & shifting pain Visceral pain Parietal pain
- 10. REFERRED PAIN & SHIFTING PAIN: • Extension of the pain from original site to another site with persisting pain at the original site. • Spreading or Shifting pain Origin of the pain at one site, shift to another site where pain at the initial side disappear Typical site of various abdominal pain
- 12. PARIETAL PAIN: Direct irritation of parietal peritoneum by: Pus Bile Blood Urine GI secretions. sharper, better localised pain. U/L sensory supply to the spinal cordT6 L1 areas
- 13. VISCERAL PAIN • Distension • Inflammation Ischemia • Malignant infiltration of sensory nerves • Slow in onset, dull, poorly localised • Felt in the midline -B/L sensory supply to the spinal cord.
- 14. CHARACTER OF PAIN Colicky pain -sharp intermittent, gripping pain Obstruction to a hollow organ (Hepatobiliary, bowel, ureteric, fallopian tube) Constant burning pain F/o peritonitis Severe agonising pain Characteristics of A/c pancreatitis Throbbing pain - S/o inflammation (Cholecystitis) Changing in character of pain – ie. colicky pain sometimes change into constant pain indicate strangulation
- 15. Characteristics of vomitus with abdomen pain Associated symptoms with pain: Bilious green Intestinal obstruction, malrotation or sepsis Coffee ground Gastritis, gastric ulcer, esophagitis Fresh blood Esophagitis. Gastritis, gastric or duodenal ulcer, mallory-weiss centre Food or stomach content Gastroenteritis, early SBO Feculent Late intestinal content.
- 16. Other symptoms assoc. with Abdominal pain Constipation :Suggest mechanical bowel obstruction Diarrhoea : Pelvic abscess Blood Stained stool : Ischemic colitis, IBD Fever : Marker of inflammation Anorexia Hematemesis Hematochezia or Malena : LGI bleed or colonic Ischemia Hematuria : Urolithiasis or cystitis, UTI
- 17. PAST MEDICAL HISTORY Pulmonary TB Cardiac disease AF APD Biliary colic & Pancreatitis IBD Abdominal trauma: Delayed splenic bleeding PAST SURGICALHISTORY • Previous abdominal surgery • Mode of operation – • Laparoscopic, Open, Endovascular • Operative notes & pathology reports should be obtained & reviewed HISTORY:
- 18. Other relevant aspects of the History: NSAID, Anticoagulant, OCP,Corticosteroids Hereditary pancreatitis Amoebic liver abscess , Hydatid cyst Malarial spleen , Tuberculosis Salmonella typhi Dysentery GYNAECOLOGICAL HISTORY • Menstrual history • Ectopic pregnancy • Mittelschmerz (Ruptured ovarian follicle ) • Endometriosis • H/o Vaginal d/d or dysmenorrhea may • denote PID
- 19. PHYSICAL EXAMINATION Appearance • Hippocratic facie’s of dehydration Attitude Vitals pulse • BP, RR, Temperature, Dehydration, SPO2 • Anaemia, Cyanosis, Jaundice
- 20. ABDOMINALEXAMINATION INSPECTION • Abdominal contour Respiratory movement Peristaltic movement Visible swelling Hernial orifices Scrotum • Renal angle • Skin condition • PALPATION • Tenderness Rebound Guarding Rigidity Distension Lump Hernia site
- 21. IMPORTANCE SIGN • Murphy’s sign : A/c cholecystitis • Kehr’s sign- Spleen rupture • Mc-burneys sign- Appendicitis Iliopsoas sign – Appendicitis Rovsin sign- Appendicitis • Grey turners sign- Hemoperitoneum • Chandelier sign- PID • Dance sign – Intussusception ( Empty RLQ & mass RUQ)
- 22. SPECIAL SIGN 4 signs : Helpful in deciding .. is this an Acute abdomen? Pointing test / pointing sign Cough test Rebound tenderness/ Release sign/ Blumberg sign Bed shaking test. Alders sign: Shifting tenderness helpful to differentiate b/w Appendicitis with Uterine origin tenderness
- 23. OTHER EXAMINATION • Percussion • Shifting dullness - Presence of free fluid Obliteration of liver dullness – Pneumoperitoneum • Auscultation • Hyper peristalsis (early) Silent abdomen (late) • Rectal examination • Vaginal examination • Tenderness on PR / PV (pelvic peritonitis ) Blood stain, malena
- 24. what kind of tests should you order ? what you are looking for! DIFFERENTIAL DIAGNOSIS IT’S HUGE! Use History & Physical exam to narrow it down.. R/o life-threatening pathology Provisional diagnosis lead investigation..
- 25. INVESTIGATIONS: • BLOOD INVESTIGATION: • CBC – Hb TC Neutrophil count ( Ectopic, UGI, LGI Bleed, widal) • S. Electrolytes- Na+, K+ , Ca2+ ( DKA, Hyperparathyroidism) P04 • RBS (DKA) • ESR • CRP • BLOOD C&S ( Cholangitis Pyelonephritis Sepsis) • Blood group
- 26. • LFT • Bilirubin- TB, DB (obstructive J) • S. Albumin (CLD) • ALP • S. amylase , S. lipase • PT INR aPTT • RFT- Blood Urea , S. Creat. • TSH T4- Toxicity Beta HCG
- 27. URINE RE • RBC – Urolithiasis/ UTI • Pus cell- Urolithiasis / UTI/ TB Sugar (DKA) • Albumin (CKD) • Crystals • Urinary 5-HIAA (as an early marker ofAppendicitis) Dipstick test for bilirubin & ketones • UPT • ABG- Lactate, Metabolic acidosis (mesenteric ischemia) • ECG • AF/ NSR • Ischemic change • Chamber abnormality ( mesenteric ischemia) • Electrolyte abnormality 25% Appendicitis -hematuria, pyuria & albuminuria Urinalysis abnormal in 19-40% .
- 28. IMAGING STUDIES X-ray chest : Free gas under diaphragm Lower lobe consolidation Elevated hemidiaphragm Pleural effusion X-ray chest is more sensitive than abdominal x-ray forPneumoperitoneum 1ml air produce pneumo in errect CXR 5 to 10 ml air pick up in lateral decubitus position (after 10minutes)
- 29. ABDOMINAL X-RAY Multiple air fluid level 3, 6, 9, rules (3cm 6cm 9cm) String of pearls sign Step ladder pattern Pneumoperitoneum Thumb print sign Calculus Calcification ( pancreatic ) Pneumatosis intestinalis Intra-peritoneal and retroperitoneal collection Radio opaque 90% renal stone 10% gall stone 5% appendicolith
- 30. Multiple air fluid level Large bowel obstruction
- 31. COFFEE BEAN sign in SIGMOID VOLVULUS
- 32. Thumb-printing Sign (Signifying Bowel wall oedema and thickening) Step ladder pattern
- 33. Calcification ( pancreatic ) Staghorn Calculus
- 34. Gas in the Portal Vein Pneumatosis Intestinalis (Gas in the wall of small bowel)
- 35. . CT shows distended small bowel loops that are not seen on x-ray abdomen because they are filled with fluid only & do not contain intraluminal air Plain x- ray -showing no abnormalities
- 36. ULTRASONOGRAPHY • Inflammatory conditions, Stone disease (KUB, GB) • Good for diagnosing AAA (not for ruptured AAA) • Good for pelvic pathology, Free fluid collection Most useful in pregnant patients (no radiation) • Distinguish from inflammatory & infectious processes Evaluation for flow through the Mesentric vesssels. • Obesity, Following previous surgery, Ascites Gaseous distension of bowel
- 37. CT SCAN Among pts those do not already have clear indications for laparotomy or laparoscopy Provides excellent diagnostic accuracy. Unknown diagnosis? Intractable abdominal pain (infection or vascular lesion ?) Plain CT- Free air, Renal colic, Ruptured AAA, Bowel obstruction Contrast study -Abscess, Infection, Inflammation, unknown cause MRI - most often used when unable to obtain CT due to contrast issue 1.children's and elderly 2.Obese 3.Critically ill patients 4.Immunocompromised pt.
- 38. Gas in Mesenteric Vein Gas in Bowel wall (Pneumatosis intestinalis) CECT abdomen
- 39. SBO4% Diagnosis is made when you see dilated & collapsed small bowel loops. Identify its cause & location. Adhesion SBO has a smooth transition from dilated to collapsed small-bowel loops Small bowel faeces sign • Seen at the zone of transition, help to identify the cause of the obstruction. • Defined as Gas & particulate material within a dilated small-bowel loop that simulates the appearance of faeces. .
- 40. FREE FLUIID & ASCITES Normally do not have a detectable amount of free intra-peritoneal fluid The presence of ascites is a nonspecific sign of abdominal pathology, indicating that 'something is wrong'. USG-guided diagnostic puncture of the ascites Sterile reactive fluid Pus Blood Urine Bile.
- 41. Presence of free intraperitoneal air is proof of bowel perforation, & indicates a surgical emergency. Frequentcauses: - Perforation of a gastric ulcer or colonic diverticulitis Free air is usually not seen in perforated appendicitis. Examine the images in lung setting for better detection of free gas . Intraperitoneal air in a patient suspected of having appendicitis FREE AIR
- 42. ROLE OF ENDOSCOPY OGD- Urgent ERCP may be indicated in cases of suspected cholangitis. - Mx of PUD Bleed. Sigmoidoscopy- to reducing a Sigmoid volvulus Colonoscopy to locate the source of bleeding in cases of lower GI bleed
- 43. ROLE OF LAPAROSCOPY Laparoscopy is a Therapeutic as well as Diagnosticmodality In cases of unclear diagnosis it guide surgical planning & avoid unwantedlaparotomy In young women it may distinguish a non surgical problem fromAppendicitis • Ruptured graffian follicle • PID • Tubo-ovarian disease
- 44. CHOLECYSTITIS GB is non-compressible (hydropic) & causes an impression in the anterior abdominal wall (arrowheads). CT –GB enlarged, edematous, thickening of its wall , & regional fat-stranding can be found. EMPHYSEMATOUS CHOLECYSTITIS
- 45. PANCREATITIS Generalized peritonitis need laparotomy (regardless of cause – except A/c pancreatitis) Get a Lipase level CT depicts fat-stranding (arrowheads) surrounding the primary focus of the inflammation: the pancreas.
- 46. DIFFERENTIAL DIAGNOSIS A complete list of all possible causes of an A/c abdomen is of little use in dailypractice Examples of frequent causes of A/c abdominalpain • Appendicitis & Appendicitis mimickers • Mesentric lymphadenitis Diverticulitis • Bacterial ileocecitis • PID • Urolithiasis
- 47. ACUTE Appendicitis Classic presentation Peri-umbilical pain - localizes to RIF Anorexia, nausea, vomiting Only in <50% patients Retrocecal - pain in the flank A pelvic appendix - supra- pubic pain, dysuria Males may have pain in the testicles Findings- Depends on duration of symptoms Rebound, guarding, rigidity Tenderness on PR Psoas sign Obturatorsign Fever (a late finding)
- 48. DIAGNOSTIC SCORING SYSTEM MANTRELS SCORE ( ALVARADO ) Score of 3 – incidence 3.6% 4 - 6 32% 7 - 10 78% FENYO- LINDBERG SCORE Cut off point -26 or less – Exclusion -26 to 0 – monitoring 0 or more – operation FENYO SCORE Cut off <11 monitoring >11 operation RIPASASCORE APPY SCORE STRATA ESKELINEN SCORE <50 Exclusion 57 Monitoring >57 Operation
- 49. Appendicitis . Normal appendix is surrounded by homogeneous non-inflamed fat, is compressible & often contains intraluminal gas. USG & CT - a blind-ending non-peristaltic tubular structure The appendix (arrows) is fluid-filled & distended with peri-appendiceal fat-stranding
- 50. APPENDIX MIMICKERS Mesenteric adenitis Bacterial ileocecitis Epiploic appendagitis Omental infarction Right-sided colonic diverticulitis Crohns disease Gynecologic conditions Urolithiasis Rectus sheath hematoma
- 51. MESENTERIC LYMPHADENITIS. Benign self-limiting inflammation of right mesenteric lymph nodes without an identifiable underlying inflammatory process MC in children than in adults.. • Key finding: lymphadenopathy with a normal appendix & normal mesenteric fat. On the left a CT of mesenteric lymphadenitis in a child suspected of appendicitis
- 52. BACTERIAL ILEOCECITIS USG typically shows sub-mucosal wall thickening (arrowheads) of the terminal ileum & cecum without inflammation of the surrounding fat. Infectious Enterocolitis cause mild symptoms resembling a common viral gastroenteritis Mimic Appendicitis especially in bacterial ileocecitis caused by yersinia, campylobacter, or salmonella. key finding: ileocecal wall thickening without inflamed fat, adenopathy, normal appendix
- 53. DIVERTICULITIS Right-sided colonic diverticulitis mimic appendicitis orcholecystitis In contrast to left, right-sided colonic diverticula are true diverticula (colonic wall containingall layers )- Essentially benign selflimiting character CT shows an inflamed cecal diverticulum (arrowhead) with regional colonic wallthickening. Right-sided diverticulitis A hypoechoic thickened diverticulum is surroundedby hyperechoic inflamed fat (arrows).
- 54. PELVIC INFLAMMATORY DISEASE PID is a common mimicker of both of appendicitis & diverticulitis. TVS depicts an inhomogeneous enlarged inflamed ovary. Enlarged adnexa due to salphingitis
- 55. Urolithiasis Small stone in right ureter (arrow) causing right flankpain. Problem with HUN EMPHYSEMATOUS PYELONEPHRITIS
- 56. RUPTURED ANEURYSM Most AAA rupture into the left (Left RP fluid collection) Mimic sigmoid diverticulitis or renal colic due to the hematoma Classic triad of hypotension, a pulsating mass and backpain. USG is a quick & convenient modality It is much less sensitive & specific for the diagnosis, than a CT Anormal USG does not rule out this entity .
- 59. Acute abdomen require an urgent therapeuticdecision. Normal findings in pt who need emergency surgery (Appendicitis) & may be abnormal in pt without a surgical disease ( Salphingitis). Always screen the whole abdomen for general signs of pathology radiologicaly Laboratory findings (TC, ESR, CRP) are equally non-conclusive C/f of A/c abdomen is often nonspecific & because ofd/d. Challenging CONCLUSION:
- 60. A plain x ray abdominal has a limited value , may falsely reassure theclinician. USG & CT helps in a rapid triage of patients. Mx may vary from emergency surgery to reassurance Misdiagnosis result in delayed necessary treatment or unnecessarysurgery. Surgery should not be delayed for time consuming tests when an indication for surgery is clear, Generalized peritonitis on examination (regardless of cause - except A/cpancreatitis) Perforation (on Chest X-RAY) Complicated hernia -Irreducible and tender hernia (risk ofstrangulation) Take home message