Acute abdomen approach to managment-hazem


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

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Acute abdomen approach to managment-hazem

  1. 1. ACUTE ABDOMEN MANAGEMENT APPROACH DR.M.HAZEM EL-FOLL FRCS-(UK) Consultant General and Laparoscopic Surgery
  2. 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.
  4. 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. 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. 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. 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. 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. 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. 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. 11. History taking
  12. 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. 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. 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. 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. 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. 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. 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. 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. 20. Associated symptoms • Nausea and vomiting • Indigestion • Anorexia and weight loss • Bowel habit • Urinary Symptoms • Gynecological Symptoms
  21. 21. Menstrual History-in women in Reproductive age • Sexual Activity and IUD • Amenorrhea(Missed period) • Vaginal Bleeding • Vaginal Discharge • Mid-Cycle
  22. 22. Medical History • Medical Diseases; HTN ; CAD ; AF ; Vascular Diseases ;Pulmonary Diseases. • Previous Surgery. • Current Medications. • Alcohol and Smoking.
  23. 23. Physical examination
  24. 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. 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. 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. 27. • Cullen sign Grey-Turner sign
  28. 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. 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. 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. 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. 32. Resuscitation and Immediate Investigations
  33. 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. 34. Resuscitation-In Critically Ill-Patients • Air Way and Oxygen Supplement. • Oxygen Saturation Monitoring • ABG • CV-Line ; Volume Replacement.
  35. 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. 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. 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. 38. Thick-walled, fluid-filled appendix with surrounding inflammation
  39. 39. Large Appendicular Abscess containing gas.
  40. 40. Acute Pancreatitis--An enlarged pancreas with indefinite border and infiltration of the surrounding fat-(the peri-pancreatic stranding)
  41. 41. Pancreatic Necrosis-- Lack of gland enhancement following IV contrast administration is diagnostic.
  42. 42. Multiple splenic abscess
  43. 43. CT-IV Contrast-Small Bowel Ischemia due to Strangulation
  44. 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. 45. Medical life threatening conditions:-  Myocardial infarction.  Spontaneous tension Pneumothorax.  D-Ketoacidosis .  Acute AD.Cortical Failure.
  46. 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. 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. 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. 49. Differential Diagnosis
  50. 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. 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. 52. Suppruative Appendicitis
  53. 53. Meckle's Diverticulum
  54. 54. Volvulus of Meckle's Diverticulum
  55. 55. Torsion Ovarian Cyst
  56. 56. Ruptured Ectopic Pregnancy
  57. 57. Acute Cholecystitis
  58. 58. Sigmoid Volvulus.
  59. 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. 60. Messages
  61. 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. 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. 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.