Acute abdomen
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Lecture on acute abdomen for medical students. Provides general overview of the condition encompassing basic sciences to assist the student to understand its various clinical features. Specific emphasis on acute appendicitis and acute cholecystitis, covering on basic sciences, classifications and principles of management.
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Acute abdomen
- 1. Acute abdomen Chea Chan Hooi Surgeon Sibu Hospital
- 2. Content • Definition • Epidemiology • Basic sciences • Etiology • Abdominal • Extra-abdominal • Diagnosis • Therapeutic • Operative • Non-operative • Discussion
- 3. Definition • Any sudden, spontaneous, non-traumatic disorder • Chief manifestation in the abdominal area • Urgent surgery may be necessary • BEWARE – might be painless in extreme ages, immunocompromised & last trimester of pregnancy
- 4. Epidemiology • Prevalence of 50% in upper abdominal pains • 50% of people experienced at least one upper GI symptoms in previous 3 months • Appendicectomy the most common abdominal surgery • Cholecystectomy the most common elective abdominal surgery
- 5. Anatomy
- 6. Physiology • Pain • Neuropathic • Nociceptive • Somatic • Visceral Somatic Visceral Site Muscles, bones, skin Internal organs Localisation Well localised Vague Character Sharp, gnawing Dull, cramping Radiation Dermatomal Diffuse Periodicity Constant Intermittent Associations Rare Sweating
- 7. • Referred pain • Pain perceived at a location other than the site of stimulus • Temporal summation • Central hyperexcitability • Usually on the same side as stimulus • Many hypotheses convergent-projection
- 9. • Pregnant patients • Enlarged uterus displaces intra-abdominal organs • Lax abdominal wall blunts physical findings • Physiological leukocytosis • Risk of ionizing radiation • Exposure <5 rads not associated with fetal defects or loss • CECT abdomen involves 3.5 rads • Teratogenic medications
- 10. Etiology • Abdominal • Viscera • Hollow • GIT • GUT – including gonads • Blood vessels • Solid • Liver • Spleen • Pancreas • Adrenals • Musculoskeletal – spine, paraspinal muscles, abdominal wall muscles • Extra-abdominal • CVS Inferior AMI • RS Lower lobar pneumonia • Endocrine DKA, hypercalcaemia
- 11. Diagnosis • History • Physical examination
- 12. • Investigations • Biochemistry • FBC, RP, coagulation profile • LFT • Serum amylase, urine diatase • Microbiology • C&S • Imaging • CXR erect • AXR supine • USG • CECT • CT angiography • Misc • ECG • Invasive • Diagnostic laparoscopy • Endoscopy
- 13. Treatment • Resuscitation (ABCDE) • Symptom control • NG tube • Analgesics – opioids are not contraindicated • Anti-pyretics • Anti-emetics • Monitoring • Pulse oximeter, BP • CBD • Arterial line • Definitive treatment • Operative • Non-operative
- 15. Basics • Blind-ending organ • Confluence of taenia coli • Functions • Maintaining gut flora • Lymphatic & immunologic surveillance • Surgical reconstruction • Mitrofanoff procedure • Malone antegrade colonic enema • Migratory pain
- 16. Clinical features • Poorly defined periumbilical pain migrated to RIF then generalised • Pain, nausea, vomiting, poor appetite, malaise, dizziness • Diarrhoea, dysuria, AUR, ileus • RIF tenderness with localised guarding • Accessory signs • Dunphy sign • Rovsing sign • Obturator sign • Psoas sign • Markle sign – 74% sensitivity
- 17. Differential diagnoses (common) • Bowel • Right colonic diverticulitis • Caecal tumour • Mesenteric adenitis • Epiploic appendagitis • Gynaecological organs • Salpingitis, tuboovarian abscess • Ruptured ectopicpregnancy, beware of heterotropic pregnancy • Ruptured/torsion/bleeding ovarian tumour • Haemorrhagic corpus luteal cyst • Acute pelvic inflammatory disease – Fitz-Hugh-Curtis syndrome • Genitourinary tract • Ascending UTI, including cystitis • Testicular torsion • AAA
- 18. Investigations • FBC, UPT, UFEME • Imaging options • AXR • Ultrasonography – TAS, TVS • CECT scan • Alvarado score • ≤ 3 discharge • 4 – 6 further investigation • ≥ 7 likely appendicitis
- 19. Management • Symptomatic control • Analgesics • Naso gastric decompression • Definitive management • Acute appendicitis • Surgical • Open appendicectomy • Laparoscopic appendicectomy • Antibiotics • Appendicular abscess • Percutaneous drainage • Surgery • Ochsner Sherren regimen • Interval colonoscopy
- 21. Basics • 5 Fs – female, forty, fat, fertile, fair • Types of gallstones • Cholesterol • Pigment • Mixed • Biliary tree anatomy • Surface anatomy of gallbladder fundus • Right mid-clavicular line, transpyloric plane, 9th costal cartilage
- 22. Clinical features • Epigastric/RUQ pain • Referred pain • Fever, nausea, vomiting • Diagnosis • Local inflammation • Murphy sign • RUQ tenderness • Systemic inflammation • Fever • Raised TWC • Radiological findings characteristic of AC
- 23. Differential diagnoses (common) • Hepatobiliary • Hepatitis • Liver abscess • Ascending cholangitis • Urinary tract • Right pyelonephritis/pyonephrosis • Right renal tumour bleed • Bowel • Perforated viscus • Right colonic diverticulitis • Extra-abdominal • Right lower lobar pneumonia • Right paraspinal muscle abscess • DKA
- 24. Investigations • FBC, UPT, UFEME, CXR, blood sugar, ECG • Ultrasonography • Pericholecystic fluid, thickened wall, sonographic Murphy sign • Associated biliary tree dilatation Mirizzi syndrome • Assess severity • ABG • BUSEC • LFT • PT/PTT
- 25. Management • Symptomatic relief • Analgesics • Anti-pyrexia • NG decompression • Cholecystectomy • Laparoscopic • Within same admission if symptoms <72 hours • Interval about 6 weeks later • Open • Obsolete nowadays • Only if contraindicated for laparoscopic surgery