ACUTE ABDOMEN CASE PRESENTATIONS.2017

A C U T E A B D O M E N
C A S E P R E S E N TAT I O N S
D R . M O H A M A D A L - G A I L A N I F R C S
‫ي‬ ‫ن‬ ‫ال‬ ‫ي‬ ‫ك‬ ‫ل‬ ‫ا‬ ‫د‬ ‫م‬ ‫ح‬ ‫م‬ ‫ر‬ ‫و‬ ‫ت‬ ‫ك‬ ‫د‬ ‫ل‬ ‫ا‬
C O N S U L TA N T S U R G E O N
‫ي‬ ‫ر‬ ‫ا‬ ‫ش‬ ‫ت‬ ‫س‬ ‫ا‬ ‫ح‬ ‫ا‬ ‫ر‬ ‫ج‬
R I YA D H , K S A
‫ض‬ ‫ا‬ ‫ي‬ ‫ر‬ ‫ل‬ ‫ا‬,‫ة‬ ‫ي‬ ‫د‬ ‫و‬ ‫ع‬ ‫س‬ ‫ل‬ ‫ا‬ ‫ة‬ ‫ي‬ ‫ب‬ ‫ر‬ ‫ع‬ ‫ل‬ ‫ا‬ ‫ة‬ ‫ك‬ ‫ل‬ ‫م‬ ‫م‬ ‫ل‬ ‫ا‬
2 0 1 7

ACUTE ABDOMEN
• A potentially life threatening condition that requires urgent diagnosis
and management
• Associated with:
1. Pain that persists for more than 6 hours
2. Guarding
3. Rigidity
4. Leucocytosis
5. Fever
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
2

ACUTE ABDOMEN
• Linear relationship between delay in treatment and
mortality
• A patient with an acute abdomen is an EMERGENCY,
and it is IMPERATIVE to get correct diagnosis and
prompt treatment
3

ACUTE ABDOMEN:
CASE PRESENTATIONS
4
Dr. Mohamad Al-Gailani FRCS Acute Abdomen Case Presentations 2017

5
Case 1
Patient presented to the Casualty department with several
hours worsening abdominal and back pain. He had had mild
back pain for some weeks. What does the plain abdominal film show?

6
Answer 1
Abdominal Aortic Aneurysm
(AAA)
Micro
Calcifications
Loss of
Psoas
Shadow

Abdominal Aortic Aneurysm
• 1% of all men over 65 years
• Rupture mortality is over 50%
• Back pain and collapse in >65 years age
• Fatal if not operated upon urgently
• Best chance of survival is early detection
• Elective surgery better than treatment once
ruptured!
7

ACUTE ABDOMEN: History
• PAIN
1. Location
2. Onset and Progression: > 6 hours-surgical
3. Character and Severity
8

ACUTE ABDOMEN: History
• Associated symptoms: vomiting follows pain,
anorexia
• Menstrual history
• Drug history: anticoagulants, steroids, beta-
blockers
• Family history
• Travel history: dysentery, Salmonellosis,
Tuberculosis
9

ACUTE ABDOMEN: Examination
• Vital signs: Temp, Pulse, BP, RR
• Inspection: General appearance, movement
• Palpation: tenderness, rebound, guarding
• Percussion: liver dullness, ascites, rebound
• Auscultation: absent, exaggerated, bruits, succussion
splash
• PR, PV
• Murphy’s sign, Rovsing’s sign, Iliopsoas sign
10

11
Case 2
75 year old man presented to the Emergency Department
with acute abdominal pain and bloody diarrhoea. What
does the plain abdominal film show?

12
Answer 2
Toxic Megacolon
Caecum
>12 cm
Transverse Colon
>6 cm

Toxic Megacolon
• Nonobstructive colonic dilatation (Caecum > 12 cm,
Transverse Colon > 6 cm) + signs of systemic toxicity
• Diagnostic criteria:
1. Radiographic evidence of colonic dilatation
2. Fever , tachycardia, leucocytosis, dehydration, altered
mental status, electrolyte abnormality or hypotension
13

Toxic Megacolon: Management
• Initiate intensive medical treatment with
systemic steroids
• Close observation; daily x-rays
• Surgical intervention if no improvement occurs
over 48-72 hours with medical therapy
• Subtotal colectomy and ileostomy
14

15
Case 3
62 year old woman presented to the emergency department with
one week's history of increasing abdominal pain and distension.
She gave a long history of chronic constipation, but was otherwise
fit and well. What does the X-ray show?

16
Answer 3
Sigmoid volvulus
 Coffee Bean
Sign
 C-pointing to
LIF

Sigmoid Volvulus
• Most common form of volvulus
• Coffee Bean sign
• Decompression by a long soft tube +- colonoscopy
• Surgery; failure of tube deflation, ischaemia &
recurrence
• Double barrel colostomy
• Per Cutaneous Colotomy (PEC)
17

ACUTE ABDOMEN: INVESTIGATIONS
BLOOD:
• FBC, U & E , LFT,
Glucose
• Serum lipase
• Clotting studies
• Pregnancy test!
RADIOLOGY:
• Erect CXR
• Plain AXR
• Ultrasound
• C/T
• Other: Contrast,
Angiography,
Radionuclide, MMR
18

19
Case 4
A 55 year old admitted with a one day history of epigastric pain and
an acute abdomen. What are the findings on this CT?

Answer 4
Severe Necrotizing Pancreatitis
20

Severe Necrotizing Pancreatitis
• Presents as Acute Abdomen
• Treatment is supportive
• Modified Glasgow scale:
• 3 or > Severe Pancreatitis (15% Mortality)  ITU
• Consider US percutaneous drainage for Abscess
• ERCP for impacted CBD stone
• Surgery: Necrosectomy, Emergency Cholecystectomy
21

22
Case 5
Acute epigastric pain of sudden onset. What is the
diagnosis?

23
Answer 5
Air under Diaphragm. Perforated Viscous

PERFORATED VISCOUS
• Peptic or Colonic?
• Laparoscopy and Proceed
• Over sewing perforated Peptic Ulcer
• Perforated Sigmoid Diverticulae:
1. Without peritonitis > Laparoscopic Washout with
Drainage
2. With Peritonitis > Hartmann’s procedure
24

25
Case 6
37-year-old woman presenting with 2 week history of right iliac
fossa pain. What does the CT show?

26
Answer 6
Ectopic Pregnancy
Ectopic
Gestation Haematoma
around uterus &
Haemoperitoneu
m
Uterine Fundus

27
ECTOPIC PREGNANCY

Ectopic Pregnancy
•Pain, Amenorrhea & Vaginal bleeding
•50% present with vaginal bleeding
•50% have a palpable adnexal mass
•75% may have abdominal tenderness
28

ACUTE ABDOMEN: Gynaecological
• Mittelschmerz pain- mid cycle pain
• Ectopic pregnancy- missed period, anaemia, B-HCG
positive
• Ovarian cyst torsion- U/S
• Salphingitis- PV, High vaginal swab
• Endometriosis
• Diagnostic Laparoscopy?
29

ACUTE ABDOMEN:
Indications For Laparotomy
• When the diagnosis is certain
• Generalized peritonitis
• Equivocal abdominal findings, Suspected ischaemia
• Deterioration/Failure conservative treatment
• Pneumoperitoneum
• Free Intra Peritoneal Blood/Fluid
30

ACUTE ABDOMEN:
Pre-operative Optimization:
• ITU?
• Pain relief
• Resuscitation
• Fluid replacement
• Antibiotics
31
• Nasogastric tube
• Foley’s catheter
• Central and arterial lines
• Consent!

ACUTE ABDOMEN:
Summary
•Never forget to measure serum lipase!
•Premenopausal? Pregnancy test!
•Management starts with Preoperative
Optimization
•Mortality depends on age, co-morbidity &
proper urgent management
32

D R . M O H A M A D A L - G A I L A N I F R C S
‫ي‬ ‫ن‬ ‫ال‬ ‫ي‬ ‫ك‬ ‫ل‬ ‫ا‬ ‫د‬ ‫م‬ ‫ح‬ ‫م‬ ‫ر‬ ‫و‬ ‫ت‬ ‫ك‬ ‫د‬ ‫ل‬ ‫ا‬
C o n s u l t a n t S u r g e o n
‫ي‬ ‫ر‬ ‫ا‬ ‫ش‬ ‫ت‬ ‫س‬ ‫ا‬ ‫ح‬ ‫ا‬ ‫ر‬ ‫ج‬
M e d i c a l E d u c a t i o n & T r a i n i n g D i r e c t o r
‫ي‬ ‫ب‬ ‫ط‬ ‫ل‬ ‫ا‬ ‫ب‬ ‫ي‬ ‫ر‬ ‫د‬ ‫ت‬ ‫ل‬ ‫ا‬ ‫و‬ ‫م‬ ‫ي‬ ‫ل‬ ‫ع‬ ‫ت‬ ‫ل‬ ‫ا‬ ‫ل‬ ‫و‬ ‫ؤ‬ ‫س‬ ‫م‬
A l H a m m a d i H o s p i t a l , S u w a i d i
‫ي‬ ‫د‬ ‫ا‬ ‫م‬ ‫ح‬ ‫ل‬ ‫ا‬ ‫ى‬ ‫ف‬ ‫ش‬ ‫ت‬ ‫س‬ ‫م‬,‫ي‬ ‫د‬ ‫ي‬ ‫و‬ ‫س‬ ‫ل‬ ‫ا‬
R i y a d h , K S A
‫ض‬ ‫ا‬ ‫ي‬ ‫ر‬ ‫ل‬ ‫ا‬,‫ة‬ ‫ي‬ ‫د‬ ‫و‬ ‫ع‬ ‫س‬ ‫ل‬ ‫ا‬ ‫ة‬ ‫ي‬ ‫ب‬ ‫ر‬ ‫ع‬ ‫ل‬ ‫ا‬ ‫ة‬ ‫ك‬ ‫ل‬ ‫م‬ ‫م‬ ‫ل‬ ‫ا‬
T E L : 0 0 9 6 6 1 1 4 2 5 0 0 0 0
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ACUTE ABDOMEN CASE PRESENTATIONS.2017

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ACUTE ABDOMEN CASE PRESENTATIONS.2017