for surgical students

1. Acute Abdomen
Dr. Robel E.
Oct, 2022
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2. Introduction
 Acute abdomen refers to abdominal pain of short duration
that requires a decision regarding whether an urgent
intervention is necessary
 Causes may be:
surgical
medical or
gynecologic
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3. Anatomy
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4. Physiology
Visceral pain
Tends to be vague and poorly localized to the epigastrium, periumbilical region,
or hypogastrium, depending on its origin from the primitive foregut, midgut, or hindgut.
 usually the result of distention of a hollow viscus
 Parietal pain corresponds to the segmental nerve roots innervating the peritoneum
and tends to be sharper and better localized.
 Referred pain is pain perceived at a site distant from the source of stimulus.
 e.g, irritation of the diaphragm may produce pain in the shoulder.
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7. Clinical Evaluation
• History
PAIN
 mode of onset : sudden, gradual ,rapidly progressing
 duration
 frequency : intermittent , continuous
 Character : burning, tearing, gripping
 Location: RUQ, RLQ, epigastric …
 chronology
 radiation, and
 intensity
 Aggravating or relieving
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8. History cont….
nausea,
 vomiting
anorexia,
diarrhea,
 Constipation
Obstipation
Non specific
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9. History cont….
fevers, chills, weight loss , hematochezia, melena, jaundice,
Age, Sex
Recent activities including travel and diet
Allergies
Past medical and surgical history,
Alcohol intake, smoking and Drug abuse
Intake of medications including over the counter medications such as
Acetaminophen
Aspirin, and
NSAIDs
Menstrual and contraceptive history in women
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10. Abdominal Examination ( Revision)
Inspection
- General observation
- Look at abdominal contour, note location of any
scars, rashes or lesions, visible peristalsis,
pulsation , mass
Patient within agony - likely has colicky abdominal pain caused by ureteral
lithiasis
Patient lying very still - more likely to have peritonitis
Patient leaning forward to relieve pain –
may have pancreatitis
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11. Diagnosis
Auscultation
- Useful in assessing peristalsis
- ? Bowel sounds-
normal/hyperactive/hypoactive
- Auscultation should precede percussion and palpation
Hypoactive bowel sounds - associated with ileus, late
• intestinal obstruction, peritonitis
- Intestinal obstruction can produce hyperactive bowel
sounds which are high pitched tinkling sounds
occurring at brief intervals; very audible
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12. Palpation
Superficial and deep palpation
Where is pain ? Begin with light palpation
Guarding - voluntary/involuntary
Rebound tenderness
Def:- Guarding
Voluntary guarding - conscious elimination of muscle
spasms
 Involuntary guarding - reported when the spasm response
cannot be eliminated, which usually indicates diffuse peritonits.
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13. Rebound Tenderness
- This is a test for peritoneal irritation.
- Asking the patient to cough is another method of eliciting
signs of peritonitis
- Palpation of Organs
 liver
 spleen
 kidneys
 Inguinal, Femoral, Umbilical,
Incisional hernias.
 CVA tenderness
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14. Percussion
- to determine organ size
- In ascites - a dull percussion note
- Shifting dullness and fluid thrill
- In intestinal obstruction - a hyper tympanic note
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Shifting Dullness
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15. • DRE or Digital Ostomy Exam
- mass
- impaction
- peristomal hernia
- frank blood
• PV Examination
- Bleeding
- Discharge
- Cervical motion tenderness
- Adnexal masses or tenderness
- Uterine Size or Contour
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16. Investigations in patients with acute
abdomen
Laboratory
studies
•
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17. Imaging studies
Plain radiographs
Chest x-ray (erect)
Plain abdominal x-ray (erect ,Lat decubitus )
Ultrasonography
CT of the abdomen and pelvis
DIAGNOSTIC LAPAROSCOPY
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18. Chest x-ray (erect)
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19. Plain abdominal x-ray
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20. Management options
 Immediate operation (“surgery now”)
 Pre-operative preparation and operation (“surgery
tomorrow morning”)
 Conservative treatment (active observation, intravenous
fluids, antibiotics, etc.)
 Discharge home
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21. Acute Appendicitis
•Anatomy
 Not a vestigial organ, immunologic role (Ig. A)
 Anatomic variation, commonest retro-cecal followed by
pelvic
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22. Cont….
• The three taeniae coli converge at the
junction of the cecum with the appendix and
can be a useful landmark to identify the
appendix
• The appendix can vary in length from <1
cm to >30 cm; most appendices are 6 to 9
cm long
• The luminal capacity of the normal appendix
is only 0.1 mL.
• outside diameter ranging from 3–8 mm and
its lumen ranging from 1–3 mm
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23. Etiology and pathogenesis
• Luminal Obstruction
• Increased luminal pressure
• Bacterial Translocation
• Gangrene formation
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24. Bacteriology
Appendicitis is a polymicrobial infection
Principal organisms are Escherichia coli and Bacteroides
fragilis
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25. Clinical features
• Symptoms
• Abdominal pain
Initially peri-umbilical and later after 4-6 hrs shifts to the right
lower quadrant area
Variation in anatomic location of the appendix account for the
variation in the location of somatic pain
• Anorexia
• Nausea and vomiting
• Fever
• Rarely obstipation/diarrhea
• The sequence of symptom appearance has great significance for the
differential diagnosis.
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26. Signs
Patients with appendicitis usually prefer to lie supine, with the thighs,
particularly the right thigh, drawn up, because any motion increases pain
Maximal point of tenderness at McBurney`s point
Direct rebound tenderness
Rovsing`s sign:Pain referred to the McBurney point on application of
pressure to descending colon
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27. Cont….
Anatomic variations in the position of the inflamed appendix lead to
deviations in the usual physical findings
Psoas sign: manifested by right lower quadrant pain with passive right
hip extension
Obturator sign: Flexion of right thigh at right angles to trunk and
external rotation of same leg in supine position result in hypogastric pain
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28. Diagnosis
• iagnosis, not always clear (females,
elderly)
• Laboratory
mild leukocytosis
• Imaging
Ultrasonography
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29. Management
• Antibiotics and supportive care
• Appendectomy
open
laparoscopic
• Complications
perforated appendix
appendiceal abscess
appendiceal mass
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30. INTESTINAL OBSTRUCTION
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31. Classification
• Generally classified into mechanical and non mechanical by
mechanism
• Mechanical Obstruction
By location  small bowel; High or Low
 Large bowel
By pathophysiology Simple, closed loop or strangulated
The obstruction may be complete or partial, acute or chronic
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32. Causes Of Obstruction
Mechanical
Intraluminal =>impaction, foreign bodies, bezoars, gall stones, ascariasis
Intramural => Inflammatory strictures, Neoplasm's, Congenital
malformations
Extramural => bands/adhesions, hernia, volvulus, intussusceptions
Non mechanical
Paralytic Ileus
Mesenteric vascular occlusion
Pseudo-obstruction
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34. Pathophysiology-Mechanical Obst.
Simple Obstruction
Fluid and Electrolyte loss (ECF)
Bacterial proliferation ; Feculent vomitus in distal SBO
N.B. Ischemic changes progressing to necrosis and perforation may occur at site of
obstruction
Closed loop obstruction
Blood Vessels enter intestinal wall tangentially => Tension on them increases rapidly
with bowel distention
Strangulated Obstruction
• Blood and Plasma loss in strangulated obstruction  shock
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35. Clinical Features
• Abdominal Pain
• Vomiting
• Abdominal Distension
• Absolute Constipation
• Dehydration –Tachycardia, Hypotension, oliguria
• Features of Peritonism –Strangulation or Perforation
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36. Cont…
C.F. vary according to
Site of the obstruction
Onset and duration of the obstruction
Underlying pathology
Presence / absence of strangulation
Constipation is a rule in intestinal obstruction doesn't apply in
Richter's hernia, gallstone obturation, obstruction associated with pelvic
abscess, partial obstruction (diarrhea may occur)
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37. Strangulation Obstruction
• Severe Continuous abdominal pain
• Fever
• Tachycardia after resuscitation
• Peritoneal signs
• Leukocytosis
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38. Diagnosis – P/E
Surgical scars
Distension ---distribution, step-ladder pattern, visible peristalsis
Hernia orifices
Bowel sounds
Guarding and tenderness
DRE --- masses, stool, blood
Investigations
Hematology; WBC, Hct, Blood group, electrolytes
Radiology; Erect abdominal and CXR
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39. Plain abdominal x-ray
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40. Treatment
• Principles of Rx
1. GI drainage
2. Fluid and Electrolyte replacement
3. Relief of Obstruction
• Resuscitation / Pre-op care
Volume replacement
Correction of electrolyte imbalance
NGT suction – reduces nausea, vomiting, distention, risk of aspiration
Catheterize - monitor urine output
Pre-op antibiotics
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41. Surgical Rx
• Timing: Immediate, urgent, delayed/elective depends on:
1. Duration of obstruction i.e. severity of fluid, electrolyte and acid-base
abnormality
2. The opportunity to improve vital organ function
3. Consideration of the risk of strangulation
Immediate
• strangulated obstructions; As soon as hemomodynamically stable
• Closed loop obstructions; Non sigmoid volvulus, incarcerated hernias
• Simple, complete obstructions; After resuscitation is complete
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42. Surgical Rx
Urgent
• Lack of response to non operative therapy within 24 to 48 hrs
• Early post-op technical complications; abscess, intussusceptions, narrow
anastomosis, stomal obstructions
Conservative
• Adhesive partial small bowel obstructions
• Early post-op obstructions
• Partial SBO due to inflammatory conditions
Delayed / Elective operations
• Deflated sigmoid volvulus
• Recurrent adhesive / stricture related SBO
• Partial colonic obstructions
• Bowel obstructions without previous abdominal operations
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43. Thank You
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