1. The Acute Abdomen : Clinical
Pattern & Management
Approach- Surgeon
perspective
By Aiman Arif
Supervisor: Mr Adham
2.
3. What is acute abdomen?
• Term ‘Acute abdomen’ refers to abdominal pain of short duration that
require GOOD DECISION whether urgent intervention is required
• 4 management options when assess patient with acute abdomen:
• Immediate surgery
• Preoperative preparation and surgery
• Conservative management
• Discharge home with SOPD review - Pain usually self limiting and does not
recur.
4. 5 Clinical pattern of acute
abdomen
1. Abdominal pain
with shock
2. Generalised
peritonitis
4. Medical
Illness
5. Intestinal obstruction
3. Localised
peritonitis
Schein’s Common Sense Emergency Abdominal Surgery 2nd Edition
5. Abdominal pain with shock
• Least common presentation but very stressful to the
surgeon.
• Patient usually presented with severe abdominal pain,
pallor and shock.
• Example
• 1. Ruptured Abdominal Aortic Aneurysm
• 2. Ruptured Ectopic Pregnancy
• Management will be immediate surgery even if patient
is not well prepared.
6. • Patient deteriorated due to hemorrhagic shock DIVC Multiorgan
failure
• Surgery is part of resuscitation, need to stop the bleeding.
10. Management
• Resuscitation/antibiotics
• Emergency surgery after adequate pre-op preparation
• Laparotomy
• Centre with expertise – laparoscopic approach
• If simple repair done
• PGU – intra-op sent ulcer edge for HPE ( risk of
malignancy)
• PDU – no need very low risk of malignancy
11. Caution !!
• Always measure serum amylase in any patient
presenting with significant abdominal pain.
• Surgery in severe acute pancreatitis may lead
to sinister disaster.
• God put the pancreas at the back because He
didn’t want surgeons messing with it.
12. Localised peritonitis
• 1. Acute Cholecystitis
• 2. Acute appendicitis
• 3. Acute Diverticulitis
• 4. Acute Pancreatitis
• As a general rule: localized peritonitis is NOT an indication for IMMEDIATE
SURGERY
• If diagnosis is uncertain, treat conservatively FIRST
• Time is your friend
13. History
• RIF pain: migratory pain – initially periumbilical region Acute appendicitis
• Associated symptoms: nausea,vomiting and anorexia/ fever
• Exclude: UTI, gynae pathology for female ectopic pregnancy/PID, testicular torsion
• Extreme age..think of other dx (Old – diverticulitis, Young – appendicitis, mesenteric
adenitis)
• RHC pain
• Biliary colic – intermittent/colicy/post meal
• Cholecystitis – worsening constant pain/fever
• • + jaundice cholangitis ( obstructed and dilated biliary system e.g CBD
stone/tumour) **Charcot’s triad?
• Obstructive Jaundice pale stool/pruritus/tea coloured urine
• Epigastric pain radiated to the back pancreatitis
14. Physical examination
• Fever?
• Jaundice?
• Tender hepatomegaly – hepatitis/liver abscess
• Tender RHC – Murphy’s sign
• If significant guarding with palpable GB mucocele
• Cullen’s sign/Grey Turner sign pancreatitis
• Tenderness at the McBurney’s point
• rebound tenderness
• Rovsing’s sign/obturator sign
15. Investigation
• FBC – leukocytosis
• CRP
• LFT – high bilirubin/liver enzyme in cholangitis
• Coagulation profile
• UFEME – to exclude UTI
• UPT – female patient
• Imaging
• CT scan
• Early date : eg suspected choledocholithiasis with no stone on USG
• USG
• Features of cholecystitis/stones
• Any dilated biliary system – cholangitis
16. Management- extensive workup & operate
later
• Conservative management with antibiotic & painkiller
• Elective surgery later.
• Then decide on definitive treatment
• Acute Cholecystitis – antibiotics & elective cholecystectomy
• Acute pancreatitis- conservative
• Acute diverticulitis- colonoscopy to exclude tumour
EXCEPT FOR ACUTE APPENDICITIS-
Performed appendicectomy
18. Intestinal obstruction
• Small bowel vs large bowel
• Small bowel
• Adhesion – most common
• Obstructed hernias
• Large bowel
• Tumor – most common is left sided colonic/rectal cancer
• Volvulus
19. 4 Cardinal features
• Abdominal pain
• Absolute constipation
• Abdominal distension
• Vomiting
Significant history
• Previous abdominal surgery
• Swelling inguinal/previous scar
• Altered bowel habit/constitutional sx
• Drug history – Buscopan given by GP
for AGE
General rule:
1. More vomiting, more
proximal obstruction
2. More abdominal
distension, more distal
obstruction
20. Examination
Abdomen examination:
• Distended abdomen
• Look for scar/swelling over the inguinal or previous scar
• Local Tenderness – indicated ischemia/strangulation
• Generalised tenderness perforation
• Intraabdominal masses – G.I tumour
• DRE – rectal mass
• Any signs of malignancy
• Virchow’s node
• Cachexic
• Jaundice liver mets
22. Management
2 option involved in the management:
1. Conservative management
- adequate fluid replacement, painkiller
2. Surgery if indicated
- after adequate resuscitation & workup
23. Indications for urgent surgery in IO
• Peritonitis
• Significant area of local tenderness ischemia
• Close loop obstruction
• Strangulated hernia
24. Ct scan
• Generally, all IO cases need for CT scan except for
obstructed inguinal hernia
• ReasonforCT Scan:
• For surgical planning
• To exclude pseudo-obstruction/non mechanical
obstruction
• To identify pathology- eg. Obstructed left sided
colonic tumour
• To decide best management, eg rectal tumour with
liver mets only need diverting stoma.
25. Specific management
• Adhesive obstruction – adhesiolysis if failed conservative mx
• Obstructed inguinal hernia – open hernioplasty +/- bowel resection
• Colonic tumour – colectomy +/- stomas
• Rectal tumour – defunction colostomy ( definitive surgery later)
26. Medical Illness
• 1. DKA
• 2. Inferior MI
• 3. Typhoid fever
• 4. Dengue with warning sign
• 5. Basal pneumonia
• Should involve medical colleague in the management of acute
abdomen
27. Second step- What’s in surgeon’s mind?
1. Acute abdomen vs septic abdomen
2. Systemic vs local
3. Gut or non gut
4. Foregut, Midgut or Hindgut
5. Infection, Inflammation, Malignancy, Functional
28. Algorithm- What’s in surgeon’s mind?
Acute Abdomen
Local
Systemic
Gut
Non-gut
Foregut
Midgut
Hindgut
Infection
Inflammation
Malignancy
Functional
- acute cholecystitis
- acute pancreatitis
- renal colic
- biliary colic
- dengue fever
- typhoid fever
- DKA
Example
-TB Colitis
- Crohn’s & UC
- Acute appendicitis
- Acute diverticulitis
- Small bowel ca
- Right side colon ca
- Post op ileus
- Obstructed hernia
29. Medical management of surgical patient
• A- analgesia & antibiotic
• B- breathing
• C – co-morbidities & cardiac
• D – Devices in & out
• E- electrolytes
• F- fluids, I/O
• G- gastro – allow orally or not
Any patient admitted to
surgical ward should be
asked this basic
questions.
Surgical decision-
usually by surgeon
Medical management-
by houseman, MO and
surgeon
