Discuss the principles of management of acute abdomen

1. Discuss the principles of
management of acute
abdomen
DR OKPAKO ISAAC OGHENERO 9/10/19
DEPARTMENT OF SURGERY UATH GWAGWALADA

2. Outline
Introduction
Epidemiology
Statement of surgical importance
Possible aetiology
Principles of management
Conclusion
References

3. Introduction
Acute abdomen is an abdominal condition of sudden onset that may require immediate
operative treatment

4. Epidemiology
John O. Agboola and Samuel A.. Olatoke (2010) It accounts for 9.6%
of total surgical emergency admission with patient aged 16- 45 years
constituting about 78.3%
The commonest cause was appendicitis 30.3%, followed by intestinal
obstruction 27.9%, perforated typhoid ilities14.9% and PUD 7.6%
(UITH)

5. Statement of surgical importance
Acute abdomen is a non specific diagnosis that draws the surgeon
attention to a more sinister pathology that the surgeon MUST sort
for in other to provide the necessary and urgent surgical intervention
that the patient so require

6. Possible aetiology
 Inflammatory conditions
Perforation of hollow viscera
Intestinal obstruction
haemorrhage
Acute pancreatitis
Colics
Gynaecological conditions
Medical conditions

7. Principles of management

8. Principles of management
Establishment of diagnosis
Focused history
Proper physical examination
Relevant investigation
Preparation for treatment
Counselling
Informed consent
Treatment
Resuscitation
Definitive treatment
Evaluation of treatment
Rehabilitation
Follow up

9. Principles of management
Establishment of diagnosis
 Focused history
 Proper physical examination
 Relevant investigation

10. Principles of management
Establishment of diagnosis
Focused history
◦ Symptomatology
◦ Aetiology
◦ Complications
◦ Treatment received prior
Age : very important as it can be a pointer to the aetiology e.g. intussusception in
children appendicitis in adolescence and young adults and complications of colorectal
CA and vascular disease in those above 50

11. Principles of management
Focused history
Symptomatology
Usually it would be pain of recent onset
The duration, location, character, radiation, aggravating and relieving factors of
the pain, severity, timing and association of the pain e.g. meal exercise, and
progression

12. Principles of management
Focused history
Aetiology
anorexia
Constipation, abdominal distention, vomiting (characterize)
Red currant jelly stool blood and mucous mixed stool (dysentery ulcerative colitis and chrons
disease)
Fever (characterize) preceded by abdominal pain
Abdominal pain preceded by fever (characterize)
Frequency dysuria, haematuria urethral discharge
Yellowish discoloration of the eyes
History of weight loss, loin pain and loin swelling

13. Principles of management
Focused history
Aetiology continued
Passage of blood stool (characterize) abdominal mass, weight loss
History of trauma
Chronic cough, contact with persons with chronic cough, drenching night
sweats, ingestion of unpasteurized milk
History of swimming in large body of water, passage of worms
Hx of SCD, diabetes, family history of colorectal CA
LMP, PV bleeding, PV discharge

14. Principles of management
Focused history
Complications
Dizziness, easy fatigability, fainting spells, facial puffiness, leg swellings
Low back pain, limb weakness, increased thirst, decreased urinary output,
Treatment
Use of herbal concoction, medication (who prescribed) interventions (IV fluid,
surgery, instrumentation)

15. Principles of management
Proper physical examination
◦ General clinical state
◦ Examination of the abdomen
◦ Examination of other system for possible involvement
General clinical state
◦ Appearance
◦ Level of consciousness
◦ temperature
◦ pallor
◦ Jaundice
◦ Level of hydration
◦ Lymphadenopathy
◦ oedema

16. Principles of management
Examination of the abdomen
Inspection
◦ Appearance (shiny) Shape (scaphoid, flat or distended) ,rhythm, swellings, position of the umbilicus,
scarification marks, scars (jagged or smooth), inspect for signs (pointing, London, van zant, kehr’s,
boas’, grey-turner’s, Cullen’s signs) expansile cough impulse
Palpation
◦ Tenderness (location –extent) masses, (carnet test), peritoneal stretch test, organomegally,, palpable
cough impulses, eliciting of signs (rovsing, obturator psoas, morphy signs, sister mary joseph nodules)
Percussion
◦ Ascites
Auscultation
◦ Bowel sound

17. Principles of management
DRE
◦ Inspection:
◦ Anal hygiene, protrusions ulcers
◦ Palpation:
◦ masses, prostate (characteristics) rectal mucosa, rectal content
Examination of other system for possible involvement
CVS: pulse (character), BP
Chest: RR, orientation of the chest wall, recessions (intercostal and subcostal), masses, trachea
centrality, palpation of masses (if present), TVF, percussion note and breath sound
UGS: meatal orifices induration of the urethra, scrotum and testes , VE (vulva vagina cervix)
MSS: skeletal indentation gibbous, masses, ulcers, muscle bulk, power and tone

18. Principles of management
Relevant investigation
Principle of investigation
◦To make diagnosis
◦Extent of diseases
◦To prepare the individual for treatment

19. Principles of management
Principle of investigation
To make diagnosis
Abdominopelvic USS
Plain abdominal x- ray
KUB x-ray
Plain chest xray
4 quadrant peritoneal tap
Diagnostic peritoneal lavage

20. Principles of management
Principle of investigation
To make diagnosis contd
CT scan
laparoscopy
Urinalysis
Urine m/c/s
serum amylase (>500somogyiunits)
RBS
Serum HCG

21. Principles of management
Principle of investigation
Extent of the disease
Abdomino-pelvic USS
Xray
CT scan
MRI
To prepare the patient for surgery
e/u/cr
FBC (urgent PCV)
GXM
Chest x-ray
ECG

22. Preparation for treatment
Counselling
Informed consent

23. Principles of management
Treatment
Resuscitation
Definitive treatment
Resuscitation
NPO
Pass 3 tubes
Vital sign monitoring (PR and BP, every 30 minutes
Correct dehydration
Correct electrolyte imbalance
Correct anaemia

24. Principles of management
Treatment
Definitive care
Treat the cause
Acute appendicitis – appendecetomy
Cholelithiasis- cholecystectomy
Perforations- resections and anastomoses
Intussusception- conservative, manual reduction of the intussusception complex, resection
and anastomoses
Volvolus – resection and anastomoses

25. Principles of management
Treatment
Definitive care
Diverticulosis- conservative treatment, resection and anastomoses
Chron’s disease and ulcerative colitis- conservative care, resection and anastomoses
Splenic injury- conservative, splenectomy
Urologic calculi- conservative, ECSWL, ECEWL, ECLWL, -tomy, cystolitholapaxy
BOO 20 to BPH prostatectomy
Ruptured ectopic: salpingectomy salpingotomy

26. Principles of management
Evaluation of treatment
Resolution of symptoms
◦ Pain, fever, PR, BP, diarrhoea, vomiting, urine volume
Return of bowel activity
◦ Decrease gastric effluent return of bowel sound supple abdomen resolution of abdominal
distension passage of flatus and faeces
Improvement of general clinical state
◦ Ambulate, tolerate meal, happy.

27. Principles of management
Rehabilitation
Commencement of
pneumococcal and haemophilus influenza vaccine in splenectomy
bladder training
Nutritional rehabilitation
physiotherapy
Follow up
Discharged home
See in short intervals which is then extended until patient is deemed fit not to come for further follow up

28. conclusion
Acute abdomen should never be a diagnosis that a surgeon should
make and go to sleep

29. Thank you

30. References
Badoe and Jaja- Principle and practice of surgery including pathology in the tropics, 4th edition,
PG 94-108.
Schwartz principles of surgery, 10th edition, Ed F. Charles Brunicardi. Shock, PG 100-124.
Bailey and Love’s short practice of surgery, 26th Edition, Shock, PG 13-23.
John O.A., Samuel A. O.: pattern and presentation of aute abdomen in a Nigerian teaching
hospital.