The document provides information on emergency conditions for abdominal surgery. It discusses common etiologies for abdominal surgical emergencies such as appendicitis, pancreatitis, hernias, intestinal obstruction, peptic ulcers, esophageal varices, and more. For each condition, it describes characteristics, causes, diagnostic methods, and treatment approaches whether through conservative management or surgery. The document serves as a reference for various acute abdominal conditions that may require emergency surgical intervention.

1. EMERGENCY CONDITIONS
FOR ABDOMINAL
SURGERY.
Kolappa Pillai Ainkareswar
Subgroup 10
6th course, UzhNU.

2. INTRODUCTION
Abdominal emergencies are one of the most common emergency
surgical procedures worldwide.
Etiology differs from case to case basis.
Often these surgical emergencies are done daycare and need
minimal hospice care.
Surgical emergencies represent more than 50% of surgical
admissions and constitute a major part of the surgeon’s workload in
most parts of the world. [1]
The acute abdomen may be caused by an infection, inflammation,
vascular occlusion, or obstruction. [2]

3. ETIOLOGY
Most common causes include the following; [3]
Acute abdominal conditions
Incarcerated and Strangulated Hernias
Appendicitis
Pancreatitis
Intestinal obstruction
Complications of peptic ulcer, including perforated ulcer and bleeding ulcer
Bleeding from esophageal varices
Pelvic infections with abscesses
Perforated typhoid ulcers
Amoebic liver abscess
Gall bladder and bile duct disease

4. ETIOLOGY
Solagberu BA, Duze AT, Kuranga
SA, Adekanye AO, Ofoegbu CK,
Odelowo EO. Surgical
emergencies in a Nigerian
university hospital. Niger
Postgrad Med J 2003;10:140-3

5. EMBRYOLOGY
Due to embryogenic development, gastrointestinal tract could be
divided into three sections.
Foregut is mouth to second part of duodenum, midgut is second
part of duodenum to transverse colon and hindgut is from transverse
colon to rectum.
Pain in foregut localises into epigastrium, pain in midgut localises
into umbilicus and pain in hindgut localises into suprapubic region.

6. CHARACTERISTIC OF ABDOMINAL
PAIN
Pain in different regions of abdomen can indicate different acute
conditions:
Left inguinal region: diverticulitis of sigmoid colon
Right inguinal region: appendicitis, meckel’s diverticulum,
diverticulitis of caecum
Left and right lumbar regions: renal colic
Right hypochondrium: biliary colic, cholecystitis, liver and
gallbladder disorders
Left hypochondrium: gastritis, stomach and spleen disorders
Epigastric region: myocardial infarction, acute pancreatitis,
abdominal aortic aneurysm
Hypogastric region: pelvic conditions such as ovarian cyst, ectopic

7. CHARACTERISTIC OF ABDOMINAL
PAIN

8. APPENDICITIS
Acute appendicitis is one of the most common acute abdominal
emergencies in the world.
It’s more common in regions where, low fiber-high fat-more meat diet is
consumed.[4]
Anatomy of appendix is retro-caecal in majority of people and incidence
peaks at adolescence.
It usually presents as colicky pain in right inguinal region.
Pain on pressing McBurney’s point, Rovsing’s sign, obturator sign and
psoas sign are appendicitis-specific tests in examination.
Gold standard diagnostic method is laparoscopy.
Management could be open or laparoscopic surgery. Grid iron or Lanz
incision is made in the surgery.

9. PANCREATITIS
Usual causes of Pancreatitis include, Gall stone, Ethanol/Alcohol
abuse, Trauma, Steroid abuse, Mumps, Autoimmune conditions,
hypercalcemia, hyperlipidemia, drugs.
Acute pancreatitis presents with epigastric pain radiating to back
usually together with vomiting.
Symptoms include, pain in right inguinal region, nausea, vomiting,
fatty stool.
Specific signs for acute appendicitis are Grey-Turners sign and
Cullens sign.
Severity is assessed by Glasgow criteria (pO2 <8kPa, albumin <32,
neutrophil 15x10^9 , Calcium <2, Urea >16, Age>55, Sugar>10)

10. PANCREATITIS
Acute pancreatitis is classified into the following: [5]
●Mild acute pancreatitis, which is characterized by the absence of organ failure
and local or systemic complications
●Moderately severe acute pancreatitis, which is characterized by transient organ
failure (resolves within 48 hours) and/or local or systemic complications without
persistent organ failure (>48 hours).
Amylase and lipase are elevated.[6]
Tests that may be useful in evaluating chronic pancreatitis include hemoglobin
A1C, immunoglobulin G4, rheumatoid factor, and anti-nuclear antibody.[7]
Radiological studies and ERCP is conducted for diagnosis.
Endoscopic ultrasound can be used for diagnosis.

11. PANCREATITIS
Complications such as abscess, pseudocyst or chronic inflammation
of pancreas; or, involvement of endocrine, renal, cardiovascular
system can occur.
Treatment is initially done through morphine administration.[8]
Surgical treatment is done through ERCP commonly, with or without
gallbladder removal on case to case basis.
Nutritional support through Nasogastric tube is done.[9]
Whipples procedure considered one of the most difficult surgeries to
perform is conducted on case to case basis on Trauma patients.[10]

12. HERNIAS
A hernia happens when part of an
internal organ or tissue bulges
through a weak area of muscle.
Most hernias are in the abdomen.
Types of hernia include Inguinal,
in the groin. It is the most
common type, Umbilical, around
the belly button, Incisional,
through a scar, Hiatal, a small
opening in the diaphragm that
allows the upper part of the
stomach to move up into the
chest, Congenital diaphragmatic, a
birth defect that needs surgery.
Symptoms include pain while
coughing, abnormal bulging in
abdomen.

13. HERNIAS
Causes for Hernia include, improper heavy weight lifting, hard
coughing bouts, sharp blows to the abdomen, obesity and incorrect
posture.
A surgically treated hernia can lead to complications such as
inguinodynia, while an untreated hernia may be complicated by,
inflammation, obstruction, strangulation, hydrocele, inflammation or
Obstruction.
Diagnosis is through radiological imaging, laparotomy.
Treatment is through Mesh Hernia repair surgery, laparoscopic
surgery.

14. INTESTINAL OBSTRUCTION
In a bowel obstruction (intestinal
obstruction), a blockage prevents the
contents of the intestines from
passing normally through the
digestive tract.
Causes include, Adhesions, volvulus,
diverticular diseases, tumors.
Symptoms is reflected through
Abdominal pain which is characterized
as intense cramping pain, nausea,
vomiting, melena, constipation and
diarrhea.
Diagnosis is through colonoscopy,
radiological imaging, contrast enema,
laparoscopy & endoscopy is used.

15. INTESTINAL OBSTRUCTION
Usually resolves conservatively, but many require surgical treatment.
[12]
Conservatively, managed via nasogastric tube and usually patients
recover quickly.
However, etiological based surgical repair is done in emergency
cases.
Laparotomy is preferred method of surgery for intestinal
obstruction.
Small bowel obstruction caused by Crohn's disease, peritoneal
carcinomatosis, sclerosing peritonitis, radiation enteritis, and
postpartum bowel obstruction are typically treated conservatively, i.e.
without surgery.

16. PEPTIC ULCER
Peptic ulcer is a sore on the
lining of stomach or duodenum.
Common causes include
Autoimmune conditions, Bacteria
infestations such as H.Pylori,
Drug abuse of NSAIDS and
Chemical causes.[13]
Symptoms include epigastric
pain, belching, hematemesis,
melena, loss of appetite.
Complications such as GI
bleeding, obstruction and
perforation.

17. PEPTIC ULCER
Perforation of a peptic ulcer allows a flood of gastric juice to flow
into the peritoneal cavity, resulting in diffuse peritonitis that is almost
always fatal if untreated.
Surgery within 24 hours, with closure of the perforation and washout
of the abdominal cavity, is simple and is almost always successful; if
followed by appropriate anti-ulcer medical treatment, it leads to a
permanent cure for 95 percent of patients. [14]
Diagnosis is through Endoscopy, Radiological imaging, Urea breath
test and Laparotomy.
Surgical treatment is indicated in severe cases, techniques such as
vagotomy, Pyloroplasty and Bilroth I and II.

18. ESOPHAGEAL VARICES
Esophageal varices are
extremely dilated sub-mucosal
veins in the lower third of the
esophagus.[15]
It is caused through Liver
cirrhosis & portal
hypertension.
Complications such as
bleeding, shock and cardiac
arrest can occur if left
untreated.
Histologically, Dilated
submucosal veins are the most
prominent features of

19. ESOPHAGEAL VARICES
Diagnosis is through endoscopy, radiological imaging.
Conservatively, hemodynamic stability of the patient must be
restored, AASLD guidelines is followed.
Endoscopic intervention, balloon tamponade are commonly used.
Esophageal de-vascularization operations such as the Sugiura
procedure is used.
To treat portal hypertension : transjugular intrahepatic
portosystemic shunt (TIPS), distal splenorenal shunt procedure, or
liver transplantation is performed.

20. ACUTE AORTIC DISSECTION
Acute aortic dissection, (AAD), is
the most common and most lethal
of the acute syndromes, and
requires urgent diagnosis and
treatment.
Aortic dissection results from a
tear in the aortic wall, and a
column of blood enters the medial
layer of the aorta creating a
hydraulic endarterectomy.[16]
The most common symptom of
AAD is sudden and severe chest
pain,other symptoms include
syncope & cardiac tamponade.

21. ACUTE AORTIC DISSECTION
Diagnostically, ECG and serum Troponin tests are carried out to rule
out myocardial infarction.
Transesophageal echocardiography and contrast based computer
tomography is the most commonly used diagnostic method.
Aortography is the most specific diagnostic tool in diagnosing AAD.
Treatment is administered according to the classification, in case of
Type A it is managed surgically to prevent pericardial tamponade &
Type B can be managed conservatively with management of
hypertension with a one year survival can be upto 90%.[17]
Open Aortic surgery, Bentail’s procedure, David’s procedure is
considered.

22. ABDOMINAL AORTIC ANEURYSM
Abdominal aortic aneurysm is a
localized enlargement (dilatation) of the
abdominal aorta such that the diameter
is greater than 3 cm or more than 50%
larger than normal.
Causes include atherosclerosis,
trauma, infection, tobacco smoking,
alcohol & hypertension.
Usually asymptomatic but severe pain
in the lower back, flank, abdomen or
groin is present.
Grey turner sign is present in cases
when retroperitoneal bleeding is

23. ABDOMINAL AORTIC ANEURYSM
An aneurysm is usually defined as an outer aortic diameter over 3
cm (normal diameter of the aorta is around 2 cm)[18] as mild.
An aneurysm is usually defined as moderate if the aortic diameter is
between 3-5cm. An aneurysm is usually defined as severe if the
aortic diameter is more than 5cm.[19]
Diagnosis is through radiological imaging such as CT & Aortography.
Conservative management is indicated only in cases where surgical
repair is contraindicated.
Surgery is considered, where both Open surgery and Endovascular
surgery is performed on case to case basis. Mortality is lower in
Endovascular surgery. [20]

24. INFERIOR VENA CAVA SYNDROME
Inferior vena cava syndrome (IVCS) is a
constellation of symptoms resulting from
obstruction of the inferior vena cava.
It can be caused by physical invasion or
compression by a pathological process or
by thrombosis within the vein itself.
Main symptoms include, tachycardia,
edema, aorto-caval compression
syndrome.
In pregnant women, it can cause fetal
distress and fetal death if left untreated.
Main causes of IVCS are compression,
obstruction, Iatrogenic and Budd-Chiari
syndrome.

25. INFERIOR VENA CAVA SYNDROME
Diagnosis is through clinical observation where multiple dilated
veins over abdomen is seen.
Ultrasound with Doppler is also helpful in diagnosing Inferior vena
cava syndrome.
Surgical treatment strategies for SVC syndrome include
thrombectomy, and/or bypass grafting with a prosthesis or
autologous spiral saphenous vein graft. Surgery is reserved for
complicated or failed endovascular stenting. [21]
If the stent placing is not advisable, placing IVC filters can alleviate
symptoms for some time.[22]
IVCS patients of intrahepatic obstruction due to malignant hepatic
enlargement are usually treated using strip radiotherapy to the
intrahepatic IVC, with or without a hepatic arterial infusion of
chemotherapy. [23]

26. AMOEBIC LIVER ABSCESS
It is caused due to amebiasis of Liver, which results in abscess
formation.
Main methods of examination include stool test (to check
trophozoites & cysts), Radiography, Hemoglobin estimation, Liver
function tests, and serological tests.
Conservatively amebicidal drugs such as emetine, dehydroemetine,
chloroquine diphosphate, metronidazole, and tinidazole can be used.
Surgically we can drain the abscess through percutaneous aspiration.
Open surgery is indicated only in cases of complications such as
peritonitis and perforation. [24]

27. ACUTE CHOLECYSTITIS
Acute cholecystitis can be defined as the
inflammation of the gall bladder, it is usually
caused by gall stones. Ascariasis is also a
main cause in developing regions such as
North Africa, Latin America and South East
Asia. [25]
Ultrasound scanning is the investigation of
choice in patients suspected of having acute
cholecystitis. Sonograms typically show
pericholecystic fluid and shadows of gall
stones.
Colour flow Doppler ultrasound shows
hyperaemic, pericholecystic blood flow and
acute inflammation, in physical examination
Acute cholecystitis presents with Murphy
sign positive.
Biliary scintigraphy (hydroxyiminodiacetic
acid (HIDA) scan) is the gold standard
investigation.

28. ACUTE CHOLECYSTITIS
Conservative management of Acute
cholecystitisinclude fasting, IV fluids and
Oxygen therapy. IV antibiotics must
prescribed if patient doesn’t improve
within 24 hours.
Analgesics such as indometacin 25mg
3times a day for a week is prescribed.
[26]
Surgically, cholecystectomy is indicated
in patients, either laparoscopically or
through open surgery.
Percutaneous cholecystectomy is a
minimally invasive procedure, which is
preferred in high risk patients.

29. ACUTE PERITONITIS
Acute peritonitis can be defined as the
inflammation of perioneum.
It is usually caused due to complication of an
underlying etiology.
Symptoms include Abdominal pain, tenderness
of the abdomen, abdominal rigidity,
inflammation of abdomen and Fever.
Various complications such as sequestrations
of fluid, abscess formation & sepsis.
Diagnosis of Peritonitis is concluded on the
basis of physical examination, a positive
Blumberg sign, radiological imaging, peritoneal
lavage and laparoscopy.
Preferred Surgery for acute peritonitis is
laparotomy.

30. HEMOPERITONEUM
Hemoperitoneum describes the presence of blood within the peritoneal
cavity, often secondary to trauma.
Causes of hemoperitoneum include; penetrating trauma, blunt abdominal
trauma, splenic or hepatic injury, abdominal aortic aneurysm rupture
perforated gastric ulcer, disseminated intravascular coagulation &
complications of abdominal surgery.
Symptoms could range from hypotension, tachycardia, abdominal pain,
visible traumatic injuries, tenderness to palpation, rebound tenderness, rigid
abdomen, tenderness with percussion.
Preferred method of diagnosis is Focussed Assessed Sonar Trauma (FAST).
[27]
Medical care include immediate blood transfusion to stabilize the patient
hemodynamically. Hemoperitoneum is a surgical emergency hence
laparotomy is performed immediately.

31. ABDOMINAL TRAUMA
Abdominal trauma is an injury to the abdomen. It can be either Open
or closed.
Symptoms include abdominal pain, tenderness, rigidity, and bruising
of the external abdomen & traumatic injury to the abdomen.
Seat belt sign is most prominent in blunt abdominal trauma.[28]
Most common causes include Road Traffic accident (RTA), gunshot
injuries, stab wounds, and incidents of trauma.
If left untreated, patient’s condition could worsen resulting in shock,
hemoperitoneum, pneumoperitoneum & infection.

32. ABDOMINAL TRAUMA
Diagnosis is through radiological
imaging, peritoneal lavage, diagnostic
laparotomy, FAST (IOC) & physical
examination.
Treatment steps include,
hemodynamic stabilization of the
patient, laparotomy surgery & Open
surgery to treat the underlying
etiology.
The main goal is to stop any sources
of bleeding before moving onto any
definitive find and repair any injuries
that are found. Due to the time
sensitive nature, this procedure also
emphasizes expedience in terms of
gaining access and controlling the
bleeding, thus favoring a long midline
incision. [29]

33. BILIARY COLIC
Biliary colic is a steady or intermittent ache in the upper abdomen, usually
under the right side of the rib cage. It happens when something blocks the
normal flow of bile from the gallbladder.
Gallstones are the most common reason for biliary colic, other causes
include a stricture of the bile duct or a tumor also can block bile flow and
cause biliary colic.
Signs and symptoms include pain in right upper quadrant, nausea, &
vomiting.
Diagnosis starts with physical examination, radiological imaging, ERCP,
MRCP, HIDA scan & biochemical tests which will suggest elevation of
bilirubin and alkaline phosphatase. Pancreatitis should be considered if the
lipase value is elevated; gallstone disease is the major cause of pancreatitis.
[30]
Initial treatment will start with medications of antispasmodic class, NSAIDs,
& anti-emetics. Surgical treatment will involve cholecystectomy

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40. THANK YOU!