1. DR. WONG SEAK KHOON
(2 November 2011)
Present by: Soediqin
Akmal
2. Abdomen
Abdomen is part of trunk that lies between the
thorax and pelvis.
It is divided into 9 parts by 2 vertical lines, right
and left midclavicular lines and also 2 horizontal
lines, subcostal and intertubercular lines.
4. Stomach
Pancreas
Lt lobe of liver
Liver
Gallbladder
Spleen
Tail of pancreas
Fundus of
stomach
Coils of
small
instestine
Right kidney
Ascending colon
Left kidney
Descending
colon
Caecum
Appendix
Urinary
bladder
Sigmoi
d
colon
6. Abdominal pain is pain that is felt in the
abdomen
Acute abdomen refers to a sudden, severe
abdominal pain of unclear etiology that is
less than a week in duration
◦ eg. acute peritonitis, acute pancreatitis, acute
cholecystitis, acute cholangitis, acute appendicitis
diabetic ketoacidosis
7. 1. Somatic pain:
- due to irritation of parietal peritoneum
- parietal peritoneum covers:
(a) anterior & posterior abd. wall
(b) undersurface of diaphgram
(c) pelvic cavity
8. - Nerve supply: derived from nerve supplying
muscles & skin of abdominal
wall (T5- L2)
*exception: central portion of diaphrgam
(phrenic nerve: C3,C4,C5)
- Sensitive to: mechanical
thermal
chemical
9. - Response to irritation:
(i) reflex contraction of corresponding
segment of muscle guarding
(ii) hyperaesthesia of overlying skin
- Nature: sharp, localised, knife-like
10. 2. Visceral pain:
- due to irritation of visceral peritoneum
- visceral peritoneum covers partially/
completely the intra-abdominal viscera
- pain is mediated through sympathetic
branches of autonomic system, to
thoracic (T6-T12) & lumbar (L1,L2)
segment of spinal cord
11. - Sensitive only to tension
- Nature: dull, poorly localised, deep,
referred to overlying skin with
same embryological origin
16. 1. Mild attack:
◦ Fluid resuscitation and analgesia
◦ NBM meant to rest the pancreas
◦ Treat predisposing factors such as gall stones
◦ Discouraged alcohol abuse
◦ NG tube to aspirate stomach content and
prevent vomiting
◦ Prophylactic antibiotic i.e. imipenem and
cephalosporin
◦ Daily measurement of plasma amylase –
progression of ds
◦ LFT and renal profile
17. 2. Severe attack:
◦ Resuscitate
◦ Defined by Ranson’s or Glasgow criteria
◦ Admit to ICU immediately
◦ Fluid and electrolyte management
◦ Treat hypocalcaemia
◦ Ventilatory support
3. Surgery:
- Abscess drainage
- Cholecystectomy-if stone in gall bladder
19. The stomach and duodenum.
1.The insulin test:
Consist of an injection of insulin which produces hypoglycemia
Stimulates the nucleus of vagus in the brain stem
Helpful when a patient develops a recurrent ulcer following vagotomy for
duodenal ulceration.
The blood sugar has to fall below 45mg/100ml
Measure before and after insulin in injected by slow i.v infusion
2.Plain x-ray:
Patients lying in supine position
Suspected peritonitis due to perforation of gastric or duodenal ulcer
Gas maybe seen under the diaphragm
Usually on the right side
20. 3. Barium meal:
Radiographic investigation
Patient swallows a suspension of radiopaque barium sulphate
Principally use in the diagnosis of gastric and duodenal ulcer and gastric
carcinoma.
Chronic gastric ulcer: seen as a projection from the wall or as a ronded deposit.
Duodenal ulcer:seen a face with a stellate appearance of the mucosal fold.
Pyloric stenosis: an increased amount of resting juice present and grossly enlarged
stomach .
4.Endoscopy and biopsy:
Possible to see the whole of the oesophagus,stomach and duodenum
Biopsy forceps:to obtain specimens for histological and cytological examination.
Can differentiate benign from malignant lesions
Rapid diagnosis of upper gastrointestinal bleeding.
21. Small intestine.
1.Barium meal follow through X-rays:
Studied by thaking filmx of abdomen at intervals after a barium meal.
Abnormalities in the transit time to the colon and in small bowel pattern such as
dilatation,narrowing, fistula and mucosal abnormalities.
2. Biopsy:
Small intestine biopsy importance in diagnosis of the malabsorption syndrome
where a flat mucosa is seen.
Colon ,rectum and anus.
1.Protoscopy:
Can see piles as reddish/blue swelling which bulge into the lumen
Can see internal opening of an anal fistula,an anal or low rectal polyp and chronic
anal fissure
22. 2. Sigmoidoscopy:
Necessary to examine the rectum and colon
Proctitis,polyps and carcinomas may be seen.
Particulary useful in the differential diagnosis of diarrhoea of colonic region.
3. Barium enema:
Can see the obstruction of the colon,tumours,diverticular disease,fistulae and other
abnormalities can be recognize.
4.Colonoscopy:
Inspect the whole colonis mucosa round to the caecum.
Polyps and diverticulitis can be seen.
23. The liver.
1.Ultrasound scan:
Diagnosis of fluid-filled lesions such as cysts and abcesses
Detecting intrahepatic bile ducts.
2.Needle biopsy of liver:
Diagnosis for liver abcess
3. Liver function test:
To see the albumin,globulin,AST and ALT level.
24. Gallbladder and bile ducts:
1.Percutaneous transhepatic cholangiography:
Useful investigation in patients with jaundice due to obstruction of the main bile
ducts.
Investigations the site of the obstruction due to tumours of the head of the
pancreas,iatrogenic and alignant bile ducts strictures –can be accurately localized
and diffrentiated.
2.ERCP(endoscopic retrograde cholangiopancreatography)
Useful in the rapid diagnosis and localization of the different causes of jaundice
due to obstruction of the main bile ducts.
25. The pancreas.
1.Lundh test;
Assessment of tryptic activity in pancreatic juice collected following duodenal
intubation
Indirect stimulation of the pancreas by prior ingestion of a meal.
Tryptic activity is less than 6 iu/litre.
2. Triple test.
Exocrine function.
Cytology
Hypotonic duodenography
3. ERCP
26. Pain
1.Site-9 region
2.Onset: acute or recurrent or gradual
3.Character :
-colicky- comes and goes in waves and
indicates obstruction of a hollow, muscular-
walled organ (intestine, gallbladder, bile duct,
ureter).
-burning-an acid cause and is related to the
stomach, duodenum or lower end of the
oesophagus
4.Radiation:
-Right scapula: gallbladder
-Shoulder-tip: diaphragmatic irritation
-Mid-back: pancreas.
27. 5.Associated symptoms, e.g vomiting, diarrhoea,
painful micturition etc
6.Timing:
since onset
Episodic or continuous. If episodic, duration and
frequency of attacks;
If continuous, any changes in the severity
Variation by day or night, during the week or
month, e.g. relating to the menstrual cycle
7.exacerbation & relieving factor
8.Severity
28. Past medical history
Ask especially about:
Previous surgical procedures including peri-
and postoperative complications and
anaesthetic complications.
Chronic bowel diseases (e.g. IBD including
recent flare-ups and treatment to date).
Possible associated conditions (e.g. diabetes
with haemachromatosis).
29. Drug history
Think about drugs that can precipitate abdominal
diseases and remember to ask about over-the-counter
drugs. For example:
Hepatitis: halothane, phenytoin, chlorothiazides,
pyrazinamide, isoniazid, methyl dopa, HMG CoA
reductase inhibitors (statins, sodium valproate,
amiodarone, antibiotics, NSAIDs.
Cholestasis: chlorpromazine, sulphonamides,
sulphonylureas, rifampicin, nitrofurantoin, anabolic
steroids, oral contraceptive pill.
Fatty liver: tetracycline, sodium valproate, amiodarone.
Acute liver necrosis: paracetamol.
Ask also about previous blood transfusions
30. Smoking
Smokers are at risk of peptic ulceration,
oesophageal cancer, colorectal cancer.
Smoking may also have a detrimental
outcome on the natural history of Crohn's
disease.
Alcohol
a detailed history is required.If dependence
is suspected
31. Urethral pain: variable in presentation ranging
from a tickling discomfort to a severe sharp pain
felt at the end of the urethra (tip of the penis in
males) and exacerbated by micturition. Can be so
severe that patients attempt to hold on to urine
causing yet more problems!
Small bowel obstruction: colicky central pain
associated with vomiting, abdominal distension &
constipation.
Colonic pain: as above under small bowel but
sometimes temporarily relieved by defaecation or
passing flatus.
32. Bowel ischaemia: dull, severe, constant, right
upper quadrant/central abdominal pain
exacerbated by eating.
Biliary pain: severe, constant, right upper
quadrant/epigastric pain that can last hours and
is often worse after eating fatty foods.
Pancreatic pain: epigastric, radiating to the back
and partly relieved by sitting up and leaning
forward.
Peptic ulcer pain: dull, burning pain in the
epigastrium. Typically episodic at night, waking
the patient from sleep. Exacerbated by eating
and sometimes relieved by consuming
33.
34. 1. Commenest abdominal emergency
(Lifetime incidence 6%)
2. Causes:
(a) Obstruction by faecolith or lesion in
caecum
(b) Recurrent inflammation
(c) Enlargement of lymphoid
follicles
36. Initiation of inflammation
Acute inflammation of mucosa
Extension of inflammation across appendiceal wall
Involvement of serosa by inflammation
Visceral peritonitis (referred pain)
Peritonitis spread to adjacent structure
(localised pain)
37. Necrotic glandular mucosa sloughs into lumen
Lumen distended with pus
End-artery (appendiceal artery) thrombosed
Appendix infarction
Gangrenous appendix
Perforation of appendix wall
Attempt to wall off perforation by: omentum, adjacent
bowel
39. 1. Pain: -vague
- begin at central abdomen/
retrosternal
- poorly localised
- colicky
- assoc. with Nausea & Vomiting
- duration: few hours/ days
- pain then shifted to Rt iliac fossa
40. 2. Localising symptoms depends on anatomical
relations of inflammed appendix
e.g. inflammed retrocecal appendix:
- irritates psoas muscle>>
involuntary Rt hip flexion, pain on
extension
41. 1. General appearance:
- Facial flush
- Low-grade pyrexia
- Tachycardia
2. Abdomen:
(i) Inspection: - Mild abdominal distension
- Reduced abd. movement
at Rt iliac fossa
42. (ii) Palpation: Rt iliac fossa:
- Guarding (indicator of tenderness
severity)
- Tenderness, Rebound tenderness
- +ve Rovsing’s sign
(iii) Percussion: pain at Rt iliac fossa
(iv) Auscultaion: Bowel sound present
Bowel sound absent when
perforation & generalised
peritonitis cause paralytic ileus
43. 1. abdominal pain <72 hours
2. Vomiting 1-3 times
3. Facial flush
4. Tenderness at Rt iliac fossa
5. Low-grade pyrexia
6. no evidence of UTI
44. No need if it can be diagnosed through
history and physical examination
AXR for confusing findings, may detect free
gas from perforated appendix.
46. Medical
◦ Antibiotics
Surgical
◦ Appendicectomy
Abdominal wall incision ( Lanz/
Classic Gridiron incision)
Dividing the blood supply
Removing the appendix
Closure
47. 1. Perforation
2. Appendiceal mass (usually resolve in the
next 2-6 weeks)
- pyrexia - LOA
- malaise - dull on percussion
3. Appendiceal abscess (formed from
appendiceal mass that fails to resolve)
- swinging pyrexia
- tachycardia
50. Duodenopancreatic reflux
Enterokinase reflux
Activate pancreatic proenzymes
Inflammation, arterioles thrombose, local infarction
More proenzymes leak out of necrotic cells to be activated
Widespread autodigestion
Obstuction of pancreatic duct
52. 1. epigastric pain:
- sudden onset
- radiate to back
- no relieving factor
- aggrevated by movement
- assoc. with - Nausea & Vomiting
53. 1. General appearance:
- in pain
- pale
- sweating
- dyspneic & cyanosed
(respiratory distress in severe
attack)
- jaundice
- tachycardic
- signs of hypovoolemic shock
56. (iv) Auscultation:
- Bowel sound present in first 24 hrs
- Bowel sound absent when
paralytic ileus develops
57. 1. FBC (WBC ,RBC )
2. Plasma amylase (>1200 IU/mL), (rises
within 12 hrs, return to normal in next 48-
72 hrs)
3. Plasma lipase (elevated level persists for
7-10 days), usefull in late-presenting
cases
4. LFT (bilirubin usually )
5. ABG (hypoxia occurs in severe attack)
58. 6. Plain CXR (free gas under diaphragm)
7. Plain AXR (no psoas shadow
>>retroperitoneal fluid)
8. Ultrasound
9. CT scan to confirm pancreatitis if
amylase level normal
10. ERCP (to find the cause)
60. A. At admission or
diagnosis
B. During initial 48 hrs
1. Age >55 years (70yrs in
gall stone disease)
1. Hematocrit fall >10 percent
2. Leukocytosis >16,000
/mm3 2. Fluid sequestration >6L
3. Hyperglycemia >10
mmol/L
3. Hypocalcemia <2mmol/L
4. Serum LDH >400 IU/L
4. Hypoxemia (PO2 <60
mmHg)
5. Serum AST >250 IU/L
5. BUN rise >10mmol/L after
IV fluids
6. Hypoalbuminemia <3.2
g/dL
61. A - Age > 55
P - PO2 < 8 kPa (60mmHg) n=10.6
N - Neutrophil count ( > 16 x 109 /L )
C - Calcium < 2.0 mmol/L
R - Raised Urea > 10 mmol/L
E - Enzyme (LDH > 350 IU/L)
A – Albumin (plasma) < 32 g/L
S - Sugar (plasma glucose) >10mmol/L in the
absence of history of diabetes)
* (3 or > factors indicates severe pancreatitis)
62. clinical assessment, relief of pain and
resuscitation come before imaging tests
Hematology biochemistr
y
imaging
63. Blood tests
1.Haemoglobin
◦ -may be normal immediately after an acute bleed
◦ -low haemoglobin concentration may represent chronic
anaemia due to occult blood loss
2.White blood count -leucocytosis is non-specific and
rarely of much diagnostic value unless greater than
about 14 × 103/L
3.Pcv—degree of hydration(vomit,diarhoea)
4.Blood culture-only in patients with rigors or shock
without obvious blood loss
5.Blood group and ordering of blood for transfusion-
for severely anaemic patients, in major haemorrhage
or when major surgery is contemplated
64. 1.C-reactive protein
◦ -non-specific indicator of inflammatory activation
◦ -confirms organic illness if substantially elevated
2.Plasma amylase-whenever pancreatitis cannot be excluded
3.Urea and electrolytes-indicated in vomiting and diarrhoea,
dehydration, poor urine output, diuretic therapy, urinary tract
disease, known or suspected renal failure, pancreatitis and
sepsis
65. 4.Glucose-for diabetics or those with glycosuria
(beware of hyperglycaemia due to acute stress or
steroid therapy)
5.Liver function tests and calcium estimation-for
pancreatitis and acute biliary disease
6.Clotting studies-for acute pancreatitis and
septicaemia (DIC), severe bleeding (consumption
coagulopathy) or those with a history of bleeding
disorders
66. 1.Plain radiography
1.Erect chest X-ray
◦ -cardiovascular disease or abnormality, e.g.
cardiomegaly, thoracic aneurysm, aortic dissection,
cardiac failure
◦ -respiratory disease
◦ -suspected visceral perforation (gas under
diaphragm)
67. 2.Supine abdominal X-ray (erect or decubitus if
necessary)
◦ -bowel (gas pattern and dilatation, fluid levels, gas
in the wall, faeces and faecoliths)
◦ -urinary tract ('KUB' = kidneys, ureters and bladder)
shows kidney size and position, calculi
◦ -biliary tract (gallstones, gas in biliary tree in
gallstone ileus)
◦ -aortic calcification (aneurysm)
◦ -psoas shadows (obscured by retroperitoneal
inflammation or haemorrhage
68. 2.Ultrasound
Gallstones
Pelvic abnormalities in obstetric and gynaecological practice
'Chronic' enlargement of the spleen
Abdominal aortic aneurysm (AAA)
Free abdominal fluid and gas indicating perforated bowel
Other stones
Dilated ducts; air in biliary tree
Hydatid, teratomas and other cysts
Intra-abdominal abscesses and masses
3.Contrast radiology
'Instant' barium enema in colonic obstruction or acute colitis
Emergency intravenous urography in ureteric colic
69. 4. CT scanning
rapid, cost-effective evaluation of acute abdominal pain
Assessment of abdominal trauma-severity and grading
of solid organ injury, free intra-abdominal fluid and
gas; retroperitoneal injuries including pancreatic and
duodenal rupture and vascular injury
Often first choice for ureteric colic, suspected aortic
aneurysm or aortic dissection
Useful where diagnosis remains in doubt, e.g.
suspected bowel perforation (detects small amount of
free gas), acute diverticulitis
Investigation of postoperative complications-abscesses,
fluid collections
Severe acute pancreatitis, especially if necrosis
suspected
70. Duodenal ulcer:
• Surgery (ulcer is sutured or plugged using an
omentum patch)
• Supportive treatment with nasogastric suction
Gastric ulcer:
• ~15% of perforated gastric ulcer prove to be
malignant. Therefore, definitive surgery is preferred
• Simple closure with biopsy @ local excision (in
poor-risk patients)
71. Acute cholecystitis
1st line treatment (medical) :
Fasting, intravenous fluid, analgesic
Start IV antibiotics (if pt has systemic signs
or if no improvement after 12-24 hours)
Surgery:
Emergency vs elective
Open vs laparoscopic
72. Laparoscopic Cholecystectomy
Optimal management
contraindications advantages disadvantages
(i) Uncorrectable
Coagulopathy
(ii) Unable to tolerate
GA
(iii) Known GB ca
(i) Lower mortality
(ii) Less pain
(iii) Shorter hosp stay
(iv) Recovery rate
faster
(i) Higher incidence
of injury to the
common hepatic
and bile ducts
(ii) Inj tend to be
more extensive
73. Pain after cholecystectomy
(I) retained or recurrent stone
(ii) iatrogenic biliary leak
(iii) stricture of CBD
(iv) papillary stenosis/dysfunction of
Sphincter of Oddi
(v) incorrect pre-op dx (eg irritable bowel
syndrome, PUD, GOR
74. Other treatment modalities :
(I) Oral bile acid treatment
- monotherapy or combine therapy (6-12 months)
- ursodeoxycholic acid and chenodeoxycholic acid
(ii) Contact dissolution therapy
- chemical litholysis of cholesterol stones (MTBE)
(iii) ESWL
- used when GB is functioning ; technically difficult
when
it is subcoastal
- long term recurrence rate high (between 28-61%)
(iv) percutaneous cholecystectomy
75. Criteria for non surgical treatment of
gallstones:
Cholesterol stones (<20mm in diameter)
Fewer than 4 stones
Functioning gallbladder
Patent cystic duct
Mild symptoms
76. MILD ATTACK
Hourly pulse, BP, urine output
Fluid resuscitation to replace fluid loss from profuse vomiting
Analgesics for pain relief – pethidine, morphine
Withhold oral intake
Treat predisposing factors
Remove stone endoscopically, stopped taking alcohol,
laparoscopic cholecyctectomy with operative cholangiography
before discharge.
Nasogastric tube to aspirate gastric content & relief
discomfort.
Prophylactic parenteral antibiotic (cephalosporin) given.
Daily measurement of serum amylase, ABG, BUSE, LFT and
serum calcium & phosphate to monitor progress
77. SEVERE ATTACK
Admit to ICU for close monitoring and early Rx of complications
Evaluated every 48 hours.
May die early b’coz of systemic toxaemia and multiple organ
dysfunction.
If PaO2 deteriorating- urgent ventilation support before ARDS
Massive fluid & electrolytes loss esp protein-rich fluid into
peritoneal cavity and 3rd space lead to shock
Rx- fluid resuscitation with large amount of colloid & crystalloid
Monitor urine output & central venous pressure.
Peritoneal lavage – reduce systemic absorption of enzymes &
toxins.
Intravenous nutrition given in paralytic ileus patient
78. Medical
◦ Antibiotics
Surgical
◦ Appendicectomy
Gridiron / Lanz skin incision
Abdominal wall incision
Dividing the blood supply
Removing the appendix
Closure