Approach of acute abdomen including Hx, Examination, DDx, Ix and Treatment

1. Parietal pain
visceral pain
More acute Sharper Better localized
Contraction of segmental area of muscle
Rigidity
Slow in onset
Poor localized
Acute Abdomen
Reffers to severe Abdominal Pain Lasting for hours to a few days. Initial
checking vital sings
approach can smundietals ciferureatening causes empared
erysm,
boval personations
quick Physical Examination
tests "Abdominal VIS or X-MaYC
Diagnostic S8-
Lab studies
Recurrent vomiting
"
Hypochloremic, Hypokalemic, metabolic Alkalosis
Bood gas analysis Bowel Ischia metabolic Acidosis (lactic Acidosis, Hyperkalemia
Lacta+
e ↑ Lactates
tissue Hypoxia (AYPotension, shock in Acute Pancreatitis, Bowel infraction
Due to bowel obstruction mesenteric Ischemical
Troponin -MI
CBC * WBC =
Infection or inflammatory, 1Hb+ bAct= Anemia + blood loss, 4 Act-
hemoconcentration
↳
Dehydration
Serum glucose -
Hyp. or Hyperglycemia
coagulation Studies (INR, PT) ASNR= sepsis, Spinal Ansthesia I4 INR, fresh frozen plasma necessary
to correct
the coagulopathy
BMP Evaluate RF+Electrolyte imbalace, 4 urea pre-penal Azotemia, a creatinine 1 IV contrast
LF Ts
Lipase, Amylayase lipase 43%old= Acute Pancreatitis
- >
Indication
Blood +yPe *
contra-indication
ESR/CRP
GUE Hematuria, nitrates, urinary crystals =
vTI, nephrolithiasis, Hematuria = Ruptured Abdo port. Aneurysm, Yuria: Appendicitis
B-hCG urine test Actopic pregnancy as it?"
is is 51:5)
cultures if
GV)=UTT -
urine cultures, Pt. suspected sepsis - Blood cultures
Pt. With signs of Diffuse Peritonitis or Sepsis may require immediate surgical
management without
further Diagnostic Imaging.
Imaging
Initial Imaging guided by the working Diagnosis AX, vital Signs, exams, in pregnancy with
Abdominal Pain JUIS and MRI) without
contrast.
Acute coronary syndrome -
ECG, Echo
Hemo-ragic shock "Bleeding" -> sonography (u/s)
Bowel Perforation -
CT (Abd+ Pelvis with contrast), X-Ray Abd., X Ray chest.
small Bowel obstruction,
CT (Ab+pe with con.), X-Ray Abd., x-Ray chest.
Intra Abd. Abscess + Acute Diverticulitis + Acute Appendicitis ->
c+Ab +
Pe
with con.
Acute mesenteric Ischemia -
CT
A
of
the Abdomin
A
cute Pancreatitis -
UIS Abd. + CY
Abd. With IV contrast.
Nephrolithiasis -
W/S Ab.+ Pel. , CT Ab.+Pel. Without con
SuSPected symptomatic AAA
in a hemodynamically stable - U/S, CTA, MRA

2. I
masing According to location of
the Bain
RUQ
Pain Initial test
U/S Aternatives (CT+iV con., MRCP)
RLQ Pain I
nitial test T+con in Aternatives (CT without
can, MRTI
con
La Pain UIS, DuPleX U/S "ovarian/testicular")
LUQ Pain I
nitial test CT+ con. IV and oral
Supra-Pubic Pain initial test
U/S Aternatives (TIcon, MRII con
Pelvic Pain Initial test
UIS, CT+IV con. Aternatives Duplex
U/S, MRI+
IV con.
Non Localized
Paininitial test CT+IV con. Aternatives CT Without
IV con., MRI1 IV con.
UIS, fluoroscopy.
-
1135- Imaging Dis Approach is
1st UIS
RUQ LUG
2nd CT I contrast
'
stot a
RLQ LLQ
-
zuo MRI I contrast
;
g)
If
Diagnosis still unclear After HX exame, Lab Studeis And Imaging
*
Diagnostic Laparoscopy -
Hemodynamically stable
*
Diagnostic Laparotomy -> Hemodynamically unstable
DDX of
Acute Abdomen:-
CU causes
Acute coronary syndrome *
Heavy, Chest Pain Radiation to L. Shoulder, Nausea, vomiting, Diaphoresis, pain may improve with nitroglycerin.
L
Investi.
- >
ECC, Troponin And Echo
Acute mesenteric schemia
ssesoolimbois savoristhrombophiliar,severe
andDiffuse
Abd. Pain, Vomitins, Diarrhea, melena, Hematocleiin
Imaging- X-Ray Abd. (Normal Early stag, Pneumatosis Intestinalis Late stage), CTA
·61 causes
6 I tract perforation
saberdenleadersseperatorseasons,verses aserieson?
"Bowel Perforation"
mechanical Bowel obstruction
*
Conistipation, Nausea, vomiting, Diffuse Abd. Distention, tympanic Abd,
collapsed Rectum on DRE, N. Abd. Surgery
⑭X-ray Dilated Bowel, Rectal Air, Multiple Air-fluid levels), CAATA
con
Acne Appendicitis Pain speriumbilical, RLQ,fPi-gastric pain), fever, Nausea, Anorexia, Rebound Tenderness in RLQ
perforated Appendicitis *wie neutrophilic", UIS, CTA IVcon
Peptic uncer
pisasiyarance isReliveringinwithorweightgainGastricteracerbatedpainwithGodweightseea
Divertical
ini" name
is
Gastro-enteritis * Diarrhea, vomiting, nausea, Abd. cramping, in sever cases (Abd tenderness, fever, Dehydrations
⑭Diagnostic studies typically not required CBC, BMP

3. DDx. According To Site of Pain:
Biliary And Pancreatic can5es
Acute Pancreatitis
iseveness,is
a
cityinternatesometimestonesareinsidiseste
Genit-o-urinary can Jes
satopic pregnancy,
evenseverlowerorairvasinbreedingohinoviewcaseduterus,
AR, Ieat
Acute pyelonephritis
isseverchillsandpainconvertebrae
intheessenUrinarsfreeene
Renal UIS (Edema, focal Hypo-echogenics, CT+ IV con.
·scanical pinsnosis, eco, is espaccess is
mains
is
Pelvic inflammatory Disease
enderness
veteransee
minine
L

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underlying causes
‫ﻣ‬
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‫ان‬
acute
abdomen
‫و‬
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causes
Treatments-
Supportive care
Par-Interal "IV"Analgesia
·Anti-biotic -> Intra-Abdominal suction .. coli(Metro-hidazole-
ceftriaxone of metro- ciprofloxacins
·Anti-metics-
Nausea And vomiting
↑ NO tube -
suspected
bowel obstruction with intra-ctable vomiting.
Urinary Catheter"foley Catheter"
⑨
E
Sjbls
eithe&
/
F

5. Axin
explosive -
My
, Angina, Rupture AAA . . .
↳
-Colicky smooth muscle contrace."Renal, GlT"(
- Character of
Pain
L Gradual Rapid ProgressiveAcute pancreitis, mesenteric thrombosis -
Strangulated bowel, Ectopic Pregnancy
Lie [ Gradual progressive acute cholecylitis, Acute Cholangitis, Acute hepatitis
Appendicitis. Acute salping it is
ferred pain -> MI, Angina
L constant
or continuous Pain Peritoneal Infla.Ischemia
2. Relieved factor - Sitting UP
XA
cute Pancreatitis
Exacerbated factor lying down
->
tating or take Antacids & Peptic ulce
=>
Abd. Pain appears 30 min-ih After meal - Intestinal Angina
->
Deep breathing, cough, sneezing -> Perionitis
3-Severity -
Depented on patient
-
mild (1-3
-moderate (4-7)
-Seven (8-10)
4. Other symptoms & Vomiting watery -> Gastro-enteritis
& Diarrhea t Blood stain -> Dysentery, IBD, Ischemic colitis
-> Nausen
-> constipation & obstipation "mechanical bowel obstruction"
>
Jaun dice
-
Hematemesis/Hematochezia/Melaena
& Hematuria
S-travel history =>
Amebic Liver Abscess
-> Hydrabid CYSt
-> TB
-> Malarial spleen
6-Drug +X & oral contraceptives - Benign hepatic
-> Adena mas
-> mesenteric venous
-> infarction

6. Indications for urgent operation:
1- Physical - Rigidity
- tender Abd
-
High lever
-Hypotention
-
Progressive Distention
-
Rebound tenderness
-failure conservative treatment
-
suspected schemia (Acidosis, fever stazly cardial
2- Radiological -
Pneumoperitoneum
-
Gross or progressive bowel Distention
-Endocopy uncontrollable bleeding
-
Lab (sepsis marked WBCs)