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Acute abdomen Prof. M K Alam M S ; F R C S Learning objectives Definition of acute abdomen Anatomy and physiology of abdominal pain. Pathophysiology of common causes of acute abdomen. Symptoms and signs of acute abdomen in relation to the underlying pathology Laboratory and imaging investigations Initial and definitive management Definition Acute abdomen: a clinical presentation of abdominal pain and tenderness, that often requires emergency surgical therapy. • Some non-surgical or non intra-abdominal diseases, can present with acute abdominal pain. • Every attempt should be made to make a correct diagnosis so that an appropriate therapy is given Types of abdominal pain • Visceral • Parietal Visceral pain • Vague, poorly localized • Splanchnic nerves • Usually the result of distention of a hollow viscus • Depending on the origin of the affected organ from the primitive foregut, midgut, or hindgut, the pain is localized to epigastrium, periumbilical , or hypogastrium respectively Parietal pain -Corresponds to the segmental nerve roots (somatic nervous system) innervating the peritoneum. -Sharper and better localized. Referred pain Definition: Pain perceived at a site distant from the source of stimulus. Common examples of referred pain: Right shoulder- Gall bladder Left shoulder- Heart, tail of pancreas, spleen (Kehr's sign) Scrotum and testis- ureter Pain locations (Great degree of overlap) • Right hypochondrium.- gallbladder • Left hypochondrium.- pancreas • Epigastrium.- Stomach and duodenum • Lumber- kidney • Umbilical- small bowel, caecum, retroperitoneal • Right iliac fossa- Appendix, caecum • Left iliac fossa- Sigmoid colon • Hypogastrium- Colon, urinary bladder, adenexae Pathophysiology Surgical Acute Abdominal Conditions • Infection- Appendicitis, cholecystitis • Perforation- Perforated duodenal ulcer • Obstruction- Small bowel adhesions, obstructed hernia, sigmoid volvulus • Ischemia- Mesenteric ischemia (thrombosis/ embolism) strangulated hernia • Hemorrhage- Ruptured ectopic pregnancy, ruptured aneurysm, solid organ trauma Nonsurgical Causes of Acute Abdomen • Diabetic crisis • Uremia • Hereditary Mediterranean fever • Sickle cell crisis • Acute leukemia Pathophysiology: Acute appendicitis • Most common general surgical emergency • Derived from the midgut • Obstruction of the lumen (fecalith, lymphoid hyperplasia, vegetable matter or seeds, parasites) is the major cause of acute appendicitis. • Obstruction contributes to bacterial overgrowth, Pathophysiology: Acute appendicitis • Continued secretion of mucus leads to intraluminal distention. • Distention produces the visceral pain sensation as periumbilical pain. • Promote a localized inflammatory process • May progress to gangrene and perforation. • Inflammation of the adjacent peritoneum- localized pain in the right lower quadrant. • Perforation usually occurs after 48 hours from the onset of symptoms Pathophysiology- peritonitis • Introduction of bacteria or irritating chemicals into the peritoneal cavity cause peritoneal inflammation • A localized inflammation (appendicitis) produce sharply localized pain and normal bowel sounds • A diffuse process (perforated viscus) produces generalized peritonitis causing generalized abdominal pain with a quiet abdomen Types of peritonitis • Secondary peritonitis: more common, secondary to an inflammatory insult from within abdomen, most often gramnegative infections with enteric organisms or anaerobes. Exampleappendicitis • Primary peritonitis: uncommon. Children: Pneumococcus or hemolytic Streptococcus. Adults: peritoneal dialysis for end-stage renal dis.(gram+ve cocci), ascites and cirrhosis(Escherichia coli and Klebsiella) • Noninfectious inflammation- pancreatitis (chemical peritonitis) Pathophysiology: Small bowel obstruction • Post-operative adhesion- most common • Hernia, tumour, Crohn’s disease- other causes • Early- the intestinal contraction increases to propel contents past the obstructing point (colicky pain) • Later- the intestine becomes fatigued and dilates, contractions becoming less intense. • Bowel dilates, water and electrolytes accumulate in lumen and in the bowel wall. • Massive third-space fluid loss: dehydration and hypovolemia. • Intraluminal pressure increases in the bowel, a decrease in mucosal blood flow occurs. Pathophysiology: Mesenteric Ischemia • Arterial: embolism, thrombosis • Venous: thrombosis • Superior mesenteric vessel distribution • Intestinal mucosal sloughing within 3 hours of onset and • Full-thickness intestinal infarction by 6 hours Symptoms & Signs in Acute abdomen Main symptom- Abdominal pain • • • • • • • • Location: finger vs hand Severity: Onset: sudden in perforation, ischemia, biliary colic Progress: develops and worsens over several hours is typical of progressive inflammation or infection such as appendicitis, cholecystitis Spasmodic: Biliary colic, or genitourinary obstruction Radiation and shift: cholecystitis, appendicitis Exacerbating factors: food worsen pain of bowel obstruction Relieving factors: food relieves pain of non-perforated peptic ulcer disease or gastritis. Associated symptoms • Vomiting likely to precede significant abdominal pain in medical conditions whereas pain presents first in acute surgical abdomen. • Constipation or obstipation can be a result of either mechanical obstruction or decreased peristalsis (ileus). • Diarrhea is associated with several medical causes of acute abdomen, including infectious enteritis, inflammatory bowel disease (IBD), and parasitic contamination • Bloody diarrhea- IBD, Colonic ischemia PHYSICAL EXAMINATION (Inspection) • Inspection of the patient: • Ischemic bowel and ureteral and biliary colic, typically cause patients to continually shift and fidget in bed while trying to find a position that lessens their discomfort. • Patients with peritonitis lie very still in the bed during the evaluation and often maintain flexion of their knees and hips to reduce tension on the anterior abdominal wall. Inspection of the abdomen • • • • • • Distension Restricted mobility- ?peritonitis Scars of previous surgery Hernias Mass effect Ecchymosis ? Acute pancreatitis (Cullen’s, Grey Turner’s sign) Palpation of the abdomen • Start gently, away from the area of pain. • Severity and exact location of tendernesslocalized/ generalized • Involuntary guarding • Organomegaly, mass • Murphy’s sign, Rovsing’s sign, • Rebound tenderness (Blumberg’s sign) Percussion of the abdomen • Hyperresonance :distended bowel loops • Dullness due to organomegaly or mass • Liver dullness lost- free intra-abdominal air is suspected. • Shifting dullness • Tenderness Auscultation of the abdomen • Quiet abdomen- ileus • Hyperactive bowel sounds- enteritis, ischemic intestine • Mechanical bowel obstruction- high-pitched “tinkling” sounds that come in rushes and are associated with pain • Bruits- high-grade arterial stenosis Digital rectal examination • Performed in all patients with acute abdominal pain • Checking for mass, pelvic pain, or intraluminal blood • Pelvic examination in female Investigations Routine laboratory investigations • Hematology: WBC count, differential count, hemoglobin, platelets, red blood cells • • • • • • • Electrolytes, urea, creatinine Amylase, lipase LFTs: Bilirubin (T & D), alkaline phosphatase, aminotransferase, Serum lactate & arterial blood gas Urine analysis Urine human chorionic gonadotropin Stool for parasites • WBC count: confirm infection • Electrolytes, blood urea nitrogen, and creatinine: the effect of vomiting or third-space fluid losses • Serum amylase and lipase- acute pancreatitis, small bowel infarction or duodenal ulcer perforation • Liver function tests: biliary tract disease. • Lactate levels and arterial blood gas: intestinal ischemia or infarction. • Urinalysis: bacterial cystitis, pyelonephritis, diabetes. • Urinary human chorionic gonadotropin: suggest pregnancy as a factor in the patient's presentation or aid in decision making regarding therapy. • Stool: occult blood, parasite, Cl. Difficile (toxin & culture). Plain radiographs • Upright chest radiographs – free gas under the dome of diaphragm Perforated duodenal ulcer-75% • Lateral decubitus abdominal radiographspneumoperitoneum in patients who cannot stand Plain x-ray abdomen • Calcifications: renal stones 90%, chronic pancreatic, aortic aneurysms, fecalith • Supine and upright films: distension, fluid levels, gas distribution (small vs large bowel), volvulus of sigmoid colon/ cecum Abdominal ultrasonography • Gallbladder: stone, wall thickness, fluid around gallbladder, diameter of bile ducts • Liver: abscess, other masses • Pelvis: Ovarian, adnexal & uterine pathologies • Free fluid in peritoneum • Limited evaluation of pancreas • Limitations: bowel gas, person dependent, difficult to interpret for most surgeons CT abdomen • Widely available • Easier to interpret by surgeons • Imaging modality of choice in acute abdomen, following plain abdominal radiographs. • Accuracy and utility of CT abdomen and pelvis in acute abdominal pain is well established. • Most common causes of acute abdomen are readily identified by CT • Highly accurate in acute appendicitis, mechanical bowel obstruction, intestinal ischemia DIAGNOSTIC LAPAROSCOPY • Ability to diagnose and treat a number of the conditions causing an acute abdomen • High sensitivity and specificity • Decreased morbidity and mortality, decreased length of stay, and decreased overall hospital costs • Advances in equipment and greater availability DIFFERENTIAL DIAGNOSIS • Differential diagnosis of acute abdominal pain is extensive. • Comprehensive knowledge of the medical and surgical conditions that create acute abdominal pain • Mild, self-limited illness to the rapidly progressive and fatal • Evaluated immediately upon presentation and reassessed at frequent intervals. • Many acute abdomen require surgical intervention but some abdominal pain are medical in aetiology. Management Preoperative preparation • Fluid and electrolyte abnormalities corrected • Antibiotic infusions for the bacteria common in acute abdominal emergencies (gram-negative enteric organisms and anaerobes) • Nasogastric tube to decrease the likelihood of vomiting and aspiration • Foley catheter- to assess urine output -0.5 mL/kg/hour • Blood typed and cross matched for operation Preoperative preparation • Frequent evaluation of the patient • Stabilization of co-morbid conditions • Surgical vs non- surgical management • Consent for surgery Surgical intervention • Excision: Appendectomy, cholecystectomy, tumors. • Resection and anastomosis: Bowel tumors, gangrenous bowel, • • • • Relieve obstruction: Hernia, division of adhesion. Repair of perforation: Perforated DU, stomach, ileum Drainage: Appendicular abscess. Bowel diversion: Colostomy. Non-surgical intervention • Conservative management: NPO, IV fluid, antibiotics • Radiological intervention: PCD, placing stents in obstructed bowel. • Endoscopic intervention: Bile duct decompression. Thank you!