Download Acute abdomen

Acute abdomen
Dr. Szathmári Miklós
Semmelweis University
First Department of Medicine
25. Nov. 2013.
The definition of acute abdomen
• Life-threatening condition due to acute onset
abdominal disease with typical symptoms and
physical findings, which requires:
– Prompt surgical intervention
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Acute appendicitis
Acute peritonitis
Acute intestinal obstruction
Acute mesenteric vascular insufficiency
Rupture of the spleen, intrauterine gravidity, dissection of
aortic aneurysm
– Emergent admission to a monitored bed or intensive
care unit
• Acute pancreatitis
• Acute cholecystitis
• Purpura abdominalis
Physical findings in acute abdomen
syndrome
• Abdominal pain
– The medication can influence. In case of shock the
pain might be diminished
• Vomiting
– Mostly in cases of obstruction of intestine
• Involuntary muscular rigidity
– Inflammation (irritation) of parietal peritoneum
• Distension
– As a consequence of mechanic or paralytic ileus
• Shock
– Hypotension, sweating, pallor, tachycardia. In case of
shock sometimes bradycardia because of the vagal
(parasympathic) activation
Acute appendicitis
• Pathogenesis:
– Acute appendicitis occurs as a result of appendicle luminal
obstruction
• Most commonly caused by a fecalith, or enlarged lymphoid follicles
associated with a viral infection, or infection with Yersinia organisms
• Clinical manifestations:
– Pathognomic sequence of abdominal discomfort and anorexia
• Periumbilical „visceral type” pain
• Localized parietal pain according to the location of appendix
– Anorexia is very common. Hungry patient does not have acute
appendicitis
– Nausea and vomiting in app.. 50-60% of cases
– Normal or slightly elevated temperature
– Distension is rare unless severe diffuse peritonitis has developed
– A mass may develop if localized perforation has occurred.
Perforation is rare before 24 h after the onset of symptoms, but
the rate may be as high as 80% after 48 h.
Physical findings of acute appendicitis
• Physical findings in acute appendicitis:
– Typically, tenderness to palpation will occur at McBurney’s point:
located on a line one-third of the way between anterior iliac spine and
the umbilicus (abdominal tenderness may be completely absent if a
retrocecal or pelvic appendix is present)
– Right-sided rectal tenderness (not specific)
– Rebound tenderness: pain in the right lower quadrant during left-sided
pressure (Rovsing’s sign)
– Psoas sign: place your hand just above the patient’s right knee and ask
the patient to raise the thigh against your hand. Increased abdominal
pain during the manoeuvre suggests irritation of the psoas muscle by an
inflamed appendix.
– Hyperaesthesia of the skin of the right lower quadrant
• Diagnostic difficulties are mostly in infants, in elderly, and pregnant
(appendicitis occurs about one in every 500-2000 pregnancies).
– The diagnosis may be missed or delayed because of gradual shift of
appendix from the right lower to the right upper quadrant during the
pregnancy
• Diagnosis: abdominal ultrasound, CT (positive predictive value
of CT is 95-97%)
Assessment of peritoneal irritation
• Press your fingers in firmly and slowly, and
then quickly withdraw them
• Ask the patient:
– Which hurt more, the pressing or the letting
go, and
– Where it hurt (if tenderness is felt elsewhere
than were trying to elicit rebound, that area
may be the real source of the problem)
Pain induced or increased by quick withdrawal means rebound tenderness.
It results from the rapid movement of inflamed peritoneum
Acute peritonitis
• Pathogenesis:
– Most often infectious and is usually related to a perforated viscus (secondary
peritonitis)
• Perforations of bowel (appendicitis, peptic ulcer disease, neoplasm's, volvulus,
ischemia, ingested foreign body, etc.)
• Perforations or leaking of other organs (pancreatitis, acute cholecystitis, urinary bladder
rupture, etc.)
• Disruption of integrity of peritoneal cavity (trauma, peritoneal dialysis, perinephric
abscess, etc.)
– When no intraabdominal source is identified, the infectious peritonitis is called
primary or spontaneous peritonitis
• Usually in patients with liver cirrhosis and ascites
• Clinical manifestations:
– Acute abdominal pain and tenderness, usually with fever. The location of the
pain depends on the underlying cause and whether the inflammation is localized
or generalized
• Localized peritonitis is most common in uncomplicated appendicitis and diverticulitis
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Distension of intestinal lumen with gas and fluid
Board like muscular rigidity in cases of diffuse peritonitis
Bowel sounds are usually absent
Disappearance of liver span
Tachycardia, hypotension, and signs of dehydration
Free air under the diaphragm
P-A X-ray: Discoid shape free air under the diaphragm on both sides.
Acute intestinal obstruction
• Aetiology:
– In 75% of patients, it results from previous abdominal surgery to
adhesive bands or internal or external hernias. Other causes
include lesions intrinsic to the wall of intestine, e.g. diverticulitis,
carcinoma, regional enteritis, and luminal obstruction, as
gallstone obstruction or intussusceptions
• Pathophysiology
– Distension of the intestine is caused by accumulation of gas and
fluid proximal to the obstructed segment.
– Massive loss of fluid from the circulation- hypovolaemia, shock
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Marked depression of flux from lumen to blood (in the first 12-24 h)
Sodium and fluid move into the lumen
Vomiting
Sequestration of fluid into the oedematous intestinal wall and
peritoneal cavity as a result of impairment of venous return from the
intestine
• Impaired blood supply of intestine – necrosis of the intestinal wall –
peritonitis
Intussusception (the prolapse of one part of
intestine into the lumen of an immediately
adjoining part)
intussusceptions
1. Colic: involving segments
of the large intestine
2. Enteric: involving only the
small intestine
intussusceptum
3. Ileocecal: the ileocecal
valve prolapses into the
cecum, drawing the ileum
along with it
4. Ileocolic: the ileum
prolapses through the
ileocecal valve into the
colon
Symptoms and physical findings in
acute intestinal obstruction
• Symptoms and physical findings
– Cramping midabdominal pain, which tends to be more severe
the higher the obstruction
– The pain occurs in paroxysms
– Audible borborygmi simultaneously with the paroxysms of the
pain
– Abdominal distension (most marked in colonic obstruction)
– Presence of a palpable abdominal mass (closed-loop
strangulating small bowel obstruction)
– Vomiting is almost invariable, and it is earlier and more profuse
the higher is the obstruction
• Initially contains bile and mucus, and remains as such if the
obstruction is high
• With low ileal obstruction, the vomitus is feculent (orange-brown in
colour with a foul odour
– Constipation and the failure to pass gas by rectum (indicating
complete obstruction)
Roentgenographic image in acute intestinal
obstruction
Fluid- and gas-filled loops of small
intestine arranged in a „stepladder”
pattern with air-fluid levels in small
intestine obstruction
Frame-like arranged distended gasfilled colonic bowels in colonic
obstruction.
Inguinal hernia
Lateral inguinal, indirect
Medial inguinal, direct
Femoral
1. Invaginate loose scrotal skin with your index
finger. 2. Follow the spermatic cord upward to
above the inguinal ligament, and find the opening
of the external inguinal ring. 3. If possible, gently
follow the inguinal canal laterally. 4. Ask the
patient to strain down or cough. 5. Note any
palpable herniating mass as it touches your finger.
If the findings suggest a hernia, try to reduce it by
sustained pressure with your finger. If the mass is
tender or the patient reports nausea and vomiting,
you have to finish this manoeuvre.
Incarcerated hernia: when its contents can not be
returned to the abdominal cavity.
Strangulated hernia: when the blood supply is
compromised (tenderness, nausea, vomiting)
Acute mesenterial ischemia
• Risk factors:
– include atherosclerosis, atrial fibrillation, recent myocardial infarction,
valvular heart disease, and recent cardiac or vascular catheterization
• Conditions:
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Arterial embolism (in >75% of cases originate from the heart)
Arterial thrombosis
Venous thrombosis
Non-occlusive mesenteric ischemia (vasospasm, dehydration)
• Clinical symptoms:
– Severe acute, non remitting abdominal pain, initially without muscular
rigidity (defense)
– Minimal abdominal distension
– Hypoactive bowel sounds
– Nausea, vomiting, transient diarrhoea, bloody stool
– Later findings will demonstrate peritonitis, adynamic ileus
• Management:
– The „gold standard for the diagnosis and management of acute arterial
occlusive disease is laparotomy. Surgical exploration should not be
delayed if suspicion of acute occlusive mesenteric ischemia is high.
Acute panreatitis
• Risk factors:
– Gallstone
– Alcoholism
– Hyperlipidemia
• Clinical manifestations:
– The abdominal pain is steady, and is located in the epigastrium and
periumbilical region and often radiates to the back. The pain is frequently
more intense when the patient is supine, and patients often obtain relief
by sitting with the trunk flexed and knees drawn up.
– Nausea, vomiting and abdominal distension are also frequent complaints
– Hypomotility, bowel sound are usually diminished or absent
– Epigastric tenderness and rebound tenderness are usually present but
the abdominal wall may be soft.
– A faint blue discoloration around the umbilicus (Cullen’s sign) may occur
as the result of hemoperitoneum, indicating the presence of a severe
necrotizing pancreatitis
– Distressed and anxious patient
– In 10-20% of cases, there are pulmonary findings (basilar rales,
atelectasis, and pleural effusion, most frequently left-sided
Summary
• Location of the abdominal pain. Rebound
tenderness
• Auscultation of bowel movement
• Free air in the abdomen – percussion of
liver span
• Hernial orifices should always carefully
examined for the presence of a mass
• Rectal digital examination