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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 • • • • • 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 – – – – – 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 • • • • 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: – – – – 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