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The Acute Surgical Abdomen

The Acute Surgical Abdomen. Ada Ekpe Amel Ibrahim. Contents. Anatomy Adominal pain Management of the acute abdomen: from history to exam Scars and surgeries Stomas Questions. Anatomy of the abdomen. 9 regions and 2 flanks Surface: Skin Linea alba and umbilicus Xiphisternum

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The Acute Surgical Abdomen

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  1. The Acute Surgical Abdomen Ada Ekpe Amel Ibrahim

  2. Contents • Anatomy • Adominal pain • Management of the acute abdomen: from history to exam • Scars and surgeries • Stomas • Questions

  3. Anatomy of the abdomen • 9 regions and 2 flanks • Surface: • Skin • Linea alba and umbilicus • Xiphisternum • Symphysis pubis • Pubic tubercle • Costal margins • Iliac crests

  4. 2 Hypochondria • Epigastrium • 2 Loins • Paraumbilical • Suprapubic • 2 Iliac fossae • 2 Flanks

  5. Surface Anatomy • Transpyloricplane of Addison: • Halfway between jugular notch and Symphysis pubis. • Contains: body and tail of pancreas, L1 body, 2nd part of duodenum, Hilum of L kidney, upper pole R kidney, pylorus, tips of 9th costal cartilages, fundus of GB, splenic and hepatic flexures, spleen and origins of SMA and portal vein.

  6. McBurneys point: • 1/3 of way between ASIS and umbilicus. • Appendix • Mid inguinal point: • halfway between ASIS and pubic tubercle. Site of deep ring. • Mid point of inguinal ligament: • Half way between ASIS and pubic symphysis. Site of femoral pulse.

  7. Referred pain • No plan for viscera • Pain referred to associated dermatome • Appendicitis: initially T10 then as peritoneum inflamed (richly innervated) pain localised to RIF

  8. Pain • Epigastric: • cardiac • Lung • Thoracic dissection/ruptured aneurysm • pancreatitis • Liver • Gall bladder • Gastric/duodenal ulcer • Transverse/small bowel • RUQ: • Gall bladder • Liver • Lung • Bowel • LUQ: • Spleen • Bowel • Lung • Cardiac

  9. RIF: • Skin: cellulitis/sebaceous cyst • Subcut tissue: necfasc • Lymph nodes: mesenteric adenitis/lymphoma/infection • Bowel: large bowel (tumour, colitis) • Appendictis/appendix mass • Constipation • Strangulated hernia • Ruptured iliac aneurysm • OVARIAN • Orchitis/undescended testis

  10. LIF: • Diverticultis • Tumour • Hernia • Testicular • Ovarian • Colitis • Lymphoma etc…

  11. Q&A • Paraumbilical? • Flank? • Suprapubic?

  12. History • Site • Onset • Character • Radiation • Associated symptoms • Time • Exacerbating/alleviating factors • Severity

  13. Change in bowels • Appetite? Is pain associated with food? • Nausea/vomiting • Urinary symptoms/systems review • Previous surgeries • Medications • Family history • Social history

  14. Examination • ABC • Observations • OBSERVE: • Jaundice • nutrition • body habitus • Discomfort • Stigmata of ETOH use • Position (mobilising/peritonitic)

  15. Volunteer? • Abdo exam: • Hands (dupuytren’s/clubbing/asterixes/pulse/nails) • Face (icteric/hydration) • Neck (Virchow’s node) • Chest (spider naevi/gynaecomastia) • Abdomen: scars, lumps, erythema, tenderness, guarding, peritonism, organomegalyand bowel sounds) • PR: skin tags/fungating tumours/haemorrhoids, tender, mass, blood and rectum empty/full (hard or soft stool). • HERNIAL ORIFICES AND TESTES

  16. Management • Analgesia • IV access • Fluids/antibiotics (if necessary) • AXR and/or USS Vs CT scan • Optimise for theatre or manage conservatively • Common emergencies: • appendicitis, diverticulitis, ischemic colitis, strangulated hernia and SBO. • Common emergency operations: • appendicectomy, herniorraphy +/- resection, Hartmann’s and (sub)total colectomy.

  17. Stomas • Ileostomy: • often RIF • spouted, liquid contents • Colostomy: • end/defunctioning • Flush • Solid contents • Urostomy: • For cystectomy • Ileal conduit • Urine in bag

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