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ACUTE ABDOMEN

ACUTE ABDOMEN. DR. D.VINDHYA Dept of Emergency & Critical Care Medicine, Vinayaka Mission Medical College & Hospital, Salem. Visceral pain Distension, inflammation or ischemia in hollow viscous & solid organs

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ACUTE ABDOMEN

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  1. ACUTE ABDOMEN DR. D.VINDHYA Dept of Emergency & Critical Care Medicine, Vinayaka Mission Medical College & Hospital, Salem

  2. Visceral pain • Distension, inflammation or ischemia in hollow viscous & solid organs • Localisation depends on the embryologic origin of the organ: • Foregut to epigastrium • Midgut to umbilicus • Hindgut to the hypogastric region

  3. Parietal pain- is localised to the dermatome above the site of the stimulus. • Referred pain • produces symptoms, not signs e.g. tenderness

  4. Abdominal topography

  5. HISTORY • Site • Nature & character • Duration • Intensity • Precipitating & relieving factors • Associated symptoms

  6. Previous episodes of AP • Investigations • Chronic disease • Immunosuppression • Medications (NSAIDs) • surgeries

  7. Generalised abdominal pain • Perforation • AAA • Acute pancreatitis • DM • Bilateral pleurisy

  8. Central abdominal pain • Early appendicitis • SBO • Acute gastritis • Acute pancreatitis • Ruptured AAA • Mesenteric thrombosis

  9. Epigastric pain • DU / GU • Oesophagitis • Acute pancreatitis • AAA

  10. RUQ pain • Gallbladder disease • DU • Acute pancreatitis • Pneumonia • Sub phrenic abscess

  11. Differential diagnosis of RUQ pain

  12. LUQ pain • GU • Pneumonia • Acute pancreatitis • Spontaneous splenic rupture • Acute perinephritis • Sub phrenic abscess

  13. Differential diagnosis of LUQ & epigastric pain

  14. Supra pubic pain • Acute urinary retention • UTIs • Cystitis • PID • Ectopic pregnancy • Diverticulitis

  15. RIF pain • Acute appendicitis • Mesenteric adenitis • DU perf, Diverticulitis • PID, Salpingitis • Ureteric colic

  16. Meckel’s diverticulum • Ectopic pregnancy • Crohn’s disease • Biliary colic (low-lying gall bladder)

  17. Differential diagnosis of RLQ pain

  18. Gynecological causes of RLQ pain

  19. LIF pain • Diverticulitis • Constipation • IBS • PID • Rectal Ca • UC • Ectopic pregnancy

  20. Differential diagnosis of LLQ pain

  21. Systemic examination • Inspection- - Flat, reduced movements in peptic ulcer perforation - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

  22. GREY TURNER’S SIGN RETROPERITONEAL HEMORRAGE Discoloration of the flank

  23. CULLEN’S SIGN RETROPERITONEAL HEMORRAGE Bluish periumbilicaldiscoloration

  24. Palpation Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis. Do not miss tetanus!

  25. MC BURNEY’S SIGN ACUTE APPENDICITIS Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side

  26. ILIO PSOAS SIGN ACUTE APPENDICITIS Hyperextension of right hip causing abdominal pain ( retrocecal)

  27. OBTURATOR SIGN ACUTE APPENDICITIS Internal rotation of flexed right hip causingabdominal pain (pelvic)

  28. MURPHY’S SIGN Acute cholecystitis Abrupt interruption of inspiration on palpationof right upper quadrant

  29. ROVSING’S SIGN Acute appendicitis Right lower quadrant pain with palpation of the left lower quadrant Pain in the RLQ Palpation of LLQ

  30. KEHR’S SIGN Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture

  31. CHANDELIER’S SIGN PELVIC INFLAMMATORY DISEASE Manipulation of cervix causes patient to liftbuttocks off table

  32. Auscultation • BS • > 2min to confirm absent • High pitched, hyperactive or tinkling • Bruit in epigastrium

  33. PR Examination: - tenderness - induration - mass - frank blood

  34. Investigations • CBC • Amylase & lipase • Erect & supine abdominal XRay • stool & Urine analysis, • pregnancy test, USG, CT scan • If severe, unrelenting pain urgent surgical referral

  35. Initial management • Stabilise ABC • Resuscitate the patient • Shift for investigation only after stabilising the pt

  36. Remember to reassess patient on a regular basis.

  37. Airway management • Pt’s SPO2 – is low or when RR IS > 35/min • When the depth of breathing is shallow & inadequate • When the pt’s GCS is not adequate to maintain a patent airway • When the pattern of breathing is inappropriate

  38. circulation • Care to adequately hydrate the pt. • If pt’s cardiac status is compromised then CVP guided fluids should be administered. • A careful monitoring of I/O should be maintained

  39. Analgesia • Adequate analgesia should be provided in the ER

  40. Shift the pt only when the pt is stabilised

  41. Supine ray • Dilated bowel loop pattern, obstruction, closed loop, bowel wall edema

  42. Chest xray • Gas under diaphragm

  43. IVP To detect renal calculi, ureteric obstruction

  44. USG ascitis cholecystitis

  45. Acute pancreatitis CT detects acute pancreatitis, small bowel obstruction, diverticulitis, abscess, bowel infarction

  46. CT images Ureteric calculi Detecting ureteric calculi , appendicitis

  47. CASE DISCUSSIONS

  48. Case 1 • A male pt aged 17yrs developed mild periumblical discomfort not influenced by activity. Several hrs later pain intensifies but is now localised to RLQ.Movement becomes painful

  49. INVESTIGATION OF CHOICE ? • Abdomino pelvic CT

  50. Treatment • Initial stabilisation • Early appendicectomy within 4-12 hrs of initial presentation

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