Acute Abdomen

1. Acute Abdomen DR. David Swar Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital, Shandong University

2. Definition • A group of life threatening intra-abdominal conditions that often lead to peritonitis and require urgent surgical intervention

3. Acute Abdomen

5. Etiology • Surgical

6. Etiology, cont…

7. Common causes of abdominal pain

9. Clinical evaluation History • Age Certain conditions occur in certain age groups E.g. diverticulitis in elderly Mesenteric adenitis (inflammation of mesenteric lymph nodes) in children • Pain • Onset sudden perforation gradual inflammatory causes

10. site Peptic Ulcerative disease (PUD) Pancreatitis cholecystitis Gastric ulcer Perforated colon • Site Cholecystitis cholangitis Peptic Ulcerative Disease (PUD) Diverticulitis Salpingitis Tubo-ovarian abscess Appendicitis Salpingitis Ruptured. Ectopic pregnancy WWW.SMSO.CC

11. History, cont… • Nature colicky obstruction (cramping pain) dull inflammation e.g. pancreatitis (constant pain) • Radiation to tip of the right shoulder in acute cholecystitis (boa’s sign)

12. History, cont… • Aggravating factors breathing coughing peritonitis changing position fatty meal cholecystitis • Relieving factors lying still peritonitis leaning forward pancreatitis (prayer’s sign passing flatus Intestinal Obstruction

13. History, cont… • Associated factors • vomiting • Precedes the pain medical condition • Follows the pain surgical condition • Contents • Bilious Small Bowel Obstruction • Nonbilious pyloric stenosis • Blood -bleeding

14. History, cont… 2. Change in bowel habits • constipation • Obstipation (constipation +no flatus) • Diarrhea 3. Anorexia (poor appetite) • e.g. appendicitis 4. fever • Inflammatory causes

15. Examination • Note: physical signs may be less obvious in elderly, obese patients, and those on steroids • General examination • Motionless peritonitis • Writhing in agony colic (to twist in pain) • Jaundice- obstructive jaundice • dehydration

16. Examination, cont… • Vital signs • Pulse • Respiratory rate • Blood Pressure

17. Abdominal examination • Inspection

18. Abdominal examination, cont… • Palpation-(to feel)

19. Abdominal examination, cont… • Percussion-(tapping on a surface)

20. Abdominal examination, cont… • Auscultation-listening to the internal sounds(stethoscope)

21. Specific signs

22. Murphy’s sign, Psoas sign –if positive where is the appendix? Retrocecal

23. Obturator sign,Cullen’s sign

24. Abdominal examination, cont… • Rectal examination • Per vaginal examination

25. Digital rectal examination,Per Vaginal Examination

26. Investigations • To assess patients condition in general • Complete Blood Count (Blood Routine) • Electrolytes-Na ,K ,Cl • Blood Urea Nitrogen (BUN) & Creatinine • Arterial Blood Gas (ABG) • Urinalysis • Liver Function Test (LFT) • Prothrombin Time (PT)11 to 13.5 sec,PTT –25 to 35 sec(Partial thromboplastin time)(blood test that tells how long it takes for plasma to clot?) • Blood grouping and cross matching

27. Investigations, cont… 2. Serum Beta HCG (human chorionic gonadotrophin hormone) • In female of child bearing age • To rule out ectopic pregnancy

28. Investigations, cont… • Specific investigations A. Lab 1. Amylase & lipase • Lipase elevation is specific for pancreatitis • Amylase elevation confirms the diagnosis of Pancreatitis, but also seen in: • Perforated viscus (Internal organs) • Intestinal.Obstruction • Acute cholecystitis

29. Investigations, cont… B. Radiological • Chest x-ray • Air under the diaphragm in perforated viscus (duodenal perforation) • Elevated diaphragm in abdominal distention

30. Investigations, cont… • Abdominal x-ray • air fluid levels in intestinal obstruction • Stones (90% of kidney stones can be seen in x-ray and 10% can’t be seen but 10% of gallstones can be seen in x-ray but 90% can’t be seen) why ? Calcium .

31. Investigations, cont…

32. Kidney stone, Gall stones

33. Investigations, cont… 3.USG-Ultra sound Scan • Gallstones • Appendicitis • Ectopic pregnancy • Torsion of ovarian cyst • empyema 4.CT scan • pancreatic pathology • Acute aortic aneurysm • Severe diverticulitis • Abdominal abscess

34. Gall stones

35. Abdominal CT scan

36. Investigations, cont… 5.Duplex scan or angiography for superior mesenteric embolus or thrombosis 6. ERCP (Endoscopic retrograde cholangio-pancreatography)

37. Investigations, cont… C. Paracentesis • To assess Small Bowel Perforation in ascitis • Free blood, bile, bowel contents suggest Bowel perforation D. Endoscopy & laparoscopy E. Diagnostic peritoneal lavage

38. Peritoneal lavage, Paracentesis

39. Management • Initial management • Nil Per Oral • Intravenous fluids, Bolus Ringer Lactate solution • Monitor urine output • Nasogastric tube • Decompression • suction • Analgesia • Pethidine

40. Management, cont… • Antibiotics • Broadspectrum • In case of sepsis or peritonitits C

41. Management, cont… • Surgical management • Indications • Physical findings • Localized peritoneal irritation with guarding or rigidity • Spreading tenderness • Tense or progressive distension • Tender abdominal or rectal mass with high fever or hypotension

42. Indications for surgery, cont… • Rectal bleeding with shock or acidosis • Equivocal (uncertain)abdominal findings with • Septicemia: high fever, leukocytosis, mental status changes • Bleeding: shock, acidosis, falling hematocrit • Suspected ischemia: acidosis, fever, tachycardia

43. Indications for surgery, cont… 2. Radiological findings • Pneumoperitonium –bowel perforation • Gross or progressive bowel distension-bowel obstruction • Free extravasation of contrast media-bowel perforation • Space occupying lesion –Mass or tumor • Mesenteric occlusion-Ischemia

44. Indications for surgery, cont… 3. Endoscopic findings • Perforated lesion • Uncontrolled bleeding lesion 4. Paracentesis • Blood • bile • bowel contents • urine

45. Thank you