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Acute Abdomen

Acute Abdomen. 宋天洲醫師 一般外科. Acute Abdomen. Challenge to Surgeons & Physicians Most common cause of surgical emergency admission Encompass various conditions ranging from the trivial to the life-threatening Clinical course can vary from minutes to hours, to weeks

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Acute Abdomen

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  1. Acute Abdomen 宋天洲醫師 一般外科

  2. Acute Abdomen • Challenge to Surgeons & Physicians • Most common cause of surgical emergency admission • Encompass various conditions ranging from the trivial to the life-threatening • Clinical course can vary from minutes to hours, to weeks • It can be an acute exacerbation of a chronic problem e.g. Chronic Pancreatitis, Vascular Insufficiency

  3. DEFINITION • Acute Abdomen – “any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered.” Stedman’s Medical Dictionary, 27th Edition

  4. The primary symptom of the "acute abdomen" is–Abdominal pain.

  5. Pathophysiology of Abdominal Pain • Somatic pain • Visceral pain

  6. Somatic pain -Parietal peritoneum -Somatic n. (T5-L2), except diaphragm (C3-C5 & lower 6 intercostal and subcostal nn.) -Sensitive to mechanical, thermal or chemical stimulation -Muscle rigidity/guarding and hyperaesthesia -Sharp or knife-cut like in nature; well localized

  7. Visceral pain -Visceral peritoneum -Mediated through sympathetic branches of autonomic nerve system joining presacral and splanchnic nn., which eventually join thoracic(T6-T12) and lumbar (L1-L2) nn. -Insensitive to mechanical, thermal or chemical stimulation -Sensitive to tension-overdistension or traction on mesenteries, visceral m. spasm & ischemia -Dull and deep-seated; vaguely to localize

  8. Pathogenesis • Inflammation • Obstruction

  9. ASSESMENT • A Full history • Thorough physical examination Diagnosis can be made most of the time by a good history and a proper physical examination. - An exact diagnosis often impossible to make after the initial assessment, and often relying on further investigation

  10. Investigations are usually carried out : • only to support the diagnosis. • or to narrow down the differential diagnoses.

  11. History • History of Present illness • Family History • Past Medical history • Operation history • History of drugs taken or Medication eg. ingestion of certain toxic drugs or Alcohol intake

  12. PAIN • The Most Important Symptom Characteristics of abdominal pain • Site • Onset – time and mode • Severity • Nature – colicky, spasm, gripping, dull, vague, sharp, knife-cut, throbbing, etc. • Progression or change of pain – persistent, gradually improve or worsen, fluctuate, etc. • Duration • Radiation • Movement of pain • Aggravating or relieving factors • Associated symptoms – bowel or urinary, etc.

  13. Onset of Pain • Sudden onset pain which wakes the patient from sleep eg. perforation or strangulation of bowel • Slow insidious Onset a. Inflammation of visceral peritoneum. b. Contained process such as evolving abscess. • Crampy or colicky pain Biliary colic, Ureteric colic or Intestinal colic

  14. Progression of Pain Progression from: Dull, aching, poorly localized character To: Sharp, constant & better localized pain indicates involvement of Parietal peritoneum

  15. Associated Symptoms CONSTIPATION a. Progressive intestinal obstruction from a neoplasm or inflammatory bowel disease b. Paralytic Ileus c. Post Operative d. Obstructed groin hernia

  16. Associated Symptoms DIARRHEA Diarrhea with pain is mainly medical. The following are the exceptions: a. Obstructed Richter's Hernia b. Gall Stone ileus c. Superior mesenteric vascular occlusion d. Intestinal Obstruction associated with pelvic abscess e. Spurious diarrhea in chronic faecal impaction

  17. DRUG HISTORY • Corticosteroids – mask pain • Anticoagulants – can lead to an intramural haematoma of the gut causing obstruction • Oral Contraceptives - rupture of hepatic adenomas • NSAIDs - erosive gastritis & peptic ulcers

  18. NAUSEA & VOMITING • Frequency of vomiting (ii) Character of vomiting: projectile, non-projectile or self-induced (iii) Nature of vomiting: a. Bilious vomiting of small bowel obstruction b. Non-bilious vomiting in obstruction proximal to ampulla of Vater c. Faeculent vomiting in distal small gut obstruction, large bowel obstruction , strangulation

  19. NAUSEA & VOMITING • Pain first, followed by Vomiting is usually surgical. The vomiting is due to ‘reflex pylorospasm’ • Nausea & vomiting first , followed by pain is usually due to a medical condition

  20. Vomiting (cont.) • Vomiting is very prominent in a. Mallory-Weiss syndrome. b. Boerhaave syndrome(trans- mural esophageal tear) c. Acute gastritis d. Acute pancreatitis

  21. ANOREXIA • Anorexia or decreased appetite with pain is usually seen in Acute appendicitis

  22. Urinary Symptomswith Pain • Ureteric colic • Cystitis

  23. FEVER & CHILLS/RIGORS • Amoebic Liver Abscess • Pygenic Liver Abscess • Perinephric Abscess • Intra-abdominal abscess

  24. OTHER HISTORY • Past Surgical history: previous operations- leading to adhesions • Past Medical history: Sickle cell disease, Diabetes or Cancer or Renal failure • Menstrual History in females (i) Missed period- ectopic pregnancy (ii) Mid of period-ovulation pain (Mittel- schmerz) (iii) With heavy periods- endometriosis • Family history of colon cancer, any other malignancy or inflammatory bowel disease

  25. Physical Examination General Appearance a. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitis b. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colic c. Writhing in Pain: Mesenteric Ischemia

  26. Physical Examination(contd.) d. Bending Forward: Chronic Pancreatitis e. Jaundiced: CBD obstruction f. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

  27. Physical Examination(contd.) • Vital Charting • Temperature, Pulse, BP, Respiratory rate • Ruptured AAA or ectopic pregnancy can lead to -Pallor -Hypotension -Tachycardia -Tachypnea

  28. Physical Examination(contd.) Low grade temp. is seen with - Appendicitis - Acute cholecystitis High grade temp. is seen with - Salpingitis - Abscess Very High Grade Temp.with increasing lethargy seen in imminent septic shock - Peritonitis - Acute cholangitis - Pyonephrosis

  29. Systemic Examination Cardiopulmonary examination Check for: - Possible MI - Basal Pneumonia - Pleural Effusion

  30. Systemic Examination Per Abdomen: Inspection - Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

  31. Systemic Examination • Erythema or discolouration a. Peri-umbilical - Cullen sign b. Inguinal – Fox sign c. Flanks - Grey Turner sign Seen in Hemorrhagic pancreatitis or any other cause of haemoperitoneum • Any Visible masses • Any visible cough impulse at hernia site

  32. Systemic Examination Per abdomen: Palpation • Be gentle • Start away from site of pathology then towards • Check for Hernia sites • Tenderness • Rebound tenderness • Guarding- involuntary spasm of muscles during palpation • Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis.

  33. Systemic Examination • Local Right Iliac Fossa tenderness: a. Acute appendicitis b. Acute Salpingitis in females c. Amoebiasis of Caecum • Low grade, poorly localized tenderness: Intestinal Obstruction • Tenderness out of proportion to examination: a. Mesenteric Ischemia b. Acute Pancreatitis • Flank Tenderness: a. Perinephric Abscess b. Retrocaecal Appendicitis

  34. Systemic Examination • Rovsing’s Sign in Acute Appendicitis • Obturator Sign in Pelvic Appendicitis • Psoas Sign - Retrocaecal appendicitis - Crohn’s Disease - Perinephric Abscess • Dunphy’s sign in acute appendicitis

  35. Systemic Examination • Murphy’s sign in Acute Cholecystitis • Boas’ sign – pain radiates to tip of right scapula with hyperaesthesia in Acute Cholecystitis • Thumping tenderness over lower ribs in inflammation of -Diaphragm - liver or spleen

  36. Systemic Examination Pulsatile Abdominal Mass with Hypotension Leaking AAA Cutaneous Hyperaesthesia indicates involvement of Parietal Peritoneum

  37. Systemic Examination Per Rectal Examination: - tenderness - induration - mass (Blummer’s shelf) - frank blood

  38. Systemic Examination Per Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

  39. INVESTIGATIONS • Complete Blood Count with differential • C-reactive protein estimation • Electrolyte ,Blood Urea , Creatinine • Urine dipstick • Amylase or Lipase • Liver Function Test • HCG

  40. Radiology Upright X ray chest for - Basal Pneumonia - Ruptured Oesophagus - Elevated Hemi diaphragm - Free Gas under diaphragm

  41. Radiology Abdominal X ray film • Air-Fluid Levels • Stones • Ascites • Eggshell calcification in AAA • Air in Biliary tree. • Obliteration of Psoas Shadow in retro- peritoneal disease • Right lower quadrant sentinel loops in acute appendicitis

  42. INVESTIGATIONS Other Investigations - Ultrasonography • CT abdomen • Angiography for Ischaemia, Haemorrhage

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