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Acute Abdomen

Dr. Fahmi Jubran. 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. Dr. FahmiJubran Acute Abdomen

  2. 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 Acute Abdomen

  3. 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 DEFINITION

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

  5. Somatic pain • Visceral pain Pathophysiology of Abdominal Pain

  6. Somatic pain -Parietal peritoneum -Somatic n. (T5-L2), except diaphragm (C3-C5 & lower 6 intercostal and subcostalnn.) -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 splanchnicnn., 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. Inflammation Obstruction Pathogenesis

  9. 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 ASSESMENT

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

  11. 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 History

  12. 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. PAIN

  13. 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 Onset of Pain

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

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

  16. 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 Associated Symptoms

  17. 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 DRUG HISTORY

  18. 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 NAUSEA & VOMITING

  19. 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 NAUSEA & VOMITING

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

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

  22. Ureteric colic Cystitis Urinary Symptomswith Pain

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

  24. 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 OTHER HISTORY

  25. 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 Physical Examination

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

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

  28. 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 Physical Examination(contd.)

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

  30. 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) Systemic Examination

  31. 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 Systemic Examination

  32. 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. Systemic Examination

  33. 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 Systemic Examination

  34. 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 Systemic Examination

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

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

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

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

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

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

  41. 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 Radiology

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

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