ACUTE ABDOMEN

Mugarura Robert

Definition

Severe rapid onset of abdominal pain in a previously well patient 6 hrs An abdomen with immense pain and/or peritonitis. An abdominal condition that needs immediate attention but does not necessarily require an operation

Classify as Peritonic Obstructive Hemorrhagic Medical Chest-

Gastrointestinal causes

Bowel perforations Appendicitis Gastritis, penetrating/perforated peptic ulcer Bowel obstruction Stragulated hernias Pancreatitis Biliary colic Diverticulitis mesenteric embolus/thrombus IBD

Acute cholecystitis Raptured spleen, Cholangitis

Urology causes

Testicular torsion Pyelonephritis Cystitis Renal colic- ureteral stones Renal infarct Vascular causes.

Raptured abdominal aorta aneurysm Mesenteric thrombosis

Gyn - causes

Raptured ectopic pregnancy Raptured / twisted ovarian cyst Pyosalphinx, Acute PID Endometritis Mitschelmerz pain Endometriosis

Extra peritoneal

Myocardial infarction Pleurisy Lower lobe pneumonia Abdominal wall Psoas inflamation/ abscess

others

Diabetes mellitus (DM) Lead poisoning Porphyria Herpes Zoster Tertiary syphilis

Abdominal pain

Visceral pain

Impulses carried by ANS- sympathetic nerves caused by irritation of peritoneum, ischemia, stretch Dull and Poorly localized

Foregut Epigastrium Mid gutUmblical region Hind gut- Hypogastrium

Somatic pain

Impulses carried by somatic nerves T5-L2 Due to irritation of the parietal peritoneum Sharp and well localized Associated with Muscle spasms

Assessment

ObjectiveTo elicit symptoms and signs necessary to make a diagnosis Need for immediate treatment before diagnosis Senior surgeon- 4/5 correct diagnosis

50% for junior doctors

Abdominal Pain

Site Radiation, migration Onset Frequency/ character Aggravation/ alleviation Nausea and vomiting Bowel function- diarrhea / vomiting

Gyn

LNMP Vaginal discharge Assess risk of pregnancy Altered micturition

Urinary system

Past surgery Adhesions, prev. diagnosis, Drugs- steroids, anticoagulants, diuretics,

Specific signs

Blumberg's sign (rebound tenderness): constant, held pressure with sudden release causes severe tenderness GuardingCourvoisier's sign: palpable, non-tender gall bladder with jaundice Cullen's sign: blue discoloration around umbilicus Grey Turner's sign: flank discoloration Iliopsoas sign: flexion of hip against resistance or passive hyperextension of hip causes pain Murphy's sign: inspiratory arrest on deep palpation of RUQ McBurney's point tenderness: 1/3 from anterior superior iliac spine (ASIS) to umbilicus;

Obturator sign: flexion then external or internal rotation about the right hip Percussion tenderness: often good substitute for rebound tenderness Rovsing's sign: palpation pressure to left abdomen causes McBurney's point tenderness Shake tenderness: peritoneal irritation Boass sign: right subscapular pain due to cholelithiasis Foxs sign: ecchymosis of inguinal ligament seen with retroperitoneal bleeding Kehrs sign: severe left shoulder pain with splenic rupture Dances sign: empty right lower quadrant in children with ileocecal intussusception

Investigation

Specific- help in making the diagnosis

Baseline- important in the management of patients

Laboratory

CBC and differential Group + x match Electrolytes, BUN, Creatinine Amylase, Lipase levels Liver function tests Urinalysis - C&S, Stool for occult blood -hCG Serum lactate

DPL Radiology

X Ray- abdominal, CXR Contrast / contrast

Abdominal USS Endoscopy Arteriograhy Laparascopy- direct visualization CT, MRI

Decision to operate

Signs of peritonitis Severe or increasing localized abdominal tenderness Abdominal pain with unexplained sepsis Suspected acute intestinal ischemia Radiological confirmation of diagnosis

free air massive bowel distention (colon > 12 cm) space occupying lesion with fever

Persistent unequivocal abdominal findings/ if you are in doubt

Decision to op

Endoscopic

perforation uncontrollable bleeding

blood, pus, bile, feces, urine

Paracentesis/ DPL