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ABDOMEN
ALL YOU NEED
TO KNOW
INTRODUCTION TO
ACUTE ABDOMEN
ANATOMY OF ABDOMEN
ACUTE ABDOMEN
Definition:
Acute abdomen may be defined as any
sudden, spontaneous, non-traumatic
condition whose chief manifestation is pain in
the abdominal area which needs immediate
medical attention with or without surgical
intervention.
EPIDEMIOLOGY
The most Common causes of acute abdomen are:
Non-specific abdominal pain(NSAP)(33.0%)
Acute appendicitis(23.3%)
Acute billiary disease(8.8%)
RISK FACTORS
Extreme of ages
Low fiber high protein diet (Appendicitis)
Alcoholism (Acute pancreatitis)
Injudicial use of NSAID (pepctic Ulcer
Perforation)
ileus
Mesentaric vascular occlusion
Pancreatic Disorders:
Acute pancreatitis
Genito-urinary Disorders:
Acute Pyelonephritis
Acute Ureteric or Renal Colic (Stone)
Testicular Torsion
Gynaecological Disorders:
Ruptured Ectopic Pregnancy
Twisted Ovarian Tumor
Vascular disorders:
Ruptured aortic aneurysms
Acute ischemic colitis
Mesenteric vascular occlusion
Peritoneal and retroperitoneal disorders:
Mesentaric Lymphadenitis
Intra abdominal abscess
Retroperitoneal hemorrhage
Spinal Disorders:
Potts disease
Gastric crisis in Tabes Dorsalis
Endocrine Disorders:
Diabetic ketoacidosis
General Diseases:
Sickle cell Crisis
Acute porphyria
Uraemia
Acute appendicitis
Intussusception
Mesentaric
Lymphadenitis
Meckels
diverticulitis
Ruptured ectopic
pregnancy
Twisted ovarian
tumor
Acute salpingitis
Acute cholecystitis
Torsion or
degeneration of
uterine fibroid.
HISTORY IN A CASE OF
ACUTE ABDOMEN
AGE
Infant: Intussusception, Meckels
Diverticulitis
Children: Acute appendicitis, mesentaric
lymphadenitis, round worm intestinal
obstruction.
Adult: Perforation of peptic ulcer, Acute
cholecystitis, Acute pancreatitis
Elderly: Sigmoid volvulus, Intestinal
obstruction from malignant growth
SEX
Male:
Peptic
ulcer perforation
Acute Pancreatitis
Volvulus
Intussusception
Female:
Acute
Cholecystitis
Acute appendicitis
CHIEF COMPLAINTS
Abdominal pain (Most Important)
Vomiting
Bowel habit
Jaundice
Haematemesis
Haematuria
Haematochezia
ABDOMINAL PAIN
ONSET OF PAIN
Sudden, like a light switching on onset of
pain in, rupture ectopic pregnancy, torsion of
ovary or testis, ruptured aneurysms.
Less sudden onset; on most other cases.
CHARACTER OF PAIN
MOVEMENTS OF PAIN
nervous
system
sensory level
Pain felt at
Phrenic nerve
C 3-5
Stomach, gall
bladder, small bowl
T 6-9
Epigastric region
Appendix, Colon
Mesentaric plexus
& lesser splanchic
nerve
T 10-11
Umbilical region
sigmoid colon,
rectum, kidney,
testes
Pelvic splanchic
nerve
T 11-12
Hypogastric region
S 2-4
Hypogastric region
SEVERITY OF PAIN
peptic ulcer
Peritonitis
Acute
Pancreatitis
Pyelolithiasis (Kidney stone)
Twisted ovarian tumor
Testicular torsion
RECURRENCE OF PAIN
It suggests recurrent problems such as ulcer
disease, gallstone colic, diverticulits
Vomitus:
Recently
BOWEL HABIT
Absolute constipation:
Relative constipation:
Diarrhoea:
Bloody stool:
OTHER SYMPTOMS
Jaundice
Haematemesis
Haematuria
Haematochezia
PAST HISTORY
intake
Personal History:
Smooking
Alcohol
Irregular
food habit
Drinking contaminated water (dysentery)
Menstrual History:
Ruptured
ectopic pregnancy
CLINICAL FINDINGS ON
ACUTE ABDOMEN
Appearance:
Abdominal facies: Abdominal cause of
acute abdomen
Facies hippocratica: Terminal stage of
peritonitis
Facies of dehydration: Intestinal
obstruction
Dequibitus:
Lying
quiet: Peritonitis
Tossing on bed: Colicky pain
Mohamedan prayer position: Acute
pancreatitis
Pulse:
Normal:
Respiratory rate:
Increased:
peritonitis
Normal: other cases
INSPECTION (CONTD..) :
Visible peristalsis:
Left
Discolouration
Hernial orifice
PALPATION :
Superficial palpation:
Temperature:
organ
Tenderness:
McBurney's point: Acute appendicitis
Boass sign: Acute cholecystitis
Sherrens triangle: Gangreneous
appendicitis
Muscle guard: Over inflamed organ
Muscle rigidity: Generalised peritonitis
PALPATION (CONTD...) :
Deep palpation:
Organ palpation : Liver,Spleen,Kidney,Bladder,
Genitalia
Special Attention:
Rebound tenderness
Rovsings sign
Cope psoas test
Obturator test
Murphys sign
Lump: Intussusception (sausage shaped lump in
left lumber region associated with empty right ilic
fossa)- sign of Dance
Palpation of hernial orifice
PERCUSSION :
Shifting dullness:
Perforation
AUSCULTATION :
Silent
abdomen:
Diffuse
peritonitis
intestinal obstruction
wall tenderness:
Pelvic
appendicitis
peptic ulcer
tenderness:
Respiratory system:
To
Cardiovascular system:
To
Neurological
To
examination:
Examination of spine:
Compression
disease
ACUTE APPENDICITIS :
RETROCAECAL
APPENDIX
Pelvic
appendix
ACUTE PANCREATITIS
Severe,
Cullens sign
Gray Turners
sign
ACUTE CHOLECYSTITIS :
Acute right upper quadrant pain and
tenderness may radiate to the back and tip
of the right shoulder.
Temperature usually ranges from 38C to
38.5C.
Murphys sign will be positive.
Fever and leukocytosis (12,00015,000/L)
Palpable gallbladder in one third of the
cases
INTESTINAL OBSTRUCTION :
Colicky pain in the abdomen,
Vomiting,
Distention,
Constipation,
Visible peristalsis,
Hernia or rectal mass,
MALIGNANCY :
Unexplained weakness and anemia
Occult or fresh blood in feces
Palpable abdominal mass
Feature of obstruction may be present
Change in bowel habit, e.g: tenesmus
Sensation of incomplete evacuation
INVESTIGATION OF
ACUTE ABDOMEN
PURPOSE
Urine RME :
Haematuria
Pus cell
Imaging:
Ultrasonogram
X-ray (plain X-ray of abdomen on erect posture)
Contrast X-ray
Barium Swallow
Barium meal
Barium follow through
Small bowel enema
Intra Venous Urogram
ACUTE APPENDICITIS
Routine:
> Full blood count: Neutrophilic leucocytosis
Raised ESR
Urine analysis:
of pus cell, few RBC UTI
Plenty of RBC, few pus cell Stone
Plenty
Selective:
> Pregnancy test- Suspected ectopic pregnancy
> Blood urea and electrolyte
> Supine abdominal radiograph/Plain X-ray KUB regionHigh resolution focused USG of the abdomen or pelvisTo
ACUTE CHOLECYSTITIS
Blood Analysis- Neutrophilia, C-reactive protein.
ACUTE PANCREATITIS
Routine blood investigationModerate leucocytosis around 12000 cumm
Haematocrit- High due to dehydration or low as a
result of haemorrhage in haemorrhagic pancreatitis
Coagulation profile
Blood Urea, Serum Creatinine
Blood Glucose - hyperglycemia
Serum Electrolyte- Hypocalcaemia
Serum Amylase -
titre
USG abdomen:
valuable in detecting free peritoneal fluid,
gallstones, dilatation of CBD and occasionally
abdominal aortic aneurysm
Contrast enhanced CT scan:
Indication:
If there is diagnostic uncertainty
In patient with severe acute pancreatitis, to
distinguish interstitial from necrotizing pancreatitis.
In the 1st 72 hours, CT may underestimate the
extent of necrosis
In patient with organ failure, signs of necrosis or
progressive clinical deterioration
Localised complications eg-fluid collection,
pseudocyst or pseudoaneurysm.
INTESTINAL OBSTRUCTION
Plain X-ray abdomen :
RENAL CALCULI
Blood-ESR,serum calcium, phosphate,
creatitine, blood urea, uric acid, PTH level
Urine- Calcium,urate, cysteine if suspected
only, pH, specific gravity
Plain X-ray KUB region- To see kidney
shadow, stones (90% of kidney stones are
radio opaque)
IVU-To see renal function
USG Abdomen- To detect even radiolucent
stones and give information about the
changes in renal parenchyma
USG OF KIDNEY
PNEUMOPERITONEUM
Investigations :
Pregnancy test
USG
CT scan.
Examination under anaesthesia
Laparoscopy
Cytology
MANAGEMENT OF ACUTE
ABDOMEN
IS SURGICAL INTERVENTION
NEEDED IN ALL CASES OF ACUTE
ABDOMEN???
THE ANSWER IS NO
Here are some Medical Causes of an Acute
Abdomen for Which Surgery Is Not Indicated
Endocrine and metabolic
disorders
Uremia
Tabes dorsalis
Diabetic Ketoacidosis
Herpes zoster
Addisonian crisis
Henoch-Schnlein purpura
Referred pain
Haematological Disorders
Sickle cell crisis
Acute leukemia
Myocardial infarction,
Angina
Lobar pneuminia
Diaphragmatic pleurisy
Physical finding:
Bleeding
Radiologic finding:
Pneumoperitoneum
Gross or progressive bowel distention
Free extravasations of contrast material
Mesenteric occlusion on angiography
Space occupying lesion on imaging
Endoscopic findings:
Perforated or uncontrollably bleeding lesion
Paracentesis findings:
Blood, bile, pus, bowel contents, or urine
PRE-OPERATIVE MANAGEMENT
GENERAL MANAGEMENT:
Nothing
by mouth
Nasogastric suction If indicated
Correction of dehydration by Intravenous fluid
Prophylactic Antibiotics:
Cephalosporin/ Ciprofloxacin+Metronidazole
Correction of anemia by blood transfusion
Thromboprophylaxis (for high risk patient)
Urinary catheterization,if indicated
Consult to anesthetists before giving any
drugs prior to the surgery
SPECEFIC
MANAGEMENT
ACUTE APPENDICITIS
If there is formation of
Appendicular lump conservative
treatment is preferred, Ochsnersherren regimen.
If there is formation of
Appendicular abscess, treatment is
incision & drainage by
percuteneous drain, recovery is
followed by interval Appendectomy
after 3 months.
INCISIONS IN APPENDICECTOMY
ACUTE CHOLECYSTITIS:
Conservative
Surgical
- Laparoscopic Cholecystectomy
- Open Cholecystectomy
CHOLECYSTECTOMY
LAPAROSCOPIC CHOLECYSTECTOMY
Acute Pancreatitis:
Mainly conservative treatment
Gastric Suction
Fluid replacement
Calcium & magnesium
supplimentation
Oxygen
Peritonial lavage
Nutrition
Other drugs (octreonide,H2 blocker)
Immediate resuscitation
followed by laparotomy
for repair of perforation
with omental patch
reinforcement and
thorough peritoneal
toileting.
INTESTINAL OBSTRUCTION
Nephrectomy
Ureteroscopic Stone
removal :
Push Bang
Lithotripsy in situ
Ureterolithotomy (Open)
Figure Ureteroscopy.
Radiograph showing a
ureteroscope and guidewire
in the lower ureter.
POSTOPERATIVE MANAGEMENT
Physiological support:
Ventilation and supplementary oxygenation.
Intravenous fluid administration
First nothing by mouth followed by fluid by mouth and
gradually returning back to normal diet.
Monitoring of urinary output.
CONCLUSION
The abdomen is like
a magic box.
And among the surgical
disorders Acute
Abdomen is the most
urgent which should be
managed as soon as
possible to reduce the
mortality and morbidity of
the patient.
THANK YOU