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Felix Halim
405110204
ACUTE ABDOMEN
Definition
Acute abdomen sign and
symptoms of abdominal pain and
tenderness, a clinical presentation
that often requires emergency
surgical therapy.
Nonsurgical Causes of
Acute Abdomen
Endocrine and Metabolic Causes
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria
Hereditary Mediterranean fever
Hematologic Causes
Sickle cell crisis
Acute leukemia
Other blood dyscrasias
Toxins and Drugs
Lead poisoning
Other heavy metal poisoning
Narcotic withdrawal
Black widow spider poisoning
Surgical Acute Abdominal
Conditions
Hemorrhage
Solid organ trauma
Leaking or ruptured arterial aneurysm
Ruptured ectopic pregnancy
Bleeding gastrointestinal deiverticulum
Arteriovenous malformation of gastrointestinal tract
Intestinal ulceration
Aortoduodenal fistula after aortic vascular graft
Hemorrhagic pancreatitis
Mallory Weiss syndrome
Spontaneous rupture of spleen
Infection
Appendicitis
Cholecystitis
Meckels diverticulitis
Hepatic abscess
Diverticular abscess
Psoas abscess
Perforation
Perforated gastrointestinal ulcer
Perforated gastrointestinal cancer
Boerhaaves syndrome
Perforated diverticulum
Obstruction
Adhesion related small or large bowel obstruction
Sigmoid volvulus
Cecal volvulus
Incarcerated hernias
Inflammatory bowel disease
Gastrointestinal malignancy
Intussusception
Ischemia
Buergers disease
Mesenteric thrombosis or embolism
Ovarian torsion
Ischemic colitis
Testicular torsion
Strangulated hernias
Classification
Visceral
pain
Abdomin Parietal
al Pain pain
Reffered
pain
Classification
Visceral pain
Tends to be vague, poorly localized to the epigastrium,
periumbilical region, or hypogastrium
Depending on its origin from the primitive foregut,
midgut, or hindgut
Mediated by autonomic nerves (sympathetic and
parasympathetic)
Parietal pain
Coorresponds to the segmental nerve roots innervating
the peritoneum
Tends to be sharper and better localized
Referred pain
Perceived at a site that is distant from the
sourced of stimulus
For example irritation of the diaphragm
may produce pain in the shoulder
Locations of Reffered Pain and
Its Causes
Right Shoulder
Liver
Gallbladder
Right hemidiaphragm
Left Shoulder
Heart
Tail of pancreas
Spleen
Left hemidiaphragm
Scrotum and Testicles
Ureter
Some mechanisms of pain
originating in abdomen
Inflammation of the parietal peritoneum
Pain of parietal peritoneal inflammation is steady and aching
in character and is located directly over the inflamed area
transmitted by somatic nerves supplying the parietal
peritoneum
Pain intensity type and amount of material to which the
peritoneal surfaces are exposed in a given time period
The pain of peritoneal inflammation is invariably accentuated
by pressure or changes in tension of the peritoneum
Produced by palpation or by movement, as in coughing or sneezing
Lies quietly in bed, preferring to avoid motion,
In contrast to the patient with colic, who may writhe incessantly
Tonic reflex spasm of the abdominal musculature, localized to
the involved body segment
Obstruction of hollow viscera
Intermittent, or colicky
Distention of a hollow viscus steady pain + very occasional
exacerbations
The colicky pain of obstruction of the small intestine
periumbilical or supraumbilical, poorly localized
Acute distention of the gallbladder pain in the right upper
quadrant with radiation to right posterior region of the thorax / to
the tip of the right scapula
Distention of the common bile duct pain in the epigastrium
radiating to the upper part of the lumbar region
Obstruction of the urinary bladder dull suprapubic pain, usually
low in intensity
In contrast, acute obstruction of the intravesicular portion of the ureter
severe suprapubic and flank pain radiates to penis, scrotum, or inner aspect
of the upper thigh
Vascular Disturbances
Pain associated with intraabdominal vascular
disturbances is sudden and catastrophic in nature
Embolism or thrombosis of the superior mesenteric artery
Severe & diffuse; only mild continuous diffuse pain for 2 or 3 days before
vascular collapse or findings of peritoneal inflammation appear
Impending rupture of an abdominal aortic aneurysm
Abdominal pain with radiation to the sacral region, flank, or genitalia;
persist over a period of several days before rupture and collapse occur
Abdominal wall
Pain from the abdominal wall constant & aching
e/ Movement, prolonged standing, and pressure
accentuate the discomfort and muscle spasm
Ex: hematoma of the rectus sheath
Approach to the patient
Only those patients with exsanguinating
intraabdominal hemorrhage (e.g., ruptured
aneurysm) operate
But in such instances only a few minutes are
required to assess the critical nature of the
problem
Other examination
>250 PMNs/L is diagnostic for PBP
Blood culture
enteric gram-negative bacilli (Escherichia coli) most commonly encountered
gram-positive organisms (streptococci, enterococci, or even pneumococci)
sometimes found
Aerobic bacteria
Contrast-enhanced CT intraabdominal source for infection
Chest & abdominal radiography to exclude free air
Treatment
Third-generation cephalosporins (cefotaxime 2 g q8h,
administered IV) initial coverage in moderately ill patients
Broad-spectrum antibiotics, such as penicillin/-lactamase
inhibitor combinations (piperacillin/tazobactam 3.375 g q6h IV
for adults with normal renal function); ceftriaxone (2 g q24h IV)
Prevention
Up to 70% of patients experience a recurrence within 1 year
Antibiotic prophylaxis reduces this rate to <20%
Prophylaxis agents
fluoroquinolones (ciprofloxacin, 750 mg weekly; norfloxacin, 400 mg/d)
trimethoprim-sulfamethoxazole (one double-strength tablet daily)
Secondary peritonitis
Develops when bacteria contaminate the peritoneum
as a result of spillage from an intraabdominal viscus
chemical irritation and/or bacterial contamination
Found almost always constitute a mixed flora in which
facultative gram-negative bacilli
anaerobes predominate, especially when the contaminating
source is colonic
Early death in this gram-negative bacillary sepsis
and to potent endotoxins circulating in the
bloodstream
E. coli, are common bloodstream isolates, but Bacteroides
fragilis bacteremia also occurs
Clinical manifestation
local symptoms may occur in secondary peritonitis, ex:
Epigastric pain from a ruptured gastric ulcer
Appendicitis vague, with periumbilical discomfort and nausea;
number of hours pain localized right lower quadrant
lie motionless
knees drawn up to avoid stretching the nerve fibers of the
peritoneal cavity
Coughing and sneezing increase pressure within the
peritoneal cavity sharp pain
Physical examination
voluntary and involuntary guarding of the anterior abdominal
musculature
tenderness, especially rebound tenderness
Treatment
antibiotics aimed particularly at aerobic gram-negative
bacilli and anaerobes
penicillin/-lactamase inhibitor combinations
(ticarcillin/clavulanate, 3.1 g q46h IV); cefoxitin (2 g
q46h IV)
Patients in the intensive care unit imipenem (500
mg q6h IV), meropenem (1 g q8h IV), or combinations
of drugs, such as ampicillin plus metronidazole plus
ciprofloxacin
Surgical intervention + antibiotics (bacteremia)
decrease incidence of abscess formation & wound
infection; prevent distant spread of infection
Peritonitis in Patients Undergoing
CAPD
CAPD (continuous ambulatory
peritoneal dialysis)
CAPD-associated peritonitis usually
involves skin organisms
Pathogenesis
skin organisms migrate along the
catheter serves as an entry point and
exerts the effects of a foreign body
usually caused by a single organism
Clinical presentation
diffuse pain and peritoneal signs are common
The first diagram shows the non-fixed terminal ileum and cecum.
The second diagram showsearly volvulusas this area begins to
twist on itself. The twisting continues until, as shown in the third
diagram (late volvulus), the intestines are obstructed and the
blood supply to this area is constricted (shut-off).
HERNIA
Hernia
Hernia is the protrusion of an organ or
part of an organ through a defect in the
wall of the cavity containing it, into an
abnormal position.
Abdominal wall hernia
Inguinal (direct or indirect)
Femoral
Umbilical & para-umbilical
Incisional
Ventral & epigastric
Etiology
Weakness in the abdominal wall
Occur at the site of penetration of structures through the
abdominal wall
The layers of the abdominal wall may be weakened following a
surgical incision
Poor healing as a result of infection, hematoma formation
Damage to the nerve paralysis of abdominal muscles
Increase of intra-abdominal pressure
Chronic cough
Constipation
Urinary obstruction
Pregnancy
Abdominal distention with ascites
Weak abdominal muscles
Varieties
Reducible hernia
Can be replaced completely into the peritoneal cavity
Presents as a lump that may disappear on lying down, not painful
Examination: reveals a reducible lump with cough impulse
Irreducible hernia
Adhesions of its contents to the inner wall of the sac
Painless, absence of cough impulse
Strangulated hernia
The hernia constricted on the neck of the sac circulation is cut off
perforation & gangrene
Severe pain of sudden onset, colicky pain, vomitting, distention, absolute
constipation
Examination: tender, tense hernia, overlying skin become inflamed, noisy
bowel sound
(femoral, indirect inguinal, umbilical)
Inguinal hernia
Indirect inguinal hernia
Passes through the internal ring, along the canal in front of the
spermatic cord ; if large enough emerges through the external
ring into scrotum
Features
Hernia doesnt reach its full size until patient has been up & around a
little time; doesnt reduce immediately when lies down
Distinct tendency to strangulate
Examination
Can be felt in the mid-inguinal point
Direct inguinal hernia
Pushes its way directly forward through the posterior wall of the
inguinal canal
Features
Appears immediately on standing; disappearing at once when lies down
Treatment
Herniotomy
Patent processus vaginalis is ligated & hernial
sac excised at the age of about 1 year and adult
Shouldice repair
Excision of the sac & repair of the weakened
inguinal canal by plicating the transversalis
fascia in the posterior wall by nylon suture
Lichtenstein repair
Reinforcing the posterior wall with a nylon or
polypropylene mesh
Femoral hernia
Hernia passes through the femoral
canal
Clinical features
Commonly in women (wider female
pelvis)
A non strangulated globular swelling
below & lateral to the pubic tubercle; it
enlarged on standing, coughing,
disappear when lies down
Hernia enlargement passes through
the saphenous opening in the deep
Richters hernia
Occur in femoral sac, only part of the
wall of small intestine herniates
through the defect strangulated
Knuckle of bowel can become
necrotic perforate acute
peritonitis
Treatment
Repaired with excision of the sac &
closure of the femoral canal because the
danger of strangulation
Umbilical hernia
Exomphalos
Failure of all part of the midgut to return to the abdominal cavity
in fetal life
Bowel is contained within a translucent sac through a defective
anterior wall
Untreated rupture fatal peritonitis (rupture may occur
during delivery)
Treatment
Surgical repair immediately
Congenital umbilical hernia
Result from failure of complete clossure of the umbilical cicatrix
Common in black children
Treatment
Not surgical repair (unless the hernia persist when the child is 2 yo
Para-umbilical hernia
Acquired hernia that occurs just above or
below umbilicus
Occurs in obese, multiparous, middle-aged
women
Neck is narrow, prone to become
irreducible or strangulated
Treatment
Sac is excised and the edges of the rectus
sheath are overlapped above and below the
hernia (Mayos operation)
Ventral, epigastric,
incisional hernia
Ventral hernia
Exist as an elongated gap between the recti
No treatment is required
Epigastric hernia
Consists of one or more small protursions through the defects in the
linea alba above umbilicus
Contain only extraperitoneal fat, often surprisingly painful
Treatment
Suturing the defect
Incisional hernia
Occurs through a defect in the scar of a previous abdominal operation
Wide neck, strangulation is rare
Treatment
Dissecting out and suturing the individual layers of abdominal wall
If operation is inadviseable abdominal belt
ADHESIONS
Adhesions
Adhesions are fibrous bands of tissue that
are a common cause of postoperative small
bowel obstruction after abdominal surgery.
The risk of forming an adhesion that causes
obstructive symptoms in childhood has not
been well studied but seems to occur in 2-
3% of patients after abdominal surgery.
The majority of obstructions are associated
with single adhesions and can occur at any
time after the 2nd postoperative week.
Diagnostic
Abdominal pain, constipation, emesis, and a history of intraperitoneal
surgery
Nausea and vomiting quickly follow the development of pain
Bowel sounds initially are hyperactive, and the abdomen is flat
The bowel subsequently dilates abdominal distention bowel
sounds disappear
Fever and leukocytosis are suggestive of necrotic bowel and peritonitis
Plain radiographs obstructive features; contrast studies may be
needed to define the cause
Treatment
Nasogastric decompression, intravenous fluid resuscitation, and broad-
spectrum antibiotics in anticipation of surgery
Nonoperative intervention is contraindicated unless a patient is stable
with clear evidence of clinical improvement.
IBD
Irritable Bowel Syndrome
Definition
A disorder characterized most commonly by cramping,
abdominal pain, bloating, constipation, and diarrhea.
Symptoms
Some people have constipation
Abdominal pain
Bloating
Discomfort ( the main symptoms of IBS )
Some people with IBS experience diarrhea, which is
frequent, loose, watery, stools
Inflammatory Bowel Disease
Symptoms
Abdominal cramps and pain
Diarrhea
Fever
Loss of appetite
Weight loss
Anemia
Bleeding ( intestines )
Inflammatory Bowel Disease
Ulcerative Colitis
Clinical manifestation:
Bloody diarrhea
Mucus
Fever
Abdominal pain
Tenesmus
Weight loss
Inflammatory Bowel Disease
Ulcerative Colitis
Complication:
Toxic megacolon
Colonic perforation
Diagnostic:
sigmoidoscopy / colonoscopy mucosal
erythema, granularity, friability, exudate,
hemorrhage, ulcers, inflammatory polyps
Inflammatory Bowel Disease
Crohns Disease
Clinical manisfestation:
Fever
Abdominal pain
Diarrhea (often without blood)
Fatigue
Weight loss
Growth retardation in children
Inflammatory Bowel Disease
Crohns Disease
Diagnosis
Sigmoidoscopy/colonoscopy:
nodularity, rigidity, ulcers that may
deep or longitudinal, strictures,
fistulas
CT-scan
Inflammatory Bowel Disease
Treatments
Aminosalicylates
These drugs can be given either orally or rectally (enema,
suppository formulations). They are useful both for treating flare-
ups of the IBD and the maintenance of remission.
Corticosteroids
Corticosteroids are rapid-acting anti-inflammatory agents. The
indication for use inIBD is for acute flare-ups of the disease only.
There is no role for corticosteroids in the maintenance of
remission.
Immune modifiers
They are useful in reducing or eliminating some persons'
dependence on corticosteroids.
Inflammatory Bowel Disease
Treatments
Anti-TNF agent
Infliximab (Remicade) is an anti-TNF agent.
TNF is produced by white blood cells and is believed to be
responsible for promoting the tissue damage noted in persons with
Crohn's disease.
Infliximab acts by binding to TNF, thereby inhibiting its effects on
the tissues.
Antibiotics
Metronidazole and ciprofloxacin are the most commonly used.
In persons withulcerative colitis, they have an increased risk of
developing antibiotic-associated pseudomembranous colitis (a
type of infectious diarrhea).
In persons with Crohn's disease, antibiotics are used for
thetreatment of complications (perianal disease, fistulae,
inflammatory mass).