ACUTE ABDOMEN

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ACUTE ABDOMEN

• Done by- Fatima Salim

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INTRODUCTION

• Is the most common presenting surgical emergency.
  It has been estimated that at least 50 of
  general surgical admissions are emergencies and
  50 of them present with acute abdominal pain.
• Studies have shown a 30-day mortality of 4 among
  patients admitted with acute abdomen. So, it
  represents a significant part of the general
  surgical workload. The aim is to differentiate
  serious causes from less serious causes of acute
  abdominal pain.

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INTRODUCTION

• Acute abdomen is a term used to encompass a
  spectrum of surgical, medical and gynecological
  conditions, ranging from the trivial to the
  life-threatening, which require hospital
  admission, investigation and treatment.
• The acute abdomen may be defined generally as an
  intra-abdominal process causing severe pain
  requiring admission to hospital, and which has
  not been previously investigated or treated and
  may need surgical intervention.

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INTRODUCTION

• The mortality rate varies with age, being the
  highest at the extremes of age.
• The highest mortality rates are associated with
  laparotomy for unresectable cancer, ruptured
  abdominal aortic aneurysm and perforated peptic
  ulcer.
• Most common causes in any population will vary
  according to age, sex and race, as well as
  genetic and environmental factors.

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Causes-

• A. Gastrointestinal-
• 1-Gut
• Acute appendicitis
• Intestinal obstruction
• Perforated peptic ulcer
• Diverticulitis
• Inflammatory bowel disease
• Acute exacerbation of peptic ulcer
• Gastroenteritis
• Mesensteric adenitis
• Meckels diverticulitis

• 2-Liver and biliary tract
• cholecystitis
• cholangitis
• Hepatitis
• biliary colic
• 3-Pancreas
• Acute pancreatitis
• 4-Spleen
• Splenic infarct and spontaneous rupture

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Causes-

• B. Urinary tract
• Cystitis
• Acute pyelonephritis
• Ureteric colic
• Acute retention
• C. Vascular
• Ruptured aortic aneurysm
• Mesenteric embolus
• Mesenteric venous thrombosis
• Ischemic colitis
• Acute aortic dissection

• D. Abdominal wall conditions
• Rectus sheath haematoma
• E. Peritoneum
• Primary peritonitis
• Secondary peritonitis

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Causes-

• F. Retroperitoneal
• Hemorrhage e.g anticoagulants
• G. Gynecological
• Torsion of ovarian cyst
• Ruptured ovarian cyst
• Fibroid denegeration
• Ovarian infarction
• Salpingitis
• Pelvic endometriosis
• Severe dysmenorrhea
• Endometriosis

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Causes-

• H. Extra-abdominal causes
• Lobar pneumonia
• Pleurisy
• MI
• Sickle cell crisis
• Uremia
• Hypercalcemia
• DKA
• Addisons disease
• Acute intermitent porphyria

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Classification with age

• Children
• Gastroenteritis
• Mesentric adenitis
• Meckels diverticulitis
• Intussusception
• Henoch-schonlein purpura
• Adult
• Regional enteritis
• Ureteric colic
• Perforated ulcer
• Testicular torsion
• Pancreatitis

Adult female Salpingitis Pyelonephritis
Ectopic pregnancy Elderly
Diverticulitis Intestinal obstruction
Colonic carcinoma Mesentric infarction
Aortic aneurysm
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Relation of pain to embryology

• Intestine and its outgrowths (the liver, biliary
  system and pancreas)-gt midline.
• Irritation of foregut structures
• (oesophagus to the second part of the duodenum)
• -gtepigastric area.
• Midgut structures
• (the second part of the duodenum to the splenic
• flexure) -gtumbilicus.
• Hindgut structures (the splenic flexure to the
  rectum)-gt
• hypogastrium.

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Management

• History
• Physical examination
• Management
• History-
• Biodata
• Age
• Mesenteric adenitis in children
• Diverticulitis in elderly
• Gender

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• Characteristics of abdominal pain
• Site
• Time and mode of onset
• Severity
• Nature/Character
• Progression
• Radiation
• Duration
• Cessation
• Exacerbating/relieving factors
• Associated symptoms

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Site-pain

• Whole abdomen
• Peritonitis or mesentric
  infarction
• Right upper quadrant
• Acute cholycystitis
• Cholangitis
• Hepatitis
• Peptic ulceration
• Left upper quadrant
• Peptic ulceration
• Pancreatitis
• Splenic infarct

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• Right lower quadrant
• Appendicitis
• Ovarian cyst Ectopic pregnancy PID
  Right ureteric colic
• Left lower quadrant
• Sigmoid diverticular disease
• Ovarian cyst
• Ectopic pregnancy
• PID
• Left ureteric colic

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Symptoms--Pain

• Onset
• sudden perforation of bowel, smooth muscle
  colic
• slow insidious onset inflammation of visceral
  peritoneum
• Severity
• Patient asked to rate pain from 1-10
• Ureteric colic is one of worst pains
• Character
• Aching-dull pain poorly localised
• Burning- peptic ulcer symptoms
• Stabbing-ureteric colic
• Gripping-smooth muscle spasm e.g. intestinal
  obstruction worse by movement wringing of cloth
  

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Symptoms--Pain

• Progression
• -Constant e.g. peptic ulcer
• -Colicky e.g. seconds(bowel), minutes(ureteric
  colic) or tens of minutes (gallbladder
• -may change character completely from dull
  poorly localized pain to sharp pain indicates
  involvement of parietal peritoneum
  e.g.appendicitis
• Radiation of the pain
• Back duodenal ulcer, pancreatitis, aortic
  aneurysm
• Scapula gall bladder
• Sacroiliac region ovary
• Loin to groin ureteric colic
• Groin testicular torsion

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• Cessation-
• abrupt ending- colicky pains
• resolving slowly-inflammatory pain, biliary pain
• Exacerbating/relieving factors-
• Movement/Rest-inflammatory conditions
• Food- peptic ulcers

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History

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History

• Past history
• previous surgery
• trauma
• any medical diseases
• Drug history
• corticosteroid mask pain
• anti-coagulant intra-mural hematoma
• NSAIDS gastritis, peptic ulcer
• Family history
• colon cancer
• IBD

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Physical Examination
General appearance -Patient is lying
motionless acute appendicitis, peritonitis
-Rolling in bed ureteric colic, intestinal
colic -Bending forward chronic
pancreatitis
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Physical Examination
Vital signs Temp. low grade
appendicitis, acute cholycystitis high
grade abscess Pulse, BP,
Resp.rate General examination- Conjuctival
pallor cyanosis jaundice Signs of
dehydation Cervical lymphadenopathy -mesentric
adenitis
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Physical Examination
Cardio-pulmonary examination -MI
-basal pneumonia -pleural
effusion
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Physical Examination
Abdomen Inspection Palpation
Percussion Auscultation Inspection
-movement with respiration -distension,
peristalsis, mass, scars and any obvious cough
impulse at hernia site
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Physical Examination
Palpation superficial palpation
-tenderness, rebound tenderness, guarding,
rigidity, masses, hernial orifices deep
palpation -organomegaly Percussion
-tympanic note intestinal obstruction
-dullness over bladder acute retention
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Physical Examination
Auscultation -silent abdomen peritonitis
-increase bowel sound intestinal
obstruction Dont forget to examine rectum for
tenderness, mass, blood and vaginal examination
for discharge, tenderness( PID).
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Investigation

• CBC with differential (infection and
  inflammation)
• Urea, electrolyte, creatinine, glucose (DKA)
• LFT
• Amylase ( high in acute pancreatitis)
• urinalysis
• CXR ( basal pneumonia, gas under diaphragm)
• AXR
• -distended bowel with air fluid level
• -stones
• -calcified aorta
• -air in biliary tree

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Investigation

• U/S (ovarian cyst, ectopic pregnancy)
• IVU for stones
• Angiography (mesentric embolus or thrombosis)
• Sickling test
• Pregnancy test

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Treatment
1. Relieve the pain 2. IV fluids and nasogastric
suction 3. Antibiotics in case of peritonitis or
sepsis 4. Surgery if indicated Indication for
surgery If patient has guarding or rigidity
with peritoneal irritation spreading
tenderness Progressive distension or generalized
peritonitis Shock with bleeding or sepsis Free
gas on x-ray Mesentric occlusion on
angiography Blood, pus or bile on paracentesis
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• Intestinal
• Obstruction

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Intestinal obstruction

• One of the common cause of acute abdomen
• May lead to high morbidity and mortality if not
  treated correctly
• It can be classified into two types
• Dynamic (mechanical)
• Adynamic

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Dynamic

• 1.Intraluminal impacted faeces, foreign bodies,
  gallstones
• 2.Intramural tumours, inflammatory strictures,
  congenital atresia
• 3.Extramural adhesion, hernias, volvulus,
  intussusception, tumours

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Dynamic

• also can be divided into
• 1. Small bowel obstruction (SBO)
• -high -gtearly perfuse vomiting
• rapid dehydration
• -low-gtpredominant pain, and central distention
• Vomiting delayed
• air-fluid levels seen on AXR
• 2. Large bowel obstruction (LBO)
• early pronounced distension, mild pain
• vomiting, dehydration late
• e.g. -carcinoma
• -diverticulitis or volvulus

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Adynamic

• 1.Paralytic ileus (peristalsis is absent)
• 2.Peristalsis is present in a non-propulsive
  form e.g. mesentric vascular occlusion

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Obstruction can be-

• Simple blockage without interfering with
  vascular supply
• Strangulation significant impairment of blood
  supply most commonly associated with hernia,
  volvulus, intussusception and vascular occlusion
• -surgical emergency
• Closed loop obstruction bowel is obstructed
  at both the proximal and distal end)

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Pathophysiology

• Irrespective of etiology or acuteness of onset
• Proximal to obstruction
• Increased fluid secretion ? abdominal distention
• Accumulation of gas ? abdominal distention
• Increased intraluminal pressure
• Decreased reabsorption with time and flaccidity
  to prevent vascular damage from high pressure
• Vomiting
• Dehydration
• Dilatation of bowel
• Reflex contraction of smooth muscle ? colicky
  pain
• Increased peristalsis to overcome obstruction ?
  increased bowel sounds
• If obstruction not overcome ? bowel atony
• Distal to obstruction nothing is passed bowel
  collapse ? constipation

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Symptoms

• The four cardinal features of intestinal
  obstruction
• -abdominal pain
• -vomiting
• -distension
• -constipation
• Vary according to-
• location of obstruction
• age of obstruction
• underlying pathology
• intestinal ischemia

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Symptoms

• Abdominal pain
• colicky in nature, around the umbilicus in
  SBO while in the lower abdomen in LBO
• if it becomes continuous, think about
  perforation or strangulation
• Vomiting
• -starts early in SBO and late in LBO
• -vomitus starts with clear color then
  becomes thick, brown and foul ( faeculent)
• -more with lower or complete obstruction
• -diarrhea may be present with partial
  obstruction
• Distension
• -more with lower obstruction

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Symptoms

• Constipation
• -more with lower or complete obstruction
• -diarrhea may be present with partial
  obstruction
• -either absolute (no feces or flatus)lt-cardinal
  in absolute IO
• or relative (flatus passed)
• Distension
• -more with lower obstruction

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Symptoms

• In strangulation
• severe constant abdominal pain
• distended abdomen
• fever
• tachycardia
• tender abdomen

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Clinical examination

• General examination-
• Vital signs
• Signs of dehydration tachycardia, hypotension
• dry mucus membrane, decreased skin turgor,
  decreased urine output
• Inspection
• distension, scars, peristalsis, masses, hernial
  orifices
• Palpation
• tenderness, masses, rigidity
• Percussion tympanitic abdomen
• Auscultation
• high pitched bowel sound or silent abdomen
• Examine rectum for mass, blood, feces or it may
  be empty in case of complete obstruction

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Investigations

• CBC- WBC (neutrophilia-strangulation)
• Hb
• UE
• Plain AXR
• Sigmoidoscopy (carcinoma, volvulus)
• Double Contrast x-ray ( complete or incomplete)
• CT abdomen

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Normal Gas PatternAXR

• Stomach
• Always
• Small Bowel
• Two or three loops of non-distended bowel
• Normal diameter 2.5 cm
• Large Bowel
• In rectum or sigmoid almost always

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Gas in stomach
Gas in a few loops of small bowel
Gas in rectum or sigmoid
Normal Gas Pattern
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Normal Fluid Levels

• Stomach
• Always (except supine film)
• Small Bowel
• Two or three levels possible
• Large Bowel
• None normally

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Always air/fluid level in stomach
A few air/fluid levels in small bowel
Erect Abdomen
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Large vs. Small Bowel

• Large Bowel
• Peripheral
• Haustral markings don't extend from wall to wall
• Small Bowel
• Central
• Valvulae extend across lumen
• Maximum diameter of 2"

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Abnormal Gas Patterns

• Mechanical Obstruction
• SBO
• LBO
• Functional Ileus
• Localized (Sentinel Loops)
• Generalized adynamic ileus

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Mechanical SBOKey Features

• Dilated small bowel
• Fighting loops
• Little gas in colon, especially rectum
• Key disproportionate dilatation of SB

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Small bowel obstruction
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Mechanical LBO

• Causes-
• Tumor
• Volvulus
• Hernia
• Diverticulitis
• Intussusception

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Prone
Supine
LBO
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Mechanical LBOPitfalls

• Incompetent ileocecal valve
• Large bowel decompresses into small bowel
• May look like SBO
• Get BE or follow-up

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Carcinoma of Sigmoid,LBO Decompressed into SB
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Localized IleusKey Features

• One or two persistently dilated loops of large or
  small bowel
• Gas in rectum or sigmoid

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Localized IleusPitfalls

• May resemble early mechanical SBO
• Clinical course
• Get follow-up

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Generalized IleusKey Features

• Gas in dilated small bowel and large bowel to
  rectum
• Long air-fluid levels
• Only post-op patients have generalized ileus

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Generalized Adynamic Ileus
Erect
Supine
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(No Transcript)
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Treatment

• Three main measures-
• - GI drainage
• FE replacement
• - Relief of obstruction, usually surgical

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Treatment
Conservative -Nasogastric aspiration by Ryle
or Salem tube -IV fluids- volume varies
depending on dehydration -NPO -urinary
catheter -check temp. and pulse 2 hourly
-abdominal examination 8 hourly -Broad spectrum
antibiotics initiated early-reduce bacterial
overgrowth
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Treatment

• Some cases will settle by using this conservative
  regimen, other need surgical intervention.
• Surgery should be delayed till resuscitation is
  complete unless signs of strangulation and
  evidence of acute or closed-loop obstruction.
• Cases that show reasons for delay should be
  monitored continuously for 72 hours in hope of
  spontaneous resolution e.g. adhesions with
  radiological findings but no pain or tenderness
• The sun should not both rise and set in cases
  of unrelieved obstruction.

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Treatment

• Indication for surgery
• - failure of conservative management
• - tender, irreducible hernia
• -strangulation
• Type of surgery depends upon the nature of the
  cause.
• Laprotomy is usually done
• Decompression of obstruction ( by repair of
  hernia, complete lysis of adhesion)

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Surgical treatment

• Operative decompression required-
• if dilatation of bowel loops prevent exposure, if
  bowel wall viability is compromised, or if
  subsequent closure will be compromised.
• Savages decompressor used within seromuscular
  purse-string suture.
• Or large-bore NG tube maybe used for milking
  intestinal contents into stomach.

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Surgical treatment

• Once obstruction relieved, the bowel is
  inspected for viability, and if non-viable,
  resection is required.
• Indication of non-viability
• 1.absent peristalsis
• 2.loss of normal shine
• 3.loss of pulsation in mesentry
• 3.green or black color of bowel

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Surgical treatment

• If in doubt of viability, bowel is wrapped in hot
  packs for 10 minutes with increased oxygen and
  reassessed for viability.
• Sometimes a second look laprotomy is required in
  24-48 hours e.g. multiple ischemic areas.
• Right sided large bowel lesion is treated by
  right hemicolectomy with covering colostomy

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Prognosis

• Simple small bowel obstruction has a very low
  mortality rate but increases in case of
  strangulation
• Reaches up to 15 in case of large bowel
  obstruction mainly due to perforation

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