Acute Abdomen http:www'surgicaltraining'co'uk

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Acute Abdomenhttp//www.surgicaltraining.co.uk/
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Mrs GJ

• Presentation
• 62 yrs Female
• Right upper quadrant pain

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Mrs GJ HPC

• Colicky
• no radiation
• nausea, vomiting
• feels warm
• no appetite for 2 days
• DH nil. No allergies. Non Smoker. Alc. nil

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Mrs GJ On examination

• Restless, sweating, rolling in agony
• T 37.4 P 116 BP 128/88
• chest clear
• soft abdo, tender RUQ, no peritonism
• normal BS
• PR NAD

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Initial Management

• Analgesia
• Paracetamol 1g QDS/Coproxamol 2tabs QDS
• NSAID Diclofenac 150mg max in 24hrs divided doses
• Buscopan (anti-spasmodic) 20 mg IM/IV/PO
• Opiates Morphine Sulphate 5-10mg IM/IV 4hrly max

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Mrs GJ Investigations

• dark urine MSU dip NAD Gluc 5.3
• Hb 14.2
• WBC 11.9
• Plt 243
• Amy 420 (25 - 125)
• AST 52 (12 - 40)
• Bili 47 (lt17)
• Alp 194 (39 - 117)
• Urea 3.2
• Creat 95

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Mrs GJ Further Investigations

• CXR
• AXR
• USS Abdomen

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Mrs GJ Further Investigations

• USS Abdomen report
• The gall bladder is full of calculi
• There is a gallstone in the distal common bile
  duct
• The ducts are dilated
• Kidneys, pancreas, liver all normal

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Mrs GJ Further Investigations

• ERCP

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Mrs GJ Follow up

• Went on to have a laparoscopic cholecystectomy
  and made a good recovery.

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Ms JW

• 47 year old female
• Generalised abdominal pain for 2 days
• Pain and vomiting
• Feels very weak

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Ms JW HPC

• Pain was colicky, now constant
• Some relief of pain by vomiting
• Vomiting clear/brown fluid
• No appetite
• Bowels opened yesterday - soft brown stool only

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Ms JW PMH

• Appendicectomy aged 13
• Laparoscopy cholecystectomy 7 years ago
• DH - simple analgesia
• SH - Barrister. Non Smoker. Occ. Alcohol

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Ms JW Examination

• Reduced skin turgor. Dry mucus membranes
• Clinically dehydrated
• HR 118 BP 98/72 T 37.6

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Ms JW Abdo Exam

• Distended. Tense.
• Generalised tenderness. No peritonism.

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Ms JW Abdo Exam

• Hernial Orifices - Inguinal/femoral/umbilical NAD
• Tympanic PN
• High pitched bowel sounds
• PR empty rectum

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Ms JW Investigations

• FBC
• HB 12.8 WCC 8.2 Plt 334
• UEs
• Urea 9.1 Creatinine 187
• Amylase/LFTs normal

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Ms JW Investigations - AXR
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Ms JW Management

• NBM
• IV fluid resusitation
• Nasogastric Tube (NGT) decompression
• Urinary catheter - hrly urine measurment
• drip and suck then identify cause

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Ms JW

• CT abdomen
• ?ultrasound

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Ms JWs progress

• Worsening pain
• HR 128 T 38.4
• Peritonism
• WBC 15.8
• ABG metabolic acidosis

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Ms JW - Laparotomy

• Numerous bands of adhesions seen - adhesions
  divided
• Bowel decompressed
• 4cm of non-viable bowel resected
• End-to-end anastomosis
• Returned to ward and made good post-op recovery

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Other causes of bowel obstruction

• Gallstone ileus
• Volvulus
• Hernia-induced
• Neoplasm
• Foreign bodies
• Think
• extra-luminal/mural/intra-luminal
• Mechanical vs Pseudo-obstruction

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Bowel Obstruction

• Small Bowel Large Bowel
• Central Peripheral
• Valvulae conniventes Haustrae
• Dia gt 5cm gt 10cm

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SBO LBO
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Mr AD

• 24 yr old male
• RTA 6 hrs
• Restrained front seat passenger
• Walked into AE
• c/o severe central abdominal pain

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Mr AD

• Airway - maintaining own
• Breathing - sats 96 room air RR 14/min
• Circulation - P 98 BP 124/83

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Mr AD HPC

• Central, constant pain.
• Back pain
• Nausea, No vomiting
• No urinary symptoms

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Mr AD

• PMH - nil
• Drug Hx - nil. No allergies
• SH - bank clerk, smokes 10/day. Alcohol - 1 to 2
  units daily

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Mr AD examination

• T 36.8
• Bruising to hypochondrium
• Acute abdomen- tender epigastrium, rigid,
  guarding
• BS - silent
• PR - patient refused

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Mr AD Investigations

• MSU dip NAD
• Blood Glucose 21
• WCC 18.4 HB 14.2 Plt 248
• Urea 7 Creatinine 98
• Amylase 2643
• LFT ALT 7 AST 241 Bili 10 LDH 301
• ABG - PO2 9.7 PCO2 5.5 HCO3- 24.1

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Mr AD

• Nil by mouth
• NG tube
• IV fluids - keep well hydrated
• Urinary catheter - hrly urine measurment
• Oxygen
• Sliding scale insulin regime
• Analgesia
• Treatment is Supportive

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Mr AD

• Ransons Criteria Severity of Pancreatitis
• On Admission At 48Hrs
• Age gt 55 Haematocrit fall gt 10
• WCC gt 16 Blood Urea N gt 8mg/dl
• Glucose gt 20 Calcium lt 8mg/dl
• LDH gt 350 PO2 lt 60mmHg
• AST gt 250 Base Deficit gt 4
• Fluid sequestration gt600ml

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Complications of Pancreatitis - Local

• Pancreatic necrosis
• 2o to inflammation and oedema. Diagnosed on CT
• May need surgery - necrosectomy
• Sepsis
• Antibiotics Imipinem
• Pancreatic Pseudocyst -
• Will need drainage
• Chronic Pancreatits

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Complications of Pancreatitis - Systemic

• Cardiovascular
• CVP monitoring, inotropes
• Renal
• Failure may necessitate dialysis
• Respiratory
• ARDS, ventilation
• Nutrition
• TPN

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Get Smashd

• Gallstones
• Ethanol
• Advise Mr AD to STOP drinking
• Toxins and drugs
• Surgery or Trauma
• Metabolic
• Autoimmune and inherited
• Snake bites and infections
• Hypothermia
• Duodenal Obstruction

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DN

• 19 year old female
• 3 days of lower abdominal pain

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DN HPC

• Constant. Across lower abdo.
• No radiation
• Nausea , vomited x3
• Anorexia
• Bowels opening - soft brown stool
• Feverish
• Urinary
• some frequency and urgency

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DN PMH

• Gynae -
• Regular periods. No PV disch./blood loss
• Mild asthma
• DH -
• OCP, salbutamol inhaler
• Allergies
• penicillin - rash

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DN Examination

• T 37.7 P 72 BP 108/74
• Tender supra-pubic area
• Has rebound with guarding
• PR exam NAD
• Speculum exam. No discharge. No cervical
  excitation.

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DN Investigations

• Urine dipstick - blood 1 nil else
• ßHCG - negative
• Hb 12.2
• WBC 14.3
• UEs normal
• LFT/Amylase normal

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DN Plan

• Admit
• Analgesia
• Withold antibiotics
• IV fluids
• Keep NBM pending further investigations

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DN Investigations

• USS
• Laparoscopy - Very inflamed appendix seen in the
  pelvis.

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Follow up

• Patient proceeded and underwent laparoscopic
  appendicectomy for pelvic appendicitis

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Appendicitis

• Retrocaecal
• can be difficult to diagnose
• poorly localised signs
• Pelvic
• may tickle the bladder and give misleading
  signs.
• MUST do a pregnancy test
• think ectopic/spontaneous abortions

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Appendicitis

• Can be treated non-operatively
• Appendicectomy if signs of peritonitis
• DD
• Crohns
• Adhesions
• Salpingitis
• Ovarian pathology
• Can perforate
• Can form an appendix mass