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The Acute Abdomen

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The Acute Abdomen Raymond Yiu Surgery Team 3 Acute Life-threatening intra-abdominal conditions Requires Emergency admissions Often requires Emergency surgery ... – PowerPoint PPT presentation

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Title: The Acute Abdomen


1
The Acute Abdomen
  • Raymond Yiu
  • Surgery Team 3

2
  • Acute Life-threatening intra-abdominal conditions
  • Requires Emergency admissions
  • Often requires Emergency surgery

3
Aetiology Abdominal Pain
  • EXTRAABDOMINAL
  • Cardiovascular MI
  • Metabolic DKA
  • Abdominal wall rectus sheath haematoma
  • Neurogenic referred pain
  • INTRABDOMINAL
  • Imflammatory
  • Traumatic
  • Obstructive
  • Vascular

4
INTRABDOMINAL
  • Imflammatory Conditions (Peritonitis)
  • Localised / Generalised
  • Primary / Secondary / Tertiary
  • Traumatic Blunt / Penetrating Injury
  • Bleeding / Peritonitis
  • Obstructive Gastric/ Small / Large Bowel
  • Vascular Mesenteric infarction
  • Strangulated hernias
  • Volvulus (small or large bowel)
  • Rupture AAA
  • Aortic dissection

5
Imflammatory Conditions
  • Peritonitis

6
Peritonitis
  • Bacteria
  • primary/ secondary/ tertiary spontaneous
  • Chemical

7
Peritonitis Bacterial
  • secondary majority of cases
  • perforated viscus / GIT
  • primary very rare
  • healthy people in absence of surgery and
    trauma (children and young adult females)
  • streptococcal pneumoniae/ gonococcus
  • laparotomy washout antibiotics
  • tertiary ICU patients
  • persistent/ recurrent sepsis following
    adequate therapy of secondary peritonitis
  • poor prognosis

8

Spontaneous bacterial peritonitis
  • Immunocompromised patients with ascites,
    cirrhosis, renal failure on CAPD, nephrotic
    syndrome
  • Gram negative organisms
  • E. Coli in ascites (bacterial translocation)
  • Present with abdominal pain, fever, generalised
    perionitis
  • Ascitic fluid tap?white cells, gm stain, culture
  • Treatment by iv cephalosporins, intraperitoneal
    antibiotics (vancomycin/netelmicin for gm ve
    organisms)

9
Peritonitis Chemical
  • Leakage of irritant fluids ie urine, bile, acid
  • leading to initial chemical peritonitis
  • Later secondary infection occurs after a few
    hours
  • Clinical Examples PPU, Bile leak from cystic
    duct stump post cholecystectomy

10
PeritonitisClinical Features
  • Abdominal pain (recent onset)
  • Irritation of somatic nerves supplying parietal
    peritoneum
  • Constant, sharp, aggravated by movement
  • May be referred to other parts of body (eg
    shoulder-tip pain in acute cholecystitis)

11
PeritonitisClinical Features
  • Systemic Fever
  • Tachycardia
  • Leucocytosis
  • Chills/rigors
  • Dehydration
  • Abdominal tenderness, guarding, rigidity,absent
    BS, distention (ileus)

Generalised
localised
12
PeritonitisLocalisation of signs and pathology
13
PeritonitisClinical Features
Pancreatitis
Liver abscess
PPU
Cholecystitis Cholangitis
Diverticultis
Meckels diverticultis Small bowel perf
Appendicitis
14
Acute abdomenCommon conditionsAppendicitisCho
lecystitis
15
Acute appendicitis aetiology
Obstruction of lumen by Lymphoid
hyperplasia Faecolith Parasites Cancer/ carcinoid
16
Acute appendicitis Clinical Features
7 population 10-30 years Mortality rate
lt1 5 Elderly and young (delay in
diagnosis)
17
Acute appendicitis
  • RLQ pain
  • Pain migration
  • Anorexia, nausea
  • RLQ tenderness
  • RLQ guarding
  • RLQ rebound
  • Fever
  • Leucocytosis (80)

Mcburneys point
18
Acute appendicitis Signs
Rovsings sign Pain in RLQ on pressing
LLQ Dumphys sign Pain on coughing
Psoas sign
Obturator sign
19
Acute appendicitis Signs
  • Depends on where inflamed appendix is
  • Retrocecal Lumbar sign Pain in right flank
  • Pelvic irritate bladder dysuria
  • irritate rectum diarhoea

20
Acute appendicitis Ix
21
Acute appendicitis
Open
Laparoscopic
Young women of child bearing age
22
Acute appendicitis appendiceal mass
  • Usually reflects delayed presentation
  • Patient presents with mass in RLQ
  • /- peritoneal signs
  • Mass represents walling off of appendix by
    surrounding structures
  • Rx Osler-schering regime in absence of clinical
    signs
  • Conservative rx with IVF and iv antibiotics until
    sx subside (follow by colonoscopy and interval
    appendicectomy 4-6 weeks later)

23
Acute Cholecystitis
Remember 4 Fs
Pigment
Calcium
Cholesterol
24
Acute Cholecystitis
Chemical peritonitis initally
25
Acute Cholecystitisclinical features
Short onset RUQ pain
Fever RUQ peritoneal signs Murphys signs
26
Acute CholecystitisImaging
27
Acute CholecystitisTreatment
  • Short duration of sx (lt5days pain)
  • Consider surgery (lap)
  • Higher incidence of conversion
  • Longer duration of sx (gt5days)
  • conservative treatment by npo, iv antibiotics
  • Followed by lap cholecystectomy 6-8 weeks later
  • Any signs of perforation requires urgent surgery
  • Interval cholecystitis
  • Unfit patients
  • cholecystostomy

28
Intestinal Obstruction
29
Aetiology
  • Extramural adhesions
  • hernias (int/ext)
  • tumor
  • Intramural tumor
  • stricture (radiation/crohns/tb)
  • Intraluminal Food bolus
  • GS
  • FB
  • Faecal impaction

30
Aetiology by incidence (SBO)
  • Previous OT adhesions
  • Virgin abdomen carcinoma, hernias

31
Questions to ask?
  • Site Stomach vs SB vs LB
  • Presentation Acute vs Subacute
  • Urgency simple mechanical vs strangulating

32
Site Sx
Gastric outlet Small bowel Large bowel
Pain Epigastric Central colic Lower colic
Vomiting Early Early/late Late/none
BO/flatus Normal Normal/ none none
Distension upper General General/ localised (just LB)
Ausculatation Sucussion splash Hyperactive BS Hyperactive BS
33
Site X-ray
Mainly LB dilatation (SB if competent ICV)
AXR
Large gastric bubble
Mainly SB dilatation (no LB or rectal gas)
Gastric outlet obstruction
LB obstruction
SB obstruction
Contrast enema (Watersoluble)
RT decompression OGD Oral contrast study
Virgin abdo
Previous OT
Ca caecum hernias
adhesions
34
Presentation Acute vs Subacute SBO
  • Acute
  • short onset
  • May require laparotomy if does not resolve
  • Subacute
  • on/off symptoms that subside but does not
    completely resolve
  • Investigate (eg colonoscopy) if subside
  • Repeated attacks may require laparotomy

35

Simple Mechanical Obstruction
Strangulating
vs
Can wait
Cannot wait
36
Simple Mechanical Obstruction
37
Simple Mechanical ObstructionFemoral hernias
38
Strangulating obstruction
  • Vascular supply compromised
  • Can occur in any type of obstruction
  • Closed loop obstruction (eg volvulus, LBO with
    competent ICV)
  • Intussusception
  • Stangulation of mesenteric blood supply (adhesive
    band, hernias)

39
Sigmoid Volvulus
Example of close loop obstruction both ends of
the bowel are blocked and air enters in a one-way
valve
40
Sigmoid Volvulus
Decompression bedside sigmoidoscopy or
colonoscopy
failure
41
intussusception
Usually associated with polyps acting as lead
point
42
Small bowel ischemia
Prolonged strangulation from adhesion band, hernia
Small bowel volvulus
43
Recognising bowel ischemia
  • Awareness is the most important
  • Pain out of proportion to abdominal signs
  • Peritoneal signs (may be late)
  • Sepsis (fever, high WCC, shock , acidosis)

44
Management
Hx and exam Initial Mx Baseline Ix Special
Ix Preparation for OT
45
History and Examination
Discharge Diagnosis 1972 1977
1993 Undifferentiated 41 39 25
GI causes 13 19 18
Gastroenteritis 7 12
5 Surgical GI 10 18
8 UTI 11 -- 11
Pelvic Disorder 12 --
12

Brewer, Am J Surg, 1976 Jazon, AC Scand,
1982 Powers, AJEM,
  • History examination and simple lab tests have
    about a 50-60 accuracy in giving a diagnosis

46
Pattern Recognition is very important !
47
Pattern Recognition
Central colicky abdo pain? shifts to RLQ region
RLQ peritoneal signs Temp 38 C
Young male
appendicitis



RUQ peritoneal signs (Murphys) Temp 38 C
ElderlyObese female
Acute cholecystitis



RUQ pain
48
Initial Mx
NGT
NPO
analgesia
Resuscitation IVF
Iv antibiotics
Monitoring devices
Foley (CVP)
49
Baseline Laboratory testing
Blood tests Plain X-rays ECG

50
WBC
  • Limited utility
  • WBC gt 11,000 LR 2
  • lt 11,000 LR- 0.5
  • WBC alone doesnt distinguish patients with
    surgical disease from non-specific abdominal pain

51
Liver function tests
  • ? Bilirubin/ALP suggestive of biliary
    obstruction
  • ? Bilirubin/ ALT suggestive of hepatitis
  • Normal LFT in up to 40 with acute cholecystitis
  • May be deranged in all types of sepsis. Not
    specific for any disease entity


52
Amylase
  • ? in acute pancreatitis
  • May be normal in 40 cases of pancreatitis
  • Raised in other intra-abdominal conditions eg
    PPU, hyperamylassaemia, renal failure

53
Urinalysis
  • Pregnancy test ------gt Mandatory for all young
    females
  • (ectopic)
  • WBC
  • UTI
  • Haemuturia (RBC)
  • Renal colic (LR 2 , LR- 0.3)
  • Hematuria occurs in up to 30 with AAA
  • Most common misdiagnosis in AAA- kidney stone

54
Plain X-rays
Sensitive for free air 90-95
  • Aerobilia (RPC, GS ileus)

Bowel obstruction- 70 sensitive
Renal stones 90 radio-opaque GS 10 Normal
X-rays does not exclude acute abdomen!
55
Special investigations
  • History examination and simple lab tests have
    about a 50-60 accuracy
  • Technological advances in imaging are responsible
    for our increased accuracy in diagnosing patients
    with acute abdominal pain
  • CT
  • Ultrasound

56
Imaging-Ultrasound
Good first line investigation for most
intra-abdominal conditons
Non-invasive, no radiation
57
Imaging-Ultrasound
Biliary tract Cholecystitis Cholangitis
Appendicitis Gynaecological
conditions Ovarian cysts (rupture,
torsion) Ectopic(TVS) Urological conditions
(renal, ureteric stones, hydronephrosis)
58
CT scan
High accuracy in most acute abdominal conditions
  • GI
  • Small/ large bowel obstruction
  • Diverticulitis (hinchey grading)
  • Vascular
  • AAA (esp leaking)
  • Aortic dissection
  • Mesenteric ischemia
  • Hepatobiliary
  • Biliary tract (stones)
  • Rupture HCC
  • Pancreatitis

59
Contrast Enema
LB obstruction
60
Hx and exam
Baseline Ix CBC, RFT, LFT, Amylase, AXR,
CXR Initial MX
peritonitis
No peritoneal signs or equivocal
Equivocal signs
Operation
Further Ix CT/USS
Serial Examination
peritonitis
Def RX
Peritonitis or condition requiring surgery
Diagnosis
61
Preoperative preparation
Informed consent IV antibiotics X-match Optimize
comorbidities Booking of emergency OT
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