Title: The Acute Abdomen
1The Acute Abdomen
- Raymond Yiu
- Surgery Team 3
2- Acute Life-threatening intra-abdominal conditions
- Requires Emergency admissions
- Often requires Emergency surgery
3Aetiology Abdominal Pain
- EXTRAABDOMINAL
- Cardiovascular MI
- Metabolic DKA
- Abdominal wall rectus sheath haematoma
- Neurogenic referred pain
- INTRABDOMINAL
- Imflammatory
- Traumatic
- Obstructive
- Vascular
4INTRABDOMINAL
- 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
5Imflammatory Conditions
6Peritonitis
- Bacteria
- primary/ secondary/ tertiary spontaneous
- Chemical
7Peritonitis 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) -
9Peritonitis 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
10PeritonitisClinical 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)
11PeritonitisClinical Features
- Systemic Fever
- Tachycardia
- Leucocytosis
- Chills/rigors
- Dehydration
- Abdominal tenderness, guarding, rigidity,absent
BS, distention (ileus)
Generalised
localised
12PeritonitisLocalisation of signs and pathology
13PeritonitisClinical Features
Pancreatitis
Liver abscess
PPU
Cholecystitis Cholangitis
Diverticultis
Meckels diverticultis Small bowel perf
Appendicitis
14Acute abdomenCommon conditionsAppendicitisCho
lecystitis
15Acute appendicitis aetiology
Obstruction of lumen by Lymphoid
hyperplasia Faecolith Parasites Cancer/ carcinoid
16Acute appendicitis Clinical Features
7 population 10-30 years Mortality rate
lt1 5 Elderly and young (delay in
diagnosis)
17Acute appendicitis
- RLQ pain
- Pain migration
- Anorexia, nausea
- RLQ tenderness
- RLQ guarding
- RLQ rebound
- Fever
- Leucocytosis (80)
Mcburneys point
18Acute appendicitis Signs
Rovsings sign Pain in RLQ on pressing
LLQ Dumphys sign Pain on coughing
Psoas sign
Obturator sign
19Acute appendicitis Signs
- Depends on where inflamed appendix is
- Retrocecal Lumbar sign Pain in right flank
- Pelvic irritate bladder dysuria
- irritate rectum diarhoea
20Acute appendicitis Ix
21Acute appendicitis
Open
Laparoscopic
Young women of child bearing age
22Acute 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)
23Acute Cholecystitis
Remember 4 Fs
Pigment
Calcium
Cholesterol
24Acute Cholecystitis
Chemical peritonitis initally
25Acute Cholecystitisclinical features
Short onset RUQ pain
Fever RUQ peritoneal signs Murphys signs
26Acute CholecystitisImaging
27Acute 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
28Intestinal Obstruction
29Aetiology
- Extramural adhesions
- hernias (int/ext)
- tumor
- Intramural tumor
- stricture (radiation/crohns/tb)
- Intraluminal Food bolus
- GS
- FB
- Faecal impaction
30Aetiology by incidence (SBO)
- Previous OT adhesions
- Virgin abdomen carcinoma, hernias
31Questions to ask?
- Site Stomach vs SB vs LB
- Presentation Acute vs Subacute
- Urgency simple mechanical vs strangulating
32Site 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
33Site 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
34Presentation 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
36Simple Mechanical Obstruction
37Simple Mechanical ObstructionFemoral hernias
38Strangulating 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)
39Sigmoid Volvulus
Example of close loop obstruction both ends of
the bowel are blocked and air enters in a one-way
valve
40Sigmoid Volvulus
Decompression bedside sigmoidoscopy or
colonoscopy
failure
41intussusception
Usually associated with polyps acting as lead
point
42Small bowel ischemia
Prolonged strangulation from adhesion band, hernia
Small bowel volvulus
43Recognising 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)
44Management
Hx and exam Initial Mx Baseline Ix Special
Ix Preparation for OT
45History 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
46Pattern Recognition is very important !
47Pattern 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
48Initial Mx
NGT
NPO
analgesia
Resuscitation IVF
Iv antibiotics
Monitoring devices
Foley (CVP)
49Baseline 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
-
51Liver 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
53Urinalysis
- 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
54Plain 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!
55Special 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
56Imaging-Ultrasound
Good first line investigation for most
intra-abdominal conditons
Non-invasive, no radiation
57Imaging-Ultrasound
Biliary tract Cholecystitis Cholangitis
Appendicitis Gynaecological
conditions Ovarian cysts (rupture,
torsion) Ectopic(TVS) Urological conditions
(renal, ureteric stones, hydronephrosis)
58CT 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
59Contrast Enema
LB obstruction
60Hx 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
61Preoperative preparation
Informed consent IV antibiotics X-match Optimize
comorbidities Booking of emergency OT