Dr. Abdul Ghani Soomro Associate Professor Surgery LUMHS Jamshoro

ACUTE ABDOMEN 1 .Pain 2.Vomiting 3.Constipation 4.Abdominal distention

Acute abdomen Spectrum of medical and surgical conditions ranging from trivial to life threatening that requires hospital admission investigations and treatment .

Diffuse difficult to localize Referred pain Somatic Abdominal wall Peritoneum Visceral Diffuse difficult to localize Referred pain Irritation of abdominal organ

Symptoms Luminal obstruction Inflammation. Appendicitis Cholecystitis Pancreatitis Peritonitis. Perforated viscus Strangulation Intra peritoneal collection Bile Blood Pus I

Organ Location of Pain Pathology Liver Right Upper quadrant Hepatitis Common Causes of acute abdominal pain Organ Location of Pain Pathology Liver Right Upper quadrant Hepatitis Liver abscess CCF

Organ Location of Pain Pathology Biliary Tract Right Upper quadrant Common Causes of acute abdominal pain Organ Location of Pain Pathology Biliary Tract Right Upper quadrant Choleycystitis Cholelithiasis Choledocholithiasis

Common Causes of acute abdominal pain Organ Location of Pain Pathology Pancreas Epigastrium Right Hypochondrium Left Hypochondrium Acute Pancreatitis Ca Pancreas Ca Oesaphagus

Common Causes of acute abdominal pain

Common Causes of acute abdominal pain

Common Causes of acute abdominal pain

Common Causes of acute abdominal pain

Common Causes of acute abdominal pain

Common Causes of acute abdominal pain

Common Causes of acute abdominal pain

Common Causes of acute abdominal pain

Common Causes of acute abdominal pain

Taking the history of a patient with acute abdomen Specific question When did the pain start and was the onset sudden? What brought the pain on and are there any aggravating or relieving factors? Where did the pain start and where is it now? Does it radiate elsewhere? What is the character of the pain and how severe is it?

Taking the history of a patient with acute abdomen Specific question Are there any associated symptoms? (e.g. distension, nausea, vomiting, fever, diarrhoea, absolute constipation, anorexia, jaundice, pruritis, gastrointestinal bleeding, dysuria, oliguria, chest pain) Was there any similar episode in the past? When was your last period and is there any chance that you may be pregnant?

Taking the history of a patient with acute abdomen General enquiries History of alcohol intake Drug history History of previous surgery History of Pre-existing disease History of travel (Especially foreign) Family history

Investigations Blood CP Urea Creatinine Blood Sugar Serum Amylase LFTs Pregnancy Test Urine DR ECG

Imaging Radiography Abdomen Chest Ultrasound Abdomen CT Scan MRI Barium Studies Endoscopy Laparoscopy / Laparotomy

Acute abdomen in infants & Children Congenital atresia Volvulus Meconieum ileus Meckl’s diverticulum Inguinal Hernia

Common Surgical Emergencies Acute Appendicitis Liver Abscess Abdominal Tuberculosis Typhoid Perforation perforated peptic ulcer Abdominal wall hernia

Acute Appendicitis Most common abdominal emergency. Uncommon before the age of 2 years. Peak incidence in twenties and thirties

Aetiology The vermiform appendix is a vestigial structure. 7-10 cm in length. Exact cause is unclear but luminal obstruction, diet, familial factors have been suggested.

Pathology Minor, simple, acute with spontaneous resolution to supperactive necrosis and perforation. Bacteria (E Coli, Klebsilla, Proteus). Enter through ulcer (caused by faceolith). Edema purulent inflammation thrombosis, gangrene.

Clinical Features Age can influence presentation. Clinical picture also dictated by position of appendix. Epigastric / periumblical pain . Shift to right iliac fossa. Colicky / dull pain. Aggravated by movement and coughing. Loss of appetite constipation nausea and vomiting.

Clinical Examination Tachycardia. Mild Pyrexia Guarding in RIF Fetor oris Tenderness on rectal / vaginal examination. Rovsings sign, psoas stretch sign. Obturater test

Anatomical Feature influencing Presentation 1. Retrocaecal Muscular rigidity often absent Right hip in flexed position due to psoas spasm Psoas stretch sign.

2. Post ileal 3. Pelvic Diarrohea and Vomiting Prominent feature due to irritation of ileum. 3. Pelvic Diarrohea due to irritation of rectum. Increased frequency of micturation. Microspic haematuria. Tenderness on rectal and viginal examination. Obturator sign.

Age Related features affecting presentation Children Difficulty in obtaining Proper history Difficulty in differentiating from mesenteric adenitis and enteritis.

Elderly Under developed omentum leading to early complications. Less prominent Symptoms Afebrile Normal white cell count.

Pregnancy 1 per 1500-2000 / years in UK. Displacement of appendix by Gravid uterus can result in atypical presentation. Symptoms may be confused with onset of labor. Tenderness may not be marked due to gravid uterus. Less maternal mortality in case of simple appendix. Risk of featal death is about 10% . Complications both at risk.

Complications Perforation Appendix mass Appendix abscess

Differential Diagnosis Thorax and Respiratory Tract Tonsilltis Pneumonia

Abdomem Intestinal Obstruction Intussusception Acute cholecystitis Perforated Peptic ulcer Mesenteric adenitis Terminal ileitis Meckel’s diverticulitis

PELVIS Ectopic Pregnancy Ruptured ovarian follicle Torsion of ovarian cyst Salpingitis PID

URINARY SYSTEM Right Pyelonephritis Right Uretric Colic

OTHER Diabetic ketoacidosis Rectus sheath haematoma Pancreatitis Pre Herpetic Pain

INVESTIGATIONS Blood cp Urine analysis

Faecolith 50% of children < 2 years RADIOGRAPHY Faecolith 50% of children < 2 years Ultrasound abdomen C.T Scan Laparoscopy

TREATMENT Appendicetomy Open Laparoscopic

Amoebic liver Abscess It is common in indo-pak Caused by parasite entamoeba histolytica Common in alcoholics Infection commonly occurs in caecum and rectosigmoid junction via superior and inferior mesentric veins and portal vein to liver.

Right lobe of liver is commonly involved, size of right lobe, portaly vein is in direct continuation with right branch. Infection Leads to liquefaction necrosis and formation of pus (Anchovy Sauce) which is chocolate brown in colour odourless. Pus may be green if mixed with bile. Secondary infection is common in (30%) 70% single abscess, 30% multiple.

E. Histolytica Life Cycle 2 stages: -Infective cyst stage - Multiplying trophozite stage 2 forms: - Active parasite (trophozite) - Dormant parasite (cyst) Infection begins when cysts are swallowed Cysts hatch---releasing trophozites that multiply Trophozites cause ulcers on the lining of intestine and produce diarrhea. Once the intestinal epithelium is invaded, extra intestinal spread to the peritoneum, liver, brain and other sites may follow. Some of the trophozites forms cysts which are excreted in the faeces along with trophozites Outside the body, trophozites die but cysts remain. Merck Manual Home Edition 2003

Complications Rupture of the abscess with extension into the peritoneum, pleural cavity, or pericardium. Extra hepatic amebic abscesses have occasionally been described in the lung, brain, and skin Amebiasis: Parasitic Infections: Merck Manual Edition 2007

Treatment Drugs Aspiration under ultrasound guidance Metronidazole Tinidazole Chloroquine Diloxanate furoate Iodoquinol Paromycin Aspiration under ultrasound guidance

Surgery Thick pus Ruptured liver abscess

Common Surgical Emergencies Acute Appendicitis Liver Abscess Abdominal Tuberculosis Typhoid Perforation perforated peptic ulcer Abdominal wall hernia

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