Approach to acute abdomen Supervised by , Dr.B.Faki Presented by, Eman Al.harbi

Introduction defined as any clinical condition characterized by severe abdominal pain which develops over a period of 8 hrs. In pt who have been previously well. rapid and accurate diagnosis is essential for morbidity and mortality process.

Pathophsiology Visceral pain; due to stimulation of visceral afferent nerve plexus usually in midline result from contraction or distension against resistance & chemical irritation usually colicky in nature.

Pathophsiology Parietal pain; 2dry to partial peritoneum irritation perceived through segmental somatic fibers reflex involuntary muscle wall rigidity may result from irritation of segmental sensory nerves. Hyperesthesia of the skin may be result from ipsilateral peritoneal irritation usually a sharp ache.

Abdomen

Epidemiology

Abdominal quadrant

Causes Gastrointestinal tract* Acute appendicitis Meckl”s diverticulitis bowelPerforated ulcer Perforated peptic obstruction Small and large bowel herniaStrangulated Diverticulitis Gastritis Gastroenteritis Inflammatory bowel disease lymphadinitis Mesenteric

spleen. and , liverBiliaryTract sCholangiti acute Cholecystitis acute Hepatic abscess tumor Ruptured hepatic spleen Ruptured biliary colic , Hepatitis acute infarct Splenic

Peritoneum Intra-abdominal abscess Peritoneum Intra-abdominal abscess* Primary peritonitis Tuberculosis peritonitis Pancreas Pancreatitis, acute ca pancreases Urinary Tract Cystitis acute Pyelonephritis acute Renal infarct teral colicUre

Gynecological ; ruptured ectopic pregnancy Ruptured ovarian follicular cyst Twisted ovarian tumor Dysmenorrheal Endometriosis acute salpingitis. PIDs

Male reproductive tract. Prostatitis Cystitis Torsion of testes Vascular causes Acute ischemic colitis . Mesenteric thrombosis* Ruptured arterial aneurysm*

Medical causes Pneumonia. Myocardial infarction Sickle cell crisis. DKA Leukemia Herpes zoster psychogenic

Approach to acute abdomen History. 1. pain 2. Associated symptoms, nausea, vomiting, Change of bowel habitués, jaundice, anorexia, Heamatemsis, melena, dyspepsia 3.Menstruatin & sexual history.

Cont.. 4.ROS 5.past medical & surgical hx 6.hx /o medications 7.familay Hx 8.social Hx

Eg Acute appendicitis, constant ,progressive more severe start per umbilical move toward RIF.+ nausea, vomiting, low grade fever, anorexia &/or constipation.

Inflamed appendix

Acute cholecytitis Constant moderate pain in RUQ radiated to Rt shoulder tip + nausea, bilious vomitus, low grade fever & jundice

Perforated peptic ulcer, Sudden onset of pain in midepigastrium that spreads and is aggravated by movement; patient appears acutely ill and is reluctant to move; rigid abdomen; grunting respiration; bowel sounds absent

Ectopic pregnancy, Pain sudden, severe,persistent,following a missed or abnormal period, typically epigastric; associated with hypotension and tachycardia Ovarian cyst Pain constant with sharp, sudden onset, usually in ipsilateral hypogastrium; may have nausea and vomiting following the pain.

Pelvic inflammatory disease. Pain at end of or after normal menstrual period, bilateral lower quadrant pain aggravated by cervical manipulation; anorexia, nausea, and vomiting rare; possible cervical discharge; fever

Urinary stone, Pain location changes with movement of stone, may radiate to testicle, groin of involved side, pain very severe; patient cannot get comfortable

Physical examination 1.general appearance, 2. Vital signs. 3.abdomial exam 4.rectal exam 5.pelvic exam (female pt)

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investigation 1.CBCs, WBCs & differential. RBC & hct, degree of anemia & hemocon. Platelet count, evidence of cougalopathy. 2.electrolyte, (G, Na, K, Cl, Ca ,Mg, Po) Indicative of volume status, GIT loss,

. 3.ABG, Indicate metabolic acidosis or alklosis. M.acidosis with generalized abdominal pain in elderly is ischemic colitis till proven other wise.

. 4.liver function test Bilirubin (D or ID), ALP elevation in biliary obstruction & transaminase elevation in case of hepatocellular injury. 5.RFT Urea, creatinin elevation in renal insufficiency Serum albumin decrease in edema / ascitis.

. 6. serum amylase Seen in pancreatitis although non specific may be elevated in mesenteric ischemia, perforated peptic ulcer, rupture ovarian cyst & renal failure. But lipase more sensitive.

. 7.serum B_HCG Mandatory for all women in childbearing period. 8.urinalysis See WBC RBC & casts.

Radiological evaluation 1.CXR, Look for pneumonia, free gases under diaphragm .pleural effusion suggest sub diaphragmatic inflammatory process.

. 2.abdominal Xray. (Erect & supine position ) * bowel distension & air fluid level *bowel gas cut off vs air through rectum. *sentinel loop vs pancreatitis *abn calcification vs ch.pancreatitis,stone *pnumatosis vs omnious sign of dead gut.

Intestinal obstruction

. 3.ultrasound, *hepatobiliray tree(stones,mass,thickining of the wall) *pancreases *kidney *pelvic organ *intrabdominal fluid collection

Gall stone\ appendicolith

. 4.CT_scan Helpful in case of abdominal pain without clear etiology better in evaluation of abdominal oartic aneurysm. 5.helical CT_scan Provide rapid cost effictive dignostic tool.

Acute pancreatitis\dilated loop

. 5.contrast study A. barium study *perforation, *discering point of obstruction in small bowel. *avoid if colonic diverticuilitis is suspected

Multiple stones in CBD

. B_ intravenous pyelogram For dignosis of ureteral stone or obstuction C_angiography For mesenteric ischemia

angiograph

Other study 6.endoscopy, EGE, for evaluation epigastric pain in non acute setting.& git bleeding Sigmoid\colonoscopy *colonic obstruction *dig IBD,ischimic colitis lower bleeding, *nonstrangulated sigmidal volvulus

ERCP

. 7.paracentesis &\or peritoneal lavage *spontaneous bacterial peritonitis in cirrhotic pt *peritoneal lavage may be useful bedside test in diagnosis of mesenteric infarction in critically ill pt.

. 8.culdocentesis Valuable in diagnosis of rupture ectopic pregnancy. 9.laproscopy *D & ttt of suspected gynec.cause *appendectomy if appendicitis is found in a women in childbearing period.

laparoscopy

Plan of treatment *promote timely work up in first 4_6hrs. *keep pt Npo till the diagnosis is firm & ttt plan is formulated. *IV fluid. based in expected fluid loss. *heamodynamic monitoring. *NGT bleeding ,vomiting ,sign of obstruction or when urgent laparoscopy is planned in pt not NPo.

. Foley catheter to monitor fluid out put decisions Immediate surgery * what is the timing of operative intervention( does pt need time for resuscitation) *what incision should be used?

. * what are the likely findings? *develop primary operative plan. * consider alternative diagnosis & plan. * use appropriate pre-operative antibiotic based on suspected pathology.

. 2. admit & observe for possible operation. *serial examination every 2-4 hrs during the first 12-24 hrs in case without definite diagnosis; minimal use of narcotics & sedatives to avoid masking physical sign & symptoms. *monitor vital signs frequently *serial lab exam may be useful ;repeat CBC every 4-6hrs.

. 3.no operation develop ttt plan for further diagnostic workup or non operative therapy.

Case 36 yrs old female pt status post oratic valve replacement who present with one week hx of acute abdominal pain becoming severe over last 24hrs O\E tachycardia, PR=145\min, B.P=100\45 temp=38. abd. Distended , rigid with moderate tenderness.wbc=23. amy=200 LDH=1500.

. What is mostly like diagnosis? What is the investigation of choice? Management plane?

. Thanks