ACUTE ABDOMEN Begashaw M

ACUTE ABDOMEN Denotes any sudden condition with chief manifestation of pain of recent onset in the abdominal area which may require urgent surgical intervention

Sites of referred pain

Sites of Abdominal Pain

CLASSIFICATION Obstruction Inflammation Hemorrhage Infarction perforation

CLINICAL FEATURES Symptoms _Colicky and Intermittent pain ( visceral) _Continuous pain ( somatic) _Vomiting _Fever _Tachycardia Colic pain obstruction Continuous pain infection, inflammation or ischemia

Signs Abdominal distention, visible peristalsis Direct and rebound tenderness, guarding Anemia, hypotension Toxic with Hippocratic faces Absence of bowel sound ( peritonitis) Psoas signappendicitis Murphy‘s signacute cholecystitis Dehydrationsunken eyeballs

DIFFERENTIAL DIAGNOSIS Surgical - Intestinal obstruction Gynecologic & obstetric - Ectopic ruptured pregnancy Medical - enteritis

Surgical causes A- InflammationAcute appendicitis Acute cholecystitis B- Obstruction Intestinal obstruction C- Infarction Mesenteric ischemia D-Strangulation volvulus E- Perforation perforated peptic ulcer

DIAGNOSIS Clinical: Hx & p/E Lab: CBC, cross match, urine analysis, serum amylase & electrolytes Ultrasound plain film of abdomen

MANAGEMENT A-Preoperative - Resuscitation with IV fluids - Antibiotics - Catheterization & NGT insertion - Analgesics after confirming the diagnosis B- Surgery Definitive laparotomy CMonitoring Follow up

INTESTINAL OBSTRUCTION is partial or complete blockage of the intestine producing symptoms _Vomiting _Constipation _Distension _Abdominal pain

Causes of mechanical intestinal 0bstruction

Intestinal Obstruction

CLASSIFICATION Mechanical  physical barrier blocks Paralytic ileus disordered propulsive motility High _Small bowel Low _Large bowel Simple -> adequate blood supply Strangulated -> Mesenteric vessels occluded

Mechanical A- Luminal _Gallstone Ileus _Food bolus _Meconium Ileus _Malignancy _Inflammatory mass _Ascaris bolus B- Mural _Stricture _Congenital _Inflammatory _Ischemic _Neoplastic _Intussusception

Intussusception

C- Extra mural Adhesionsinflammatory/malignant Hernia External/internal Volvulus Small bowel large bowel -> Sigmoid volvulus

Small bowel obstruction

Adhesion

PATHOPHYSIOLGY Proximal dilatation disrupts peristalsis Above the obstruction  distended with fluid and gas stimulates excessive peristalsis ->colicky pain blood vessels-stretched & narrowed ischemia Absorptive capacity decreases increased vomiting  depletion of extra cellular fluid  hypovolemia & dehydration

Pathophysiology

A strangulated loop dies and perforates to produce severe bacterial peritonitis which is often fatal Grossly distended abdomen restricts diaphragmatic movement and interferes with respiration A multiple organ failure

Clinical features Symptoms -Abdominal pain-colic -Vomiting -Constipatio-partial -absolute Signs -Abdominal distension visible bowel loops -High pitched bowel sounds -Tenderness & guarding -Dehydration & hypotension -Empty rectum DRE Large bowel obstruction

DIAGNOSIS Clinical: Hx & P/E Lab: CBC, electrolytes Plain abdominal film : - distension of bowel with air fluid level - Central located distended loops with multiple air fluid levelsmall bowel - Peripherally located distended bowel with haustral marksLarge bowel

X-ray of intestinal obstruction

MANAGEMENT Fluids resuscitation to restore the circulatory state Early preoperative preparation Attempt rectal tube deflation-simple sigmoid volvulus Supportive measures Early operationLaparotomy Post operative care

NG tube suction

SIGMOID VOLVULUS Sigmoid colon is the most frequent site of volvulus Predisposing factors - A long redundant sigmoid with a narrow pedicle - High fiber diet Chronic constipation_elderly _chronic mental pts

Sigmoid volvulus

PATHOPHYSIOLOGY Redundant sigmoid twists on its base in a clockwise direction Mesocolic veins become occluded & arterial inflow into the twisted loop perpetuates the volvulus until it becomes irreversible Twisted loop distends grossly Perforation may occur due to either pressure necrosis at the base of the twist or to avascular necrosis at the apex

DIAGNOSIS CLINICAL _Abdominal cramp & distension _Constipation (early) & vomiting (late) _Empty rectum on DRE RADIOLOGIC FINDINGS Two long fluid levels in the lower quadrant Inverted U shape of the sigmoid lumen “Coffee bean” appearance or the ‘Omega sign”

MANAGEMENT Conservative simple volvulusdeflation with a well greased large bore rectal tube under the guide of a sigmoidoscope Deflation fails laparotomy & derotation Elective resection & anastomosis Intravenous fluid - rehydrate if sign of dehydration

Sigmoidoscopic deflation

Emergency Surgery _Complicated volvulus with signs of peritonitis _Resuscitative measures _Antibiotics _Resection of the gangrenous segment with Hartman’s colostomy

Laparatomy

APPENDICITIS is an inflammation of the appendix that results from bacterial invasion usually distal to an obstruction of the lumen

Appendix

Pathogenesis Luminal obstruction bacterial overgrowth  lnflammation/swelling Increased pressure-localized ischemiagangrene/perforationlocalized abscess (walled off by Omentum) or Peritonitis Etiology: _Hyperplasia of lymphoid follicles _Fecolith, obstructing neoplasm _Parasites, foreign body

CLINICAL PRESENTATION Symptoms -Central abdominal colic which shifts to the right Iliac fossa -Anorexia, nausea, episodes of vomiting and low grade fever -High grade fever indicates perforation and peritonitis

Signs -Tenderness and localized rigidity in RLQ MC Burney’s point -Rovsing’s sign: Pain in RLQ on pressing in LLQ -Psoas sign: Pain on extension of right flexed hip -Obturator sign: Pain on passive internal or external rotation of the flexed right hip -Right sided tenderness on rectal examination. -Diminished bowel sounds indicating peritonitis

Appendicitis signs

Differential diagnosis IN CHILDREN -Intussusceptions -Mesenteric adenitis FEMALE -PID -Twisted ovarian cyst( torsion) - ruptured ovarian follicle GENERAL -Acute chlolecystitis -Perforated PUD -Renal or ureteric calculi -UTI -Early small bowel obstruction (volvulus) -Gastroenteritis

Investigations Labs leukocytosis with left shift beta-hCG to rule out ectopic pregnancy Urinalysis Imaging: Upright CXR, AXR-free air Ultrasound: may visualize appendix

MANAGEMENT PREOPERATIVE -Resuscitation with fluids -Appropriate antibiotics (combination for coverage of gram positive, gram negative and anaerobes) -Correct all deficits ( dehydration) SURGERY -Surgical removal of the appendix is the definitive treatment-Appendectomy

COMPLICATIONS Perforation - local or generalized peritonitis Appendiceal mass and abscess formation Death

APPEDECIAL MASS Inflammatory process walled off in the right iliac fossa by omentum and loops of bowel to form a mass Management-Conservative -antibiotics -fluids _Drug of choice- metronidazole and ceftriaxone Ampicilline, Chloramphenicol & Gentamycin

Follow up -Vital signs every 4 hourly -Mass size & consistency 12 hourly -Patient’s condition -Laboratory every other day Interval appendectomy 6 weeks later

Appendiceal abscess Increasing mass size Fluctuation persistence of systemic signs Management - drainage of the abscess and appendectomy Interval appendectomy after emergency drainage

Draining appendeceal abscess

PERITONITIS is an inflammation of the peritoneum is an acute life threatening condition caused by bacterial or chemical contamination of the peritoneal cavity

Peritoneum

Peritoneal abscess

Differential diagnosis Perforated appendix Perforated PUD Anastomotic leak Strangulated bowel Pancreatitis Cholecystitis Intra abdominal abscess Typhoid perforation Ascending infection e.g salpingitis

CLASSIFICATION Primary peritonitis: caused by bacterial spread via the blood stream Secondary peritonitis: caused during perforation or rupture of abdominal organ allowing access of bacteria and irritant digestive Juices to the peritoneum

Classification Acute peritonitis: rapid onset or brief duration Chronic peritonitis: long duration Localized peritonitis - confined to a limited space - pelvis Generalized peritonitis - whole peritoneal cavity involved

ROUTES OF BACTERIAL INVASION 1- Direct- contamination via perforation, a penetrating wound or during surgery 2-Local Extension: contamination by migration from an infected organ - through gut wall, via the fallopian tube 3-Blood stream: via the blood as consequence of general septicemia

CLINICAL FEATURES Sharp pain which is worse on movement Fever & tachycardia Abdominal distension Tenderness & guarding Diminished or absent bowel sounds Shoulder pain _referred pain -diaphragmatic irritation Tenderness on rectal examination (pelvic peritonitis) Abdominal distension & vomiting

Generalized peritonitis

MANAGEMENT Resuscitation: intravenous fluids Analgesia Naso-gastric tube insertion (NGT) Triple antibiotics (ampicilline , gentamycin and metornidazole or chloramphenicol) Monitoring in put & out put by catheterization Surgery Drainage & peritoneal lavage