The Acute Surgical Abdomen Ada Ekpe Amel Ibrahim
Contents Anatomy Adominal pain Management of the acute abdomen: from history to exam Scars and surgeries Stomas Questions
Anatomy of the abdomen 9 regions and 2 flanks Surface: Skin Linea alba and umbilicus Xiphisternum Symphysis pubis Pubic tubercle Costal margins Iliac crests
2 Hypochondria Epigastrium 2 Loins Paraumbilical Suprapubic 2 Iliac fossae 2 Flanks
Surface Anatomy Transpyloric plane of Addison: Halfway between jugular notch and Symphysis pubis. Contains: body and tail of pancreas, L1 body, 2 nd part of duodenum, Hilum of L kidney, upper pole R kidney, pylorus, tips of 9 th costal cartilages, fundus of GB, splenic and hepatic flexures, spleen and origins of SMA and portal vein.
McBurneys point: 1/3 of way between ASIS and umbilicus. Appendix Mid inguinal point: halfway between ASIS and pubic tubercle. Site of deep ring. Mid point of inguinal ligament: Half way between ASIS and pubic symphysis. Site of femoral pulse.
Referred pain No plan for viscera Pain referred to associated dermatome Appendicitis: initially T10 then as peritoneum inflamed (richly innervated) pain localised to RIF
Pain Epigastric: cardiac Lung Thoracic dissection/ruptured aneurysm pancreatitis Liver Gall bladder Gastric/duodenal ulcer Transverse/small bowel RUQ: Gall bladder Liver Lung Bowel LUQ: Spleen Bowel Lung Cardiac
RIF: Skin: cellulitis/sebaceous cyst Subcut tissue: nec fasc Lymph nodes: mesenteric adenitis/lymphoma/infectio n Bowel: large bowel (tumour, colitis) Appendictis/appendix mass Constipation Strangulated hernia Ruptured iliac aneurysm OVARIAN Orchitis/undescended testis
LIF: Diverticultis Tumour Hernia Testicular Ovarian Colitis Lymphoma etc…
Q&A Paraumbilical? Flank? Suprapubic?
History Site Onset Character Radiation Associated symptoms Time Exacerbating/alleviating factors Severity
Change in bowels Appetite? Is pain associated with food? Nausea/vomiting Urinary symptoms/systems review Previous surgeries Medications Family history Social history
Examination ABC Observations OBSERVE: Jaundice nutrition body habitus Discomfort Stigmata of ETOH use Position (mobilising/peritonitic)
Volunteer? Abdo exam: Hands (dupuytren’s/clubbing/asterixes/pulse/nails) Face (icteric/hydration) Neck (Virchow’s node) Chest (spider naevi/gynaecomastia) Abdomen: scars, lumps, erythema, tenderness, guarding, peritonism, organomegalyand bowel sounds) PR: skin tags/fungating tumours/haemorrhoids, tender, mass, blood and rectum empty/full (hard or soft stool). HERNIAL ORIFICES AND TESTES
Management Analgesia IV access Fluids/antibiotics (if necessary) AXR and/or USS Vs CT scan Optimise for theatre or manage conservatively Common emergencies: appendicitis, diverticulitis, ischemic colitis, strangulated hernia and SBO. Common emergency operations: appendicectomy, herniorraphy +/- resection, Hartmann’s and (sub)total colectomy.
Stomas Ileostomy: often RIF spouted, liquid contents Colostomy: end/defunctioning Flush Solid contents Urostomy: For cystectomy Ileal conduit Urine in bag