1. Acute abdomen 4 th year part I 2012 Dr Abdulhakim Al-Tamimi, MD Assiss prof of suregry Aden university

3. Acute abdomen Definition: “An acute intra-abdominal condition of abrupt onset that is usually associated with pain due to inflammation, perforation, obstruction, infarction or rupture of abdominal organs in previously healthy person and usually requiring emergency intervention. Called also surgical abdomen.” Dorland’s Medical Dictionary 2007

4. General rule can be made that majority of severe abdominal pain in pts who have been previously fairly well and last longer than 6 hours are caused by surgical conditions

5. “The term “acute abdomen” should never be equated with the invariable need for operation.” Zachary Cope, MD, 1927

6. THE USUAL causes Non-Surgical:34% Appendicitis28% Cholecystitis10% Small Bowel Obstr.4% GYN4% Pancreatitis3% Renal3% Cancer3% Diverticulitis3%

7. Acute Abdomen Acute abdominal pain with peritoneal signs and often abnormal vital signs Peritoneal signs = peritoneal irritation from inflammation/infection Symptoms include nausea, vomiting Signs include fever, shallow respiration, hypotension, guarding,rigidity and rebound tenderness Needs to have urgent assessment in Emergency room

8. Red Flags New onset of pain, change in pain or altered bowel habits in the elderly Weight loss, hx CAD Bleeding per rectum or melena New anemia, hx of ETOH abuse Supraclavicular nodes A personal or family history of serious bowel pathology Pain waking the patient at night Immunocompromised, previous abdominal surgery Abnormal vital signs

9. Necessity for Diagnosis A serious and thorough attempt at diagnosis Abdominal pain is the most common symptom Acute abdomen = surgery is not always indicated

11. Course of action Urgent operation Wait for evolution of symptoms Medical management

12. What you should know as 4 th year ? Plan 1. Common causes 2. History and examination 3. Investigations 4. Case example

13. Epidemiology Abdominal pain present in 10% of hospital admissions. 1/3 of these require surgical intervention.

14. Classification of acute abdomen According to the related cause Inflammatory Obstruction Perforation Hemorrhage ( rupture or infarction )

15. Syndromic classification : Peritoneal syndrome Obstructive syndrome Hemorrhagic syndrome Mixed syndrome

16. Causes at sites Diffuse Acute pancreatitis DKA Gastroenteritis Intestinal obstruction Peritonitis Mesenteric ischaemia RUQ Cholecystitis Biliary colic Hepatitis Hepatic abscess LUQ Gastritis Splenic rupture/abscess RUQ/LUQ Acute pancreatitis Lower lobe pneumonia Myocardial ischaemia RLQ Appendicitis Caecal diverticulitis Meckel’s diverticulitis LLQ Sigmoid diverticulitis RLQ/LLQ IBD Renal stones Cystitis Endometriosis Ruptured ectopic pregnancy Incarcerated hernias Psoas abscess

17. Types of Pain caused by stimulation of nerve fibers of organs. described as dull,crampy, colicky (comes and goes) tends to be diffuse and difficult for a patient to pinpoint commonly seen with other signs and symptoms such as sweats, vomiting, nausea and tachycardia visceral

18. Abdominal Pain Visceral pain – stretching of visceral organs caused by inflammation of the visceral peritoneum and capsule of solid organs. Example: Early appendicitis---paraumblical region or epigastrium

19. Types of Pain, continued a focal pain that occurs when nerve fibers within the peritoneum are irritated by chemical or bacterial inflammation more localized and is usually described as sharp and knifelike constant and made worse by coughing or movement somatic

20. Abdominal Pain Example: Late appendicitis with peritonitis, perforated peptic ulcer

21. Types of Pain, continued a radiating pain that is felt at a location away from the point of origin pain associated with kidney stones may be referred to the testicle myocardial infarction, pneumonia and musculoskeletal injuries can refer pain to the abdominal area referred

22. Gall bladder diseases – right shoulder,scapular region LLQ pain with appendicitis

23. Obturator internus spasm – pain on rotation of the flexed thigh inwards and this pain is referred to hypogastrium - in pelvic appendicitis and haematocele

24. Types of Pain, continued shifting pain – when the pain move to other site without any other relation to the previous site Example paraumlical pain shifted to the right iliac fossa

27. History is very important ?? Description of pain - OPQRST: Onset Provoking and relieving factors (what makes it worse or better ) Quality (burning, cramping, dull) Relieving factors, and radiation Severity (out of 10) Timing ( duration )

28. OPQRST OnsetWhat were you doing when it started? Did the pain come suddenly or gradually? ProvocationDoes the pain move around? Does anything lessen the pain? QualityCan you describe the pain? Is it constant? Does it come and go? Is it sharp, dull or burning? RadiationDo you feel the pain anywhere else? SeverityHow severe on a scale of 1-10 scale? TimeWhat time did the pain come on?

29. SAMPLE History FactorDescription Signs/SymptomsChief complaint What happened? AllergiesTo medications, etc. MedicationsPrescription, over the counter, and recreational (illicit) drugs Past medical historyMedical conditions Last oral intakeFood and drink Events leading to incidentInclude precipitating factors

30. Pain History-other way to keep by heart SOCRATES Site – where started, has the pain moved? Onset - usually sudden Character – visceral, somatic, colic

31. Radiation - pain in retroperitoneal structures radiates to the back - Loin to groin in ureteric colic - Epigastrium to the back in peptic ulcer - Gallbladder to the right shoulder - Like a belt around the abdomen in acute pancreatitis

32. Associated symptoms - GI symptoms: nausea, vomiting bleeding also GU symptoms and cardiopulmonary symptoms Time of onset ( duration )

33. Elevating and relieving factors Severity – elderly patients have increased pain threshold/reduced visceral sensation.

34. Thorough history and physical examination and recognition of the early stages of the disease Record the earliest symptoms Attempt a specific diagnosis – prevents carelessness and ignorance

35. A correct diagnosis essential to correct treatment Spot diagnosis is magnificent but not sound, is impressive but unsafe.

36. Early Diagnosis Diagnose early No narcotics or analgesics until diagnosis is made Examination,reexamination,testing by inexperienced hands leads to delay in diagnosis and early pain relief

37. Again we said Severe abdominal pain in pts who have been previously healthy and last longer than 6 hours are caused by surgical conditions

38. Early diagnosis improves recovery Decreases mortality Reduces hospital stay due to infections Reduces long term complications

39. What it need this acute abdomen ? Life-threatening condition due to acute onset abdominal disease with typical symptoms and physical findings, which reqiures: Prompt surgical intervention Acute appendicitis Acute peritonitis Acute intestinal obstruction Acute mesenteric vascular insufficiency Rupture of the spleen, ectopic pregnancy, dissection of aortic aneurysm

40. What it need this acute abdomen ? Emergent admission to a monitored bed or intensive care unit Acute pancreatitis Acute cholecystitis

42. Anatomy The abdomen is the largest cavity in the body. The diaphragm separates the abdominal cavity from the chest cavity. Most of the abdominal organs are enclosed within a membrane called the peritoneum. Those organs behind and outside the peritoneum include the kidneys, pancreas and the abdominal aorta called retroperitoneal organs

43. Anatomy Apply your knowledge of anatomy in diagnosing abdominal conditions Diaphragmatic spasm – decreased movement of lower chest and upper abdomen Rectus and lateral abdominal muscle rigidity – in subjacent inflammation Psoas spasm – flexion of thigh and internal rotation

44. Umbilicus at the level of T10 ( thoracic nerves) Abdominal cavity three portions Under costal margin True abdomen Pelvic abdomen

45. Quadrant View of the Abdomen

46. Right Upper

47. Left Upper

48. Left Lower

49. Right Lower

50. Abdominal quadrant

51. Four Quadrants Right upper quadrant (RUQ) contains the liver, gallbladder and part of the large intestine. Left upper quadrant (LUQ) contains the stomach, spleen, pancreas and part of the large intestine. Right lower quadrant (RLQ) contains the appendix, small intestine, fallopian tube and ovary. Left lower quadrant (LLQ) contains the small and large intestine, fallopian tube and ovary.

52. Irritation to the diaphragm will cause pain in the shoulder as the diaphragm has its origin from the 4th cervical segment and is supplied by the cervical segment via phrenic nerve. Pain may be felt in the shoulders in cases of subphrenic abscess, diaphragmatic pleurisy, a/c cholecystitis, ruptured spleen etc.

53. The pain is felt in supraspinatous fossa, over the acromion, clavicle or in subclavicular fossa The shoulder pain is often missed as it is attributed to arthritis.

57. Small bowel colic pain is referred to the epigastrium and the umbilicus Large bowel colic to the hypogastrium Renal colic from loin to groin and the testicles Biliary colic to the right subscapular region

58. Tenderness due to irritation of nerves by unilateral lesion is not felt on the opposite side usually. Eg. Right sided pleurisy causes tenderness in RIF but not in LIF.

59. Exclude medical disease before calling for surgical intervention. (esp a laparotomy) Cardiac disease, tuberculosis, cirrhosis, chronic interstitial nephritis and arteriosclerosis. Porphyrias and diabetic disease (DKA)

60. SEVERE ABDOMINAL PAIN 1. Hollow organ perforation 2. Acute pancreatitis 3. Colic pain a. Biliary system b. Renal system 4. Ischemia pain

61. COMMON DISEASES 1. Acute appendicitis 2. (Perforated) Peptic ulcer 3. Acute cholecystitis 4. Acute pancreatitis 5. Small bowel obstruction 6. Colon obstruction 7. Vascular occlusion 8. Others

62. RE-EVALUATION Time interval Same personnel Vital signs Laboratory examination Early suspicion Early consultation

63. MEDICAL ETHICS Treat a person not a disease Treat a patient as your family Be patient to a patient’s complaint Be kind and more smile Careful explanation

65. Methods of diagnosis Record history in the chronological order of symptoms Age- intussusception in infants (<2) Cancerous stricture rare below30 A/c pancreatitis rare below 20 Perforated GU rare below 15

67. Exact time and onset Many conditions are precipitated by many factors. It is important to know what the patient was doing at the time of onset. Fainting occurs with ectopic gestation, perforated GU/DU, a/c pancreatitis, ruptured aortic aneurysm. Intestinal obstruction gradual in onset and culminates in crisis

68. Shifting or localisation of pain When peritoneal cavity is filled with pus, blood or fluid pain is felt all over the abdomen and later shifts to site of perforation. Pain of small intestine is always felt first in epigastric or umbilical region (T9 to T11 nerves) Remember appendicular nerves are also derived from the T9 to T11 so pain may be initially felt in the epigastric region

69. Vomiting Severe irritation of nerves of the peritoneum or the mesentery eg. DU perforation or torsion ovarian cyst. Obstruction of an involuntary muscle tube. Absence of vomiting is sufficiently common in many abdominal catastrophes as rupture ectopic

70. Vomiting is early, sudden and violent in ureteric colic Early and copious in upper intestinal obstruction No vomiting until late in large bowel obstruction Frequent scanty in A/c pancreatitis Vomiting precedes pain in gastroenteritis

71. Character of Vomitus In gastritis vomitus contains food particle and some bile In CHPS( congenital hypertrophic pyloric stenosis ) and duodenal atresia differentiated by presence of bile in the latter In intestinal obstruction content varies from gastric, bilious greenish yellow to orange and brown indicating feculent vomitus.

75. Double bubble sign

77. Duodenal atresiaCHPS

78. Hypogastric pain and diarrhoea when followed by hypogastric tenderness and constipation suspect pelvic abscess. Partial small bowel obstruction may produce profuse watery diarrhoea without passage of flatus

79. Other symptoms of acute abdomen Distension Diarrhea Constipation Anorexia

80. Inflammatory causes of acute abdomen ? Itis --------------- inflamma-------itis Acute appendicitis Acute cholecystitis Acute pancreatitis Acute diverticulitis Perforated viscous Acute pylenephritis Acute colitis Acute salpingitis

81. All these inflammatory process leads to : Irritation of the peritoneum: Peritonisim Inflammation of the peritoneum: Peritonitis

82. Peritonitis

85. Types of peritonitis Primary peritonitis Secondary peritonitis

86. Localized Regionalized Generalized

87. Acute peritonitis Symptoms– according to part and extent of peritoneum involved, presence of infection and acuteness of onset. Reflex symptoms– pain, vomiting, rigidity. Toxic symptoms– alteration in temperature, collapse, distension, general toxemia. Pain is the most common symptom. Vomiting common at the onset but infrequent until late.

88. Primary peritonitis

95. Clinical picture of primary pretonitis Pain Nausea Vomiting Fever Mild tenderness depend upon the degree of contamination

96. Treatment Usually conservative Antibiotics Waiting for the response Rarely need surgical intervention

97. Secondary pretonitis Most common cause is acute appendicitis Most often infectious and is usually related to a perforated viscus

98. Acute secondary peritonitis Perforations of bowel (appendicitis, peptic ulcer disease, neoplasms, volvulus, ischemia, ingested foreign body, etc.) Perforations or leaking of other organs (pancreatitis, acute cholecystitis, urinary bladder rupture, etc.) Disruption of integrity of peritoneal cavity (trauma, peritoneal dialysis, perinephric abscess, etc.)

99. Clinical manifestations: Acute abdominal pain and tenderness, usually with fever. The location of the pain depends on the underlying cause and whether the inflammation is localized or generalized Localized peritonitis is most common in uncomplicated appendicitis and diverticulitis Distension of intestinal lumen with gas and fluid Boardlike muscular rigidity in cases of diffuse peritonitis Bowel sounds are usually absent Disappearance of liver dullness Tachycardy, hypotension, and signs of dehydration

101. Perforated peptic ulcer Usually adult but it can affected young Sudden onset There may be history of gastric pr duodenal ulcer Duodenal perforation is more common and usually in the first part anterior wall May follow heavy meal May related to drugs as anti inflammatory or steriods

105. Stages of perforated peptic ulcer Three stages Chemical peritonitis 0-6 h Lucid interval ( illusion,reactionary ) up to 12h Diffuse septic peritonitis >24h

106. Severe epigastric pain,which become early diffused all over the abdomen Vomiting once or twice Anorexia Sweating Tender all over board like rigidity Rebound tenderness Loss of hepatic dullness

107. Peritoneal Signs Palpation and Percussion – BE GENTLE Rebound – please do not perform this test Causes unexpected and unnecessary pain Does not add information to an examination after percussion Rigidity not present in pelvic inflammation or obstruction, unreliable

108. Physical Examination 1. General Appearance 1. Level of discomfort 2. Nutrition status 3. Hydration status 2. Attitude in Bed 1. Still – peritonitis 2. Restless – colic 3. Writhing – consider mesenteric vascular event

109. Mechanisms of pain transmission Visceral Somatic Referred

110. Do not forget the RECTAL & PELVIC exams !!

111. Investigations CBC with leukocytosis Thoracoabdominal X-ray in standing position may show air under the diaphragm 70—80%

114. Free air under the diaphragma P-A X-ray: Discoid shape free air under the diaphragma on both sides.

115. What is the exam to evaluate for pneumoperitoneum? Upright abdomen film

116. If a patient can not stand what radiograph can be substituted? Left lateral Decubitus pneumoperitoneum Liver side UP Patient lying on their LEFT side. ==

118. Treatment Admission to the emergency room Clinical and para clinical assessment IV fluids Antibiotics NG tube Urinary catheterization Closure of the perforation Omental patch ( Graham’s method)

120. In perforated gastric ulcer take biopsy

122. -1- Dist = 1.30cm -2- Dist = 0.91cm

134. Diverticulitis

143. TB peritonitis