1. Acute Abdomen 林怡成醫師 大腸直腸外科 2013.10.21

2. Acute Abdomen Challenge to Surgeons & Physicians Most common cause of surgical emergency admission Encompass various conditions ranging from the trivial to the life-threatening Clinical course can vary from minutes to hours, to weeks It can be an acute exacerbation of a chronic problem e.g. Chronic Pancreatitis, Vascular Insufficiency

3. DEFINITION Acute Abdomen – “ any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered. ” Stedman ’ s Medical Dictionary, 27 th Edition

4. The primary symptom of the "acute abdomen" is Abdominal pain.

5. Pathophysiology of Abdominal Pain Somatic pain Visceral pain

6. Somatic pain -Parietal peritoneum -Somatic n. (T5-L2), except diaphragm (C3-C5 & lower 6 intercostal and subcostal nn.) -Sensitive to mechanical, thermal or chemical stimulation -Muscle rigidity/guarding and hyperaesthesia -Sharp or knife-cut like in nature; well localized

8. Visceral pain -Visceral peritoneum -Mediated through sympathetic branches of autonomic nerve system joining presacral and splanchnic nn., which eventually join thoracic(T6- T12) and lumbar (L1-L2) nn. -Insensitive to mechanical, thermal or chemical stimulation -Sensitive to tension-overdistension or traction on mesenteries, visceral m. spasm & ischemia -Dull and deep-seated; vaguely to localize

10. ASSESMENT A Full history Thorough physical examination Diagnosis can be made by a good history and a proper physical examination. - An exact diagnosis often impossible to make after the initial assessment, and often relying on further investigation

11. Investigations are usually carried out : only to support the diagnosis. or to narrow down the differential diagnoses.

12. History History of Present illness Family History Past Medical history Operation history History of drugs taken or Medication eg. ingestion of certain toxic drugs or Alcohol intake

13. PAIN The Most Important Symptom Characteristics of abdominal pain 1. Site 2. Onset – time and mode 3. Severity 4. Nature – colicky, spasm, dull, vague, sharp, knife-cut, etc. 5. Progression or change of pain – persistent, gradually improve or worsen, fluctuate, etc. 6. Duration 7. Radiation 8. Movement of pain 9. Aggravating or relieving factors 10. Associated symptoms – bowel or urinary, etc.

15. Onset of Pain Sudden onset pain which wakes the patient from sleep eg. perforation or strangulation of bowel Slow insidious Onset a. Inflammation of visceral peritoneum. b. Contained process such as evolving abscess. Crampy or colicky pain Biliary colic, Ureteric colic or Intestinal colic

17. Progression of Pain Progression from: Dull, aching, poorly localized character To: Sharp, constant & better localized pain indicates involvement of Parietal peritoneum

18. Associated Symptoms CONSTIPATION a. Progressive intestinal obstruction from a neoplasm or inflammatory bowel disease b. Paralytic Ileus c. Post Operative d. Obstructed groin hernia

19. Associated Symptoms DIARRHEA Diarrhea with pain is mainly medical. The following are the exceptions: a. Obstructed Richter's Hernia b. Gall Stone ileus c. Superior mesenteric vascular occlusion d. Intestinal Obstruction associated with pelvic abscess

20. DRUG HISTORY Corticosteroids – mask pain Anticoagulants – can lead to an intramural haematoma of the gut causing obstruction Oral Contraceptives - rupture of hepatic adenomas NSAIDs - erosive gastritis & peptic ulcers

21. NAUSEA & VOMITING a. Bilious vomiting of small bowel obstruction b. Non-bilious vomiting in obstruction proximal to ampulla of Vater c. Faeculent vomiting in distal small gut obstruction, large bowel obstruction, strangulation

22. NAUSEA & VOMITING Pain first, followed by Vomiting is usually surgical. The vomiting is due to ‘ reflex pylorospasm ’ Nausea & vomiting first, followed by pain is usually due to a medical condition

23. Vomiting (cont.) Vomiting is very prominent in a. Mallory-Weiss syndrome. b. Boerhaave syndrome(trans- mural esophageal tear) c. Acute gastritis d. Acute pancreatitis

24. ANOREXIA Anorexia or decreased appetite with pain is usually seen in Acute appendicitis

25. Urinary Symptoms with Pain Ureteric colic Cystitis

26. FEVER & CHILLS Liver Abscess Perinephric Abscess Intra-abdominal abscess

27. OTHER HISTORY Past Surgical history: previous operations- leading to adhesions Past Medical history: Diabetes or Cancer or Renal failure Menstrual History in females (i) Missed period- ectopic pregnancy (ii) With heavy periods- endometriosis Family history of colon cancer, any other malignancy or inflammatory bowel disease

28. Physical Examination General Appearance a. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitis b. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colic c. Writhing in Pain: Mesenteric Ischemia

29. Physical Examination (contd.) d. Bending Forward: Chronic Pancreatitis e. Jaundiced: CBD obstruction f. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

30. Physical Examination (contd.) Vital Charting Temperature, Pulse, BP, Respiratory rate Ruptured AAA or ectopic pregnancy can lead to -Pallor -Hypotension -Tachycardia -Tachypnea

31. Physical Examination (contd.) Low grade temp. is seen with - Appendicitis - Acute cholecystitis High Grade Temp.with increasing lethargy seen in imminent septic shock - Peritonitis - Acute cholangitis - Pyonephrosis

32. Systemic Examination Cardiopulmonary examination Check for: - Possible MI - Basal Pneumonia - Pleural Effusion

33. Systemic Examination Per Abdomen: Inspection - Flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

34. Systemic Examination Erythema or discolouration a. Peri-umbilical - Cullen sign b. Inguinal – Fox sign c. Flanks - Grey Turner sign Seen in Hemorrhagic pancreatitis or any other cause of haemoperitoneum Any Visible masses Any visible cough impulse at hernia site

35. Systemic Examination Per abdomen: Palpation Be gentle Start away from site of pathology then towards Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board- like. Indicates peritonitis.

36. Systemic Examination Local Right Iliac Fossa tenderness: a. Acute appendicitis b. Acute Salpingitis in females Low grade, poorly localized tenderness: Intestinal Obstruction Tenderness out of proportion to examination: a. Mesenteric Ischemia b. Acute Pancreatitis Flank Tenderness: a. Perinephric Abscess b. Retrocaecal Appendicitis

37. Systemic Examination Rovsing ’ s Sign in Acute Appendicitis Obturator Sign in Pelvic Appendicitis Psoas Sign - Retrocaecal appendicitis - Perinephric Abscess

38. Systemic Examination Murphy ’ s sign in Acute Cholecystitis Boas ’ sign – pain radiates to tip of right scapula in Acute Cholecystitis

39. Systemic Examination Pulsatile Abdominal Mass with Hypotension Leaking AAA

40. Systemic Examination Per Rectal Examination: - tenderness - induration - mass - frank blood

41. Systemic Examination Per Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

42. INVESTIGATIONS Complete Blood Count with differential C-reactive protein estimation Electrolyte,Blood Urea, Creatinine Urine dipstick Amylase or Lipase Liver Function Test HCG

43. Radiology Upright X ray chest for - Basal Pneumonia - Ruptured Oesophagus - Elevated Hemi diaphragm - Free Gas under diaphragm

44. Radiology Abdominal X ray film - Air-Fluid Levels - Stones - Ascites - Eggshell calcification in AAA - Air in Biliary tree. - Obliteration of Psoas Shadow in retro- peritoneal disease

45. INVESTIGATIONS Other Investigations - Ultrasonography - CT abdomen - Angiography for Ischaemia, Haemorrhage

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