1. Approach to acute abdomen
Dr.Mohammad Al- Akeely
Associate prof. & Consultant general surgeon
KKUH & KSMC

2. Any clinical condition characterized by
Introduction
Definition:
Any clinical condition characterized by
severe abdominal pain which develops in less than a week, In a patient who has been previously well.
Rapid and accurate diagnosis is essential to
reduce the morbidity and mortality.

3. Pathophsiology
Visceral pain: Due to stimulation of visceral afferent nerve plexus usually results from contraction or distension against resistance & chemical irritation . It is usually midline colicky in nature.

4. Pathophsiology
Parietal pain: Secondary to parietal peritoneal irritation perceived through segmental somatic fibers, reflex involuntary muscle wall (guarding) may be present. Tenderness and rebound tenderness is usually associated with parietal peritoneal irritation.

5. Epidemiology

6. Abdominal quadrants

7. Differential Diagnosis
It’s Huge!
Use history and physical exam to narrow it down
Rule out life-threatening pathology
Half the time you will send the patient home with a
diagnosis of nonspecific abdominal pain (NSAP)
90% will be better or asymptomatic at weeks.

8. Causes: Gastrointestinal tract Acute appendicitis
Mesenteric lymphadenitis
Bowel obstruction or Perforation
Peptic ulcer disease
Peptic ulcer perforation
Strangulated hernia
Diverticulitis
Gastritis
Gastroenteritis
Inflammatory bowel disease
Meckl’s diverticulitis

10. spleen& liver,biliaryTract
Biliary colic
Acute cholecystitis
Acute cholangitis
Hepatic abscess
Ruptured hepatic tumor
Ruptured spleen
Acute hepatitis
Splenic infarction

11. Peritoneum
Primary peritonitis Tuberculus peritonitis, infected ascites
Secondary peritonitis (bowel perforation or abscess) Pancreas
Acute pancreatitis
Chronic pancreatitis
Ca pancreases
Urinary tract Acute cystitis Acute pyelonephritis Renal infarction Renal colic

12. Gynecological Ruptured ectopic pregnancy Ruptured ovarian follicular cyst torsion ovarian tumor or cyst Dysmenorrhea Endometriosis acute salpingitis.

13. Male reproductive tract. Torsion of testes
Prostatitis
Cystitis
Vascular causes:
Acute ischemic colitis .
Mesenteric vascular occlusion
Ruptured aortic aneurysm

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

15. Approach to acute abdomen
History.
1.Pain (detail)
2. Associated symptoms, nausea, vomiting,
change of bowel habits, jaundice, anorexia,
haematemsis, melena, cough, dyspepsia.. etc.
3.Menstrual & sexual history.

16. Cont.. 4.History of similar attacks 5.past medical & surgical history
6.medications
7.familay history
8.social history

17. Examples: Acute appendicitis
Starts as colicky central abdominal pain(visceral) and then becomes constant ,progressive more severe in the RIF (somatic).
nausea, vomiting, low grade fever, anorexia dysuria or loose motion (?).
P/E:
reveal tenderness & rebound tenderness in RIF ,guarding or mass .
Generalized tenderness indicates peritonitis.

19. Appendicitis: Psoas Sign

20. Appendicitis: Obturator Sign
Passively flex
right hip and knee
then internally
rotate the hip

21. Inflamed appendix

23. Complications of appendicitis: -Acute suppuration -Appendicular mass -Appendicular abscess -Generalized peritonitis Complication of appendectomy: -Bleeding -Surgical site infection (SSI ) -Faecal fistula -Incisional hernia or muscle weakness

24. Acute cholecystitis
Constant moderate pain in RUQ radiating to the right shoulder tip , nausea, vomiting, low grade fever & ? Jaundice. Past h/o biliary colic precipitated by fatty meal.

27. Acute Pancreatitis:
Usually diffuse epigastric abd. pain , back pain, emesis, elevated amylase & lipase
Often attributed to gallstones, alcohol or hyperlipidemia, but many cases are idiopathic.
Can have severe complications:
Hypovolemia, ARDS, hypocalcemia,
retroperitoneal bleeding or necrosis and abscess.
CT is the diagnostic method of choice.

28. Perforated peptic ulcer Sudden onset of pain in mid epigastrium that may become generalized and is aggravated by movement; patient appears acutely ill and is reluctant to move; rigid abdomen; shallow respiration; bowel sounds diminished. ?Past h/o peptic ulcer or NSAD use.

31. Inflammatory Bowel Diseases: Two types :
Ulcerative colitis
Crohn's Disease
Ulcerative colitis can sometimes have complication of "toxic megacolon"
Complications of either type may need Rx with high dose IV steroids in addition to other usual Rx's

32. Acute Diverticlitis: More common after age 45
Typically pain & tenderness in LLQ, but can be diffuse
Can result in inflammatory mass in LLQ or perforation and abcess.
CT with contrast is the best modality for diagnosis.
Milder cases can be managed with antibiotics and discharged from ER

35. Ovarian cyst Ectopic pregnancy,
Pain sudden, severe, persistent,following a missed or abnormal period, typically hypogastric; associated with ? hypotension and tachycardia.Kehr sign ? Positive.
Ovarian cyst
Pain constant with sharp, sudden onset, usually in ipsilateral hypogastrium or iliac fossa and may have nausea and vomiting following the pain. may be periodic at mid cycle.

40. 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 vaginal discharge; fever.
Poor hygiene & Sexually transmitted diseases are important causes (gonorrhea , chlamydia).

41. Urinary stone
Pain location changes with movement of stone, may radiate to loin, testicle or groin of involved side, pain is very severe and colicky, patient may be rolling in bed.

42. RENAL COLIC

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

44. investigations 1.CBC 2.electrolyte WBCs & differential.
RBC & HCT, Hg .
Platelet count, INR.
2.electrolyte
Glucose, urea, Cr, electrolytes
(Indicative of volume status, GIT loss).

45. 3.ABG May indicate metabolic acidosis or alkalosis.
M.acidosis with generalized abdominal pain in elderly is suggestive of ischemic colitis or mesenteric vascular occlusion.

46. 4.liver function test 5.RFT
Bilirubin (D & ID), ALP elevation in biliary obstruction . Transaminase elevation in case of hepatocellular disease (eg, hepatitis).
Low serum albumin causes edema & ascites
5.RFT
Urea, creatinine elevated in renal impairment due to hypovolaemia.

47. 6. serum amylase /Lipase
Although amylase may be grossly elevated in pancreatitis , it is non specific (may be elevated in mesenteric ischemia, perforated peptic ulcer, rupture ovarian cyst & renal failure).
Lipase is more sensitive in pancreatitis.

48. Mandatory in all women in childbearing period. 8.urine analysis
7. Pregnancy Test
Mandatory in all women in childbearing
period.
8.urine analysis
For WBC, RBC, casts and glucose.

49. Radiological evaluation
1.CXR,
Look for pneumonia, free gases under diaphragm & pleural effusion(? Sympathatic).

51. 2. Plain abdominal Xray. (Erect & supine position ) bowel distension & air fluid level bowel gas pattern, cut off sign, air in the rectum. sentinel loop of pancreatitis abnormal calcification of ch.pancreatitis & stones. pnumatosis intestinalis or pneumo-bilia.

53. Intestinal obstruction

55. 3.ultrasound Hepatobiliray tree: (hepatomegally ,gallstones, mass, thickining of the wall, dilated biliary tree, pancreas) also used to evaluate kidneys, pelvic organs, intra-abdominal fluid collection)

56. Gall stone appendicolith

57. abdominal oartic aneurysm & MVA and pancreatitis.
4.CT scan
Helpful in case of abdominal pain without clear etiology and in the diagnosis of
abdominal oartic aneurysm & MVA and pancreatitis.
5.helical (spiral) CT scan
Provide rapid cost effective diagnostic tool especially in the diagnosis of pulmonary embolism.

58. Acute pancreatitis dilated loop

60. 5. contrast study Barium vs Gastrografine
5.contrast study Barium vs Gastrografine. Gastrografine study to diagnose intestinal obstruction or bowel anastomotic leak.

62. Intravenous pyelogram
For dignosis of ureteral stone or obstuction
Angiography
For mesenteric ischemia and lower GI bleeding.

63. Angiogram (arrow shows superior mesenteric artery clot) of a 65 year old male with bowel ischemia

64. Other studies 6.Endoscopy
For evaluation of epigastric pain in non acute setting & upper GI bleeding .
Sigmoid\colonoscopy
colonic obstruction eg, tumours.
diagnosis of IBD, ischemic colitis, lower GI bleeding,
non-strangulated sigmid volvulus and diverticular disease.

65. 7.paracentesis and peritoneal lavage
Usually done for spontaneous bacterial peritonitis in cirrhotic patients.

66. 8. Diagnostic laparoscopy
in suspected gynaecological pathology (e.g. Ectopic pregnancy or ruptured ovarian cyst v/s appendicitis).
It is also helpful in the diagnosis of abdominal pain of obscure origin and chronic abdominal pain.

67. Plan of treatment
promote timely work up in first 4_6hrs. keep pt NPO till the diagnosis is confirmed & treatment plan is formulated. IV fluid. based on expected fluid loss. haemodynamic monitoring. NG tube in cases of vomiting or intestinal obstruction or when urgent surgery is planned in pt not npo. Foley cath. To monitor urine output.

68. Decision
Immediate surgery vs conservative treatment.
what is the timing of operative intervention
(does pt need time for resuscitation?)
what incision should be used?

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

70. Avoid analgesia till definitive diagnosis
Avoid analgesia till definitive diagnosis. monitor vital signs frequently Regular physical examination and assessment of the patient serial lab exam e.g.; CBC every 4-6hrs.

71. If no surgical operation is needed then the plan for further diagnostic workup should be planned.

72. Now its time to discuss some clinical scenarios

73. Scenario Cases: 1
74 yrs old male pt. presented with 12 hours history of acute sudden severe colicky central abdominal pain that became severe ,steady and generalized all over the abdomen since last 2 hours. No history of trauma. what are the likely differential diagnoses?

74. 1- mesenteric vascular occlusion 2-intestinal obstruction with strangulation (adhesion , hernia , volvulus ) What further relevant important points in the history ?

75. History of haematemesis/melena, abd
History of haematemesis/melena, abd.distention, constipation ,medications, previous similar attacks,hernia, previous surgery. History of cardio-vascular disease: .hypertension .MI .atrial fibrillation .valvular disease .intermttent claudication

76. stool ,but no constipation. He is hypertensive on Rx.
Detailed scenario:
74 years old male c/o sudden acute central abdominal pain for 12 hours that became very severe , steady all over the abdomen last 2 hours. It was associated with nausea and passage of blood with
stool ,but no constipation. He is hypertensive on Rx.
No hx of trauma. No hx of hernia, similar attacks or abdominal surgery, but he had aortic valve replacement one year ago and receiving plavix since then.
Now what is the likely diagnosis?

77. Acute Mesenteric vascular occlusion

78. What are the important examination findings you are looking for?

79. General exam: Sensorium, respiratory rate, pallor, tachycardia, fever, hypotension. Cardio-vascular exam. Abdomen exam: Movement with respiration, distension, scars, hernias, percussion for tenderness, rebound tenderness, masses. Auscultation for bowel sounds. PR exam for masses and blood.

80. Clinical examination revealed: Patient is drowsy, PR 120/m, blood pressure 90/60 , RR 30/m, temperature 38.2 Abdomen distended, no scars, no hernias. Tenderness and guarding all over the abdomen, bowel sounds are diminished. PR revealed fresh blood in the finger but no masses . What investigations would you like to do?

81. Hb = 13gm%, Wbc = 25, ABG = metabolic acidosis, Urea elevated, Elect
Hb = 13gm%, Wbc = 25, ABG = metabolic acidosis, Urea elevated, Elect. = normal, Cr = normal, LDH 360 INR = 1.5 ECG , Echo-cardiogram (vegetations on the aortic valve) CXR no air under diaphragm and no lung pathology Abdomen X ray: distended loop of small bowel . CT scan: distended thick wall segment of small bowel loop, minimal fluid in abdomen and filling defect in superior mesenteric artery.

82. What is your plan now?

83. Preparation for laparotomy:
Oxygyn, IV fluid, NG tube, FC.
Cross match FFP & blood.
Consent for laparotomy and possible resection and stoma placement.
Start i.v antibiotics.
Post op : heparinization.

84. Gangrenous bowel Doubtful bowel Normal bowel

85. scenario: 2
46 years old lady c/o right upper quadrant abdominal pain for 2 days associated with fever What is the likely differential diagnosis?

86. Acute cholecystitis Cholangitis liver abcess hepatitis right lobar pneumonia What further questions you need to ask?

87. Pain: Type, nature, aggravating, relieving factors and radiation
Pain: Type, nature, aggravating, relieving factors and radiation. History of URTI, cough and sputum. History of jaundice, pale stool, dark urine, nausea, vomiting, chills, rigors, diarrhea, contact with jaundiced patient or recent travel. History of similar attacks or surgery.

88. Detailed scenario: 46 years old lady c/o pain RUQ for 2 days
Detailed scenario: 46 years old lady c/o pain RUQ for 2 days. No history of rigors or chills or cough. She used to have recurrent RUQ pain which is colicky in nature, radiating to the right shoulder, aggravated by fatty food and relieved by analgesics, she also has history of nausea and vomiting but no change in bowel habits and no urinary symptoms, on examination she is not jaundiced and not pale, her pulse is 100/m, normo-tensive, febrile 38.2c. she has tenderness and guarding in RUQ with pain during deep inspiration. What is the most likely diagnosis?

89. What investigations you need to do?
Acute cholecystitis
What investigations you need to do?

90. CBC, U/E, Cr, LFT, INR, Chest x ray Ultra sound biliary tree

91. WBC 16 U/E, Cr, LFT, INR: all normal
WBC 16 U/E, Cr, LFT, INR: all normal. Ultra sound revealed distended gall bladder with thick oedematous wall and containing multiple gall stones.Pericholecystic fluid. No dilatation of CBD What is the management?

92. Antibiotics NPO IVF Analgesia NG tube (if vomiting) Consent for surgery Early laparoscopic cholecystectomy vs conservative and later interval cholecystectomy in 6-8 weeks.(reason?) What are the common complications of cholecystectomy ??

93. Scenario: 3
18 years old female presented to the hospital with right iliac fossa pain for 12 hours . She has nausea and vomiting, but passing normal stool. What are the important differential diagnosis ?

94. 1. Acute appendicitis 2. Mesenteric adenitis 3. Mid cyclic pain 4
1. Acute appendicitis 2. Mesenteric adenitis 3. Mid cyclic pain 4. Chronic inflammatory bowel disease 5. Rupture or torsion ovarian cyst 6. Ectopic pregnancy 7. Renal colic & UTI 8. PID What further history is required ?

95. Assocaited symtoms eg: fever ,anorexia,diarrhoea.
Evalution of the pain
Assocaited symtoms eg: fever ,anorexia,diarrhoea.
History of similar episodes
History of urinary symptoms
Recent history of URTI
Gynaecology history
-marriage , pregnancy
-menstrual cycle
-PV bleeding & discharge

96. Detailed scenario: 18 years old female presented with pain RIF since 12 hours. it was colikey in nature starting in epigastric area then shifted to RIF, it was associated with N/V and anorexia. No fever, no change in bowel habit and no urinary symptoms. she is not pregnant and she has regular period and no vaginal discharge. What is the most likely diagnoses ?

97. What is the examination findings to support your diagnoses ?
Acute appendicitis
What is the examination findings to support your diagnoses ?

98. Tachycardia, fever, negative throat exam, tender RIF and rebound tenderness positve psoas. sign, positve obturator sign. What about investigation findings that supports your diagnosis ?

99. Leucocytosis Negative pregnancy test Imaging: ( in doubtful cases) -U/S to r/o gynecological pathology. -CT scan for complicated appendicitis. The diagnoses of acute appendicitis remains a clinical one with sensitivity approaching 85%.The imaging is reserved for doubtful or complicated cases e.g: appendicular mass or abscess.

100. Scenario: 4
50 years old male patient presented with a gradually increasing stabbing pain in LIF for 3 days. it was associated with nausea but no vomiting. He is having constipation for more than 10 years, for which he is occasionally taking laxatives ,he had similar but mild attacks before. He is diabetic on Rx. What is your main deferential diagnosis?

101. 1-Acute left colon diverticulitis 2-Carcinoma left colon
1-Acute left colon diverticulitis 2-Carcinoma left colon. 3-Ureteric colic. 4-Ischemic colitis. What further important history is required ?

102. Radiation of pain (loin or groin). Dysuria,haematuria,pneumaturia
Radiation of pain (loin or groin). Dysuria,haematuria,pneumaturia. Bleeding per rectum,tenesmus. Weight loss & loss of appetite History of fever. Family history of cancer or colonic disease.

103. Detailed scenario: 50 years old diabetic male presented to ER complaining of localized pain in the LIF for 3 days.the pain was not radiating,and associated with mild fever.no urinary symptoms or haematuria.No history of bleeding per rectum ,no family h/o colonic disease or cancer. Examination revealed pulse 95/m ,BP 110/85mhg,temp.38.4c.no pallor or jaundice.Abdomen showed no scars, was mildely distended and tender in LIF but no rebound tenderness.PR showed no bloody stool and no masses. now what is your likely diagnosis?

104. ACUTE DIVERTICULITIS What investigations are nesssary?

105. CBC, U/E ,Cr , glucose , INR. Urine analysis CxR , abdomen x ray Gastrografin enema can be done. CT scan abdomen with contrast is the modality of choice. Colonoscopy and barium enema are contra indicated in acute diverticulitis.(why) ? How would you manage acute diverticulits?

107. Uncomplicated: NPO IV fluid Antibiotics once symptoms improve, start feeding. Local abscess: Drainage under CT scan. Generalized peritonitis: Laparotomy and resection of involved segment. (Hartman procedure)

110. Scenario: 5
39 years old male presented with sudden epigastric pain 8 hours ago, associated with nausea but no vomiting or change in bowel habits. What is the likely differential diagnosis?

111. What other important history?
Perforated peptic ulcer
Pancreatitis
Myocardial infarction
Intestinal obstruction
Gastritis
What other important history?

112. Nature of pain (colicky, stabbing …
Nature of pain (colicky, stabbing ….) Associated regurgitation, fever, dizziness, SOB , change in bowel habit. Smoking, alcohol intake, hyperlipidemia. History of PUD or NSAD. History of RUQ pain or gall stones Past medical and surgical history -hypertension -cardiac disease -previous surgery

113. Detailed scenario: 39 years old male presented with sudden sharp epigastric pain 8 hours ago that graduwally spreads all over the abdomen.It was associated with nausea but no vomiting or dizziness.No change in bowel habits.No cough or SOB.No previous history of PUD, gall stones , hyper lipidemia , cardiac disease or surgery.He is not alcoholic.He is taking voltarine 50 mg tds since one week for ankle sprain.Examiation revealed pulse 100/m,temp 37.8c,tenderness and guarding in epigastrium and the rest of abdomen is mildly distended. Now what is the most likely diagnosis?

114. Perforated peptic ulcer
What are the appropriate investigations ?

115. cbc , urea, cr, electrolytes, INR, s. amylase, s. lipase. ECG
cbc , urea, cr, electrolytes, INR, s.amylase, s. lipase. ECG. Chest x ray erect. air under the diaphragm is diagnostic for perforation in this patient). How do you manage perforated duodenal ulcer?

116. Npo Iv fluid Ng tube Folly catheter Admission Antibiotics Cross matching blood Consent Surgery…..( laparotomy or laparoscopic Grahamm patch )

119. Thanks