1. ACUTE ABDOMEN DR. D.VINDHYA Dept of Emergency & Critical Care Medicine, Vinayaka Mission Medical College & Hospital, Salem

2. Visceral pain –Distension, inflammation or ischemia in hollow viscous & solid organs –Localisation depends on the embryologic origin of the organ: Foregut to epigastrium Midgut to umbilicus Hindgut to the hypogastric region

3. Parietal pain- is localised to the dermatome above the site of the stimulus. Referred pain –produces symptoms, not signs e.g. tenderness

4. Abdominal topography

5. HISTORY Site Nature & character Duration Intensity Precipitating & relieving factors Associated symptoms

6. Previous episodes of AP Investigations Chronic disease Immunosuppression Medications (NSAIDs) surgeries

7. Generalised abdominal pain Perforation AAA Acute pancreatitis DM Bilateral pleurisy

8. Central abdominal pain Early appendicitis SBO Acute gastritis Acute pancreatitis Ruptured AAA Mesenteric thrombosis

9. Epigastric pain DU / GU Oesophagitis Acute pancreatitis AAA

10. RUQ pain Gallbladder disease DU Acute pancreatitis Pneumonia Sub phrenic abscess

11. Differential diagnosis of RUQ pain

12. LUQ pain GU Pneumonia Acute pancreatitis Spontaneous splenic rupture Acute perinephritis Sub phrenic abscess

13. Differential diagnosis of LUQ & epigastric pain CONDITION CLUES Splenic ruptureh/o trauma or splenic disease Fractured ribsh/o trauma, gross deformity, extreme tenderness on palpation pancreatitish/o alcohol consumption, past h/o, labs Gastritis, peptic ulcer diseaseRecurrent relationship to posture or meals

14. Supra pubic pain Acute urinary retention UTIs Cystitis PID Ectopic pregnancy Diverticulitis

15. RIF pain Acute appendicitis Mesenteric adenitis DU perf, Diverticulitis PID, Salpingitis Ureteric colic

16. Meckel’s diverticulum Ectopic pregnancy Crohn’s disease Biliary colic (low-lying gall bladder)

17. Differential diagnosis of RLQ pain CONDITIONS CLUES Mesentric adenitisFever, inconstant signs Rt renal colicColic pain,haematuria Rt.testis torsionTender swollen testis Crohns diseaseRecurrent h/o diarrhoea, colicky pain, wt loss

18. Gynecological causes of RLQ pain CONDITION CLUES Ruptured follicleFever, cervical discharge Torsion ovaryMidcycle, sudden onset Ruptured ectopic pregnancySevere pain, shock, missed periods PID sever pain, foul smelling discharge, dyspareunia

19. LIF pain Diverticulitis Constipation IBS PID Rectal Ca UC Ectopic pregnancy

20. Differential diagnosis of LLQ pain CONDITIONS CLUES Diverticular diseaseElderly patient recurrent Acute urinary retentionPalpable bladder, difficulty in passing urine Urinary tract infectionDysuria, frequency Inflammatory bowel diseaseRecurrent attacks, diarrhoea Large bowel obstructionColicky pain, constipation Ischemic bowel diseaseRectal bleeding, pain out of proportion to examination

21. Systemic examination Inspection- - Flat, reduced movements in peptic ulcer perforation - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

22. GREY TURNER’S SIGN RETROPERITONEAL HEMORRAGE Discoloration of the flank

23. CULLEN’S SIGN RETROPERITONEAL HEMORRAGE Bluish periumbilical discoloration

24. Palpation Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis. Do not miss tetanus!

25. MC BURNEY’S SIGN ACUTE APPENDICITIS Tenderness located 2/3 distance from anterior iliac spine to umbilicus on right side

26. ILIO PSOAS SIGN ACUTE APPENDICITIS Hyperextension of right hip causing abdominal pain ( retrocecal)

27. OBTURATOR SIGN ACUTE APPENDICITIS Internal rotation of flexed right hip causing abdominal pain (pelvic)

28. MURPHY’S SIGN Acute cholecystitis Abrupt interruption of inspiration on palpation of right upper quadrant

29. ROVSING’S SIGN Acute appendicitis Right lower quadrant pain with palpation of the left lower quadrant

30. KEHR’S SIGN Severe left shoulder pain Splenic rupture Ectopic pregnancy rupture

31. CHANDELIER’S SIGN PELVIC INFLAMMATORY DISEASE Manipulation of cervix causes patient to lift buttocks off table

32. Auscultation BS –> 2min to confirm absent –High pitched, hyperactive or tinkling –Bruit in epigastrium

33. PR Examination: - tenderness - induration - mass - frank blood

34. Investigations CBC Amylase & lipase Erect & supine abdominal XRay stool & Urine analysis, pregnancy test, USG, CT scan If severe, unrelenting pain urgent surgical referral

35. Initial management Stabilise ABC Resuscitate the patient Shift for investigation only after stabilising the pt

36. Remember to reassess patient on a regular basis.

37. Airway management Pt’s SPO2 – is low or when RR IS > 35/min When the depth of breathing is shallow & inadequate When the pt’s GCS is not adequate to maintain a patent airway When the pattern of breathing is inappropriate

38. circulation Care to adequately hydrate the pt. If pt’s cardiac status is compromised then CVP guided fluids should be administered. A careful monitoring of I/O should be maintained

39. Analgesia Adequate analgesia should be provided in the ER

40. Shift the pt only when the pt is stabilised

41. Supine ray Dilated bowel loop pattern, obstruction, closed loop, bowel wall edema

42. Chest xray Gas under diaphragm

43. IVP To detect renal calculi, ureteric obstruction

44. USG ascitis cholecystitis

45. Acute pancreatitis CT detects acute pancreatitis, small bowel obstruction, diverticulitis, abscess, bowel infarction

46. CT images Ureteric calculi Detecting ureteric calculi, appendicitis

47. CASE DISCUSSIONS

48. Case 1 A male pt aged 17yrs developed mild periumblical discomfort not influenced by activity. Several hrs later pain intensifies but is now localised to RLQ.Movement becomes painful

49. INVESTIGATION OF CHOICE ? Abdomino pelvic CT

50. Treatment Initial stabilisation Early appendicectomy within 4-12 hrs of initial presentation

51. CASE 2 A 47 yr old obese lady developed severe mid-epigastric pain. Pain not influenced with any position or movement. O/E pt’s temp -100 degree, Tachycardia +, murphy’s sign positive

52. INVESTIGATIONS? Xray USG – study of choice to detect stone < 2mm HIDA scans – investigation of choice

53. Treatment Initial stabilisation cholecystectomy open laparoscopy

54. CASE 3 A 62yr old man C/O severe abdominal pain – generalised in nature. H/O consumption of NSAIDS. He also c/o lt shoulder pain. He feels more comfortable sitting than lying. O/E pt conscious,afebrile, sweating profusely HR-120/min, BP-120/90 mm hg

55. Abd- rigid, tenderness,rebound tenderness & guarding present in all quadrants.percussion –absence of liver dullness What is the likely diagnosis? Investigations ?

56. Chest xray IMP- PERITONITIS FOLLOWING DU PERFORATION ? tetanus

57. Treatment Initial stabilisation Laparotomy & DU perforation closure

58. Case 4 A 34y old female pt rushed to ER in shock. O/E HR-120/min, BP- 90/60mmhg, RR-26/min, SPO2-94% on RA CVS, RS – NAD ABD – LLQ tenderness + Next ?

59. Pt’s LMP – 1&1/2 mth back – H/O Investigation? Urine HCG Pelvic USG IMP- ECTOPIC PREGNANCY

60. Treatment Initial stabilisation Anti D in RH negative mother laparoscopic salpingostomy

61. Case 5 A 23 yr old student brought to ER writhing with pain radiating from lt lumbar to groin associated with vomiting Next ?

62. Xray KUB,IVP USG IMP- URETERIC COLIC

63. Treatment Initial stabilisation Expectant treatment Ureteroscopic removal ureterolithotomy

64. Case 6 A 65 yr old male, known diabetic admitted at 9pm with h/o abdominal pain associated with profuse sweating & vomiting since evening 7pm O/E HR- 68/min, BP – 90/70 mmhg. What next?

65. ECG done – ANTERIOR WALL MI

66. Management Initial stabilisation Nasal O2,Aspirin, clopilet, NTG Consider thrombolysis

67. Case 7 A 42yr old male pt, known alcoholic presented to our ER with H/O persistent epigastric pain improving on bending forward & worsens with lying down. O/E vitals are stable except for tachycardia Systemic examination – NAD except for tenderness in the epigastric region

68. What is the likely diagnosis? What are the investigations to be done?

69. S.amylase elevated Xray – colon cutoff sign IMP- ACUTE PANCREATITIS

70. Management Initial stabilisation Prophylactic antibiotics Nutrition Treat the cause

71. Case 8 23 yr old female pt delivered 2 days back with c/o vomiting, abdominal pain & constipation since the time of delivery Usg abdomen shows -

72. Target sign. Diagnosis? Treatment ?

73. Carry home message Our priority- ABC All abdominal aches need not arise from the abdomen Adequate hydration, adequate analgesia, appropriate antibiotic coverage at ER

74. THANQ