1. Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital, Shandong University

2. Definition A group of life threatening intra- abdominal conditions that often lead to peritonitis and require urgent surgical intervention A group of life threatening intra- abdominal conditions that often lead to peritonitis and require urgent surgical intervention

3. Acute Abdomen

5. Etiology Surgical Surgical InflammatoryobstructionIschemicPerforation Inflammatory Bowel Disease AppendicitisDiverticulitisPancreatitscholecystitisCholangitis Meckel’s diverticulum. Intestinal Obstruction Biliary colic Ureteric colic Mesenteric ischemia Torsion of viscus (organ) Peptic Ulcerative Disease (PUD) Diverticular disease Appendix Toxic megacolon

6. Etiology, cont… Medicalgynecological Myocardial Infarction GastritisGastroenteritisHepatitis Urinary Tract Infection Ectopic pregnancy Ovarian cyst torsion Endometriosis (endometrial cells are deposited in areas outside the uterine cavity )

7. Common causes of abdominal pain

9. Clinical evaluation History Age Age Certain conditions occur in certain age groups E.g. diverticulitis in elderly Mesenteric adenitis (inflammation of mesenteric lymph nodes) in children Mesenteric adenitis (inflammation of mesenteric lymph nodes) in children Pain Pain –Onset sudden perforation sudden perforation gradual inflammatory causes gradual inflammatory causes

10. WWW.SMSO.CC site Site Site Cholecystitis cholangitis Peptic Ulcerative Disease (PUD) Peptic Ulcerative disease (PUD) Pancreatitis cholecystitis Gastric ulcer Perforated colon Appendicitis Salpingitis Ruptured. Ectopic pregnancy Diverticulitis Salpingitis Tubo-ovarian abscess

11. History, cont… –Nature colicky obstruction (cramping pain) colicky obstruction (cramping pain) dull inflammation e.g. pancreatitis (constant pain) dull inflammation e.g. pancreatitis (constant pain) –Radiation to tip of the right shoulder in acute to tip of the right shoulder in acute cholecystitis (boa’s sign) cholecystitis (boa’s sign)

12. History, cont… –Aggravating factors breathing breathing coughing peritonitis coughing peritonitis changing position changing position fatty meal cholecystitis fatty meal cholecystitis –Relieving factors lying still peritonitis lying still peritonitis leaning forward pancreatitis (prayer’s sign leaning forward pancreatitis (prayer’s sign passing flatus Intestinal Obstruction passing flatus Intestinal Obstruction

13. History, cont… –Associated factors 1. vomiting Precedes the pain medical condition Precedes the pain medical condition Follows the pain surgical condition Follows the pain surgical condition Contents Contents –Bilious Small Bowel Obstruction –Nonbilious pyloric stenosis –Blood -bleeding

14. History, cont… 2. Change in bowel habits –constipation –Obstipation (constipation +no flatus) –Diarrhea 3. Anorexia (poor appetite) –e.g. appendicitis 4. fever –Inflammatory causes

15. Examination Note: physical signs may be less obvious in elderly, obese patients, and those on steroids Note: physical signs may be less obvious in elderly, obese patients, and those on steroids General examination General examination –Motionless peritonitis –Writhing in agony colic (to twist in pain) –Jaundice- obstructive jaundice –dehydration

16. Examination, cont… Vital signs Vital signs –Pulse –Respiratory rate –Blood Pressure High grade fever Low grade fever Acute cholangitis (Fever,jaundice,abdominal pain due to bacterial proliferation superimposed on obstruction of biliary tree due to gall stones) Peritonitis Acute cholecystitis Appendicitis

17. Abdominal examination Inspection Inspection What you see What it means DistensionRigidity Decreased movement ScarsHernia Visible peristalsis Intestinal Obstruction, Ascitis PeritonitisPeritonitisAdhesions Intestinal Obstruction

18. Abdominal examination, cont… Palpation-(to feel) Palpation-(to feel) signsignificance Tenderness, guarding, Rebound tenderness Rigidity (board like) Pulsatile mass Succession splash (splashing sound due to presence of air or fluid) Inflammation of parietal peritonium peritoniumperitonitis Aortic aneurysm Gastric outlet obstruction

19. Abdominal examination, cont… Percussion -(tapping on a surface) Percussion -(tapping on a surface) signsignificance Resonance Loss of liver dullness Shifting dullness Intestinal Obstruction Perforation Ascitis, free fluid

20. Abdominal examination, cont… Auscultation- listening to the internal sounds(stethoscope) Auscultation- listening to the internal sounds(stethoscope) signsignificance Absent bowel sounds Increased sound, Borborygmi (rumbling sound caused by gas moving) Bruit (Abnormal sound over blood vessel) Paralytic ileus etc Mechanical obstruction Vascular disease

21. Specific signs signindication Murphy’s sign Boa’s sign Rovsing’s sign Obturator sign Psoas sign Grey turner & cullen’s sign Acute cholecystits Appendicitis Retrocecal appendicitis, Hemorrhagic pancreatitis

22. Murphy’s sign, Psoas sign –if positive where is the appendix? Retrocecal

23. Obturator sign,Cullen’s sign

24. Abdominal examination, cont… Rectal examination Rectal examination Per vaginal examination Per vaginal examination

25. Digital rectal examination,Per Vaginal Examination

26. Investigations To assess patients condition in general To assess patients condition in general 1. Complete Blood Count (Blood Routine) 2. Electrolytes-Na,K,Cl 3. Blood Urea Nitrogen (BUN) & Creatinine 4. Arterial Blood Gas (ABG) 5. Urinalysis 6. Liver Function Test (LFT) 7. Prothrombin Time (PT)11 to 13.5 sec,PTT –25 to 35 sec (Partial thromboplastin time)(blood test that tells how long it takes for plasma to clot?) 8. Blood grouping and cross matching

27. Investigations, cont… 2. Serum Beta HCG (human chorionic gonadotrophin hormone) –In female of child bearing age –To rule out ectopic pregnancy

28. Investigations, cont… Specific investigations Specific investigations A. Lab 1. Amylase & lipase 1. Amylase & lipase –Lipase elevation is specific for pancreatitis –Amylase elevation confirms the diagnosis of Pancreatitis, but also seen in: Perforated viscus (Internal organs) Perforated viscus (Internal organs) Intestinal.Obstruction Intestinal.Obstruction Acute cholecystitis Acute cholecystitis

29. Investigations, cont… B. Radiological 1. Chest x-ray Air under the diaphragm in perforated viscus (duodenal perforation) Elevated diaphragm in abdominal distention

30. Investigations, cont… 2.Abdominal x-ray air fluid levels in intestinal obstruction air fluid levels in intestinal obstruction Stones (90% of kidney stones can be seen in x-ray and 10% can’t be seen but 10% of gallstones can be seen in x-ray but 90% can’t be seen) why ? Calcium. Stones (90% of kidney stones can be seen in x-ray and 10% can’t be seen but 10% of gallstones can be seen in x-ray but 90% can’t be seen) why ? Calcium.

31. Investigations, cont…

32. Kidney stone, Gall stones

33. Investigations, cont… 3. USG-Ultra sound Scan Gallstones Gallstones Appendicitis Appendicitis Ectopic pregnancy Ectopic pregnancy Torsion of ovarian cyst Torsion of ovarian cyst empyema empyema 4. CT scan pancreatic pathology pancreatic pathology Acute aortic aneurysm Acute aortic aneurysm Severe diverticulitis Severe diverticulitis Abdominal abscess Abdominal abscess

34. Gall stones

35. Abdominal CT scan

36. Investigations, cont… 5. Duplex scan or angiography for superior mesenteric embolus or for superior mesenteric embolus or thrombosis thrombosis 6. ERCP (Endoscopic retrograde cholangio-pancreatography)

37. Investigations, cont… C. Paracentesis –To assess Small Bowel Perforation in ascitis –Free blood, bile, bowel contents suggest Bowel perforation D. Endoscopy & laparoscopy E. Diagnostic peritoneal lavage

38. Peritoneal lavage, Paracentesis

39. Management Initial management Initial management – Nil Per Oral –Intravenous fluids, Bolus Ringer Lactate solution –Monitor urine output –Nasogastric tube Decompression Decompression suction suction –Analgesia Pethidine Pethidine

40. C Management, cont… –Antibiotics Broadspectrum Broadspectrum In case of sepsis or peritonitits In case of sepsis or peritonitits

41. Management, cont… Surgical management Surgical management –Indications 1.Physical findings Localized peritoneal irritation with guarding or rigidity Localized peritoneal irritation with guarding or rigidity Spreading tenderness Spreading tenderness Tense or progressive distension Tense or progressive distension Tender abdominal or rectal mass with high fever or hypotension Tender abdominal or rectal mass with high fever or hypotension

42. Indications for surgery, cont… Rectal bleeding with shock or acidosis Rectal bleeding with shock or acidosis Equivocal (uncertain)abdominal findings with Equivocal (uncertain)abdominal findings with –Septicemia: high fever, leukocytosis, mental status changes –Bleeding: shock, acidosis, falling hematocrit –Suspected ischemia: acidosis, fever, tachycardia

43. Indications for surgery, cont… 2. Radiological findings Pneumoperitonium –bowel perforation Pneumoperitonium –bowel perforation Gross or progressive bowel distension-bowel obstruction Gross or progressive bowel distension-bowel obstruction Free extravasation of contrast media-bowel perforation Free extravasation of contrast media-bowel perforation Space occupying lesion –Mass or tumor Space occupying lesion –Mass or tumor Mesenteric occlusion-Ischemia Mesenteric occlusion-Ischemia

44. Indications for surgery, cont… 3. Endoscopic findings Perforated lesion Perforated lesion Uncontrolled bleeding lesion Uncontrolled bleeding lesion 4. Paracentesis Blood Blood bile bile bowel contents bowel contents urine urine