1. ACUTE ABDOMEN
Begashaw M

2. ACUTE ABDOMEN
Denotes any sudden condition with chief manifestation of pain of recent onset in the abdominal area which may require urgent surgical intervention

3. Sites of referred pain

4. Sites of Abdominal Pain

5. CLASSIFICATION Obstruction Inflammation Hemorrhage Infarction
perforation

6. CLINICAL FEATURES Symptoms _Colicky and Intermittent pain ( visceral)
_Continuous pain ( somatic)
_Vomiting
_Fever
_Tachycardia
Colic pain obstruction
Continuous pain infection, inflammation or ischemia

7. Signs Abdominal distention, visible peristalsis
Direct and rebound tenderness, guarding
Anemia, hypotension
Toxic with Hippocratic faces
Absence of bowel sound ( peritonitis)
Psoas signappendicitis
Murphy‘s signacute cholecystitis
Dehydrationsunken eyeballs

8. DIFFERENTIAL DIAGNOSIS
Surgical - Intestinal obstruction
Gynecologic & obstetric - Ectopic ruptured pregnancy
Medical - enteritis

9. Surgical causes
A- InflammationAcute appendicitis Acute cholecystitis B- Obstruction Intestinal obstruction C- Infarction Mesenteric ischemia D-Strangulation volvulus E- Perforation perforated peptic ulcer

10. DIAGNOSIS Clinical: Hx & p/E
Lab: CBC, cross match, urine analysis, serum amylase & electrolytes
Ultrasound
plain film of abdomen

11. MANAGEMENT
A-Preoperative - Resuscitation with IV fluids - Antibiotics - Catheterization & NGT insertion - Analgesics after confirming the diagnosis B- Surgery Definitive laparotomy CMonitoring Follow up

12. INTESTINAL OBSTRUCTION
is partial or complete blockage of the intestine producing symptoms
_Vomiting
_Constipation
_Distension
_Abdominal pain

13. Causes of mechanical intestinal 0bstruction

14. Intestinal Obstruction

15. CLASSIFICATION Mechanical  physical barrier blocks
Paralytic ileus disordered propulsive motility
High _Small bowel
Low _Large bowel
Simple -> adequate blood supply
Strangulated -> Mesenteric vessels occluded

16. Mechanical A- Luminal _Gallstone Ileus _Food bolus _Meconium Ileus
_Malignancy
_Inflammatory mass
_Ascaris bolus
B- Mural
_Stricture
_Congenital
_Inflammatory
_Ischemic
_Neoplastic
_Intussusception

17. Intussusception

18. C- Extra mural
Adhesionsinflammatory/malignant
Hernia External/internal
Volvulus Small bowel
large bowel -> Sigmoid volvulus

19. Small bowel obstruction

21. Adhesion

22. PATHOPHYSIOLGY Proximal dilatation disrupts peristalsis
Above the obstruction  distended with fluid and gas
stimulates excessive peristalsis ->colicky pain
blood vessels-stretched & narrowed ischemia
Absorptive capacity decreases
increased vomiting  depletion of extra cellular fluid  hypovolemia & dehydration

23. Pathophysiology

24. A strangulated loop dies and perforates to produce severe bacterial peritonitis which is often fatal
Grossly distended abdomen restricts diaphragmatic movement and interferes with respiration
A multiple organ failure

25. Clinical features Symptoms -Abdominal pain-colic -Vomiting
-Constipatio-partial
-absolute
Signs
-Abdominal distension visible bowel loops
-High pitched bowel sounds
-Tenderness & guarding
-Dehydration & hypotension
-Empty rectum DRE Large bowel obstruction

26. DIAGNOSIS Clinical: Hx & P/E Lab: CBC, electrolytes
Plain abdominal film :
- distension of bowel with air fluid level
- Central located distended loops with multiple air fluid levelsmall bowel
- Peripherally located distended bowel with haustral marksLarge bowel

27. X-ray of intestinal obstruction

29. MANAGEMENT Fluids resuscitation to restore the circulatory state
Early preoperative preparation
Attempt rectal tube deflation-simple sigmoid volvulus
Supportive measures
Early operationLaparotomy
Post operative care

30. NG tube suction

31. SIGMOID VOLVULUS Sigmoid colon is the most frequent site of volvulus
Predisposing factors
- A long redundant sigmoid with a narrow pedicle
- High fiber diet
Chronic constipation_elderly
_chronic mental pts

32. Sigmoid volvulus

33. PATHOPHYSIOLOGY
Redundant sigmoid twists on its base in a clockwise direction
Mesocolic veins become occluded & arterial inflow into the twisted loop perpetuates the volvulus until it becomes irreversible
Twisted loop distends grossly
Perforation may occur due to either pressure necrosis at the base of the twist or to avascular necrosis at the apex

34. DIAGNOSIS CLINICAL _Abdominal cramp & distension
_Constipation (early) & vomiting (late)
_Empty rectum on DRE
RADIOLOGIC FINDINGS
Two long fluid levels in the lower quadrant
Inverted U shape of the sigmoid lumen
“Coffee bean” appearance or the ‘Omega sign”

36. MANAGEMENT Conservative
simple volvulusdeflation with a well greased large bore rectal tube under the guide of a sigmoidoscope
Deflation fails laparotomy & derotation
Elective resection & anastomosis
Intravenous fluid - rehydrate if sign of dehydration

37. Sigmoidoscopic deflation

38. Emergency Surgery
_Complicated volvulus with signs of peritonitis
_Resuscitative measures
_Antibiotics
_Resection of the gangrenous segment with Hartman’s colostomy

39. Laparatomy

40. APPENDICITIS
is an inflammation of the appendix that results from bacterial invasion usually distal to an obstruction of the lumen

41. Appendix

43. Pathogenesis
Luminal obstruction bacterial overgrowth  lnflammation/swelling Increased pressure-localized ischemiagangrene/perforationlocalized abscess (walled off by Omentum) or Peritonitis
Etiology:
_Hyperplasia of lymphoid follicles
_Fecolith, obstructing neoplasm
_Parasites, foreign body

44. CLINICAL PRESENTATION
Symptoms
-Central abdominal colic which shifts to the right Iliac fossa
-Anorexia, nausea, episodes of vomiting and low grade fever
-High grade fever indicates perforation and peritonitis

45. Signs
-Tenderness and localized rigidity in RLQ MC Burney’s point -Rovsing’s sign: Pain in RLQ on pressing in LLQ -Psoas sign: Pain on extension of right flexed hip -Obturator sign: Pain on passive internal or external rotation of the flexed right hip -Right sided tenderness on rectal examination. -Diminished bowel sounds indicating peritonitis

46. Appendicitis signs

47. Differential diagnosis
IN CHILDREN
-Intussusceptions
-Mesenteric adenitis
FEMALE
-PID
-Twisted ovarian cyst( torsion)
- ruptured ovarian follicle
GENERAL
-Acute chlolecystitis
-Perforated PUD
-Renal or ureteric calculi
-UTI
-Early small bowel obstruction (volvulus)
-Gastroenteritis

48. Investigations Labs leukocytosis with left shift
beta-hCG to rule out ectopic pregnancy
Urinalysis
Imaging:
Upright CXR, AXR-free air
Ultrasound: may visualize appendix

49. MANAGEMENT PREOPERATIVE -Resuscitation with fluids
-Appropriate antibiotics (combination for coverage of gram positive, gram negative and anaerobes)
-Correct all deficits ( dehydration)
SURGERY
-Surgical removal of the appendix is the definitive treatment-Appendectomy

50. COMPLICATIONS Perforation - local or generalized peritonitis
Appendiceal mass and abscess formation
Death

51. APPEDECIAL MASS
Inflammatory process walled off in the right iliac fossa by omentum and loops of bowel to form a mass
Management-Conservative
-antibiotics
-fluids
_Drug of choice- metronidazole and ceftriaxone
Ampicilline, Chloramphenicol & Gentamycin

52. Follow up -Vital signs every 4 hourly
-Mass size & consistency 12 hourly
-Patient’s condition
-Laboratory every other day
Interval appendectomy 6 weeks later

53. Appendiceal abscess Increasing mass size Fluctuation
persistence of systemic signs
Management - drainage of the abscess and appendectomy
Interval appendectomy after emergency drainage

54. Draining appendeceal abscess

55. PERITONITIS is an inflammation of the peritoneum
is an acute life threatening condition caused by bacterial or chemical contamination of the peritoneal cavity

56. Peritoneum

57. Peritoneal abscess

58. Differential diagnosis
Perforated appendix
Perforated PUD
Anastomotic leak
Strangulated bowel
Pancreatitis
Cholecystitis
Intra abdominal abscess
Typhoid perforation
Ascending infection e.g salpingitis

59. CLASSIFICATION
Primary peritonitis: caused by bacterial spread via the blood stream
Secondary peritonitis: caused during perforation or rupture of abdominal organ allowing access of bacteria and irritant digestive Juices to the peritoneum

60. Classification Acute peritonitis: rapid onset or brief duration
Chronic peritonitis: long duration
Localized peritonitis - confined to a limited space - pelvis
Generalized peritonitis - whole peritoneal cavity involved

61. ROUTES OF BACTERIAL INVASION
1- Direct- contamination via perforation, a penetrating wound or during surgery 2-Local Extension: contamination by migration from an infected organ - through gut wall, via the fallopian tube 3-Blood stream: via the blood as consequence of general septicemia

62. CLINICAL FEATURES Sharp pain which is worse on movement
Fever & tachycardia
Abdominal distension
Tenderness & guarding
Diminished or absent bowel sounds
Shoulder pain _referred pain -diaphragmatic irritation
Tenderness on rectal examination (pelvic peritonitis)
Abdominal distension & vomiting

63. Generalized peritonitis

64. MANAGEMENT Resuscitation: intravenous fluids Analgesia
Naso-gastric tube insertion (NGT)
Triple antibiotics (ampicilline , gentamycin and metornidazole or chloramphenicol)
Monitoring in put & out put by catheterization
Surgery
Drainage & peritoneal lavage