1. The Acute Surgical Abdomen Ada Ekpe Amel Ibrahim

2. Contents  Anatomy  Adominal pain  Management of the acute abdomen: from history to exam  Scars and surgeries  Stomas  Questions

3. Anatomy of the abdomen  9 regions and 2 flanks  Surface:  Skin  Linea alba and umbilicus  Xiphisternum  Symphysis pubis  Pubic tubercle  Costal margins  Iliac crests

4.  2 Hypochondria  Epigastrium  2 Loins  Paraumbilical  Suprapubic  2 Iliac fossae  2 Flanks

5. Surface Anatomy  Transpyloric plane of Addison:  Halfway between jugular notch and Symphysis pubis.  Contains: body and tail of pancreas, L1 body, 2 nd part of duodenum, Hilum of L kidney, upper pole R kidney, pylorus, tips of 9 th costal cartilages, fundus of GB, splenic and hepatic flexures, spleen and origins of SMA and portal vein.

6.  McBurneys point:  1/3 of way between ASIS and umbilicus.  Appendix  Mid inguinal point:  halfway between ASIS and pubic tubercle. Site of deep ring.  Mid point of inguinal ligament:  Half way between ASIS and pubic symphysis. Site of femoral pulse.

8. Referred pain  No plan for viscera  Pain referred to associated dermatome  Appendicitis: initially T10 then as peritoneum inflamed (richly innervated) pain localised to RIF

9. Pain  Epigastric:  cardiac  Lung  Thoracic dissection/ruptured aneurysm  pancreatitis  Liver  Gall bladder  Gastric/duodenal ulcer  Transverse/small bowel  RUQ:  Gall bladder  Liver  Lung  Bowel  LUQ:  Spleen  Bowel  Lung  Cardiac

10.  RIF:  Skin: cellulitis/sebaceous cyst  Subcut tissue: nec fasc  Lymph nodes: mesenteric adenitis/lymphoma/infectio n  Bowel: large bowel (tumour, colitis)  Appendictis/appendix mass  Constipation  Strangulated hernia  Ruptured iliac aneurysm  OVARIAN  Orchitis/undescended testis

11.  LIF:  Diverticultis  Tumour  Hernia  Testicular  Ovarian  Colitis  Lymphoma etc…

12. Q&A  Paraumbilical?  Flank?  Suprapubic?

13. History  Site  Onset  Character  Radiation  Associated symptoms  Time  Exacerbating/alleviating factors  Severity

14.  Change in bowels  Appetite? Is pain associated with food?  Nausea/vomiting  Urinary symptoms/systems review  Previous surgeries  Medications  Family history  Social history

15. Examination  ABC  Observations  OBSERVE:  Jaundice  nutrition  body habitus  Discomfort  Stigmata of ETOH use  Position (mobilising/peritonitic)

16. Volunteer?  Abdo exam:  Hands (dupuytren’s/clubbing/asterixes/pulse/nails)  Face (icteric/hydration)  Neck (Virchow’s node)  Chest (spider naevi/gynaecomastia)  Abdomen: scars, lumps, erythema, tenderness, guarding, peritonism, organomegalyand bowel sounds)  PR: skin tags/fungating tumours/haemorrhoids, tender, mass, blood and rectum empty/full (hard or soft stool).  HERNIAL ORIFICES AND TESTES

18. Management  Analgesia  IV access  Fluids/antibiotics (if necessary)  AXR and/or USS Vs CT scan  Optimise for theatre or manage conservatively  Common emergencies:  appendicitis, diverticulitis, ischemic colitis, strangulated hernia and SBO.  Common emergency operations:  appendicectomy, herniorraphy +/- resection, Hartmann’s and (sub)total colectomy.

19. Stomas  Ileostomy:  often RIF  spouted, liquid contents  Colostomy:  end/defunctioning  Flush  Solid contents  Urostomy:  For cystectomy  Ileal conduit  Urine in bag