Transcript Seminar Acute Abdomen II

Acute abdomen
th
4 year
part I
2012
Dr Abdulhakim Al-Tamimi , MD
Assiss prof of suregry
Aden university
Acute abdomen
Definition:
“An acute intra-abdominal condition of abrupt
onset that is usually associated with pain due
to inflammation, perforation, obstruction,
infarction or rupture of abdominal organs in
previously healthy person and usually
requiring emergency intervention.
Called also surgical abdomen.”
Dorland’s Medical Dictionary 2007

General rule can be made that majority
of severe abdominal pain in pts who
have been previously fairly well and last
longer than 6 hours are caused by
surgical conditions
“The term “acute abdomen” should
never be equated with the invariable
need for operation.”
Zachary Cope, MD, 1927
THE USUAL causes
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Non-Surgical:
Appendicitis
Cholecystitis
Small Bowel Obstr.
GYN
Pancreatitis
Renal
Cancer
Diverticulitis
34%
28%
10%
4%
4%
3%
3%
3%
3%
Acute Abdomen
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Acute abdominal pain with peritoneal
signs and often abnormal vital signs
Peritoneal signs = peritoneal irritation
from inflammation/infection
Symptoms include nausea, vomiting
Signs include fever, shallow respiration,
hypotension, guarding ,rigidity and
rebound tenderness
Needs to have urgent assessment in
Emergency room
Red Flags
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New onset of pain, change in pain or altered
bowel habits in the elderly
Weight loss, hx CAD
Bleeding per rectum or melena
New anemia, hx of ETOH abuse
Supraclavicular nodes
A personal or family history of serious bowel
pathology
Pain waking the patient at night
Immunocompromised,
previous abdominal surgery
Necessity for Diagnosis
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A serious and thorough attempt at
diagnosis
Abdominal pain is the most common
symptom
Acute abdomen = surgery is not always
indicated
Course of action
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Urgent operation
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Wait for evolution of symptoms
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Medical management
What you should know as 4th year ?
Plan
1.
Common causes
2.
History and examination
3.
Investigations
4.
Case example
Epidemiology
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Abdominal pain present in
10% of hospital admissions.
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1/3 of these require surgical
intervention.
Classification of acute abdomen
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According to the related cause
• Inflammatory
• Obstruction
• Perforation
• Hemorrhage (
rupture or infarction )
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Syndromic classification :
• Peritoneal syndrome
• Obstructive syndrome
• Hemorrhagic syndrome
• Mixed syndrome
Causes at sites
Diffuse
Acute pancreatitis
DKA
Gastroenteritis
Intestinal obstruction
Peritonitis
Mesenteric ischaemia
RUQ/LUQ
Acute pancreatitis
Lower lobe pneumonia
Myocardial ischaemia
RUQ
LUQ
Cholecystitis
Biliary colic
Hepatitis
Hepatic abscess
Gastritis
Splenic rupture/abscess
RLQ
LLQ
Appendicitis
Caecal diverticulitis
Meckel’s diverticulitis
Sigmoid diverticulitis
RLQ/LLQ
IBD
Renal stones
Cystitis
Endometriosis
Ruptured ectopic
pregnancy
Incarcerated hernias
Types of Pain
visceral
• caused by stimulation of
nerve fibers of organs.
• described as dull
,crampy, colicky (comes
and goes)
• tends to be diffuse and
difficult for a patient to
pinpoint
• commonly seen with
other signs and
symptoms such as
sweats, vomiting,
nausea and tachycardia
Abdominal Pain
• Visceral pain – stretching of visceral organs
• caused by inflammation of the visceral peritoneum
and capsule of solid organs.
• Example: Early appendicitis---paraumblical region or
epigastrium
Types of Pain, continued
somatic
• a focal pain that
occurs when nerve
fibers within the
peritoneum are
irritated by chemical
or bacterial
inflammation
• more localized and
is usually described
as sharp and
knifelike
• constant and made
Abdominal Pain
• Example: Late appendicitis with peritonitis , perforated
peptic ulcer
• a radiating pain that
Types of Pain, continued
is felt at a location
away from the point
referred
of origin
• pain associated with
kidney stones may
be referred to the
testicle
• myocardial
infarction,
pneumonia and
musculoskeletal
injuries can refer
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Gall bladder diseases – right shoulder
,scapular region
LLQ pain with appendicitis
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Obturator internus spasm – pain on
rotation of the flexed thigh inwards and
this pain is referred to hypogastrium - in
pelvic appendicitis and haematocele
Types of Pain, continued
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shifting pain – when the pain move
to other site without any other relation to
the previous site
•
Example paraumlical pain shifted to the right
iliac fossa
History is very
important ??
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Description of pain - OPQRST:
• Onset
• Provoking and relieving factors
(what makes it worse or better )
• Quality (burning, cramping, dull)
• Relieving factors, and radiation
• Severity (out of 10)
• Timing ( duration )
OPQRST
Onset
• What were you doing when it started?
• Did the pain come suddenly or gradually?
Provocation • Does the pain move around?
• Does anything lessen the pain?
Quality
Radiation
•
•
•
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Can you describe the pain?
Is it constant? Does it come and go?
Is it sharp, dull or burning?
Do you feel the pain anywhere else?
Severity
• How severe on a scale of 1-10 scale?
Time
• What time did the pain come on?
SAMPLE History
Factor
Description
Signs/Symptoms
Chief complaint
What happened?
Allergies
To medications, etc.
Medications
Prescription, over the
counter, and recreational
(illicit) drugs
Past medical history
Medical conditions
Last oral intake
Food and drink
Events leading to incident
Include precipitating factors
Pain History-other way to keep by heart
SOCRATES
Site – where started, has the pain
moved?
Onset - usually sudden
Character – visceral, somatic, colic
Radiation
- pain in retroperitoneal structures radiates
to the back
-Loin to groin in ureteric colic
-Epigastrium to the back in peptic ulcer
-Gallbladder to the right shoulder
-Like a belt around the abdomen in acute
pancreatitis
Associated symptoms
-GI
symptoms: nausea, vomiting bleeding
also GU symptoms and cardiopulmonary
symptoms
Time of onset ( duration )
Elevating and relieving factors
Severity – elderly patients have increased
pain threshold/reduced visceral sensation.
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Thorough history and physical
examination and recognition of the early
stages of the disease
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Record the earliest symptoms
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Attempt a specific diagnosis – prevents
carelessness and ignorance
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A correct diagnosis essential to correct
treatment
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Spot diagnosis is magnificent but not
sound, is impressive but unsafe.
Early Diagnosis
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Diagnose early
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No narcotics or analgesics until
diagnosis is made
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Examination ,reexamination ,testing by
inexperienced hands leads to delay in
diagnosis and early pain relief
Again we said
 Severe
abdominal pain in pts
who have been previously
healthy and last longer than 6
hours are caused by surgical
conditions
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Early diagnosis improves
recovery
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Decreases mortality
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Reduces hospital stay due to
infections
What it need this acute
abdomen ?
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Life-threatening condition due to acute onset
abdominal disease with typical symptoms and
physical findings, which reqiures:
• Prompt surgical intervention
• Acute appendicitis
• Acute peritonitis
• Acute intestinal obstruction
• Acute mesenteric vascular insufficiency
• Rupture of the spleen, ectopic pregnancy, dissection of
aortic aneurysm
What it need this acute
abdomen ?
• Emergent admission to a monitored bed or
intensive care unit
• Acute pancreatitis
• Acute cholecystitis
Anatomy
•
The abdomen is the largest cavity in the
body. The diaphragm separates the
abdominal cavity from the chest cavity.
•
Most of the abdominal organs are enclosed
within a membrane called the peritoneum.
•
Those organs behind and outside the
peritoneum include the kidneys, pancreas
and the abdominal aorta called
retroperitoneal organs
Anatomy
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Apply your knowledge of anatomy in
diagnosing abdominal conditions
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Diaphragmatic spasm – decreased
movement of lower chest and upper
abdomen
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Rectus and lateral abdominal muscle rigidity
– in subjacent inflammation
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Umbilicus at the level of T10 ( thoracic
nerves)
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Abdominal cavity three portions
• Under costal margin
• True abdomen
• Pelvic abdomen
Quadrant View of the Abdomen
Right Upper
Left Upper
Left Lower
Right Lower
Abdominal quadrant
Four Quadrants
Right
upper quadrant
(RUQ) contains the
liver, gallbladder and
part of the large
intestine.
Right lower quadrant
(RLQ) contains the
appendix, small
intestine, fallopian
tube and ovary.
Left upper quadrant
(LUQ) contains the
stomach, spleen,
pancreas and part
of the large
intestine.
Left lower
quadrant (LLQ)
contains the small
and large intestine,
fallopian tube and
ovary.
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Irritation to the diaphragm will cause pain
in the shoulder as the diaphragm has its
origin from the 4th cervical segment and
is supplied by the cervical segment via
phrenic nerve.
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Pain may be felt in the shoulders in
cases of subphrenic abscess,
diaphragmatic pleurisy, a/c cholecystitis
, ruptured spleen etc.
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The pain is felt in supraspinatous fossa,
over the acromion, clavicle or in
subclavicular fossa
The shoulder pain is often missed as it is
attributed to arthritis.
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Small bowel colic pain is referred to the
epigastrium and the umbilicus
Large bowel colic to the hypogastrium
Renal colic from loin to groin and the
testicles
Biliary colic to the right subscapular
region
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Tenderness due to irritation of nerves by
unilateral lesion is not felt on the
opposite side usually. Eg. Right sided
pleurisy causes tenderness in RIF but
not in LIF.
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Exclude medical disease before calling
for surgical intervention. (esp a
laparotomy)
Cardiac disease, tuberculosis, cirrhosis,
chronic interstitial nephritis and
arteriosclerosis. Porphyrias and diabetic
disease (DKA)
SEVERE ABDOMINAL PAIN
1. Hollow organ perforation
2. Acute pancreatitis
3. Colic pain
a. Biliary system
b. Renal system
4. Ischemia pain
COMMON DISEASES
1. Acute appendicitis
2. (Perforated) Peptic ulcer
3. Acute cholecystitis
4. Acute pancreatitis
5. Small bowel obstruction
6. Colon obstruction
7. Vascular occlusion
8. Others
RE-EVALUATION
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Time interval
Same personnel
Vital signs
Laboratory examination
Early suspicion
Early consultation
MEDICAL ETHICS
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Treat a person not a disease
Treat a patient as your family
Be patient to a patient’s
complaint
Be kind and more smile
Careful explanation
Methods of diagnosis
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Record history in the chronological order
of symptoms
Age- intussusception in infants (<2)
Cancerous stricture rare below30
A/c pancreatitis rare below 20
Perforated GU rare below 15
Exact time and onset
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Many conditions are precipitated by many
factors . It is important to know what the
patient was doing at the time of onset.
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Fainting occurs with ectopic gestation,
perforated GU/DU, a/c pancreatitis, ruptured
aortic aneurysm.
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Intestinal obstruction gradual in onset and
culminates in crisis
Shifting or localisation of pain
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When peritoneal cavity is filled with pus,
blood or fluid pain is felt all over the
abdomen and later shifts to site of
perforation.
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Pain of small intestine is always felt first in
epigastric or umbilical region (T9 to T11
nerves)
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Remember appendicular nerves are also
derived from the T9 to T11 so pain may be
initially felt in the epigastric region
Vomiting
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Severe irritation of nerves of the
peritoneum or the mesentery eg. DU
perforation or torsion ovarian cyst.
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Obstruction of an involuntary muscle
tube.
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Absence of vomiting is sufficiently
common in many abdominal
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Vomiting is early, sudden and violent in
ureteric colic
Early and copious in upper intestinal
obstruction
No vomiting until late in large bowel
obstruction
Frequent scanty in A/c pancreatitis
Vomiting precedes pain in gastroenteritis
Character of Vomitus
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In gastritis vomitus contains food particle
and some bile
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In CHPS( congenital hypertrophic pyloric
stenosis ) and duodenal atresia
differentiated by presence of bile in the
latter
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In intestinal obstruction content varies
from gastric , bilious greenish yellow to
Double bubble sign
Duodenal atresia
CHPS
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Hypogastric pain and diarrhoea when
followed by hypogastric tenderness and
constipation suspect pelvic abscess.
Partial small bowel obstruction may
produce profuse watery diarrhoea
without passage of flatus
Other symptoms of acute abdomen
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Distension
Diarrhea
Constipation
Anorexia
Inflammatory causes of acute
abdomen ?
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Itis --------------- inflamma-------itis
Acute appendicitis
Acute cholecystitis
Acute pancreatitis
Acute diverticulitis
Perforated viscous
Acute pylenephritis
Acute colitis
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All these inflammatory process leads to :
• Irritation of the peritoneum:
Peritonisim
• Inflammation of the peritoneum:
Peritonitis
Peritonitis
Types of
peritonitis
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Primary peritonitis
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Secondary peritonitis
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Localized
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Regionalized
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Generalized
Acute peritonitis
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Symptoms– according to part and extent of
peritoneum involved, presence of infection
and acuteness of onset.
Reflex symptoms– pain, vomiting, rigidity.
Toxic symptoms– alteration in temperature,
collapse, distension, general toxemia.
Pain is the most common symptom. Vomiting
common at the onset but infrequent until late.
Primary peritonitis
Clinical picture of primary
pretonitis
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Pain
Nausea
Vomiting
Fever
Mild tenderness depend upon the
degree of contamination
Treatment
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Usually conservative
Antibiotics
Waiting for the response
Rarely need surgical intervention
Secondary pretonitis
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Most common cause is acute
appendicitis
Most often infectious and is usually
related to a perforated viscus
Acute secondary peritonitis
•Perforations of bowel (appendicitis,
peptic ulcer disease, neoplasms,
volvulus, ischemia, ingested foreign
body, etc.)
•Perforations or leaking of other
organs (pancreatitis, acute
cholecystitis, urinary bladder rupture,
etc.)
•Disruption of integrity of peritoneal
cavity (trauma, peritoneal dialysis,
perinephric abscess, etc.)
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Clinical manifestations:
• Acute abdominal pain and tenderness, usually
with fever. The location of the pain depends on
the underlying cause and whether the
inflammation is localized or generalized
• Localized peritonitis is most common in uncomplicated
appendicitis and diverticulitis
• Distension of intestinal lumen with gas and fluid
• Boardlike muscular rigidity in cases of diffuse
peritonitis
• Bowel sounds are usually absent
• Disappearance of liver dullness
• Tachycardy, hypotension, and signs of
dehydration
Perforated peptic ulcer
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Usually adult but it can affected young
Sudden onset
There may be history of gastric pr
duodenal ulcer
Duodenal perforation is more common
and usually in the first part anterior wall
May follow heavy meal
May related to drugs as anti
inflammatory or steriods
Stages of perforated peptic
ulcer
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Three stages
Chemical peritonitis 0-6 h
Lucid interval ( illusion ,reactionary ) up
to 12h
Diffuse septic peritonitis >24h
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Severe epigastric pain ,which become
early diffused all over the abdomen
Vomiting once or twice
Anorexia
Sweating
Tender all over
board like rigidity
Rebound tenderness
Loss of hepatic dullness
Peritoneal Signs
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Palpation and Percussion – BE GENTLE
Rebound – please do not perform this
test
• Causes unexpected and unnecessary pain
• Does not add information to an examination
after percussion
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Rigidity
• not present in pelvic inflammation or
obstruction, unreliable
Physical Examination
1.
General Appearance
1.
2.
3.
2.
Level of discomfort
Nutrition status
Hydration status
Attitude in Bed
1.
2.
3.
Still – peritonitis
Restless – colic
Writhing – consider mesenteric
vascular event
Mechanisms of pain transmission
Somatic
Visceral
Referred
 Do
not forget the RECTAL
& PELVIC exams !!
Investigations
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CBC with leukocytosis
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Thoracoabdominal X-ray in standing
position may show air under the
diaphragm 70—80%
Free air under the diaphragma
P-A X-ray: Discoid shape free air under the diaphragma on both sides.
What is the exam to
evaluate for
pneumoperitoneum?
Upright abdomen film
If a patient can not stand what radiograph can be
substituted?
pneumoperitoneum
Liver side UP
Left lateral Decubitus
==
Patient lying on their LEFT
side.
Treatment
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Admission to the emergency room
Clinical and para clinical assessment
IV fluids
Antibiotics
NG tube
Urinary catheterization
Closure of the perforation
Omental patch ( Graham’s method)
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In perforated gastric ulcer take biopsy
-1- Dist = 1.30cm
-2- Dist = 0.91cm
Diverticulitis
TB peritonitis