acute abdomen inflammatory, ileus & trauma · 90 % of acute abdomen in this subpopulation...
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Acute Abdomen
Inflammatory, Ileus & Trauma
1st Department of Surgery, Pavol Jozef Šafarik UniversitySlovak Republic
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Acute Abdomen
Inflammatory
1st Department of Surgery, Pavol Jozef Šafarik UniversitySlovak Republic
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Inflammatory AA
Defined by inflammation in the abdominal cavity
Limited to the organ
Spreading into surrounding tissues – localized peritonitis
Affecting whole abdominal cavity – diffuse peritonitis
Includes:
Acute appendicitis
Acute cholecystitis
Acute pancreatitis
Acute diverticulitis
Perforated peptic ulcer
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Acute appendicitis
The most common reason for inflammatory AB
Inflammation starts at the mucosa
Pathological classification
Catarrhal
Phlegmonous
Gangrenous
Perforated (within 48 hours) Periapendicular abscess
Diffuse peritonitis
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Diagnosis
Early recognition needed !
Based on history & physical examination
Symptoms may vary according to the position of appendix:
Pelvic (diff. Dg. adnexitis, diarrhoe)
Mediocecal (diff. Dg. small bowel obstruction)
Retrocecal (diff. Dg. renal colic)
Subhepatic (diff. Dg. acute cholecystitis)
Left-sided (diff. Dg. acute diverticulitis)
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History
Epigastric & periumbilical pain
Anorexia, nauzea
Pain migrating to the right lower quadrant
Single episode of vomiting (no relief)
Adynamic ileus or 1-2 episodes of diarrhea
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Physical examination
Axillar body temperature slightly increased (below 38 ˚C)
Disproportional tachycardia (>90/min)
Pain on palpation in the Mc Burney´s point
Signs of peritoneal irritation:
Dunphy´s sign (movement or coughing)
Rovsing´s sign (preassure on the left)
Blumberg´s sign (relieved compression on the left)
Plenies´s sign (percussion)
Obturator sign (internal rotation of right hip)
Iliopsoas sign (extension of the right hip)
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Laboratory investigations
Not specific
Elevation of white blood cells count with neutrophilia
CRP usually normal
Increased in subacute appendicitis
Elevation in Crohn´s disease
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Imaging
Minor value
Abdominal ultrasonography
Thickening of the wall
Diameter over 7 mm
Negative finding vs. appendix not visualized
CT scan
In dubious cases
Irradiation
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Differential diagnosis
Perforated gastroduodenal ulcer
Acute pancreatitis
Crohn´s disease
Perforated right-sided colonic cancer
Acute gastroenteritis
Acute cholecystitis/right sided renal colic
Gynecological diseases
Adnexitis
Perforated or torquated ovarian cyst
Ruptured ectopic pregnancy
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Treatment
Surgical – appendectomy
Open
Laparoscopic
Advantages of laparoscopic approach
Diagnostic laparoscopy
Fewer wound complications
Earlier restoration of physical activity
What if appendix macroscopically negative?
Other pathology explaining symptoms?
No pathology present?
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Appendicitis in children
90 % of acute abdomen in this subpopulation
Diarrhea with fever & vomiting
Perforation occurs quickly
Relatively short omentum
Decreased inflammatory response
Limited systemic resistance against infection
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Appendicitis in elderly
Rare, but possible !
Mild symptoms
Subacute appendicitis
Periapendicular abscess
Differential diagnosis from cancer necassary
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Appendicitis in pregnancy
Early recognition needed !
Based on history & physical examination
Symptoms may vary according to the position of appendix:
Pelvic
Mediocecal
Laterocecal
Retrocecal
Subhepatic
Left-sided
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Subacute appendicitis
Inflammatory process slowed down
Pseudotumor involving appendix & surrounding tissues/organs
Symptoms & clinical findings
Righ lower quadrant pain, >48 hours
Increased body temperature
Palpable painful mass in the right iliac region
Positive USG/CT finding
Elevated CRP
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Treatment
Conservative
ATB
Bowel rest & observation
Colonoscopy a froad !
Dealayed appendectomy
8-12 weeks after the resolution of symptoms
Laparoscopic
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Other inflammatory AA
Acute cholecystitis
Acute pancreatitis
Acute diverticulitis
Perforated peptic ulcer
Acute gastroenteritis
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Diffuse peritonitis
Generalized infection of the peritoneum
Primary (bacterial, chlamydial, fungal, mycobacterial)
Secondary (spread from inflamed organs)
Tertiary (after surgical interventions)
Pathomorfological classification
Purulent
Stercoral
Biliary
Urinal
Chemical
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Symptoms & therapy
Sudden or slow onset
Severe shocking diffuse abdominal pain
Tachycardia, tachypnoe, overall alteration
Vomiting & bowel paralysis
Defanse musculaire
Do not loose time – urgent surgical intervention
Source control
Cleaning of the abdominal cavity
Drainage
Management of subsequent shock
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Localized peritonitis
Symptoms depend on the extent – phlegmone vs. abscess
Tenderness & guarding
Increased CRP
USG, CT, NMR
Typical abscess localizatios
Subphrenic abscess
Douglas pouch abscess
Interintestinal abscess
Course of the disease
Resolution with conservative/surgical treatment
Progression into generalized peritonitis
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Acute Abdomen
Ileus
1st Department of Surgery, Pavol Jozef Šafarik UniversitySlovak Republic
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ILEUSClassification
I. Mechanical
1. Obturation: A/ intraluminal
B/ intramural
C/ extramural
2. Strangulation:
A/ adhaesions
B/ incarceration
C/ invagination
D/ volvulus
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ILEUS Obturation:
a/ intraluminal
b/ intramural
c/ extramural
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ILEUS Strangulation:
a/ adhesions
b/ incarceration
c/ invagination
d/ volvulus
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Plain Y-ray
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Plain X-ray
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ILEUSClassification
II. Neurogenic
1. Paralytic
2. Spastic
III. Vascular - embolisation, thrombosis
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Ischaemic small
bowel
Gangraenous
small bowel
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Acute Abdomen
Trauma
1st Department of Surgery, Pavol Jozef Šafarik UniversitySlovak Republic
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Trauma
Blunt or penetrating
Usually High Energy injuries
Parenchymal organs mostly affected
Spleen
Liver
Pancreas
Symptoms of haemorrhagic shock and/or GIT perforation
May be mimicked by subsequent injuries and/or shock
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Trauma
Abdominal USG or CT – depending on severity of injury
Awarness of possible intraabdominal injury !
Damage control !
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Suggested readings
Frankovicova et al.
Surgery for Medical Students, 2nd edition
Chapter 31, pages 273-277
Chapter 32, pages 289-290