acute abdomen[1]
DESCRIPTION
surgeyTRANSCRIPT
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The Acute Abdomen
Richard Aitken, DM General Surgery UHWI,Consultant General Surgeon KPH
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Definition
• “Any sudden spontaneous non-traumatic disorder whose chief manifestation is in the abdominal area and for which urgent operation may be necessary”1
1 Gerald Doherty, Current Surgical diagnosis and Treatment, pg 503, 2003.
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Symptoms
• Acute Abdominal Pain• Other associated Symptoms
– Vomiting– Distention– Alterations in Bowel Movement– Urinary Symptoms– Gynecologic
1 Rozycki GS, et al. J Trauma 19932 Rozycki GS, et al. J Trauma 19953 Ma OJ, et al J Trauma 1995
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Abdominal Anatomy
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Abdominal Anatomy
• Peritoneal cavity divided into greater and lesser sac– Connected by epiploic
foramen
• Greater sac divided into supramesocolic and inframesocolic (pelvis) compartments
From: Gray, H. Anatomy of the Human Body 20th ed. 2000
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Abdominal Anatomy
• Paracolic gutters connect supramesocolic spaces with pelvis
• Right connects hepatorenal
• Left connects subphrenic and splenorenal– Obstructed by
phrenicocolic ligament
From: Gray, H. Anatomy of the Human Body 20th ed. 2000
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Abdominal Contents
• Esophagus• Stomach• Duodenum• Liver• Biliary System• Pancreas• Kidneys/adrenals• Aorta/IVC• Spleen
• Small Intestine• Large intestine• Ureters/Bladder• Uterus/Ovaries/Tubes• Prostate/Urethra• Diaphragm/Abd wall• Retroperitoneum• Spinal column• Peritoneum
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Pain vs Tenderness
• Based on abdominal innervation:– Visceral Pain
• Sense stretching and ischemia only
• mediated via Visceral Afferent fibers
– Follow the blood supply
– Difuse, not mapped 1:1 on sensory cortex
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Pain and Tenderness(continued)
• Tenderness– Somatic Afferent
Innervation• Parietal peritoneum
• Abdominal Wall
– Precisely mapped on sensory cortex
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Common Abdominal Conditions
• Appendicitis
• Cholecystitis/Biliary Colic
• Small Bowel Obstruction
• Perforated Peptic Ulcer
• Pancreatitis
• Constipation/Gastroenteritis
• Gastritis/PUD
• Gynecological Pathology
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Causes of the Acute Abdomen
• Gynecologic Pathology– Pelvic inflammatory disease– Ectopic pregnancy– Ovarian Pathology– Uterine fibroids– Dysmenorrohea
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Causes of the Acute Abdomen
• Inflammatory bowel disease
• Mesenteric adenitis• Aortic aneurysm• Mesenteric
thrombosis/ischemia• Hepatitis• Liver abscess• Splenic infarct• Renal colic
• Pyelonephritis• Intraabdominal abscess• Primary Peirtonitis• Volvulus of bowel• Many more• Including Medical
causes and extraabdominal pathology
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Management Strategy
• Make a Diagnosis of cause within a reasonable time (24 hrs)
• Stability of patient/suspected cause determines how long we are willing to wait for Investigation/Observation
• Tailored Ix
• Final arbiter may have to be laparotomy/Laparoscopy
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Management Strategy
• History
• Physical examination
• Resuscitation
• Tailored Investigations
• Diagnosis
• Treatment + or - Laparotomy
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History
• Pain
• Associated Symptoms– Vomiting, diarrhoea, constipation, distension– Jaundice, fever, wt loss, bleeding per orifice
• PMH
• Menstrual Hx
• Drug Hx
• Family Hx
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Pain
• Location
• Character
• Intensity
• Periodicity
• Radiation
• Relieving / Aggravation factors
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Physical Examination
• General Obs
• Systemic signs / Vital signs
• Fever
• Abdominal signs– Inspection– Auscultation– Palpation– Percussion– Rectal Digital / Vaginal Ex
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Investigation
• Urinalysis
• Bhcg
• Blood Studies
• Abd/C-xrays
• Abd U/S
• CT scan
• Other eg IVU , Contrast studies, Endoscopy
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Pneumoperitoneum
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Gallstones
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Intestinal Obstruction
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AAA
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Bodypacker
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Tongue Ornament Misadventure
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Management/Resuscitation
• NG tube
• Urinary catheter
• IV line – Fluid, blood studies, cross-match
• Pain Mx
• Antibiotics?
• Definitive Mx determined by Stability and Diagnosis