acute abdomen
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Acute abdomen
Prof. M K Alam M S ; F R C S
Learning objectives
Definition of acute abdomen
Anatomy and physiology of abdominal pain.
Pathophysiology of common causes of acute abdomen.
Symptoms and signs of acute abdomen in relation to
the underlying pathology
Laboratory and imaging investigations
Initial and definitive management
Definition
Acute abdomen: a clinical presentation
of
abdominal pain and tenderness,
that often requires emergency
surgical therapy.
• Some non-surgical or non intra-abdominal
diseases, can present with acute abdominal
pain.
• Every attempt should be made to make a correct diagnosis so that an appropriate therapy is given
Anatomy and Physiology of Abdominal pain
Types of abdominal pain
• Visceral
• Parietal
Visceral pain
• Vague, poorly localized • Splanchnic nerves
• Usually the result of distention of a hollow viscus
• Depending on the origin of the affected organ from the primitive
foregut, midgut, or hindgut, the pain is localized to epigastrium,
periumbilical , or hypogastrium respectively
Parietal pain
-Corresponds to the segmental nerve roots (somatic nervous system) innervating the peritoneum.
-Sharper and better localized.
Referred pain
Definition: Pain perceived at a site distant from the source of stimulus.
Common examples of referred pain:
Gall bladder- right subscapular or shoulder
Heart, tail of pancreas, spleen- left shoulder (Kehr's sign)
Ureter- Scrotum and testis
Pain locations (Great degree of overlap)
• Right hypochondrium.- gallbladder
• Left hypochondrium.- pancreas
• Epigastrium.- Stomach and duodenum
• Lumber- kidney
• Umbilical- small bowel, caecum, retroperitoneal
• Right iliac fossa- Appendix, caecum
• Left iliac fossa- Sigmoid colon
• Hypogastrium- Colon, urinary bladder, adenexae
Pathophysiology
Surgical Acute Abdominal Conditions
• Infection- Appendicitis, cholecystitis
• Perforation- Perforated duodenal ulcer, ileum, colon
• Obstruction- Small bowel adhesions, obstructed hernia,
sigmoid volvulus, carcinoma colon
• Ischemia- Mesenteric ischemia (thrombosis/ embolism),
strangulated hernia
• Hemorrhage- Ruptured ectopic pregnancy, ruptured
aneurysm, solid organ-trauma, tumour
Common nonsurgical causes of Acute Abdomen
• Diabetic crisis
• Uremia
• Hereditary Mediterranean fever
• Sickle cell crisis
• Acute leukemia
• Myocardial ischemia
Pathophysiology: Acute appendicitis
• Most common general surgical emergency
• Derived from the midgut
• Obstruction of the lumen (fecalith, lymphoid hyperplasia,
vegetable matter or seeds, parasites) - the major cause of
acute appendicitis.
• Obstruction contributes to bacterial overgrowth,
Pathophysiology: Acute appendicitis
• Continued secretion of mucus leads to intraluminal distention.
• Distention produces the visceral pain sensation as
periumbilical pain.
• Promote a localized inflammatory process
• May progress to gangrene and perforation.
• Inflammation of the adjacent peritoneum- localized pain in RLQ
• Perforation usually after 48 hours from the onset of symptoms
Bacterial flora in appendicitis
• Polymicrobial
• Escherichia coli, Streptococcus viridans, and
Bacteroides and Pseudomonas
Perforated peptic ulcer
• 5% of peptic ulcers penetrate through the
duodenal wall into the peritoneal cavity
• Most common site: 1st part of the duodenum, anteriorly
• Produce chemical peritonitis initially.
Bacterial peritonitis develops within few hours.
Peritonitis
• Peritonitis is peritoneal inflammation from any cause.
• Introduction of bacteria or irritating chemicals into the peritoneal cavity cause peritoneal inflammation.
• A localized inflammation (appendicitis) produce sharply localized pain and normal bowel sounds.
• A diffuse inflammation (perforated viscus) produces generalized
peritonitis causing generalized abdominal pain with a quiet abdomen (absent bowel sound).
Types of peritonitis
• Secondary peritonitis: more common, secondary to an inflammatory insult from within abdomen, most often gram-negative infections with enteric organisms or anaerobes. Example- perforated appendicitis
• Primary peritonitis: uncommon. No intra-abdominal cause.
Children: Pneumococcus or hemolytic Streptococcus.
Adults: peritoneal dialysis for end-stage renal dis.(gram+ve cocci),
ascites and cirrhosis(Escherichia coli and Klebsiella)
• Noninfectious inflammation- chemical peritonitis –pancreatitis.
Small bowel obstruction
• Post-operative adhesion- most common
• Hernia, tumour, Crohn’s disease- other causes
• Early- the intestinal contraction increases to propel contents past the obstructing point (colicky pain)
• Later- the intestine becomes fatigued and dilates, contractions becoming less intense.
• Bowel dilates, water and electrolytes accumulate in lumen and in the bowel wall.
• Massive third-space fluid loss: dehydration and hypovolemia.
• Intraluminal pressure increases in the bowel, a decrease in mucosal blood flow occurs.
Mesenteric Ischemia
• Arterial: embolism, thrombosis
• Venous: thrombosis
• Superior mesenteric vessel distribution
• Intestinal mucosal sloughing- 3 hours of onset.
• Full-thickness intestinal infarction- 6 hours
Symptoms & Signs in
Acute abdomen
Main symptom- Abdominal pain
• Location: finger vs hand• Severity: Colic, ischemia (severe), inflammation- milder• Onset: Sudden in perforation, ischemia, biliary colic• Progress: Inflammation- develops and worsens over
several hours - appendicitis, cholecystitis• Spasmodic: Biliary colic, or genitourinary obstruction• Radiation and shift: Cholecystitis, appendicitis• Exacerbating factors: Food worsen pain- bowel
obstruction, gastric ulcer• Relieving factors: Food relieves pain- duodenal peptic
ulcer disease or gastritis.
Associated symptoms • Vomiting likely to precede abdominal pain in medical conditions
whereas pain presents first in acute surgical abdomen.
• Constipation or obstipation - mechanical obstruction or
decreased peristalsis (ileus).
• Diarrhea is associated with several medical causes of acute
abdomen, including infectious enteritis, inflammatory bowel
disease (IBD), and parasitic contamination
• Bloody diarrhea- IBD, Colonic ischemia
• Past medical history: Passage of stone(ureteric colic),
previous surgery (intestinal obstruction)
• Gynecologic history: LMP (ectopic pregnancy), mid
cycle pain (mittelschmerz)
• Medications: Create acute abdominal conditions or mask
their symptoms. NSAID (bleeding, perforation),
narcotics (constipation), steroids (mask inflammation)
PHYSICAL EXAMINATION(Inspection)
• Inspection of the patient:
• Ischemic bowel and ureteral and biliary colic- patients continually shift
and fidget in bed while trying to find a position that lessens their
discomfort.
• Patients with peritonitis lie very still in the bed, and often maintain
flexion of their knees and hips to reduce tension on the anterior
abdominal wall.
Inspection of the abdomen
• Distension- obstruction, ileus• Restricted mobility- ?peritonitis• Scars of previous surgery• Hernias• Mass effect• Ecchymosis ? Acute pancreatitis (Cullen’s, Grey
Turner’s sign)
Palpation of the abdomen
• Start gently, away from the area of pain.• Severity and exact location of tenderness-
localized/ generalized• Involuntary guarding• Organomegaly, mass• Murphy’s sign, Rovsing’s sign,• Rebound tenderness (Blumberg’s sign)
Percussion of the abdomen
• Hyperresonance :distended bowel loops
• Dullness due to organomegaly or mass
• Liver dullness lost- free intra-abdominal air is suspected.
• Shifting dullness- free fluid
• Tenderness
Auscultation of the abdomen
• Quiet abdomen- ileus• Hyperactive bowel sounds- enteritis, ischemic
intestine• Mechanical bowel obstruction- high-pitched
“tinkling” sounds that come in rushes and are associated with pain
• Bruits- high-grade arterial stenosis
Digital rectal examination
• Performed in all patients with acute abdominal pain
• Checking for mass, pelvic pain, or intraluminal blood
• Pelvic examination in female
Investigations
Routine laboratory investigations
• Hematology: WBC count, differential count, hemoglobin, platelets, red blood cells
• Electrolytes, urea, creatinine• Amylase, lipase• LFTs: Bilirubin (T & D), alkaline phosphatase, aminotransferase,
• Serum lactate & arterial blood gas• Urine analysis • Urine human chorionic gonadotropin• Stool for parasites
• WBC count: Leukocytosis in infection, ischemia
• Electrolytes, blood urea nitrogen, and creatinine: Disturbed
due to the effect of vomiting or third-space fluid losses
• Serum amylase and lipase- acute pancreatitis, small bowel
infarction or duodenal ulcer perforation
• Liver function tests: Biliary tract disease, acute pancreatitis.
• Lactate levels and arterial blood gas: intestinal
ischemia or infarction.
• Urinalysis: Bacterial cystitis, pyelonephritis, diabetes.
• Urinary human chorionic gonadotropin: Pregnancy - a factor in the patient's presentation or aid in
decision making regarding therapy.
• Stool: Fresh blood , occult blood, parasite, Cl. Difficile (toxin &
culture).
Imaging studies
None of the imaging techniques take the
place of a careful history and physical
examination.
Plain radiographs
• Upright chest radiographs – free gas under the dome of diaphragm Perforated duodenal ulcer-75%
• Lateral decubitus abdominal radiographs- pneumoperitoneum in patients who cannot stand
Plain x-ray abdomen
• Calcifications: renal stones 90%, chronic
pancreatic, aortic aneurysms, fecalith
• Supine and upright films: distension, fluid levels,
gas distribution (small vs large bowel), volvulus
of sigmoid colon/ cecum
Abdominal ultrasonography
• Gallbladder: Stone, wall thickness, fluid around
gallbladder, diameter of bile ducts
• Liver: Abscess, other masses
• Pelvis: Ovarian, adnexal & uterine pathologies
• Free fluid in peritoneum
• Limited evaluation of pancreas
• Limitations: Bowel gas, person dependent, difficult to
interpret for most surgeons
CT abdomen• Widely available. • Easier to interpret. • Imaging modality of choice in acute abdomen,
following plain abdominal radiographs.• Accuracy and utility of CT abdomen and pelvis in
acute abdominal pain is well established.• Most common causes of acute abdomen are
readily identified by CT.• Highly accurate in acute appendicitis, mechanical
bowel obstruction, intestinal ischemia.
DIAGNOSTIC LAPAROSCOPY
• Ability to diagnose and treat a number of the conditions causing acute abdomen
•High sensitivity and specificity
• Decreased morbidity and mortality, decreased length of stay, and decreased overall hospital costs
• Advances in equipment and greater availability
DIFFERENTIAL DIAGNOSIS
• Differential diagnosis of acute abdominal pain is extensive.
• Comprehensive knowledge of the medical and surgical conditions that create acute abdominal pain
• Mild, self-limited illness to the rapidly progressive and fatal
• Evaluated immediately upon presentation and reassessed at frequent intervals.
• Many acute abdomen require surgical intervention but some abdominal pain are medical in aetiology.
Initial management
Preoperative preparation• Fluid and electrolyte abnormalities corrected- IV crystalloid infusion
• Nasogastric tube to decrease the likelihood of vomiting and aspiration
• Antibiotic infusions for the bacteria common in acute abdominal emergencies (gram-negative enteric organisms and anaerobes)
• Foley catheter- to assess urine output -0.5 mL/kg/hour
• Blood typed and cross matched for operation
Preoperative preparation
• Frequent evaluation of the patient
• Stabilization of co-morbid conditions-
(diabetes, hypertension, coagulopathy)
• Decision: Surgical vs non- surgical management
• Consent for surgery
Common Causes of
Acute Abdomen
Acute appendicitis
• Most common general surgical emergency
• Derived from the midgut
• Obstruction of the lumen (fecalith, lymphoid hyperplasia,
vegetable matter or seeds, parasites) is the major cause of
acute appendicitis.
• Obstruction contributes to bacterial overgrowth,
Acute appendicitis
• Continued secretion of mucus leads to intraluminal distention.
• Distention produces the visceral pain sensation as
periumbilical pain.
• Promote a localized inflammatory process
• May progress to gangrene and perforation.
• Inflammation of the adjacent peritoneum- localized pain in
the right lower quadrant.
• Perforation usually occurs after 48 hours from the onset of
symptoms
Acute appendicitis- symptoms
• Typical periumbilical pain (activation of visceral afferent neurons)
followed by anorexia and nausea.
• Pain localizes to the right lower quadrant (inflammatory process
progresses to involve the adjacent parietal peritoneum)
• Migratory pain is the most reliable symptom.
Acute appendicitis- signs
• Ill looking patient, low grade fever
• Coughing (Dunphy's sign), may cause increased pain
• Tenderness at McBurney’s point, involuntary guarding
• Site of tenderness may vary depending on the position of the
appendix.
• Pain in the right lower quadrant during palpation of the left lower
quadrant (Rovsing's sign)
• Perforated appendicitis: more severe and diffuse abdominal pain,
tenderness and abdominal wall rigidity
Acute appendicitis- investigations• Elevated WBC and neutrophil • Normal WBC in 10%
• Very high WBC (>20,000/ml)- complicated appendicitis
• Urine analysis- exclude urinary system disease
• Abdominal x-ray- generally not indicated, ? ureteric calculi, small bowel obstruction, perforated ulcer
• Ultrasonography: Appendix of 7 mm or more in anteroposterior diameter, thick-walled, noncompressible luminal structure in cross section (target lesion), the presence of an appendicolith
• CT abdomen: appendix > 7mm in diameter, wall thickening, periappendiceal edema or fluid
Surgical treatment (Acute appendicitis)
• Uncomplicated appendicitis: Appendectomy - Laparoscopic vs open surgery
• Complicated appendicitis: Localized perforation (abscess): percutaneous drainage under CT or ultrasound guidance Free perforation (peritonitis): laparotomy vs
laparoscopic appendectomy
Perforated peptic ulcer
• 5% of peptic ulcers penetrate through the
duodenal wall into the peritoneal cavity
• Produce chemical peritonitis
Clinical features of perforated peptic ulcer
• Sudden onset epigastric pain • Fever and tachycardia• Abdominal tenderness, rigidity, rebound
tenderness• Absent bowel sound• Free air underneath the diaphragm on an
upright chest radiograph.
Perforated peptic ulcer- treatment
• Fluid resuscitation
• Early surgery to close the perforation by laparoscopy or open surgery
Small bowel obstruction
• Post-operative adhesion- most common
• Hernia, tumour, Crohn’s disease- other causes
• Early- the intestinal contraction increases to propel contents past the obstructing point (colicky pain)
• Later- the intestine becomes fatigued and dilates, contractions becoming less intense.
• Bowel dilates, water and electrolytes accumulate in lumen and in the bowel wall.
• Massive third-space fluid loss: dehydration and hypovolemia.
• Intraluminal pressure increases in the bowel, a decrease in mucosal blood flow occurs.
Clinical features
• Colicky abdominal pain, nausea, vomiting, abdominal distention, and a failure to pass flatus and feces (i.e., obstipation).
• Examination: Distended abdomen Surgical scars/ hernia Hyperactive bowel sounds Mild abdominal tenderness
Investigations
• Tests for fluid & electrolytes abnormality
• Leukocytosis may be found in patients with strangulation
• Plain x-ray abdomen: dilated bowel loops (supine) & multiple air-fluid levels (upright)
• Patient in whom the diagnosis is not readily apparent- CT abdomen
Treatment
• Isotonic saline solution such as lactated Ringer's• Antibiotics-prophylactically• Nasogastric suction • Partial intestinal obstruction may be treated
conservatively with resuscitation and tube decompression
• Operative Management: • Adhesive obst.-laparotomy & release of adhesions. • Hernia- operative reduction and repair
Mesenteric Ischemia
• Arterial: embolism, thrombosis
• Venous: thrombosis
• Superior mesenteric vessel distribution
• Intestinal mucosal sloughing within 3 hours of
onset and
• Full-thickness intestinal infarction by 6 hours
Symptoms & signs
• Abdominal pain- sudden onset
• Severity- out of proportion to the degree of tenderness
• The pain is colicky, most severe in the mid-abdomen.
• Associated symptoms- nausea, vomiting, and diarrhea
• Physical findings- absent early in the course.
• Later- abdominal distention, tenderness, guarding and
passage of bloody stools.
Investigations
• Leukocytosis, • Acidosis, and • Elevated amylase and creatine kinase- late
• CT scanning: Acute arterial mesenteric ischemia-64 to 82%. Acute mesenteric venous thrombosis- 90%
Mesenteric ischemia- treatment
• Fluid resuscitation
• Laparotomy
• Test for viability of bowel
• Resection of infarcted segment
• Anticoagulation for SMV thrombosis
Conclusion• A challenging part of a surgeon's practice.
• Careful history and physical examination remain the most
important part of the evaluation.
• Laboratory investigations and imaging techniques have
improved the diagnostic accuracy
• Surgeon often make the decision to perform surgery with a
good deal of uncertainty
• Morbidity and mortality associated with a delay in the
treatment demand an expeditious approach
Thank you!
Case presentation
Case No. 1
A 19-year old male presents with abdominal pain since last night. He has vomited once early this morning.
• History• Examination• Differential diagnosis• Investigations• Pathophysiology• Complications of delayed presentation/ treatment• Treatment
History• Location: Initially periumbilical, now RIF
• Severity: started mild, now severe
• Onset: gradual
• Progress: worsening
• Radiation and shift: Initially periumbilical, now RIF
• Exacerbating factors: none
• Relieving factors: none
• Associated symptoms: vomiting once, no anorexia
• Systemic inquiry, family, social, drug, past history- none
Examination• Appearance: Looking ill• Temperature: 38.5°C• Abdomen: Inspection- flat, moving with
respiration, no cough tenderness• Palpation- guarding & tenderness in RIF and at
McBurney’s point, Rovsing’s sign –ve• Percussion- tender RIF• Auscultation- diminished bowel sounds• Rectal examination not done
Differential diagnosis
• Children: Meckel’s diverticulitis, intussusception, gastroenteritis, mesenteric lymphadenitis
• Adults: Crohn’s disease, pyelonephritis, ileo-cecal neoplasm, bowel obstruction
• Female: Ectopic pregnancy, mid cycle pain, tubo-ovarian pathology, PID
Acute appendicitis
Investigations
• Leucocytosis with high neutrophil• Very high WBC > 20,000 in complicated app.• Urinalysis to rule out urinary infection
• Ultrasonography: Not done. Indicated in children and pregnant. Thick wall, non-compressible, edema and fluid
• CT: Not done. Distended, thick wall periappendiceal edema and fluid
Pathophysiology
• Obstruction of the lumen
• Fecalith, lymphoid hyperplasia, vegetable, seeds, parasites,
neoplasm
• Small lumen, obstruction lead to closed loop
• Bacterial overgrowth
• Continued mucous secretion lead to distension and typical
visceral pain in periumbilical area
• Inflammation of adjacent parietal peritoneum gives rise to
localized RIF (parietal) pain
Delayed presentation
• Inflammatory progress to gangrene
• Localized perforation- abscess formation
• Free perforation- peritonitis (secondary)
Treatment• Nil orally• IV fluid• Pre-op. antibiotics: cefuroxime+ metronidazole• Non-perforated: single pre-op. dose• Perforated: continue post-op. until afebrile• Consent for surgery• Appendectomy- laparoscopic or open surgery • Appendicular abscess- image guided drainage• Free perforation- Open/ laparoscopic appendectomy
Case No. 2A 30-year old female presents with right hypochondrial pain for 2 days associated with fever.
• History• Examination• Differential diagnosis• Investigations• Pathophysiology• Management
History
• Location: right hypochondrium
• Severity: started mild, now severe
• Onset: gradual
• Progress: worsening
• Radiation: back and right shoulder
• Exacerbating factors: fatty food
• Relieving factors: analgesics
• Associated symptoms: fever, no vomiting , no anorexia
• Systemic inquiry, family, social, drug history- none
• Past medical history- similar pain of shorter duration 2 months back
Examination
• Appearance: In pain
• Temp. 38.6°C
• No jaundice
• Abdomen: Inspection- normal, few striae gravidarum
• Palpation- tenderness & guarding in RH, Murphy’s
sign +ve ( tenderness & arrest of inspiration while
palpating at costal margin)
• Percussion, auscultation- none
Differential diagnosis
• Chronic cholecystitis
• Biliary colic
• Obstructive jaundice
• Liver abscess
• Viral hepatitis
Acute cholecystitis
Investigations
• Leucocytosis
• LFT: very slight elevation of bilirubin, normal alkaline phosphatase and transaminase
• Abdominal ultrasonography: gall stones, gall bladder wall thickening, edema, pericholecystic fluid
Pathophysiology
• Obstruction of the cystic duct
• Bacterial inflammation
• If obstruction persists- ischemia and gangrene
of the gall bladder
• Eventually perforation
Management
• Nil by mouth
• IV fluid
• Parenteral antibiotics- (gram –ve and gram +ve organisms)- cephalosporin
• Consent for surgery
• Early laparoscopic cholecystectomy
Thank you!
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