Acute Abdomen

ACUTE ABDOMEN ACUTE ABDOMEN BY BY S/N JANET KHOOS/N JANET KHOO

Acute AbdomenAcute Abdomen

Acute abdomen is PeritonitisAcute abdomen is Peritonitis

• The term The term acute abdomenacute abdomen refers to a refers to a sudden, severe pain in the sudden, severe pain in the abdomenabdomen that is less than 24 hours in duration. that is less than 24 hours in duration.

• It is in many cases an emergent It is in many cases an emergent condition requiring urgent and condition requiring urgent and specific diagnosis. specific diagnosis.

• Treatment usually involves surgery. Treatment usually involves surgery.

Acute AbdomenAcute Abdomen

• AAcute abdomencute abdomen can be defined as can be defined as

• Severe, persistent abdominal pain Severe, persistent abdominal pain

• Of sudden onset that is likely to require Of sudden onset that is likely to require surgical interventionsurgical intervention to treat its cause. to treat its cause.

• The pain may frequently be associated The pain may frequently be associated with with nauseanausea and and vomitingvomiting, , abdominal abdominal distentiondistention, , feverfever and signs of and signs of shockshock. .

INDICATIONS OF AN ACUTE ABDOMENINDICATIONS OF AN ACUTE ABDOMEN

• Abdominal pain Abdominal pain

• GuardingGuarding (contraction of abdominal muscles and (contraction of abdominal muscles and discomfort when the doctor presses on the discomfort when the doctor presses on the abdomen) abdomen)

• RigidityRigidity (hardness) of abdominal muscles (hardness) of abdominal muscles

• Rebound tendernessRebound tenderness (an increase in severe pain (an increase in severe pain and discomfort when the doctor abruptly stops and discomfort when the doctor abruptly stops pressing on a localized region of the abdomen) pressing on a localized region of the abdomen)

• LeukocytosisLeukocytosis (increase in white blood cell count) (increase in white blood cell count)

Traumatic CausesTraumatic Causes

• BBluntlunt or or

• Perforating Perforating traumatrauma

• To the To the stomachstomach, , bowelbowel, , spleenspleen, , liverliver, or , or kidneykidney

Mechanical CausesMechanical Causes

• Small bowelSmall bowel obstructionobstruction secondary to secondary to adhesions caused by previous surgeries, adhesions caused by previous surgeries, intussusceptionintussusception, , herniashernias, benign or , benign or malignant malignant neoplasmsneoplasms

• Large bowelLarge bowel obstructionobstruction caused by caused by colorectal cancercolorectal cancer, , inflammatory bowel diseaseinflammatory bowel disease, , volvulusvolvulus, , fecalfecal impaction impaction or or herniahernia

Inflammatory CausesInflammatory Causes

• Infections such as Infections such as appendicitisappendicitis, , cholecystitischolecystitis, , pancreatitispancreatitis, , pyelonephritispyelonephritis, , pelvic inflammatory diseasepelvic inflammatory disease, , hepatitishepatitis, , mesenteric adenitismesenteric adenitis, or a subdiaphragmatic , or a subdiaphragmatic abscessabscess

• PerforationPerforation of a of a peptic ulcerpeptic ulcer, a , a diverticulumdiverticulum, , or the or the caecumcaecum

• Complications of Complications of inflammatory bowel diseaseinflammatory bowel disease such as such as Crohn'sCrohn's disease disease or or ulcerative colitisulcerative colitis

Vascular CausesVascular Causes

• occlusive occlusive intestinal ischemiaintestinal ischemia, ,

usually caused by usually caused by thromboembolismthromboembolism

of the of the superior mesenteric arterysuperior mesenteric artery

DIAGNOSTIC TESTS FOR EVALUATING ABDOMINAL DIAGNOSTIC TESTS FOR EVALUATING ABDOMINAL PAINPAIN

1.1. Laboratory examinations of blood and urine specimens Laboratory examinations of blood and urine specimens

2.2. X-rays of the chest and abdomen X-rays of the chest and abdomen

3.3. UltrasoundUltrasound (evaluation of abdominal organs and spaces with sound (evaluation of abdominal organs and spaces with sound waves) waves)

4.4. CT scansCT scans (x-ray technique using computer programming to provide (x-ray technique using computer programming to provide detailed images) detailed images)

5.5. Endoscopy (a tube passed into the mouth to inspect the upper Endoscopy (a tube passed into the mouth to inspect the upper gastrointestinal tract or inserted into the rectum to view the lower gastrointestinal tract or inserted into the rectum to view the lower gastrointestinal tract) gastrointestinal tract)

6.6. AngiographyAngiography (dye studies exploring major blood vessels) (dye studies exploring major blood vessels)

7.7. Radionuclide scansRadionuclide scans (injected dyes that identify sources of intestinal (injected dyes that identify sources of intestinal bleeding) bleeding)

Differential diagnosis of Acute Differential diagnosis of Acute AbdomenAbdomen

• CausesCauses• Acute Acute appendicitisappendicitis. . • Acute Acute peptic ulcerpeptic ulcer and its complications. and its complications. • Acute Acute gall bladdergall bladder pathology, such as an pathology, such as an

impacted gallstone. impacted gallstone. • Acute Acute pancreatitispancreatitis. . • Acute intestinal Acute intestinal ischemiaischemia (See Section Below.) (See Section Below.) • Diabetic Diabetic KetoacidosisKetoacidosis. . • Acute Acute DiverticulitisDiverticulitis. . • EctopicEctopic Pregnancy Pregnancy with tubal rupture. with tubal rupture.

AppendicitisAppendicitis

• Is a condition characterized by Is a condition characterized by inflammationinflammation of the of the appendixappendix. While . While mild cases may resolve without mild cases may resolve without treatment, most require removal of treatment, most require removal of the inflamed appendix, either by the inflamed appendix, either by laparotomylaparotomy or or laparoscopylaparoscopy. . Untreated, mortality is high, mainly Untreated, mortality is high, mainly due to due to peritonitisperitonitis and and shockshock

Signs & SymptomsSigns & Symptoms• PPainain starting centrally (periumbilical) starting centrally (periumbilical)

before localising to the before localising to the right iliac right iliac fossafossa

• Loss of appetite (anorexia) and Loss of appetite (anorexia) and

• FFeverever, although the latter isn't a , although the latter isn't a necessary symptom.. necessary symptom..

• NauseaNausea or or vomitingvomiting may or may not may or may not occur. occur.

Perforated appendicitis with formation Perforated appendicitis with formation of an abscess (arrows), with of an abscess (arrows), with appendicolith (arrowhead) within the appendicolith (arrowhead) within the

abscess.abscess.

Deep gastric ulcer Deep gastric ulcer

PUDPUD

• A A peptic ulcerpeptic ulcer, or , or peptic ulcer diseasepeptic ulcer disease is is

• an an ulcerulcer of an area of the of an area of the gastrointestinal tractgastrointestinal tract

• that is usually acidic and thus extremely that is usually acidic and thus extremely painful. painful.

• As much as 80% of ulcers are associated As much as 80% of ulcers are associated with with Helicobacter pyloriHelicobacter pylori, a spiral-shaped , a spiral-shaped bacterium that lives in the acidic bacterium that lives in the acidic environment of the stomachenvironment of the stomach

A benign gastric ulcer A benign gastric ulcer

Signs and symptomsSigns and symptoms• Abdominal painAbdominal pain, classically epigastric with severity , classically epigastric with severity

relating to mealtimes, after around 3 hours of relating to mealtimes, after around 3 hours of taking a meal (duodenal ulcers are classically taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are relieved by food, while gastric ulcers are exacerbated by it); exacerbated by it);

• Bloating and abdominal fullness Bloating and abdominal fullness • Nausea, and lots of vomiting Nausea, and lots of vomiting • Loss of appetite and weight loss; Loss of appetite and weight loss; • HematemesisHematemesis (vomiting of blood); this can occur (vomiting of blood); this can occur

due to bleeding directly from a gastric ulcer, or due to bleeding directly from a gastric ulcer, or from damage to the esophagus from from damage to the esophagus from severe/continuing vomiting. severe/continuing vomiting.

• MelenaMelena (tarry, foul-smelling faeces due to (tarry, foul-smelling faeces due to oxidizedoxidized iron from iron from hemoglobinhemoglobin) )

• Rarely, an ulcer can lead to a gastric or duodenal Rarely, an ulcer can lead to a gastric or duodenal perforation. This is extremely painful and requires perforation. This is extremely painful and requires immediate surgeryimmediate surgery

GallbladderGallbladder

Gall Bladder DiseaseGall Bladder Disease

• The gallbladder stores about 50ml of bile The gallbladder stores about 50ml of bile • Which is released when Which is released when foodfood containing fat enters containing fat enters

the the digestive tractdigestive tract• Stimulating the Stimulating the secretionsecretion of of cholecystokinincholecystokinin (CCK). (CCK). • The bile, produced in the The bile, produced in the liverliver, , emulsifiesemulsifies fats and fats and

neutralizes acids in partly digested food.neutralizes acids in partly digested food.• After being stored in the gallbladder, the bile After being stored in the gallbladder, the bile

becomes more concentrated than when it left the becomes more concentrated than when it left the liver,liver,

• Increasing its potency and intensifying its effect on Increasing its potency and intensifying its effect on fats. Most digestion occurs in the fats. Most digestion occurs in the duodenumduodenum..

• Acute or chronic Acute or chronic inflammationinflammation of the of the gallbladder (cholecystitis) causes abdominal gallbladder (cholecystitis) causes abdominal pain. pain.

• 90% of cases of acute cholecystitis are 90% of cases of acute cholecystitis are caused by the presence of gallstones. caused by the presence of gallstones.

• The actual inflammation is due to secondary The actual inflammation is due to secondary infection with bacteria of an obstructed infection with bacteria of an obstructed gallbladdergallbladder

• With the obstruction caused by the gallstone. With the obstruction caused by the gallstone.

• When When gallstonesgallstones obstruct the obstruct the common common bile ductbile duct ( (choledocholithiasischoledocholithiasis) )

• The patient develops The patient develops jaundicejaundice and and liverliver cell damage. cell damage.

• It can be a medical emergency, It can be a medical emergency, requiring requiring endoscopicendoscopic

• Or Or surgicalsurgical treatment such as a treatment such as a cholecystectomycholecystectomy. .

Acute PancreatitisAcute Pancreatitis

Symptoms and SignsSymptoms and Signs• Severe upper abdominal pain, with Severe upper abdominal pain, with

radiation through to the backradiation through to the back• Nausea and vomiting Nausea and vomiting • Blood pressure may be high (when pain is Blood pressure may be high (when pain is

prominent) or low (if internal bleeding or prominent) or low (if internal bleeding or dehydration has occurred)dehydration has occurred)

• Abdominal tenderness is usually found but Abdominal tenderness is usually found but may be less severe than expected given may be less severe than expected given the patient's degree of abdominal pain. the patient's degree of abdominal pain.

• BowelBowel sounds may be reduced as a sounds may be reduced as a reflection of the reflex bowel paralysis (i.e. reflection of the reflex bowel paralysis (i.e. ileusileus) that may accompany any abdominal ) that may accompany any abdominal catastrophe. catastrophe.

Most common causesMost common causes

• A common A common mnemonicmnemonic for the for the causes of pancreatitis spells causes of pancreatitis spells

• "I GET SMASHED","I GET SMASHED",

• an allusion to heavy drinking (one an allusion to heavy drinking (one of the many causes): of the many causes):

• I - I - idiopathicidiopathic • G - G - gallstonegallstone. . • E - E - ethanolethanol ( (alcoholalcohol) ) • T - T - traumatrauma • S - S - steroidssteroids • M - M - mumpsmumps ( (paramyxovirusparamyxovirus ( (Epstein-Barr virusEpstein-Barr virus, ,

CytomegalovirusCytomegalovirus) ) • A - A - autoimmune diseaseautoimmune disease ( (PolyarteritisPolyarteritis nodosanodosa, , SLESLE) ) • S - S - scorpionscorpion sting - Tityus Trinitatis - Trinidad/ sting - Tityus Trinitatis - Trinidad/ snake bitesnake bite • H - H - hypercalcemiahypercalcemia, , hyperlipidemiahyperlipidemia//hypertriglyceridemiahypertriglyceridemia and and

hypothermiahypothermia • E - E - ERCPERCP ( (EEndoscopic ndoscopic RRetrograde etrograde CCholangio-holangio-

PPancreatography - D D- ancreatography - D D- drugsdrugs ( (steroidssteroids & & sulfonamidessulfonamides, , azathioprineazathioprine, , NSAIDSNSAIDS,,furosemidefurosemide and and thiazidesthiazides, & , & didanosinedidanosine))

CausesCauses• The most common cause of acute pancreatitis is gallstones. The most common cause of acute pancreatitis is gallstones. • Excessive alcohol use is often cited as the second most Excessive alcohol use is often cited as the second most

common cause of acute pancreatitis. common cause of acute pancreatitis. • Less common causes include hypertriglyceridemia (but not Less common causes include hypertriglyceridemia (but not

hypercholesterolemia) and only when triglyceride values hypercholesterolemia) and only when triglyceride values exceed 1500 mg/dl (16 mmol/L),exceed 1500 mg/dl (16 mmol/L),

• hypercalcemia, hypercalcemia, • viral infection (e.g. mumps), viral infection (e.g. mumps), • trauma (to the abdomen or elsewhere in the body) including trauma (to the abdomen or elsewhere in the body) including

post-ERCP (i.e. Endoscopic Retrograde post-ERCP (i.e. Endoscopic Retrograde Cholangiopancreatography),Cholangiopancreatography),

• vasculitis (i.e. inflammation of the small blood vessels vasculitis (i.e. inflammation of the small blood vessels within the pancreas)within the pancreas)

• autoimmune pancreatitis.autoimmune pancreatitis.• Pregnancy can also cause pancreatitis, but in some cases Pregnancy can also cause pancreatitis, but in some cases

the development of pancreatitis is probably just a reflection the development of pancreatitis is probably just a reflection of the hypertriglyceridemia which often occurs in pregnant of the hypertriglyceridemia which often occurs in pregnant women. women.

• Pancreas divisum, a common congenital malformation of the Pancreas divisum, a common congenital malformation of the pancreas may underlie some cases of recurrent pancreatitis.pancreas may underlie some cases of recurrent pancreatitis.

TreatmentTreatment

• 1. provision of pain relief.1. provision of pain relief.

• 2. provision of adequate replacement 2. provision of adequate replacement fluids and salts (intravenously) fluids and salts (intravenously)

• 3. limitation of oral intake (with dietary 3. limitation of oral intake (with dietary fat restriction the most important point)fat restriction the most important point)

• 4. Start antibiotics with signs of 4. Start antibiotics with signs of infection infection

Acute intestinal ischemiaAcute intestinal ischemia • Vascular disorders are more likely to affect the Vascular disorders are more likely to affect the

small bowel than the large bowel. small bowel than the large bowel. • Arterial supply to the intestines is provided by the Arterial supply to the intestines is provided by the

superior and inferior mesenteric arteries, (SMA superior and inferior mesenteric arteries, (SMA and IMA respectively) both of which are direct and IMA respectively) both of which are direct branches of the aorta.branches of the aorta.

• The SMA supplies:The SMA supplies:• Small bowelSmall bowel. . • AscendingAscending and proximal 2/3 of the and proximal 2/3 of the

Transverse colonTransverse colon. . • The IMA supplies:The IMA supplies:• Distal 1/3 of the Distal 1/3 of the Transverse colonTransverse colon. . • Descending colonDescending colon• Sigmoid colonSigmoid colon. .

Acute intestinal ischemia

Small bowel obstruction caused by an anterior abdominal wall incisional hernia diagnosed by Small bowel obstruction caused by an anterior abdominal wall incisional hernia diagnosed by CT. Image demonstrates dilated loop of small bowel going into the hernia and collapsed loop of CT. Image demonstrates dilated loop of small bowel going into the hernia and collapsed loop of small bowel coming out, confirming a complete small bowel obstruction with the hernia as the small bowel coming out, confirming a complete small bowel obstruction with the hernia as the

cause. Surgical skin staple and left pelvic transplant kidney are also noted on the image.cause. Surgical skin staple and left pelvic transplant kidney are also noted on the image.

CausesCauses

• A thromboembolism from the left side of the heart, A thromboembolism from the left side of the heart, such as may be generated during atrial fibrillation, such as may be generated during atrial fibrillation, occluding the SMA. occluding the SMA.

• Nonocclusive ischemia, such as that seen in Nonocclusive ischemia, such as that seen in hypotension secondary to heart failure may also hypotension secondary to heart failure may also contribute, but usually results in a mucosal or mural contribute, but usually results in a mucosal or mural infarct, as contrasted with the typically transmural infarct, as contrasted with the typically transmural infarct seen in thromboembolus of the SMA. infarct seen in thromboembolus of the SMA.

• Primary mesenteric vein thromboses may also Primary mesenteric vein thromboses may also cause ischemic acute abdomen, usually precipitated cause ischemic acute abdomen, usually precipitated by hypercoagulable states such as polycythemia by hypercoagulable states such as polycythemia vera. vera.

SIGNS & SYMPTOMSSIGNS & SYMPTOMS

• Diffuse abdominal pain Diffuse abdominal pain • Bowel distentionBowel distention• Bloody diarrhea. Bloody diarrhea. • Bowel sounds will be absent. Bowel sounds will be absent. • Neutrophilic leukocytosisNeutrophilic leukocytosis• Increased serum amylase. Increased serum amylase. • Abdominal XR will show many air-fluid Abdominal XR will show many air-fluid

levels, as well as widespread edema. levels, as well as widespread edema.

• Acute ischemic abdomen is a surgical Acute ischemic abdomen is a surgical emergency. emergency.

• Typically, treatment involves Typically, treatment involves removal of the region of the bowel removal of the region of the bowel that has undergone that has undergone infarctioninfarction, ,

• And subsequent And subsequent anastomosisanastomosis of the of the remaining healthy tissue.remaining healthy tissue.

Diabetic ketoacidosisDiabetic ketoacidosis

• (DKA) is a life-threatening (DKA) is a life-threatening complication in patients with complication in patients with untreated untreated diabetes mellitusdiabetes mellitus

Symptoms and SignsSymptoms and Signs

• Sluggish, extreme tiredness. Sluggish, extreme tiredness. • Fruity smell to breath/compare to nail polish remover, Fruity smell to breath/compare to nail polish remover,

similar to peardrops. similar to peardrops. • Extreme thirst, despite large fluid intake. Extreme thirst, despite large fluid intake. • Constant urination Constant urination • Extreme weight-loss. Extreme weight-loss. • Oral Thrush may be present, or/ yeast infections that Oral Thrush may be present, or/ yeast infections that

fail to go away, this is because the normal fungal/flora fail to go away, this is because the normal fungal/flora present in oral cavity/cervix in women, the balance is present in oral cavity/cervix in women, the balance is upset and bacterial began to feast on the high sugar upset and bacterial began to feast on the high sugar from urine output/ dry mouth from extreme thirst. from urine output/ dry mouth from extreme thirst.

• Muscle wasting. Muscle wasting. • Agitation / Irritation / Aggression / Confusion Agitation / Irritation / Aggression / Confusion

The basic principles of DKA treatment The basic principles of DKA treatment

are:are:

• Rapid restoration of adequate circulation and Rapid restoration of adequate circulation and perfusion with perfusion with isotonicisotonic intravenous fluids intravenous fluids

• Gradual rehydration and restoration of Gradual rehydration and restoration of depleted electrolytes (especially sodium and depleted electrolytes (especially sodium and potassium), even if serum levels appear potassium), even if serum levels appear adequate adequate

• Insulin to reverse ketosis and lower glucose Insulin to reverse ketosis and lower glucose levels levels

• Careful monitoring to detect and treat Careful monitoring to detect and treat complications complications

DiverticulitisDiverticulitis

• A common digestive disease A common digestive disease particularly found in the particularly found in the large intestinelarge intestine. .

• Diverticulitis develops from Diverticulitis develops from diverticulosisdiverticulosis, which involves the , which involves the formation of pouches (formation of pouches (diverticuladiverticula) on ) on the outside of the the outside of the coloncolon. .

• Diverticulitis results if one of these Diverticulitis results if one of these diverticula becomes diverticula becomes inflamedinflamed. .

Diverticula (arrowheads) and inflammation Diverticula (arrowheads) and inflammation around the sigmoid colon, indicating around the sigmoid colon, indicating diverticulitis. A small, adjacent, early diverticulitis. A small, adjacent, early

abscess (open arrow) is noted.abscess (open arrow) is noted.

CausesCauses

• Blockage of a Blockage of a diverticulumdiverticulum, possibly , possibly by a piece of by a piece of faecesfaeces or food particles, or food particles, leads to infection of the diverticulumleads to infection of the diverticulum

SymptomsSymptoms

• Abdominal painAbdominal pain

• Tenderness around the left side of Tenderness around the left side of the lower abdomenthe lower abdomen

• Fever, nausea, vomiting, chills, Fever, nausea, vomiting, chills, cramping, and constipation cramping, and constipation

TreatmentTreatment

• An initial episode of acute diverticulitis is usually An initial episode of acute diverticulitis is usually treated withtreated with

• Conservative medical management, including Conservative medical management, including bowel rest (ie, nothing by mouth),bowel rest (ie, nothing by mouth),

• IV fluid resuscitation, and IV fluid resuscitation, and • Broad-spectrum Broad-spectrum antibioticsantibiotics which cover which cover

anaerobicanaerobic bacteriabacteria and and gram-negativegram-negative rodsrods. . • Recurring acute attacks or complications, such Recurring acute attacks or complications, such

as peritonitis, abscess, or fistula mayas peritonitis, abscess, or fistula may• Require surgery, either immediately or on an Require surgery, either immediately or on an

elective basis.elective basis.

What’s this ?What’s this ?

Ectopic pregnancyEctopic pregnancy

• A A complication of pregnancycomplication of pregnancy • In which the In which the fertilizedfertilized ovumovum is implanted in any is implanted in any

tissue other than the tissue other than the uterineuterine wall. wall.• Most ectopic pregnancies occur in the Most ectopic pregnancies occur in the

Fallopian tubeFallopian tube (so-called (so-called tubal pregnanciestubal pregnancies),),• But implantation can also occur in the But implantation can also occur in the cervixcervix, ,

ovariesovaries, and , and abdomenabdomen. . • The fetus produces enzymes that allow it to The fetus produces enzymes that allow it to

implant in varied types of tissues, and implant in varied types of tissues, and • Thus an embryo implanted elsewhere than the Thus an embryo implanted elsewhere than the

uterus can cause great tissue damage in its uterus can cause great tissue damage in its efforts to reach a sufficient supply of blood. efforts to reach a sufficient supply of blood.

CausesCauses

• The causes of ectopic pregnancy are unknownThe causes of ectopic pregnancy are unknown• After fertilization of the After fertilization of the oocyteoocyte in the peritoneal in the peritoneal

cavity, the egg takes about nine days to cavity, the egg takes about nine days to migrate down the tube to the uterine cavity at migrate down the tube to the uterine cavity at which time it implants. Wherever the embryo which time it implants. Wherever the embryo finds itself at that time, it will begin to implant.finds itself at that time, it will begin to implant.

• Some speculative specific causes or Some speculative specific causes or associations:associations:

• Smoking, Smoking, • Advanced maternal age and Advanced maternal age and • Prior tubal damage of any originPrior tubal damage of any origin

SymptomsSymptoms

• Clinical presentation of ectopic pregnancy occurs Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. menstrual period, with a range of 5 to 8 weeks.

• Pain and discomfort, usually mild. Pain and discomfort, usually mild. • Vaginal bleeding, usually mild. Vaginal bleeding, usually mild. • An ectopic pregnancy is usually a failing An ectopic pregnancy is usually a failing

pregnancy and falling levels of progesterone from pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal the corpus luteum on the ovary cause withdrawal bleeding. bleeding.

• This can be indistinguishable from an early This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a miscarriage or the 'implantation bleed' of a normal early pregnancy. normal early pregnancy.

• Pain while having a bowel movement Pain while having a bowel movement • Patients with a late ectopic pregnancy Patients with a late ectopic pregnancy

typically have pain and bleeding. This typically have pain and bleeding. This bleeding will be both vaginal and internal bleeding will be both vaginal and internal and has two discrete pathophysiologic and has two discrete pathophysiologic mechanisms.mechanisms.

• External bleeding is due to the falling External bleeding is due to the falling progesterone levels. progesterone levels.

• Internal bleeding is due to hemorrhage Internal bleeding is due to hemorrhage from the affected tube. from the affected tube.

• More severe internal bleeding may cause:More severe internal bleeding may cause:• Lower Lower backback, , abdominalabdominal, or , or pelvicpelvic painpain. . • Shoulder pain. This is caused by free blood tracking up the Shoulder pain. This is caused by free blood tracking up the

abdominal cavity, and is an ominous sign. abdominal cavity, and is an ominous sign. • There may be There may be crampingcramping or even tenderness on one side of or even tenderness on one side of

the the pelvispelvis. . • The pain is of recent onset, meaning it must be The pain is of recent onset, meaning it must be

differentiated from cyclical pelvic pain, and is often getting differentiated from cyclical pelvic pain, and is often getting worse. worse.

• Ectopic pregnancy is noted that it can mimic symptoms of Ectopic pregnancy is noted that it can mimic symptoms of other diseases such as other diseases such as appendicitisappendicitis, other gastrointestinal , other gastrointestinal disorder, problems of the urinary system, as well as disorder, problems of the urinary system, as well as pelvic inflammatory diseasepelvic inflammatory disease and other gynaecologic and other gynaecologic problems. problems.

TreatmentTreatment

• Nonsurgical treatmentNonsurgical treatment• Early treatment of an ectopic pregnancy with the Early treatment of an ectopic pregnancy with the

antimetabolite antimetabolite methotrexatemethotrexate has proven to be a viable has proven to be a viable alternative to surgical treatmentalternative to surgical treatment[6][6] If administered early in If administered early in the pregnancy, methotrexate can disrupt the growth of the the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the developing embryo causing the cessation of pregnancycessation of pregnancy..

• Surgical treatmentSurgical treatment• If hemorrhaging has already occurred, surgical intervention If hemorrhaging has already occurred, surgical intervention

may be necessary if there is evidence of ongoing blood may be necessary if there is evidence of ongoing blood loss..loss..

• Surgeons use Surgeons use laparoscopylaparoscopy or laparotomy to gain access to or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and the pelvis and can either incise the affected Fallopian and remove only the pregnancy (remove only the pregnancy (salpingostomysalpingostomy) or remove the ) or remove the affected tube with the pregnancy (affected tube with the pregnancy (salpingectomysalpingectomy).).

Tubal Pregnancy showing a 1 month Tubal Pregnancy showing a 1 month

embryoembryo

Tubal pregnancy (6 week old Tubal pregnancy (6 week old

embryo)embryo)

Acute AbdomenAcute Abdomen

• An elderly man with acute An elderly man with acute abdominal painabdominal pain

• This 75 year old man presented to This 75 year old man presented to the Emergency Department with the Emergency Department with acute abdominal pain and bloody acute abdominal pain and bloody diarhoea. What does the plain diarhoea. What does the plain abdominal film show?abdominal film show?

Crohn's colitis with toxic Crohn's colitis with toxic megacolonmegacolon

LEFT: Plain abdominal film in a patient with an acute abdomen, LEFT: Plain abdominal film in a patient with an acute abdomen, showing no abnormalities. showing no abnormalities. RIGHT: Subsequent CT shows distended small bowel loops (arrowheads) that are not RIGHT: Subsequent CT shows distended small bowel loops (arrowheads) that are not

seen on plain abdominal film because they are filled with fluid only and do not seen on plain abdominal film because they are filled with fluid only and do notcontain intraluminal air.contain intraluminal air.