ACUTE ABDOMEN

ACUTE ABDOMEN

Begashaw M

ACUTE ABDOMEN

Denotes any sudden condition with chief manifestation of pain of recent onset in the abdominal area which may require urgent surgical intervention

Sites of referred pain

Sites of Abdominal Pain

CLASSIFICATION

Obstruction Inflammation Hemorrhage Infarction perforation

CLINICAL FEATURES Symptoms _Colicky and Intermittent pain ( visceral) _Continuous pain ( somatic) _Vomiting _Fever _TachycardiaColic pain obstructionContinuous pain infection, inflammation or ischemia

Signs

Abdominal distention, visible peristalsis Direct and rebound tenderness, guarding Anemia, hypotension Toxic with Hippocratic faces Absence of bowel sound ( peritonitis) Psoas signappendicitis Murphy‘s signacute cholecystitis Dehydrationsunken eyeballs

DIFFERENTIAL DIAGNOSIS

Surgical - Intestinal obstruction Gynecologic & obstetric - Ectopic ruptured

pregnancy Medical - enteritis

Surgical causes

A- InflammationAcute appendicitis Acute cholecystitisB- Obstruction Intestinal obstructionC- Infarction Mesenteric ischemiaD-Strangulation volvulusE- Perforation perforated peptic ulcer

DIAGNOSIS

Clinical: Hx & p/ELab: CBC, cross match, urine analysis,

serum amylase & electrolytesUltrasound plain film of abdomen

MANAGEMENT

A-Preoperative- Resuscitation with IV fluids- Antibiotics- Catheterization & NGT insertion- Analgesics after confirming the diagnosisB- Surgery Definitive laparotomy CMonitoring Follow up

INTESTINAL OBSTRUCTION

is partial or complete blockage of the intestine producing symptoms

_Vomiting _Constipation _Distension _Abdominal pain

Causes of mechanical intestinal 0bstruction

Intestinal Obstruction

CLASSIFICATION

Mechanical physical barrier blocksParalytic ileus disordered propulsive

motilityHigh _Small bowelLow _Large bowelSimple -> adequate blood supplyStrangulated -> Mesenteric vessels

occluded

Mechanical

A- Luminal_Gallstone Ileus_Food bolus_Meconium Ileus_Malignancy _Inflammatory mass_Ascaris bolus

B- Mural_Stricture_Congenital_Inflammatory_Ischemic_Neoplastic_Intussusception

Intussusception

C- Extra muralAdhesionsinflammatory/malignantHernia External/internalVolvulus Small bowel large bowel -> Sigmoid volvulus

Small bowel obstruction

Adhesion

PATHOPHYSIOLGY Proximal dilatation disrupts peristalsis Above the obstruction distended with fluid

and gas stimulates excessive peristalsis ->colicky pain blood vessels-stretched & narrowed ischemia Absorptive capacity decreases increased vomiting depletion of extra

cellular fluid hypovolemia & dehydration

Pathophysiology

A strangulated loop dies and perforates to produce severe bacterial peritonitis which is often fatal

Grossly distended abdomen restricts diaphragmatic movement and interferes with respiration

A multiple organ failure

Clinical features

Symptoms-Abdominal pain-colic-Vomiting-Constipatio-partial -absolute

Signs-Abdominal distension visible bowel loops

-High pitched bowel sounds-Tenderness & guarding-Dehydration &

hypotension-Empty rectum DRE Large bowel obstruction

DIAGNOSIS

Clinical: Hx & P/E Lab: CBC, electrolytes Plain abdominal film :- distension of bowel with air fluid level- Central located distended loops with multiple

air fluid levelsmall bowel- Peripherally located distended bowel with

haustral marksLarge bowel

X-ray of intestinal obstruction

MANAGEMENT

Fluids resuscitation to restore the circulatory state

Early preoperative preparationAttempt rectal tube deflation-simple

sigmoid volvulus Supportive measuresEarly operationLaparotomyPost operative care

NG tube suction

SIGMOID VOLVULUS

Sigmoid colon is the most frequent site of volvulus

Predisposing factors- A long redundant sigmoid with a narrow pedicle- High fiber diet- Chronic constipation_elderly _chronic mental pts

Sigmoid volvulus

PATHOPHYSIOLOGY

Redundant sigmoid twists on its base in a clockwise direction

Mesocolic veins become occluded & arterial inflow into the twisted loop perpetuates the volvulus until it becomes irreversible

Twisted loop distends grosslyPerforation may occur due to either pressure

necrosis at the base of the twist or to avascular necrosis at the apex

DIAGNOSIS

CLINICAL_Abdominal cramp & distension_Constipation (early) & vomiting (late)_Empty rectum on DRE RADIOLOGIC FINDINGSTwo long fluid levels in the lower quadrant Inverted U shape of the sigmoid lumen“Coffee bean” appearance or the ‘Omega sign”

MANAGEMENT

Conservativesimple volvulusdeflation with a well greased

large bore rectal tube under the guide of a sigmoidoscope

Deflation fails laparotomy & derotation Elective resection & anastomosis Intravenous fluid - rehydrate if sign of

dehydration

Sigmoidoscopic deflation

Emergency Surgery_Complicated volvulus with signs of

peritonitis_Resuscitative measures_Antibiotics_Resection of the gangrenous segment with

Hartman’s colostomy

Laparatomy

APPENDICITIS

is an inflammation of the appendix that results from bacterial invasion usually distal to an obstruction of the lumen

Appendix

Pathogenesis Luminal obstruction bacterial overgrowth

lnflammation/swelling Increased pressure-localized ischemiagangrene/perforationlocalized abscess (walled off by Omentum) or Peritonitis

Etiology:_Hyperplasia of lymphoid follicles_Fecolith, obstructing neoplasm_Parasites, foreign body

CLINICAL PRESENTATION

Symptoms-Central abdominal colic which shifts to the

right Iliac fossa-Anorexia, nausea, episodes of vomiting and

low grade fever-High grade fever indicates perforation and

peritonitis

Signs

-Tenderness and localized rigidity in RLQ MC Burney’s point

-Rovsing’s sign: Pain in RLQ on pressing in LLQ-Psoas sign: Pain on extension of right flexed hip-Obturator sign: Pain on passive internal or

external rotation of the flexed right hip-Right sided tenderness on rectal examination.-Diminished bowel sounds indicating peritonitis

Appendicitis signs

Differential diagnosis

IN CHILDREN -Intussusceptions -Mesenteric adenitis FEMALE -PID -Twisted ovarian

cyst( torsion) - ruptured ovarian

follicle

GENERAL-Acute chlolecystitis -Perforated PUD -Renal or ureteric

calculi -UTI -Early small bowel

obstruction (volvulus) -Gastroenteritis

Investigations

Labsleukocytosis with left shiftbeta-hCG to rule out ectopic pregnancyUrinalysis Imaging:Upright CXR, AXR-free air Ultrasound: may visualize appendix

MANAGEMENT

PREOPERATIVE-Resuscitation with fluids-Appropriate antibiotics (combination for coverage

of gram positive, gram negative and anaerobes)-Correct all deficits ( dehydration) SURGERY-Surgical removal of the appendix is the definitive

treatment-Appendectomy

COMPLICATIONS

Perforation - local or generalized peritonitisAppendiceal mass and abscess formationDeath

APPEDECIAL MASS

Inflammatory process walled off in the right iliac fossa by omentum and loops of bowel to form a mass

Management-Conservative -antibiotics -fluids _Drug of choice- metronidazole and ceftriaxone Ampicilline, Chloramphenicol & Gentamycin

Follow up

-Vital signs every 4 hourly -Mass size & consistency 12 hourly-Patient’s condition -Laboratory every other day Interval appendectomy 6 weeks later

Appendiceal abscess

Increasing mass sizeFluctuationpersistence of systemic signsManagement - drainage of the abscess and

appendectomy Interval appendectomy after emergency

drainage

Draining appendeceal abscess

PERITONITIS

is an inflammation of the peritoneumis an acute life threatening condition caused

by bacterial or chemical contamination of the peritoneal cavity

Peritoneum

Peritoneal abscess

Differential diagnosis

Perforated appendix Perforated PUD Anastomotic leak Strangulated bowel Pancreatitis

Cholecystitis Intra abdominal

abscess Typhoid perforation Ascending infection

e.g salpingitis

CLASSIFICATION

Primary peritonitis: caused by bacterial spread via the blood stream

Secondary peritonitis: caused during perforation or rupture of abdominal organ allowing access of bacteria and irritant digestive Juices to the peritoneum

Classification

Acute peritonitis: rapid onset or brief duration

Chronic peritonitis: long durationLocalized peritonitis - confined to a limited

space - pelvisGeneralized peritonitis - whole peritoneal

cavity involved

ROUTES OF BACTERIAL INVASION

1- Direct- contamination via perforation, a penetrating wound or during surgery

2-Local Extension: contamination by migration from an infected organ - through gut wall, via the fallopian tube

3-Blood stream: via the blood as consequence of general septicemia

CLINICAL FEATURES Sharp pain which is worse on movement Fever & tachycardia Abdominal distension Tenderness & guarding Diminished or absent bowel sounds Shoulder pain _referred pain -diaphragmatic irritation Tenderness on rectal examination (pelvic peritonitis) Abdominal distension & vomiting

Generalized peritonitis

MANAGEMENT

Resuscitation: intravenous fluidsAnalgesiaNaso-gastric tube insertion (NGT)Triple antibiotics (ampicilline , gentamycin and

metornidazole or chloramphenicol)Monitoring in put & out put by catheterizationSurgery Drainage & peritoneal lavage