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seminar on Approch to Acute abdomen pho4th year (2).pptx
- 1. Mekelle university College ofhealth sciences Ayder Comprehensive Specialized Hospital department of public health Seminar on Approach to Acute abdomen Presenter Abrha Berhe Adugna Tsegay Moderator: Dr Eyob Surgery Resident
- 2. Outlines Define acuteabdomen Describe a general approach to acute abdomen Discuss common causes of acute abdomen Discuss principle of management
- 3. Mind map Approach toacute abdomen Definition History taking Physical examination Investigation Management Diagnosis
- 4. Definition “Sudden onset ofspontaneous non-traumatic abdominal pain that requires urgent evaluation & intervention.” NB: The intervention could be Surgical or Medical.
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- 7. Right upper quadrantpain: Acute cholecystitis and Biliary colic Perforated duodenal ulcer Acute hepatitis or Abscess Hepatomegaly Rt lower lobe pneumonia pyelonephritis
- 8. Left upper quadrantpain: Acute pancreatitis Gastric ulcer Gastritis Splenic enlargement, rupture and infarction Lt lower lobe pneumonia pyelonephritis
- 9. Right lower quadrantpain: Acute appendicitis Mesenteric adenitis Meckel’s diverticulitis Crohn’s disease Perforated cecum Psoas abscess Renal/ ureteral stone Hernia SBO Gynecologic cause
- 10. Left lower quadrantpain: Diverticulitis Renal/ ureteral stones Hernia LBO Perforated colon IBD Gynecologic causes
- 11. Gynaecological Causes Ruptured EctopicPregnancy Rupture Ovarian Cyst Ovarian torsion PID Salpingitis Endometriosis
- 12. Clinical Assessment Becauseof the potential surgical nature of the acute abdomen, an expeditious workup is necessary. The workup proceeds in the usual order of • History, • Physical examination, • Investigation: Laboratory, and Imaging studies.
- 13. History taking Age: •Newborn: congenital anomalies- atresia, stenosis • Children: mesenteric adenitis, bowel obstruction due to intussusception • Adult: appendicitis • Elderly: bowel obstruction due to malignancies, acute diverticulitis
- 14. * Pain: SOCRATESapproach Site:
- 15. Onset: suddenvs gradual Typical Pain from perforation is sudden Pain that develops and worsens over several hours is typical of conditions of progressive inflammation or infection Character: Dull – mild pain Colicky Cramping Burning ...Cont’d
- 16. Equally importantas the character of the pain are its location and radiation. N.B. Solid circles are primary or most intense sites of pain.
- 17. Activities that exacerbateor relieve the pain are also important Eg: Eating often worsens the pain of bowel obstruction, biliary colic, pancreatitis, diverticulitis, or bowel perforation while relieving pain of non-perforated PUD or Gastritis.
- 18. Associated Symptoms •Nausea, • vomiting, • constipation, • diarrhea, • Hematochezia • melena, or • hematuria – can all be helpful symptoms if present and recognized.
- 19. Past MedicalHx : Prior hx of • Appendectomy • PID • Cholecyctectomy • Kidney stones, etc Hx of Medications Medications can both create acute abdominal conditions or mask their symptoms. Eg: high-dose narcotic use can interfere with bowel activity and lead to obstipation and obstruction. NSAIDs are associated with an increased risk for upper GI inflammation and perforation
- 20. Physical Examination o Despitenewer technologies, including CT scanning, ultrasound, and MRI, the P/E remains a key part of a patient's evaluation and must not be minimized. G/A: ASL- Pts lie very still in the bed during the evaluation and often maintain flexion of their knees and hips to reduce tension on the anterior abdominal wall.
- 21. Vital sign: Importantto see the hemodynamic state of the patient weather if the patient is tachycardic, tachypneic or hypotensive. If vital signs disrupted (Hypotension) they must be treated immediately to prevent patient going into shock. If the patient in shock you have to cut the examination and go directly to resuscitate the patient by Airway, breathing and circulation(ABC), when he/she get stable now examine him/her.
- 22. HEENT: • Check theeyes for jaundice. • Mucous membrane for signs of dehydration LGS: • Check for lymphadenopathy E.g: Virchows node:- abdominal cancer Chest: • Lobar pneumonia: may present with R(L)UQ pain, you will hear crackles, bronchial breathing and dullness on percussion.
- 23. Abdominal Exam Inspection: Contourof the abdomen Scars (esp. Surgical scars should be correlated with past surgical hx) Evidence of erythema or edema of skin Ecchymosis Auscultation: Bowel Sounds (Quiet Vs Hyperactive) Pitch and Pattern of the sounds Eg. high-pitched “tinkling” sounds indicate intestinal obstruction Bruits
- 24. Percussion: • Dullness- fluidascites • Hyper tympanic- air filled structure, this suggests intestinal obstruction. Palpation: start superficially and then deep, away from the site of pain. • To reveal severity and exact location of the abdominal pain • Confirm the presence of peritonitis
- 25. Additional Examinations RectalExamination • For the presence of a mass especially in elderly, pelvic pain, or intraluminal blood or melena. Pelvic examination is included in all women when evaluating pain located below the umbilicus .
- 26. Common surgicalcauses of Acute Abdomen are:- 1. Acute Appendicitis 2. Intestinal Obstruction 3. Perforated PUD 4. Acute Cholecystitis 5. Acute Pancreatitis
- 27. Acute Appendicitis • Mostcommon acute abdominal surgical emergency • Life time risk is 7.5% • Male: Female ~ 1.4:1 • common in 2nd and 3rd decades of life
- 28. • Course 1. Spontaneousresolution 2. Gangrene and perforation 3. Appendicular Mass 4. Appendicular abscess Risk factors for perforation - Extremes of age - Immunosuppresion - DM - Faecolith obstruction - Pelvic appendix - Previous abdominal surgery
- 29. • Clinical Presentation Variationsin the position of the appendix, age of the patient, and degree of inflammation make the clinical presentation of appendicitis notoriously inconsistent. – Periumbilical pain that shifts to the RLQ with ~ 80% sensitive and 53% specificity – Anorexia, nausea, vomit – Afebrile or low-grade fever. – Diarrhea/Constipation – Urinary symptoms
- 30. Physical findings • G/A:ASL usually lie supine with the thighs drawn up, b/c any motion increases pain direct and Rebound RLQ tenderness Rovsing sign Psoas sign Obturator’s sign RLQ mass Guarding and rigidity Generalized peritonitis
- 31.
- 32. • Investigation Routine techniquesare CBC- leukocytosis U/A- a few WBCs/RBC due to Irritation of the bladder or ureters by an inflamed appendix Selective investigations Pregnancy test serum electrolyte Abdominal radiographs 1. abdominal U/S – sen 55%-96% and spe 85%-98% • Non compressive,dialated appendix • Non peristaltic • Focal tenderness over the inflamed appendix 2. CT scan - higher sensitivity and specificity
- 34. Management 1. Conservative treatment •Give IV antibiotics • Parenteral fluid replacement • NPO • Follow up • Indications: Patient who refused surgery Appendiceal mass
- 35. 2.Surgical management • Appendectomyis the definitive treatment for acute appendicitis. • Give prophylactic antibiotics preoperatively • Post op antibiotics is given for complicated one. • Appendiceal abscess: Drain abscess and place drainage tube insitu, leave appendix untouched if difficult to identify, elective surgery after 6 weeks.
- 36. COMPLICATIONS: post op •SSI • Stump appendicitis Negative appendectomy Normal appearing appendix found during operation in patients presenting with signs and symptoms of acute appendicitis. • Rate is 15% - higher in women(22%) and children <5 years (25%). • Do thorough examination of the abdomen
- 37. Intestinal obstruction Intestinal obstructionOccurs when the luminal content of the GIT is prevented from passing distally Classification: 1. Based on type: Dynamic – mechanical obstruction Adynamic –paralytic ileus 2. Based on lumen: Complete obstruction Partial obstruction
- 38. 3. Based onpresence of complications: Simple / viable Strangulated 4. Based on the intestine involved: SBO LBO
- 39. Etiology Classified into: 1. Extraluminal Adhesion Hernia Volvulus Intra abdominal neoplasm 2. intrinsic/ intramural/ Inflammatory- IBD neoplasm 3. Intraluminal Gall stone Bezoars Worms Fecal impaction
- 40. Clinical presentation the 4cardinal symptoms Crampy abdominal pain Nausea & vomiting Constipation Abdominal Distension
- 41. Physical examination • G/A:ASL • Vital sign: Tachycardic, hypotensive: due to severe dehydration Fever: strangulation • Signs of dehydration • Abdominal examination Inspection: o Abdominal distention, visible peristalsis, look for scars and hernia sites carefully.
- 42. Auscultation: o Early- hyperactivebowel sounds o Later- hypoactive Palpation: o Tenderness, guarding and rigidity- peritonitis Percussion: o Hyper tympanic o Dullness – sign of fluid collection Rectal examination Presence or absence of fecal matter Blood – malignancy or strangulation
- 43. Investigation CBC serumelectrolytes RFT Imaging o Plain abdominal x-ray (Supine & erect) • SBO; Findings “ the triad” 1. Dilated small bowel loop (>3 cm in diameter) 2. Multiple air-fluid levels 3. Paucity of colonic air Additional findings – Centrally located dilations and presence of regularly spaced valvulea conniventes.
- 44. • LBO: findings 1.Dilated bowel loop (> 6 cm)- peripherally 2. Paucity of air in rectum- complete obstruction 3. Air-fluid levels 4. Haustra markings o Abdominal u/s- for intussusception & describe nature of a mass o GI Endoscope o CT scan- Useful to detect : lesions , tumors
- 45.
- 46. management 1. Conservative • Principlesof Rx -gastrointestinal drainage -fluid & electrolyte replacement -relief of obstruction
- 47. Management • Indications forsurgical Rx -Obstructed / strangulated external hernia -Internal intestinal strangulation -Acute obstruction 47
- 48. Perforated PUD • Itis one of the common complications of peptic ulcer disease • Complicates 2-10% of PUD • Most common site to perforate is the anterior duodenum • Duodnal,antral & gastric body ulcers account for 60, 20,&20 % of perforation due to PUD respectively • M:F is 2:1(in elderly higher female ratio) • Nearly 50% of them have no history of PUD
- 49. Perforated duodenal ulcer 5-10 % of DU patients More common than perforated gastric ulcer Operative mortality is 5% Over 30% of same groups are; Elderly In shock Have comorbid disease Perforations >24 hours
- 50. Perforated gastric ulcer •Associated with NSAID and tobacco use • Often present with out prior symptom • It has worst prognosis than perforated duodenal ulcer
- 51. Clinical presentation ofperforated PUD The following three phases have been described when there is free perforation Phase 1 ( with in two hours of onset) Sudden onset abdominal pain Localization is epigastric It quickly becomes generalized Sometimes collapse or syncope Tachycardia, week pulse, cool extremity & low temperature
- 52. Phase 2 (2to 12 hours) Abdominal pain may be lessen In experienced observer….lead to patient getting better Pain is generalized Worsens upon movement Board like abdomen Obliteration of liver dullness Rectal examination is tender
- 53. Phase 3(usually >12 hours of duration) Increased abdominal distention is noted But abdominal pain, tenderness& rigidity may be less evident Temperature elevation & hypovolemia
- 54. Diagnostic investigation An erectplain chest radiography gas under the diaphragm in >50% of patients Water soluble contrast swallow Free peritoneal leak Diagnostic peritoneal lavage Bile stained fluid Serum amylase Elevated but not as high as acute pancreatitis CT-scan….. perforated vs acute pancreatitis
- 55. • CXR- gasbelow the diaphragm
- 56. • Treatment - ComplicatedPUD is mainly treated sugically. - Resuscitation and analgesia - Surgical Tx: Suture the perforated ends Omental patch - If the ulcers are large Billroth II gasterctomy will be done - Lifelong antiacid therapy - Gastric ulcers should be excised
- 57. Acute Cholecystitis Thisrefers to a syndrome of RUQ pain, fever and leukocytosis associated with gallbladder inflammation. Cystic duct obst. G.B distension + inflam.+edema 20 to bacterial Infection abscess, empyema, gangrenous changes and rarely perforation
- 58. Clinical manifestations • Hx-Colicky pain at the RUQ -Nausea and Vomiting -hx of fatty food ingestion about one hour or more before the initial onset of the pain.
- 59. • P/E- -Fever - Tachycardia - Guardening & rigidity in the right upper quadrant - Murphy’s sign - Boas’s sign - Vague mass -Jaundice/mirizzi syndrome
- 60.
- 61. Investigations Lab: CBC Liverfunction test Imaging : ultrasound gallstone thickened gall bladder wall distended gall bladder sonographic murphy’s sign : HIDA scan
- 62. Management Initial conservative treatmentsfollowed by cholecystectomy after 6 weeks Early cholecystectomy within 3 days of attack - Early surgery is not difficult - Avoid complications of acute cholecystitis - Minimal hospital stay
- 63. Acute Pancreatitis anacute inflammatory process of the pancreas characterized clinically by severe acute upper abdominal pain and elevated levels of pancreatic enzymes in the blood.
- 64. • Etiology - Bileduct stone(50%) - Excessive alcohol intake(20%) - Idiopathic(20%) - Trauma(5%) Accidental Operative ERCP -Rare causes Viral infection-mumps Hyperparathyroidism Corticosteroids
- 65. Clinical presentations Severe agonizinigabdominal pain - Radiates to the back - Preceeded by fatty meal or alcohol - relief by sitting or leaning forward Vomiting and retching Restlessness
- 66. Physical finding Fever,tachycardia, tachypnea shock & coma (in severe cases) Mild icterus- in gall stone pancreatitis Respiratory- shallow breathing, dyspnea Abdomen- distension, tenderness, muscle guarding - epigastric mass - Cullen’s sign - Grey-Turner’s sign
- 67. Investigations • Lab - Serumamylase-(3-4X above normal) - Serum lipase - CBC Leukocytosis -Billirubin is elevated
- 68. Imaging - Plain abdominalX-ray Sentinel’s loop Colon cut-off sign - Abdominal U/S Gall stone - CT scan Enlargement of pancreas Peripancreatic Edema Pancreatic necrosis
- 69. Management Conservative Relief ofpain Replacement of fluid Respiratory support Rest of pancreas and bowel (NPO) Resistance of infection (Prophylactic Antibiotics)
- 70. • Surgical Tx Indications 1.A doubtful Dx 2. Drainage of pancreatic abscess or persistence of pseudocyst that doesn’t resolve with in 6 wks 3. Necrotizing Pancreatitis on CT
- 71. • REFERENCES Sabiston TextBook Of Surgery ,20th Ed… Bailey & Love’s short Practice Of Surgery ,25th Edition Schwartz’s Principle Of Surgery ,10th Edition