Acute Abdomen

Report
Dr. Abdul Ghani Soomro
Associate Professor
Surgery
LUMHS Jamshoro
ACUTE ABDOMEN
1 .Pain
2.Vomiting
3.Constipation
4.Abdominal distention
Acute abdomen
Spectrum of medical and
surgical conditions ranging
from trivial to life threatening
that requires hospital
admission investigations and
treatment .
Pain
Somatic
Visceral
to localize
Referred pain
abdominal organ
Abdominal wall
Peritoneum
Diffuse difficult
Irritation of
Symptoms
Luminal obstruction
Inflammation.
Appendicitis
Cholecystitis
Pancreatitis
Peritonitis.
Perforated viscus
Strangulation
Intra peritoneal
collection
Bile
Blood
Pus
I
Common Causes of acute abdominal pain
Organ
Location of Pain
Liver
Right Upper quadrant
Pathology
•Hepatitis
•Liver abscess
•CCF
Common Causes of acute abdominal pain
Organ
Location of Pain
Pathology
Biliary Tract
Right Upper quadrant
•Choleycystitis
•Cholelithiasis
•Choledocholithiasis
Common Causes of acute abdominal
pain
Organ
Pancreas
Location of Pain
Pathology
Epigastrium
•Acute Pancreatitis
Right Hypochondrium
•Ca Pancreas
Left Hypochondrium
•Ca Oesaphagus
Common Causes of acute abdominal
pain
Common Causes of acute abdominal
pain
Common Causes of acute abdominal
pain
Common Causes of acute abdominal
pain
Common Causes of acute abdominal
pain
Common Causes of acute abdominal
pain
Common Causes of acute abdominal
pain
Common Causes of acute abdominal
pain
Common Causes of acute abdominal
pain
Taking the history of a patient with acute
abdomen
Specific question
When did the pain start and was the onset
sudden?
What brought the pain on and are there any
aggravating or relieving factors?
Where did the pain start and where is it now?
Does it radiate elsewhere?
What is the character of the pain and how
severe is it?
Taking the history of a patient with acute
abdomen
Specific question
Are there any associated symptoms? (e.g.
distension, nausea, vomiting, fever, diarrhoea,
absolute constipation, anorexia, jaundice,
pruritis, gastrointestinal bleeding, dysuria,
oliguria, chest pain)
Was there any similar episode in the past?
When was your last period and is there any
chance that you may be pregnant?
Taking the history of a patient with acute
abdomen
General enquiries
History of alcohol intake
Drug history
History of previous surgery
History of Pre-existing disease
History of travel (Especially foreign)
Family history
Investigations
1.Blood CP
2.Urea Creatinine
3.Blood Sugar
4.Serum Amylase
5.LFTs
6.Pregnancy Test
7.Urine DR
8.ECG
Imaging
• Radiography
•
Abdomen
•
Chest
•Ultrasound Abdomen
•CT Scan
•MRI
•Barium Studies
•Endoscopy
•Laparoscopy / Laparotomy
Acute abdomen in infants & Children
Congenital atresia
Volvulus
Meconieum ileus
Meckl’s diverticulum
Inguinal Hernia
Common Surgical Emergencies
Acute Appendicitis
Liver Abscess
Abdominal Tuberculosis
Typhoid Perforation
perforated peptic ulcer
Abdominal wall hernia
Acute Appendicitis



Most common abdominal emergency.
Uncommon before the age of 2 years.
Peak incidence in twenties and thirties
Aetiology
 The vermiform appendix is a vestigial
structure.
 7-10 cm in length.
 Exact cause is unclear but luminal
obstruction, diet, familial factors have been
suggested.
Pathology
 Minor, simple, acute with spontaneous
resolution to supperactive necrosis and
perforation.
 Bacteria (E Coli, Klebsilla, Proteus).
 Enter through ulcer (caused by faceolith).
 Edema purulent inflammation thrombosis,
gangrene.
Clinical Features
 Age can influence presentation.
 Clinical picture also dictated by position of appendix.
 Epigastric / periumblical pain .
 Shift to right iliac fossa.
 Colicky / dull pain.
 Aggravated by movement and coughing.
 Loss of appetite constipation nausea and vomiting.
Clinical Examination
 Tachycardia.
 Mild Pyrexia
 Guarding in RIF
 Fetor oris
 Tenderness on rectal / vaginal examination.
 Rovsings sign, psoas stretch sign.
 Obturater test
Anatomical Feature
influencing Presentation
1.
Retrocaecal
Muscular rigidity often absent
Right hip in flexed position due to psoas spasm
Psoas stretch sign.
2.
Post ileal
Diarrohea and Vomiting
Prominent feature due to irritation of ileum.
3.
Pelvic
Diarrohea due to irritation of rectum.
Increased frequency of micturation.
Microspic haematuria.
Tenderness on rectal and viginal
examination.
Obturator sign.
Age Related features affecting
presentation
1. Children
Difficulty in obtaining
Proper history
Difficulty in differentiating from mesenteric
adenitis and enteritis.
Under developed omentum leading to early
complications.
2. Elderly
Less prominent Symptoms
Afebrile
Normal white cell count.
Pregnancy
 1 per 1500-2000 / years in UK. Displacement of
appendix by Gravid uterus can result in atypical
presentation. Symptoms may be confused with
onset of labor.
 Tenderness may not be marked due to gravid
uterus.
 Less maternal mortality in case of simple
appendix.
 Risk of featal death is about 10% .
 Complications
both at risk.
Complications
 Perforation
 Appendix mass
 Appendix abscess
Differential Diagnosis
Thorax and Respiratory Tract
Tonsilltis
Pneumonia
Abdomem







Intestinal Obstruction
Intussusception
Acute cholecystitis
Perforated Peptic ulcer
Mesenteric adenitis
Terminal ileitis
Meckel’s diverticulitis
PELVIS





Ectopic Pregnancy
Ruptured ovarian follicle
Torsion of ovarian cyst
Salpingitis
PID
URINARY SYSTEM
 Right Pyelonephritis
 Right Uretric Colic
OTHER
 Diabetic ketoacidosis
 Rectus sheath haematoma
 Pancreatitis
 Pre Herpetic Pain
INVESTIGATIONS
1. Blood cp
2. Urine analysis
RADIOGRAPHY
 Faecolith 50% of children < 2 years
 Ultrasound abdomen
 C.T Scan
 Laparoscopy
TREATMENT
Appendicetomy
Open
Laparoscopic
*Amoebic liver Abscess
 It is common in indo-pak
 Caused by parasite entamoeba histolytica
 Common in alcoholics
 Infection commonly occurs in caecum and
rectosigmoid junction via superior and inferior
mesentric veins and portal vein to liver.
 Right lobe of liver is commonly involved, size
of right lobe, portaly vein is in direct
continuation with right branch.
 Infection Leads to liquefaction necrosis and
formation of pus (Anchovy Sauce) which is
chocolate brown in colour odourless.
 Pus may be green if mixed with bile.
 Secondary infection is common in (30%)
 70% single abscess, 30% multiple.
E. Histolytica Life Cycle
2 stages:
-Infective cyst stage
- Multiplying trophozite stage
2 forms:
- Active parasite (trophozite)
- Dormant parasite (cyst)
Infection begins when cysts are swallowed
Cysts hatch---releasing trophozites that multiply
Trophozites cause ulcers on the lining of intestine
and produce diarrhea.
Once the intestinal epithelium is invaded, extra
intestinal spread to the peritoneum, liver, brain and
other sites may follow.
Some of the trophozites forms cysts which are
excreted in the faeces along with trophozites
Outside the body, trophozites die but cysts remain.
Merck Manual Home Edition 2003
Complications
• Rupture of the abscess with extension into the peritoneum,
pleural cavity, or pericardium.
• Extra hepatic amebic abscesses have occasionally been
described in the lung, brain, and skin
Amebiasis: Parasitic Infections: Merck Manual Edition 2007
Treatment
Drugs
 Metronidazole
Tinidazole
Chloroquine
Diloxanate furoate
Iodoquinol
Paromycin
Aspiration under ultrasound
guidance
Thick pus
Ruptured liver abscess
Common Surgical Emergencies
• Acute Appendicitis
• Liver Abscess
• Abdominal Tuberculosis
• Typhoid Perforation
• perforated peptic ulcer
• Abdominal wall hernia
THANK YOU

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