Approach to acute abdomen

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Approach to acute abdomen

• Supervised by ,
• Dr.B.Faki
• Presented by,
• Eman Al.harbi

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Introduction

• defined as any clinical condition characterized
  by severe abdominal pain which develops over a
  period of 8 hrs. In pt who have been
  previously well.
• rapid and accurate diagnosis is essential for
  morbidity and mortality process.

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Pathophsiology

• Visceral pain due to stimulation of visceral
  afferent nerve plexus usually in midline result
  from contraction or distension against resistance
  chemical irritation usually colicky in nature.
  

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Pathophsiology

• Parietal pain 2dry to partial peritoneum
  irritation perceived through segmental somatic
  fibers reflex involuntary muscle wall rigidity
  may result from irritation of segmental sensory
  nerves.
• Hyperesthesia of the skin may be result from
  ipsilateral peritoneal irritation usually a
  sharp ache.

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Abdomen
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Epidemiology
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Abdominal quadrant

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Causes

• Gastrointestinal tract
• Acute appendicitis
• Meckls diverticulitis
• bowelPerforated ulcer
  Perforated peptic
  obstruction
  Small and large bowel herniaStrangulated
  DiverticulitisGastritisGastroenteritisInflamma
  tory bowel disease lymphadinitis Mesenteric

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• spleen. and , liverBiliaryTractsCholangiti
  acute
  Cholecystitis acute Hepatic abscess
  tumor
  Ruptured hepatic spleen
  Ruptured
  biliary colic , Hepatitis acute
  
  infarct Splenic

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• PeritoneumIntra-abdominal abscessPrimary
  peritonitisTuberculosis peritonitisPancreasPan
  creatitis, acuteca pancreases
• Urinary TractCystitis acutePyelonephritis
  acuteRenal infarctteral colicUre

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• Gynecological ruptured ectopic
  pregnancyRuptured ovarian follicular
  cystTwisted ovarian tumorDysmenorrhealEndometri
  osisacute salpingitis.PIDs

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• Male reproductive tract.
  
• Prostatitis
• Cystitis
• Torsion of testes
• Vascular causes
• Acute ischemic colitis .Mesenteric
  thrombosisRuptured arterial aneurysm

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Medical causes

• Pneumonia.
  
• Myocardial infarction
• Sickle cell crisis.
• DKA
• Leukemia
• Herpes zoster
• psychogenic

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Approach to acute abdomen

• History.
• 1. pain
• 2. Associated symptoms, nausea, vomiting,
• Change of bowel habitués, jaundice, anorexia,
• Heamatemsis, melena, dyspepsia
• 3.Menstruatin sexual history.
  

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Cont..

• 4.ROS
• 5.past medical surgical hx
• 6.hx /o medications
• 7.familay Hx
• 8.social Hx

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Eg

• Acute appendicitis,
  constant ,progressive more severe start
  per umbilical move toward RIF. nausea, vomiting,
  low grade fever, anorexia /or constipation.

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Inflamed appendix
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• Acute cholecytitis
• Constant moderate pain in RUQ radiated to Rt
  shoulder tip nausea, bilious vomitus, low grade
  fever jundice

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• Perforated peptic ulcer,
  
• Sudden onset of pain in midepigastrium that
  spreads and is aggravated by movement patient
  appears acutely ill and is reluctant to move
  rigid abdomen grunting respiration bowel sounds
  absent

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• Ectopic pregnancy,
  
• Pain sudden, severe,persistent,following a missed
  or abnormal period, typically epigastric
  associated with hypotension and tachycardia
• Ovarian cystPain constant with sharp, sudden
  onset, usually in ipsilateral hypogastrium may
  have nausea and vomiting following the pain.

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• Pelvic inflammatory disease.
• Pain at end of or after normal menstrual period,
  bilateral lower quadrant pain aggravated by
  cervical manipulation anorexia, nausea, and
  vomiting rare possible cervical discharge fever

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• Urinary stone,
• Pain location changes with movement of stone, may
  radiate to testicle, groin of involved side, pain
  very severe patient cannot get comfortable

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Physical examination

• 1.general appearance,
  2. Vital signs.
• 3.abdomial exam
• 4.rectal exam
• 5.pelvic exam (female pt)

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?
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investigation

• 1.CBCs,
• WBCs differential.
• RBC hct, degree of anemia hemocon.
• Platelet count, evidence of cougalopathy.
• 2.electrolyte,
• (G, Na, K, Cl, Ca ,Mg, Po)
• Indicative of volume status, GIT loss,

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.

• 3.ABG,
• Indicate metabolic acidosis or alklosis.
  M.acidosis with generalized abdominal pain in
  elderly is ischemic colitis till proven other
  wise.

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• 4.liver function test
• Bilirubin (D or ID), ALP elevation in biliary
  obstruction transaminase elevation in case of
  hepatocellular injury.
• 5.RFT
• Urea, creatinin elevation in renal insufficiency
• Serum albumin decrease in edema / ascitis.

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• 6. serum amylase
• Seen in pancreatitis although non specific may be
  elevated in mesenteric ischemia, perforated
  peptic ulcer, rupture ovarian cyst renal
  failure. But lipase more sensitive.

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.

• 7.serum B_HCG
• Mandatory for all women in childbearing period.
• 8.urinalysis
• See WBC RBC casts.

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Radiological evaluation

• 1.CXR,
• Look for pneumonia, free gases under diaphragm
  .pleural effusion suggest sub diaphragmatic
  inflammatory process.

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• 2.abdominal Xray.
• (Erect supine position )
• bowel distension air fluid level
• bowel gas cut off vs air through rectum.
• sentinel loop vs pancreatitis
• abn calcification vs ch.pancreatitis,stone
• pnumatosis vs omnious sign of dead gut.

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Intestinal obstruction
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• 3.ultrasound,
• hepatobiliray tree(stones,mass,thickining of the
  wall)
• pancreases
• kidney
• pelvic organ
• intrabdominal fluid collection

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Gall stone\ appendicolith
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• 4.CT_scan
• Helpful in case of abdominal pain without clear
  etiology better in evaluation of abdominal oartic
  aneurysm.
• 5.helical CT_scan
• Provide rapid cost effictive dignostic tool.

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Acute pancreatitis\dilated loop
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• 5.contrast study
• A. barium study
• perforation,
• discering point of obstruction in small bowel.
• avoid if colonic diverticuilitis is suspected

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Multiple stones in CBD
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• B_ intravenous pyelogram
• For dignosis of ureteral stone or obstuction
• C_angiography
• For mesenteric ischemia

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angiograph
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Other study

• 6.endoscopy,
• EGE, for evaluation epigastric pain in non acute
  setting. git bleeding
• Sigmoid\colonoscopy
• colonic obstruction
• dig IBD,ischimic colitis lower bleeding,
• nonstrangulated sigmidal volvulus

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ERCP
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• 7.paracentesis \or peritoneal lavage
• spontaneous bacterial peritonitis in cirrhotic
  pt
• peritoneal lavage may be useful bedside test in
  diagnosis of mesenteric infarction in critically
  ill pt.

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• 8.culdocentesis
• Valuable in diagnosis of rupture ectopic
  pregnancy.
• 9.laproscopy
• D ttt of suspected gynec.cause
• appendectomy if appendicitis is found in a women
  in childbearing period.

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laparoscopy
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Plan of treatment

• promote timely work up in first 4_6hrs.
• keep pt Npo till the diagnosis is firm ttt
  plan is formulated.
• IV fluid. based in expected fluid loss.
• heamodynamic monitoring.
• NGT bleeding ,vomiting ,sign of obstruction or
  when urgent laparoscopy is planned in pt not NPo.

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• Foley catheter to monitor fluid out put
  decisions
• Immediate surgery
• what is the timing of operative intervention(
  does pt need time for resuscitation)
• what incision should be used?

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• what are the likely findings?
• develop primary operative plan.
• consider alternative diagnosis plan.
• use appropriate pre-operative antibiotic based
  on suspected pathology.

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• 2. admit observe for possible operation.
• serial examination every 2-4 hrs during the
  first 12-24 hrs in case without definite
  diagnosis minimal use of narcotics sedatives
  to avoid masking physical sign symptoms.
• monitor vital signs frequently
• serial lab exam may be useful repeat CBC every
  4-6hrs.

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• 3.no operation develop ttt plan for further
  diagnostic workup or non operative therapy.

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Case

• 36 yrs old female pt status post oratic valve
  replacement who present with one week hx of acute
  abdominal pain becoming severe over last 24hrs
• O\E tachycardia, PR145\min, B.P100\45 temp38.
  abd. Distended , rigid with moderate
  tenderness.wbc23. amy200 LDH1500.

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• What is mostly like diagnosis?
• What is the investigation of choice?
• Management plane?

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• Thanks