Dr. Abdul Ghani Soomro

Associate Professor SurgeryLUMHS 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 Abdominal wall

Peritoneum

Visceral Diffuse difficult to localize Referred pain Irritation of abdominal organ

SymptomsLuminal obstructionInflammation. Appendicitis Cholecystitis Pancreatitis

Peritonitis. Perforated viscus Strangulation Intra peritoneal collection

BileBloodPus

I

Common Causes of acute abdominal pain

Organ Location of Pain Pathology

Liver Right Upper quadrant•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 Location of Pain Pathology

PancreasEpigastrium

Right Hypochondrium

Left Hypochondrium

•Acute Pancreatitis

•Ca Pancreas

•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 ilealDiarrohea and Vomiting

Prominent feature due to irritation of ileum.

3. PelvicDiarrohea 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. ChildrenDifficulty in obtaining

Proper historyDifficulty in differentiating from mesenteric

adenitis and enteritis.

Under developed omentum leading to early complications.

2. ElderlyLess prominent SymptomsAfebrileNormal 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

Ectopic Pregnancy Ruptured ovarian follicle Torsion of ovarian cyst Salpingitis PID

PELVIS

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

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.

*Amoebic liver Abscess

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 TinidazoleChloroquineDiloxanate furoateIodoquinolParomycin

Aspiration under ultrasound guidance

Thick pus Ruptured liver abscess

Surgery

• Acute Appendicitis

• Liver Abscess

• Abdominal Tuberculosis

• Typhoid Perforation

• perforated peptic ulcer

• Abdominal wall hernia

Common Surgical Emergencies

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