APPROACH TO ACUTE ABDOMEN

Dr.Mohamad Al- Akeely

Associate prof. & Consultant general surgeon

KKUH & KSMC

INTRODUCTION Definition :

any clinical condition characterized by

severe abdominal pain which develops in less than a week, In a patient who

has been previously well.

Rapid and accurate diagnosis is essential to reduce the morbidity and mortality.

PATHOPHSIOLOGY Visceral pain:

Due to stimulation of visceral afferent nerve plexus usually results from contraction or distension against resistance & chemical irritation.

It is usually midline colicky in nature .

PATHOPHSIOLOGY Parietal pain: Secondary to partial peritoneal

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.

EPIDEMIOLOGY

ABDOMINAL QUADRANT

DIFFERENTIAL DIAGNOSIS

It’s Huge!

Use history and physical exam to narrow it down

Rule out life-threatening pathology

Half the time you will send the patient home with a

diagnosis of nonspecific abdominal pain (NSAP)

90% will be better or asymptomatic at 2-3 weeks.

CAUSES Gastrointestinal tract

Acute appendicitis Meckl’s diverticulitis

bowel obstruction or Perforation peptic ulcer

peptic ulcer perforation hernia Strangulated Diverticulitis Gastritis Gastroenteritis Inflammatory bowel disease mesenteric lymphadenitis

spleen& liver,biliaryTract

acute cholangitis acute cholecystitis Hepatic abscess Ruptured hepatic tumor Ruptured spleen biliary colic acute hepatitis splenic infarct

PeritoneumIntra-abdominal abscessPrimary peritonitisTuberculus peritonitis

Pancreasacute pancreatitisca pancreases

Urinary tractacute cystitis acute pyelonephritisRenal infarctRenal colic

Gynecological

Ruptured ectopic pregnancyRuptured ovarian follicular cysttorsion ovarian tumor or cystDysmenorrheaEndometriosisacute salpingitis.

Male reproductive tract. Prostatitis CystitisTorsion of testes

Vascular causes

Acute ischemic colitis .Mesenteric vascular occlusionRuptured aortic aneurysm

Medical causes:

Pneumonia.

Myocardial infarction Sickle cell crisis. DKA Leukemia Herpes zoster psychogenic

APPROACH TO ACUTE ABDOMEN

History.

1.Pain

2 .Associated symptoms, nausea, vomiting ,

change of bowel habits, jaundice, anorexia,

heamatemsis, melena, dyspepsia

3.Menstrual & sexual history .

CONT..

4.History of similar attacks 5.past medical & surgical history 6.medications 7.familay history 8.social history

EXAMPLES :Acute appendicitis

Starts as coliky central abdominal pain and then becomes constant ,progressive more severe

in the RIF.+ nausea, vomiting, low grade fever, anorexia .? dysuria or loose motion.

P/E: reveal tenderness & rebound tenderness

in RIF ,guarding or mass .Generalized tenderness indicates peritonitis.

APPENDICITIS: PSOAS SIGN

APPENDICITIS: OBTURATOR SIGN

Passively flexright hip and knee

then internally rotate the hip

INFLAMED APPENDIX

Complications of appendicitis:- Acute suppuration- Appendicular mass

- Appendicular absces- G.peritonites

Complication of appendectomy:- Bleeding

- SSI - Fecal fistula

- Incisional hernia

Acute cholecystitis

Constant moderate pain in RUQ radiating to the Rt shoulder tip + nausea, vomiting, low grade fever & ? Jaundice.Past h/o biliary colic precipitated by fatty meal.

Acute Pancreatitis:

Usually diffuse abd. pain + back pain, emesis, elevated amylase & lipase

Often attributed to gallstones, alcohol or hyperlipidemia, but many cases are idiopathic.

Can have severe complications: Hypovolemia, ARDS, hypocalcemia , retroperitoneal bleeding or abscess.

CT is the diagnostic method of choice.

Perforated peptic ulcer Sudden onset of pain in mid

epigastrium that may become generalized and is aggravated by movement; patient appears acutely ill and is reluctant to move; rigid abdomen; shallow respiration; bowel sounds diminished.Past h/o peptic ulcer or NSAD tt.

Inflammatory Bowel Diseases:

Two types: Ulcerative colitis

Crohn's DiseaseUlcerative colitis can sometimes have complication of "toxic megacolon"

Complications of either type may need Rx with high dose IV steroids in addition to other usual Rx's

Acute Diverticlitis:

More common after age 45Typically pain & tenderness in LLQ, but can be diffuseCan result in inflammatory mass in LLQ or perforation.CT with contrast is the best modality for diagnosis.Milder cases can be managed with antibiotics and discharged from ER

Ectopic pregnancy, Pain sudden, severe,persistent,following a

missed or abnormal period, typically hypogastric; associated with ? hypotension and tachycardia.Kehr sign ? Positive.

Ovarian cyst

Pain constant with sharp, sudden onset, usually in ipsilateral hypogastrium or iliac fossa and may have nausea and vomiting following the pain.may be periodic at mid cycle.

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 vaginal discharge; fever

Urinary stone

Pain location changes with movement of stone, may radiate to loin, testicle or groin of involved side, pain is very severe and colikey, patient may be rolling in bed

RENAL COLIC

PHYSICAL EXAMINATION

1.general appearance. 2. Vital signs.

3.abdomial exam 4.rectal exam 5.pelvic exam (female pt)

INVESTIGATIONS

1.CBC

WBCs & differential. RBC & hct, Hg . Platelet count, INR.

2.electrolyte Glugose, urea, cr, electrolytes Indicative of volume status, GIT loss.

3.ABG

May indicate metabolic acidosis or alkalosis .

M.acidosis with generalized abdominal pain in elderly is suggestive of ischemic colitis or mesenteric vascular occlusion.

4.liver function test

Bilirubin (D or ID), ALP elevation in biliary obstruction & transaminase elevation in case of hepatocellular disease (eg, hepatitis).ascites Low serum albumin causes

edema &

5.RFTUrea, creatinine elevated in renal impairement due to hypovolaemia .

6 .serum amylase /Lipase

Grossly elevated in pancreatitis although non specific may be elevated in mesenteric ischemia, perforated peptic ulcer, rupture ovarian cyst & renal failure .Lipase is more sensitive in pancreatitis.

7 .Pregnancy Test

Mandatory in all women in childbearing period.

8.urine analysis

For WBC, RBC, casts and glucose.

RADIOLOGICAL EVALUATION

1.CXR,

Look for pneumonia, free gases under diaphragm & pleural effusion(? Sympathatic).

2 .Plain abdominal Xray.

(Erect & supine position ) bowel distension & air fluid level

bowel gas pattern, cut off sign, air in the rectum.

sentinel loop of pancreatitis abnormal calcification of ch.pancreatitis

& stones. pnumatosis intestinalis or pneumo-bilia.

INTESTINAL OBSTRUCTION

3.ultrasound

Hepatobiliray tree (stones, mass, thickining of the wall, dilated biliary tree, pancreas)

,kidney, pelvic organ, intra-abdominal fluid collection)

GALL STONE APPENDICOLITH

4.CT scan Helpful in case of abdominal pain without

clear etiology and in the diagnosis of

abdominal oartic aneurysm & MVA.

5.helical (spiral) CT scan Provide rapid cost effictive dignostic

tool e.g in the diagnosis of pulmonary embolism .

ACUTE PANCREATITIS DILATED LOOP

CT scan of AAA (L = lumen, T = thrombus)

5.contrast study

Gastrografin study to diagnose intestinal obstruction or leak.

Intravenous pyelogram

For dignosis of ureteral stone or obstuction

Angiography

For mesenteric ischemia and lower GI bleeding.

Angiogram (arrow shows superior mesenteric artery clot) of a 65 year old male

with bowel ischemia

OTHER STUDIES6.Endoscopy

For evaluation epigastric pain in non acute setting.& upper GI bleeding

Sigmoid\colonoscopy

colonic obstruction eg, tumours . dig IBD,ischemic colitis lower GI bleeding,

non-strangulated sigmid volvulus /diverticular disease.

7.paracentesis and peritoneal lavage

spontaneous bacterial peritonitis in cirrhotic paient .

8 .Diagnostic laparoscopy

in suspected gyaenicological pathalogy (e.g. Ectopic pregnancy or ruptured ovarian cyst vs appendicitis).

It is also helpful in the diagnosis of abdominal pain of obscure origin and chronic abdominal pain .

PLAN OF TREATMENT

promote timely work up in first 4_6hrs. keep pt npo till the diagnosis is

confirmed & treatment plan is formulated.

IV fluid. based on expected fluid loss. haemodynamic monitoring.

NG tube in cases of vomiting or instinal obstruction or when urgent surgery is planned in pt not npo .

Foley cath. To monitor urine output.

Decision Immediate surgery vs conservative

treatment.

•what is the timing of operative intervention

•(does pt need time for resuscitation)?

what incision should be used ?

what are the likely findings?

develop primary operative plan.

consider alternative diagnosis & plan.

use appropriate pre-operative antibiotic based on suspected pathology.

*If the patient is for conservative treatment :

Avoid analgesia till definitive diagnosis .

*monitor vital signs frequently*Regular physical examination and

assessment of the patient

*serial lab exam e.g.; CBC every 4-6hrs .

If no surgical operation is needed then the plan for further diagnostic workup should be planned.

Now its time to discuss some clinical scenarios

SCENARIO CASES: 1

56 yrs old male pt presented with 2 days history of acute sudden central abdominal pain becoming severe over the last 6 hours.No history of trauma.

- what are the likely differential diagnoses?

1- mesenteric vascular occlusion 2- ruptured abdominal aortic aneurism 3-perforated bowel 4-Colonic volvulus 5-Intestinal obstruction

What further relevant important points in the history ?

History of haematemesis/melena, abd.distention, constipation, previous similar attacks, surgery,peptic ulcer disease or NSAD

History of cardio-vascular disease:. hypertension

. MI. atrial fibrillation. valvular disease

. intermttent claudication

Detailed scenario:56 years old male c/o sudden acute central

For 2 days that becomes pain abdominal Very severe over the last 6 hours.it was associated with

nausea and passage of blood with stool ,but no constipation. He is hypertensive on Rx .

No hx of trauma. No hx of similar attacks or abdominal surgery, but he had aortic valve replacement one year ago and receiving plavix since then .

Now what is the likely diagnosis?

Acute Mesenteric vascular occlusion

What are the important examination findings you are

looking for?

General exam:Sensorium, respiratory rate, pallor, jaundice, tachycardia, fever, hypotension

Abdomen exam:Movement with respiration, distension, scars, hernias, percussion for tenderness, rebound tenderness, masses. Auscultation for bowel sounds.

PR exam for masses and blood .

Clinical examination revealed:Patient is drowsy, PR 120/m, blood pressure 90/60 Hg, RR 30/m, temperature 38.2Abdomen distended, no scars, no hernias.Tenderness and guarding all over the abdomen, bowel sounds are absent.PR revealed fresh blood in the finger but no masses.

What investigations would you like to do?

Hb = 9gm%, Wbc = 25, ABG = metabolic acidosis, U/E = normal, Cr = normal ,

INR = 1.5ECG , Echo-cardiogram (vegitations on the aortic valve)CXR no air under diaphragm and no lung pathologyAbdomen X ray: distended small bowel with air fluid levels.CT scan: distended thick wall small bowel loop, minimal fluid in abdomen and filling defect in superior mesenteric artery.

What is your plan now?

Preparation for laparotomy :Oxygyn, IV fluid, NG tube, FC.

Consent for laparotomy and possible resection and stoma placement.

Start i.v antibiotics.

Post op : heparinization.

SCENARIO: 2 46 years old lady c/o right upper

quadrant abdomenal pain for 2 days associated with fever 38.2 She used to have frequent attacks of pain RUQ for the last 2 years.

What is the likely deferencial diagnosis?

Acute cholecystitis Cholangitis

liver abcess hepatitis

right lobar pneumonia

What further questions you need to ask ?

Pain: Type, nature, aggravating, releaving

factors and radiation. History of URTI,cough and sputum. History of jaundice, pale stool, dark

urine, nausea, vomiting, chills, rigors, diarrhoea, contact with jaundiced patient or recent travel.

History of similar attacks .

Detailed scenario:46 years old lady c/o pain RUQ for 2 days.

No history of rigors or chills or cough. She used to have recurrent RUQ pain which is colickey in nature, radiating to the right shoulder, aggravated by fatty food and releived by analgesics, she also has history of nausea and vomiting but no change in bowel habits and no urinary symptoms, on examination she is not juandiced and not pale, her pulse is 100/m, normotensive, fibrile 38.2c. she has tenderness and guarding in RUQ with pain during deep inspiration .

What is the most likely diagnosis ?

Acute cholecystitis

What investigations you need to do?

CBC, U/E, Cr, LFT, INR, Chest x ray

Ultra sound biliary tree

WBC 16U/E, Cr, LFT, INR: all normal.Ultra sound revealed distended gall bladder with thick oedematus wall and contaning multiple gall stones. No dilatation of CBD

What is the management ?

NPOIVFAnalgesiaNG tube Consent for surgery Early laparoscopic cholecystectomy vs conservative and later interval cholecystectomy in 6-8 weeks.(reason?)

What are the common complications of acute cholecystitis and cholecystectomy ??

SCENARIO: 317 years old female presented to the

hospital with right iliac fossa pain for 12 hours . She has nausea and vomiting, but passing normal stool .

What are the important defferencial daiagnosis?

1 .Acute appendicitis2 .Mesenteric adenitis

3 .PID4 .Mid cyclic pain

5 .Rupture or torsion ovarian cyst 6 .Ectopic pregnancy

7 .Renal colic & UTI8 .Chronic inflammatory bowel disease

What further history is required ?

Evalution of the painAssocaited symtoms eg:fever anorexia,diarrhoea .

History of similar episodesHistory of urinary symptomsRecent history of URTIGyanecology history

-marriage , pregnancy

-menstrual cycle-PV bleeding/discharge

Detailed scenario:17 years old female presented with pain

RIF since 12 hours. it was colikey in nature starting in epigastric area then shifted to RIF, it was associated with N/V and anorexia.No fever, no change in bowel habit and no urinary symptoms. she is not pregnant and she has regular period and no vaginal discharge

What is the most likely diagnoses?

Acute appendicitis

What is the examination findings to support your diagnoses?

Palapitation, fever, throat exam, tender RIF positve Rov. Sign, positve obt. Sign.

What about investigation findings that supports your diagnosis ?

LeucocytosisNegative pregnancy testImaging:

- U/S- CT scan

The diagnoses of acute appendicitis remains a clinical one with sensitivity approaching 85%.The imaging is reserved for doubtful or complicated cases e.g:mass or absces .

SCENARIO: 450 years old male patient presented with

a gradually increasing stabbing pain in LIF for 3 days. it was associated with nausea but no vomiting. He is having constipation since one year, for which he is occasionally taking laxatives ,he had similar but mild attacks before. He is diabetic on Rx.

What is your main deferential diagnosis ?

1-Acute left colon diverticulitis2-Carcinoma left colon.

3-Ureteric colic.4-Ischemic colitis.

What further important history is required?

Radiation of pain (loin or groin).Dysuria,haematuria,pneumaturia.Bleeding per rectum,tenesmus.Weight loss & loss of appetiteHistory of fever.Family history of cancer or colonic disease.

Detailed scenario:50 years old diabetic male presented to ER

complaining of localized pain in the LIF for 3 days.the pain was not radiating,and associated with mild fever.no urinary symptoms or haematuria.he occasionally passing fresh blood per rectum ,no family h/o colonic disease or cancer.Examination revealed pulse 95/m ,BP 110/85mhg,temp.38.4c.no pallor or jaundice.Abdomen showed no scars, was mildely distended and tender in LIF but no rebound tenderness.PR showed no bloody stool and no masses.

now what is your likely diagnosis ?

ACUTE DIVERTICULITIS

What investigations are nesssary?

CBC, U/E ,Cr , glucose , INR.Urine analysisCxR , abdomen x rayGastrografin enema can be done.CT scan abdomen is the modality of choice.

Colonoscopy and barium enema are contra indicated in acute diverticulitis.

(why)?

How would you manage diverticulits?

Uncomplicated:NPO

IV fluidAntibiotics

once symptoms improve, start feeding.Local abscess:Drainage under CT scan.Generalized peritonitis:Laparotomy and resection of involved sigment.( Hartman procedure)

SCENARIO: 539 years old male presented with sudden

epigastric pain 8 hours ago, associted with nausea but no vomiting or change in bowel habits.

What is the likely defferencial diagnosis?

Perforated peptic ulcerPancreatitisMyocardial infarctionIntestinal obstructionMesenteric ischemiaDissecting aortic aneurysm.

What other important history?

Nature of pain (colikey, stabbing ….)Associated regurgitation, fever, dizziness, SOB , change in bowel habit.Smoking, alcohol intake, hyperlipidemiaHistory of PUD or NSAD.History of RUQ pain or gall stonesPast medical and surgical history

- hypertension- cardiac disease

- previous surgery

Detailed scenario:39 years old male presented with sudden

sharp epigastric pain 8 hours ago that graduwally spreads all over the abdomen.It was associated with nausea but no vomiting or dizziness.No change in bowel habits.No cough or SOB.No previous history of PUD, gall stones , hyper lipidemia , cardiac disease or surgery.He is not alcoholic.He is taking voltarine 50 mg tds since one week for ankle sprain.Examiation revealed pulse 100/m,temp 37.8c,tenderness. guarding in epigastrium and the rest of abdomen is mildly distended.

Now what is the most likely diagnosis ?

Perforated peptic ulcer

What are the appropriate investigations?

Cbc , urea, cr, electrolytes, INR, s.amylase, s. lipase.ECG.Chest x ray erect.

air under the diaphragm is diagnostic for perforation in this patient.)

How do you manage perforated duodenal ulcer?

NpoIv fluidNg tubeFolly catheterAdmissionAntibioticsCross matching bloodConsentSurgery…..( laparotomy or laparoscopic Grahamm patch )

Thanks