Acute Abdomen (1)

8/12/2019 Acute Abdomen (1)

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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

Visceralpain; 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

Parietalpain; 2dry to partial peritoneum

irritation perceived through segmental

somatic fibers reflex involuntary muscle

wall rigidity may result from irritation ofsegmental sensory nerves.

Hyperesthesia of the skin may be result

from ipsilateral peritoneal irritation usuallya 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 pepticobstruction Small and large bowelherniaStrangulatedDiverticulitisGastritisGastroenteritisInflammatory bowel diseaselymphadinitis Mesenteric


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spleen. and, liverBiliaryTractsCholangiti acute Cholecystitis acuteHepatic abscess

tumor Ruptured hepaticspleen Rupturedbiliary colic, Hepatitis acute infarct Splenic


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PeritoneumIntra-abdominal abscess*Primary peritonitisTuberculosis peritonitis

PancreasPancreatitis, acuteca pancreases

UrinaryTractCystitis acute

Pyelonephritis acuteRenal infarctteral colicUre


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Gynecological;

ruptured ectopic pregnancy

Ruptured ovarian follicular cyst

Twisted ovarian tumorDysmenorrheal

Endometriosis

acute salpingitis.PIDs


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Male reproductive tract.

Prostatitis

Cystitis

Torsion of testes Vascular causes

Acute ischemic colitis .Mesenteric thrombosis*Ruptured 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 habitus, jaundice,

anorexia,

Heamatemsis, melena, dyspepsia3.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

Acuteappendicitis,

constant ,progressive more severe start

per umbilical move toward RIF.+ nausea,

vomiting, low grade fever, anorexia &/orconstipation.


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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 Ovariancyst

Pain 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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Urinarystone,

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 biliaryobstruction & transaminase elevation in

case of hepatocellular injury.5.RFT

Urea, creatinin elevation in renal

insufficiencySerum 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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Radiologicalevaluation

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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Gallstone\ 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 awomen in childbearing period.


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laparoscopy


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Planoftreatment

*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 ofobstruction 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 duringthe 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 ;repeatCBC 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

36yrs old female pt status postoraticvalvereplacement who present with one week

hx of acute abdominal pain becoming

severe over last 24hrsO\E tachycardia, PR=145\min, B.P=100\45

temp=38. abd. Distended , rigidwith

moderate tenderness.wbc=23. amy=200LDH=1500.


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.

What is mostly like diagnosis?

What is the investigation of choice?

Management plane?


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.

Thanks

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Acute Abdomen (1)

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