Date post: | 19-Dec-2015 |
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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 .
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 .
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.
Causes
• Gastrointestinal tract*•Acute appendicitis
•Meckl”s diverticulitis• bowelPerforated
ulcer Perforated peptic obstruction Small and large bowel herniaStrangulated DiverticulitisGastritisGastroenteritisInflammatory bowel disease lymphadinitis Mesenteric
spleen. and , liverBiliaryTractsCholangiti acute Cholecystitis acute Hepatic abscess tumor Ruptured hepatic
spleen Ruptured biliary colic , Hepatitis acute infarct Splenic
PeritoneumIntra-abdominal abscess*Primary peritonitisTuberculosis peritonitis
PancreasPancreatitis, acuteca pancreases
Urinary TractCystitis acutePyelonephritis acuteRenal infarctteral colicUre
Gynecological ;ruptured ectopic pregnancyRuptured ovarian follicular cystTwisted ovarian tumorDysmenorrhealEndometriosisacute salpingitis.PIDs
• Male reproductive tract. • Prostatitis • Cystitis• Torsion of testes• Vascular causes Acute ischemic colitis .
Mesenteric thrombosis*Ruptured arterial 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 habitués, jaundice, anorexia,
Heamatemsis, melena, dyspepsia
3.Menstruatin & sexual history .
Eg
• Acute appendicitis, constant ,progressive more severe start per umbilical move toward RIF.+ nausea, vomiting, low grade fever, anorexia &/or constipation.
•Acute cholecytitis
• Constant moderate pain in RUQ radiated to Rt shoulder tip + nausea, bilious vomitus, low grade fever & jundice
• 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
• 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.
• 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
• Urinary stone,
• Pain location changes with movement of stone, may radiate to testicle, groin of involved side, pain very severe; patient cannot get comfortable
Physical examination
• 1.general appearance, 2. Vital signs.
• 3.abdomial exam
• 4.rectal exam
• 5.pelvic exam (female pt)
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,
.
•3.ABG,
•Indicate metabolic acidosis or alklosis. M.acidosis with generalized abdominal pain in elderly is ischemic colitis till proven other wise.
.
•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.
.
•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.
.
•7.serum B_HCG
•Mandatory for all women in childbearing period.
•8.urinalysis
•See WBC RBC & casts.
Radiological evaluation
•1.CXR,
•Look for pneumonia, free gases under diaphragm .pleural effusion suggest sub diaphragmatic inflammatory process.
.
•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.
.
•3.ultrasound,
•*hepatobiliray tree(stones,mass,thickining of the wall)
•*pancreases
•*kidney
•*pelvic organ
•*intrabdominal fluid collection
.
•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.
.
•5.contrast study
•A. barium study
•*perforation,
•*discering point of obstruction in small bowel.
•*avoid if colonic diverticuilitis is suspected
.
•B_ intravenous pyelogram
•For dignosis of ureteral stone or obstuction
•C_angiography
•For mesenteric ischemia
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
.
•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.
.
•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 .
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.
.
•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 ?
.
• *what are the likely findings?
•*develop primary operative plan.
• *consider alternative diagnosis & plan.
• *use appropriate pre-operative antibiotic based on suspected pathology.
.
•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 .
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, PR=145\min, B.P=100\45 temp=38. abd. Distended , rigid with moderate tenderness.wbc=23. amy=200 LDH=1500.