Recent Updates in Recent Updates in Acute Abdomen Acute Abdomen

ManagementManagement

DR. Dr. Toar JM Lalisang, SpB(K)BDDR. Dr. Toar JM Lalisang, SpB(K)BDDigestive Surgery Division – Department of Surgery Digestive Surgery Division – Department of Surgery

Faculty of Medicine, University of IndonesiaFaculty of Medicine, University of Indonesia

Cipto Mangunkusumo HospitalCipto Mangunkusumo Hospital

The Acute Abdomen

The Abdomen - Anatomy

Acute Abdomen

Hippocrates Celsus

illiac passion ileus volvulus

Digestive Surgery Division – Department of Surgery Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital

Acute Abdomen

• Be defined generally as an intra abdominal process causing severe pain and often requiring surgical intervention.

Acute AbdomenAcute conditions of the abdomen are produced by : congenital inflammatory obstructive trauma vascular mechanisms or high intra abdominal pressure

manifested by sudden onset of abdominal pain, gastrointestinal symptoms and varying degrees of local and systemic reaction.

Causes and Pathophysiology of Acute Abdomen

Inflamation

Causes and Pathophysiology of Acute Abdomen

Perforated Viscous

Causes and Pathophysiology of Acute Abdomen

Mechanical

HISTORY IN PATIENT WITH ACUTE ABDOMEN

Where is the pain ?

Question No.1 :

It is important to know :The originThe locationRadiation and Character of abdominal pain

in order to understand its significance.

Characteristics of the Acute Abdomen

• Since pain is the most prominent presenting complaint in a patient with an acute abdomen,

• The perception of abdominal pain is first visceral and then becomes somatic.

Pathophysiology • Visceral pain :– Distention, inflammation or

ischaemia in hollow viscous & solid organs

– Localisation depends on the embryologic origin of the organ:

• Forgut to epigastrium• Midgut to umbilicus• Hindgut to the

hypogastric region• Parietal pain :

– is localised to the dermatome above the site of the stimulus.

• Referred pain :– produces symptoms, not

signs e.g. tenderness

Acute Abdominal Pain

Visceral Pain Somatic Pain

Visceral sensation Parietal sensation

Ischemic/Extention Mechanic/Chemical

Vague Localized

Dull Sharp

Autonomy symptomps (+) Autonomy symptomps (-)

Does the pain travel to any other part of the body ?

Question No. 2 :What is the pain like ?

• Acute waves of sharp constricting pain that “take the breath away” renal or biliary colic

• Waves of dull pain with vomiting intestinal obstruction• Colicky pain that becomes steady appendicitis, strangulating

intestinal obstruction, mesenteric ischemia• Sharp, constant pain, worsened by movement peritonitis• Tearing pain dissecting aneurysm• Dull ache initial epigastric pain in appendicitis, diverticulitis,

pyelonephritis• Aching pelvic inflammatory disease • Pleuritic intensified by breathing • Lancinating acute pancreatitis

Classic Appendicitis

• Patient presents initially with vague peri-umbilical pain with associated nausea and vomitting due to distention of the appendix (visceral peritoneum).

• Followed by localized RLQ pain due to progression of inflammation to parietal peritoneum.

Infected Appendix and Fecolith

Perforated Appendicitis

Meckel’s Diverticulum

Intestinal Perforation

If the answer is “Yes” suggests recurrent problems such as ulcer disease, gallstone colic or diverticulitis.

Question No. 3 :Have you had it before ?

Question No. 4 :Was the onset sudden ?• Yes, Sudden : “like a light switching on”

(perforated ulcer, renal stone, ruptured ectopic pregnancy, torsion of ovary or testis, some ruptured aneurysms).

• No, Less sudden : most other causes (gradual pain mesenteric thrombosis)

Question No. 5 :How severe is the pain (intensity of the pain) ?

• Severe pain (perforated viscus, kidney stone, peritonitis, pancreatitis)

• Moderate appendicitis • Pain out of proportion to physical findings (mesenteric

ischemia)

Gaster Perforation

Kidney Stone

Ureter Stone

Question No.6 :What is the temporal features of the pain ?

• Continuous - acute pancreatitis • Pulsatile - abdominal aneurysm • Colicky - lumen obstruction, intermittent

severe pain with pain-free intervals

Frequency & duration transient pain of short duration which does not recur is usually insignificant.

The longer the duration the more likely a surgical condition.

Question No. 7 :What other symptoms occur with the pain?

• Vomiting precedes pain and is followed by diarrhea (gastroenteritis).

• Delayed, repeated vomiting, absent bowel movement and flatus, large amounts, often bile stained and may become fecal (acute intestinal obstruction; the delay increases with a lower site of obstruction).

Erect Supine

LLD

Mechanical Obstruction

Strangulated Right Scrotal Hernia

Protracted vomiting

• Early : in high GI obstruction

• Late : in low GI obstruction

• Character of vomitus : blood - bleeding ulcer bile stained - obstruction below ampulla of

Vater fecal - intestinal obstruction, mechanical or with

paralytic ileus; copious amount

Question No. 8 :What are the factors which may intensify or relieve pain ?

• Relation to meals - peptic ulcer pain relieved by food. Cholecystitis pain aggravated by fatty meal.

• Posture jack-knifing leg drawn up, to decrease peritoneal irritation in suppurative appendicitis.

• Motion - any movement causes intense pain in generalized peritonitis and the patient lies motionless.

• Diarrhea most common with acute gastroenteritis or food poisoning, but it may occur with appendicitis or other focal inflammatory lesions of the gut

• Constipation or obstipation – Complete small bowel obstruction -

unrelenting constipation (obstipation) after fecal material below obstruction has been passed.

– Progressive constipation with carcinoma of the large bowel.

• Gas stoppage with decreased or absent bowel sounds - paralytic ileus

Pain Vomiting Abdominal distension Constipation Diarrhea Hematemesis & Melena Haematoschezia

Acute ABDOMEN - Symptoms & Sign

Patient's Symptoms

• All of the patient's symptoms must be carefully considered and analyzed, especially with regard to organs most likely to give rise to acute conditions.

• Extra-abdominal conditions which simulate the acute abdomen arise most often in the heart, lungs, urinary tract and female reproductive organs.

System Disease System Disease

Cardiac Myocardial infarction

Acute pericarditis

Endocrine Diab ketoacidosis

Addisonian crisis

Pulmonary Pneumonia

Pulmonary infarction

PE

Metabolic Acute porphyria

Mediterranean fever

Hyperlipidemia

GI Acute pancreatitis

Gastroenteritis

Acute hepatitis

Musculo- skeletal

Rectus muscle hematoma

GU Pyelonephritis CNS

PNS

Tabes dorsalis (syph)

Nerve root compression

Vascular Aortic dissection Heme Sickle cell crisis

Extra – abdominal Conditions Associated with Acute Abdominal Pain

Volvulus

Invagination

The age and sex…..

• Females - gallbladder - female, fair, fat, forty (4F), Ectopic pregnancy, PID.

• Older age - mesenteric thrombosis or embolus often after myocardial infarction, large bowel neoplasms, diverticulitis.

• Past history of disease or abdominal operation :– abdominal scars – adhesions – intestinal obstruction, peptic ulcer - possible perforation – chronic cholecystitis or biliary colic - acute cholecystitis

PHYSICAL EXAMINATION

Important Signs in Patients with Abdominal Pain

Sign Finding Association

Cullen's sign Bluish periumbilicaldiscoloration

Retroperitoneal haemorrhage

Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture

McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side

Appendicitis

Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant

Acute cholecystitis

Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis

Obturator's sign Internal rotation of flexed right hip causingabdominal pain

Appendicitis

Grey-Turner's sign

Discoloration of the flank Retroperitoneal haemorrhage

Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table

Pelvic inflammatory disease

Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant

Appendicitis

Digital Rectal Examination

• Important physical examination in acute abdomen :

Abdominal Compartment Syndrome

Physical Examination in Acute Abdomen

General Condition Circulation Tenderness Fever Shock

Laboratory Examination

Routine Blood Test Specific Test (amilase) Urine test

Certain lab tests when associated with characteristic clinical features :

• Markedly elevated serum amylase levels acute pancreatitis

• Free air under diaphragm in an upright x-ray film perforation of a hollow viscus usually a duodenal ulcer

• Distended loops of small bowel above the level of obstruction in small bowel obstruction with absence of gas below by x-ray; generalized distention of large and small bowel paralytic

Imaging

Plain abd X - rays USG CT Scan DPL Endoscopic Laparoscopic

Free Air

Free Air

Double Wall and Football Sign

Double Wall and Football Sign

MANAGEMENT IN ACUTE ABDOMEN

I V line Resuscitation Decompression Catheterization Antibiotic

Acute Abdomen Management

Pain is the most aggravated symptoms must be overcome first !!!

Action on Acute Abdomen

• Require immediate surgery• Require watchful expectancy, • Require medical rather than surgical management

• Often the patient's condition is such that extensive laboratory investigation requiring many hours would compromise the patient's life.

• The outcome often depends on a precise and detailed history and physical examination.

Surgical Interventions

• Surgical intervention is mandatory in : Severe abdominal pain in patients who have

been fairly well, and which persists as long as six hours.

Persistent localized tenderness with muscle spasm, indicative of localized peritoneal inflammation The tenderness may be best determined by rectal or pelvic exam.

Characteristic, severe, intermittent cramping, colicky pain, with obstruction of a hollow viscus.

Surgical Case• Markedly hyperactive bowel sounds with

small intestinal obstruction, or decreased to absent bowel sounds with paralytic ileus.

• Paralytic ileus not secondary to other abdominal pathology is treated nonsurgically.

• Paralytic ileus as an end-result of mechanical small bowel obstruction or perforated duodenal ulcer requires surgical intervention to relieve the underlying pathology.

• Repeated vomiting of copious amounts of bile-stained or fecal material - in small bowel obstruction.

• Palpation of a mass : In RLQ or RUQ intussusception. Adnexal mass by pelvic exam ectopic pregnancy. Tender and thickened adnexae by pelvic PID. An irreducible incarcerated inguinal hernia. A tender RLQ mass by abdominal palpation or rectal

exam appendiceal abscess.

Surgical Case

Surgical Intervention in Acute Abdomen Severe contaminated peritonitis Strangulated GI Obstruction GI obstruction + Respiratory distress Perforation Abdominal shot gun wound. Penetrated Abdominal wound Massive GI bleeding ABOMINAL COMPARTMENT SYNDROME (ACS)

ABDOMINAL TRAUMA :BLUNT TRAUMA

PENETRATING TRAUMA

Blunt Abdominal TraumaMechanisms• Direct impact• Acceleration-deceleration

forces• Shearing forces

• No correlation between size of contact area and resultant injuries.

• Abdomen = potential site of major blood loss.

Is there a surgical intraabdominal injury?

PE: guarding, peritoneal signs, tenderness, nausea. DRE.Lower rib fxs: 10-20% a/w spleen/liver injury Seatbelt sign a/w intestinal injury and mesenteric tears.

Direct blunt trauma: rupture/tear of solid organs.Flank pain or contusion often late signs of retroperitoneal bleed

Rapid resuscitationCXR, Pelvic X-rayFAST v DPL v CTLabs: Hct, WBC, amylase, UA, ABG, T+C

Blunt Abdominal Trauma

Shock with expanding abdomen,pnemoperitoneum,retroperitoneal air

Peritoneal signs, HD unstable, sepsis

Stable w/ peritoneal signs

Imaging:CXRFAST/DPL/CT

Observe,+/- re-image

INDICATIONS FOR LAPAROTOMYIN BLUNT ABDOMINAL TRAUMA

Role of Diagnostic Laparoscopy

• Hemodynamically stable patients• Inadequate/equivocal FAST or borderline

DPL (80K-120K RBC/HPF)• Intermittent mild hypotension or persistent

tachycardia• Persistent abdominal signs/symptoms• Potential to decrease numbers of

nontherapeutic laparotomies (negative laparotomy)

Blunt Abdominal Trauma

Bruises in the Abdomen and Flank Region

Perforated Ileum due to Blunt Abdominal Trauma

Perforated Ileum

Penetrating Abdominal Trauma

Penetrating Abdominal Trauma

Evaluation of Stab Wounds• Local exploration• DPL

– 5cc gross blood on aspiration– >20K RBC/mm3– >500 WBC/mm3– >175U amylase/100mL– Bacteria– Bile, Food particles

• CT– Limited ability to dx hollow organ

injury– Useful for posterior SW

• FAST

– Limited, high false negative rate

– Useful for pericardial injuries

• Diagnostic laparoscopy

– Useful for assessing peritoneal penetration, diaphragm injury

– Shorter LOS than negative laparotomy

Penetrating Abdominal Trauma

Penetrating Abdominal TraumaPenetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest

Anterior Abdominal

Flank

Peristernal Potential

Mediastinal

Back

Penetrating Abdominal TraumaPenetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest

Anterior Abdominal Explore locally, manage expectantly with serial PE

Flank

Peristernal Potential

Mediastinal

Back

Penetrating Abdominal TraumaPenetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest

Anterior Abdominal Explore locally, manage expectantly with serial PE

Flankexplore

locally

triple contrast CT

Peristernal Potential

Mediastinal

Back

Penetrating Abdominal TraumaPenetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest

Anterior Abdominal Explore locally, manage expectantly with serial PE

Flankexplore

locally

triple contrast CT

Peristernal Potential

Mediastinal

Backadmit for obs

Penetrating Abdominal TraumaPenetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest?Thoracoscopy,

Laparoscopy

Anterior Abdominal Explore locally, manage expectantly with serial PE

Flankexplore

locally

triple contrast CT

Peristernal Potential

Mediastinal

Backadmit for obs

Penetrating Abdominal TraumaPenetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest?Thoracoscopy,

Laparoscopy

Anterior Abdominal Explore locally, manage expectantly with serial PE

Flankexplore

locally

triple contrast CT

Peristernal Potential

Mediastinal

Backadmit for obs

CVP monitor, U/S

Observe >6h, repeat CXR

Stab Wound and Liver Laceration

Diagnostic Laparoscopy

•Usually require urgent exploration.

•Evaluation for peritoneal penetration vs tangential GSW. • CT, diagnostic laparoscopy• Use of DPL controversial due to high false negative

rate

Gun Shot Wound

• Ballistics: • Civilian=lower velocity handgun missiles; military = higher

velocity rifle missiles.

• Permanent and temporary cavities: Yaw, Bullet size and type.

• Shotgun: • Short range: high-velocity and more concentrated• Distant range: multiple low-velocity projectiles, more

diffuse, less severe

Balistic Gel

Terrorism and Bomb

Blast Injury

Blast Abdominal Trauma• Primary Damage

Shear injury in solid organ

•Secondary DamagePenetrating injury due to projectile

•Tertiary Damage Impact of victim being thrown By the blast

Management BAT

• A B C • Demand Laparotomy • Stop bleeding & Contamination • Temporary reconstruction • Ongoing process • Plan Laparotomy/Second look

Blast Injury• Correlate to others Injury• Tympanic injury• Lung Injury

References :

• DebasDePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast Injuries. N Engl J Med 2005; 352:1335-42.

• Hoff SW. Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma. Eastern Association for The Surgery of Trauma, 2001.

• Diagnostic Laparoscopy. Practice/Clinical Guidelines 2007. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

• Ahmed, N., Whelan, J., Brownlee, J., Chari, V., and Chung, R. The Contribution of Laparoscopy in Evaluation of Penetrating Abdominal Wounds. Journal of the American College of Surgeons 2005;201(2):213-6.