Date post: | 24-May-2015 |
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ACUTE ABDOMEN(ABDOMINAL EMERGENCIES)
One of the most common causes for hospitalization
Meaning= acute abdominal symptoms which lead
patients to ER , excluding obvious
abdominal injuries
May or may not require immediate operations
Some aspect has been changed
Pathophysiology of Abdominal pain
Origins of intraabdominal visceral organs
Stomach to 2nd part of duodenum, including liver,
biliary trees, pancreas, and spleen are derived from
forgut
3rd and 4th part of duodenum, jejunum, ileum,
appendix, ascending colon to proximal 2/3 of
transverse colon are derived from midgut
Distal 1/3 of transverse colon to anal canal above
dentate line are derived from hindgut
Visceral pain from organs derived from foregut and midgut
is at midline and above or around umbilicus.
Visceral pain from organs derived from hindgut
is at midline and below umbilicus.
Peritoneum innervations
Visceral peritoneum
-Sympathetic and parasympathetic nerve innervations(C fibers)
dull or cramping pain
-character
insidious
sensitive to distension, ischemia, squeezing, torsion
insensitive to heat, cutting, or electrical shock
Parietal peritoneum
character
somatic nerve innervation (A fiber)
sharp and exquisite pain
somatic nerve distribution (T7-L2, umbilicus at T12)
sensitive to mechanical stimuli (stretching, pinprick,
pinch), heat, electrical shock, chemical stimulus,
infection-inflammation
ASSESSMENT
2 most important things in assessment of the patients are
Carefully and precise history taking, and
Physical examination
Basic History Taking
onset
sudden
insidious
Perforated PU,Gallstone,UC,Aortic
dissection,Rupture AAA, SMA
Embolism,Ruptured ectopic preg.,
Ruptured corpus luteal or follicular
cysts,Twisted ovarian cyst
Acute Appendicitis,Acute pancreatitis,
Intestinal obstruction,Acute pyelonephritis,
Acute gastritis or gastroenteritis
Age
Childhood:
Adults:
Middle to old age:
Constipation, Acute appendicitis
Intussusception, Viral enteritis
Infecion-inflammation,
Female reproductive organs
Malignancies,
Degenerative diseases
Sex
Nature of pain
Colicky: sharp shooting,intermittent,restless,
associated with vomiting
is likely from acute obstruction of hallow
viscus organs (small bowel,biliary trees,
ureter,or even appendix).
SMA occlusion maybe possible
Acute Gastritis, Gastroenteritis
sudden,sharp & persistent: Leakage of irritating fluid, i.e.
blood from Ruptured ectopic preg,
AAA, corpus luteal or follicular
cysts, Hepatoma
Fluid from ovarian cyst, Perforated
PU
Shearing or Tearing: Aortic dissection, Ruptured AAA
Dull aching: general
Associated symptoms Nausea,vomiting, respiratory
symptoms
Bowel habits
Gynecologic History menstruation,leucorrhea, sexual
intercourse
Concomitant History Underlying diseases
Family History
Drug usage
Substance exposure
Diarrhea,constipation,
mucous bloody stool
Physical Examination
posture
General physical exam.
anemia
jaundice
hypotension
hypertension
fever
tachypnea: Kussmal breathing, dyspnea
dehydration
Sepsis
Chronic illness
Abdominal Examination
Palpation : soft, repeated, reproducible tenderness,Fothergill’s sign
Signs of Peritonitis
Point of maximal tenderness
guarding
rigidity
rebound tenderness
Bowel sound
Increase, decrease
Borborygmi
high pitch
infrequent
loud
Relate with abdominal pain
Rectal examination : Cul de sac palpation
Pelvic examination
Investigations
Beware of misleading by investigations
CBC
In RLQ pain to rule in or rule out Acute Appendicitis
wbc count (n>70%) < 8,000 very unlikely
8,000-10,000 unlikely
10,000-12000 equivocal
12,000-15,000 suggestive
15,000-20,000 highly suggestive
>20,000 probably ruptured
Urine pregnancy test
Beta HCG
urinalysis
Blood chemistry
General: BS, BUN, Cr, Electrolyte
Specific: Amylase, Lipase LFT,
Imaging Investigations
Plain film
Chest X-Ray
Plain Abdomen
Ultrasonography
•Biliary trees
•Mass
•fluid
•Retroperitoneal organs
Ultrasound in Acute Appendicitis +
CT Scan
Similar benefit as in U/S but
more time consumed
more accurate
more expensive
more sophisticated
more risk
ACUTE APPENDICITIS
Most common cause of acute abdomen
The earlier the diagnosis is made, the less
complicated the outcome, the shorter hospital stay
and recovery ,and the less expense are.
Aim = earliest and most accurate
Makarathep Score
1 History
Typical = 2
Not typical = 1
Unusual = 0
2 Age 10-30 = 1
<2 or >70 = -1
others = 0
3 Gender Male = 2
Female
Virgin = 0
Not virgin= -1
Hx of PID,
Salpingitis, = -2
Endometriosis
4 tender RLQ
Definite just one point = 3
Definite with other area= 2
Vague = 1
5 Rebound
tenderness
definite = 2
not definite = 1
no = 0
6 Guarding present = 2
no = 0
7 Rectal exam definite tender = 1, 2
not definite = 0
No = 0,-1
8 Vaginal exam purulent leucorrhea = -1
cervical excitation
pain = -1,-2
definite tenderness
left adnexa = -2
definite tenderness
right adnexa = -1
9 Fever (T>37.5 C) present = 1
no = 0
10 CBC
WBC (N>70%) > 12,000 = 2
10,000-12,000 = 0
8,000-10,000 = -1
<8,000 = -2
11 Neutrophil count > 90% = 2
80-89% = 1
70-79% = 0
< 70% = -1
12 Urinalysis
wbc 5-15/HD = 0
wbc> 15/HD = -1
13 Hypovolemic shock without obvious cause
Female = -10
Male = -5
wbc<5/HD = 1
Total score
20 >95%
11-19 90-94%
5-10 50-89%
0-4 30-50%
possibility
Common Differential Diagnosis of Acute Appendicitis
Ureteric Stone
Acute Pyelonephritis
CA Caecum with perforation, Diverticulitis
Gynecologic conditions
•Ruptured corpus luteal cyst or follicular cyst
•Ectopic pregnancy
•Salpingitis and Acute PID
•Endometriosis
Non surgical causes of Acute Abdomen
Pleuritis and Basal Pneumonia
Acute MI
Congestive Heart Failure
Dengue (Hemorrhagic) Fever
Acute Hepatitis
Acute
Hepatomegaly
Acute Pyelonephritis and Ureteric stone
Uremia
DKA
Vasculitis (SLE, Henoch-Scholein Purpura)
Aortic dissection
AIDS with Abdominal Tuberculosis
Drug Withdrawal
Irritable Bowel Syndrome
Constipation
Acute Abdomen in Children
Constipation
Viral Enteritis
Acute Appendicitis
Mesenteric Adenitis
Intussusception
Specific Investigations for Diseases in Acute Abdomen
1.Acute Appendicitis CT Scan
2.Acute Gastritis, PU Gastroscopy
3.PU Perforation CXR, CT Scan for free air
4.Biliary Tract Disease U/S
5.Diverticulitis CT Scan
6.Acute Pancreatitis serum Lipase
7.Ectopic Pregnancy Pregnancy test, Beta HCG with Transvaginal U/S
8.Acute PID CT Scan
11.SMA Occlusion CT Scan, SMA Angiography
9. Ureteric Stone IVP, CT Scan, U/S
12.Rptured AAA, CT Scan, U/SAortic Dissection
10.Small Bowel GI Follow through, CT ScanObstruction
Management
1.Manage hemodynamic instability
2.Oxygenation
General Management
3.Analgecics
4.Nursing process
Specific Treatment
Superior Mesenteric Artery Occlusion
Embolism or Thrombosis
Severe intractable abdominal pain, not corresponding
to abdominal signs
In late stage Gangrene nearly the whole small bowel
Profound intractable shock
Investigation (tough to proceed) : Mesenteric angiography
CT scan
Mini-explore lap.
Thank you very much
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