Dr. Abdul Ghani Soomro
Associate Professor SurgeryLUMHS Jamshoro
ACUTE ABDOMEN
1 .Pain
2.Vomiting
3.Constipation
4.Abdominal distention
Acute abdomen
Spectrum of medical and surgical conditions ranging from trivial to life threatening that requires hospital admission investigations and treatment .
Pain
Somatic Abdominal wall
Peritoneum
Visceral Diffuse difficult to localize Referred pain Irritation of abdominal organ
SymptomsLuminal obstructionInflammation. Appendicitis Cholecystitis Pancreatitis
Peritonitis. Perforated viscus Strangulation Intra peritoneal collection
BileBloodPus
I
Common Causes of acute abdominal pain
Organ Location of Pain Pathology
Liver Right Upper quadrant•Hepatitis
•Liver abscess
•CCF
Common Causes of acute abdominal pain
Organ Location of Pain Pathology
Biliary Tract Right Upper quadrant •Choleycystitis
•Cholelithiasis
•Choledocholithiasis
Common Causes of acute abdominal pain
Organ Location of Pain Pathology
PancreasEpigastrium
Right Hypochondrium
Left Hypochondrium
•Acute Pancreatitis
•Ca Pancreas
•Ca Oesaphagus
Common Causes of acute abdominal pain
Common Causes of acute abdominal pain
Common Causes of acute abdominal pain
Common Causes of acute abdominal pain
Common Causes of acute abdominal pain
Common Causes of acute abdominal pain
Common Causes of acute abdominal pain
Common Causes of acute abdominal pain
Common Causes of acute abdominal pain
Taking the history of a patient with acute abdomen
Specific question
When did the pain start and was the onset sudden?
What brought the pain on and are there any aggravating or relieving factors?
Where did the pain start and where is it now? Does it radiate elsewhere?
What is the character of the pain and how severe is it?
Taking the history of a patient with acute abdomen
Specific question
Are there any associated symptoms? (e.g. distension, nausea, vomiting, fever, diarrhoea, absolute constipation, anorexia, jaundice, pruritis, gastrointestinal bleeding, dysuria, oliguria, chest pain)
Was there any similar episode in the past?
When was your last period and is there any chance that you may be pregnant?
Taking the history of a patient with acute abdomen
General enquiries
History of alcohol intake
Drug history
History of previous surgery
History of Pre-existing disease
History of travel (Especially foreign)
Family history
Investigations
1.Blood CP
2.Urea Creatinine
3.Blood Sugar
4.Serum Amylase
5.LFTs
6.Pregnancy Test
7.Urine DR
8.ECG
Imaging
• Radiography
• Abdomen
• Chest
•Ultrasound Abdomen
•CT Scan
•MRI
•Barium Studies
•Endoscopy
•Laparoscopy / Laparotomy
Acute abdomen in infants & Children
Congenital atresia Volvulus Meconieum ileus Meckl’s diverticulum Inguinal Hernia
Common Surgical Emergencies
Acute Appendicitis
Liver Abscess
Abdominal Tuberculosis
Typhoid Perforation
perforated peptic ulcer
Abdominal wall hernia
Acute Appendicitis
Most common abdominal emergency. Uncommon before the age of 2 years. Peak incidence in twenties and thirties
Aetiology
The vermiform appendix is a vestigial structure.
7-10 cm in length. Exact cause is unclear but luminal
obstruction, diet, familial factors have been suggested.
Pathology
Minor, simple, acute with spontaneous
resolution to supperactive necrosis and
perforation.
Bacteria (E Coli, Klebsilla, Proteus).
Enter through ulcer (caused by faceolith).
Edema purulent inflammation thrombosis,
gangrene.
Clinical Features
Age can influence presentation.
Clinical picture also dictated by position of appendix.
Epigastric / periumblical pain .
Shift to right iliac fossa.
Colicky / dull pain.
Aggravated by movement and coughing.
Loss of appetite constipation nausea and vomiting.
Clinical Examination
Tachycardia.
Mild Pyrexia
Guarding in RIF
Fetor oris
Tenderness on rectal / vaginal examination.
Rovsings sign, psoas stretch sign.
Obturater test
Anatomical Feature influencing Presentation
1. Retrocaecal
Muscular rigidity often absent
Right hip in flexed position due to psoas spasm
Psoas stretch sign.
2. Post ilealDiarrohea and Vomiting
Prominent feature due to irritation of ileum.
3. PelvicDiarrohea due to irritation of rectum.Increased frequency of micturation.
Microspic haematuria.Tenderness on rectal and viginal
examination.Obturator sign.
Age Related features affecting presentation
1. ChildrenDifficulty in obtaining
Proper historyDifficulty in differentiating from mesenteric
adenitis and enteritis.
Under developed omentum leading to early complications.
2. ElderlyLess prominent SymptomsAfebrileNormal white cell count.
Pregnancy
1 per 1500-2000 / years in UK. Displacement of appendix by Gravid uterus can result in atypical presentation. Symptoms may be confused with onset of labor.
Tenderness may not be marked due to gravid uterus. Less maternal mortality in case of simple appendix. Risk of featal death is about 10% . Complications both at risk.
Complications
Perforation
Appendix mass
Appendix abscess
Differential Diagnosis
Thorax and Respiratory Tract
Tonsilltis
Pneumonia
Abdomem
Intestinal Obstruction Intussusception Acute cholecystitis Perforated Peptic ulcer Mesenteric adenitis Terminal ileitis Meckel’s diverticulitis
Ectopic Pregnancy Ruptured ovarian follicle Torsion of ovarian cyst Salpingitis PID
PELVIS
URINARY SYSTEM
Right Pyelonephritis Right Uretric Colic
OTHER
Diabetic ketoacidosis Rectus sheath haematoma
Pancreatitis Pre Herpetic Pain
INVESTIGATIONS
1. Blood cp
2. Urine analysis
RADIOGRAPHY
Faecolith 50% of children < 2 years Ultrasound abdomen
C.T Scan Laparoscopy
TREATMENT
Appendicetomy
Open
Laparoscopic
It is common in indo-pak
Caused by parasite entamoeba histolytica
Common in alcoholics
Infection commonly occurs in caecum and
rectosigmoid junction via superior and inferior
mesentric veins and portal vein to liver.
*Amoebic liver Abscess
Right lobe of liver is commonly involved, size of right lobe, portaly vein is in direct continuation with right branch.
Infection Leads to liquefaction necrosis and formation of pus (Anchovy Sauce) which is chocolate brown in colour odourless.
Pus may be green if mixed with bile.Secondary infection is common in (30%) 70% single abscess, 30% multiple.
E. Histolytica Life Cycle
2 stages:
-Infective cyst stage
- Multiplying trophozite stage
2 forms:
- Active parasite (trophozite)
- Dormant parasite (cyst)
Infection begins when cysts are swallowed
Cysts hatch---releasing trophozites that multiply
Trophozites cause ulcers on the lining of intestine and produce diarrhea.
Once the intestinal epithelium is invaded, extra intestinal spread to the peritoneum, liver, brain and other sites may follow.
Some of the trophozites forms cysts which are excreted in the faeces along with trophozites
Outside the body, trophozites die but cysts remain.
Merck Manual Home Edition 2003
Complications
• Rupture of the abscess with extension into the peritoneum,
pleural cavity, or pericardium.
• Extra hepatic amebic abscesses have occasionally been
described in the lung, brain, and skin
Amebiasis: Parasitic Infections: Merck Manual Edition 2007
Treatment
Drugs Metronidazole TinidazoleChloroquineDiloxanate furoateIodoquinolParomycin
Aspiration under ultrasound guidance
Thick pus Ruptured liver abscess
Surgery
• Acute Appendicitis
• Liver Abscess
• Abdominal Tuberculosis
• Typhoid Perforation
• perforated peptic ulcer
• Abdominal wall hernia
Common Surgical Emergencies
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