Acute Abdomen: Acute Abdomen By Dr. Haitham A. Hammoud Definition: : Definition: "An acute abdomen" denotes any sudden, spontaneous, nontraumatic disorder whose chief manifestation is in the abdominal area and for which urgent operation may be necessary . Because there is frequently a progressive underlying intra-abdominal disorder, undue delay in diagnosis and treatment adversely affects outcome PowerPoint Presentation: The approach to a patient with an acute abdomen must be orderly and thorough . An acute abdomen must be suspected even if the patient has only mild or atypical complaints. The history and physical examination should suggest the probable causes and guide the choice of initial diagnostic studies. The clinician must then decide if in-hospital observation is warranted, if additional tests are needed, if early operation is indicated, or if nonoperative treatment would be more suitable Common Causes of the Acute Abdomen. : Common Causes of the Acute Abdomen . Gastrointestinal tract disorders *Nonspecific abdominal pain *Appendicitis *Small and large bowel obstruction *Perforated peptic ulcer Incarcerated hernia Bowel perforation Meckel's diverticulitis Boerhaave's syndrome *Diverticulitis Inflammatory bowel disorders Mallory-Weiss syndrome Gastroenteritis Acute gastritis Mesenteric adenitis Parasitic infections PowerPoint Presentation: Liver, spleen, and biliary tract disorders *Acute cholecystitis Acute cholangitis Hepatic abscess Ruptured hepatic tumor Spontaneous rupture of the spleen Splenic infarct Biliary colic Acute hepatitis Pancreatic disorders *Acute pancreatitis PowerPoint Presentation: Urinary tract disorders *Ureteral or renal colic Acute pyelonephritis Acute cystitis Renal infarct Gynecologic disorders Ruptured ectopic pregnancy Twisted ovarian tumor Ruptured ovarian follicle cyst *Acute salpingitis Dysmenorrhea Endometrios PowerPoint Presentation: Vascular disorders Ruptured aortic and visceral aneurysms Acute ischemic colitis Mesenteric thrombosis Peritoneal disorders Intra-abdominal abscesses Primary peritonitis Tuberculous peritonitis Retroperitoneal disorders Retroperitoneal hemorrhage Sensory Levels Associated with Visceral Structures: Sensory Levels Associated with Visceral Structures Structures Nervous System Pathways Sensory Level Liver, spleen, and central part of diaphragm Phrenic nerve C3–5 Peripheral diaphragm, stomach, pancreas, gallbladder, and small bowel Celiac plexus and greater splanchnic nerve T6–9 Appendix, colon, and pelvic viscera Mesenteric plexus and lesser splanchnic nerve T10–11 Sigmoid colon, rectum, kidney, ureters, and testes Lowest splanchnic nerve T11–L1 Bladder and rectosigmoid Hypogastric plexus S2–4 History: History Abdominal Pain Location of Pain visceral pain : is elicited by distention, by inflammation or ischemia stimulating the receptor neurons, or by direct involvement (e.g., malignant infiltration) of sensory nerves. The centrally perceived sensation is generally slow in onset, dull, poorly localized, and protracted parietal pain : is mediated by both C and A delta nerve fibers, the latter being responsible for the transmission of more acute, sharper, better-localized pain sensation. Direct irritation of the somatically innervated parietal peritoneum (especially the anterior and upper parts) by pus, bile, urine, or gastrointestinal secretions leads to more precisely localized pain Referred pain : denotes noxious (usually cutaneous) sensations perceived at a site distant from that of a strong primary stimulus. Distorted central perception of the site of pain is due to the confluence of afferent nerve fibers from widely disparate areas within the posterior horn of the spinal cord PowerPoint Presentation: Spreading or shifting pain parallels the course of the underlying condition. The site of pain at onset should be distinguished from the site at presentation Mode of Onset and Progression of Pain The mode of onset of pain reflects the nature and severity of the inciting process. Onset may be explosive (within seconds), rapidly progressive (within 1–2 hours), or gradual (over several hours). PowerPoint Presentation: Character of Pain : The nature, severity, and periodicity of pain provide useful clues to the underlying cause Sharp superficial constant pain due to severe peritoneal irritation is typical of perforated ulcer or a ruptured appendix, ovarian cyst, or ectopic pregnancy The gripping, mounting pain of small bowel obstruction (and occasionally early pancreatitis) is usually intermittent, vague, deep-seated, and crescendo at first but soon becomes sharper, unremitting, and better localized Unlike the disquieting but bearable pain associated with bowel obstruction, pain caused by lesions occluding smaller conduits (bile ducts, uterine tubes, and ureters) rapidly becomes unbearably intense colic if there are pain-free intervals that reflect intermittent smooth muscle contractions, as in ureteral colic "biliary colic" is a misnomer because biliary pain does not remit. The reason is that the gallbladder and bile duct, in contrast to the ureters and intestine, do not have peristaltic movements The "aching discomfort" of ulcer pain the "stabbing, breathtaking" pain of acute pancreatitis and mesenteric infarction the "searing" pain of ruptured aortic aneurysm PowerPoint Presentation: Despite the use of such descriptive terms, the quality of visceral pain is not a reliable clue to its cause . gas stoppage sign : An occasional patient will deny pain but complain of a vague feeling of abdominal fullness that feels as though it might be relieved by a bowel movement. It is due to reflex ileus induced by an inflammatory lesion walled off from the free peritoneal cavity, as in retrocecal or retroileal appendicitis . factors that aggravate or relieve pain Pain caused by localized peritonitis, especially when it affects upper abdominal organs, tends to be exacerbated by movement or deep breathing. Other Symptoms Associated with Abdominal Pain: Other Symptoms Associated with Abdominal Pain Vomiting When sufficiently stimulated by secondary visceral afferent fibers, the medullary vomiting centers activate efferent fibers to induce reflex vomiting. Hence, pain in the acute surgical abdomen usually precedes vomiting, whereas the reverse holds true in medical conditions. The absence of bile in the vomitus is a feature of pyloric stenosis. Where associated findings suggest bowel obstruction, the onset and character of vomiting may indicate the level of the lesion . Severe, uncontrollable retching provides temporary pain relief in moderate attacks of pancreatitis. The absence of bile in the vomitus is a feature of pyloric stenosis. Where associated findings suggest bowel obstruction, the onset and character of vomiting may indicate the level of the lesion. Disorders that induce vomiting in younger patients may give rise only to anorexia or nausea in older patients . Although vomiting may present in either acute appendicitis or nonspecific abdominal pain, coexisting nausea and anorexia are more suggestive of the former condition . PowerPoint Presentation: Constipation Reflex ileus is often induced by visceral afferent fibers stimulating efferent fibers of the sympathetic autonomic nervous system (splanchnic nerves) to reduce intestinal peristalsis. Hence, paralytic ileus undermines the value of constipation in the differential diagnosis of an acute abdomen . Constipation itself is hardly an absolute indicator of intestinal obstruction. However, obstipation (the absence of passage of both stool and flatus) strongly suggests mechanical bowel obstruction if there is progressive painful abdominal distention or repeated vomiting. PowerPoint Presentation: Diarrhea Copious watery diarrhea is characteristic of gastroenteritis and other medical causes of an acute abdomen . Blood-stained diarrhea suggests ulcerative colitis, Crohn disease, or bacillary or amebic dysentery . It is also common with ischemic colitis but often absent in intestinal infarction due to superior mesenteric artery occlusion. PowerPoint Presentation: Other Specific Symptoms Jaundice suggests hepatobiliary disorders. hematochezia or hematemesis, a gastroduodenal lesion or Mallory-Weiss syndrome. hematuria, ureteral colic or cystitis. The passage of blood clots or necrotic mucosal debris may be the sole evidence of advanced intestinal ischemia . Other Relevant Aspects of the History :: Other Relevant Aspects of the History : Gynecologic History The menstrual history is crucial to the diagnosis of ectopic pregnancy, mittelschmerz (due to a ruptured ovarian follicle), and endometriosis. A history of vaginal discharge or dysmenorrhea may denote pelvic inflammatory disease . Drug History Anticoagulants have been implicated in retroperitoneal and intramural duodenal and jejunal hematomas. Oral contraceptives have been implicated in the formation of benign hepatic adenomas and in mesenteric venous infarction. Corticosteroids, in particular, may mask the clinical signs of even advanced peritonitis. Pyloric perforation has been caused by "crack" smoking. PowerPoint Presentation: Family History often provides the best information about medical causes of an acute abdomen . Travel History may raise the possibility of: Amebic liver abscess . Hydatid cyst. Malarial spleen. Tuberculosis. Salmonella typhi infection of the ileocecal area. Dysentery. PowerPoint Presentation: Operation History Any history of a previous abdominal, groin, vascular, or thoracic operation may be relevant to the current illness. Particular attention to the mode of operation (laparoscopic, open, endovascular) and any anatomic reconstructions may clarify aspects of the current complaint. If possible within the time constraints imposed by the urgency of the current problem, operative notes and pathology reports should be obtained and reviewed. Physical Examination: Physical Examination The tendency to concentrate on the abdomen should be resisted in favor of a methodical and complete general physical examination. A systematic approach to the abdominal examination. One should search for specific signs that confirm or rule out differential diagnostic possibilities. General observation: affords a fairly reliable indication of the severity of the clinical situation. The writhing of patients with visceral pain (e.g., intestinal or ureteral colic) contrasts with the rigidly motionless bearing of those with parietal pain (e.g., acute appendicitis, generalized peritonitis). Diminished responsiveness or an altered sensorium often precedes imminent cardiopulmonary collapse. PowerPoint Presentation: Systemic signs : usually accompany rapidly progressive or advanced disorders associated with an acute abdomen. Extreme pallor, hypothermia, tachycardia, tachypnea, and sweating suggest major intra-abdominal hemorrhage (e.g., ruptured aortic aneurysm or tubal pregnancy). Fever: Constant low-grade fever is common in inflammatory conditions such as diverticulitis, acute cholecystitis, and appendicitis. High fever with lower abdominal tenderness in a young woman without signs of systemic illness suggests acute salpingitis. Disorientation or extreme lethargy combined with a very high fever (> 39 °C) or swinging fever or with chills and rigors signifies impending septic shock. This is most often due to advanced peritonitis, acute cholangitis, or pyelonephritis. However, fever is often mild or absent in elderly, chronically ill, or immunosuppressed patients with a serious acute abdomen. Examination of the acute abdomen :: Examination of the acute abdomen : Inspection : The abdomen should be thoughtfully inspected before palpation. A tensely distended abdomen with an old surgical scar suggests both the presence and the cause (adhesions) of small bowel obstruction. A scaphoid contracted abdomen is seen with perforated ulcer. visible peristalsis occurs in thin patients with advanced bowel obstruction. Soft doughy fullness is seen in early paralytic ileus or mesenteric thrombosis. PowerPoint Presentation: Auscultation : Auscultation of the abdomen should also precede palpation. Peristaltic rushes synchronous with colic are heard in mid small bowel obstruction and in early acute pancreatitis. They differ from the high-pitched hyperperistaltic sounds unrelated to the crampy pain of gastroenteritis, dysentery, and fulminant ulcerative colitis. An abdomen that is silent except for infrequent tinkly or squeaky sounds characterizes late bowel obstruction or diffuse peritonitis PowerPoint Presentation: . Coughing to elicit pain: The patient should be asked to cough and point to the area of maximal pain. Peritoneal irritation so demonstrated may be confirmed afterward without causing unnecessary pain by rigorous testing for rebound tenderness. Unlike the parietal pain of peritonitis, colic is visceral pain and is seldom aggravated by deep inspiration or coughing. PowerPoint Presentation: Percussion: Percussion serves several purposes. Tenderness on percussion is akin to eliciting rebound tenderness; both reflect peritoneal irritation and parietal pain. With a perforated viscus, free air accumulating under the diaphragm may efface normal liver dullness. Tympany near the midline in a distended abdomen denotes air trapped within distended bowel loops. Free peritoneal fluid may be detected by demonstrating shifting dullness. PowerPoint Presentation: Palpation: Palpation is performed with the patient resting in a comfortable supine position. Guarding is assessed by placing both hands over the abdominal muscles and depressing the fingers gently. If there is voluntary spasm , the muscle will be felt to relax when the patient inhales deeply through the mouth. With true involuntary spasm , however, the muscle will remain taut and rigid ("boardlike") throughout respiration. Except for rare neurologic disorders—and, for unknown reasons, renal colic—only peritoneal inflammation (by reflex afferent stimulation of efferent motor fibers) produces rectus muscle rigidity. Unlike peritonitis, renal colic induces spasm confined to the ipsilateral rectus muscle. PowerPoint Presentation: Tenderness that connotes localized peritoneal inflammation is the most important finding in patients with an acute abdomen. Its extent and severity are determined first by one- or two-finger palpation, beginning away from the area of cough tenderness and gradually advancing toward it. Tenderness is usually well demarcated in acute cholecystitis, appendicitis, diverticulitis, and acute salpingitis. If there is poorly localized tenderness unaccompanied by guarding, one should suspect gastroenteritis or some other inflammatory intestinal process without peritonitis. Compared with the degree of pain, unexpectedly little and only vague tenderness is elicited in uncomplicated hollow viscus obstruction, walled-off or deep-seated perforations (e.g., retrocecal or retroileal appendicitis or diverticular phlegmons), and in very obese patients. PowerPoint Presentation: Carnett test: When the patient raises his or her head from the bed or examination table, the abdominal muscles will be tensed. Tenderness persists in abdominal wall conditions (e.g., rectus hematoma), whereas deeper peritoneal pain due to intraperitoneal disease is lessened. Hyperesthesia may be demonstrable in abdominal wall disorders or localized peritonitis, but it is more prominent in herpes zoster, spinal root compression, and other neuromuscular problems. Trigger point sensitivity, lateral costal rib tip tenderness, and pain exacerbated by spinal motion reflect parietal abdominal wall conditions that subside dramatically after infiltration with local anesthetic agents. PowerPoint Presentation: Abdominal masses Are usually detected by deep palpation. Superficial lesions such as a distended gallbladder or appendiceal abscess are often tender and have discrete borders . Murphy sign: If one suspects that abdominal guarding is masking an acutely inflamed gallbladder, the right subcostal area should be palpated while the patient inhales deeply. Inspiration will be arrested abruptly by pain ( Murphy sign ), or the gallbladder fundus may be felt as it strikes the examining fingers during descent of the diaphragm. Deeper masses may be adherent to the posterior or lateral abdominal wall and are often partially walled off by overlying omentum and small bowel. As a result, their borders are ill-defined, and only dull pain may be elicited by palpation. Examples include pancreatic phlegmon and ruptured aortic aneurysm If a mass cannot be directly felt?: If a mass cannot be directly felt? Even if a mass cannot be directly felt, its presence may be inferred by other maneuvers: Iliopsoas sign A large psoas abscess arising from a perinephric abscess or perforated Crohn enteritis may cause pain when the hip is passively extended or actively flexed against resistance . Obturator sign Similarly, internal and external rotation of the flexed thigh may exert painful pressure on a loop of the small bowel entrapped within the obturator canal (obturator hernia). Bump tenderness Over the lower costal ribs indicates an inflammatory condition affecting the diaphragm, liver, or spleen or its adjacent structures. While this may suggest a hepatic, splenic, or subphrenic abscess, it is also common in acute cholecystitis, acute hepatitis, or splenic infarct. Costovertebral angle tenderness is common in acute pyelonephritis. PowerPoint Presentation: Inguinal and femoral rings; male genitalia: The inguinal and femoral rings in both sexes and the genitalia in male patients should be examined next . Rectal examination: Diffuse tenderness is nonspecific, but right-sided rectal tenderness accompanied by lower abdominal rebound tenderness is indicative of peritoneal irritation due to pelvic appendicitis or abscess. Other useful findings include a rectal tumor, blood-stained stool, or occult blood (detected by guaiac testing). Pelvic examination: A pelvic examination is vital in women with a vaginal discharge, dysmenorrhea, menorrhagia, or left lower quadrant pain. A properly performed pelvic examination is invaluable in differentiating among acute pelvic inflammatory diseases that do not require operation and acute appendicitis, twisted ovarian cyst, or tubo-ovarian abscess . Investigative Studies: Investigative Studies The history and physical examination by themselves provide the diagnosis in two thirds of cases of an acute abdomen . Supplementary laboratory and radiologic examinations are indispensable for diagnosis of many surgical conditions, for exclusion of medical causes ordinarily not treated by operation, and for assistance in preoperative preparation. Test results must always be interpreted within the clinical context of each case. Basic studies should be obtained in all but the most desperately ill patients. General Principles of Timing of Diagnostic Studies in an Acute Abdomen: General Principles of Timing of Diagnostic Studies in an Acute Abdomen Immediate Same Day Next Day Blood Hematocrit, white blood cell count, urea, creatinine, crossmatching, arterial gases. Clotting studies, amylase, liver function tests. Specific tests. Urine Microscopy, dipstick testing, culture. Specific tests. Stool Occult blood. Warm smear, culture. Radiography and ultrasound Chest, abdomen Ultrasonography or CT scan, angiography, water-soluble upper gastrointestinal series, HIDA scan. Repeat abdominal films; barium enema or small bowel follow-through, intravenous urogram, and percutaneous transhepatic cholangiography; liver-spleen, gallium, and technetium scans. Endoscopy Proctosigmoidoscopy, upper endoscopy ERCP, colonoscopy, laparoscopy. Other Paracentesis, culdocentesis Laboratory Investigations: Laboratory Investigations Blood Studies: Hemoglobin, hematocrit, and white blood cell and differential counts taken on admission are highly informative. Only a rising or marked leukocytosis (> 13,000/L), especially in the presence of a shift to the left on the blood smear, is indicative of serious infection. Moderate leukocytosis, commonly encountered in medical as well as surgical inflammatory conditions, is nonspecific and may be even absent in elderly or debilitated patients with infections. A low white blood cell count (< 8000/L) is a feature of viral infections such as mesenteric adenitis or gastroenteritis and nonspecific abdominal pain. PowerPoint Presentation:
A specimen of clotted blood for crossmatching should be sent whenever urgent surgery is anticipated. An additional tube of clotted blood may be reserved in case of such need. Serum electrolytes, urea nitrogen, and creatinine are important, especially if hypovolemia is expected (i.e., due to shock, copious vomiting or diarrhea,
abdominal distention, or delay of several days after onset of symptoms). Arterial blood gas determinations should be obtained in patients with hypotension, generalized peritonitis, pancreatitis, possible ischemic bowel, and septicemia. Unsuspected metabolic acidosis may be the first clue to serious disease. serum amylase : A raised serum amylase level corroborates a clinical diagnosis of acute pancreatitis. Moderately elevated values must be interpreted with caution, since abnormal levels frequently accompany strangulated or ischemic bowel, twisted ovarian cyst, or perforated ulcer. Moreover, a normal or even low amylase value may be seen in hemorrhagic pancreatitis or pseudocyst. Cloudy (lactescent) serum in a patient with abdominal pain suggests pancreatitis even though the serum amylase is normal.
PowerPoint Presentation: liver function tests (serum bilirubin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, albumin, and globulin.are useful to differentiate medical from surgical hepatic disorders and to gauge the severity of underlying parenchymal disease. Clotting studies (platelet counts, prothrombin time, and partial thromboplastin time) and a peripheral blood smear. be requested if the history hints at a possible hematologic abnormality (cirrhosis, petechiae, etc). The erythrocyte sedimentation rate: O ften nonspecifically raised in the acute abdomen, is of dubious diagnostic value; a normal value does not exclude serious surgical illness. Antibody titers: For amebic, typhoid, or viral disease, and other special blood tests may pinpoint a specific disease, but therapeutic decisions often cannot await their results. Urine Tests: Urine Tests Dark urine or a raised specific gravity reflects mild dehydration in patients with normal renal function. Hyperbilirubinemia may give rise to tea-colored urine that froths when shaken. Microscopic hematuria or pyuria can confirm ureteral colic or urinary tract infection and obviate a needless operation. Dipstick testing (for albumin, bilirubin, glucose, and ketones) may reveal a medical cause of an acute abdomen. Pregnancy tests should be ordered if there is a history of a missed period. Stool Tests: Stool Tests Occult fecal blood : positive test points to a mucosal lesion that may be responsible for large bowel obstruction or chronic anemia, or it may reflect an unsuspected carcinoma. Warm stool smears :for bacteria, ova, and animal parasites may demonstrate amebic trophozoites in patients with bloody or mucous diarrhea. Stool samples for culture should be taken in patients with suspected gastroenteritis, dysentery, or cholera. Imaging Studies: Imaging Studies Plain Chest X-Ray Studies : An erect chest x-ray is essential in all cases of an acute abdomen. it is vital for preoperative assessment, but it may also demonstrate supradiaphragmatic conditions that simulate an acute abdomen (e.g., lower lobe pneumonia or ruptured esophagus). An elevated hemidiaphragm or pleural effusion may direct attention to subphrenic inflammatory lesions. Plain Abdominal X-Ray Studies: Plain supine films of the abdomen should be obtained only selectively. erect (or lateral decubitus) views contribute little additional information except in suspected intestinal obstruction. Plain films are indicated in patients who have appreciable abdominal tenderness or distention, abnormal bowel sounds, a history of abdominal surgery, suspected foreign body ingestion, or who have a depressed sensorium or are in a high-risk category. They are helpful in patients with possible intestinal obstruction or ischemia, perforated viscus, renal or ureteral calculi, or acute cholecystitis. They are seldom of value in patients suspected to have appendicitis or urinary tract infection. They are inappropriate in pregnant patients, unstable individuals in whom clear-cut physical signs mandating laparotomy already exist, or patients with only mild, resolving nonspecific pain. One should observe the gas pattern of the hollow viscera; free or abnormal air patterns under the diaphragm, within the biliary radicles, or outside the bowel wall; the outline of solid organs and the peritoneal fat lines; and radiopaque densities . PowerPoint Presentation: An abnormal bowel gas pattern suggests paralytic ileus, mechanical bowel obstruction, or pseudo-obstruction. A diffuse gas pattern with air outlining the rectal ampulla suggests paralytic ileus, especially if bowel sounds are absent. Gaseous distention is the rule in bowel obstruction. Air-fluid levels are usually seen in distal small bowel obstruction and a distended cecum with small bowel dilation in large bowel obstruction. Adynamic ileus associated with longstanding acute appendicitis or with an atypical appendix location often produces a pattern that suggests localized right lower quadrant ileus. "Thumbprint" impressions on the colonic wall are noted in about half of patients with ischemic colitis. A displaced gastric or colonic air shadow may be the only sign of subcapsular splenic hematoma. Free gas under the hemidiaphragm must be looked for specifically. Its presence in approximately 80% of perforated ulcers corroborates the clinical diagnosis. Massive pneumoperitoneum is observed in free colonic perforations PowerPoint Presentation: Biliary tree air designates a biliary-enteric communication, such as a spontaneous or surgically created choledochoduodenal fistula or gallstone ileus. Air delineating the portal venous system characterizes pylephlebitis. Air between loops of small bowel may arise from a small localized perforation. Obliteration of the psoas muscle margins or enlargement of the kidney shadows indicates retroperitoneal disease. Radiopaque densities of characteristic appearance and location may confirm a clinical suspicion of biliary, renal staghorn, or ureteral calculi; appendicitis; or aortic aneurysm. Whereas pelvic phleboliths are readily distinguishable, a migrant gallstone may be mistaken for a calcified mesenteric lymph node if the accompanying small bowel distention or biliary tree air is overlooked in gallstone ileus. PowerPoint Presentation: Angiography: Percutaneous invasive angiographic studies, or magnetic resonance angiography (MRA), are indicated if intra-abdominal intestinal ischemia or ongoing hemorrhage is suspected. They should precede any gastrointestinal contrast study that might obscure film interpretation. Selective visceral angiography is a reliable method of diagnosing mesenteric infarction. Emergency angiography may confirm a ruptured liver adenoma or carcinoma or an aneurysm of the splenic artery or other visceral artery. In patients with massive lower gastrointestinal bleeding, angiography may identify the bleeding site, may suggest the likely diagnosis (e.g., vascular ectasia, polyarteritis nodosa) and may even be therapeutic if embolization can be performed. Angiography is of little value in ruptured aortic aneurysm or if frank peritoneal findings (peritonitis) are present. It is contraindicated in unstable patients with severe shock or sepsis and seldom warranted if other findings or tests already dictate the need for laparotomy or laparoscopy. Magnetic resonance angiography is most useful to evaluate the aortic, celiac, and mesenteric vasculature in the setting of possible subacute or chronic mesenteric ischemia Gastrointestinal Contrast X-Ray Studies : Gastrointestinal Contrast X-Ray Studies should not be requested routinely or be regarded as screening studies. For suspected perforations of the esophagus or gastroduodenal area without pneumoperitoneum, a water-soluble contrast medium (eg, meglumine diatrizoate [Gastrografin]) is preferred. If there is no clinical evidence of bowel perforation, a barium enema may identify the level of a large bowel obstruction or even reduce a sigmoid volvulus or intussusception. Only if there is no likelihood of large bowel obstruction should a barium small bowel follow-through study be used to study a partial small bowel obstruction or to look for an intramural duodenal (or jejunal) hematoma that is best managed conservatively . PowerPoint Presentation: An emergency intravenous urogram is seldom necessary to evaluate nontraumatic causes of hematuria. It should be performed electively after microscopic examination of a stained and centrifuged urine specimen and cystoscopic examination. Ultrasonography : Is useful in evaluating upper abdominal pain that does not resemble ulcer pain or bowel obstruction and in investigating abdominal masses. Ultrasonography has a diagnostic sensitivity of about 80% for acute appendicitis and is most useful in pregnant patients and those presenting with features suggestive of atypical appendicitis or in young women with midabdominal or lower abdominal pain. Color Doppler studies can distinguish avascular cysts and twisted masses from inflammatory and infectious processes. CT scanning may be more useful if excessive bowel gas, so common in elderly and ill patients, precludes satisfactory ultrasound examination. It is particularly helpful in pancreatic and retroperitoneal lesions and any severe localized infections (eg, acute diverticulitis). PowerPoint Presentation: CT Scan: Urgent or emergent CT scan of the abdomen is now generally routinely and rapidly available. This has proved extremely useful in the evaluation of abdominal complaints for patients who do not already have clear indications for laparotomy or laparoscopy. CT is helpful in identifying small amounts of free intraperitoneal gas and sites of inflammatory diseases that may prompt (appendicitis, tubo-ovarian abscess) or postpone (diverticulitis, pancreatitis, hepatic abscess) operation. It should not replace or delay operation in a patient for whom the scan will not change the decision to operate Radionuclide Scans : Liver-spleen scans, HIDA scans, and gallium scans may be useful for localizing intra-abdominal abscesses in rare cases. Radionuclide blood pool or Tc-sulfur colloid scans may identify sources of slow or intermittent intestinal bleeding. Technetium pertechnetate scans may reveal ectopic gastric mucosa in Meckel’s diverticulum PowerPoint Presentation: Endoscopy: Proctosigmoidoscopy is indicated in any patient with suspected large bowel obstruction, grossly bloody stools, or a rectal mass . Minimal air should be used for bowel insufflation. Besides reducing a sigmoid volvulus, colonoscopy may also locate the source of bleeding in cases of lower gastrointestinal hemorrhage that has subsided. Gastroduodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP) are usually done electively to evaluate less urgent inflammatory conditions (eg, gastritis, peptic disease) in patients without alarming abdominal signs PowerPoint Presentation: Paracentesis: In patients with free peritoneal fluid, aspiration of blood, bile, or bowel contents is a strong indication for urgent laparotomy. On the other hand, infected ascitic fluid may establish a diagnosis in spontaneous bacterial peritonitis, tuberculous peritonitis, or chylous ascites, which rarely require surgery. Culdocentesis may be useful for suspected ruptured corpus luteum cyst. Peritoneal cytology (obtained by direct aspiration through a fine catheter) or diagnostic peritoneal lavage may disclose tumor or an acute intra-abdominal inflammatory problem. These investigations should be used selectively after imaging studies in patients with equivocal findings and in those who would poorly tolerate a negative laparotomy PowerPoint Presentation: Laparoscopy: Laparoscopy is now a therapeutic as well as a diagnostic modality. In young women, it may distinguish a nonsurgical problem (ruptured graafian follicle, pelvic inflammatory disease, tubo-ovarian disease) from appendicitis. In obtunded, elderly, or critically ill patients, who often have deceptive manifestations of an acute abdomen, it may facilitate earlier treatment in those with positive findings while eliminating the added morbidity of a laparotomy in negative cases. Where appendicitis is confirmed, laparoscopic appendectomy may be performed. Increasingly, surgeons must acquire new laparoscopic skills in order to deal with other acute intra-abdominal conditions (eg, adhesive bowel obstruction) that previously demanded a formal laparotomy. Differential Diagnosis: Differential Diagnosis The age and gender of the patient help in the differential diagnosis : Mesenteric adenitis mimics acute appendicitis in the young, gynecologic disorders complicate the evaluation of lower abdominal pain in women of childbearing age, and malignant and vascular diseases are more common in the elderly. The clinical picture in early cases is often unclear. The following observations should be borne in mind: (1) Any patient with acute abdominal pain persisting for over 6 hours should be regarded as having a surgical problem requiring in-hospital evaluation . Well-localized pain and tenderness usually indicate a surgical condition. Systemic hypoperfusion in conjunction with generalized abdominal pain is seldom due to a nonsurgical problem PowerPoint Presentation: (2 ) Acute cholecystitis, appendicitis, bowel obstruction, cancer, and acute vascular conditions are the most common causes of the surgical acute abdomen in older patients. In children, appendicitis accounts for one third of all cases and nonspecific abdominal pain for nearly all of the remainder. (3) Acute appendicitis and intestinal obstruction are the most frequent final diagnoses in cases erroneously believed at first to be nonsurgical. Appendicitis should always remain a foremost concern if sepsis or an inflammatory lesion is suspected. It is the commonest cause of bizarre peritoneal findings that produce ileus or intestinal obstruction. Half of children with appendicitis present with a marked facial flush (due to high serotonin levels). The presence of the gas stoppage sign or x-ray findings of right lower quadrant ileus should raise the possibility of retrocecal or retroileal appendicitis. Appendicitis is less likely in previously healthy individuals if the history exceeds 3 days' duration and the patient has no fever, appreciable tenderness, ileus, or leukocytosis. Pelvic appendicitis, with mild abdominal pain, vomiting, and frequent loose stools, simulates gastroenteritis. The initial abdominal signs may be mild and the rectal and pelvic examinations unremarkable. A low white blood cell count or lymphocytosis favors gastroenteritis. Atypical presentations of appendicitis are encountered during pregnancy. Maternal illness and fetal death in such cases are caused mainly by complications following delayed diagnosis. Appendectomy is well tolerated during pregnancy, and removal of a normal appendix is more frequently tolerated than observation of a perforation. PowerPoint Presentation: (4) Salpingitis, dysmenorrhea, ovarian lesions, and urinary tract infections complicate the evaluation of the acute abdomen in young women. Many diagnostic errors can be avoided by taking a careful menstrual history and performing a pelvic examination and urinalysis. Ultrasound study and pregnancy tests are helpful in appropriate cases. Compared with patients with appendicitis, patients with acute salpingitis tend to present with a longer history of pain, often related to the menstrual cycle, and to have higher fever, bilateral pelvic signs, and a markedly elevated white blood cell count. (5) Unusual types or atypical manifestations of intestinal obstruction , especially early cases, are easily missed. Emesis, abdominal distention, and air-fluid levels on x-ray may be negligible in Richter hernia, proximal or closed-loop small bowel obstructions, and early cecal volvulus. Intestinal obstruction in an elderly woman who has not had a previous operation suggests an incarcerated femoral hernia or, rarely, an obturator hernia or gallstone ileus. There may be no pain or tenderness in the area of the hernia. Carefully examine the inguinofemoral region; repeat the rectal and pelvic examinations; and check for an obturator sign. Transient mild upper abdominal pain followed several days later by signs of intestinal obstruction is typical of gallstone ileus. Look for a radiopaque stone and air outlining the biliary tree on the plain abdominal x-ray PowerPoint Presentation: (6 ) Elderly or cardiac patients with severe unrelenting diffuse abdominal pain but without commensurate peritoneal signs or abnormalities on plain abdominal films may have intestinal ischemia. Arterial blood pH should be measured and visceral angiography performed expediently. (7) Medical causes of the acute abdomen should be considered and excluded if possible before exploratory laparotomy is planned . Upper abdominal pain may be encountered in myocardial infarction, acute pulmonary conditions (pneumothorax, lower lobe pneumonia, pleurisy, empyema, infarction), and acute hepatitis. Generalized or migratory abdominal discomfort may be felt in acute rheumatic fever, polyarteritis nodosa and other types of diffuse vasculitis, acute intermittent porphyria, and acute pleurodynia. Sharp flank pain, often accompanied by rectus spasm and cutaneous hyperesthesia, may be caused by osteoarthritis with thoracic or spinal nerve compression. Likewise, acute bursitis and hip joint disorders may produce pain radiating into the lower quadrants. Exquisite tingling or pinpricking sensations along a flank dermatome are characteristic of preeruptive herpes zoster. Medical Causes of an Acute Abdomen for which Surgery Is Not Indicated: Medical Causes of an Acute Abdomen for which Surgery Is Not Indicated Endocrine and metabolic disorders Infections and inflammatory disorders Uremia Tabes dorsalis Diabetic crisis Herpes zoster Addisonian crisis Acute rheumatic fever Acute intermittent porphyria Henoch-Schönlein purpura Acute hyperlipoproteinemia Systemic lupus erythematosus Hereditary Mediterranean fever Polyarteritis nodosa Hematologic disorders Referred pain Sickle cell crisis Thoracic region Acute leukemia Myocardial infarction Other dyscrasias Acute pericarditis Toxins and drugs Pneumonia Lead and other heavy metal poisoning Pleurisy Narcotic withdrawal Pulmonary embolus Black widow spider poisoning Pneumothorax Empyema Hip and back Indications for Surgical Exploration: Indications for Surgical Exploration Indications for Urgent Operation in Patients with an Acute Abdomen. Physical findings Involuntary guarding or rigidity, especially if spreading. Increasing or severe localized tenderness. Tense or progressive distention. Tender abdominal or rectal mass with high fever or hypotension. Rectal bleeding with shock or acidosis. Equivocal abdominal findings along with septicemia (high fever, marked or rising leukocytosis, mental changes, or increasing glucose intolerance in a diabetic patient). Bleeding (unexplained shock or acidosis, falling hematocrit). Suspected ischemia (acidosis, fever, tachycardia). Deterioration on conservative treatment. Radiologic findings Pneumoperitoneum. Gross or progressive bowel distention. Free extravasation of contrast material. Space-occupying lesion on scan, with fever. Mesenteric occlusion on angiography. Endoscopic findings Perforated or uncontrollably bleeding lesion. Paracentesis findings Blood, bile, pus, bowel contents, or urine. PowerPoint Presentation: A liberal policy of exploration is advisable in patients with inconclusive but persistent right lower quadrant tenderness. Pain in the left upper quadrant infrequently requires urgent laparotomy, and its cause can usually await elective confirmatory studies Preoperative Management: Preoperative Management After initial assessment, parenteral analgesics for pain relief should not be withheld. In moderate doses, analgesics neither obscure useful physical findings nor mask their subsequent development . Indeed, abdominal masses may become obvious once rectus spasm is relieved. Pain that persists in spite of adequate doses of narcotics suggests a serious condition often requiring operative correction. Resuscitation of acutely ill patients should proceed based on their intravascular fluid deficits and systemic diseases. Medications should be restricted to only essential requirements. Particular care should be given to use of cardiac drugs and corticosteroids and to control of diabetes . Antibiotics are indicated for some infectious conditions or as prophylaxis during the perioperative period . PowerPoint Presentation: A nasogastric tube should be inserted in patients likely to undergo surgery and for those with hematemesis or copious vomiting , suspected bowel obstruction , or severe paralytic ileus . A urinary catheter should be placed in patients with systemic hypoperfusion . In some elderly patients , it eliminates the cause of pain (acute bladder distention) or unmasks relevant abdominal signs. Informed consent for surgery may be difficult to obtain when the diagnosis is uncertain. It is prudent to discuss with the patient and family the possibility of multiple-staged operations, temporary or permanent stomal openings. PowerPoint Presentation: For your patience !!! Thanks