Acute abdomen

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APPROACH TO ACUTE ABDOMEN in adults

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Approach to acute abdomen :

Approach to acute abdomen Dr Ashok Kumar Assistant professor Dept of Surgical Gastroenterology SGPGIMS Lucknow

INTRODUCTION:

INTRODUCTION Demand prompt and decisive action Inflammatory, obstructive, or vascular Sudden onset of abdominal pain, gastrointestinal symptoms and varying degrees of local and systemic reaction Require urgent treatment, often including emergency operation Usually precludes prolonged investigation

IF IN DOUBT, OPERATE ? :

IF IN DOUBT, OPERATE ?

Purpose of course:

Purpose of course Define the acute abdomen . Describe the cause and pathophysiology of the following acute abdominal diseases: a. Acute appendicitis - inflammatory b. Acute small bowel obstruction - mechanical c. Mesenteric vascular occlusion- vascular d. Perforated duodenal ulcer - perforated viscus e. Peritonitis Identify and describe the symptoms, signs, clinical course and laboratory and x-ray findings for the acute abdominal diseases Identify the clinical features that help to distinguish the surgical from the non-surgical acute abdomen . Construct an approach to evaluation and management of the acute abdomen.

Definition of the Acute Abdomen:

Definition of the Acute Abdomen An intraabdominal process causing severe pain and often requiring surgical intervention . It is a condition that requires a fairly immediate judgement or decision as to management. SIX LARGE CATEGORIES: a . Inflammatory -   Bacterial , Chemical b. Mechanical -   Incarcerated hernia, Post-operative adhesions, Intussusception c. Neoplastic - d. Vascular - AAA, Embolism,  Mesenteric arterial thrombosis, NOMI, Mesenteric vein thrombosis e. congenital defects - Duodenal atresia, Omphalocele , diaphragmatic hernia, Malrotation of bowel   f . Traumatic -

EXERCISE 1:

EXERCISE 1 1. What is meant by the term "acute abdomen . 2. Give an example of an acute abdomen due to each of the following MACHNISM a . Inflammation b . Mechanical obstruction c . Vascular entities

Cause and pathophysiology of the following acute abdominal diseases::

Cause and pathophysiology of the following acute abdominal diseases: a. Acute appendicitis – Inflammatory b. Acute small bowel obstruction - Mechanical c. Mesenteric vascular occlusion – Vascular d. Perforated duodenal ulcer - Perforated viscus e. Peritonitis

Beware- Abdominal pain in the elderly:

Beware- Abdominal pain in the elderly Many more vague presentation Comorbid disease Morbidity and mortality rise after age 50 Twice as likely to need surgery after age 65 Diminished pain sensation

Pathophysiology of appendicitis:

Pathophysiology of appendicitis Obstruction of the appendiceal lumen by fecaliths   Interference of the vascular supply Invasion by bacteria   Superficial ulceration of the mucosa Necrosis and perforation   Localized abscess  Generalized peritonitis

Acute appendicitis:

Acute appendicitis

Pathophysiology acute small bowel obstruction:

Pathophysiology acute small bowel obstruction Associated interference with the blood and nerve supply for the intestines Strangulated Obstruction Oedema of the gut Impairment of the blood supply Ischemic necrosis or infarction Gangrenous .

Acute small bowel obstruction:

Acute small bowel obstruction

Acute small bowel obstruction clinical presentation:

Acute small bowel obstruction clinical presentation Nausea , vomiting, cramping abdominal pain, and obstipation (inability to pass flatus or stool ) Proximal versus distal Abdominal pain Nausea and vomiting  Dehydration Abdominal distension High-pitched “tinkling

PROX –VS- DISTAL INTESTINAL OBSTRUCTION:

PROX –VS- DISTAL INTESTINAL OBSTRUCTION PROX DISTAL

Pathophysiology Mesenteric vascular occlusion:

Pathophysiology Mesenteric vascular occlusion Recent myocardial infarction and atrial fibrillation   Thrombosis or embolism of the superior mesenteric vessels   Paralytic obstruction without any mechanical blockage Congested , oedematous and finally necrotic

Pathophysiology-Mesenteric ischemia:

Pathophysiology-Mesenteric ischemia

Acute Mesentric ischemia clinical presentation:

Acute Mesentric ischemia clinical presentation Rapid onset severe periumbilical abdominal pain (Which is often out of proportion to finding of physical examination) Accompanied by forceful bowel evacuation Hemodynamically unstable patient who are worsening, despite optimal therapy MESENTRIC VEIN THROMBOSIS - After 1-2 weeks

Pathophysiology Perforated Duodenal Ulcer :

Pathophysiology Perforated Duodenal Ulcer Stage of peritonitis Acid peptic juice , bile and pancreatic juice come in contact with general peritoneal cavity Patient cries out with sever pain in this stage Stage of reaction Peritoneum react to chemical insult by secreting peritoneal fluid copiously (sterile ), this give relief of pain and last for 3-6 hours Stage of diffuse peritonitis Acid secretion abolished once perforation occurs Since there is no acid barrier. Bacterial invasion become easy There is diffuse bacterial peritonitis

EXERCISE 2 :

EXERCISE 2 1. Outline the sequence of events in the pathogenesis of acute perforated appendicitis . 2. The two most common causes of acute mechanical small bowel obstruction in adults are. 3. What is the sequence of changes which occur when a loop of bowel becomes strangulated. 4. What is the underlying mechanism of the rapid development of generalized peritonitis, hypovolemic shock and perforated duodenal ulcer.

Clinical presentation of acute abdomen pain :

Clinical presentation of acute abdomen pain Think OLD CAR O – Onset L - Location D - Duration C - Character A – Aggravating /Alleviating factors R - Radiation S - Severity

ACUTE ABDOMINAL PAIN:

ACUTE ABDOMINAL PAIN HISTORY IS MORE VALUABLE Perception of pain Visceral Somatic Visceral pain tension in muscle fiber Obstructing pain Sever and cramping n nature Ischemic pain Pain loss of motility distension Somatic pain localized tenderness spasm of muscle

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REFERRED PAIN Pain other than stimulated site Epigastric pain – T6 – T8 Periubillical pain – T9-T10 Hypogastric pain – T11-T12 RADIATION OF PAIN – moving pain – eg – appendicitis , acute cholecystitis, renal colic LOCATION CAUSES Right Shoulder Liver, Bile duct, Right hemi diaphragm Left Shoulder Heart, Caudal pancreas, Spleen, Scrotum and Testis Ureter

T5-T8 T9-T10 T11-T12:

T5-T8 T9-T10 T11-T12

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Biliary colic Ureteric colic ey stone Smal Intestinal obstruction Colon obstruction

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Cholecystitis patitis Tubo ovarian abscess or ectopic pregnancy ncy pancreatitis diverticulitis

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Perforated ulcer Pielo Nephritis,renal or ureteric colic Perforated ulcer

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Cholecystitis Appendicitis Pancreatitis

COMPARISON OF COMMON CAUSE OF ABDOMINAL PAIN:

COMPARISON OF COMMON CAUSE OF ABDOMINAL PAIN

History – more info:

History – more info PMH- prior episodes; prior medical conditions making some diagnoses more common PSH – adhesion cause SBO Medication – NSAIDS, Abx Social- drugs, withrawal Gyn / urol - timing of periods, bleeding, testicular pain, bloody urine

Physical exam:

Physical exam Vitals General- Appears sick or in obvious pain Inspection- Bruises , scars, distension Auscultation- Hyper, normal , none Palpation- tenderness ( Start away from painful area, guarding ) Extra- abdominal exam

Physical Examination:

Physical Examination APPROACH … Calm, Gentle, Sympathetic Deep palpation – Deferred ..muscle spasm/tenderness is very marked Very painful Uninformative Unnecessary Pointing ........for peritoneal inflammation Jarring test Percussion .. demonstrate …… Fluid or Gas Rectal/ pelvic examination Bowel sound …

Physical eaxm signs:

Physical eaxm signs Murphys Rovsings Iliopsoas obturator

PRIMARY SURVEY:

PRIMARY SURVEY FEVER EVIDENCE OF SHOCK HEMORRAGE ANAEMIA DEHYDRATION CARDIAC DECOMPANSATION

RESUCCITATION:

RESUCCITATION HISTORY / EXAMINATION ………………….Deferred Temporarily TEMPRETURE /PULSE/RR/BP…………………Base line recording Complete / Systemic examination for all organs CARDIAC/ LUNG EXA….. Extra abdominal cause of abdominal pain Satisfactory condition for surgery

Investigation:

Investigation LABORATORY – Hb %, TLC , DLC S- Amylase, sugar, RFT, S- Electrolytes X- Ray Examination – immediate Supine AP erect Plain film in upright position ……………..OBSTRUCTION USEFULL – Gall Stone, Kidney, Porcelin Gall Bladder, chronic pancreatitis GI barium study - intussusception, diverticulitis Sigmoidoscopy - biopsy

X- RAY ABDOMEN:

X- RAY ABDOMEN

Surgical VS nonsurgical acute abdomen:

Surgical VS nonsurgical acute abdomen Severe abdominal pain persists as long as six hours . Persistent localized tenderness with muscle spasm or The tenderness may on rectal or pelvic exam . CHARACTERISTIC - Severe , intermittent cramping, colicky pain, with obstruction of a hollow viscus . Markedly hyperactive bowel sounds , or decreased to absent bowel sounds 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 - with intussusception. Adnexal mass by pelvic exam - ectopic pregnancy. Tender and thickened adnexae by pelvic in PID. An irreducible incarcerated inguinal hernia. A tender RLQ mass by abdominal palpation or rectal exam appendiceal abscess .

Certain tests when associated with characteristic clinical features: Surgical abdomen:

Certain tests when associated with characteristic clinical features : Surgical abdomen Free air under diaphragm Distended loops of small bowel above the level of obstruction with absence of gas below by x-ray; Intra mural gas Features of obstruction with intra luminal stone

EXERCISE 4 Questions:

EXERCISE 4 Questions 6 causes of right lower quadrant pain in a adult female. Identify 2 or 3 clinical features of each of the above on which a reasonable presumptive diagnosis can be based . Which of the above require immediate or fairly immediate surgery? Explain the clinical features which led you to decide that surgery is indicated in each of the conditions you selected .

The Acute Abdomen in the Morbidly Obese :

The Acute Abdomen in the Morbidly Obese More challenging Subtle changes in Vital signs, atypical symptoms, and underwhelming physical exam A mildly elevated heart rate, fever, nausea, and malaise may be the only indications Obese body habitus, interpreting any exam findings more difficult . By the time the patient is found to have peritonitis, it is often imaging studies being unattainable or more difficult to interpret Tools - high index of suspicion ……………operate or not. Advent of laparoscopy and the development of bariatric laparoscopic ports and instruments less invasive measures may be taken to both diagnose and treat the source of the patient’s symptoms.

Evaluation and Management of the Acute Abdomen Priority I  :

Evaluation and Management of the Acute Abdomen Priority I   Indicates   catastrophic   events - Perforation of a viscus, massive hemorrhage, sudden arterial occlusion with extensive tissue necrosis CHARACTERIZATION-  * Sudden onset of severe continuous pain , * Moderate to extreme abdominal tenderness and muscle spasm , * Rapid development of shock CONSEQUENCES – Mark tissue damage - Fluid loss, chemical and vascular insult

Supportive and resuscitative measures :

Supportive and resuscitative measures   Intravenous correction of fluid Electrolyte imbalance , Blood replacement, Gastric suction, Vasopressor agents, Oxygen , narcotics Emergency operation as soon as the patient's condition permits ( Orderly approach should abandoned ) ACUTE PANCEARTIS AND MYOCARDIAL CAUSES MUST BE EXCLUDED

Priority II:

Priority II Conditions associated with vigorous smooth muscle contractions E ARLY PHASE (No systemic reaction) ……… NEED SURGICAL TREATMENT PREVENT ISCHEMIC NECROSIS D X - Clinical evaluation , Hyperactive bowel sounds, Demonstration by x- ray of distended loops of gut Mx – Fluid electrolytes correction Gastric suction SURGERY Biliary colic, Renal colic, Gastroenteritis CONCERVATIVE TREATMENT

PRIORITY III:

PRIORITY III Lowest category of urgency Inflammatory condition- ABD Pain, Possible acute abdomen PROGRESSION …..Several hours ……………………..Few days Considerably requires more time to observe Localized ( C/L , INV ) Perforated Until a diagnosis  made Antibiotic should differ Mask the pain Change the course

PRIORITY III……..:

PRIORITY III…….. eg . Acute appendicitis Dx Clinical Operation Diverticulitis Acute cholecystitis good condition ….. Cholecystectomy Seriously ill……..defer operation for 6 week

Treatment Of Right Upper Quadrant pain Algorithm :

Treatment Of Right Upper Quadrant pain Algorithm

Treatment Of left Upper Quadrant pain in adults Algorithm :

Treatment Of left Upper Quadrant pain in adults Algorithm

Treatment Of Right lower Quadrant pain Algorithm :

Treatment Of Right lower Quadrant pain Algorithm

Treatment Of left Upper Quadrant pain Algorithm :

Treatment Of left Upper Quadrant pain Algorithm

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REGIONAL ENTERITIS – Chronic granulomatous inflammation C/L – weight loss, bout of infection, diarrhoea, cramping Barium- study- string appearance Acute PID – C/L, Culture of cervical discharge Tx General supportive measure+ vigorous antibiotic MISCELLNEOUS GROUP CONDITION – Prominent pain Avoid mistake in Dx and Tx Eg . Diabetic acidosis, lead poisoning, sickle cell crisis, black widow spider bite

NONSURGICAL CAUSES OF THE ACUTE ABDOMEN :

NONSURGICAL CAUSES OF THE ACUTE ABDOMEN METABOLIC Diabetic ketoacidosis Porphyria Adrenal insufficiency Uremia Hypercalcemia TOXIC Insect bites Venoms (scorpion, snake) Lead poisoning Drugs MISCELLANEOUS Hemolytic crises Rectus sheath hematoma NEUROGENIC Herpes zoster Abdominal epilepsy Spinal cord tumor , infection Nerve root compression CARDIOPULMONAR Y Pneumonia Myocardial infarction Myocarditis Empyema Costochondritis

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