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2/24/2012 1 Pain Suffering

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2/24/2012 2 Theatre…..

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2/24/2012 3

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2/24/2012 4 ACUTE ABDOMEN

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2/24/2012 5 Presented by: Dr:NAJAH M.NOURELDIN


2/24/2012 6 The onset of abdominal pain is a common condition, which demands an expedient diagnosis and treatment plan. The general rule for abdominal pain is: The majority of severe abdominal pains, which appear in previously healthy patients and last for at least six hours, may require surgical intervention. Emergent problems i.e appendicitis, perforated ulcer, intestinal obstruction, or other obstructive problems may require immediate surgical intervention. Introduction

Definition of the Acute Abdomen:

2/24/2012 7 Definition of the Acute Abdomen Acute abdomen may be defined generally as an intra-abdominal process causing severe pain and often requiring surgical intervention. It is a condition that requires a fairly immediate judgment or decision as to management. The assessment of these patients and the decision-making process regarding their management is crucial, since some will have life-threatening conditions that require surgical interventions either immediately or soon after resuscitation.

Definition (cont.):

2/24/2012 8 Definition (cont.) Others need a period of observation and conservative management, which may lead to surgery if the condition fails to settle or complications ensue.

Etiology: :

2/24/2012 9 Etiology: Generally, acute abdomen may arise from any of the following causes: Inflammatory. Mechanical. Neoplastic. Vascular. Congenital defects. Traumatic.

Inflammatory: :

2/24/2012 10 Inflammatory: The inflammatory category of causes may be divided into two subgroups: 1) bacterial  acute appendicitis, diverticulitis, and some cases of pelvic inflammatory disease. 2)  chemical  perforation of a peptic ulcer, where spillage of acid gastric contents causes an intense peritoneal reaction.


2/24/2012 11 Mechanical Mechanical causes include obstructive conditions as incarcerated hernia, post-operative adhesions, intussusception, malrotation of the gut, congenital atresia or stenosis of the gut. carcinoma of the colon is the most common cause of large bowel mechanical obstruction.


2/24/2012 12 Vascular Vascular entities include mesenteric arterial thrombosis or embolism. When the blood supply is cut off  necrosis of tissue + gangrene of the bowel.

Congenital defects:

2/24/2012 13 Congenital defects Congenital defects can produce an acute abdominal surgical emergency any time from the minute of birth (duodenal atresia, omphalocele or diaphragmatic hernia) to years afterward (chronic malrotation of the intestine). Traumatic causes of an acute abdomen range from stab and gunshot wounds to blunt abdominal injuries producing such conditions as splenic rupture.

Causes of acute abdomen :

2/24/2012 14 Causes of acute abdomen Anatomically, the causes of acute abdomen are: The upper abdomen: Liver: Acute hepatitis (viral or alcoholic)  swelling of the liver + stretching of (Glisson’s capsul). Liver tumours, (primary hepatoma or secondary metastases) due to haemorrhage or infarction.

Anatomical causes:

2/24/2012 15 Anatomical causes Biliary tract: Acute cholecystitis or biliary colic Acute cholangitis (infection/obstruction of biliary tree, often secondary to common bile duct stones. Oesophagus: Reflux oesophagitis Spontaneous rupture of the oesophagus due to (sever vomiting or retching (Boerhaave’s syndrome).

Anatomical causes (cont.):

2/24/2012 16 Anatomical causes (cont.) Stomach and duodenum: Peptic ulceration of the stomach and duodenum especially if perforated. Acute gastritis. Gastric carcinoma (rarely). Spleen: (torsion and/or infarction).

Anatomical causes (cont.):

2/24/2012 17 Anatomical causes (cont.) The lower abdomen: Small bowel: Obstruction Meckel’s diverticulitis mimic acute appendicitis. Terminal ileitis due to Crohn’s disease or yersinia infection.

Anatomical causes (cont.):

2/24/2012 18 Anatomical causes (cont.) Large bowel: Large bowel obstruction. Acute diverticulitis Ulcerative colitis or crohn’s colitis. Appendix: Acute appendicitis. Omentum and mesentery: Torsion of a portion of the greater omentum (rare). Mesenteric lymphadenitis

Anatomical causes (cont.):

2/24/2012 19 Anatomical causes (cont.) The retroperitoneum: Pancreas: Acute pancreatitis (gallstone or alcohol). Chronic pancreatitis  complicated by acute exacerbations. Infarction of a panceriatic tumour. Renal tract: Ureteric colic. Cystitis. Aorta: ruptured aortic aneurysm.

Anatomical causes (cont.):

2/24/2012 20 Anatomical causes (cont.) The pelvis: Ovaries: Mid-cycle lower abdominal pain( mittleschmers). Ovarian cyst (benign or malignant)  torsion/ rupture. Fallopian tube: Ectopic pregnancy Pelvic inflammatory disease. Uterus: Pelvic inflammatory disease Fibroids (Torsion /infarction).

Anatomical causes (cont.):

2/24/2012 21 Anatomical causes (cont.) The chest: Myocardium: Myocardial infarction. Congestive cardiac failure  acute epigastric pain (owing to congestion of the liver and tenderness under the right costal margin). Pericarditis  epigastric pain/ tenderness (if the diaphragm is affected). Lungs: Lobar pneumonia  (basal and close to the diaphragm).

 Other causes: :

2/24/2012 22 Other causes: Non-specific abdominal pain (NSAP): Is acute self-limiting abdominal pain of unknown etiology. It must be emphasized that (NSAP) is not a diagnosis but merely a convenient label to describe this category of patients with acute abdomen. Other rare causes include: Diabetic ketoacidosis, Herpes zoster, sickle cell crises, acute intermittent prophyria, familial Mediterranean fever and poisoning with lead, arsenic, chromium, copper, mercury, organophosphate and certain fungi.

The most common causes of acute abdomen in the west are: :

2/24/2012 23 The most common causes of acute abdomen in the west are: Condition percentage NSAP 34 Acute appendicitis 28 Acute cholecystitis 10 Small bowel obstruction 04 Gynaecological conditions 04 Acute pancreatitis 03 Renal colic 03 Perforated peptic ulcer 03 Malignancy 02 Diverticulitis 02 Dyspepsia 01 Miscellaneous 07

Acute abdomen in tropical countries:

2/24/2012 24 Acute abdomen in tropical countries In tropical countries, the spectrum of disease causing acute abdominal pain is very different from that seen in western countries, these diseases are: Malaria Ameobiasis Schistosomiasis Typhoid Abdominal tuberculosis Abdominal crises of sickle cell disease.

Malaria :

2/24/2012 25 Malaria Plasmodium vivax:  Enlarged spleen may rupture either spontaneously or in response to minor trauma. Plasmodium falciparum:  Abdominal presentations resembling appendicitis and acute abdominal pain have been described.


2/24/2012 26 Amoebiasis: Sudden perforation of amoebic ulcer a slow leaking through an extensively diseased bowel  peritonitis. In amoebic liver abscess  liver is enlarged and becomes tender.


2/24/2012 27 Schistosomiasis: Schistosoma haematobium:  Urinary bladder ulceration occur, it is accompanied by suprapubic or perineal pain.  renal colic. Shistosoma mansoni and schistosoma japonicum:  perforation and stricture of the colon occur, yet this is relatively uncommon.


2/24/2012 28 Typhoid The ulcration of terminal ilium  frank perforation causing peritonitis and sever bleeding. The deferential diagnosis includes perforated appendicitis.

Abdominal tuberculosis:

2/24/2012 29 Abdominal tuberculosis In the acute form, it causes severe abdominal pain that the abdomen is opened. The diagnosis is made thereafter by the presence straw coloured ascites and the finding tubercles. A biopsy of a portion of the omentum confirms the diagnosis.

Abdominal crisis of sickle cell disease::

2/24/2012 30 Abdominal crisis of sickle cell disease: Elongated sickle shaped and rigid red blood cells  increased blood viscosity.  block microcirculation of various organs,  episodes of pain and infarction in various organs in the gastrointestinal tract. A sickle cell crisis can present without acute abdominal pain and even with perforation and peritonitis.

History in patients with an acute abdomen :

2/24/2012 31 History in patients with an acute abdomen It is important to use a systemic approach in order to avoid missing important information. It will suffice here to concentrate on those parts of the history that are of specific importance in acute abdomen, these are:

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2/24/2012 32 Pain. Nausea and vomiting. Appetite. Bowel habit. Micturition. Dysphagia. Jaundice. Gynaecological symptoms. Weight loss. Past medical history. Drugs and allergies.

Pain :

2/24/2012 33 Pain When evaluating the pain the following should be considered: Site of pain: It’s useful to ask the patient to point with one finger to the precise spot. If the pain is diffuse, however, the patient will usually open the hand and rub it over the affected area.


2/24/2012 34 pain Shifting of pain: This is the feeling of pain in a position different than the first one, the pain in the original site disappears. The typical example is that of acute appendicitis in which the pain starts in the center then goes to the right iliac fossa. This is because the initial visceral pain is usually felt centrally and then shifts to the right lower quadrant when the overlying parietal peritoneum becomes inflamed.


2/24/2012 35 pain It is important to describe the site of the pain and this is best done by dividing the abdomen into nine areas or regions.


2/24/2012 36 pain Radiation of pain: The radiation is the feeling of pain in another position along with the original site. It’s important to ask whether the pain radiates anywhere i.e the back or to the shoulder or down to the groin. Typically, retroperitoneal pain i.e acute pancreatitis  the back. Irritation of the diaphragm  the shoulder and pain of ureteric colic will radiate from the renal angle to the groin.

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2/24/2012 37

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2/24/2012 38 Type of onset: Sudden  rupture of viscus, mesenteric thrombosis. Gradual  inflammations (cholecystitis, appendicitis.) Nature of pain: It's important to know if the pain is intrmittent or not and if it is intermittent, it's important to establish whether it is colicky in nature (i.e coming and going every few minutes). this is typical pattern of intestinal colic and should be differentiated from biliary or uretric colic.  in general, episodes of colicky pain reach a crescendo of intensity and make the patient restless.

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2/24/2012 39 Quality of pain: Dull - initial epigastric pain of appendicitis. Sharp - renal or biliary colic or obstruction of gut. Aching - pelvic inflammatory disease Pleuritic - intensified by breathing. Lancinating - acute pancreatitis. Tearing - dissecting aneurysm.

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2/24/2012 40 Intensity: severe - rupture of viscus moderate - RLQ appendiceal mild peptic ulcer, without perforation

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2/24/2012 41 Temporal features: continuous - acute pancreatitis pulsatile – abdominal aortic aneurysm colicky - lumen obstruction, intermittent severe pain with pain-free intervals The longer the duration the more likely a surgical condition.

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2/24/2012 42 Factors which intensify or relieve pain : relation to meals - peptic ulcer pain relieved by food, cholecystitis pain aggravated by fatty meal posture “Prone Jack-knifing” leg drawn up to decrease peritoneal irritation in suppurative appendicitis movement causes intense pain in generalized peritonitis and the patient lies still. Associated nausea and vomiting .

Nausea and vomiting::

2/24/2012 43 Nausea and vomiting: Nausea: Is the sensation of ensuing vomiting, heaving and retching may occur but there is no expulsion of gastric contents. Vomiting: Is the actual expulsion of gastric contents. time - early in high G.I. obstruction; late in low G.I. Obstruction. Character of vomitus - blood  bleeding ulcer. bile stained  obstruction below ampulla of Vater and fecal - intestinal obstruction, mechanical or with paralytic ileus; copious amount.


2/24/2012 44 Appetite: Change of appetite is important in the acute situation and recent anorexia is often found with intra-abdominal inflammation. It's important to know when the patient had his/her last meal or had anything to eat or drink. This is also important if general anathesia is being considered.

Bowel habit: :

2/24/2012 45 Bowel habit: The most important feature is whether or not this has changed in the recent past. A history of melena should be sought Diarrhea : If the patient has been having diarrhea, it should be noticed whether this is watery or loose stools and if there is blood. Most common with acute gastroenteritis, appendicitis or other focal inflammatory lesions of the gut. .

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2/24/2012 46 Constipation: It’s complete in small bowel obstruction 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


2/24/2012 47 Micturition: We should ask if there is any frequency, dysuria and cloudy or blood-stained urine. This will help in the diagnosisf U.T.I. Or if ureteric colic is suspected.


2/24/2012 48 Dysphagia: It's present if the patient had severe oesophagitis or neoplasm of the lower oesophagus or proximal stomach.

Jaundice: :

2/24/2012 49 Jaundice: It's useful to find out whether there have been previous episodes of jaundice. It's better to ask whether the patient has noticed any change in the color of the whites of the eyes and to ask about changes in color of urine and stool. This is important when suspecting biliary tract disease.

Weight loss: :

2/24/2012 50 Weight loss: It's highly indicative of malignancy or severe chronic inflammatory condition. Dysphagia from benign conditions can causes weight loss too (acalasia ).

    Gynaecological symptoms: :

2/24/2012 51 Gynaecological symptoms: Should be considered when examining female patients.

   Post medical history::

2/24/2012 52 Post medical history: The most important fact to establish is whether or not there have been previous episodes of similar pain and whether diagnosis had been made in the past. History of previous surgery is also significant. Complications resulting from either the surgery or anaesthesia should be carefully recorded.

Drugs and allergies: :

2/24/2012 53 Drugs and allergies: List of current medication. Allergies to medications. Especially antibiotics must be established. NSAIDs.

   Examination of a patient with acute abdomen: :

2/24/2012 54 Examination of a patient with acute abdomen: The first part of the examination of acute abdomen takes place as soon as the interview with the patient begins. General observation of patients color "pallor, jaundice" and general level of anxiety and distress is assessed.

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2/24/2012 55 It's essential to assess the patients circulatory state by feeling the pulse and looking for signs of hypovolaemia or dehydration. It is extremely important to carry out a through examination of the cardio-respiratory system. We should concentrate on the examination of the abdomen itself.

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2/24/2012 56 1st the patient should lie flat, we start by: observation: For obvious abnormalities such as distention, visible peristalisis, ecchymosis, vissible masses and previous operation scars. The patient should then be asked again to indicate the point of maximum tenderness so that palpation does not start at this point.

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2/24/2012 57 Palpation: Starting distant from the point of maximum tenderness. This is done to assess for tenderness, rebound tenderness, guarding or rigidity then deeper palpation should follow for abdominal masses and to palpate the liver, kidney and spleen.

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2/24/2012 58 Percussion: Useful in assessing the acute abdomen as it helps in the detection of gas-filled loops of bowel (tympanic note) or fluid (dull note), if ascites is suspected then shifting dullness should be elicited. also gentle percussion in assessing pain due to perotinitis  (rebound tenderness).

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2/24/2012 59 Auscultation: Intestinal obstruction  (typical high-pitched cavernous sounds), Borborygmi is the term applied to the very hyperactive bowel sounds associated with mechanical obstruction. In cases of a dynamic obstruction  exagerated . Abscent bowel sounds are considered if it’s not heard for 3 minutes. It is necessary to examine the groins, particularly for an irreducible hernia. For males, it's essential to to examine external genitalia , testicular pathology "torsion or orchitis may well present as lower abdominal pain"

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2/24/2012 60 Rectal examination: Is an integral part of abdominal examination. when doing PR it's important to: Palpate the prostate in male Palpate the cervix in females  pain (pelvic inflammatory disease). Pain on right side, pelvic appendicitis or abnormal pelvic masses. When the finger is withdrawn . it is important to check for blood, mucus or melaena.

   Investigation: :

2/24/2012 61 Investigation: General investigation: Complete haemogram Urine general Pus or blood in the urine  disease of the urinary tract and can also result from an inflamed appendix lying in proximity to the ureter or bladder. In dehydration the specific gravity of the urine  increased, and the red cell and hemoglobin values increased as a result of haemoconcentration.

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2/24/2012 62 The TWBCs + % of polymorphonuclear cells are  elevated in acute inflammatory conditions. Conditions in which tissue necrosis occurs, as in a strangulated intestinal obstruction, are generally associated with a marked polymononuclear leukocytosis. With acute appendicitis, the leukocytosis isn't great unless a perforated appendix is already present .

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2/24/2012 63 The serum amylase test is essential when the possibility of acute pancreatitis exists when it gives high reading. Certain tests are indicated when extra-abdominal conditions are suspected as the cause of an acute abdomen. These include blood and urine sugar determinations in diabetic keto- acidosis, hemoglobin electrophoresis in possible sickle cell crisis, chest x-ray in pneumonia, ECG in coronary artery disease, and lead levels in children with lead poisoning.

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2/24/2012 64 Serum electrolytes to determine the degree of dehydration and electrolyte imbalance should be done when fluid loss has been significant.

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2/24/2012 65 Specific investigations: Plain radiography. Contrast radiography. Endoscopy. Ultrasound. CT scan. Radionuclide scan.

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2/24/2012 66 Plain radiography: Erect chest x-ray:-  Gas under diaphragm.  Cardiopulmonary pathology.

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2/24/2012 67 Plain abdominal x-ray:- Dilatation of intestinal loops. free blood or fluid in the pritoneal cavity. distortion of the stomach air bubble. Kidney outlines: Calculi. Calcified wall of an aneurism other vesseles. Fractures (ribs, spine, pelvic).

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2/24/2012 68 Erect abdominal film: Is useful when intestinal obstruction is suspected.  Air-fluid level.


2/24/2012 69

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2/24/2012 70 Fig 3. Small bowel obstruction ­supine Fig 4. Small bowel obstruction­erect

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2/24/2012 71 Contrast radiology: Contrast enema: Large bowel obstruction to distinguish a mechanical obstruction from pseudo-obstruction. Contrast swallow: Rupture of the oesophagus. Using: Gastrogroffin. Niopam. Contrast radiology of renal tract: Intravenous urogram:  Haematuria + renal colic. Mesentric angiography:  Massive bleeding from small or large bowel.

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2/24/2012 72 Endoscopy: Upper gastro intestinal endoscopy: Epigastric pain. Gastrointestinal bleeding. Varices, bleeding peptic ulcer. Theraputic:- injection, sclerotherapy of varices and injection or coagulation of bleeding peptic ulcer. Colonscopy : Decompress large bowel in pseudo-obstruction. .

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2/24/2012 73 Flexible sigmoidscopy: Deflate sigmoid valvulus investigate nature of a stricture. inflammatory bowel disease.

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2/24/2012 74 Contraindication for flexible endoscopy: Risk of perforation, active inflammation + peritoneal irritation i.e toxic mega colon or acute diverticulitis. Rigid sigmoidscopy or proctoscopy : Rectal + anal bleeding.

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2/24/2012 75 Ultrasound: Indication: If available in the A & E department + only if the general condition of the patient allow. suspected cholelithiasis or acute cholecystitis. acute appendicitis. Detection of intra-abdominal abscess and fluid collection e.g pancreatic pseudocysts or ascites obstructive jaundice/appendicular masses confirmation. Investigations of palpable abdominal mass. suspected abdominal aortic aneurysm.

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2/24/2012 76 Computed tomographic scanning: Used for intra-abdominal abscesses with intravenous.(angio-CT) for severe pancreatitis ) pancreatic necrosis. Radionuclide scanning: E-HIDA scintiscanning )  cystic duct obstruction in patients with acute cholecystitis.

   Management of patient with acute abdomen: :

2/24/2012 77 Management of patient with acute abdomen: Resuscitation: This step should be considered to be of utmost importance as all patients going for surgery should be haemodynamically stable. A quick check of the pulse rate and blood pressure, “the pulse is the most sensitive indicator for the haemodynamic state”.

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2/24/2012 78 1. An I.V. canula is inserted, initially some blood is withdrawn for: a. grouping. b. Hb% & PCV. c. U & E. d. blood sugar. e. others. 2. I.V. infusions are inistituted, preferably crystalloids.

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2/24/2012 79 3.  A urinary catheter is inserted & the urine output is checked. 4. The patient is charted (pulse, Bp, urine output & abdominal signs) and the findings are continually registered & corrected. 5. Any electrolyte deficiencies are corrected. 6. Monitoring with a central venous line might be indicated in the elderly and unstable patients.

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2/24/2012 80 8.Generally analgesics are given when the diagnosis is known or the patient is considered for surgery. Analgesics are considered on arrival by some with the argue the idea that they mask the physical signs has been totally unfounded and has been excluded by clinical trials. (Cuschieri 2000)

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2/24/2012 81 Observation: Because the diagnosis of acute abdomen is not immediate a period of observation is needed if the patient is static or improving. To enable a definite plan of reassessment and to detect any signs. Re-evaluation of symptoms and physical signs. Regular measurement of pulse, blood pressure and temperature.

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2/24/2012 82 Laproscopy: Useful in management of lower abdominal pain in young women. It’s important to view the appendix, ovaries, fallopian tubes. Scan of the abdomen for free fluid or signs of inflammation of infarction must be done.

Laprotomy: :

2/24/2012 83 Laprotomy: Midline laparotomy incision is found to be quick, easy to give wide area of exposure, but still the site of the incision is determined by the pathology.

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2/24/2012 84 Examples of management of specific conditions

Acute appendicitis (1):

2/24/2012 85 Acute appendicitis (1) The diagnosis of Acute Appendicitis is clinical. Typically patients complain of central abdominal pain that shifts to the RIF And nausea. They are locally tender (in the RIF). Once diagnosed then the treatment is appendicectomy.

Acute appendicitis (2):

2/24/2012 86 Acute appendicitis (2) When decided to operate one should examine carefully for a mass in the area. If this can not be performed usually because of pain & muscle spasm then it should be remembered to examine when the patient is anaesthetized before opening the abdomen.

Acute appendicitis (3):

2/24/2012 87 Acute appendicitis (3) Having insured that there is no mass, then the abdomen is opened usually through: Grid-iron incision (at McBurney’s point) Lanz (transverse skin crease) incision give better exposure and con be extended. When in doubt of the diagnosis the a midline or Para-median incision is preferred.

Acute appendicitis (4):

2/24/2012 88 Acute appendicitis (4) Having entered the abdomen, Pus “if present” is mopped. The appendix is removed. If the appendix is not inflamed then another cause should be sought and dealt with as necessary.

Perforated peptic ulcer:

2/24/2012 89 Perforated peptic ulcer Duodenal ulcers are the ones that usually perforate. The patient would complain of sudden severe epigastric pain and may or may not give a history of peptic ulcer. On examination board-like rigidity is noted. Chest X-ray may show air under the diaphragm.

Perforated peptic ulcer:

2/24/2012 90 Perforated peptic ulcer After the patient is haemodynamically stable then surgical intervention is considered. This depends on the site of the perforation, that is:

Surgical treatment (1) :

2/24/2012 91 Surgical treatment (1) Perforated DU: Laparotomy with a midline incision. Thorough peritoneal lavage. The perforation is closed with an omental patch.

Surgical treatment (2):

2/24/2012 92 Surgical treatment (2) Perforated G U Should be excised and closed to exclude malignancy. Billroth II gasterectomy in some patients with big perforations. A third method for closure is Endoscopic closure of perforation.

Acute cholecystitis (1) :

2/24/2012 93 Acute cholecystitis (1) In this condition, the management is primarily conservative. The patient is put on Analgesics. NPO (this rests the bowel). NG tube and suction. IV fluids.

Acute Cholecystitis (2):

2/24/2012 94 Acute Cholecystitis (2) Antibiotics (Cefuroxime & Metronidazole). Monitoring of abdominal signs. Monitoring of pulse, BP, temp. & general condition of the patient. Usually the condition subsides in a day or two leaving the patient for cholecystectomy depending on the school of the surgeon.

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2/24/2012 95 Special Thanks to: Medical Information Center (Meridien Internet)

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