APPROACH TO ACUTE ABDOMEN

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APPROACH TO ACUTE ABDOMEN Dr.RAMKUMAR.S

The Acute Abdomen:

The Acute Abdomen

DEFINITION :

DEFINITION A syndrome of sudden abdominal pain with accompanying symptoms and signs that focus attention on the abdominal region. Pain of less than 24 hrs duration. Associated symptoms.

NEUROANATOMY OF PAIN:

NEUROANATOMY OF PAIN SENSORY NEURORECEPTORS – Mucosa, muscularis of hollow viscera, peritoneum and mesentry. Nerve fibres A delta – skin , muscle. - sharp sudden well localising pain -conveys somatoparietal pain through spinal nerves. C fibres - muscle , periosteum, mesentry ,peritoneum, viscera. - dull, burning , poorly localising pain. - substance P , Calcitonin gene related peptide

NEURAL PATHWAY:

NEURAL PATHWAY Visceral afferent fibers Dorsal horn cells (lamina 1 and 5 ) From the dorsal horn, second-order neurons transmit nociceptive impulses via fibers that pass across the anterior commissure and ascend the spinal cord in the contralateral spinothalamic tract thalamus and reticular formation The thalamic nucleus sends third-order neurons to the somatosensory cortex - discriminative aspect of pain. The reticular formation nucleus sends neurons to the limbic system and frontal cortex, where the emotional aspects of pain are interpreted

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Almost all nerve fibers that transmit painful sensation travel in association with sympathetic nerves ,hence, although 80% to 90 % of vagal fibers are afferent , vagotomy does not block abdominal pain. Stimulants - mechanical - chemical

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Mechanical – stretch is the chief stimulus. - cutting, tearing, crushing of viscera doesnot result in pain. Chemical - injury, inflammation, ischemia, necrosis. - H+ ions, serotonin, bradykinins, CGRP,PGs, LTs In hollow organs , afferent fibers situated in muscular wall. In solid organs , limited to capsule of the organ – mass lesions of liver parenchyma doesnot produce pain until it stretches the capsule.

TYPES OF PAIN:

TYPES OF PAIN Visceral pain – dull,poorly localised in midline epigastrium , periumblical, or hypogastrium because afferent fibres transmit to both sides of spinal cord. Somatoparietal pain - sharp, well localised, aggravated by coughing or movements. Eg acute appendicitis Refered pain – pain felt in areas remote from diseased organs - due to visceral & somatic afferent neuron converge on second order neuron in spinal cord at the same spinal segment. Eg- subphrenic hematoma or abscess.

APPENDICITIS – PSOAS SIGN:

APPENDICITIS – PSOAS SIGN

APPENDICITIS- OBTURATOR SIGN - passively flex right hip and knee and internally rotate hip:

APPENDICITIS- OBTURATOR SIGN - passively flex right hip and knee and internally rotate hip

Appendicitis: CT findings:

Appendicitis: CT findings Abscess, fat stranding Cecum

Abdominal Aortic Aneurysm:

Abdominal Aortic Aneurysm

CAUSES:

CAUSES ABDOMINAL INFLAMMATION – Acute appendicitis, pancreatitis , hepatitis, cholecystitis, diverticulitis, salpingitis,cholangitis. OBSTRUCTION – intestine,biliary, ureter. ISCHEMIA – Strangulated hernia, volvulus , thromboembolism, torsion of ovarian cyst PERFORATION – duodenum,stomach,colon,gall bladder RUPTURE – spleen, aorta, ectopic gestation.

EXTRA ABDOMINAL:

EXTRA ABDOMINAL CARDIAC – Ischemia,MI, Myocarditis,CCF THORACIC – Pneumonitis,pleurodynia, embolism, infarct,esophagitis,esophageal spasm,rupture. HEMATOLOGICAL – sickle cell anemia, hemolytic anemia , HSP , acutye leukemia METABOLIC – DKA, CRF, porphyria, addison disease, hyperlipidemia, hyperparathyroidism. TOXIN – lead, insect bite, reptile venom INFECTION – Zoster, osteomyelitis , typhoid NEUROLOGICAL – Spine disease,tabes dorsalis MISC – FMF, Psychiatry, narcotic withdrawal

Most Common Causes in the ED:

Most Common Causes in the ED Non-specific abd pain 34% Appendicitis 28% Biliary tract dz 10% SBO 4% Gyn disease 4% Pancreatitis 3% Renal colic 3% Perforated ulcer 3% Cancer 2% Diverticular dz 2% Other 6%

HISTORY:

HISTORY PAIN - ONSET SUDDEN – perforation,mesentric ischemia,rupture. GRADUAL – appendicitis,diverticulitis,small bowel obstruction, gastroenteritis,PID. - CHARACTER DIFFUSE – ischemia , rupture, obstruction,gastroenteritis. LOCALISED – cholecystitis,pancreatitis, diverticulitis. - DESCRIPTOR ACHING – Appendicitis, diverticulitis, PID AGONISING – ischemia. BORING – pancreatitis. BURNING – perforated DU CRAMPING – obstruction CONSTRICTING – cholecystitis. TEARING – Ruptured AAA.

History:

History Location gives clues to pathology Character – crampy usually from hollow viscus Progression often more important in post op patients

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RADIATION – scapula- cholecystitis. mid back – pancreatitis upper thigh – PID VOMITING,NAUSEA,ANOREXIA – non specific. feculent vomiting – colonic obstruction severe vomiting – MW Tear,Boerhaave syndrome. DIARRHOEA – BLOODY – IBD , ischemia,AGE WATERY – AGE CONSTIPATION – habitual - disease process eg. diverticulitis - complication eg. Perforation ABDOMINAL DISTENTION – Obstruction , ileus.

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PAST H/O : Recurrent – renal calculi,PID,small bowel obstruction(partial) HT – ruptured AAA DM – DKA HEART DISEASE – embolism. SLE , PORPHYRIA SICKLE CELL DISEASE , SCLERODERMA. ANALGESICS – DU.

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PERSONAL H/O : ALCOHOL – Pancreatitis - Perforated DU SMOKING – Ruptured AAA - Peptic ulcer NARCOTIC ABUSE IN FEMALES – STDs , pregnancy,menstrual disturbances ( PID , Ectopic, uterine rupture) OCCUPATION – Painters, toy workers.(Lead exposture)

CLINICAL EXAMINATION :

CLINICAL EXAMINATION Appearance : Hippocratic facies – peritonitis Posture : Mohammedian prayer sign – pancreatitis. Immobile – peritonitis. restless – ureteric colic , ischemia. Fever : Infective cause Jaundice: hepatitis, cholecystitis Pallor : ruptured AAA , Perforation.

ABDOMEN EXAMINATION :

ABDOMEN EXAMINATION INSPECTION : distension or not bluish discolouration periumblical - CULLEN SIGN flanks – GREY TURNER SIGN scars. PALPATION : Rebound tenderness ( Blumberg sign ) Guarding & rigidity – peritonitis. Rovsing sign, hypereasthesia in sherren triangle, differential tenderness – acute appendicitis Murphy sign - acute cholecystitis.

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AUSCULTATION : Bowel Sounds Absent – peritonitis. Increased – IBD, bowel obstruction, PID, AGE. Per Rectal exam : appendicitis Vaginal exam : manual & speculum.

INVESTIGATIONS :

INVESTIGATIONS CBC : Increased TC Hb low RFT : Urea , Creatinine blood sugar. LFT : Hepatitis,cholecystitis. S. Ca : pancreatitis. S . Amylase : 40 – 80 somogyi units > 400 – suggestive > 1000- diagnostic raised in salivary gland, fallopian tube,kidney,liver small intestine. S. lipase : Most Specific - < 40 U / dL

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URINE : Sugar , bilirubin , bile salts , porphobilinogen. STOOL : Fecal occult blood – IBD, bleeding peptic ulcer. S.Trypsinogen : increased in acute pancreatitis.decreased in chronic pancreatitis with steatorrhea. Normal in chronic pancreatitis without steatorrhea and steatorrhoea with normal pancreas. Other pancreatic function tests : CCK test, feces elastase,fecal nitrogen.

IMAGING :

IMAGING X RAY ABD : Perforation – air under the diaphragm. - ground glass appearance - obliteration of psoas shadow and preperitonial fat. Pancreatitis – Sentinal loop sign - Colon cut off sign Stones – Gall stone : 10% radioopaque porcelain GB Renal stone : 10% radiolucent,enlarged renal shadow. Obstruction - multiple air fluid levels > 2 in number. jejunum – volvulae conniventis produced by valve of kirckring ileum – characteristic loop of wangensteen large bowel – haustrations , incomplete mucosal folds not placed opposite to eachother. caecum – no haustrations.

Acute pancreatitis\dilated loop:

Acute pancreatitis\dilated loop

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USG ABD : Appendicitis – probe tenderness over RIF,Aperistaltic non compressible thick walled tubular organ. Pancreatitis – edematous pancreas. Cholecystitis – thickened GB , demonstrate gall stone Ectopic pregnancy,PID CT ABD : Pancreas – dilated pancreatic duct. To detect stones,abscess,pnumoperitoneum,calcification,trauma, portal vein inflammation (pylephlebitis) intraperitoneal hemorrhage. CT ANGIO : To evaluate aorta & visceral vasculature. To diagnose mesentric ischemia.

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ENDOSCOPY : To evaluate mucosa of stomach , duodenum and colon for ulceration , ischemia & inflammation Four quadrant abdominal tap : Aspiration of blood – hemopertonium,bowel gangrene Bile – biliary peritonitis Pus – gram-ve peritonitis. Amylase - pancreatitis

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Diagnostic laproscopy : - to reconfirm peritonitis - to diagnose pancreatitis ( lapratomy may be avoided.) -to treat primary cause eg closure of DU perforation - peritoneal lavage can be given Exploratory laprotomy : reserved for pts with intra abdominal catastrophe ( rupture AAA, spleen,ectopic pregnancy)

TREATMENT :

TREATMENT GENERAL MEASURES : NPO Ryle`s tube aspiration Bowel care- avoid purgatives Adequae hydration Correction of eletrolyte disturbances Vitals monitoring Higher antibiotics

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SPECIFIC TREATMENT : Treatment of the cause acute appendicitis – appendicectomy acute pancreatitis – 85% to 95% self subsided. Antibiotics usage is controversial.Imepenam cilastin 500mg tds for 7 days. Octreotide to decrease pancreatic juice . Glucagon,NSAIDS,Glucocorticoids,calcitonin,aprotonin are doubtful. Antifungal if pt develop candidiasis. surgery – infected necrosis,pancreatic abscess,doubtful diagnosis,massive bleed not responsive to conservative treatment,cholangitis not responding to treatment.

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Cholecystitis : cholecystectomy Gall stones : medical treatment indicated for pure cholestrol stones only. CDCA,UDCA – oral dissolution. methyl terbutyl ether - direct contact role. Bowel obstruction : exploratory laparotomy resection of gangrene and anastomosis adhesions – release bands – divide volvulus – untwist or resection stricture - stricturoplasty

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MESENTRIC ISCHEMIA : EARLY : Emergency angiography followed by papaverin infusion into affected artery can be tried. LATE : Massive resection of gangrenous bowel and end to end anastomosis. FORGARTY catheter used for embolectomy.

Confounding factors :

Confounding factors PREGNANCY EXTREMES OF AGE IMMUNOCOMPROMISED RECENT LAPRAROTOMY FEMALE GENDER

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PREGNANCY : MC Cause – appendicitis why confounding ..? - uterine enlargement displaces organs from their normal position.eg : appendix - RLQ to RUQ - Absence of parietal peritoneum irritation due to displacement from abdominal wall.

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EXTREMES OF AGE . INFANTS …? - Abdominal wall not developed muscularly so guarding not prominent - fever & leucocytosis diagnostic usefulness is reduced. ELDERLY..? - FEVER & LEUCOCYTOSIS less common even in advanced cases. - physical signs are diminished.

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IMMUNOSUPPRESSION : Physical signs are absent in patients with immuno compromised state, on chemotherapy,coticosteroid,organ transplantation. Early use of CT is appropriate

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RECENT LAPAROTOMY : acute abdominal process difficult to evaluate after recent lapratomy. uncomplicated recovery means lessening abdominal pain,resolving biochemical markers, predictable recovery from ileus and increase in mobility.failure to achieve this warrants investigation. MC cause of abdominal sepsis after operation due to inadequate of surgical technique.

Chronic abdominal pain manifesting as acute exacerbation :

Chronic abdominal pain manifesting as acute exacerbation INTERMITTENT : Mechanical – GB stone, sphincter oddi dysfunction,intestinal obstruction,hernia. Inflammatory – IBD , FMF,Endometriosis. Neurological /metabolic – porphyria.CRF , abdominal epilepsy,diabetic radiculopathy, Misc : Mittelschmerz,IBS,functional.

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CONSTANT : malignancy abscess chronic pancreatitis psychiatric

Abdominal Pain Clinical Pearls:

Abdominal Pain Clinical Pearls Significant abdominal tenderness should never be attributed to gastroenteritis Incidence of gastroenteritis in the elderly is very low Always perform genital examinations when lower abdominal pain is present – in males and females, in young and old In older patients with renal colic symptoms, exclude AAA Severe pain should be taken as an indicator of serious disease Pain awakening the patient from sleep should always be considered signficant Sudden, severe pain suggests serious disease Pain almost always precedes vomiting in surgical causes; converse is true for most gastroenteritis and NSAP Acute cholecystitis is the most common surgical emergency in the elderly A lack of free air on a chest xray does NOT rule out perforation Signs and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia have significant overlap If the pain of biliary colic lasts more than 6 hours, suspect early cholecystitis

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