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