Transcript The Acute Abdomen

The Acute Abdomen
Major causes of the 'acute
abdomen'
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Acute cholecystitis
Acute appendicitis or Meckel's diverticulitis
Acute pancreatitis
Peptic ulcer disease
Pelvic inflammatory disease
Intestinal obstruction, including paralytic ileus (adynamic
obstruction)
Acute intestinal ischaemia/infarction or vasculitis
Gastrointestinal haemorrhage
Non-surgical disease, e.g. myocardial infarction, pericarditis,
pneumonia, sickle cell crisis, hepatitis, inflammatory bowel
disease, opiate withdrawal, typhoid, acute intermittent
porphyria, HIV-associated lymphadenopathy or enteritis
Gallstones and Cholecystitis
 Gallstones
may cause no symptoms and
are occasionally discovered
 The second commonest presentation is
acute cholecystitis, caused by distension
of the gallbladder with subsequent
necrosis and ischaemia of the mucosal
wall.
Biliary colic
 The
pain starts suddenly in the
epigastrium,
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Vomiting often accompanies the pain,
Investigations
 Urinalysis,
chest X-ray and ECG may
help exclude other diseases.
 Ultrasound is the best way to
demonstrate stones.
 Ultrasonography can also allow
measurement of the diameter of the
common bile duct
Investigations
 Endoscopic
retrograde
cholangiopancreatography (ERCP) is
currently the only reliable and widely
available investigation for duct stones.
 CT may be useful when filling the bile
duct is unsuccessful
 Oral cholecystograms (contrast given
orally is concentrated in a healthy GB
Cholecystitis
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main difference from biliary colic is the
inflammatory component
 If the stone moves to the common bile
duct (CBD) jaundice may occur
 Ultrasonography confirms dilatation of the
common bile duct (>7mm diameter )
Non-surgical
 Biliary
colic and acute cholecystitis - these
conditions will usually respond to an opioid
such as morphine
 Pain continuing for over 24 hours or
accompanied by fever usually
necessitates hospital admission.
 Require antibiotics
Surgical
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Laparoscopic cholecystectomy
 Early surgery (within seven days of the onset of
symptoms) appears to be safe and shortens
hospital stay, but further studies are needed.
 Postoperative complications are rare but do
occur. The most significant is injury to the
bile duct which occurs at a rate of 0.2% in
both open and laparoscopic surgery.
Acute Appendicitis
 Sudden
inflammation of the appendix
usually caused by obstruction of the lumen
resulting in invasion of the appendix wall
by the gut flora.
 Appendicitis is more common in men.
 Appendicectomy is performed more
often in women
Classic symptoms
 Pain:
 Early
peri-umbilical pain moves after
hours or sometimes days to the right
iliac fossa
 Vomiting, anorexia
 Temperature and pulse are normal at first
 Rectal examination:
 TR-Appendicectomy
Intestinal obstruction and ileus
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Obstruction to free passage of contents can
occur at any level of the gut but problems such
as oesophageal stricture, oesophageal
carcinoma, carcinoma of stomach and pyloric
stenosis will not be considered here but only
obstruction beyond the duodenum. Ileus means
intestinal blockage. The term paralytic ileus is
used when the problem is inactivity of the bowel.
Ileus is often used as a synonym. This may also
be called intestinal pseudo-obstruction.
Risk factors:
 Small
intestinal obstruction is caused by
adhesions in 60%, strangulated hernia in
20%, malignancy in 5% and volvulus in
5%.
 Large intestinal obstruction is most
often the result of colo-rectal malignancies
 Sigmoid and caecal volvulus describes
rotation of the gut on its mesenteric axis
Paralytic ileus
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Paralytic ileus describes the condition in which
the bowel ceases to function and there is no
peristalsis.
chest infection
acute myocardial infarction
Stroke, trauma
acute renal failure
severe hypothyroidism
electrolyte disturbance
diabetic ketoacidosis
Clinical
 Central
abdominal pain
 Vomiting tends to be early in high level
obstruction
 Abdominal distension
 Check hernial orifices
 Plain abdominal x-ray is a very important
investigation
Management:
 Resuscitation
is very important
 Nasogastric tube will reduce vomiting
 Early surgery is required if there is local or
generalised peritonitis,
 The management of patients with
obstruction due to malignancy who are
unfit for surgery
Prognosis:
 The
prognosis of advanced carcinoma
of the colon remains poor. 25% have
distant metastases
 50% of sigmoid volvulus will recur in
the next 2 years
 60% of stomas are never reversed
 Older patients are less able to
withstand the rigours of serious illness
and major surgery
Acute Pancreatitis
 Pathogenesis
-Gallbladder disease and excess
alcohol consumption account for most
cases and typically cause periductal
necrosis.
Biliary disease and alcohol abuse together
account for 70%-80% of cases,
Signs
 Take
temperature to exclude hypothermia
 Probable tachycardia
 Epigastric or generalised abdominal
tenderness, often with rigidity.
 In severe cases: gross hypotension,
pyrexia, tachypnoea
 Hypoxaemia is characteristic of acute
pancreatitis
Investigations
 Serum
amylase >4 x normal:
 Raised bilirubin and/or serum
aminotransferase suggest gall stones.
 Hypocalcaemia is relatively common.
 CT with contrast enhancement may be
diagnostic where clinical and
biochemical results are equivocal on
admission
Management
 Pain
relief with pethidine or
buprenorphine ± IV benzodiazepines.
Morphine relatively contraindicated
because of possible spastic effect on
sphincter of Oddi.
 Nasogastric tube only for severe
vomiting.
 Antibiotics for specific infections.
Complications
 Pancreatic
necrosis
 Infected necrosis
 Pancreatic abscess
 Acute pseudocyst
 Pancreatic ascites
 Systemic complications Respiratory,
Cardiovascular, Disseminated
intravascular coagulopathy (DIC),
Hypocalcaemia