Acute Abdomen

 

 Acute abdomen Jan 26,2009

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Out line 1. 2. 3. 4.

 Acute abdomen abdomen Intestinal obstruction  Acute appendicitis appendicitis Peritonitis

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 Acute Abdomen 

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Defined as a Non-traumatic abdominal emergency characterized by sudden onset of abdominal pain. It signifies the need for prompt diagnosis/treatment, never be equated with need for mandatory operation. Even though most are self-limiting conditions, it presents a diagnostic dilemma.

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Introduction 

Most will be benign, however the small percentage of patients with a life-threatening condition need to be treated with greater urgency

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 Acute abdominal pain: Three categories 

Visceral ( Splanchnic) Tension,

stretch, ischemia, distension Dull poorly localized, mid line 

Parietal (Somatic) Parietal

peritoneal involvement Sharp, intense, discrete, well localized 

 Referred Same

as parietal, but felt remote

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Clinical evaluation: Pain 1. 2. 3. 4. 5. 6. 7. 8. 9.

Sudden/Gradual onset Time course of pain Site and character  Aggravating/Relieving factor  Aggravating/Relieving Radiation/Shift Pain severity Progression and migration  Analgesic use Prior history of similar pain 6

 

History: Associated Symptoms 

Nausea/vomiting Before or after pain? ◦

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Diarrhea/Bloody Before or after pain? ◦

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Constipation Jaundice

History of trauma Urinary symptoms Cough and chest symptoms  Alcohol intake  Associated symptoms

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Gynecologic Past illness history Family history Drug use

 Anorexia 7

 

Physical Exam: General 

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General Appearance ◦

Lies perfectly still: Inflammation, peritonitis

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Restless, writhing: Colic, obstruction

Vital signs ◦

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Tachycardic? Early shock (Important than BP) Rapid shallow breathing: peritonitis Level of hydration Fever 8

 

Physical Exam: Abdominal Abdominal 

Bowel Sounds Listen 1 minute in each quadrant before palpation ◦

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 Absent shock bowel sounds:

 ileus, peritonitis,

Palpate each quadrant ◦

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Work toward area of pain with warm hands Patient on back and knee bent (if possible)  Tenderness/Rebound tenderness, rigidity, involuntary guarding, voluntary guarding, masses 9

 

Physical Exam 

Percussion: Indirect rebound tenderness Gaseous or fluidly distention ◦

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Rectal exam Bleeding, Mass, Tenderness ◦

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Pelvic exam and testicular exam Chest exam ,Jaundice, pallor pallor,, Cullen's, Grey Turner urner’s, ’s, … …   10

 

 Abdominal Special Tests: Signs 

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Obturator Psoas

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Murphy’s   Murphy’s

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Rovsing’s   Rovsing’s

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Differential rential diagnosis of acute Diffe abdomen 

Children -gastrenteritis -acute appendicitis -mesenteric adenitis -meckel’s meckel’s   diverticulitis

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 Adult -acute appendicitis - incarcerated hernia -Volvulus -regional enteritis -ureteric colic -perforated peptic

-intussusception -incarcerated hernia -Urinary tract infection

ulcer -Urinary tract infection -torsion testis

-lobar pneumonia

-pancreatitis 12

 

DDX 

 Adult female -PID -Threatened abortion -mittelschmerz -pyelonephrosis -ectopic pregnancy -torsion/rupture of ovarian cyst -endometriosis

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Elderly -acute appendicitis -incarcerated hernia -diverticulitis -intestinal obstruction -colonic cancer -mesenteric infarction -aortic aneurism 13

 

Intestinal obstruction 

Dynamic -peristalsis is working against a

mechanical obstruction  Adynamic

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-absent peristalsis:-paralytic ileus -non propulsive form:-mesenteric vascular occlusion 14

 

Dynamic obstruction 

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Small bowel obstruction high-vomiting high -vomiting occurs early & profuse distension is minimal low low -pain  -pain is predominant -central distension -vomiting is delayed -multiple central fluid levels are seen on radiograph Large bowel obstruction -distension is early & pronounced -pain is mild -vomiting & dehydration are late -colon is distended in abdominal radiograph

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Dynamic obs. 

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 Acute obs.-usually obs.-usually seen in small bowel obs. -sudden onset of abdominal pain distension ,early vomiting & constipation Chronic obs.-usually obs.-usually seen in large bowel obs. -lower abdominal colic &constipation  Acute on chronic obs.-short obs .-short history of distension & vomiting against a background of Pain & constipation Subacute obstruction-incomplete obstruction-incomplete obstruction

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Cont’d 

Simple obstruction-blood obstruction-blood supply is intact

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Strangulated obs.-blood supply is compromisedobs.-blood

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Causes of bowel obstruction Dynamic   Dynamic 

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Intraluminal -impaction -foreign body -gallstones Intramural -stricture -malignancy Extramural -bands/adhesion -hernia -volvulus -intussusception

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Cont’d  Adynamic -paralytic ileus

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-mesenteric -mesenteri c vascular occlusion

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Pathophysiology 

Proximal bowel→dilates bowel→dilates &  & develops an altered motility

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Below the obstruction-normal peristalsis & absorption until it becomes empty 

If obstruction is not relieved→bowel relieved→bowel begins to dilate → reduction of peristalyitic strength→   strength→

flaccidity & paralysis

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Cont’d Cont’d   

Distension is caused by gas-nitrogen(90%) gas-nitrogen(90%) and hydrogen sulphide fluid fluid-digestive -digestive fluid and sequestration of fluid in the bowel lumen

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Strangulation Strangulation   

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Compromised blood supply Venous return is compromised first Extravasations of fluid Extravasations Hemorrhagic infarction Translocation of bacteria & their toxins

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Causes of strangulation 

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External -hernial orifices -adhesions/bands Interrupted blood supply -volvulus -intussusception Increased intraluminal pressure -closed loop obstruction Primary -mesenteric infarction

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 Acute intestinal obstruction obstruction Clinical features Vary according to

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-the location of obs. -the age of obstruction obstruction -the underlying pathology -the presence or absence of intestinal ischemia

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Cardinal features of obstruction  Abdominal pain 

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Distension

Vomiting  Absolute constipation constipation

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Cont’d 

Late manifestations -dehydration -oliguria -hypovolemic -hypovolem ic shock -pyrexia -septicemia -respiratory embarrassment embarrassment -peritonism

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Cont’d   Cont’d 

Clinical features of strangulation -constant pain -tenderness with rigidity -shock

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Radiological DX of bowel obstruction  

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abdominal film(Supine or erect) Small bowel obs. -straight segments lie central &transversely no gas is seen in the colon Jejunum-valvulae conniventes-ladder effect Ileum-featureless Cecum-gas shadow in the right iliac fossa Large bowel-houstral folds In advanced obstruction-air fluid levels becomes more conspicuous & more numerous

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RX of acute intestinal obstruction 

Principles of Rx -gastrointestinal drainage -fluid & electrolyte replacement -relief of obstruction

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appendicitis:  Acute appendicitis: 

 Acute appendicitis  Acute is the abdominal pain leading tocommonest emergency cause of 

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abdominal surgery Life time risk: 7%, 1.1 cases per 1000 people per year and some familial predisposition exists. The Pathophysiology of appendicitis is due to a closed loop obstruction of the appendix. hyperplasia of the submucosal lymphoid follicles. Fecaliths Parasites ◦

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Foreign bodies

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Incidence 

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Sex:: Male: female ~ 1.4:1. Sex Age: common in 2nd & 3rd decayed of life  life  Incidence of appendicitis is rare in neonate and infants, rises and peaks in the late teen years, and gradually declines in the geriatric years.

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In the younger child, the omentum is less developed and less likely to wall off a perforation, making peritonitis more likely. likely.

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Pathophysiology 

Obstruction of the appendiceal lumen Increasing intraluminal pressure + mucosal edema. Venous and lymphatic obstruction Ischemic Bacterial

inflammation of the appendix. proliferation Perforation  Arterial obstruction and gangrene gangrene Peritonitis develops. 

The overall mortality ~ 0.2-0.8% is attributable to complications of the disease..

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Clinical presentation 

Variations in the position of the appendix, age of the patient, and degree of inflammation make the clinical presentation of appendicitis notoriously inconsistent. ◦

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Periumbilical pain that shifts to the RLQ**~ 80% sensitive  Anorexia, nausea, few vomit vomit Diarrhea/Constipation Urinary symptoms  Afebrile or low-grade fever. fever.

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Physical findings 

 Tende  T enderne rness ss ◦

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Mc Burney’s  Burney’s 

Rebound tenderness Guarding and rigidity

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Rovsing’s Rovsing’s sign  sign Psoas sign Obturator sign

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Cough sign Generalized peritonitis RLQ mass PR tenderness or mass Inflamed scrotum hemi CVA tenderness Child Lies still

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Psoas sign

Obturator sign

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Laboratory studies 

WBC count and differential count Leukocytosis with a left shift ◦

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C-reactive proteins

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Urinalysis ◦

Irritation of the bladder or ureters by an inflamed appendix may result in a few WBCs in the urine.

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Imaging: Ultra sound 

Sensitivity = 85%, specificity = 94% in experienced hands. ◦

Specific findings can support the diagnosis.  Non-compressible dilated appendix  Transverse diameter of 6 mm or more. 

Lack of peristalsis Peri appendiceal phlegmon or abscess formation.  An appendicoliths  Focal tenderness over the inflamed 

appendix  

Ultra sound

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Management 

 A patient with with a classic history for appendicitis appendiciti s require prompt surgical intervention. ◦

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Kept NPO  Administer analgesics once decision is made IV fluids and ensure adequate hydration.  Antibiotics Gm-ve and anaerobic organisms such as E. coli  and  and Bacteroides.

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Surgery 

 Appendectomy is the definitive treatment for acute appendicitis. Rocky Davis/Grid iron incision ◦

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Fascia cut/Muscle spilt Identify the appendix and remove ?? No purse-string Local mopping or lavage Wound closure

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Surgical management 

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Appendiceal mass: mass: Conservative treatment, followed by elective appendectomy after 6 weeks. Appendiceal abscess: abscess: Drain abscess, leave appendix untouched if difficult to identify, elective surgery after 6 weeks.  weeks.  

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Complications        

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Perforation Sepsis Shock Dehiscence Wound infection Bowel obstruction  Abdominal/pelvic abscess Death (rare) The prognosis is generally excellent

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Peritonitis 

The term peritonitis symptoms & signs refers to a constellation of ◦

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 Abdominal pain pain Tenderness on palpation palpa tion  Abdominal wall wall muscle rigidity rigidity and Systemic signs of inflammation.

May be ◦

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Primary ► Spontaneous Secondary ► Related to a pathologic process in an organ Tertiary ► Persistent or recurrent infection after adequate initial therapy. 

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Paths of bacterial invasion 1.

Direct infection i. Via a GI perforation ii. Via an abdominal wall breach iii. Post operative: Drains, foreign materials

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Local infection i. From an inflamed organ ii. Migration through a gut wall iii. Via the fallopian tubes

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Blood-stream

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Microbiology 

Gram-negative ◦

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E coli

 Anaerobic

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Enterobacter species ◦

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Klebsiella species

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Proteus species  ◦

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Bacteroides fragilis 

Gram-positive ◦

Streptococcus species

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Enterococcus species

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Other Bacteroides  species

Clostridium species

 Anaerobic Streptococcus  species

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Natural history 1. 2.

Localized peritonitis Generalized peritonitis 1. Initial phase 2. Intermediate phase 3. Terminal phase

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Clinical features: History 

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The diagnosis of peritonitis is clinical!!!  Abdominal pain 

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Dull and poorly localized  Stea  Steady dy,, more more severe,  More severe  Generalized

Fever/ hypothermia  Anorexia, nausea and Vomiting Vomiting Diarrhea/Constipation Symptoms referable to specific organs

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Clinical features: Physical 

Physical exam Unwell and in acute distress Fascis hippocraticus Tachycardia, hypotension or overt septic shock.  Abdominal wall rigidity ◦

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Tenderness and rebound tenderness Patients avoid all motion and keep their hips flexed Hypoactive/absent bowel sounds. Rectal and vaginal findings

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Lab studies 

CBC with differential Leukocytosis/leuc

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openia with left shift 

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Serum electrolyte panel BUN and creatinine Coagulation profile Liver function tests

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Serum amylase and lipase levels Urinalysis  Aerobic and anaerobic blood cultures Peritoneal fluid analysis Intra operative fluid analysis

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Imaging studies: Auxiliary 

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Plain abdominal radiograph CXR Ultra sound Contrast scans

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Treatment 

The general principles of treatment are (1) To control the infectious source (2) To purge bacteria and toxins (3) To maintain organ system function (4) To control the inflammatory process. ◦

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Medical support includes ◦

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(1) antibiotic therapy (2) Systemic Intensive care and organ function support (3) Nutrition and metabolic support (4) Inflammatory response modulation therapy. therapy.

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Preoperative preparation 

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Fluid resuscitation + blood transfusion  Administration of antibiotics

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Oxygen

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Nasogastric intubation

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Urinary catheterization

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Monitoring of vital signs and homodynamic data.  Analgesia Early surgery

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 Antibiotic therapy 

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Begin empiric therapy , mainly active against gram-negative organisms and anaerobes. In uncomplicated peritonitis with early adequate source control, a course of 5-7 5 -7 days is adequate in most cases. Several studies suggest that antibiotic therapy is not as effective in later stages of the infection.

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Surgery 

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Surgery remains an important therapeutic modality for all cases of peritoneal infection.  Any operation should address the first 2 principles of the treatment of intra-peritoneal intra -peritoneal infections: Early and definitive source control Purging of bacteria and toxins from the cavity. ◦

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Complications of peritonitis 1.

2. 3. 4. 5. 6. 7. 8. 9.

Residual abscess Bacterial septicemia Bronchopneumonia Electrolyte imbalance Renal; failure Bone marrow suppression Multi organ failure Post operative adhesion Paralytic ileus

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Prognosis 

 Average mortality=10% mortality=10% ◦

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 Appendicitis, PUD: 10%  Appendicitis, Post operative: 50% Fecal: 75%

Mortality depends on: ◦

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the degree and duration of peritoneal contamination contamination the age of the patient The general health of the patient The nature of the underlying cause

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END

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