Acute abdomen power point presentat.pptx

Acute abdomen

1. Acute abdomen Presente r Dr Bukenya Ali Lecturer : M r Basimbe Francis

2. Objectives Introduction Causes Clinical presentation Investigations Overview of management

3. Introduction The term acute abdomen refers to any non-traumatic disorder of acute onset in which the symptoms are predominantly abdominal and for which in some cases, urgent surgery may be indicated. In practice, it represents a spectrum of problems ranging from sudden onset of severe abdominal pain with a life-threatening underlying cause to minor abdominal symptoms for short duration Patients of acute abdomen present with pain of varying severity depending on the cause 3 types of pain in acute abdomen: Visceral pain, Somatic pain, Referred pain

4. Visceral pain comes from the abdominal viscera, which are innervated by autonomic nerve fibers and respond mainly to the sensations of distention and muscular contraction. Visceral pain is typically vague, dull, and nauseating. It is poorly localized and tends to be referred to areas corresponding to the embryonic origin of the affected structure.

5. Somatic pain comes from the parietal peritoneum, which is innervated by somatic nerves, which respond to irritation from infectious, chemical, or other inflammatory processes. Somatic pain is sharp and well localized. Referred pain is pain perceived distant from its source and results from convergence of nerve fibers at the spinal cord. Common examples of referred pain are scapular pain due to biliary colic, groin pain due to renal colic, and shoulder pain due to blood or infection irritating the diaphragm.

6. Causes of acute abdomen The principal causes of acute abdominal pain can be: Inflammatory/infectious Perforation of a viscus Obstruction of a viscus Infarction/vascular Intraperitoneal/retroperitoneal haemorrhage

7. Site of abdominal pain in relation to suspected pathology RUQ Pain Acute cholecystitis Cholangitis Hepatitis Peptic ulceration

8. LUQ Pain Peptic ulceration Pancreatitis Splenic infarct

9. RLQ Pain Appendicitis Meckel's diverticulum Mesenteric adenitis Ureteric colic Rectus sheath haematoma Right-sided lobar pneumonia Twisted Ovarian cyst Ectopic pregnancy Pelvic inflammatory disease

10. LLQ Pain Sigmoid diverticular disease Ureteric colic Rectus sheath haematoma Left-sided lobar pneumonia Ovarian cyst Ectopic pregnancy Pelvic inflammatory disease

11. Radiating pain (Back, Groin ) Peptic ulcer Pancreatitis Aortic aneurysm Acute aortic dissection Ureteric colic Testicular torsion

12. vascular causes Ruptured aortic aneurysm Mesenteric embolus Mesenteric venous thrombosis Acute aortic dissection lschaemic colitis

13. Medical causes Degenerative disease of thoracic spine, herpes zoster, lobar pneumonia, pleurisy, MI; these cause referred pain Haematological : sickle cell crisis. Infective and inflammatory: tabes dorsalis (late stage syphilis), Henoch- Schonlein purpura. Endocrine and metabolic: uraemia , hypercalcaemia , diabetic ketoacidosis, Addison's disease, acute intermittent porphyria.

14. Clinical presentation of acute abdomen Pain : This can be remembered from the mnemonic ' SOCRATES ': S ite: where did it start, has it moved? O nset: sudden, gradual C haracter: e.g. dull, vague, cramping/colicky, sharp, burning R adiation: e.g. loin to groin in ureteric colic A ssociations: e.g. vomiting, diarrhea, fever, effect of movement, effect of micturition, etc. T iming: is the pain constant or intermittent; how long does the pain last? E xacerbations and relieving factors: what makes the pain better/worse? S everity: Pain score

15. Age: e.g. intussusception common in children, diverticulitis in the older patient • Vomiting: frequency, Color of vomitus, e.g. bilious, faeculent, blood Constipation: absolute constipation with colicky abdominal pain, distension, and vomiting suggests intestinal obstruction. Diarrhea: frequency, consistency of stools, blood stained

16. Fever Previous surgery, e.g. adhesions causing intestinal obstruction Recent trauma, e.g. delayed rupture of spleen Menstrual history, e.g. ectopic pregnancy.

17. General exam: Is the patient lying comfortably? Is the patient lying still but in pain, e.g. peritonitis? Is the patient writhing in agony, e.g. ureteric or biliary colic? Pulse, temperature, respiration Cervical lymphadenopathy. (mesenteric adenitis). Chest exam (e.g. referred pain from lobar pneumonia). Abdomen: Distension, visible bowel loops, soft, firm, area of tenderness, guarding, shifting dullness, Tympanic, masses, palpable, bowel sounds- high pitched in IO DRE

18. Patients with acute abdomen can be classified as Acute abdomen + shock, e.g. ruptured abdominal aortic aneurysm, pancreatitis Generalized peritonitis, e.g. perforated viscus Localized peritonitis, e.g. acute appendicitis Bowel obstruction Medical causes, e.g. lobar pneumonia

19. Investigations Blood work up: CBC, blood culture, RBS, CRP, ABGs, Pancreatic enzymes, RFTs Urinalysis Radiological: Plain abd xray , U/S, CT scan MRCP, ERCP CT Angiography IVU for stones Endoscopy, colonoscopy

20. Overview of Management Relieve pain Intravenous fluids Nasogastric tube Broad-spectrum antibiotics if peritonitis or sepsis Surgery if indicated.

21. Conservative treatment - numerous causes of an acute abdomen may only require conservative treatment, i.e. nil by mouth, antibiotics (e.g. acute cholecystitis). Observation - many patients may have equivocal clinical signs but be in the early stages of a condition. Time is a great diagnostic tool and frequent re-examination may reveal evolving signs.

22. Indications for surgery in the acute abdomen • Localized peritoneal irritation with guarding or rigidity • Spreading tenderness • Tense or progressive distension • Generalized peritonitis • Shock with bleeding or sepsis • Free gas on radiograph • Mesenteric occlusion on angiography • Blood, bile, pus or bowel contents on paracentesis.

23. Churchill’s book of surgery 4 th edition Medscape Uptodate