acute abdomen........................pptx

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1. ACUTE ABDOMEN Dr. Bethlehem Abera (General Surgeon, Ass. Professor of Surgery)

2. Introduction An acute abdomen is a clinical entity characterized by sudden onset of abdominal symptoms that demand urgent attention and management . Around 7%- 10% of emergency department visits are for acute abdomen(CDC). Acute abdomen can be medical or surgical That means, the underlying cause is either medically or surgically manageable.

3. Some of the medical conditions that give us acute abdomen are Diabetic ketoacidosis Hepatitis Basal pneumonia MI Addison’s crysis Porphyria

4. 4 important causes of acute abdomen Vascular causes Mesenteric ischemia Ruptured aneurismal arteries Infection AGE, colitis Inflammation Acute appendicitis, diverticulitis, IBD Obstruction of a hollow viscus Obstruction of biliary ducts Intestinal obstruction Renal colic

5. Approach In caring for the patient that has acute abdomen The first important thing is to determine if surgical intervention is needed Reaching to a definitive diagnosis timely is crucial Investigations can not replace the importance of vigilant clinical evaluation, i.e , history taking and physical examination.

6. History Abdominal pain Location of abdominal pain

7. Nature of abdominal pain in different causes of acute abdomen Obstructed hollow viscus Gradually worsening crampy abdominal pain with intervals of relief Can be colicky Associated nausea and vomiting Perforation of viscus, ruptured aneurism (usually life threatening) Excruciating, incapacitating pain Initially localized which can later be generalized Inflammation Gradually increasing discomfort, vague/dull aching and poorly localized abdominal pain that becomes more localized with time Eg - appendicitis, diverticulitis N.B.- there are always exceptions with patterns of abdominal pain!

8. Differential diagnosis

9. Acute appendicitis Cardinal symptoms Anorexia Periumbilical abdominal pain which later shifts to the RLQ area Nausea and vomiting Physical findings RLQ direct and rebound tenderness, guarding, rigidity Some findings specific to appendicitis are Rouvzing sign, psoas sign, obturator sign, Dunphy’s sign

10. If patients don’t present with classical s/s of acute appendicitis, we do the Alvarado score.

11. Intestinal obstruction Symptoms Crampy abdominal pain that comes with intervals Associated nausea/vomiting, failure to pass feces and flatus Abdominal distention Physical findings Abdominal distention, visible peristalysis Hyper-active or hypo-active bowel sounds in early or late presentation respectively Tenderness Hyper-resonant percussion not Ballooned rectum in sigmoid volvulus

12. Acute diverticulitis Abdominal pain localized to left lower quadrant especially in uncomplicated diverticulitis Fever, loss of appetite Abdominal tenderness more on LLQ and periumbilical area

13. Mesenteric ischemia The cardinal symptom is abdominal pain that is out of proportion. That means the physical finding of the abdomen is more stable than the symptoms patient is experiencing.

14. Acute cholecystitis Symptoms RUQ pain that is persistent and dull aching, radiates to the shoulder and back RUQ intermittent colicky pain is for biliary colic Associated loss of appetite, nausea and vomiting, fatty food intolerance Physical findings RUQ tenderness Positive Murphy’s sign GB can be palpable

15. Acute pancreatitis Symptoms Severe aching, epigastric pain that reliefs by leaning forward. Pain radiates to the center of the back Nausea, vomiting, loss of appetite Most have either history of gall stones or drinking alcohol Physical findings Epigastric tenderness, guarding and rigidity Cullen sign and Gray Turner sign can be seen in hemorrhagic pancreatitis

16. What is peritonitis

17. Peritonitis is inflammation or irritation of the peritoneum. Can be Primary occurs in the background of ascites, when the fluid is infected. Usually needs only medical management with IV antibiotics Secondary As it is self-explanatory, it occurs secondary to pathologies of abdominal structures E.g. perforation, inflammation, gangrene Usually requires surgical intervention Tertiary Occurs in the abdomen for which adequate surgical source control was made. Nosocomial infection

18. It is crucial to identify secondary peritonitis as early diagnosis and surgical intervention is life saving. Symptoms Abdominal pain Fever Nausea and vomiting Loss of appetite Can have normal stool, diarrhea or failure to pass feces or flatus Abdominal distention

19. Physical findings Acutely sick looking If delayed presentation/diagnosis- confusion, letargic Dry buccal mucosa, sunken eye balls Abdomen Abdomen doesn’t move respiration Direct and rebound tenderness Guarding and rigidity Hypoactive bowel sounds DRE- finding is different for each underlying cause

20. Peritonits is a clinical diagnosis!!