ACUTE ABDOMEN resident surgical presentation

Acute abdomen

1. ACUTE ABDOMEN

2. OUTLINE Introduction Etiology Clinical features Investigations Management Group features Conclusion References

3. INTRODUCTION An abdominal condition of sudden onset that may require immediate operative treatment Accounts for 7- 10% of all emergency department visits Many conditions can give rise to it Can be grouped broadly in eight categories

4. ETIOLOGY 1. Inflammatory conditions Acute appendicitis. Acute cholecystitis. Acute salpingitis. (Pelvic Inflammatory Disease) Acute diverticulitis 2. Haemorrhage Ruptured ectopic pregnancy. Traumatic rupture of viscera especially spleen. Ruptured aortic aneurysm Ruptured liver cell carcinoma Ruptured pseudo-aneurysm of splenic artery

5. ETIOLOGY 3. Perforations of hollow viscera Typhoid perforation of ileum. Perforation of peptic ulcer (duodenal or gastric). Perforation of gastrointestinal carcinoma. Traumatic perforations. Perforation of amoebic colitis Perforated diverticular disease 4. Colics Ureteric colic Biliary colic

6. ETIOLOGY 5. Intestinal Obstruction Strangulated external and internal herniae Bands and adhesions. Volvulus. Intussusception Mesenteric ischaemia or infarction Tumours , strictures and foreign bodies 6. Acute pancreatitis 7. Other Gynaecological conditions Ruptured Graafian follicle. Twisted ovarian cyst. Degenerating myoma .

7. ETIOLOGY 8. Medical conditions that may cause abdominal pain Gastro-enteritis Dysentery Gastritis Sickle cell disease Urinary tract infection Malaria Myocardial infarction Pneumonia Herpes zoster Hepatitis Prediabetic coma Measles, poliomyelitis, mumps

8. HISTORY Accurate history and methodical examination help solve the puzzle Age: Intussusception, tumours PAIN Duration: Acute appendicitis vs typhoid perforation Location : Radiation : gallstone coli, ureteric colic Onset : Character Severity : Aggravating factor/ Relieving factors: Progress :

9. Digestive Symptoms Nausea and vomiting Frequency Quantity Colour Presence of stale food Blood Effortless or projectile Anorexia Constipation or diarrhea

10. History Cont’d Urinary symptoms, reduced urinary symptoms Gynecological symptoms Last menstrual period (Ruptured ectopic gestation) Vaginal discharge (PID) Previous history History of dyspepsia Previous abdominal operation

11. EXAMINATION General condition May be acutely ill, in pain, shocked, or dehydrated Sunken eyes and cheeks Conjunctivae: palor or jaundice Tongue: Dry tongue suggests Temperature Pyrexia is indicative of inflammation Pulse : rate, volume and rhythm Blood pressure: Hypotension in shock

12. EXAMINATION Chest : Right basal pneumonia in a child Myocardial infarction Abdomen Inspection: Abdomino -Thoracic rhythm Distension Lump Hernial orifices

13. Abdominal Examination Cont’d Pointing Test Palpation : Tenderness Rebound tenderness Guarding or rigidity Ascites Auscultation Murphy's sign Rectal examination Vaginal examination Testes

14. INVESTIGATIONS Complete blood count Radiology Plain X-ray of the Chest and Abdomen Fluid levels or distended bowel Free gas in peritoneum or under the diaphragm Elevation of the diaphragm in subphrenic abscess Calcification in aortic aneurysm. Pulmonary or cardiac pathology Ultrasound: Hepatobiliary, renal and tubo -ovarian pathology and masses Calculi Ascites, inflamed appendix

15. INVESTIGATIONS Focused Assessment with Sonography in Trauma (FAST): In hypotensive blunt abdominal trauma patients CT Scan : Useful in stable patients with pancreatic pathology 4-quadrant peritoneal tap: Where other diagnostic methods are not available High false-negative rate Diagnostic peritoneal lavage: Trauma patients with equivocal abdominal sign

16. INVESTIGATIONS Urinalysis : RBC, WBC and crystals in ureteric stone Glucose: Diabetes Nitrites Laparoscopy In doubtful gynaecological conditions Others: Serum amylase, serum βHCG

17. MANAGEMENT Treatment depends on the cause In most cases the diagnosis is straight forward May require initial resuscitation: IV fluid therapy Nasogastric tube aspiration Hourly urine output monitoring Antibiotics where indicated May require laparotomy

18. CLINICAL FEATURES OF THE MAIN GROUPS Inflammatory group Pain is insidious, constant, throbbing and worse on movement Nausea or vomiting occurs once or twice Anorexia Tenderness, rebound tenderness, guarding or rigidity are localized May become generalized

19. CLINICAL FEATURES OF THE MAIN GROUPS Perforations Sudden onset, severe and constant pain Nausea or vomiting occurs once or twice Constipation i Generalized peritonitis, board-like rigidity Absent bowel sounds History of dyspepsia in peptic ulcer History of diarrhoea , fever and headache before the onset of severe abdominal pain in TIP

20. CLINICAL FEATURES OF THE MAIN GROUPS Intestinal Obstruction The cardinal symptoms are» Colicky abdominal pain Vomiting and/or distension Absolute constipation Signs Tender irreducible swelling in a hernial orifice A scar may be a pointer to the diagnosis Peristalsis may be evident Bowel sounds are increased and high pitched

21. CLINICAL FEATURES OF THE MAIN GROUPS Haemorrhage The signs are: Pallor Sweating Rising pulse rate Falling blood pressure Abdominal distension Abdominal tenderness history of missed period and slight vaginal bleeding In ruptured ectopic

22. CLINICAL FEATURES OF THE MAIN GROUPS Acute pancreatitis Patient, usually over 40, may collapse Severe upper abdominal pain with penetration to back Profuse vomiting with wretching Moderately distended abdomen with tenderness and guarding mainly in the upper abdomen Elevated serum amylase and lipase Glycosuria

23. CLINICAL FEATURES OF THE MAIN GROUPS Colics - Ureteric and Biliary Pain is severe, waxes, steady for some time, and then gradually wanes Restlessness, vomiting and sweating Ureteric colic Starts in the loin and radiates down towards the groin. Desire to micturate Macroscopic or microscopic haematuria . Ultrasound shows the calculus

24. CLINICAL FEATURES OF THE MAIN GROUPS Biliary colic Pain in right hypochondrium or epigastrium May radiate to the lower end of the right scapula Jaundice and fever Ultrasound reveals the calculi

25. Conclusion

26. References BAJA’s Principles and Practice of Surgery 5 th edition