ACUTE ADOMEN AND APPENDICITIS for Surgery.ppt

ACUTE ADOMEN AND APPENDICITIS for undergraduate Surgery

1. Surgical Education SeriesSurgical Education Series
The Acute AbdomenThe Acute Abdomen
CHARLES ADEYINKA ADISA
ABIA STATE UNIVERSITY

2. Acute AbdomenAcute Abdomen

3. OutlineOutline
•Definitions
•What causes an “acute abdomen”
•Differential Diagnosis
•History and physical
•Labs
•Diagnostic imaging
•Special emphasis
•Appendicitis
•Bowel infarction
•Perforated viscous

4. Acute AbdomenAcute Abdomen
Symptoms and signs of acute
intra- abdominal disease
processes, usually treated best by
surgical operation

5. Common Causes of Abdominal Pain
of Surgery, 16th ed.

6. Ag e
Time and mode of onset of pain
Duration of symptoms
Character of pain
Location of pain and site(s) of
radiation
Associated symptoms and their
relation to pain
Nausea or anorexia
Vomiting
Diarrhea or constipation
Menstrual history
DIAGNOSIS: KEY HISTORICAL FEATURES IN
ACUTE ABDOMINAL PAIN

7. General observations
 
  General appearance
 
  Attitude in bed
 
  Vital signs, including temperature
Chest
 
  Auscultation
Abdomen
 
  Inspection (distention, localized swelling, hernia)
 
  Percussion (tympany or dullness, tenderness, referred tenderness)
 
  Palpation (muscle rigidity, tenderness, [rebound pain], hyperesthesia)
 
  [Auscultation]
Pelvis
 
  Rectal examination (tenderness, presence of stool, occult blood, mass)
 
  Bimanual examination (cervical motion tenderness, adnexal masses)
 
  Obturator sign
Back and flanks
 
  Percussion (costovertebral angle tenderness)
 
  Iliopsoas sign

8. Acute Abdomen-SymptomsAcute Abdomen-Symptoms
•Symptoms linked to visceral distention
or ischemia
•Inflammation of the peritoneum
•Parietal component provides localization
•End result of a process involving viscera
•Early diagnosis means understanding
the patterns that lead up to peritoneal
irritation

9. Symptom QualitySymptom Quality
•Timing
•Matched to clinical condition
–Emerges over time and then concentrates (acute appy)
–Sudden onset (perforated viscous)
•Referred pain
•Linked to anatomic distribution
•Required reading
•Copes “ Early diagnosis of the Acute abdomen”

10. TABLE 74.3 DIAGNOSIS: SITES OF REFERRED
PAIN
Site Organ(s) Common examples
Right
subscapular
or shoulder
Diaphragm, gallbladder,
liver
Biliary colic, perforated
ulcer,
pneumoperitoneum
Left
subscapular
or shoulder
Diaphragm, spleen,
stomach, tail of pancreas,
splenic flexure
Splenic rupture,
pancreatitis
Back Pancreas, duodenum, aorta Pancreatitis, ruptured
AAA
Coccyx Uterus, rectum Uterine colic
Groin or
genitalia
Kidney, ureter, iliac arteriesUreterolithiasis
AAA, abdominal aortic aneurysm.

11. Process Common examples
Obstruction Intestinal colic, renal calculi, biliary colic
Inflammation Enterocolitis, mesenteric adenitis
Perforation Perforated peptic ulcer
Torsion Ovarian torsion, sigmoid volvulus
Ischemia Mesenteric artery thrombosis, splenic
infarction
ETIOLOGY: PATHOLOGIC PROCESSES
UNDERLYING ABDOMINAL PAIN

12. History of Present IllnessHistory of Present Illness
•O nset
•P recipitating/ relieving
•Q uality
•R adiation
•S everity
•T iming

13. Physical ExaminationPhysical Examination
•Overall appearance
•Walking and recumbent
•Vital signs
•Temperature
–High/low/low-grade
•Tachycardia
•Hypotension
•Inspection: scars, hernias, masses
•Auscultation
•Palpation

14. Physical ExaminationPhysical Examination
•Percussion:
•Tenderness
–No sudden moves
–Take your time
–Rigidity and guarding
–“Board-like abdomen”
•Tympanitic
•Dull

15. Lab TestsLab Tests
•WBC + differential
•Basic chemistry panel
•K
•Bicarbonate
•Amylase
•Liver function tests
•Urinalysis
•Pregnancy test

16. Diagnostic ImagingDiagnostic Imaging

17. Plain FilmsPlain Films
•Upright CXR
•“Free” air
•KUB (kidney/ureter/bladder)
•Calcifications
•Air/ Fluid levels
•Reactive bowel patterns
•Foreign bodies

18. •LATERAL DECUBITUS

19. Lateral Decubitus FilmLateral Decubitus Film

20. UltrasoundUltrasound
•Rapid, safe, low cost
–Operator dependent
•Fluid, inflammation, air in walls, masses
•Liver, GB, CBD, Spleen, Pancreas,
Appendix, Kidney, Ovaries, Uterus

21. UltrasoundUltrasound
Textbook of Sabiston, 16th ed.

22. CT ScansCT Scans
•Better than plain films and US for
evaluation of solid and hollow organs
–Intravenous contrast
–Oral contrast
–Per rectal contrast
•High use in appendicitis, diverticulitis,
abscess, pancreatitis

26. When to Operate ?When to Operate ?
•Peritonitis
•Excluding primary peritonitis
•Abdominal pain/tenderness + sepsis
•Acute intestinal ischemia
•Pneumoperitoneum
•Make sure pancreatitis is excluded

27. What if it’s not clear?What if it’s not clear?
•Challenging patients
–Neurologically compromised
–Intoxicated
–Steroids
–Inmmunosupressed
•If signs and symptoms are equivocal
–Serial exams (same person)
–Imaging
–Serial labs (check for WBC increases)
–Keep off antibiotics
–“Tincture of time”

28. When When NOT NOT to Operate ?to Operate ?
•Cholangitis
•Appendiceal mass
•Acute diverticulitis + abscess
•Acute pancreatitis or hepatitis
•Ruptured ovarian cysts
•Long standing perforated ulcers?

29. Non Surgical CausesNon Surgical Causes
•MI, Acute pericarditis
•PTE, pulmonary infarction
•GE reflux, hepatitis
•DKA, Ac Adrenal Insufficiency
•Acute Porphyria
•Rectus muscle hematoma
•Pyelonephritis, Acute salpingitis
•Sickle cell crisis

30. AppendicitisAppendicitis

32. ANATOMYANATOMY
LYMPHOID/IMMUNE ORGAN
APPEARS 5
TH
MONTH OF GESTATION
POSITION VARIES
2-20CM(9CM)
ILEOCOLIC ARTERY
AUTONOMIC NERVOUS SYSTEM
ABSENT IN DOGS,LIONS
TIGERS ,PRESENT IN PRIMATES

33. AppendicitisAppendicitis
•7-12% lifetime risk of appendectomy
•~500,000 performed yearly
•15% misdiagnosed
•47,000 appys/year
•1 in 4 women will have a “negative
appendectomy”
•$740 million dollars spent/yr on
misdiagnosis

34. PathophysiologyPathophysiology
•Obstruction of the appendiceal lumen
•Lymphoid hyperplasia
•Fecalith
–Inspissated stool
–Not always present
•Foreign body

35. Pathophysiology of Pathophysiology of
AppendicitisAppendicitis
•obstruction
•bacterial overgrowth
•mucous secret
•distention
•Increased intraluminal
pressure
•lymphatic obstruction
•venous obstruction
•inflammation
•edema
•ischemia
•necrosis
•perforation
•abscess or localized
peritonitis
•diffuse peritonitis

36. History and Physical ExamHistory and Physical Exam
Table 6 --Clinical Features of Appendicitis

Symptoms
Duration of symptoms (hrs, median) 22.0 hrs
Abdominal pain (% of cases) 100.0
Nausea or vomiting (% of cases) 67.5
Anorexia (% of cases) 61.0
Fever by history (% of cases) 17.9
Dysuria or frequency (% of cases) 10.6
Physical Findings
Right lower quadrant tenderness (%
of cases)
95.9
Rebound tenderness (% of cases) 69.5
Rectal tenderness (% of cases) 41.5


Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.

37. Distinguishing Appendiceal Distinguishing Appendiceal
PerforationPerforation

Appendicitis
With Perforation
N=70
Appendicitis
w/o Perforation
N=176
Duration of symptoms (hrs,
median)
48.5 hrs 18.0 hrs
Fever as presenting
complaint (% of cases)
34.3 11.4
Nausea or vomiting (% of
cases)
60.0 70.5
Anorexia (% of cases) 52.9 64.2
Urinary symptoms (% of
cases)
10.0 10.8
Rebound tenderness (% of
cases)
64.3 71.6
Rectal tenderness (% of
cases)
41.4 41.5
Impression of a mass (% of
cases)
21.4 6.2
Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.

38. Signs and SymptomsSigns and Symptoms
•Umbilical then migrates towards the RLQ
•Tenderness, then rebound
•Rovsing
•Psoas
–Extension of leg-pt on left
•Obturator
–Rotation of flexed thigh-pt supine
•Rectal
•Perforation related symptoms

39. Sign What it indicates Description
Dunphy Inflammation
involving the partial
peritoneum
Increased pain with coughing
or other movement
Rovsing Localized peritoneal
inflammation in the
right lower quadrant
Lower left quadrant palpation
induces right lower quadrant
pain
Obturator Pelvic appendicitis Pain on internal rotation of the
right hip
IliopsoasRetrocecal
appendicitis
Pain on extension of
right hip

40. Differential DiagnosisDifferential Diagnosis
•Preschool-age
•Intussusception, acute gastroenteritis, Meckel’s diverticulum
•School-age
•Acute GE, constipation, Sickle cell
•Young males
•Crohn’s, UC, epididymitis

•Young females
•Crohn’s, PID, ovarian cysts, UTI, pregnancy
•Older adults
•Malignancies of GI and GU
•Diverticulitis
•Perforated ulcers
•Cholecystitis

41. LabsLabs
•WBC: 12,000-18,000
•left shift important
•HCG negative
•UA
•mild pyuria possible

42. RadiographicsRadiographics
•Plain films
•fecolith, ileus
•CT scan
•Distention of appendix, thickened > 5-7
mm walls, target sign
•US
•Non-compressible, 7 mm, fluid, mass
•Nuclear MD: Tc 99 WBC Ig G

43. AppendicitisAppendicitis
U/SU/S

44. AppendicitisAppendicitis
CT ScanCT Scan

45. TreatmentTreatment
•Urgent appendectomy
•Antibiotics
•Only preoperative abx needed for
uncomplicated cases
•For complicated appendicitis 7-10 days

46. AppendectomyAppendectomy
Textbook of Sabiston, 16th ed.

47. Laparoscopic AppendectomyLaparoscopic Appendectomy

48. Postoperative ComplicationsPostoperative Complications
•Infection: < 5 % to 60 %
•Wound Closure
•Primary
•Delayed primary
•Secondary
•Bowel obstruction
•Infertility-no longer suspected

49. Normal appearing appendix?Normal appearing appendix?
•Remove appendix
anyway?
•Especially if the pt has a
RLQ incision
•Negative predictive value
of macroscopic
judgments of the
appendix are low
•Check for ovarian
pathology
•Check for mesenteric
adenitis

50. Name That Disease…Name That Disease…

51. Meckel’s DiverticulitisMeckel’s Diverticulitis
Rule of 2’s
•2% incidence
•2 types of mucosa
•2 feet from ileocecal
valve
•2-4% (now 6%) with
Meckel’s develop
symptoms
•<2 yr olds bleeding
(50%)

52. Infarcted/Ischemic BowelInfarcted/Ischemic Bowel

53. Mesenteric Infarction/IschemiaMesenteric Infarction/Ischemia
•Always consider in patient with atypical
presentation of abdominal pain-
•Older patients
•Hx of arrhythmias or previous emboli
•Pain out of proportion to exam
•Evidence of visceral complaints without peritonitis
•Systemic complications
•Acidosis

54. Infarction by EndoscopyInfarction by Endoscopy

55. Anatomy of the SMAAnatomy of the SMA

56. Occlusion of the SMAOcclusion of the SMA
•Source
•Embolic (>50%)
•Venous, Atherosclerotic (thrombotic), NOMI
•Chronic
•Mesenteric/intestinal angina
•30-60 minutes post eating
•Voluntary anorexia/wt loss
•Acute (>60% mortality)
•“Abdominal apoplexy”
•Variable symptoms at first with progression
•System collapse

57. Arteriogram of Normal SMAArteriogram of Normal SMA

58. Occluded SMAOccluded SMA

59. Treatment of Acute SMA Treatment of Acute SMA
OcclusionOcclusion
•High index of suspicion
•Arteriogram
•Medical therapy
•Papavarin
•Heparin
•Surgical intervention

60. Perforated ViscousPerforated Viscous

61. Perforated ViscousPerforated Viscous
•Sudden onset of pain
•“Set your watch to it”
–Epigastric/shoulder/RLQ-often DU
–Lower quadrant-often diverticulum
•Often pre-existing history of ulcer or
diverticular disease

62. DiagnosisDiagnosis
•Plain x-rays often demonstrate
•Upright CXR
•75% of perforated DU will have free air
•Sensitive to 5 cc
•CT scan
•Sensitive to <2 cc air

63. ManagementManagement
•Acute perforation of a viscous requires
emergent exploration
•Delayed presentations are more
complex
•Can avoid operation if the perforation is
contained
•May require delayed interventions

64. Acute Abdomen-SummaryAcute Abdomen-Summary
•History and physical more important than
tests
•Making the decision to operate is much more
important than making the diagnosis
•Treatment is often (BUT NOT ALWAYS)
surgical
•“Very old, very young, very odd…be very
careful!” de Domball

65. KEY POINTS
Pathologic processes affecting abdominal viscera that produce
abdominal pain with characteristic symptoms and signs include
obstruction, inflammation, perforation, torsion, and ischemia.
Acute abdominal pain in immunosuppressed patients presents a
particular diagnostic challenge both in making the diagnosis and
due to the unusual infectious causes of abdominal pain that may be
present.
The cause of acute appendicitis in most patients is luminal
obstruction that leads to bacterial overgrowth and increased
luminal pressure leading to obstruction of venous outflow and then
arterial inflow, resulting in gangrene and eventual perforation.

66. Ultrasonographic findings of acute appendicitis
include demonstration of a so-called target lesion
(i.e., a thick-walled noncompressible, luminal
structure in the right lower quadrant with peritoneal
fluid and even frank abscess in advanced cases).
A number of studies suggest that laparoscopic
appendectomy is associated with a benefit in regard
to shorter hospital stay, narcotic use, and overall
recovery with a perioperative complication rate
comparable to open appendectomy.

67. A patient presenting late with appendicitis and an appendiceal mass
should undergo initial percutaneous drainage and intravenous
antibiotics followed by interval appendectomy in about 8 weeks.
The diagnosis of acute appendicitis in children is difficult leading to
a perforation rate as high as 50%.
The diagnosis of acute appendicitis in the elderly is difficult leading
to a perforation rate as high as 50% and higher associated rates of
morbidity and mortality.
Appendicitis is the most frequent nonobstructive indication for
laparotomy during pregnancy and the difficulty in diagnosis leads to a
high perforation rate and associated high fetal mortality.
Carcinoid tumors less than 1.5 cm are adequately treated by
appendectomy, whereas tumors 2 cm in size or greater have metastatic
potential and a right hemicolectomy is indicated