seminar on Approch to Acute abdomen pho4th year (2).pptx

surgery

1. Mekelle university College of health sciences Ayder Comprehensive Specialized Hospital department of public health Seminar on Approach to Acute abdomen Presenter Abrha Berhe Adugna Tsegay Moderator: Dr Eyob Surgery Resident

2. Outlines Define acute abdomen Describe a general approach to acute abdomen Discuss common causes of acute abdomen Discuss principle of management

3. Mind map Approach to acute abdomen Definition History taking Physical examination Investigation Management Diagnosis

4. Definition “Sudden onset of spontaneous non-traumatic abdominal pain that requires urgent evaluation & intervention.” NB : The intervention could be Surgical or Medical.

5. Abdominal quadrant

6. Differential diagnosis

7. Right upper quadrant pain : Acute cholecystitis and Biliary colic Perforated duodenal ulcer Acute hepatitis or Abscess Hepatomegaly Rt lower lobe pneumonia pyelonephritis

8. Left upper quadrant pain: Acute pancreatitis Gastric ulcer Gastritis Splenic enlargement, rupture and infarction Lt lower lobe pneumonia pyelonephritis

9. Right lower quadrant pain: Acute appendicitis Mesenteric adenitis Meckel’s diverticulitis Crohn’s disease Perforated cecum Psoas abscess Renal/ ureteral stone Hernia SBO Gynecologic cause

10. Left lower quadrant pain: Diverticulitis Renal/ ureteral stones Hernia LBO Perforated colon IBD Gynecologic causes

11. Gynaecological Causes Ruptured Ectopic Pregnancy Rupture Ovarian Cyst Ovarian torsion PID Salpingitis Endometriosis

12. Clinical Assessment Because of the potential surgical nature of the acute abdomen, an expeditious workup is necessary . The workup proceeds in the usual order of H istory, P hysical examination, Investigation: L aboratory, and Im aging studies.

13. History taking Age: Newborn: congenital anomalies- atresia, stenosis Children: mesenteric adenitis, bowel obstruction due to intussusception Adult: appendicitis Elderly: bowel obstruction due to malignancies, acute diverticulitis

14. * P ain : SOCRATES approach Site:

15. Onset: sudden vs gradual Typical Pain from perforation is sudden Pain that develops and worsens over several hours is typical of conditions of progressive inflammation or infection Character: Dull – mild pain Colicky Cramping Burning ... C ont’d

16. Equally important as the character of the pain are its location and radiation . N.B. S olid circles are primary or most intense sites of pain.

17. Activities that exacerbate or relieve the pain are also important Eg : Eating often worsens the pain of bowel obstruction, biliary colic, pancreatitis, diverticulitis, or bowel perforati on while relieving pain of non-perforated PUD or Gastritis.

18. Associated Symptoms Nausea, vomiting, constipation, diarrhea, Hematochezia melena, or hematuria can all be helpful symptoms if present and recognized.

19. Past Medical Hx : Prior hx of Appendectomy PID Cholecyctectomy Kidney stones, etc Hx of Medications Medications can both create acute abdominal conditions or mask their symptoms. Eg : high-dose narcotic use can interfere with bowel activity and lead to obstipation and obstruction. NSAID s are associated with an increased risk for upper GI inflammation and perforation

20. Physical Examination D espite newer technologies, including CT scanning, ultrasound, and MRI, the P/E remains a key part of a patient's evaluation and must not be minimized . G/A: ASL- P ts lie very still in the bed during the evaluation and often maintain flexion of their knees and hips to reduce tension on the anterior abdominal wall.

21. Vital sign: Important to see the hemodynamic state of the patient weather if the patient is tachycardic, tachypneic or hypotensive. If vital signs disrupted (Hypotension) they must be treated immediately to prevent patient going into shock. If the patient in shock you have to cut the examination and go directly to resuscitate the patient by Airway, breathing and circulation(ABC), when he/she get stable now examine him/her.

22. HEENT: Check the eyes for jaundice. Mucous membrane for signs of dehydration LGS : Check for lymphadenopathy E.g : Virchows node:- abdominal cancer Chest: Lobar pneumonia: may present with R(L)UQ pain, you will hear crackles, bronchial breathing and dullness on percussion.

23. Abdominal Exam Inspection: C ontour of the abdomen S cars (esp. Surgical scars should be correlated w ith past surgical hx) Evidence of erythema or edema of skin E cchymosis Auscultation: Bowel Sounds (Quiet Vs Hyperactive) Pitch and Pattern of the sounds Eg. high-pitched “tinkling” sound s indicate intestinal obstruction Bruits

24. Percussion: Dullness- fluid ascites Hyper tympanic- air filled structure, this suggests intestinal obstruction. Palpation: start superficially and then deep, away from the site of pain. To reveal severity and exact location of the abdominal pain Confirm the presence of peritonitis

25. A dditional Examinations Rectal Examination F or the presence of a mass especially in elderly, pelvic pain, or intraluminal blood or melena. P elvic examination is included in all women when evaluating pain located below the umbilicus .

26. Common surgical causes of Acute Abdomen are:- 1. Acute Appendicitis 2. Intestinal Obstruction 3. Perforated PUD 4. Acute Cholecystitis 5. Acute Pancreatitis

27. Acute Appendicitis Most common acute abdominal surgical emergency Life time risk is 7.5% Male: Female ~ 1.4:1 common in 2 nd and 3 rd decades of life

28. Course 1. Spontaneous resolution 2. Gangrene and perforation 3. Appendicular Mass 4. Appendicular abscess Risk factors for perforation - Extremes of age - Immunosuppresion - DM - Faecolith obstruction - Pelvic appendix - Previous abdominal surgery

29. 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. Periumbilical pain that shifts to the RLQ with ~ 80% sensitive and 53% specificity Anorexia, nausea, vomit Afebrile or low-grade fever. Diarrhea/Constipation Urinary symptoms

30. Physical findings G/A: ASL usually lie supine with the thighs drawn up, b/c any motion increases pain direct and Rebound RLQ tenderness Rovsing sign Psoas sign Obturator’s sign RLQ mass Guarding and rigidity Generalized peritonitis

31. 31                                                                                                         Psoas sign Obturator sign

32. Investigation Routine techniques are CBC - leukocytosis U/A- a few WBCs/RBC due to Irritation of the bladder or ureters by an inflamed appendix Selective investigations Pregnancy test serum electrolyte Abdominal radiographs 1. abdominal U/S – sen 55%-96% and spe 85%-98% Non compressive,dialated appendix Non peristaltic Focal tenderness over the inflamed appendix 2. CT scan - higher sensitivity and specificity

33. Management 1. Conservative treatment Give IV antibiotics Parenteral fluid replacement NPO Follow up Indications: Patient who refused surgery Appendiceal mass

34. 2.Surgical management Appendectomy is the definitive treatment for acute appendicitis. Give prophylactic antibiotics preoperatively Post op antibiotics is given for complicated one. Appendiceal abscess : Drain abscess and place drainage tube insitu , leave appendix untouched if difficult to identify, elective surgery after 6 weeks.

35. COMPLICATIONS: post op SSI Stump appendicitis Negative appendectomy Normal appearing appendix found during operation in patients presenting with signs and symptoms of acute appendicitis. Rate is 15% - higher in women(22%) and children <5 years (25%). Do thorough examination of the abdomen

36. Intestinal obstruction Intestinal obstruction Occurs when the luminal content of the GIT is prevented from passing distally Classification: Based on type: Dynamic – mechanical obstruction Adynamic –paralytic ileus 2. Based on lumen: Complete obstruction Partial obstruction

37. 3. Based on presence of complications: Simple / viable Strangulated 4. Based on the intestine involved: SBO LBO

38. Etiology Classified into: Extraluminal Adhesion Hernia Volvulus Intra abdominal neoplasm 2. intrinsic/ intramural/ Inflammatory- IBD neoplasm 3. Intraluminal Gall stone Bezoars Worms Fecal impaction

39. Clinical presentation the 4 cardinal symptoms Crampy abdominal pain Nausea & vomiting Constipation Abdominal Distension

40. Physical examination G/A : ASL Vital sign : Tachycardic, hypotensive: due to severe dehydration Fever: strangulation Signs of dehydration Abdominal examination Inspection: Abdominal distention, visible peristalsis, look for scars and hernia sites carefully.

41. Auscultation: Early- hyperactive bowel sounds Later- hypoactive Palpation: Tenderness, guarding and rigidity- peritonitis Percussion: Hyper tympanic Dullness – sign of fluid collection Rectal examination Presence or absence of fecal matter Blood – malignancy or strangulation

42. Investigation CBC serum electrolytes RFT Imaging Plain abdominal x-ray (Supine & erect) SBO; Findings “ the triad” Dilated small bowel loop (>3 cm in diameter) Multiple air-fluid levels Paucity of colonic air Additional findings Centrally located dilations and presence of regularly spaced valvulea conniventes .

43. LBO: findings Dilated bowel loop (> 6 cm)- peripherally Paucity of air in rectum- complete obstruction Air-fluid levels Haustra markings Abdominal u/s- for intussusception & describe nature of a mass GI Endoscope CT scan- Useful to detect : lesions , tumors

44. Abdominal radiography

45. management 1. Conservative Principles of Rx -gastrointestinal drainage -fluid & electrolyte replacement -relief of obstruction

46. Management Indications for surgical Rx -Obstructed / strangulated external hernia -Internal intestinal strangulation -Acute obstruction 47

47. Perforated PUD It is one of the common complications of peptic ulcer disease Complicates 2-10% of PUD Most common site to perforate is the anterior duodenum Duodnal,antral & gastric body ulcers account for 60, 20,&20 % of perforation due to PUD respectively M:F is 2:1(in elderly higher female ratio) Nearly 50% of them have no history of PUD

48. Perforated duodenal ulcer 5-10 % of DU patients More common than perforated gastric ulcer Operative mortality is 5% Over 30% of same groups are; Elderly In shock Have comorbid disease Perforations >24 hours

49. Perforated gastric ulcer Associated with NSAID and tobacco use Often present with out prior symptom It has worst prognosis than perforated duodenal ulcer

50. Clinical presentation of perforated PUD The following three phases have been described when there is free perforation Phase 1 ( with in two hours of onset) Sudden onset abdominal pain Localization is epigastric It quickly becomes generalized Sometimes collapse or syncope Tachycardia, week pulse, cool extremity & low temperature

51. Phase 2 (2 to 12 hours) Abdominal pain may be lessen In experienced observer….lead to patient getting better Pain is generalized Worsens upon movement Board like abdomen Obliteration of liver dullness Rectal examination is tender

52. Phase 3 (usually >12 hours of duration) Increased abdominal distention is noted But abdominal pain, tenderness& rigidity may be less evident Temperature elevation & hypovolemia

53. Diagnostic investigation An erect plain chest radiography gas under the diaphragm in >50% of patients Water soluble contrast swallow Free peritoneal leak Diagnostic peritoneal lavage Bile stained fluid Serum amylase Elevated but not as high as acute pancreatitis CT-scan….. perforated vs acute pancreatitis

54. CXR- gas below the diaphragm

55. Treatment - Complicated PUD is mainly treated sugically. - Resuscitation and analgesia - Surgical Tx: Suture the perforated ends Omental patch - If the ulcers are large Billroth II gasterctomy will be done - Lifelong antiacid therapy - Gastric ulcers should b e excised

56. Acute Cholecystitis This refers to a syndrome of RUQ pain, fever and leukocytosis associated with gallbladder inflammation. Cystic duct obst .  G.B distension + inflam .+edema 2 to bacterial Infection  abscess, empyema, gangrenous changes and rarely perforation

57. Clinical manifestations Hx - Colicky pain at the RUQ - Naus e a and Vomiting - h x of fatty food ingestion about one hour or more befor e the initial onset of the pain.

58. P/E- - Fever - Tachycardia - G uardening & rigidity in the right upper quadrant - Murphy’s sign - Boas’s sign - V ague mass -Jaundice/ mirizzi syndrome

59. Complications Mucocelle/pyocelle Gangrenous cholecystitis Perforation Gallstone ileus Emphysematous cholecystitis

60. Investigations Lab: CBC Liver function test Imaging : ultrasound gallstone thickened gall bladder wall distended gall bladder sonographic murphy’s sign : HIDA scan

61. Management Initial conservative treatments followed by cholecystectomy after 6 weeks Early cholecystectomy within 3 days of attac k - Early surgery is not difficult - Avoid complications of acute cholecystitis - Minimal hospital stay

62. Acute Pancreatitis an acute inflammatory process of the pancreas characterized clinically by severe acute upper abdominal pain and elevated levels of pancreatic enzymes in the blood.

63. Etiology - Bile duct stone(50%) - Excessive alcohol intake(20%) - Idiopathic(20%) - Trauma(5%) Accidental Operative ERCP - Rare causes Viral infection-mumps Hyperparathyroidism Corticosteroids

64. Clinical presentations Severe agonizinig abdominal pain - Radiates to the back - Preceeded by fatty meal or alcohol - relief by sitting or leaning forward Vomiting and retching Restlessness

65. Physical finding Fever, tachycardia, tachypnea shock & coma (in severe cases) Mild icterus- in gall stone pancreatitis Respiratory - shallow breathing, dyspnea Abdomen - distension, tenderness, muscle guarding - epigastric mass - Cullen ’ s sign - Grey-Turner ’ s sign

66. Investigations Lab - Serum amylase -(3-4X above normal) - Serum lipase - CBC Leukocytosis - Billirubin is elevated

67. Imaging - Plain abdominal X-ray Sentinel’s loop Colon cut-off sign - Abdominal U/S Gall stone - CT scan Enlargement of pancreas Peripancreatic Edema Pancreatic necrosis

68. Management Conservative Relief of pain Replacement of fluid Respiratory support Rest of pancreas and bowel (NPO) Resistance of infection (Prophylactic Antibiotics)

69. Surgical Tx Indications 1. A doubtful Dx 2. Drainage of pancreatic abscess or persistence of pseudocyst that doesn’t resolve with in 6 wks 3. Necrotizing Pancreatitis on CT

70. REFERENCES Sabiston Text Book Of Surgery ,20 th Ed… Bailey & Love’s short Practice Of Surgery ,25 th Edition Schwartz’s Principle Of Surgery ,10 th Edition