“Evaluation of Use of Pupil Expansion Device in Resident-Performed Phacoemulsification Surgery”
Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery...
-
Upload
eustacia-bryan -
Category
Documents
-
view
219 -
download
3
Transcript of Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery...
Acute Acute AbdomenAbdomen
DR. David SwarDR. David Swar Department of General surgery -Department of General surgery -(Resident)(Resident)
Stomach & Colorectal diseases Stomach & Colorectal diseases
Qilu hospital, Shandong UniversityQilu hospital, Shandong University
DefinitionDefinition
A group of life threatening intra-A group of life threatening intra-abdominal conditions that often abdominal conditions that often lead to peritonitis and require lead to peritonitis and require urgent surgical interventionurgent surgical intervention
Acute Abdomen
EtiologyEtiology SurgicalSurgical
InflammatoryInflammatory obstructionobstruction IschemicIschemic PerforationPerforationInflammatory Inflammatory Bowel DiseaseBowel Disease
AppendicitisAppendicitis
DiverticulitisDiverticulitis
PancreatitsPancreatits
cholecystitischolecystitis
CholangitisCholangitis
Meckel’s Meckel’s diverticulum.diverticulum.
Intestinal Intestinal ObstructionObstruction
Biliary colicBiliary colic
Ureteric colicUreteric colic
Mesenteric Mesenteric ischemiaischemia
Torsion of Torsion of viscus (organ)viscus (organ)
Peptic Ulcerative Peptic Ulcerative Disease (PUD)Disease (PUD)
Diverticular Diverticular diseasedisease
AppendixAppendix
Toxic megacolonToxic megacolon
Etiology, cont…Etiology, cont…
MedicalMedical gynecologicalgynecological
Myocardial Myocardial InfarctionInfarction
GastritisGastritis
GastroenteritisGastroenteritis
HepatitisHepatitis
Urinary Tract Urinary Tract InfectionInfection
Ectopic pregnancyEctopic pregnancy
Ovarian cyst torsionOvarian cyst torsionEndometriosis Endometriosis (endometrial cells are deposited in (endometrial cells are deposited in areas outside the uterine cavity )areas outside the uterine cavity )
Common causes of abdominal pain
Clinical evaluationClinical evaluation
HistoryHistory AgeAgeCertain conditions occur in certain age groupsCertain conditions occur in certain age groupsE.g.E.g. diverticulitis in elderly diverticulitis in elderly Mesenteric adenitis Mesenteric adenitis (inflammation of mesenteric (inflammation of mesenteric
lymph nodes)lymph nodes) in children in children
PainPain– OnsetOnset sudden perforationsudden perforation gradual inflammatory causesgradual inflammatory causes
WWW.SMSO.CCWWW.SMSO.CC
sitesite
SiteSite
Cholecystitis
cholangitis
Peptic Ulcerative Disease (PUD)
Peptic Ulcerative disease (PUD)
Pancreatitis
cholecystitis
Gastric ulcer
Perforated colon
Appendicitis
Salpingitis
Ruptured. Ectopic pregnancy
Diverticulitis
Salpingitis
Tubo-ovarian abscess
History, cont…History, cont…
– NatureNature
colicky obstruction (cramping colicky obstruction (cramping pain)pain)
dull inflammation e.g. dull inflammation e.g. pancreatitis (constant pain) pancreatitis (constant pain)
– RadiationRadiation
to tip of the right shoulder in acuteto tip of the right shoulder in acute
cholecystitis (boa’s sign)cholecystitis (boa’s sign)
History, cont…History, cont…
– Aggravating factorsAggravating factors breathingbreathing coughing peritonitiscoughing peritonitis changing positionchanging position fatty meal cholecystitisfatty meal cholecystitis
– Relieving factorsRelieving factors lying still peritonitislying still peritonitis leaning forward pancreatitis (prayer’s leaning forward pancreatitis (prayer’s
signsign passing flatus Intestinal Obstructionpassing flatus Intestinal Obstruction
History, cont…History, cont…
– Associated factorsAssociated factors
1.1. vomitingvomiting Precedes the pain medical conditionPrecedes the pain medical condition Follows the pain surgical conditionFollows the pain surgical condition ContentsContents
– Bilious Small Bowel ObstructionBilious Small Bowel Obstruction– Nonbilious pyloric stenosisNonbilious pyloric stenosis– Blood -bleedingBlood -bleeding
History, cont…History, cont…
2. 2. Change in bowel habitsChange in bowel habits– constipationconstipation– Obstipation (constipation +no flatus)Obstipation (constipation +no flatus)– DiarrheaDiarrhea
3. 3. Anorexia (poor appetite)Anorexia (poor appetite)– e.g. appendicitise.g. appendicitis
4. 4. feverfever– Inflammatory causesInflammatory causes
Examination Examination
Note: physical signs may be less Note: physical signs may be less obvious in elderly, obese patients, obvious in elderly, obese patients, and those on steroidsand those on steroids
General examinationGeneral examination– Motionless peritonitisMotionless peritonitis– Writhing in agony colic Writhing in agony colic (to twist in (to twist in
pain)pain)
– Jaundice- obstructive jaundiceJaundice- obstructive jaundice– dehydrationdehydration
Examination, cont…Examination, cont… Vital signsVital signs
– PulsePulse– Respiratory rateRespiratory rate– Blood PressureBlood Pressure
High grade feverHigh grade fever Low grade feverLow grade fever
Acute cholangitis Acute cholangitis (Fever,jaundice,abdominal pain due (Fever,jaundice,abdominal pain due to bacterial proliferation to bacterial proliferation superimposed on obstruction of superimposed on obstruction of biliary tree due to gall stones)biliary tree due to gall stones)
PeritonitisPeritonitis
Acute cholecystitisAcute cholecystitis
AppendicitisAppendicitis
Abdominal Abdominal examinationexamination
InspectionInspection
What you seeWhat you see What it meansWhat it meansDistensionDistension
Rigidity Rigidity
Decreased movementDecreased movement
ScarsScars
HerniaHernia
Visible peristalsisVisible peristalsis
Intestinal Obstruction , AscitisIntestinal Obstruction , Ascitis
PeritonitisPeritonitis
PeritonitisPeritonitis
AdhesionsAdhesions
Intestinal ObstructionIntestinal Obstruction
Intestinal ObstructionIntestinal Obstruction
Abdominal Abdominal examination, cont…examination, cont… Palpation-(to Palpation-(to
feel)feel) signsign significancesignificance
Tenderness, Tenderness, guarding,guarding,
Rebound Rebound tendernesstenderness
Rigidity (board like)Rigidity (board like)
Pulsatile massPulsatile massSuccession splash Succession splash (splashing sound due to (splashing sound due to presence of air or fluid)presence of air or fluid)
Inflammation of Inflammation of parietal parietal
peritoniumperitonium
peritonitisperitonitis
Aortic aneurysmAortic aneurysm
Gastric outlet Gastric outlet obstructionobstruction
Abdominal Abdominal examination, cont…examination, cont… PercussionPercussion-(tapping on a -(tapping on a
surface)surface)
signsign significancesignificance
ResonanceResonance
Loss of liver Loss of liver dullnessdullness
Shifting dullnessShifting dullness
Intestinal Intestinal ObstructionObstruction
PerforationPerforation
Ascitis, free fluidAscitis, free fluid
Abdominal Abdominal examination, cont…examination, cont…
Auscultation-Auscultation-listening to the internal listening to the internal soundssounds(stethoscope)(stethoscope)
signsign significancesignificance
Absent bowel Absent bowel soundssoundsIncreased sound, Increased sound, Borborygmi Borborygmi (rumbling (rumbling sound caused by gas moving)sound caused by gas moving)
Bruit Bruit (Abnormal sound (Abnormal sound over blood vessel)over blood vessel)
Paralytic ileusParalytic ileus etc etc
Mechanical Mechanical obstructionobstruction
Vascular diseaseVascular disease
Specific signsSpecific signssignsign indicationindication
Murphy’s signMurphy’s sign
Boa’s signBoa’s sign
Rovsing’s signRovsing’s sign
Obturator signObturator sign
Psoas signPsoas sign
Grey turner & Grey turner & cullen’s signcullen’s sign
Acute cholecystitsAcute cholecystits
AppendicitisAppendicitis
Retrocecal Retrocecal appendicitis, appendicitis,
Hemorrhagic Hemorrhagic pancreatitispancreatitis
Murphy’s sign, Psoas sign –if positive where is the appendix? Retrocecal
Obturator sign,Cullen’s sign
Abdominal Abdominal examination, cont…examination, cont… Rectal examinationRectal examination Per vaginal examination Per vaginal examination
Digital rectal examination,Per Vaginal Examination
InvestigationsInvestigations To assess patients condition in To assess patients condition in generalgeneral
1.1. Complete Blood Count (Blood Routine)Complete Blood Count (Blood Routine)2.2. Electrolytes-Na ,K ,ClElectrolytes-Na ,K ,Cl3.3. Blood Urea Nitrogen (BUN) & CreatinineBlood Urea Nitrogen (BUN) & Creatinine4.4. Arterial Blood Gas (ABG)Arterial Blood Gas (ABG)5.5. UrinalysisUrinalysis6.6. Liver Function Test (LFT)Liver Function Test (LFT)7.7. Prothrombin Time (PT)11 to 13.5 Prothrombin Time (PT)11 to 13.5
sec,PTT –25 to 35 secsec,PTT –25 to 35 sec(Partial thromboplastin time)(Partial thromboplastin time)(blood test that tells how long it takes for plasma to clot?)(blood test that tells how long it takes for plasma to clot?)
8.8. Blood grouping and cross matchingBlood grouping and cross matching
Investigations, Investigations, cont…cont…2. Serum Beta HCG 2. Serum Beta HCG (human chorionic (human chorionic
gonadotrophin hormone)gonadotrophin hormone)
– In female of child bearing ageIn female of child bearing age– To rule out ectopic pregnancyTo rule out ectopic pregnancy
Investigations, Investigations, cont…cont… Specific investigationsSpecific investigationsA. Lab A. Lab 1.1. Amylase & lipase Amylase & lipase
– Lipase elevation is specific for Lipase elevation is specific for pancreatitispancreatitis
– Amylase elevation confirms the diagnosis Amylase elevation confirms the diagnosis of Pancreatitis, but also seen in:of Pancreatitis, but also seen in:
Perforated viscus (Internal organs)Perforated viscus (Internal organs) Intestinal.ObstructionIntestinal.Obstruction Acute cholecystitisAcute cholecystitis
Investigations, Investigations, cont…cont…
B. RadiologicalB. Radiological1.1. Chest x-rayChest x-ray
Air under the diaphragm Air under the diaphragm in perforated viscus in perforated viscus (duodenal perforation)(duodenal perforation)
Elevated diaphragm in Elevated diaphragm in abdominal distentionabdominal distention
Investigations, Investigations, cont…cont…
2.2. Abdominal x-rayAbdominal x-ray air fluid levels in intestinal obstructionair fluid levels in intestinal obstruction
Stones (90% of kidney stones can be Stones (90% of kidney stones can be seen in x-ray and 10% can’t be seen seen in x-ray and 10% can’t be seen but 10% of gallstones can be seen in but 10% of gallstones can be seen in x-ray but 90% can’t be seen) why ? x-ray but 90% can’t be seen) why ? Calcium .Calcium .
Investigations, Investigations, cont…cont…
Kidney stone, Gall stones
Investigations, Investigations, cont…cont…
3.3. USG-Ultra sound ScanUSG-Ultra sound Scan GallstonesGallstones AppendicitisAppendicitis Ectopic pregnancyEctopic pregnancy Torsion of ovarian cystTorsion of ovarian cyst empyemaempyema
4.4. CT scanCT scan pancreatic pathologypancreatic pathology Acute aortic aneurysmAcute aortic aneurysm Severe diverticulitisSevere diverticulitis Abdominal abscessAbdominal abscess
Gall stones
Abdominal CT scan
Investigations, Investigations, cont…cont…
5.5. Duplex scan or angiography Duplex scan or angiography
for superior mesenteric for superior mesenteric embolus orembolus or
thrombosisthrombosis
6.6. ERCP (Endoscopic ERCP (Endoscopic retrograde cholangio-retrograde cholangio-pancreatography)pancreatography)
Investigations, Investigations, cont…cont…C. ParacentesisC. Paracentesis
– To assess Small Bowel Perforation in To assess Small Bowel Perforation in ascitis ascitis
– Free blood, bile, bowel contents Free blood, bile, bowel contents suggest Bowel perforation suggest Bowel perforation
D. Endoscopy & laparoscopyD. Endoscopy & laparoscopyE. Diagnostic peritoneal lavageE. Diagnostic peritoneal lavage
Peritoneal lavage, Paracentesis
ManagementManagement
Initial management Initial management – Nil Per OralNil Per Oral– Intravenous fluids, Bolus Ringer Lactate Intravenous fluids, Bolus Ringer Lactate
solutionsolution– Monitor urine outputMonitor urine output– Nasogastric tubeNasogastric tube
DecompressionDecompression suctionsuction
– AnalgesiaAnalgesia PethidinePethidine
CC
Management, cont…Management, cont…
– Antibiotics Antibiotics BroadspectrumBroadspectrum In case of sepsis or peritonititsIn case of sepsis or peritonitits
Management, cont…Management, cont…
Surgical managementSurgical management– IndicationsIndications
1.1. Physical findingsPhysical findings Localized peritoneal irritation with Localized peritoneal irritation with
guarding or rigidityguarding or rigidity Spreading tendernessSpreading tenderness Tense or progressive distensionTense or progressive distension Tender abdominal or rectal mass with Tender abdominal or rectal mass with
high fever or hypotensionhigh fever or hypotension
Indications for Indications for surgery, cont…surgery, cont…
Rectal bleeding with shock or acidosisRectal bleeding with shock or acidosis
Equivocal (uncertain)abdominal findings Equivocal (uncertain)abdominal findings with with
– Septicemia: high fever, leukocytosis, Septicemia: high fever, leukocytosis, mental status changesmental status changes
– Bleeding: shock, acidosis, falling Bleeding: shock, acidosis, falling hematocrithematocrit
– Suspected ischemia: acidosis, fever, Suspected ischemia: acidosis, fever, tachycardiatachycardia
Indications for Indications for surgery, cont…surgery, cont…2. Radiological findings2. Radiological findings
Pneumoperitonium –bowel perforationPneumoperitonium –bowel perforation Gross or progressive bowel distension-Gross or progressive bowel distension-
bowel obstructionbowel obstruction Free extravasation of contrast media-Free extravasation of contrast media-
bowel perforationbowel perforation Space occupying lesion –Mass or tumorSpace occupying lesion –Mass or tumor Mesenteric occlusion-IschemiaMesenteric occlusion-Ischemia
Indications for Indications for surgery, cont…surgery, cont…3. Endoscopic findings3. Endoscopic findings
Perforated lesionPerforated lesion Uncontrolled bleeding lesionUncontrolled bleeding lesion
4. Paracentesis4. Paracentesis Blood Blood bilebile bowel contentsbowel contents urineurine