7/27/2019 43 Acute Abdomen
1/60
ACUTE ABDOMEN
Dr.Viswanathan.K.V
MS, DNB,FRCS
Associate Professor of SurgeryMedical College,Trivandrum
7/27/2019 43 Acute Abdomen
2/60
Necessity for Diagnosis
a serious and thorough attempt at
diagnosis
Abdominal pain is the most common
symptom
Acute abdomen = surgery is not always
true
7/27/2019 43 Acute Abdomen
3/60
Course of action
Urgent operation
Wait for evolution of symptoms
Medical management
7/27/2019 43 Acute Abdomen
4/60
Thorough history and physical
examination and recognition of the early
stages of the disease
Record the earliest symtoms
Attempt a specific diagnosis prevents
carelessness and callousness
7/27/2019 43 Acute Abdomen
5/60
A correct diagnosis essential to correct
treatment
Spot diagnosis is magnificent but not
sound, is impressive but unsafe.
Deduction and induction from observed
facts less chances of fallacies
7/27/2019 43 Acute Abdomen
6/60
Early Diagnosis
Diagnose early
No narcotics until diagnosis is made
Examination ,reexamination ,testing byinexperienced hands leads to delay in
diagnosis and early pain relief
7/27/2019 43 Acute Abdomen
7/60
General rule can be made that majority of
severe abdominal pain in pts who have
been previously fairly well and last longer
than 6 hours are caused by surgicalconditions
7/27/2019 43 Acute Abdomen
8/60
Early diagnosis improves recovery
Decreases mortality
Reduces hospital stay due to infections Reduces long term complications
7/27/2019 43 Acute Abdomen
9/60
Anatomy
Apply your knowledge of anatomy in diagnosing
abdominal conditions
Cultivate habit of thinking anatomically
Diaphragmatic spasm decreased movt oflower chest and upper abdomen
Rectus and lateral abd muscle rigidity in
subjacent inflammation Psoas spasm flexion of thigh and internal
rotation
7/27/2019 43 Acute Abdomen
10/60
Obturator internus spasm pain on
rotation of the flexed thigh inwards and
this pain is referred to hypogastrium - in
pelvic appendicitis and haematocele
7/27/2019 43 Acute Abdomen
11/60
Knowledge of course and distribution of
segmental nerves
Note both the ventral and dorsal
distribution of referred pain
Radiating pain to testis does not always
denote genitourinary disease and can also
occur with appendicitis
7/27/2019 43 Acute Abdomen
12/60
7/27/2019 43 Acute Abdomen
13/60
7/27/2019 43 Acute Abdomen
14/60
Irritation to the diaphragm will cause pain in the shoulderas the diaphragm has its origin from the 4th cervicalsegment and is supplied by the cervical segment viaphrenic nerve
Pain may be felt in the shoulders in cases of subphrenicabscess, diaphragmatic pleurisy, a/c pancreatitis,ruptured spleen etc.
The pain is felt in supraspinatous fossa, over theacromion, clavicle or in subclavicular fossa
The shoulder pain is often overlooked as it is attributedto arthritis.
7/27/2019 43 Acute Abdomen
15/60
Errors in diagnosis
Errors occur due to failure of thinking
towards another anatomical site for the
origin of pain (eg. Lack of representation in
the abdominal wall of segments that frompelvis)
7/27/2019 43 Acute Abdomen
16/60
Physiology
The required stimulus for pain in hollow tube is
stretch/ distension or excessive contraction
against an obstruction
Mild degree of bowel contractions is calledflatulence and severe form, colic
Colics occurs in paroxysms and is severe and
referred to the centre from which the nerves
come and also to the segmental distribution
7/27/2019 43 Acute Abdomen
17/60
Small bowel colic pain is referred to the
epigastrium and the umbilicus
Large bowel colic to the hypogastrium
Renal colic from loin to groin and the
testicles
Biliary colic to the right subscapular region
7/27/2019 43 Acute Abdomen
18/60
7/27/2019 43 Acute Abdomen
19/60
Tenderness due to irritation of nerves by
unilateral lesion is not felt on the opposite
side usually. Eg. Right sided pleurisy
causes tenderness in RIF but not in LIF.
7/27/2019 43 Acute Abdomen
20/60
Exclude medical disease before calling for
surgical intervention. (esp a laparotomy)
Cardiac disease, tuberculosis, cirrhosis,
chronic interstitial nephritis and
arteriosclerosis. Porphyrias and diabetic
disease (DKA)
7/27/2019 43 Acute Abdomen
21/60
Methods of diagnosis
History and physical examination is the
most important part.
Record history in the chronological order
of symptoms
Age- intussusception in infants (
7/27/2019 43 Acute Abdomen
22/60
Exact time and onset
Many conditions are precipitated by exertion . It
is important to know what the patient was doing
at the time of onset.
Fainting occurs with ectopic gestation,perforated GU/DU, a/c pancreatitis, ruptured
aortic aneurysm.
Intestinal obstruction gradual in onset and
culminates in crisis
7/27/2019 43 Acute Abdomen
23/60
Shifting or localisation of pain
When peritoneal cavity is filled with pus, blood orfluid pain is felt all over the abdomen and latershifts to site of perforation.
Pain of small intestine is always felt first inepigastric or umbilical region (T9 to T11 nerves)
Remember appendicular nerves are alsoderived from the T9 to T11 so pain may be
initially felt in the epigastric region
7/27/2019 43 Acute Abdomen
24/60
Vomiting
Severe irritation of nerves of the
peritoneum or the mesentery eg. DU
perforation or torsion ovarian cyst.
Obstruction of an involuntary muscle tube.
Absence of vomiting is sufficiently
common in many abdominal catastrophes
as rupture ectopic
7/27/2019 43 Acute Abdomen
25/60
Vomiting is early, sudden and violent inureteric colic
Early and copious in upper intestinal
obstruction No vomiting until late in large bowel
obstruction
Frequent scanty in A/c pancreatitis
Vomiting precedes pain in gastroenteritis
7/27/2019 43 Acute Abdomen
26/60
Character of Vomitus
In gastritis vomitus contains food particleand some bile
In CHPS and duodenal atresia
differentiated by presence of bile in thelatter
In intestinal obstruction content varies
from gastric , bilious greenish yellow toorange and brown indicating feculentvomitus.
7/27/2019 43 Acute Abdomen
27/60
Hypogastric pain and diarrhoea when
followed by hypogastric tenderness and
constipation suspect pelvic abscess.
Partial small bowel obstruction may
produce profuse watery diarrhoea without
passage of flatus
7/27/2019 43 Acute Abdomen
28/60
Laboratory and radiological tests
Over reliance on lab and radiological
investigation often misleads the clinician
Plain X-Ray can interpret many condition like
perforated DU, intestinal obstruction, stones etc. To demonstrate free air in peritoneum a semi
upright or lateral decubitus position for at least
5-10min before the exposure is a must.
7/27/2019 43 Acute Abdomen
29/60
Nuclear scans
Largely replaced by radioisotope scans
Diagnosis of a/c cholecystitis is excluded if GB isvisualised
USG is highly operator dependant and subjective.
C.T. is costly but can demonstrate free air, fluid, andother complications of acute pancreatitis
M.R.I. has no role in evaluation of acute abd. Except invascular pathologies
UGIscopy has limited role in a/c abdomen whileLGIscopy may useful in certain conditions likeintussusception
Laparoscopy and abdominal paracentesis
7/27/2019 43 Acute Abdomen
30/60
Acute appendicitis
Pain, vomiting and fever in order is the classicaltriad of symptoms
Typical symptoms if present indicates that theinflammation is advanced
Atypical symptoms like diarrhoea occur inchildren and in pelvic appendix inflammation
Initial pain is vague producing sense ofdownward urge.
Vomiting occurs early about 3-4hrs after onset ofpain.
7/27/2019 43 Acute Abdomen
31/60
Degree and frequency of vomiting is related to
the degree of appendicular distension
Vomiting before pain is extremely rare in
appendicitis and almost excludes it. Local tenderness elicited by light percussion is
a remarkably reliable indication of parietal
peritoneal inflammation
7/27/2019 43 Acute Abdomen
32/60
Hyperesthesia confined to areas of
T10,11,12,L1 distribution
Rigidity frequent but not constant
No rigidity in appendicitis without
peritonitis Fever develops 24hrs of onset of pain
presence of fever at the beginning of
attack or rigor accompanies the onset of
pain excludes appendicitis
7/27/2019 43 Acute Abdomen
33/60
Other symptoms
Constipation
Tachycardia
Abdominal distension Testicular symptoms
7/27/2019 43 Acute Abdomen
34/60
Diagnosis of appendicitis
Constant findings epigastric pain,
nausea vomiting, RIF pain, low grade
fever, local tenderness
Local rigidity, fever, hyperesthesia and
constipation- inconstant
7/27/2019 43 Acute Abdomen
35/60
Diagnosis after perforation
Perforation with presence of mass orgeneralized peritonitis usually does not occurbefore 48 hrs.
After rupture the pain decreases and localisedpelvic peritonitis sets in but there is no rigidityand patient seems to be better.
Perforated pelvis appendix will cause symptoms
like diarrhoea, tenesmus, frequency ofmicturition
7/27/2019 43 Acute Abdomen
36/60
Differential diagnosis
Intestinal obstruction a/c
Mesenteric vessel thrombosis
A/c pancreatitis
Peritonitis due to other causes
Pylephlebitis
Cholecystitis
DU perforation
Merkels diverticulitis
Perforated typhoid ulcer
7/27/2019 43 Acute Abdomen
37/60
D/D in females
Uterine colic
Twisted/ rupture ovarian cyst
Ruptured ectopic Twisted fibroid/ hydrosalpinx
7/27/2019 43 Acute Abdomen
38/60
Duodenal ulcer perforation
Diagnose early and treat promptly usually surgical If treatment delayed for >24hrs outcome is poor (
7/27/2019 43 Acute Abdomen
39/60
Late stage >12hrs increasing distension
and Hippocratic facies
7/27/2019 43 Acute Abdomen
40/60
Acute Pancreatitis
Failure to diagnose is due to failure to
consider its possibility
Symptoms variable- pain in the acute with
the patient crying out in agony, shock due
to hypovolemia, reflux vomiting and fever
invariable
7/27/2019 43 Acute Abdomen
41/60
Epigastric tumour
Jaundice- Heads on CBD
Obstructive vomiting -heads on duodenum
7/27/2019 43 Acute Abdomen
42/60
Ecchymosis, Cullen and Grey Turner
indicate severe disease and never occurs
until 2-3 days
7/27/2019 43 Acute Abdomen
43/60
Acute Cholecystitis
Prodormal stage episode of biliary colic
usually a forerunner
Vomiting, fever common and rarely
jaundice
GB when palpable with compatible history,
establishes the diagnosis.
7/27/2019 43 Acute Abdomen
44/60
7/27/2019 43 Acute Abdomen
45/60
Colics
Intestinal colic
Main feature of colic is occurrence ofacute agonizing spasmodic pain which
causes the patient to double up and partialor complete relief in between.
Other features- vomiting, visible
peristalsis, borborygmi on auscultation
7/27/2019 43 Acute Abdomen
46/60
Biliary colic
Misnomer because pain is steady
7/27/2019 43 Acute Abdomen
47/60
Renal colic
Renal colic- due to renal stones
Characteristic pain from loin radiating to
groin, testes/vulva
Restlessness, vomiting, dysuria, increased
urinary frequency and hematuria
7/27/2019 43 Acute Abdomen
48/60
Uterine colic
Uterine colic (dysmenorrhoea)
Lower lumbar pain sometimes radiating to
thighs and hips
Congestive dysmenorrhoea pain increases
before the onset on menses and is
relieved with the onset of menstruation
A t i t ti l b t ti
7/27/2019 43 Acute Abdomen
49/60
Acute intestinal obstruction
Causes- hernia (mc), adhesions,intussusception, Ca, volvulus etc.
Symptoms according to site and cause ofobstruction
In general higher up the gut, more severe thesymptoms
Pain very severe referred to epigastrium,
umbilical or hypogastium Clinically- distension, visible peristalsis, features
of shock
Ob t ti hi h i ll
7/27/2019 43 Acute Abdomen
50/60
Obstruction high up in small
intestine
Vomiting very early, frequent and violent,
green and bilious
Distension is not an early feature
7/27/2019 43 Acute Abdomen
51/60
Obstruction distal small intestine
Pain is less severe than proximal small
bowel obstruction
Vomiting and distension delayed
7/27/2019 43 Acute Abdomen
52/60
Large bowel obstruction
Distension is an early feature except inintussusception
Pain less acute, shock and vomiting rare.
Can be due to strangulation of bowelwhere tenderness on applying pressure ispositive.
Obstruction can be due to volvulus, Cacolon, impacted fecal matter etc
7/27/2019 43 Acute Abdomen
53/60
Acute abdomen in pregnant women
Ectopic gestation
Retroverted gravid uterus
Threatened abortion
Sepsis following abortion
Torsion ovarian cyst/ fibroid
Red degeneration fibroid
Rupture uterus
Appendicitis
7/27/2019 43 Acute Abdomen
54/60
Ectopic Gestation
Symptoms before rupture
ammenorrhoea, localised hypogastric pain
and tenderness, uterine bleeding and
sometimes tender swelling in lateral fornixand passage of membrane per vagina
7/27/2019 43 Acute Abdomen
55/60
Symptoms of rupture sudden abdominalpain, vomiting, faintness, sudden anemiaand collapse with small, rapid pulse and
subnormal temp. Signs tender tumid, free fluid in
abdominal cavity, tenderness on pressingthe finger against pouch of Douglas
7/27/2019 43 Acute Abdomen
56/60
7/27/2019 43 Acute Abdomen
57/60
Acute peritonitis
Symptoms according to part and extent ofperitoneum involved, presence of infection andacuteness of onset.
Reflex symptoms pain, vomiting, rigidity.
Toxic symptoms alteration in temperature,collapse, distension, general toxemia.
Pain is the most common symptom. Vomiting
common at the onset but infrequent until late.
7/27/2019 43 Acute Abdomen
58/60
Acute abdomen in tropics
Amebiasis
Malaria
Worm infestation
Sickle cell anemia
Pyomyositis (in HIV)
Enteric fever
Diseases that simulate acute
7/27/2019 43 Acute Abdomen
59/60
Diseases that simulate acute
abdomen Diabetic ketoacidosis
Typhoid
Malaria
TB peritonitis
Food poisoning
Lead colic
Porphyia
Pleurisy/pneumonia
Cardiac disease (eg. MI)
Disease of spine affecting nerve roots
Renal disease
7/27/2019 43 Acute Abdomen
60/60
Thank you
Top Related