The Acute Surgical AbdomenAda EkpeAmel Ibrahim
Contents Anatomy Adominal pain Management of the acute abdomen:
from history to exam Scars and surgeries Stomas Questions
Anatomy of the abdomen 9 regions and 2 flanks Surface:
Skin Linea alba and umbilicus Xiphisternum Symphysis pubis Pubic tubercle Costal margins Iliac crests
2 Hypochondria Epigastrium 2 Loins Paraumbilical Suprapubic 2 Iliac fossae 2 Flanks
Surface Anatomy Transpyloric plane of Addison:
Halfway between jugular notch and Symphysis pubis.
Contains: body and tail of pancreas, L1 body, 2nd part of duodenum, Hilum of L kidney, upper pole R kidney, pylorus, tips of 9th costal cartilages, fundus of GB, splenic and hepatic flexures, spleen and origins of SMA and portal vein.
McBurneys point: 1/3 of way between ASIS
and umbilicus. Appendix
Mid inguinal point: halfway between ASIS and
pubic tubercle. Site of deep ring.
Mid point of inguinal ligament: Half way between ASIS and
pubic symphysis. Site of femoral pulse.
Referred pain No plan for viscera Pain referred to
associated dermatome
Appendicitis: initially T10 then as peritoneum inflamed (richly innervated) pain localised to RIF
Pain Epigastric:
cardiac Lung Thoracic dissection/ruptured aneurysm pancreatitis Liver Gall bladder Gastric/duodenal ulcer Transverse/small bowel
RUQ: Gall bladder Liver Lung Bowel
LUQ: Spleen Bowel Lung Cardiac
RIF: Skin: cellulitis/sebaceous
cyst Subcut tissue: nec fasc Lymph nodes: mesenteric
adenitis/lymphoma/infection Bowel: large bowel (tumour,
colitis) Appendictis/appendix mass Constipation Strangulated hernia Ruptured iliac aneurysm OVARIAN Orchitis/undescended testis
LIF: Diverticultis Tumour Hernia Testicular Ovarian Colitis Lymphoma etc…
Q&A Paraumbilical? Flank? Suprapubic?
History Site Onset Character Radiation Associated symptoms Time Exacerbating/alleviating factors Severity
Change in bowels Appetite? Is pain associated with food? Nausea/vomiting Urinary symptoms/systems review Previous surgeries Medications Family history Social history
Examination ABC Observations OBSERVE:
Jaundice nutrition body habitus Discomfort Stigmata of ETOH use Position (mobilising/peritonitic)
Volunteer? Abdo exam: Hands (dupuytren’s/clubbing/asterixes/pulse/nails) Face (icteric/hydration) Neck (Virchow’s node) Chest (spider naevi/gynaecomastia) Abdomen: scars, lumps, erythema, tenderness,
guarding, peritonism, organomegalyand bowel sounds) PR: skin tags/fungating tumours/haemorrhoids, tender,
mass, blood and rectum empty/full (hard or soft stool). HERNIAL ORIFICES AND TESTES
Management Analgesia IV access Fluids/antibiotics (if necessary) AXR and/or USS Vs CT scan Optimise for theatre or manage conservatively Common emergencies:
appendicitis, diverticulitis, ischemic colitis, strangulated hernia and SBO.
Common emergency operations: appendicectomy, herniorraphy +/- resection,
Hartmann’s and (sub)total colectomy.
Stomas Ileostomy:
often RIF spouted, liquid contents
Colostomy: end/defunctioning Flush Solid contents
Urostomy: For cystectomy Ileal conduit Urine in bag
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