Acute abdomen
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Acute abdomen. Prof. M K Alam M S ; F R C S. Learning objectives. Definition of acute abdomen Anatomy and physiology of abdominal pain. Pathophysiology of common causes of acute abdomen. Symptoms and signs of acute abdomen in relation to the underlying pathology

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Acute abdomen

Acute abdomen

Prof. M K Alam M S ; F R C S


Learning objectives

Learning objectives

  • Definition of acute abdomen

  • Anatomy and physiology of abdominal pain.

  • Pathophysiology of common causes of acute abdomen.

  • Symptoms and signs of acute abdomen in relation to the underlying pathology

  • Laboratory and imaging investigations

  • Initial and definitive management


Definition

Definition

Acute abdomen A clinical presentation of

abdominal pain and tenderness,

that often requires emergency

surgical therapy.


Acute abdomen

  • Some non-surgical or non intra-abdominal diseases, can present as an acute abdomen.

  • A correct diagnosis so important for an appropriate therapy.


Anatomy and physiology of abdominal pain

Anatomy and Physiology of Abdominal pain


Types of abdominal pain

Types of abdominal pain

  • Visceral

  • Parietal


Visceral pain

Visceral pain

  • Vague, poorly localized ( patient directs with full hand)

  • Splanchnic nerves

  • Usually the result of distention of a hollow viscus

  • Depending on the origin of the affected organ from the primitive foregut, midgut, orhindgut, the pain is localized to epigastrium, periumbilical , or hypogastrium respectively


Acute abdomen

Parietal pain

-Corresponds to the segmental nerve roots (somatic nervous system) innervating the peritoneum.

-Sharper and better localized.


Referred pain

Referred pain

Definition:Pain perceived at a site distant from the source of stimulus.

Common examples of referred pain:

Right shoulder- Gall bladder

Left shoulder- Heart, tail of pancreas, spleen (Kehr's sign)

Scrotum and testis- ureter


Pain location according to organs great degree of overlap

Pain location according to organs(Great degree of overlap)

  • Right hypochondrium.- gallbladder

  • Left hypochondrium.- pancreas

  • Epigastrium.- Stomach and duodenum

  • Lumber- kidney

  • Umbilical- small bowel, caecum, retroperitoneal

  • Right iliac fossa- Appendix, caecum

  • Left iliac fossa- Sigmoid colon

  • Hypogastrium- Colon, urinary bladder, adenexae


Pain location in common acute abdominal conditions

Pain location in common acute abdominal conditions

  • Right hypochondrium: Acute cholecystitis, Hepatitis

  • Epigastrium: Acute pancreatitis, Perforated duodenal ulcer

  • Left hypochondrium: Splenic infarction, acute pancreatitis

  • Right lower quadrant: Ac. Appendicitis, Crohn’s disease

    Ectopic pregnancy, mid-cycle pain- female

  • Left lower quadrant: Diverticulitis

  • Periumbilical: appendicitis (initial), small bowel obstruction

  • Lumber (flank): pyelonephritis, renal colic

  • Hypogastrium: Colonic obstruction


Pathophysiology

Pathophysiology


Surgical acute abdominal conditions

Surgical Acute Abdominal Conditions

  • Infection-Appendicitis, cholecystitis

  • Perforation-Perforated duodenal ulcer

  • Obstruction-Small bowel adhesions, obstructed hernia, sigmoid volvulus

  • Ischemia- Mesenteric ischemia (thrombosis/ embolism) strangulated hernia

  • Hemorrhage-Ruptured ectopic pregnancy, ruptured aneurysm, solid organ trauma


Nonsurgical causes of acute abdomen

Nonsurgical Causes of Acute Abdomen

  • Diabetic crisis

  • Uremia

  • Hereditary Mediterranean fever

  • Sickle cell crisis

  • Acute leukemia


Pathophysiology acute appendicitis

Pathophysiology: Acute appendicitis

  • Most common general surgical emergency

  • Derived from the midgut

  • Obstruction of the lumen (fecalith, lymphoid hyperplasia, vegetable matter or seeds, parasites) is the major cause of acute appendicitis.

  • Obstruction contributes to bacterial overgrowth,


Pathophysiology acute appendicitis1

Pathophysiology: Acute appendicitis

  • Continued secretion of mucus leads to intraluminal distention.

  • Distention produces the visceral pain sensation as periumbilical pain.

  • Promote a localized inflammatory process

  • May progress to gangrene and perforation.

  • Inflammation of the adjacent peritoneum- localized pain in the right lower quadrant.

  • Perforation usually occurs after 48 hours from the onset of symptoms


Bacterial flora in appendicitis

Bacterial flora in appendicitis

  • Polymicrobial nature of perforated appendicitis.

  • Escherichia coli, Streptococcus viridans, and Bacteroides and Pseudomonas


Acute abdomen

Part II


Pathophysiology perforated peptic ulcer

Pathophysiology: Perforated peptic ulcer

  • 5% of peptic ulcers penetrate through the duodenal wall into the peritoneal cavity

  • Most common site: anterior wall of 1st part of the duodenum

  • Produce chemical peritonitis


Pathophysiology peritonitis

Pathophysiology- peritonitis

  • Introduction of bacteria or irritating chemicals into the peritoneal cavity cause peritoneal inflammation

  • A localized inflammation (appendicitis) produce sharply localized pain and normal bowel sounds

  • A diffuse process (perforated viscus) produces generalized peritonitis causing generalized abdominal pain with a quiet abdomen


Acute abdomen

  • Peritonitis is peritoneal inflammation from any cause.

  • Recognized by severe tenderness , with or without rebound tenderness, and guarding.


Acute abdomen

Types of peritonitis

  • Secondary peritonitis: more common, secondary to an inflammatory insult from within abdomen, most often gram-negative infections with enteric organisms or anaerobes. Example- appendicitis

  • Primary peritonitis: uncommon.

    Children: Pneumococcus or hemolytic Streptococcus.

    Adults: peritoneal dialysis for end-stage renal dis.(gram+ve cocci),

    ascites and cirrhosis(Escherichia coli and Klebsiella)

  • Noninfectious inflammation- pancreatitis (chemical peritonitis)


Pathophysiology small bowel obstruction

Pathophysiology: Small bowel obstruction

  • Post-operative adhesion- most common

  • Hernia, tumour, Crohn’s disease- other causes

  • Early- the intestinal contraction increases to propel contents past the obstructing point (colicky pain)

  • Later- the intestine becomes fatigued and dilates, contractions becoming less intense.

  • Bowel dilates, water and electrolytes accumulate in lumen and in the bowel wall.

  • Massive third-space fluid loss: dehydration and hypovolemia.

  • Intraluminal pressure increases in the bowel, a decrease in mucosal blood flow occurs.


Pathophysiology mesenteric ischemia

Pathophysiology: MesentericIschemia

  • Arterial: embolism, thrombosis

  • Venous: thrombosis

  • Superior mesenteric vessel distribution

  • Intestinal mucosal sloughing within 3 hours of onset

  • Full-thickness intestinal infarction by 6 hours


Symptoms signs in acute abdomen

Symptoms & Signs in Acute abdomen


Main symptom abdominal pain

Main symptom- Abdominal pain

  • Location: finger vs hand (visceral)

  • Severity:

  • Onset: sudden in perforation, ischemia, biliary colic

  • Progress: develops and worsens over several hours is typical of progressive inflammation or infection such as appendicitis, cholecystitis

  • Spasmodic: Biliary colic, or genitourinary obstruction

  • Radiation and shift: cholecystitis, appendicitis

  • Exacerbating factors: food worsen pain of bowel obstruction

  • Relieving factors: food relieves pain of non-perforated peptic ulcer disease or gastritis.


Associated symptoms

Associated symptoms

  • Vomiting likely to precede significant abdominal pain in medical conditions whereas pain presents first inacute surgical abdomen.

  • Constipationor obstipation can be a result of either mechanical obstruction or decreased peristalsis (ileus).

  • Diarrhea is associated with several medical causes of acute abdomen, including infectious enteritis, inflammatory bowel disease (IBD), and parasitic contamination

  • Bloody diarrhea- IBD, Colonic ischemia


Acute abdomen

  • Past medical history: passage of stone(ureteric colic) previous surgery (intestinal obstruction)

  • Gynecologic history: LMP (ectopic pregnancy), mid cycle pain (mittelschmerz)

  • Medications: create acute abdominal conditions or mask their symptoms. NSAID (bleeding, perforation), narcotics (constipation), steroids (mask inflammation)


Physical examination inspection

PHYSICAL EXAMINATION(Inspection)

  • Inspection of the patient:

  • Ischemic bowel and ureteral and biliary colic, typically cause patients to continually shift and fidget in bed while trying to find a position that lessens their discomfort.

  • Patients with peritonitis 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.


Inspection of the abdomen

Inspection of the abdomen

  • Distension

  • Restricted mobility- ?peritonitis

  • Scars of previous surgery

  • Hernias

  • Mass effect

  • Ecchymosis ? Acute pancreatitis (Cullen’s, Grey Turner’s sign)


Palpation of the abdomen

Palpation of the abdomen

  • Start gently, away from the area of pain.

  • Severity and exact location of tenderness- localized/ generalized

  • Involuntary guarding

  • Organomegaly, mass

  • Murphy’s sign, Rovsing’s sign,

  • Rebound tenderness (Blumberg’s sign)


Percussion of the abdomen

Percussion of the abdomen

  • Hyperresonance :distendedbowel loops

  • Dullness due to organomegaly or mass

  • Liver dullness lost- free intra-abdominal air is suspected.

  • Shifting dullness

  • Tenderness


Auscultation of the abdomen

Auscultation of the abdomen

  • Quiet abdomen- ileus

  • Hyperactive bowel sounds- enteritis, ischemic intestine

  • Mechanical bowel obstruction- high-pitched “tinkling” sounds that come in rushes and are associated with pain

  • Bruits- high-grade arterial stenosis


Digital rectal examination

Digital rectal examination

  • Performed in all patients with acute abdominal pain

  • Checking for mass, pelvic pain, or intraluminal blood

  • Pelvic examination in female


Acute abdomen

Part III


Investigations

Investigations


Routine laboratory investigations

Routine laboratory investigations

  • Hematology:WBC count, differential count, hemoglobin, platelets, red blood cells

  • Electrolytes, urea, creatinine

  • Amylase, lipase

  • LFTs: Bilirubin (T & D), alkaline phosphatase, aminotransferase,

  • Serum lactate & arterial blood gas

  • Urine analysis

  • Urine human chorionic gonadotropin

  • Stool for parasites


Acute abdomen

  • WBC count: confirm infection

  • Electrolytes, blood urea nitrogen, and creatinine:the effect of vomiting or third-space fluid losses

  • Serum amylase and lipase- acute pancreatitis (high level), small bowel infarction or duodenal ulcer perforation (mild to moderate rise)

  • Liver function tests: biliary tract disease.


Acute abdomen

  • Lactate levels and arterial blood gas: intestinal ischemia or infarction.

  • Urinalysis: bacterial cystitis, pyelonephritis, diabetes.

  • Urinary human chorionic gonadotropin: suggest pregnancy as a factor in the patient's presentation or aid in decision making regarding therapy.

  • Stool:occult blood, parasite, Cl. Difficile (toxin & culture).


Imaging studies

Imaging studies

None of the imaging techniques take the place of a careful history and physical examination.


Plain radiographs

Plain radiographs

  • Upright chest radiographs – free gas under the dome of diaphragm Perforated duodenal ulcer-75%

  • Lateral decubitus abdominal radiographs- pneumoperitoneum in patients who cannot stand


Plain x ray abdomen

Plain x-ray abdomen

  • Calcifications: renal stones 90%, chronic pancreatic, aortic aneurysms, fecalith

  • Supine and upright films: distension, fluid levels, gas distribution (small vs large bowel), volvulus of sigmoid colon/ cecum


Abdominal ultrasonography

Abdominal ultrasonography

  • Gallbladder: stone, wall thickness, fluid around gallbladder, diameter of bile ducts

  • Liver: abscess, other masses

  • Pelvis: Ovarian, adnexal & uterine pathologies

  • Free fluid in peritoneum

  • Limited evaluation of pancreas

  • Limitations: bowel gas, person dependent, difficult to interpret for most surgeons


Ct abdomen

CT abdomen

  • Widely available

  • Easier to interpret by surgeons

  • Imaging modality of choice in acute abdomen, following plain abdominal radiographs.

  • Accuracy and utility of CT abdomen and pelvis in acute abdominal pain is well established.

  • Most common causes of acute abdomen are readily identified by CT

  • Highly accurate in acute appendicitis, mechanical bowel obstruction, intestinal ischemia


Diagnostic laparoscopy

DIAGNOSTIC LAPAROSCOPY

  • Ability to diagnose and treat a number of the conditions causing an acute abdomen

  • High sensitivity and specificity

  • Decreased morbidity and mortality, decreased length of stay, and decreased overall hospital costs

  • Advances in equipment and greater availability


Differential diagnosis

DIFFERENTIAL DIAGNOSIS

  • Differential diagnosis of acute abdominal pain is extensive.

  • Comprehensive knowledge of the medical and surgical conditions that create acute abdominal pain

  • Mild, self-limited illness to the rapidly progressive and fatal

  • Evaluated immediately upon presentation and reassessed at frequent intervals.

  • Many acute abdomen require surgical intervention but some abdominal pain are medical in aetiology.


Acute abdomen

Part IV


Initial management

Initial management


Preoperative preparation

Preoperative preparation

  • Fluid and electrolyte abnormalities corrected

  • Antibiotic infusions for the bacteria common in acute abdominal emergencies (gram-negative enteric organisms and anaerobes)

  • Nasogastric tube to decrease the likelihood of vomiting and aspiration

  • Foley catheter- to assess urine output -0.5 mL/kg/hour

  • Blood typed and cross matched for operation


Preoperative preparation1

Preoperative preparation

  • Frequent evaluation of the patient

  • Stabilization of co-morbid conditions

  • Surgical vs non- surgical management

  • Consent for surgery


Common causes of acute abd omen

Common Causes of Acute Abdomen


Acute appendicitis

Acute appendicitis

  • Most common general surgical emergency

  • Derived from the midgut

  • Obstruction of the lumen (fecalith, lymphoid hyperplasia, vegetable matter or seeds, parasites) is the major cause of acute appendicitis.

  • Obstruction contributes to bacterial overgrowth,


Acute appendicitis1

Acute appendicitis

  • Continued secretion of mucus leads to intraluminal distention.

  • Distention produces the visceral pain sensation as periumbilical pain.

  • Promote a localized inflammatory process

  • May progress to gangrene and perforation.

  • Inflammation of the adjacent peritoneum- localized pain in the right lower quadrant.

  • Perforation usually occurs after 48 hours from the onset of symptoms


Acute appendicitis symptoms

Acute appendicitis- symptoms

  • Typical periumbilical pain (activation of visceral afferent neurons) followed by anorexia and nausea.

  • Pain localizes to the right lower quadrant (inflammatory process progresses to involve the parietal peritoneum)

  • Migratory pain is the most reliable symptom.


Acute appendicitis signs

Acute appendicitis- signs

  • Ill looking patient, low grade fever

  • Coughing may cause increased pain(Dunphy's sign)

  • Tenderness at McBurney’s point, involuntary guarding

  • Site of tenderness may vary depending on the position of the appendix.

  • Pain felt in the right lower quadrant during palpation of the left lower quadrant (Rovsing's sign)

  • Perforated appendicitis: more severe and diffuse abdominal pain, tenderness and abdominal wall rigidity


Acute appendicitis investigations

Acute appendicitis- investigations

  • Elevated WBC and neutrophil

  • Normal WBC in 10%

  • Very high WBC (>20,000/ml)- complicated appendicitis

  • Urine analysis- exclude urinary system disease

  • Abdominal x-ray- generally not indicated, ? ureteric calculi, small bowel obstruction, perforated ulcer

  • Ultrasonography:appendix of 7 mm or more in anteroposterior diameter, thick-walled, noncompressible luminal structure in cross section (target lesion), the presence of an appendicolith

  • CT abdomen: appendix > 7mm in diameter, wall thickening, periappendiceal edema or fluid


Surgical treatment acute appendicitis

Surgical treatment (Acute appendicitis)

  • Uncomplicated appendicitis:

    Appendectomy - Laparoscopic vs open surgery

  • Complicated appendicitis:

    Localized perforation (abscess): percutaneous drainage under CT or ultrasound guidance

    Free perforation (peritonitis): laparotomy vs laparoscopic appendectomy


Acute abdomen

Part V


Perforated peptic ulcer

Perforated peptic ulcer

  • 5% of peptic ulcers penetrate through the duodenal wall into the peritoneal cavity

  • Produce chemical peritonitis


Clinical features of perforated peptic ulcer

Clinical features of perforated peptic ulcer

  • Sudden onset epigastric pain

  • Fever and tachycardia

  • Abdominal tenderness, rigidity, rebound tenderness

  • Absent bowel sound

  • Free air underneath the diaphragm on an upright chest radiograph.


Perforated peptic ulcer treatment

Perforated peptic ulcer- treatment

  • Fluid resuscitation

  • Early surgery to close the perforation by laparoscopy or open surgery


Small bowel obstruction

Small bowel obstruction

  • Post-operative adhesion- most common

  • Hernia, tumour, Crohn’s disease- other causes

  • Early- the intestinal contraction increases to propel contents past the obstructing point (colicky pain)

  • Later- the intestine becomes fatigued and dilates, contractions becoming less intense.

  • Bowel dilates, water and electrolytes accumulate in lumen and in the bowel wall.

  • Massive third-space fluid loss: dehydration and hypovolemia.

  • Intraluminal pressure increases in the bowel, a decrease in mucosal blood flow occurs.


Clinical features

Clinical features

  • Colicky abdominal pain, nausea, vomiting, abdominal distention, and a failure to pass flatus and feces (i.e., obstipation).

  • Examination:

    Distended abdomen

    Surgical scars/ hernia

    Hyperactive bowel sounds

    Mild abdominal tenderness


Investigations1

Investigations

  • Tests for fluid & electrolytes abnormality

  • Leukocytosis may be found in patients with strangulation

  • Plain x-ray abdomen: dilated bowel loops (supine) & multiple air-fluid levels (upright)

  • Patient in whom the diagnosis is not readily apparent- CT abdomen


Treatment

Treatment

  • Isotonic saline solution such as lactated Ringer's

  • Antibiotics-prophylactically

  • Nasogastric suction

  • Partial intestinal obstruction may be treated conservatively with resuscitation and tube decompression

  • Operative Management:

  • Adhesive obst.-laparotomy & release of adhesions.

  • Hernia- operative reduction and repair


Mesenteric ischemia

MesentericIschemia

  • Arterial: embolism, thrombosis

  • Venous: thrombosis

  • Superior mesenteric vessel distribution

  • Intestinal mucosal sloughing within 3 hours of onset and

  • Full-thickness intestinal infarction by 6 hours


Symptoms signs

Symptoms & signs

  • Abdominal pain- sudden onset

  • Severity- out of proportion to the degree of tenderness

  • The pain is colicky, most severe in the mid-abdomen.

  • Associated symptoms- nausea, vomiting, and diarrhea

  • Physical findings- absent early in the course.

  • Later- abdominal distention, tenderness, guarding and passage of bloody stools.


Investigations2

Investigations

  • Leukocytosis,

  • Acidosis, and

  • Elevated amylase and creatine kinase- late

  • CT scanning:

    Acute arterial mesenteric ischemia-64 to 82%.

    Acute mesenteric venous thrombosis- 90%


Mesenteric ischemia treatment

Mesenteric ischemia- treatment

  • Fluid resuscitation

  • Laparotomy

  • Test for viability of bowel

  • Resection of infarcted segment

  • Anticoagulation for SMV thrombosis


Conclusion

Conclusion

  • A challenging part of a surgeon's practice.

  • Careful history and physical examination remain the most important part of the evaluation.

  • Laboratory investigations and imaging techniques have improved the diagnostic accuracy

  • Surgeon often make the decision to perform surgery with a good deal of uncertainty

  • Morbidity and mortality associated with a delay in the treatment demand an expeditious approach


Thank you

Thank you!


Acute abdomen

Part VI


Case presentation

Case presentation


Case no 1

Case No. 1

A 19-year old male presents with abdominal pain since last night. He has vomited once early this morning.

  • History

  • Examination

  • Differential diagnosis

  • Investigations

  • Pathophysiology

  • Complications of delayed presentation/ treatment

  • Treatment


History

History

  • Location: Initially periumbilical, now RIF

  • Severity: started mild, now severe

  • Onset: gradual

  • Progress: worsening

  • Radiation and shift: Initially periumbilical, now RIF

  • Exacerbating factors:none

  • Relieving factors: none

  • Associated symptoms: vomiting once, no anorexia

  • Systemic inquiry, family, social, drug, past history- none


Examination

Examination

  • Appearance: Looking ill

  • Temperature: 38.5°C

  • Abdomen:Inspection- flat, moving with respiration, no cough tenderness

  • Palpation- guarding & tenderness in RIF and at McBurney’s point, Rovsing’s sign –ve

  • Percussion- tender RIF

  • Auscultation- diminished bowel sounds

  • Rectal examination not done


Differential diagnosis1

Differential diagnosis

  • Children: Meckel’s diverticulitis, intussusception, gastroenteritis, mesenteric lymphadenitis

  • Adults: Crohn’s disease, pyelonephritis, ileo-cecal neoplasm, bowel obstruction

  • Female: Ectopic pregnancy, mid cycle pain, tubo-ovarian pathology, PID


Acute abdomen

Acute appendicitis


Investigations3

Investigations

  • Leucocytosis with high neutrophil

  • Very high WBC > 20,000 in complicated app.

  • Urinalysis to rule out urinary infection

  • Ultrasonography: Not done. Indicated in children and pregnant. Thick wall, non-compressible, edema and fluid

  • CT: Not done. Distended, thick wall periappendiceal edema and fluid


Pathophysiology1

Pathophysiology

  • Obstruction of the lumen

  • Fecalith, lymphoid hyperplasia, vegetable, seeds, parasites, neoplasm

  • Small lumen, obstruction lead to closed loop

  • Bacterial overgrowth

  • Continued mucous secretion lead to distension and typical visceral pain in periumbilical area

  • Inflammation of adjacent parietal peritoneum gives rise to localized RIF (parietal) pain


Delayed presentation

Delayed presentation

  • Inflammatory progress to gangrene

  • Localized perforation- abscess formation

  • Free perforation- peritonitis (secondary)


Treatment1

Treatment

  • Nil orally

  • IV fluid

  • Pre-op. antibiotics: cefuroxime+ metronidazole

  • Non-perforated: single pre-op. dose

  • Perforated: continue post-op. until afebrile

  • Consent for surgery

  • Appendectomy- laparoscopic or open surgery

  • Appendicular abscess- image guided drainage

  • Free perforation- Open/ laparoscopic appendectomy


Case no 2

Case No. 2

A 30-year old female presents with right hypochondrial pain for 2 days associated with fever.

  • History

  • Examination

  • Differential diagnosis

  • Investigations

  • Pathophysiology

  • Management


History1

History

  • Location: right hypochondrium

  • Severity: started mild, now severe

  • Onset: gradual

  • Progress: worsening

  • Radiation: back and right shoulder

  • Exacerbating factors:fatty food

  • Relieving factors: analgesics

  • Associated symptoms: fever, no vomiting , no anorexia

  • Systemic inquiry, family, social, drug history- none

  • Past medical history- similar pain of shorter duration 2 months back


Examination1

Examination

  • Appearance: In pain

  • Temp. 38.6°C

  • No jaundice

  • Abdomen: Inspection- normal, few striae gravidarum

  • Palpation- tenderness & guarding in RH, Murphy’s sign +ve( tenderness & arrest of inspiration while palpating at costal margin)

  • Percussion, auscultation- none


Differential diagnosis2

Differential diagnosis

  • Chronic cholecystitis

  • Biliary colic

  • Obstructive jaundice

  • Liver abscess

  • Viral hepatitis


Acute abdomen

Acute cholecystitis


Investigations4

Investigations

  • Leucocytosis

  • LFT: very slight elevation of bilirubin, normal alkaline phosphatase and transaminase

  • Abdominal ultrasonography: gall stones, gall bladder wall thickening, edema, pericholecystic fluid


Pathophysiology2

Pathophysiology

  • Obstruction of the cystic duct

  • Bacterial inflammation

  • If obstruction persists- ischemia and gangrene of the gall bladder

  • Eventually perforation


Management

Management

  • Nil by mouth

  • IV fluid

  • Parenteral antibiotics- (gram –ve and gram +ve organisms)- cephalosporin

  • Consent for surgery

  • Early laparoscopic cholecystectomy


Acute abdomen

Thank you!


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