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ACUTE ABDOMEN

ACUTE ABDOMEN. Begashaw M . ACUTE ABDOMEN. Denotes any sudden condition with chief manifestation of pain of recent onset in the abdominal area which may require urgent surgical intervention. Sites of referred pain . Sites of Abdominal Pain . CLASSIFICATION. Obstruction Inflammation

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ACUTE ABDOMEN

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  1. ACUTE ABDOMEN Begashaw M

  2. ACUTE ABDOMEN • Denotes any sudden condition with chief manifestation of pain of recent onset in the abdominal area which may require urgent surgical intervention

  3. Sites of referred pain

  4. Sites of Abdominal Pain

  5. CLASSIFICATION • Obstruction • Inflammation • Hemorrhage • Infarction • perforation

  6. CLINICAL FEATURES • Symptoms _Colicky and Intermittent pain ( visceral) _Continuous pain ( somatic) _Vomiting _Fever _Tachycardia • Colic pain obstruction • Continuous paininfection, inflammation or ischemia

  7. Signs • Abdominal distention, visible peristalsis • Direct and rebound tenderness, guarding • Anemia, hypotension • Toxic with Hippocratic faces • Absence of bowel sound ( peritonitis) • Psoassignappendicitis • Murphy‘s signacutecholecystitis • Dehydrationsunken eyeballs

  8. DIFFERENTIAL DIAGNOSIS • Surgical - Intestinal obstruction • Gynecologic & obstetric - Ectopic ruptured pregnancy • Medical - enteritis

  9. Surgical causes A- InflammationAcute appendicitis Acute cholecystitis B- Obstruction Intestinal obstruction C- Infarction Mesenteric ischemia D-Strangulation volvulus E- Perforation perforated peptic ulcer

  10. DIAGNOSIS Clinical: Hx & p/E Lab: CBC, cross match, urine analysis, serum amylase & electrolytes Ultrasound plain film of abdomen

  11. MANAGEMENT A-Preoperative - Resuscitation with IV fluids - Antibiotics - Catheterization & NGT insertion - Analgesics after confirming the diagnosis B- Surgery Definitive laparotomy CMonitoring Follow up

  12. INTESTINAL OBSTRUCTION • is partial or complete blockage of the intestine producing symptoms _Vomiting _Constipation _Distension _Abdominal pain

  13. Causes of mechanical intestinal 0bstruction

  14. Intestinal Obstruction

  15. CLASSIFICATION Mechanical  physical barrier blocks Paralytic ileusdisordered propulsive motility High _Small bowel Low _Large bowel Simple -> adequate blood supply Strangulated -> Mesenteric vessels occluded

  16. Mechanical A- Luminal _Gallstone Ileus _Food bolus _MeconiumIleus _Malignancy _Inflammatory mass _Ascaris bolus B- Mural _Stricture _Congenital _Inflammatory _Ischemic _Neoplastic _Intussusception

  17. Intussusception

  18. C- Extra mural Adhesionsinflammatory/malignant Hernia External/internal VolvulusSmall bowel large bowel -> Sigmoid volvulus

  19. Small bowel obstruction

  20. Adhesion

  21. PATHOPHYSIOLGY • Proximal dilatation disrupts peristalsis • Above the obstruction  distended with fluid and gas • stimulates excessive peristalsis ->colicky pain • blood vessels-stretched & narrowed ischemia • Absorptive capacity decreases • increased vomiting  depletion of extra cellular fluid  hypovolemia & dehydration

  22. Pathophysiology

  23. A strangulated loop dies and perforates to produce severe bacterial peritonitis which is often fatal Grossly distended abdomen restricts diaphragmatic movement and interferes with respiration A multiple organ failure

  24. Clinical features • Symptoms -Abdominal pain-colic -Vomiting -Constipatio-partial -absolute • Signs -Abdominal distension visible bowel loops -High pitched bowel sounds -Tenderness & guarding -Dehydration & hypotension -Empty rectum DRE Large bowel obstruction

  25. DIAGNOSIS • Clinical: Hx & P/E • Lab: CBC, electrolytes • Plain abdominal film : - distension of bowel with air fluid level - Central located distended loops with multiple air fluid levelsmall bowel - Peripherally located distended bowel with haustralmarksLarge bowel

  26. X-ray of intestinal obstruction

  27. MANAGEMENT Fluids resuscitation to restore the circulatory state Early preoperative preparation Attempt rectal tube deflation-simple sigmoid volvulus Supportive measures Early operationLaparotomy Post operative care

  28. NG tube suction

  29. SIGMOID VOLVULUS • Sigmoid colon is the most frequent site of volvulus • Predisposing factors - A long redundant sigmoid with a narrow pedicle - High fiber diet • Chronic constipation_elderly _chronic mental pts

  30. Sigmoid volvulus

  31. PATHOPHYSIOLOGY Redundant sigmoid twists on its base in a clockwise direction Mesocolic veins become occluded & arterial inflow into the twisted loop perpetuates the volvulus until it becomes irreversible Twisted loop distends grossly Perforation may occur due to either pressure necrosis at the base of the twist or to avascular necrosis at the apex

  32. DIAGNOSIS • CLINICAL _Abdominal cramp & distension _Constipation (early) & vomiting (late) _Empty rectum on DRE • RADIOLOGIC FINDINGS • Two long fluid levels in the lower quadrant • Inverted U shape of the sigmoid lumen • “Coffee bean” appearance or the ‘Omega sign”

  33. MANAGEMENT • Conservative • simple volvulusdeflation with a well greased large bore rectal tube under the guide of a sigmoidoscope • Deflation fails laparotomy & derotation • Elective resection & anastomosis • Intravenous fluid - rehydrate if sign of dehydration

  34. Sigmoidoscopic deflation

  35. Emergency Surgery _Complicated volvulus with signs of peritonitis _Resuscitative measures _Antibiotics _Resection of the gangrenous segment with Hartman’s colostomy

  36. Laparatomy

  37. APPENDICITIS is an inflammation of the appendix that results from bacterial invasion usually distal to an obstruction of the lumen

  38. Appendix

  39. Pathogenesis • Luminal obstruction bacterial overgrowth lnflammation/swelling Increased pressure-localized ischemiagangrene/perforationlocalized abscess (walled off by Omentum) or Peritonitis • Etiology: _Hyperplasia of lymphoid follicles _Fecolith, obstructing neoplasm _Parasites, foreign body

  40. CLINICAL PRESENTATION Symptoms -Central abdominal colic which shifts to the right Iliac fossa -Anorexia, nausea, episodes of vomiting and low grade fever -High grade fever indicates perforation and peritonitis

  41. Signs -Tenderness and localized rigidity in RLQ MC Burney’s point -Rovsing’s sign: Pain in RLQ on pressing in LLQ -Psoas sign: Pain on extension of right flexed hip -Obturator sign: Pain on passive internal or external rotation of the flexed right hip -Right sided tenderness on rectal examination. -Diminished bowel sounds indicating peritonitis

  42. Appendicitis signs

  43. Differential diagnosis • IN CHILDREN -Intussusceptions -Mesenteric adenitis • FEMALE -PID -Twisted ovarian cyst( torsion) - ruptured ovarian follicle • GENERAL -Acute chlolecystitis -Perforated PUD -Renal or ureteric calculi -UTI -Early small bowel obstruction (volvulus) -Gastroenteritis

  44. Investigations • Labs • leukocytosis with left shift • beta-hCG to rule out ectopic pregnancy • Urinalysis • Imaging: • Upright CXR, AXR-free air • Ultrasound: may visualize appendix

  45. MANAGEMENT • PREOPERATIVE -Resuscitation with fluids -Appropriate antibiotics (combination for coverage of gram positive, gram negative and anaerobes) -Correct all deficits ( dehydration) • SURGERY -Surgical removal of the appendix is the definitive treatment-Appendectomy

  46. COMPLICATIONS Perforation - local or generalized peritonitis Appendiceal mass and abscess formation Death

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