Presentation

1. ACUTE ABDOMEN
BY
Dr. Alesi
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2. Introduction
• acute abdomen is any clinical condition
characterized by acute onset of severe
abdominal pain.
• Presenting 24hrs from onset of pain.
• In pt who has been previously well.
• In whom the cause of the acute abdominal
pain is obscure.
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3. Pathophsiology
Visceral pain; due to stimulation of visceral
afferent nerve plexus
• Pain is usually in midline, result from
contraction or distension against resistance &
chemical irritation
• Pain is usually colicky in nature.
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4. • Pain from the viscera is principally due to
ischaemia, muscle spasm and stretching of
the visceral peritoneum.
• Unlike somatic pain, autonomic pain is deep
and poorly localised. This pain
• is transmitted via sympathetic fibres and so is
referred to the appropriate somatic
distribution of that nerve root from T1 toL2.
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5. • However, when an inflamed organ touches the
• parietal peritoneum, the pain becomes sharp
and localises to the appropriate segmental
dermatome of the abdominal wall. Pain
• arising from the parietal peritoneum may
radiate to the back or the front along the
appropriate dermatome. This referral pattern
is classically seen in acute cholecystitis when
an inflamed gall bladder touches the parietal
peritoneum. 5

6. Pathophysiology
• Parietal pain; 2dry to parietal peritoneum
irritation perceived through segmental
somatic fibers
• reflex involuntary muscle wall rigidity may
result from irritation of segmental sensory
nerves.
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7. pain
• Abdominal wall and parietal peritoneum are
supplied by the somatic nerves
• Abdominal organs and the visceral peritoneum are
supplied by the autonomic nervous system
• Skin, muscles and parietal peritoneum are supplied
by the iliohypogastric and ilioinguinal nerve and the
lower sixintercostal nerves
• Afferent pain fibres from the abdominal organs and
visceral peritoneum travel with sympathetic nerves
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8. Distribution of the anterior abdominal wall
dermatomes and nerves
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9. Pathways for parietal and visceral pain.
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10. Abdominal quadrant
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11. Causes of acute abdomen.
• They are classified as :
• Traumatic
• Non –traumatic.
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12. Common non traumatic causes
of acute abdomen.
There are different pathological processes that are
behind acute abdomen and this include:
Inflamation
Obstruction
Ischaemia
Perforation
Rapture.
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13. inflammation
Organ involved
• Appendix.
• Gallbladder.
• Colon.
• Fallopian tubes.
• Pancrease.
• etc
disease
• Acute appendicitis
• Acute cholecystitis.
• Diverticulitis.
• Salpingitis.
• Acute pancreatitis.
• etc
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14. obstruction
Organ involved
• Intestines.
• Gallbladder.
• Ureter.
• Urethra.
• etc
disease
• Intestinal obstruction.
• Cholelithiathesis.
• Ureteric colic.
• Acute urine retension.
• etc
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15. ischemia
Organ involved
• intestines..
• Ovary.
disease
• Strangulated hernia.
• Volvulus.
• Mesenteric ischemia.
• Tubal ovarian masses
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16. perforation
organ
• Duodenum.
• Stomach.
• Colon.
• Gallbladder.
• etc
disease
• Perforated pud.
• Perforaed gastric ulcer.
• Cancer.
• Perforated diverticulitis.
• Biliary peritonitis
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17. rapture
organs
• Spleen
• Fallopian tube.
• Abdominal aorta
disease
• Raptured spleen.
• Raptured ectopic pregnancy..
• Raptured aneurysm
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18. Approach to acute abdomen
• History.
1. pain
2. Associated symptoms, nausea, vomiting,
Change of bowel habits, jaundice, anorexia,
Heamatemesis, melena, dyspepsia
3.Menstruation & sexual history.
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19. Cont..
• 4.ROS
• 5.past medical & surgical hx
• 6.hx /o medications
• 7.familay Hx
• 8.social Hx
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20. 20

21. 21

22. Clinical features of acute abdomen
• Following history taking .an abdominal
examination is done to elicit various signs.i.e.
• On inspection.
• Palpation.
• Percussion.
• auscultation
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23. Inspection.
• Distension.e.g io,ascitis.
• Rigid abdomen i.e peritonotis.
• Scars.
• Hernia.
• Visible peristalsis
• Visible masses
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24. palpation
• Superfical
• Tenderness and rigidity.
• Deep.
• Palpable organs.
• Masses
• Rebound tenderness
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25. percussion
• Resonance.
• Loss of liver dullness.
• Dullness i.e. free fluid and full bladder.
• Shifting dullness i.e. in ascitis
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26. auscultation
• Absence of bowel sounds i.e. Paralytic ileus.
• Increased sounds i.e. Mechanical obstruction and
gastroenteritis.
• bruits
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27. • N.B.
• Never forget to:
• Examine the groin.
• Do digital exam
• A vaginal examination
• A chest exam.
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28. Specific clinical signs of acute
abdomen
• Blumberg's sign (rebound tenderness): constant,
held pressure with sudden release causes severe
tenderness (peritoneal irritation)
• Courvoisier's sign: palpable, non-tender gall
bladder with jaundice (pancreatic or biliary
malignancy)
• Cullen's sign: blue discoloration around umbilicus
(peritoneal hemorrhage).
• Grey Turner's sign: flank discoloration
(retroperitoneal hemorrhage)
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29. • Iliopsoas sign: flexion of hip against
resistance or passive hyperextension of hip
causes pain (retrocecal appendix
• Murphy's sign: inspiratory arrest on deep
palpation of RUQ (cholecystitis)
• McBurney's point tenderness: 1/3 from
anterior superior iliac spine (ASIS) to
umbilicus; indicates local peritoneal irritation
(appendicitis)
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30. • Obturator sign: flexion then external or internal
rotation about the right hip causes pain (pelvic
appendicitis)
• Percussion tenderness: often good substitute
for rebound tenderness
• Rovsing's sign: palpation pressure to left
abdomen causes McBurney's point tenderness
(appendicitis)
• Shake tenderness: peritoneal irritation (bump
side of bed in suspected malingerers)
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31. • Boas’s sign: right subscapular pain due to
cholelithiasis
• Fox’s sign: ecchymosis of inguinal ligament seen
with retroperitoneal bleeding
• Kehr’s sign: severe left shoulder pain with splenic
rupture
• Dance’s sign: empty right lower quadrant in
children with ileocecal intussusception
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32. investigation
• 1.CBCs, (complete blood count)
• WBCs & differential..
• Platelet count
• 2.electrolyte,
• ( Na, K, Cl, Ca ,Mg, )
• Indicative of volume status, GIT loss,
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33. .
• 4.liver function test
• Bilirubin (D or ID), ALP elevation in biliary
obstruction & transaminase elevation in case
of hepatocellular injury.
• 5.RFT
• Urea, creatinin elevation in renal insufficiency
• Serum albumin decrease in edema / ascitis.
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34. .
• 6. serum amylase
• Seen in pancreatitis although non specific may
be elevated in mesenteric ischemia,
perforated peptic ulcer, rupture ovarian cyst &
renal failure. But lipase more sensitive.
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35. .
• 7.serum B_HCG
• Mandatory for all women in childbearing
period.
• 8.urinalysis
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36. Radiological evaluation
• 1.CXR,
• Look for pneumonia, free gases under
diaphragm .pleural effusion suggest sub
diaphragmatic inflammatory process.
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37. .
• 2.abdominal Xray.
• (Erect & supine position )
• * bowel distension & air fluid level
• *bowel gas cut off vs air through rectum.
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38. Intestinal obstruction
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39. .
• 3.ultrasound,
• *hepatobiliray tree(stones,mass,thickening of
the wall)
• *pancreases
• *kidney
• *pelvic organ
• *intrabdominal fluid collection
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40. Other study
• 6.endoscopy,
• git bleeding
• Sigmoidcolonoscopy
• *colonic obstruction
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41. .
• 7.paracentesis &or peritoneal lavage
• *spontaneous bacterial peritonitis
• *peritoneal lavage may be useful bedside test
in diagnosis of mesenteric infarction in
critically ill pt.
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42. .
• 8.culdocentesis
• Valuable in diagnosis of rupture ectopic
pregnancy.
• 9.laproscopy
• *D & ttt of suspected gynec.cause
• *appendectomy if appendicitis is found in a
women in childbearing period.
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43. Plan of treatment
• *promote timely work up.
• *keep pt Npo till the diagnosis is firm &
treatment plan is formulated.
• *IV fluid. based on expected fluid loss.
• *heamodynamic monitoring.
• *NGT bleeding ,vomiting ,sign of obstruction
or when urgent laparotomy is planned in pt
not NPO.
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44. .
• Foley catheter to monitor fluid out put
decisions
• ??? Immediate surgery
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45. • N.B. Apatient with acute abdomen is a CRITICALLY
ILL SURGICAL PATIENT. The aproach of this patient is
summarised as
• ABC, I’M FINE.
• ABC (see Emergency Medicine Chapter)
• I - IV: two large bore IV’s with normal saline, wide
open
• M - Monitors: O 2 sat, EKG, BP
• F - Foley catheter to measure urine output
• I - Investigations: see above
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46. • N - +/– NG tube
• E - Ex rays (3 views, CXR.
END
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