1. DR. WONG SEAK KHOON
(2 November 2011)
Present by: Soediqin
Akmal

2.  Abdomen
Abdomen is part of trunk that lies between the
thorax and pelvis.
It is divided into 9 parts by 2 vertical lines, right
and left midclavicular lines and also 2 horizontal
lines, subcostal and intertubercular lines.

3. Epigastrium
Right
Hypochondriu
m
Left
Hypochondriu
m
Umbilic
al
Right Lumbar Left lumbar
Right iliac fossa Hypogastrium Left iliac fossa

4. Stomach
Pancreas
Lt lobe of liver
Liver
Gallbladder
Spleen
Tail of pancreas
Fundus of
stomach
Coils of
small
instestine
Right kidney
Ascending colon
Left kidney
Descending
colon
Caecum
Appendix
Urinary
bladder
Sigmoi
d
colon

5. Stomach
DuodenumGallbladder Pancreas
Small
intestine
Caecum
Kidney Kidney
Caecum
Appendix
Transverse
colon
Bladder
Sigmoi
d
colon

6.  Abdominal pain is pain that is felt in the
abdomen
 Acute abdomen refers to a sudden, severe
abdominal pain of unclear etiology that is
less than a week in duration
◦ eg. acute peritonitis, acute pancreatitis, acute
cholecystitis, acute cholangitis, acute appendicitis
diabetic ketoacidosis

7. 1. Somatic pain:
- due to irritation of parietal peritoneum
- parietal peritoneum covers:
(a) anterior & posterior abd. wall
(b) undersurface of diaphgram
(c) pelvic cavity

8. - Nerve supply: derived from nerve supplying
muscles & skin of abdominal
wall (T5- L2)
*exception: central portion of diaphrgam
(phrenic nerve: C3,C4,C5)
- Sensitive to: mechanical
thermal
chemical

9. - Response to irritation:
(i) reflex contraction of corresponding
segment of muscle guarding
(ii) hyperaesthesia of overlying skin
- Nature: sharp, localised, knife-like

10. 2. Visceral pain:
- due to irritation of visceral peritoneum
- visceral peritoneum covers partially/
completely the intra-abdominal viscera
- pain is mediated through sympathetic
branches of autonomic system, to
thoracic (T6-T12) & lumbar (L1,L2)
segment of spinal cord

11. - Sensitive only to tension
- Nature: dull, poorly localised, deep,
referred to overlying skin with
same embryological origin

12. Causes of
Abdominal Pain
Surgical
Medical
Non-traumatic
Traumatic

13. Hemorrhage
Infarction/
Strangulation Obstruction
Perforation
Inflammation/
Infection
Non- traumatic
Abdominal Pain

14. Pathology Disease
Inflammation •Diverticulitis
•Salphingitis
•Acute Pancreatitis
•Acute appendicitis
•Acute cholecystitis
Obstruction •Ureteric obstruction
•Urinary retention
•Intestinal obstruction
•Biliary obstruction
Ischaemia •Strangulated hernia
•volvulus
•Torsion of ovarian cyst
Perforation •Perforated peptic ulcer
•Perforated cancer
•Biliary peritonitis
Rupture •Ruptured ectopic
pregnancy
•Ruptured aneurysm

15.  The causes of generalized abdominal pain :
• Irritable bowel syndrome
• Recurrent adhesive obstruction
• Mesenterric carcinoma
• Carcinomatosis
• Chronic constipation
• Radiation damage
• Reptriperitonial tumours
• Endomettriosis
• Pelvic-uriteric junction obstruction
• Lumbar spine pain
• Retroperitonial fibrosis
• psychosomatic
•

16. 1. Mild attack:
◦ Fluid resuscitation and analgesia
◦ NBM meant to rest the pancreas
◦ Treat predisposing factors such as gall stones
◦ Discouraged alcohol abuse
◦ NG tube to aspirate stomach content and
prevent vomiting
◦ Prophylactic antibiotic i.e. imipenem and
cephalosporin
◦ Daily measurement of plasma amylase –
progression of ds
◦ LFT and renal profile

17. 2. Severe attack:
◦ Resuscitate
◦ Defined by Ranson’s or Glasgow criteria
◦ Admit to ICU immediately
◦ Fluid and electrolyte management
◦ Treat hypocalcaemia
◦ Ventilatory support
3. Surgery:
- Abscess drainage
- Cholecystectomy-if stone in gall bladder

18. 1. Pancreatic necrosis & pseudocyst
formation
2. Abscess formation
3. Haemorrhage
4. Thrombosis
5. Fistulae
6. Recurrent edematous pancreatitis

19.  The stomach and duodenum.
1.The insulin test:
 Consist of an injection of insulin which produces hypoglycemia
 Stimulates the nucleus of vagus in the brain stem
 Helpful when a patient develops a recurrent ulcer following vagotomy for
duodenal ulceration.
 The blood sugar has to fall below 45mg/100ml
 Measure before and after insulin in injected by slow i.v infusion
2.Plain x-ray:
 Patients lying in supine position
 Suspected peritonitis due to perforation of gastric or duodenal ulcer
 Gas maybe seen under the diaphragm
 Usually on the right side

20. 3. Barium meal:
 Radiographic investigation
 Patient swallows a suspension of radiopaque barium sulphate
 Principally use in the diagnosis of gastric and duodenal ulcer and gastric
carcinoma.
 Chronic gastric ulcer: seen as a projection from the wall or as a ronded deposit.
 Duodenal ulcer:seen a face with a stellate appearance of the mucosal fold.
 Pyloric stenosis: an increased amount of resting juice present and grossly enlarged
stomach .
4.Endoscopy and biopsy:
 Possible to see the whole of the oesophagus,stomach and duodenum
 Biopsy forceps:to obtain specimens for histological and cytological examination.
 Can differentiate benign from malignant lesions
 Rapid diagnosis of upper gastrointestinal bleeding.

21.  Small intestine.
1.Barium meal follow through X-rays:
 Studied by thaking filmx of abdomen at intervals after a barium meal.
 Abnormalities in the transit time to the colon and in small bowel pattern such as
dilatation,narrowing, fistula and mucosal abnormalities.
2. Biopsy:
 Small intestine biopsy importance in diagnosis of the malabsorption syndrome
where a flat mucosa is seen.
 Colon ,rectum and anus.
1.Protoscopy:
 Can see piles as reddish/blue swelling which bulge into the lumen
 Can see internal opening of an anal fistula,an anal or low rectal polyp and chronic
anal fissure

22. 2. Sigmoidoscopy:
 Necessary to examine the rectum and colon
 Proctitis,polyps and carcinomas may be seen.
 Particulary useful in the differential diagnosis of diarrhoea of colonic region.
3. Barium enema:
 Can see the obstruction of the colon,tumours,diverticular disease,fistulae and other
abnormalities can be recognize.
4.Colonoscopy:
 Inspect the whole colonis mucosa round to the caecum.
 Polyps and diverticulitis can be seen.

23.  The liver.
1.Ultrasound scan:
 Diagnosis of fluid-filled lesions such as cysts and abcesses
 Detecting intrahepatic bile ducts.
2.Needle biopsy of liver:
 Diagnosis for liver abcess
3. Liver function test:
 To see the albumin,globulin,AST and ALT level.

24.  Gallbladder and bile ducts:
1.Percutaneous transhepatic cholangiography:
 Useful investigation in patients with jaundice due to obstruction of the main bile
ducts.
 Investigations the site of the obstruction due to tumours of the head of the
pancreas,iatrogenic and alignant bile ducts strictures –can be accurately localized
and diffrentiated.
2.ERCP(endoscopic retrograde cholangiopancreatography)
 Useful in the rapid diagnosis and localization of the different causes of jaundice
due to obstruction of the main bile ducts.

25.  The pancreas.
1.Lundh test;
 Assessment of tryptic activity in pancreatic juice collected following duodenal
intubation
 Indirect stimulation of the pancreas by prior ingestion of a meal.
 Tryptic activity is less than 6 iu/litre.
2. Triple test.
 Exocrine function.
 Cytology
 Hypotonic duodenography
3. ERCP

26. Pain
1.Site-9 region
2.Onset: acute or recurrent or gradual
3.Character :
-colicky- comes and goes in waves and
indicates obstruction of a hollow, muscular-
walled organ (intestine, gallbladder, bile duct,
ureter).
-burning-an acid cause and is related to the
stomach, duodenum or lower end of the
oesophagus
4.Radiation:
-Right scapula: gallbladder
-Shoulder-tip: diaphragmatic irritation
-Mid-back: pancreas.

27. 5.Associated symptoms, e.g vomiting, diarrhoea,
painful micturition etc
6.Timing:
 since onset
 Episodic or continuous. If episodic, duration and
frequency of attacks;
 If continuous, any changes in the severity
 Variation by day or night, during the week or
month, e.g. relating to the menstrual cycle
7.exacerbation & relieving factor
8.Severity

28.  Past medical history
 Ask especially about:
 Previous surgical procedures including peri-
and postoperative complications and
anaesthetic complications.
 Chronic bowel diseases (e.g. IBD including
recent flare-ups and treatment to date).
 Possible associated conditions (e.g. diabetes
with haemachromatosis).

29.  Drug history
 Think about drugs that can precipitate abdominal
diseases and remember to ask about over-the-counter
drugs. For example:
 Hepatitis: halothane, phenytoin, chlorothiazides,
pyrazinamide, isoniazid, methyl dopa, HMG CoA
reductase inhibitors (statins, sodium valproate,
amiodarone, antibiotics, NSAIDs.
 Cholestasis: chlorpromazine, sulphonamides,
sulphonylureas, rifampicin, nitrofurantoin, anabolic
steroids, oral contraceptive pill.
 Fatty liver: tetracycline, sodium valproate, amiodarone.
 Acute liver necrosis: paracetamol.
 Ask also about previous blood transfusions

30.  Smoking
 Smokers are at risk of peptic ulceration,
oesophageal cancer, colorectal cancer.
Smoking may also have a detrimental
outcome on the natural history of Crohn's
disease.
 Alcohol
a detailed history is required.If dependence
is suspected

31.  Urethral pain: variable in presentation ranging
from a tickling discomfort to a severe sharp pain
felt at the end of the urethra (tip of the penis in
males) and exacerbated by micturition. Can be so
severe that patients attempt to hold on to urine
causing yet more problems!
 Small bowel obstruction: colicky central pain
associated with vomiting, abdominal distension &
constipation.
 Colonic pain: as above under small bowel but
sometimes temporarily relieved by defaecation or
passing flatus.

32.  Bowel ischaemia: dull, severe, constant, right
upper quadrant/central abdominal pain
exacerbated by eating.
 Biliary pain: severe, constant, right upper
quadrant/epigastric pain that can last hours and
is often worse after eating fatty foods.
 Pancreatic pain: epigastric, radiating to the back
and partly relieved by sitting up and leaning
forward.
 Peptic ulcer pain: dull, burning pain in the
epigastrium. Typically episodic at night, waking
the patient from sleep. Exacerbated by eating
and sometimes relieved by consuming

34. 1. Commenest abdominal emergency
(Lifetime incidence 6%)
2. Causes:
(a) Obstruction by faecolith or lesion in
caecum
(b) Recurrent inflammation
(c) Enlargement of lymphoid
follicles

35. Base of appendix: McBurney’s point

36. Initiation of inflammation
Acute inflammation of mucosa
Extension of inflammation across appendiceal wall
Involvement of serosa by inflammation
Visceral peritonitis (referred pain)
Peritonitis spread to adjacent structure
(localised pain)

37. Necrotic glandular mucosa sloughs into lumen
Lumen distended with pus
End-artery (appendiceal artery) thrombosed
Appendix infarction
Gangrenous appendix
Perforation of appendix wall
Attempt to wall off perforation by: omentum, adjacent
bowel

38. Intense & extensive
walling-off rxn Inadequate
containment
Appendiceal
mass
Generalised
peritonitis
Appendiceal
abscess

39. 1. Pain: -vague
- begin at central abdomen/
retrosternal
- poorly localised
- colicky
- assoc. with Nausea & Vomiting
- duration: few hours/ days
- pain then shifted to Rt iliac fossa

40. 2. Localising symptoms depends on anatomical
relations of inflammed appendix
e.g. inflammed retrocecal appendix:
- irritates psoas muscle>>
involuntary Rt hip flexion, pain on
extension

41. 1. General appearance:
- Facial flush
- Low-grade pyrexia
- Tachycardia
2. Abdomen:
(i) Inspection: - Mild abdominal distension
- Reduced abd. movement
at Rt iliac fossa

42. (ii) Palpation: Rt iliac fossa:
- Guarding (indicator of tenderness
severity)
- Tenderness, Rebound tenderness
- +ve Rovsing’s sign
(iii) Percussion: pain at Rt iliac fossa
(iv) Auscultaion: Bowel sound present
Bowel sound absent when
perforation & generalised
peritonitis cause paralytic ileus

43. 1. abdominal pain <72 hours
2. Vomiting 1-3 times
3. Facial flush
4. Tenderness at Rt iliac fossa
5. Low-grade pyrexia
6. no evidence of UTI

44.  No need if it can be diagnosed through
history and physical examination
 AXR for confusing findings, may detect free
gas from perforated appendix.

45. 1. UTI
2. Mesenteric adenitis
3. Constipation
4. Gynaecological disorder
(ectopic pregnancy)
5. Acute pancreatitis
6. Diverticulitis
7. Perforated ulcer

46.  Medical
◦ Antibiotics
 Surgical
◦ Appendicectomy
 Abdominal wall incision ( Lanz/
Classic Gridiron incision)
 Dividing the blood supply
 Removing the appendix
 Closure

47. 1. Perforation
2. Appendiceal mass (usually resolve in the
next 2-6 weeks)
- pyrexia - LOA
- malaise - dull on percussion
3. Appendiceal abscess (formed from
appendiceal mass that fails to resolve)
- swinging pyrexia
- tachycardia

49. Aetiology :
- Gallstones (38%-60%)
- Ethanol (35%)
- Trauma (1.5%)
- Mumps
- Autoimmune (PAN)
- Scorpion venom
- Hyperlipidemia, hypercalcemia,
hyperthyroidism
- ERCP (5%) & emboli
- Drugs
* 10%-20% idiopathic

50. Duodenopancreatic reflux
Enterokinase reflux
Activate pancreatic proenzymes
Inflammation, arterioles thrombose, local infarction
More proenzymes leak out of necrotic cells to be activated
Widespread autodigestion
Obstuction of pancreatic duct

51. 1. Mild attack:
- Acute interstitial pancreatitis
2. Severe attack:
- Acute haemorrhagic pancreatitis
- Acute necrotising pancreatitis

52. 1. epigastric pain:
- sudden onset
- radiate to back
- no relieving factor
- aggrevated by movement
- assoc. with - Nausea & Vomiting

53. 1. General appearance:
- in pain
- pale
- sweating
- dyspneic & cyanosed
(respiratory distress in severe
attack)
- jaundice
- tachycardic
- signs of hypovoolemic shock

54. 2. Abdomen:
(i) Inspection:
- mild abdominal distension
- Grey Turner’s sign only in Acute
Haemorrhagic
- Cullen’s sign Pancreatitis

55. - fullness in epigastrium (abscess,
pseudocyst)
(ii) Palpation:
- Tender
- Guarding
- Rebound tenderness
(iii) Percussion:
- Pain >> peritonitis
- Dullness >> pseudocyst

56. (iv) Auscultation:
- Bowel sound present in first 24 hrs
- Bowel sound absent when
paralytic ileus develops

57. 1. FBC (WBC ,RBC )
2. Plasma amylase (>1200 IU/mL), (rises
within 12 hrs, return to normal in next 48-
72 hrs)
3. Plasma lipase (elevated level persists for
7-10 days), usefull in late-presenting
cases
4. LFT (bilirubin usually )
5. ABG (hypoxia occurs in severe attack)

58. 6. Plain CXR (free gas under diaphragm)
7. Plain AXR (no psoas shadow
>>retroperitoneal fluid)
8. Ultrasound
9. CT scan to confirm pancreatitis if
amylase level normal
10. ERCP (to find the cause)

59. 1.Scoring system by Ranson
2.Glasgow Criteria by Imrie

60. A. At admission or
diagnosis
B. During initial 48 hrs
1. Age >55 years (70yrs in
gall stone disease)
1. Hematocrit fall >10 percent
2. Leukocytosis >16,000
/mm3 2. Fluid sequestration >6L
3. Hyperglycemia >10
mmol/L
3. Hypocalcemia <2mmol/L
4. Serum LDH >400 IU/L
4. Hypoxemia (PO2 <60
mmHg)
5. Serum AST >250 IU/L
5. BUN rise >10mmol/L after
IV fluids
6. Hypoalbuminemia <3.2
g/dL

61.  A - Age > 55
 P - PO2 < 8 kPa (60mmHg) n=10.6
 N - Neutrophil count ( > 16 x 109 /L )
 C - Calcium < 2.0 mmol/L
 R - Raised Urea > 10 mmol/L
 E - Enzyme (LDH > 350 IU/L)
 A – Albumin (plasma) < 32 g/L
 S - Sugar (plasma glucose) >10mmol/L in the
absence of history of diabetes)
* (3 or > factors indicates severe pancreatitis)

62.  clinical assessment, relief of pain and
resuscitation come before imaging tests
Hematology biochemistr
y
imaging

63. Blood tests
1.Haemoglobin
◦ -may be normal immediately after an acute bleed
◦ -low haemoglobin concentration may represent chronic
anaemia due to occult blood loss
2.White blood count -leucocytosis is non-specific and
rarely of much diagnostic value unless greater than
about 14 × 103/L
3.Pcv—degree of hydration(vomit,diarhoea)
4.Blood culture-only in patients with rigors or shock
without obvious blood loss
5.Blood group and ordering of blood for transfusion-
for severely anaemic patients, in major haemorrhage
or when major surgery is contemplated

64. 1.C-reactive protein
◦ -non-specific indicator of inflammatory activation
◦ -confirms organic illness if substantially elevated
2.Plasma amylase-whenever pancreatitis cannot be excluded
3.Urea and electrolytes-indicated in vomiting and diarrhoea,
dehydration, poor urine output, diuretic therapy, urinary tract
disease, known or suspected renal failure, pancreatitis and
sepsis

65. 4.Glucose-for diabetics or those with glycosuria
(beware of hyperglycaemia due to acute stress or
steroid therapy)
5.Liver function tests and calcium estimation-for
pancreatitis and acute biliary disease
6.Clotting studies-for acute pancreatitis and
septicaemia (DIC), severe bleeding (consumption
coagulopathy) or those with a history of bleeding
disorders

66. 1.Plain radiography
1.Erect chest X-ray
◦ -cardiovascular disease or abnormality, e.g.
cardiomegaly, thoracic aneurysm, aortic dissection,
cardiac failure
◦ -respiratory disease
◦ -suspected visceral perforation (gas under
diaphragm)

67. 2.Supine abdominal X-ray (erect or decubitus if
necessary)
◦ -bowel (gas pattern and dilatation, fluid levels, gas
in the wall, faeces and faecoliths)
◦ -urinary tract ('KUB' = kidneys, ureters and bladder)
shows kidney size and position, calculi
◦ -biliary tract (gallstones, gas in biliary tree in
gallstone ileus)
◦ -aortic calcification (aneurysm)
◦ -psoas shadows (obscured by retroperitoneal
inflammation or haemorrhage

68. 2.Ultrasound
 Gallstones
 Pelvic abnormalities in obstetric and gynaecological practice
 'Chronic' enlargement of the spleen
 Abdominal aortic aneurysm (AAA)
 Free abdominal fluid and gas indicating perforated bowel
 Other stones
 Dilated ducts; air in biliary tree
 Hydatid, teratomas and other cysts
 Intra-abdominal abscesses and masses
3.Contrast radiology
 'Instant' barium enema in colonic obstruction or acute colitis
 Emergency intravenous urography in ureteric colic

69. 4. CT scanning
 rapid, cost-effective evaluation of acute abdominal pain
Assessment of abdominal trauma-severity and grading
of solid organ injury, free intra-abdominal fluid and
gas; retroperitoneal injuries including pancreatic and
duodenal rupture and vascular injury
 Often first choice for ureteric colic, suspected aortic
aneurysm or aortic dissection
 Useful where diagnosis remains in doubt, e.g.
suspected bowel perforation (detects small amount of
free gas), acute diverticulitis
 Investigation of postoperative complications-abscesses,
fluid collections
 Severe acute pancreatitis, especially if necrosis
suspected

70.  Duodenal ulcer:
• Surgery (ulcer is sutured or plugged using an
omentum patch)
• Supportive treatment with nasogastric suction
 Gastric ulcer:
• ~15% of perforated gastric ulcer prove to be
malignant. Therefore, definitive surgery is preferred
• Simple closure with biopsy @ local excision (in
poor-risk patients)

71.  Acute cholecystitis
 1st line treatment (medical) :
Fasting, intravenous fluid, analgesic
Start IV antibiotics (if pt has systemic signs
or if no improvement after 12-24 hours)
 Surgery:
Emergency vs elective
Open vs laparoscopic

72. Laparoscopic Cholecystectomy
 Optimal management
contraindications advantages disadvantages
(i) Uncorrectable
Coagulopathy
(ii) Unable to tolerate
GA
(iii) Known GB ca
(i) Lower mortality
(ii) Less pain
(iii) Shorter hosp stay
(iv) Recovery rate
faster
(i) Higher incidence
of injury to the
common hepatic
and bile ducts
(ii) Inj tend to be
more extensive

73.  Pain after cholecystectomy
(I) retained or recurrent stone
(ii) iatrogenic biliary leak
(iii) stricture of CBD
(iv) papillary stenosis/dysfunction of
Sphincter of Oddi
(v) incorrect pre-op dx (eg irritable bowel
syndrome, PUD, GOR

74.  Other treatment modalities :
(I) Oral bile acid treatment
- monotherapy or combine therapy (6-12 months)
- ursodeoxycholic acid and chenodeoxycholic acid
(ii) Contact dissolution therapy
- chemical litholysis of cholesterol stones (MTBE)
(iii) ESWL
- used when GB is functioning ; technically difficult
when
it is subcoastal
- long term recurrence rate high (between 28-61%)
(iv) percutaneous cholecystectomy

75. Criteria for non surgical treatment of
gallstones:
 Cholesterol stones (<20mm in diameter)
 Fewer than 4 stones
 Functioning gallbladder
 Patent cystic duct
 Mild symptoms

76. MILD ATTACK
 Hourly pulse, BP, urine output
 Fluid resuscitation to replace fluid loss from profuse vomiting
 Analgesics for pain relief – pethidine, morphine
 Withhold oral intake
 Treat predisposing factors
 Remove stone endoscopically, stopped taking alcohol,
laparoscopic cholecyctectomy with operative cholangiography
before discharge.
 Nasogastric tube to aspirate gastric content & relief
discomfort.
 Prophylactic parenteral antibiotic (cephalosporin) given.
 Daily measurement of serum amylase, ABG, BUSE, LFT and
serum calcium & phosphate to monitor progress

77. SEVERE ATTACK
 Admit to ICU for close monitoring and early Rx of complications
 Evaluated every 48 hours.
 May die early b’coz of systemic toxaemia and multiple organ
dysfunction.
 If PaO2 deteriorating- urgent ventilation support before ARDS
 Massive fluid & electrolytes loss esp protein-rich fluid into
peritoneal cavity and 3rd space lead to shock
 Rx- fluid resuscitation with large amount of colloid & crystalloid
 Monitor urine output & central venous pressure.
 Peritoneal lavage – reduce systemic absorption of enzymes &
toxins.
 Intravenous nutrition given in paralytic ileus patient

78.  Medical
◦ Antibiotics
 Surgical
◦ Appendicectomy
 Gridiron / Lanz skin incision
 Abdominal wall incision
 Dividing the blood supply
 Removing the appendix
 Closure