ACUTE ABDOMEN Begashaw M - PowerPoint Presentation

Slide1

ACUTE ABDOMEN

Begashaw

M

Slide2

ACUTE ABDOMEN

Denotes

any sudden condition with

chief manifestation

of pain of recent onset in the abdominal area which may require

urgent surgical intervention

Slide3

Sites of referred pain

Slide4

Sites of Abdominal Pain

Slide5

CLASSIFICATION

Obstruction

Inflammation

Hemorrhage

Infarction

perforation

Slide6

CLINICAL FEATURES

Symptoms

_Colicky

and Intermittent pain ( visceral)

_Continuous

pain ( somatic)

_Vomiting

_Fever

_Tachycardia

Colic

pain



obstruction

Continuous pain



infection, inflammation or

ischemia

Slide7

Signs

Abdominal

distention, visible

peristalsis

Direct

and rebound tenderness,

guarding

Anemia

,

hypotension

Toxic

with Hippocratic

faces

Absence

of bowel sound (

peritonitis)

Psoas

sign



appendicitis

Murphy‘s

sign



acute

cholecystitis

Dehydration



sunken

eyeballs

Slide8

DIFFERENTIAL DIAGNOSIS

Surgical -

Intestinal

obstruction

Gynecologic &

obstetric

- Ectopic

ruptured

pregnancy

Medical - enteritis

Slide9

Surgical causes

A- Inflammation



Acute

appendicitis



Acute

cholecystitis

B- Obstruction

I

ntestinal

obstruction

C- Infarction



Mesenteric

ischemia

D-Strangulation



volvulus

E- Perforation



perforated

peptic ulcer

Slide10

DIAGNOSIS

Clinical

:

Hx

& p/E

Lab: CBC, cross

match, urine analysis, serum amylase

& electrolytes

Ultrasound

plain

film of abdomen

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MANAGEMENT

A-Preoperative

- Resuscitation

with IV fluids

- Antibiotics

- Catheterization &

NGT insertion

- Analgesics

after confirming the diagnosis

B- Surgery



Definitive

laparotomy

C



Monitoring



Follow

up

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INTESTINAL OBSTRUCTION

is partial or complete blockage of the intestine producing symptoms

_Vomiting

_Constipation

_Distension

_Abdominal pain

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Causes of mechanical intestinal 0bstruction

Slide14

Intestinal Obstruction

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CLASSIFICATION

Mechanical



physical barrier blocks

Paralytic

ileus



disordered propulsive motility

High _Small bowel

Low _Large bowel

Simple -> adequate blood supply

Strangulated -> Mesenteric vessels occluded

Slide16

Mechanical

A-

Luminal

_Gallstone

Ileus

_Food bolus

_

Meconium

Ileus

_Malignancy

_Inflammatory mass

_

Ascaris

bolus

B

- Mural

_Stricture

_Congenital

_Inflammatory

_Ischemic

_

Neoplastic

_

Intussusception

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Intussusception

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C- Extra mural

Adhesions



inflammatory

/malignant

Hernia



External/internal

Volvulus

S

mall bowel



large bowel -> Sigmoid

volvulus

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Small bowel obstruction

Slide20

Slide21

Adhesion

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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

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Pathophysiology

Slide24

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

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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

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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

haustral

marks



Large

bowel

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X-ray of intestinal obstruction

Slide28

Slide29

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

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NG tube suction

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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

Slide32

Sigmoid

volvulus

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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

Slide34

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”

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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

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Sigmoidoscopic

deflation

Slide38

Emergency Surgery

_Complicated

volvulus

with signs of peritonitis

_Resuscitative measures

_Antibiotics

_Resection of the gangrenous segment with Hartman’s colostomy

Slide39

Laparatomy

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APPENDICITIS

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

Slide41

Appendix

Slide42

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Pathogenesis

Luminal obstruction



bacterial overgrowth



lnflammation

/swelling

I

ncreased pressure-



localized

ischemia



gangrene

/

perforation



localized

abscess (walled off by

Omentum

) or Peritonitis

Etiology:

_Hyperplasia of lymphoid follicles

_

Fecolith

, obstructing neoplasm

_Parasites, foreign body

Slide44

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

Slide45

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

Slide46

Appendicitis signs

Slide47

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

Slide48

Investigations

Labs

leukocytosis

with left shift

beta-

hCG

to rule out ectopic pregnancy

Urinalysis

Imaging:

Upright CXR, AXR-free air

Ultrasound: may visualize appendix

Slide49

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

Slide50

COMPLICATIONS

Perforation - local or generalized peritonitis

Appendiceal

mass and abscess formation

Death

Slide51

APPEDECIAL MASS

Inflammatory process walled off in the right iliac

fossa

by

omentum

and loops of bowel to form a mass

Management-Conservative

-antibiotics

-fluids

_Drug of choice-

metronidazole

and

ceftriaxone

Ampicilline

,

Chloramphenicol

&

Gentamycin

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Follow up

-Vital signs every 4 hourly

-Mass size & consistency 12 hourly

-Patient’s condition

-Laboratory every other day

Interval appendectomy 6 weeks later

Slide53

Appendiceal

abscess

Increasing mass size

Fluctuation

persistence of systemic signs

Management - drainage of the abscess and appendectomy

Interval appendectomy after emergency drainage

Slide54

Draining

appendeceal

abscess

Slide55

PERITONITIS

is an inflammation of the peritoneum

is an acute life threatening condition caused by bacterial or chemical contamination of the peritoneal cavity

Slide56

Peritoneum

Slide57

Peritoneal abscess

Slide58

Differential diagnosis

Perforated appendix

Perforated PUD

Anastomotic

leak

Strangulated bowel

Pancreatitis

Cholecystitis

Intra abdominal abscess

Typhoid perforation

Ascending

infection

e.g

salpingitis

Slide59

CLASSIFICATION

Primary peritonitis: caused by bacterial spread via the blood stream

Secondary peritonitis: caused during perforation or rupture of abdominal organ allowing access of bacteria and irritant digestive Juices to the peritoneum

Slide60

Classification

Acute peritonitis: rapid onset or brief duration

Chronic peritonitis: long duration

Localized peritonitis - confined to a limited space - pelvis

Generalized peritonitis - whole peritoneal cavity involved

Slide61

ROUTES OF BACTERIAL INVASION

1- Direct- contamination via perforation, a penetrating wound or during surgery

2-Local Extension: contamination by migration from an infected organ - through gut wall, via the fallopian tube

3-Blood stream: via the blood as consequence of general septicemia

Slide62

CLINICAL FEATURES

Sharp pain which is worse on movement

Fever & tachycardia

Abdominal distension

Tenderness & guarding

Diminished or absent bowel sounds

Shoulder pain _referred pain -diaphragmatic irritation

Tenderness on rectal examination (pelvic peritonitis)

Abdominal distension & vomiting

Slide63

Generalized peritonitis

Slide64

MANAGEMENT

Resuscitation: intravenous fluids

Analgesia

Naso

-gastric tube insertion (NGT)

Triple antibiotics (

ampicilline

,

gentamycin

and

metornidazole

or

chloramphenicol

)

Monitoring in put & out put by catheterization

Surgery

Drainage & peritoneal

lavage