Acute Abdomen Prepared by: assistant - PowerPoint Presentation

1. Acute AbdomenPrepared by: assistant Bazhora Ya. I.Odesa National Medical UniversityDepartment of family medicine and polyclinic therapy

2. Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammatio, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Patients will typically have severe tenderness with associated rigidity and rebound tenderness

3. Causes of Acute AbdomenIntestinalAcute appendicitis, mesenteric adenitis, mekel’s diverticulitis, perforated peptic ulcer, gastroenteritis, diverticulitis, intestinal obstruction, strangulated herniaHepatobiliaryBiliary colic, cholecystitis, cholangitis, pancreatitis, hepatitisVascularRuptured AAA, acute mesenteric ischaemia, ischaemic colitisUrologicalRenal colic, UTI, testicular torsion, acute urinary retentionGynaecologicalEctopic pregnancy, ovarian cyst pathology (rupture/haemorrhage into cyst/torsion), salpingitis, endometriosis, mittelschmerz (mid-cycle pain)Medical (can mimic an acute abdomen)Pneumonia, MI, DKA, sickle cell crisis, porphyria

4. Acute Abdomen: The ExaminationLiver (hepatitis)Gall bladder (gallstones)Stomach (peptic ulcer, gastritis)Hepatic flexure colon (cancer)Lung (pneumonia)Ascending colon (cancer,)Kidney (stone, hydronephrosis, UTI)Appendix (Appendicitis)Caecum (tumour, volvulus, closed loop obstruction)Terminal ileum (crohns, mekels)Ovaries/fallopian tube (ectopic, cyst, PID)Ureter (renal colic)Liver (hepatitis)Gall bladder (gallstones)Stomach (peptic ulcer, gastritis)Transverse colon (cancer)Pancreas (pancreatitis)Heart (MI)Spleen (rupture)Pancreas (pancreatitis)Stomach (peptic ulcer)Splenic flexure colon (cancer)Lung (pneumonia)Descending colon (cancer)Kidney (stone, hydronephrosis, UTI)Sigmoid colon (diverticulitis, colitis, cancer)Ovaries/fallopian tube (ectopic, cyst, PID)Ureter (renal colic)Uterus (fibroid, cancer)Bladder (UTI, stone)Sigmoid colon (diverticulitis)Small bowel (obstruction/ischaemia)Aorta (leaking AAA)

5. Intestinal

6. Intestinal (Large Bowel)

7. Hepatobilliary

8. Vascular

9. GU

10. OBG

11. Medical

12. Acute Abdomen: The HistoryAbdominal pain – features will point you towards diagnosisSOCRATESSite and durationOnset – sudden vs gradualCharacter – colicky, sharp, dull, burningRadiation – e.g. Into back or shoulder(Associated symptoms – discussed later)Timing – constant, coming and goingExacerbating and alleviating factorsSeverity2 other useful questions about the pain:Have you had a similar pain previously?What do you think could be causing the pain?

13. Acute Abdomen: The HistoryAssociated symptomsGI: bowels last opened, bowel habit (diarrhoea/constipation), PR bleeding/melaena, dyspeptic symptoms, vomitingUrine: dysuria, heamaturia, urgency/frequencyGynaecological: normal cycle, LMP, IMB, dysmenorrhoea/menorrhagia, PV dischargeOthers: fever, appetite, weight loss, distentionAny previous abdominal investigations and findingsOther components of historyPMH e.g. Could patient be having a flare up/complication of a known condition e.g. Known diverticular disease, previous peptic ulcers, known gallstonesDH e.g. Steroids and peptic ulcer disease/acute pancreatitisSH e.g. Alcoholics and acute pancreatitis

14. Acute Abdomen: The ExaminationInspection: scars/asymmetry/distentionPalpation:Point of maximal tendernessFeatures of peritonitis (localised vs generalised)GuardingPercussion tendernessRebound tendernessMassSpecific signs (Rosvig’s sign, murphy’s sign, cullen’s sign, grey-turner’s sign)Percussion: shifting dullness/tympanicAuscultation: bowel soundsAbsentNormalHyperactivetinklingThe above will point you to potential diagnosis

15. RIF Pain: APPENDICITISAppendix/ abscessPelvic inflammation/ period painPancreasEctopic/ endometriosisNeoplasmDiverticulitisIntussusseptionChrohn’s/ CystIBDTorsionIBSStones

16. LIF Pain: SUPERCLOTSSigmoid diverticuli, volvulousUreteric colicPelvic inflammation/ period painEctopic/ endometriosisRectal HaematomaColon cancerLeft lower pneumoniaOvarian cystTorsionStones

17. Acute Abdomen: InvestigationsSimple Investigations:Bloods tests (FBC, U&E, LFT, amylase, clotting, CRP, G&S/ Xmatch, ABG)BM Urine dipstickPregnancy test (all women of child bearing age with lower abdominal pain)AXR/E-CXRECGMore complex investigations:USSContrast studiesEndoscopy (OGD/colonoscopy/ERCP)CTMRI

18. AXR

19. Air in AbdomenPost-op/ Post-ERCPPerforationCholangitisAbscessGallstone Ileus

20. Acute Abdomen: Indication for theatreUrgent surgery should not be delayed for time consuming tests when an indication for surgery is clearThe following three categories of general surgical problems will require emergency surgeryGeneralised peritonitis on examination (regardless of cause – except acute pancreatitis, hence all patients get amylase)Perforation (air under diaphragm on E-CXR)Irreducible and tender hernia (risk of strangulation)

21. Management - ConservativeLifestyle: Weight loss, smoking cessation alcohol reduction exercisemodified diet (low fat/ high fibre)MDT: Physio/ OT/ Nutrition Team/ Dietician/ Specialist Nurses, other specialties

22. Management - MedicalA - Secure airwayB – Oxygen 15LC - Fluid Balance: large bore, IVF, catheter, bloods, XmatchC - Blood TransfusionD - AnalgesiaE – IV AntibioticsE –Thromboprophylaxis?Anti-emetics/ NG aspirationSupportive nutrition/ NBMRe-assessTherapeutic procedures: ERCP

23. Management - SurgicalEmergency Laparotomy or Watch+Wait?Monitor PainSerial CTsUnstable?E.g.:AppendicectomyCholecystectomyDefunctioning IleostomyAbscess drainage/ Necrosectomy

24. Thank you