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Acute Abdomen Revision Ahmed Al- Acute Abdomen Revision Ahmed Al-

Acute Abdomen Revision Ahmed Al- - PowerPoint Presentation

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Acute Abdomen Revision Ahmed Al- - PPT Presentation

Naher FY1 Learning Objectives Causes of an acute abdomen Differential Diagnosis Hx Exam Investigations Management Clinical Cases Causes of Acute Abdomen Intestinal Acute appendicitis mesenteric adenitis ID: 907820

pain acute colon abdomen acute pain abdomen colon cancer peptic diverticulitis pancreatitis ectopic colic ulcer presents bowel investigations intestinal

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Slide1

Acute Abdomen Revision

Ahmed Al-

Naher

FY1

Slide2

Learning Objectives

Causes of an acute abdomen

Differential Diagnosis

Hx

/Exam

Investigations

Management

Clinical Cases

Slide3

Causes of Acute Abdomen

Intestinal

Acute appendicitis

, mesenteric adenitis,

mekel’s

diverticulitis,

perforated peptic ulcer

, gastroenteritis,

diverticulitis, intestinal obstruction

,

strangulated hernia

Hepatobiliary

Biliary

colic,

cholecystitis

,

cholangitis

, pancreatitis

, hepatitis

Vascular

Ruptured AAA, acute mesenteric

ischaemia

,

ischaemic

colitis

Urological

Renal colic, UTI, testicular torsion, acute urinary retention

Gynaecological

Ectopic 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

Slide4

Acute Abdomen: The Examination

Liver (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)

Slide5

Intestinal

Slide6

Intestinal (Large Bowel)

Slide7

Hepatobilliary

Slide8

Vascular

Slide9

GU

Slide10

O+G

Slide11

Medical

Slide12

Acute Abdomen: The History

Abdominal pain – features will point you towards diagnosis

SOCRATES

Site and duration

Onset – sudden

vs

gradual

Character – colicky, sharp, dull, burningRadiation – e.g. Into back or shoulder(Associated symptoms – discussed later)Timing – constant, coming and going

Exacerbating 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?

Slide13

Acute Abdomen: The History

Associated symptoms

GI: bowels last opened, bowel habit (diarrhoea/constipation), PR bleeding/

melaena

, dyspeptic symptoms, vomiting

Urine:

dysuria

, heamaturia, urgency/frequencyGynaecological: normal cycle, LMP, IMB, dysmenorrhoea/menorrhagia, PV dischargeOthers: fever, appetite, weight loss, distention

Any 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

Slide14

Acute Abdomen: The Examination

Inspection: scars/asymmetry/

distention

Palaption

:

Point of maximal tenderness

Features of peritonitis (localised

vs generalised)GuardingPercussion tenderness

Rebound 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

Slide15

RIF Pain: APPENDICITIS

Appendix/ abscess

Pelvic inflammation/ period pain

Pancreas

Ectopic/ endometriosis

Neoplasm

Diverticulitis

IntussusseptionChrohn’s/ CystIBDTorsionIBSStones

Slide16

LIF Pain: SUPERCLOTS

Sigmoid

diverticuli

,

volvulous

Ureteric colic

Pelvic inflammation/ period pain

Ectopic/ endometriosisRectal HaematomaColon cancerLeft lower pneumoniaOvarian cystTorsionStones

Slide17

Acute Abdomen: Investigations

Simple Investigations:

Bloods tests (FBC, U&E, LFT, amylase, clotting, CRP, G&S/

Xmatch

, ABG)

BM

Urine dipstick

Pregnancy test (all women of child bearing age with lower abdominal pain)AXR/E-CXRECG

More complex investigations:USSContrast studiesEndoscopy (OGD/colonoscopy/ERCP)

CTMRI

Slide18

AXR

Slide19

Slide20

Slide21

Air in Abdomen

Post-op/ Post-ERCP

Perforation

Cholangitis

Abscess

Gallstone Ileus

Slide22

Slide23

Acute Abdomen: Indication for theatre

Urgent surgery should not be delayed for time consuming tests when an indication for surgery is clear

The following three categories of general surgical problems will require emergency surgery

Generalised 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)

Slide24

Management - Conservative

Lifestyle:

Weight loss,

smoking cessation

alcohol reduction

exercise

modified diet (low fat/ high fibre)

MDT: Physio/ OT/ Nutrition Team/ Dietician/ Specialist Nurses, other specialties

Slide25

Management - Medical

A - Secure airway

B – Oxygen 15L

C - Fluid Balance: large bore, IVF, catheter, bloods,

Xmatch

C - Blood Transfusion

D - Analgesia

E – IV AntibioticsE –Thromboprophylaxis?Anti-emetics/ NG aspirationSupportive nutrition/ NBMRe-assessTherapeutic procedures: ERCP

Slide26

Management - Surgical

Emergency Laparotomy or

Watch+Wait

?

Monitor Pain

Serial CTs

Unstable?

E.g.:AppendicectomyCholecystectomyDefunctioning IleostomyAbscess drainage/ Necrosectomy

Slide27

Clinical Scenarios

87

yr

M worsening LIF pain associated PR bleed,

tachycardic

, hypotensive

Diverticulitis, IBD,

Adenoca

Slide28

Clinical Scenarios

50

yr

old obese female presents with 2 day

hx

right upper quadrant tenderness, yellow sclera and high pyrexia.

78

yr old male with fatigue, anaemia and supraclavicular lymphadenopathy. o/e you find axillary pigmentation.56 yr old female non-smoker with known primary sclerosing cholangitis, presents with change in bowel habit and PR bleed, she is found to have tender symmetrical purple shin nodules35 year old female smoker with known depression presents with generalised hypertenderness, diarrhoea and bloating sensations worse after meals

Slide29

Acute Abdomen

Thin 21

y.o

. male presents with generalised

abdo

tenderness, polydipsia and sunken eyes, with reduced skin turgor.

Slide30

Clinical Scenario

A 22 year old lady presents with one day history of right iliac fossa pain associated with vomiting and diarrhoea. She is normally fit and well and takes the oral contraceptive pill. She has no known allergies, does not smoke, and drinks alcohol

infrequently

Slide31

What other questions would you like to ask this lady?

What are your main differential diagnoses for this lady? (make sure these include all important differentials that must be ruled out)

Slide32

Questions?