ACUTE ABDOMEN

Dr.Viswanathan.K.V MS, DNB,FRCS Associate Professor of Surgery Medical College,Trivandrum

Necessity for Diagnosis

a serious and thorough attempt at diagnosis Abdominal pain is the most common symptom Acute abdomen = surgery is not always true

Course of action
Urgent operation Wait for evolution of symptoms Medical management

 Thorough history and physical examination and recognition of the early stages of the disease Record the earliest symtoms Attempt a specific diagnosis prevents carelessness and callousness

 A correct diagnosis essential to correct treatment Spot diagnosis is magnificent but not sound, is impressive but unsafe. Deduction and induction from observed facts less chances of fallacies

Early Diagnosis
Diagnose early No narcotics until diagnosis is made Examination ,reexamination ,testing by inexperienced hands leads to delay in diagnosis and early pain relief

 General rule can be made that majority of severe abdominal pain in pts who have been previously fairly well and last longer than 6 hours are caused by surgical conditions

Early diagnosis improves recovery Decreases mortality Reduces hospital stay due to infections Reduces long term complications

Anatomy
Apply your knowledge of anatomy in diagnosing abdominal conditions Cultivate habit of thinking anatomically Diaphragmatic spasm decreased movt of lower chest and upper abdomen Rectus and lateral abd muscle rigidity in subjacent inflammation Psoas spasm flexion of thigh and internal rotation

 Obturator internus spasm pain on rotation of the flexed thigh inwards and this pain is referred to hypogastrium - in pelvic appendicitis and haematocele

 Knowledge of course and distribution of segmental nerves Note both the ventral and dorsal distribution of referred pain Radiating pain to testis does not always denote genitourinary disease and can also occur with appendicitis

 Irritation to the diaphragm will cause pain in the shoulder as the diaphragm has its origin from the 4th cervical segment and is supplied by the cervical segment via phrenic nerve Pain may be felt in the shoulders in cases of subphrenic abscess, diaphragmatic pleurisy, a/c pancreatitis, ruptured spleen etc. The pain is felt in supraspinatous fossa, over the acromion, clavicle or in subclavicular fossa The shoulder pain is often overlooked as it is attributed to arthritis.

Errors in diagnosis
Errors occur due to failure of thinking towards another anatomical site for the origin of pain (eg. Lack of representation in the abdominal wall of segments that from pelvis)

Physiology
The required stimulus for pain in hollow tube is stretch/ distension or excessive contraction against an obstruction Mild degree of bowel contractions is called flatulence and severe form, colic Colics occurs in paroxysms and is severe and referred to the centre from which the nerves come and also to the segmental distribution

 Small bowel colic pain is referred to the epigastrium and the umbilicus Large bowel colic to the hypogastrium Renal colic from loin to groin and the testicles Biliary colic to the right subscapular region

 Tenderness due to irritation of nerves by unilateral lesion is not felt on the opposite side usually. Eg. Right sided pleurisy causes tenderness in RIF but not in LIF.

 Exclude medical disease before calling for surgical intervention. (esp a laparotomy) Cardiac disease, tuberculosis, cirrhosis, chronic interstitial nephritis and arteriosclerosis. Porphyrias and diabetic disease (DKA)

Methods of diagnosis
History and physical examination is the most important part. Record history in the chronological order of symptoms Age- intussusception in infants (<2) Cancerous stricture rare below30 A/c pancreatitis rare below 20 Perforated GU rare below 15

Exact time and onset

Many conditions are precipitated by exertion . It is important to know what the patient was doing at the time of onset. Fainting occurs with ectopic gestation, perforated GU/DU, a/c pancreatitis, ruptured aortic aneurysm. Intestinal obstruction gradual in onset and culminates in crisis

Shifting or localisation of pain

When peritoneal cavity is filled with pus, blood or fluid pain is felt all over the abdomen and later shifts to site of perforation. Pain of small intestine is always felt first in epigastric or umbilical region (T9 to T11 nerves) Remember appendicular nerves are also derived from the T9 to T11 so pain may be initially felt in the epigastric region

Vomiting
Severe irritation of nerves of the peritoneum or the mesentery eg. DU perforation or torsion ovarian cyst. Obstruction of an involuntary muscle tube. Absence of vomiting is sufficiently common in many abdominal catastrophes as rupture ectopic

 Vomiting is early, sudden and violent in ureteric colic Early and copious in upper intestinal obstruction No vomiting until late in large bowel obstruction Frequent scanty in A/c pancreatitis Vomiting precedes pain in gastroenteritis

Character of Vomitus
In gastritis vomitus contains food particle and some bile In CHPS and duodenal atresia differentiated by presence of bile in the latter In intestinal obstruction content varies from gastric , bilious greenish yellow to orange and brown indicating feculent vomitus.

 Hypogastric pain and diarrhoea when followed by hypogastric tenderness and constipation suspect pelvic abscess. Partial small bowel obstruction may produce profuse watery diarrhoea without passage of flatus

Laboratory and radiological tests

Over reliance on lab and radiological investigation often misleads the clinician Plain X-Ray can interpret many condition like perforated DU, intestinal obstruction, stones etc. To demonstrate free air in peritoneum a semi upright or lateral decubitus position for at least 5-10min before the exposure is a must.

Nuclear scans
Largely replaced by radioisotope scans Diagnosis of a/c cholecystitis is excluded if GB is visualised USG is highly operator dependant and subjective. C.T. is costly but can demonstrate free air, fluid, and other complications of acute pancreatitis M.R.I. has no role in evaluation of acute abd. Except in vascular pathologies UGIscopy has limited role in a/c abdomen while LGIscopy may useful in certain conditions like intussusception Laparoscopy and abdominal paracentesis

Acute appendicitis
Pain, vomiting and fever in order is the classical triad of symptoms Typical symptoms if present indicates that the inflammation is advanced Atypical symptoms like diarrhoea occur in children and in pelvic appendix inflammation Initial pain is vague producing sense of downward urge. Vomiting occurs early about 3-4hrs after onset of pain.

 Degree and frequency of vomiting is related to the degree of appendicular distension Vomiting before pain is extremely rare in appendicitis and almost excludes it. Local tenderness elicited by light percussion is a remarkably reliable indication of parietal peritoneal inflammation

 Hyperesthesia confined to areas of T10,11,12,L1 distribution Rigidity frequent but not constant No rigidity in appendicitis without peritonitis Fever develops 24hrs of onset of pain presence of fever at the beginning of attack or rigor accompanies the onset of pain excludes appendicitis

Other symptoms
Constipation Tachycardia Abdominal distension Testicular symptoms

Diagnosis of appendicitis
Constant findings epigastric pain, nausea vomiting, RIF pain, low grade fever, local tenderness Local rigidity, fever, hyperesthesia and constipation- inconstant

Diagnosis after perforation

Perforation with presence of mass or generalized peritonitis usually does not occur before 48 hrs. After rupture the pain decreases and localised pelvic peritonitis sets in but there is no rigidity and patient seems to be better. Perforated pelvis appendix will cause symptoms like diarrhoea, tenesmus, frequency of micturition

Differential diagnosis
Intestinal obstruction a/c Mesenteric vessel thrombosis A/c pancreatitis Peritonitis due to other causes Pylephlebitis Cholecystitis DU perforation Merkels diverticulitis Perforated typhoid ulcer

D/D in females
Uterine colic Twisted/ rupture ovarian cyst Ruptured ectopic Twisted fibroid/ hydrosalpinx

Duodenal ulcer perforation

Diagnose early and treat promptly usually surgical If treatment delayed for >24hrs outcome is poor (<6hrs good) Early stage- first 2hrs- symptoms are due to pain consequent on flooding of peritoneal cavity with gastric contents Intermediate stage 2-12 hrs pain subsides patient looks comfortable. Other clinical symptoms show improvement but local signs remain. The most opportune period for surgery and should never be allowed to pass Most reliable signs are rigidity, tenderness of pelvic peritoneum, shifting dullness, free air and pain shoulder

 Late stage >12hrs increasing distension and Hippocratic facies

Acute Pancreatitis
Failure to diagnose is due to failure to consider its possibility Symptoms variable- pain in the acute with the patient crying out in agony, shock due to hypovolemia, reflux vomiting and fever invariable

 Epigastric tumour Jaundice- Heads on CBD Obstructive vomiting -heads on duodenum

 Ecchymosis, Cullen and Grey Turner indicate severe disease and never occurs until 2-3 days

Acute Cholecystitis
Prodormal stage episode of biliary colic usually a forerunner Vomiting, fever common and rarely jaundice GB when palpable with compatible history, establishes the diagnosis.

Colics
Intestinal colic Main feature of colic is occurrence of acute agonizing spasmodic pain which causes the patient to double up and partial or complete relief in between. Other features- vomiting, visible peristalsis, borborygmi on auscultation

 Biliary colic Misnomer because pain is steady

Renal colic
Renal colic- due to renal stones Characteristic pain from loin radiating to groin, testes/vulva Restlessness, vomiting, dysuria, increased urinary frequency and hematuria

Uterine colic
Uterine colic (dysmenorrhoea) Lower lumbar pain sometimes radiating to thighs and hips Congestive dysmenorrhoea pain increases before the onset on menses and is relieved with the onset of menstruation

Acute intestinal obstruction

Causes- hernia (mc), adhesions, intussusception, Ca, volvulus etc. Symptoms according to site and cause of obstruction In general higher up the gut, more severe the symptoms Pain very severe referred to epigastrium, umbilical or hypogastium Clinically- distension, visible peristalsis, features of shock

Obstruction high up in small intestine

Vomiting very early, frequent and violent, green and bilious Distension is not an early feature

Obstruction distal small intestine

Pain is less severe than proximal small bowel obstruction Vomiting and distension delayed

Large bowel obstruction

Distension is an early feature except in intussusception Pain less acute, shock and vomiting rare. Can be due to strangulation of bowel where tenderness on applying pressure is positive. Obstruction can be due to volvulus, Ca colon, impacted fecal matter etc

Acute abdomen in pregnant women

Ectopic gestation Retroverted gravid uterus Threatened abortion Sepsis following abortion Torsion ovarian cyst/ fibroid Red degeneration fibroid Rupture uterus Appendicitis

Ectopic Gestation
Symptoms before rupture ammenorrhoea, localised hypogastric pain and tenderness, uterine bleeding and sometimes tender swelling in lateral fornix and passage of membrane per vagina

 Symptoms of rupture sudden abdominal pain, vomiting, faintness, sudden anemia and collapse with small, rapid pulse and subnormal temp. Signs tender tumid, free fluid in abdominal cavity, tenderness on pressing the finger against pouch of Douglas

 Subacute presentation repeated slight hemorrhages with no history of a/c collapse Presents with repeated attacks of pain, faintness and uterine bleeding Signs lower abdominal tenderness, fullness in one or both fornices, retention of urine.

Acute peritonitis
Symptoms according to part and extent of peritoneum involved, presence of infection and acuteness of onset. Reflex symptoms pain, vomiting, rigidity. Toxic symptoms alteration in temperature, collapse, distension, general toxemia. Pain is the most common symptom. Vomiting common at the onset but infrequent until late.

Acute abdomen in tropics

Amebiasis Malaria Worm infestation Sickle cell anemia Pyomyositis (in HIV) Enteric fever

Diseases that simulate acute abdomen

Diabetic ketoacidosis Typhoid Malaria TB peritonitis Food poisoning Lead colic Porphyia Pleurisy/pneumonia Cardiac disease (eg. MI) Disease of spine affecting nerve roots Renal disease

Thank you