Approach to acute abdomen

Supervised by ,
Dr.B.Faki
Presented by,
Eman Al.harbi
Introduction
defined as any clinical condition
characterized by severe abdominal pain
which develops over a period of 8 hrs.
In pt who have been previously well.
rapid and accurate diagnosis is essential for
morbidity and mortality process.
Pathophsiology
Visceral pain; due to stimulation of visceral
afferent nerve plexus usually in midline
result from contraction or distension
against resistance & chemical irritation
usually colicky in nature.
Pathophsiology
Parietal pain; 2dry to partial peritoneum
irritation perceived through segmental
somatic fibers reflex involuntary muscle
wall rigidity may result from irritation of
segmental sensory nerves.
Hyperesthesia of the skin may be result
from ipsilateral peritoneal irritation usually
a sharp ache.
Abdomen
Epidemiology
Abdominal quadrant

Causes
Gastrointestinal tract*
Acute appendicitis
Meckls diverticulitis
bowelPerforated
ulcer Perforated peptic
obstruction Small and large bowel
herniaStrangulated
Diverticulitis
Gastritis
Gastroenteritis
Inflammatory bowel disease
lymphadinitis Mesenteric

spleen. and , liverBiliaryTract
sCholangiti acute
Cholecystitis acute
Hepatic abscess
tumor Ruptured hepatic
spleen Ruptured
biliary colic
, Hepatitis acute
infarct Splenic


Peritoneum
Intra-abdominal abscess*
Primary peritonitis
Tuberculosis peritonitis

Pancreas
Pancreatitis, acute
ca pancreases

Urinary Tract
Cystitis acute
Pyelonephritis acute
Renal infarct
teral colicUre

Gynecological ;
ruptured ectopic pregnancy
Ruptured ovarian follicular cyst
Twisted ovarian tumor
Dysmenorrheal
Endometriosis
acute salpingitis.
PIDs
Male reproductive tract.
Prostatitis
Cystitis
Torsion of testes
Vascular causes
Acute ischemic colitis .
Mesenteric thrombosis*
Ruptured arterial aneurysm*




Medical causes

Pneumonia.
Myocardial infarction
Sickle cell crisis.
DKA
Leukemia
Herpes zoster
psychogenic
Approach to acute abdomen
History.
1. pain
2. Associated symptoms, nausea, vomiting,
Change of bowel habitus, jaundice,
anorexia,
Heamatemsis, melena, dyspepsia
3.Menstruatin & sexual history.
Cont..
4.ROS
5.past medical & surgical hx
6.hx /o medications
7.familay Hx
8.social Hx
Eg
Acute appendicitis,
constant ,progressive more severe start
per umbilical move toward RIF.+ nausea,
vomiting, low grade fever, anorexia &/or
constipation.
Inflamed appendix
Acute cholecytitis
Constant moderate pain in RUQ radiated
to Rt shoulder tip + nausea, bilious
vomitus, low grade fever & jundice
Perforated peptic ulcer,
Sudden onset of pain in midepigastrium
that spreads and is aggravated by
movement; patient appears acutely ill and
is reluctant to move; rigid abdomen;
grunting respiration; bowel sounds absent

Ectopic pregnancy,
Pain sudden, severe,persistent,following a
missed or abnormal period, typically epigastric;
associated with hypotension and tachycardia
Ovarian cyst
Pain constant with sharp, sudden onset, usually
in ipsilateral hypogastrium; may have nausea
and vomiting following the pain.

Pelvic inflammatory disease.
Pain at end of or after normal menstrual
period, bilateral lower quadrant pain
aggravated by cervical manipulation;
anorexia, nausea, and vomiting rare;
possible cervical discharge; fever

Urinary stone,
Pain location changes with movement of
stone, may radiate to testicle, groin of
involved side, pain very severe; patient
cannot get comfortable

Physical examination
1.general appearance,
2. Vital signs.
3.abdomial exam
4.rectal exam
5.pelvic exam (female pt)
?
investigation
1.CBCs,
WBCs & differential.
RBC & hct, degree of anemia & hemocon.
Platelet count, evidence of cougalopathy.
2.electrolyte,
(G, Na, K, Cl, Ca ,Mg, Po)
Indicative of volume status, GIT loss,
.
3.ABG,
Indicate metabolic acidosis or alklosis.
M.acidosis with generalized abdominal
pain in elderly is ischemic colitis till proven
other wise.
.
4.liver function test
Bilirubin (D or ID), ALP elevation in biliary
obstruction & transaminase elevation in
case of hepatocellular injury.
5.RFT
Urea, creatinin elevation in renal
insufficiency
Serum albumin decrease in edema /
ascitis.
.
6. serum amylase
Seen in pancreatitis although non specific
may be elevated in mesenteric ischemia,
perforated peptic ulcer, rupture ovarian
cyst & renal failure. But lipase more
sensitive.

.
7.serum B_HCG
Mandatory for all women in childbearing
period.
8.urinalysis
See WBC RBC & casts.
Radiological evaluation
1.CXR,
Look for pneumonia, free gases under
diaphragm .pleural effusion suggest sub
diaphragmatic inflammatory process.

.
2.abdominal Xray.
(Erect & supine position )
* bowel distension & air fluid level
*bowel gas cut off vs air through rectum.
*sentinel loop vs pancreatitis
*abn calcification vs ch.pancreatitis,stone
*pnumatosis vs omnious sign of dead gut.

Intestinal obstruction
.
3.ultrasound,
*hepatobiliray tree(stones,mass,thickining
of the wall)
*pancreases
*kidney
*pelvic organ
*intrabdominal fluid collection
Gall stone\ appendicolith
.
4.CT_scan
Helpful in case of abdominal pain without
clear etiology better in evaluation of
abdominal oartic aneurysm.
5.helical CT_scan
Provide rapid cost effictive dignostic tool.
Acute pancreatitis\dilated loop
.
5.contrast study
A. barium study
*perforation,
*discering point of obstruction in small
bowel.
*avoid if colonic diverticuilitis is suspected
Multiple stones in CBD
.
B_ intravenous pyelogram
For dignosis of ureteral stone or obstuction
C_angiography
For mesenteric ischemia

angiograph
Other study
6.endoscopy,
EGE, for evaluation epigastric pain in non
acute setting.& git bleeding
Sigmoid\colonoscopy
*colonic obstruction
*dig IBD,ischimic colitis lower bleeding,
*nonstrangulated sigmidal volvulus


ERCP
.
7.paracentesis &\or peritoneal lavage
*spontaneous bacterial peritonitis in
cirrhotic pt
*peritoneal lavage may be useful bedside
test in diagnosis of mesenteric infarction in
critically ill pt.
.
8.culdocentesis
Valuable in diagnosis of rupture ectopic
pregnancy.
9.laproscopy
*D & ttt of suspected gynec.cause
*appendectomy if appendicitis is found in a
women in childbearing period.

laparoscopy
Plan of treatment
*promote timely work up in first 4_6hrs.
*keep pt Npo till the diagnosis is firm & ttt
plan is formulated.
*IV fluid. based in expected fluid loss.
*heamodynamic monitoring.
*NGT bleeding ,vomiting ,sign of
obstruction or when urgent laparoscopy is
planned in pt not NPo.

.
Foley catheter to monitor fluid out put
decisions
Immediate surgery
* what is the timing of operative
intervention( does pt need time for
resuscitation)
*what incision should be used?
.
* what are the likely findings?
*develop primary operative plan.
* consider alternative diagnosis & plan.
* use appropriate pre-operative antibiotic
based on suspected pathology.
.
2. admit & observe for possible operation.
*serial examination every 2-4 hrs during
the first 12-24 hrs in case without definite
diagnosis; minimal use of narcotics &
sedatives to avoid masking physical sign &
symptoms.
*monitor vital signs frequently
*serial lab exam may be useful ;repeat
CBC every 4-6hrs.
.
3.no operation develop ttt plan for further
diagnostic workup or non operative
therapy.
Case
36 yrs old female pt status post oratic valve
replacement who present with one week
hx of acute abdominal pain becoming
severe over last 24hrs
O\E tachycardia, PR=145\min, B.P=100\45
temp=38. abd. Distended , rigid with
moderate tenderness.wbc=23. amy=200
LDH=1500.
.
What is mostly like diagnosis?
What is the investigation of choice?
Management plane?
.
Thanks