Sie sind auf Seite 1von 52

Acute Abdomen

A 67-year-old white woman:


- generalized abdominal pain that began this morning
- check her for cough, shortness of breath, and an unusual odor
to her breath
 none of these signs.

Blood pressure: 95/60; pulse: 110 per minute

Examination of the abdomen:


- generalized rebound tenderness
- guarding and hypoactive bowel sounds
Rectal examination: bloody stools
. .
. .

Abdominal
pain

. .
. .
Abdominal pain = common symptom of abdominal and extra-
abdominal disorders

Abdominal pain
- acute
- recent onset (hours - days)
- rapid evolution
- high intensity
- cronic
- longer history (days - weeks - months)
- slower evolution
- mild intensity
Abdominal pain
– producing mechanisms

transmition ways

visceral

pain

somatic
Visceral pain
- caused by spasm, distension, inflammation or ischemia
Visceral pain

- transmitted through vegetative sensory


pathways
- large, imprecise cortical projection
- felt diffused in the center of the
abdomen
Visceral pain

- felt away from the viscera of origin


Visceral pain
- intensity
usually low intensity  extreme form = colic

-accompanied by vegetative phenomena


- nausea, vomiting, - headache,
- diarrhea / constipation, - sweating
Somatic (parietal) pain
- caused by mechanical / chemical
aggression, inflammation
- origin in the abdominal wall,
diaphragm,
parietal peritoneum
- somatic transmission (myelinated fibers);
precise cortical projection (inerpreted at a
specific cortical location)
=› well localized
Somatic (parietal) pain
- intense, exacerbated by movements / cough
- may be accompanied by vegetative
phenomena
-reflex mechanism
The parietal pain, in contrast to
visceral pain, often can be
localized to the region of the
painful stimulus.

This pain is typically sharp, knife-


like and constant; coughing and
moving are likely to aggravate it.
Ex. pain in acute appendicitis
The classic presentation of appendicitis involves both
visceral and parietal pain..

The pain of early presentation is


often periumbilical (visceral ) but
localizes to the right lower quadrant
( RLQ) when the inflammation
1 extends to the peritoneum (parietal).

2
Abdominal pain of abdominal origin
 the digestive organs (esophagus, stomach, duodenum,
small intestine, colon, gall bladder, pancreas)
 peritoneal disorders - peritonitis
 vascular disease: mesenteric thrombosis, abdominal
angor, abdominal aortic aneurysm
 disorders that cause the distention of the capsules of
some organs (liver, spleen)
Abdominal pain of extra-abdominal causes
-thoracic: basal pleurisy, pericarditis, acute myocardial
infarction
-abdominal wall: myositis, shingles (herpes zoster)
-urinary: renal lithiasis, acute and chronic pyelonephritis
-irradiation from diseases of the spine and spinal cord
-pain in metabolic disorders: uremia, porphyria, DZ,
tetany
Acute Abdomen
= a large group of abdominal disorders
which is manifested clinically by acute abdominal pain,
accompanied by local (abdominal) and general signs
and requiring emergency surgical treatment

In absenţa tratamentului
chirurgical survin alterari
fiziopatologice progresive,
care conduc într-un timp
variabil la decesul pacientului.
Acute Abdomen

In the absence of surgical treatment, progressive


pathophysiological disorders occur which lead to a variable time
to the patient's death.

Surgical AA
Medical AA = abdominal disorders
which is manifested by acute abdominal pain
who receive treatment
by non-surgical (medical) means

Ex.:
- biliary and renal colic
- gastric and duodenal ulcer in acute episode
- mesenteric lymphadenitis
Medical-Surgical AA
= abdominal disorders that
have as a first therapeutic indication the medical treatment,
but which, depending on evolution and response to
treatment, may require surgery

Ex.: - acute pancreatitis


- upper digestive haemorrhage
False AA = extra-abdominal disorders
which is manifested by abdominal pain
can simulate an acute abdomen

Ex.: basal pneumonia / pleural effusion


infarction of the lower face of the myocardium
diabetic acidosis
porphyria
Types of AA

- peritoneal irritation syndrome (peritonitic AA)

- bowel obstruction syndrome (occlusive AA)

- internal hemorrhage syndrome (haemorrhagic AA)

- visceral ischemia syndrome (ischemic AA)

+/- traumatic AA
Common pathophysiological elements:

- hypovolemia

- digestive stasis

- abdominal distension

- hydro-electrolytic disorders

- acido-basic disorders
Patient with abdominal pain:

Surgical abdomen?

Medical abdomen?

False AA?
Which of them has
an ‘acute abdomen’?

Surgical abdomen?
Medical abdomen?
False AA?

1. Establishing the diagnosis of acute abdomen


Acute
abdomen!!!

2.Positive & precise diagnosis of the


disease Operate
Not mandatory! !
The Operation is mandatory!
Diagnosis of acute abdomen
= a provisional diagnosis

- draws attention to the need for immediate therapeutic


intervention
- surgical treatment = essential

Sometimes etiological diagnosis can not even be established


preoperatively!

Important = setting the operator indication!


- surgery - in due time
(usually a few hours)
Three types of emergency operative
indication / policy:
Operation! When?
-immediate surgery (surgery-now!) Now –Tonight -
Tomorrow?
- “extremă urgenţă”
- operation - a few minutes-hours
Ex.: severe internal bleeding
- liver / spleen trauma
Three types of emergency operative
indication / policy:
Operation! When?
Now –Tonight -
-surgery after a short preparation Tomorrow?
(surgery tonight)
- “urgenţă imediată”
-operation - after brief preoperative treatment
- up to 6 hours
Ex.: peritonitis
Three types of emergency operative
indication / policy:

-surgery after a longer preparation Operation! When?


Now –Tonight -
(surgery tomorrow) Tomorrow?

- “urgenţă amânată”

- operation - after a longer


preoperative preparation (12-24 hours)
Ex.: bowel obstruction
Where is the
pain located?

Diffuse

- peritonitis
- bowel obstruction
Abdominal
- pancreatitis
Pain
- mesenteric artery occlusion

Focal What quadrant

- acute appendicitis
- acute colecystitis
- sigmoid diverticulitis
What is the
nature of the
pain?
Colicky pain

- intestinal obstruction
- renal calculus
Abdominal
- cholelithiasis
Pain
- common bile duct stone

Constant pain

- acute appendicitis
- pancreatitis
- perforated peptic ulcer
- diverticulitis
- ruptured ectopic pregnancy
What is the
nature of the
pain?
Colicky pain

- intestinal obstruction
- renal calculus
Abdominal
- cholelithiasis
Pain
- common bile duct stone

Constant pain

- acute appendicitis
- pancreatitis
- perforated peptic ulcer
- diverticulitis
- ruptured ectopic pregnancy
Does the pain
radiate?

The pain of acute cholecystitis typically radiates to the right


scapula or right shoulder.

The pain of a ruptured peptic ulcer may also radiate to the


shoulder.

The pain of acute renal calculus may radiate to the testicle


What are the
associated signs
and symptoms?

Generalized tenderness and rebound and diminished


or absent bowel sounds + shock  a ruptured
peptic ulcer or acute pancreatitis.

Acute right upper quadrant pain with nausea and vomiting  acute
cholecystitis.

Appendicitis: onset and is associated with anorexia and nausea,


rarely vomiting, as well as constipation.

Renal colic presents with hematuria.


Could this patient’s ab-
dominal pain be caused
by an extraabdominal
condition?

Remember!
- lobar pneumonia,
- myocardial infarction,
- diabetic acidosis,
- porphyria
may be responsible for acute abdominal pain.

There are numerous other conditions that need to be considered.


If the patient is an
infant, is there projectile
vomiting or current
jelly stools?

Projectile vomiting suggests


pyloric stenosis,

whereas bloody stools would


suggest intussusception
Early DIFFUSE
SHOCK PERITONEAL
+ + IRRITATION
-pain or tenderness on
palpation - DIFFUSE !!!

PAIN +
+

LOCAL
STOPPING INTESTINAL TRANSIT PERITONEAL
VOMITING IRRITATION
ABDOMINAL DISTENSION -pain or tenderness on
palpation – LOCAL !!!
- the most dramatic and rare clinical presentation of acute abdomen

- common causes:
- the broken ectopic pregnancy
- the broken aneurysm of the abdominal aorta
Clinical presentation:
- pain with signs of hemorrhagic shock
- hypotension, tachycardia,
- pallor,
- dizziness and vertigo, syncope

Gravity: haemorrhage

- operation: surgery now or surgery today

Atention! acute entero-mesenteric ischemia, acute pancreatitis


- generalized peritonitis associates:

abdominal pain with signs of peritoneal irritation


(tenderness, muscular defense)
- the most common causes of generalized peritonitis:
- perforation of gastro-duodenal ulcer
- perforation of the colon (tumor, diverticulitis, etc)
- perforated appendicitis

- surgery today
(preoperative perparation - several hours)

Sometimes acute pancreatitis causes periombilical muscular


defense, which can be confused with peritonitis.
=> dosing of serum amylase
- the inflammatory intraperitoneal process is limited to a region
of the abdomen

- signs of peritoneal irritation (muscular defense, Blumberg sign,


cough or percussion pain) = limited to this level

Right Upper Quadrant Left Upper Quadrant

Right Lower Quadrant Left Lower Quadrant


The most common causes of localized peritoneal irritation

acute cholecystitis sigmoid diverticulitis

acute sigmoid diverticulitis


appendicitis

Acute appendicitis: surgery today


The others: surgery tomorrow or conservative treatment and
wait!
Clinical presentation:
- abdominal pain
Depending on the
- abdominal distension (flatulence) location of the obstruction,
- stopping intestinal transit some of these clinical signs
are predominant, others are
- vomiting dimmed.

Mandatory o physical examination:


- check a strangulated hernia
-rectal examination
- (rectal tumor?)
Pain + SHOCK
Probable:
-broken ectopic pregnancy
-broken aneurism of abdominal aortaanevrism rupt al aortei abdominale
Possible:
-acute pancreatitis
-acute mesenteric ischemia
-neglected bowell obstruction, peritonitis
Anamnesis
Physical exam. Pain + DIFFUSE PERITONEAL IRRITATION
Probable:
- perforation of appendix
- ulcer perforation
Abdominal - perforation of the colon (tumor, diverticulitis)
Pain Posibible:
- other causes of generalized peritonitis

Pain + LOCAL PERITONEAL IRRITATION


Probabble:
- acute appendicitis
- acute colecystitis
- sigmoid diverticulitis
Posibible:
- Meckel's diverticulitis, tubo-ovarian abscess, others

Pain + STOPING INTESTINAL TRANSIT


Bowell obstruction:
- tumor
- strangulated hernia
- adherents
- invagination
- other causes
Serious medical conditions that can mimic an acute abdomen
Some medical conditions (non-surgical) - abdominal or extra-
abdominal - can mimic an acute abdomen!

Two must always be considered:


-inferior myocardial infarction
-diabetic ketoacidosis

A diagnostic error unnecessary but possibly catastrophic


laparotomy!
-anamnesis and careful examination
- glycemia, electrocardiogram, markers of myocardial necrosis
For AA diagnosis in practice we use:
-blood cytological examinations: H,Hb,Hct, L, ESR (VSH)
-amylasemia / serum lipase level
-glycemia
-acid-base parameters; serum ionogram; kidney tests
-human chorionic gonadotrophin
-urinalysis
-electrocardiogram
-creatine kinase (CK), cardiospecific isoenzyme, creatine
kinase MB (CK-MB), troponin
-simple abdominal radioscopy; chest radioscopy
-abdominal ultrasonography
-abdominal CT scan
Do not waste time with unnecessary
investigations!
1. In a patient with acute pain
-make the difference between
a surgical acute abdomen (the real AA)
a “medical” acute abdomen
un fals acute abdomen
Treatment depends on this differentiation!

2. There are four main clinical presentations of acute abdomen


Based on these, the need for the operation and its timing are
established.
It is less important to establish the exact etiology before
surgery.
3. Time is an excellent diagnostician! (Zachary Cope)
In a patient with unclear symptoms repeat the examination over
30-60-90-120 minutes.
"missing signs" may occur after a while
During this time: investigations according to main clinical suspicion.

4. Do not administer antialgic drugs until the diagnosis is


established!
Once the diagnosis and therapeutic strategy has been established,
the delay in antialgic treatment is not justified.
5. Preoperative preparation
-shorter or longer duration
Preoperative preparation include:
-correcting hypovolemia
-correcting hydroelectrolytic and acido-basic disorders
-combat abdominal distension and digestive stasis
-correction of tissue hypoxia (oxygen therapy)
-antibiotic therapy
-treatment of pain
6. Surgery is the essential therapeutic act!
There is no alternative to surgical treatment!

7. The prognosis of patients with acute surgical abdomen


depends on the precocity of the diagnosis and the appropriate
treatment.