43 Acute Abdomen

7/27/2019 43 Acute Abdomen

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ACUTE ABDOMEN

Dr.Viswanathan.K.V

MS, DNB,FRCS

Associate Professor of SurgeryMedical College,Trivandrum


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Necessity for Diagnosis

a serious and thorough attempt at

diagnosis

Abdominal pain is the most common

symptom

Acute abdomen = surgery is not always

true


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Course of action

Urgent operation

Wait for evolution of symptoms

Medical management


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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


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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


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Early Diagnosis

Diagnose early

No narcotics until diagnosis is made

Examination ,reexamination ,testing byinexperienced hands leads to delay in

diagnosis and early pain relief


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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 surgicalconditions


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Early diagnosis improves recovery

Decreases mortality

Reduces hospital stay due to infections Reduces long term complications


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Anatomy

Apply your knowledge of anatomy in diagnosing

abdominal conditions

Cultivate habit of thinking anatomically

Diaphragmatic spasm decreased movt oflower chest and upper abdomen

Rectus and lateral abd muscle rigidity in

subjacent inflammation Psoas spasm flexion of thigh and internal

rotation


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Obturator internus spasm pain on

rotation of the flexed thigh inwards and

this pain is referred to hypogastrium - in

pelvic appendicitis and haematocele


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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


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Irritation to the diaphragm will cause pain in the shoulderas the diaphragm has its origin from the 4th cervicalsegment and is supplied by the cervical segment viaphrenic nerve

Pain may be felt in the shoulders in cases of subphrenicabscess, diaphragmatic pleurisy, a/c pancreatitis,ruptured spleen etc.

The pain is felt in supraspinatous fossa, over theacromion, clavicle or in subclavicular fossa

The shoulder pain is often overlooked as it is attributedto arthritis.


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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 frompelvis)


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Physiology

The required stimulus for pain in hollow tube is

stretch/ distension or excessive contraction

against an obstruction

Mild degree of bowel contractions is calledflatulence 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


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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


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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.


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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)


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Methods of diagnosis

History and physical examination is the

most important part.

Record history in the chronological order

of symptoms

Age- intussusception in infants (


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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


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Shifting or localisation of pain

When peritoneal cavity is filled with pus, blood orfluid pain is felt all over the abdomen and latershifts to site of perforation.

Pain of small intestine is always felt first inepigastric or umbilical region (T9 to T11 nerves)

Remember appendicular nerves are alsoderived from the T9 to T11 so pain may be

initially felt in the epigastric region


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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


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Vomiting is early, sudden and violent inureteric 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


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Character of Vomitus

In gastritis vomitus contains food particleand some bile

In CHPS and duodenal atresia

differentiated by presence of bile in thelatter

In intestinal obstruction content varies

from gastric , bilious greenish yellow toorange and brown indicating feculentvomitus.


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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


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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.


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Nuclear scans

Largely replaced by radioisotope scans

Diagnosis of a/c cholecystitis is excluded if GB isvisualised

USG is highly operator dependant and subjective.

C.T. is costly but can demonstrate free air, fluid, andother complications of acute pancreatitis

M.R.I. has no role in evaluation of acute abd. Except invascular pathologies

UGIscopy has limited role in a/c abdomen whileLGIscopy may useful in certain conditions likeintussusception

Laparoscopy and abdominal paracentesis


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Acute appendicitis

Pain, vomiting and fever in order is the classicaltriad of symptoms

Typical symptoms if present indicates that theinflammation is advanced

Atypical symptoms like diarrhoea occur inchildren and in pelvic appendix inflammation

Initial pain is vague producing sense ofdownward urge.

Vomiting occurs early about 3-4hrs after onset ofpain.


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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


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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


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Other symptoms

Constipation

Tachycardia

Abdominal distension Testicular symptoms


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Diagnosis of appendicitis

Constant findings epigastric pain,

nausea vomiting, RIF pain, low grade

fever, local tenderness

Local rigidity, fever, hyperesthesia and

constipation- inconstant


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Diagnosis after perforation

Perforation with presence of mass orgeneralized peritonitis usually does not occurbefore 48 hrs.

After rupture the pain decreases and localisedpelvic peritonitis sets in but there is no rigidityand patient seems to be better.

Perforated pelvis appendix will cause symptoms

like diarrhoea, tenesmus, frequency ofmicturition


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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


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D/D in females

Uterine colic

Twisted/ rupture ovarian cyst

Ruptured ectopic Twisted fibroid/ hydrosalpinx


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Duodenal ulcer perforation

Diagnose early and treat promptly usually surgical If treatment delayed for >24hrs outcome is poor (


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Late stage >12hrs increasing distension

and Hippocratic facies


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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


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Epigastric tumour

Jaundice- Heads on CBD

Obstructive vomiting -heads on duodenum


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Ecchymosis, Cullen and Grey Turner

indicate severe disease and never occurs

until 2-3 days


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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.


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Colics

Intestinal colic

Main feature of colic is occurrence ofacute agonizing spasmodic pain which

causes the patient to double up and partialor complete relief in between.

Other features- vomiting, visible

peristalsis, borborygmi on auscultation


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Biliary colic

Misnomer because pain is steady


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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


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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

A t i t ti l b t ti


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Acute intestinal obstruction

Causes- hernia (mc), adhesions,intussusception, Ca, volvulus etc.

Symptoms according to site and cause ofobstruction

In general higher up the gut, more severe thesymptoms

Pain very severe referred to epigastrium,

umbilical or hypogastium Clinically- distension, visible peristalsis, features

of shock

Ob t ti hi h i ll


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Obstruction high up in small

intestine

Vomiting very early, frequent and violent,

green and bilious

Distension is not an early feature


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Obstruction distal small intestine

Pain is less severe than proximal small

bowel obstruction

Vomiting and distension delayed


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Large bowel obstruction

Distension is an early feature except inintussusception

Pain less acute, shock and vomiting rare.

Can be due to strangulation of bowelwhere tenderness on applying pressure ispositive.

Obstruction can be due to volvulus, Cacolon, impacted fecal matter etc


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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


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Ectopic Gestation

Symptoms before rupture

ammenorrhoea, localised hypogastric pain

and tenderness, uterine bleeding and

sometimes tender swelling in lateral fornixand passage of membrane per vagina


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Symptoms of rupture sudden abdominalpain, vomiting, faintness, sudden anemiaand collapse with small, rapid pulse and

subnormal temp. Signs tender tumid, free fluid in

abdominal cavity, tenderness on pressingthe finger against pouch of Douglas


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Acute peritonitis

Symptoms according to part and extent ofperitoneum involved, presence of infection andacuteness 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.


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Acute abdomen in tropics

Amebiasis

Malaria

Worm infestation

Sickle cell anemia

Pyomyositis (in HIV)

Enteric fever

Diseases that simulate acute


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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


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Thank you

43 Acute Abdomen

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