Acute Abdomen and Appendix Xu Xiao M.D. Ph.D. Department of Hepatobiliary and Pancreatic Surgery The...

Acute Abdomen and Appendix

Xu Xiao

M.D. Ph.D.

Department of Hepatobiliary and Pancreatic Surgery

The First Affiliated Hospital, College of Medicine, Zhejiang University

1

Part Acute AbdomenⅠ

2

Definition of acute abdomen

Acute abdominal pain

the patient feel pain anywhere between chest and groin. This is often referred to the stomach region or belly

sudden, severe abdominal pain that is less than 24 hours in duration

medical emergency in many cases, requiring urgent and specific diagnosis. Several causes need surgical treatment

3

Classification

Physiology of abdominal pain

Diagnosis

Differential diagnosis

Treatment

4

Classification

Internal acute abdomen Refers to the existing medical disease which can induce abdominal

pain with no surgical or gynecological indications, abdominal pain can be

alleviated after existing medical disease control with the comprehensive

examination and dynamic observation

Such as acute myocardial infarction, acute mesenteric lymphadenitis,

abdominal purpura, abdominal epilepsy, acute non-specific appendicitis

Surgical acute abdomen

Refers to the existing abdominal pain caused by some diseases which

need surgical treatment

5

Classification of surgical acute abdomen

Peritonitis is the most specific term

Five types

Perforation: perforated ulcer, intestinal perforation

Parenchymatous organic rupture:

hepatorrhexis, splenic rupture

Inflammatory: acute peritonitis, appendicitis

Obstruction: intestinal obstruction

Strangulation: mesenteric thrombosis

6

The Physiology of Abdominal Pain

Visceral PainThe most common form of pain

Manifestation of damaged or injured internal organs

Many forms of visceral pain are particularly prevalent in women and are associated with their reproductive life

period pains, labour pain or postmenopausal pelvic pain

For both men and women, pain of internal origin is the number one reason to consult a doctor

pain

7

Parietal Pain

Corresponds to the segmental nerve roots innervating the peritoneum

Tends to be sharper and better localized

Caused by pneumonia; empyema; pneumothorax; tuberculosis; neoplasm; or the accumulation of fluid resulting from heart, liver, or kidney disease

Aggravated by respiration and thoracic movements


8

Referred Pain (sometimes referred to as reflective pain)

Referred pain is a term used to describe the phenomenon of pain perceived at a site adjacent to or at a distance from the site of an injury‘s origin.

One of the best examples :

myocardial infarction (heart attack): pain is often felt in the neck, shoulders, and back rather than in the chest, the site of the injury

surface areas of referred pain from different visceral organs


9

Common Causes of Acute Abdomen

Appendicitis

Peritonitis

Bowel Perforation

Pancreatitis

Diverticular disease

Cholecystitis

Perforating gastric/duodenal ulcer

Ruptured ectopic pregnancy

Ruptured or hemorrhagic ovarian cyst

Pelvic inflammatory disease

Abdominal aortic aneurysm

Tubo-ovarian abscess

10

Diagnosis

History

Physical examination

Laboratory Findings

Imaging studies

Diagnostic laparoscopy

Atypical patients11

History

Type of onset

Sudden - rupture of viscus, mesenteric thrombosis

Gradual - cholecystitis, appendicitis

Quality

Dull - initial epigastric pain of appendicitis

Sharp - renal or biliary colic or obstruction of gut

Aching - pelvic inflammatory disease

Pleuritic - intensified by breathing

Lancinating - acute pancreatitis

Tearing - dissecting aneurysm

12

Frequency & duration

History

Intensity

Severe - rupture of viscus or blood in the peritoneal cavity

Moderate - RLQ appendiceal mild peptic ulcer, without perforation

Features

Pulsatile - abdominal aneurysm

Continuous - acute pancreatitis

Transient pain of short duration which does not recur is usually insignificant. The longer the duration the more likely a surgical condition13

History

Factors which intensify or relieve pain

Relation to meals - peptic ulcer pain relieved by food,

cholecystitis pain aggravated by fatty meal

Posture jack-knifing - leg drawn up to decrease peritoneal

irritation in suppurative appendicitis

Motion - any movement causes intense pain in generalized

peritonitis and the patient lies motionless

14

History

Associated nausea and vomiting

Nausea & vomiting - reflex, or irritative non-specific

vomiting occurs in many conditions

Such as acute appendicitis, anorexia always occurs

and vomiting, if it occurs, usually follows abdominal pain

rather than preceding it, as in gastroenteritis

Repeated vomiting of large amounts occurs in gut

obstruction, is often bile stained and may become fecal

15

History

Diarrhea

Most occur with acute gastroenteritis or food poisoning

May also occur with appendicitis or other focal inflammatory lesions of the gut

Constipation or obstipation

With complete small bowel obstruction - unrelenting constipation (obstipation)

Progressive constipation with carcinoma of the large bowel

Gas stoppage with decreased or absent bowel sounds - paralytic ileus

16

Physical Examination

Overall appearance ( Facial expression, diaphoresis, pallor,

and degree of agitation)

Inspection: scars, hernias, masses

Palpation : The most critical step

Tenderness

Rigidity and guarding

Board-like abdomen

Rebounding pain

17


Auscultation

Hyperactive BS(bowel sound) , hypoactive BS or silent BS

Percussion

Digital examination of rectum A routine part of the physical examination

Check for problems with organs or other structures in the pelvis and lower belly

18

Laboratory Findings

WBC-DC (differential counting )

The total leukocyte count and percentage of polymorph nuclear cells are usually elevated in acute inflammatory conditions

Whereas early in the course of intestinal obstruction there may be no significant alterations

Urinalysis

Blood in the urine suggest disease of the urinary tract and can also result from an inflamed appendix lying in proximity to the ureter or bladder

In dehydration the specific gravity of the urine may be increased, and the red cell and hemoglobin values

19

Amylase, lipase

Serum amylase values in excess of 500 units are significant and levels

of 1500-2000 units or more are not unusual in the early stages of severe

acute pancreatitis.

β-HCG (human chorionic gonadotrophin)

– woman of childbearing age

Bilirubin, ALT, AST, Alkaline phosphatase

Laboratory Findings

20

Imaging Studies

Standing CXR and KUB

Ultrasound for solid organs

CT of abdomen for abscess, free air, vessel, tumor and

ischemia bowel

Angiography: Especially in non-diagnostic ischemia bowel

21

Imaging Studies

Gastric ulcer

22

Imaging Studies

Urethral calculus

23

Imaging Studies

Pneumoperitoneum

24

Imaging Studies

Incomplete intestinal obstruction

25

Imaging Studies

Cholecystitis Pancreatitis

Effusion

A buildup of fluid

26

Imaging Studies

Gall stone

27

Imaging Studies

Hemorrhage of large hepatocellular carcinoma

TACE (Transcatheter Arterial Chemoembolization )

28

Imaging Studies

Biliary ascariasis

29

Diagnostic Laparoscopy

A high sensitivity and specificity

Decreased morbidity and mortality

Decreased length of stay

Decreased overall hospital costs

30

Atypical Patients

Pregnancy

Acute Abdomen in the Critically Ill

Immunocompromised Patients With Acute Abdomen

Acute Abdomen in the Morbidly Obese

31

(1) Pregnancy

The underlying pregnancy has symptoms similar with acute abdomen, including abdominal pains, nausea, vomiting, and anorexia

Pregnancy can alter the presentation of some disease processes and make the physical examination more challenging because of the enlarged uterus in the pelvis

Pregnancy can alter the laboratory findings, such as white blood cell counts

Pregnancy can influence the doctor’s decision to perform typical imaging studies because of concern about radiation exposure to the developing fetus

The reasons for delayed diagnosis

32

(1) Pregnancy

Most common surgical diseases seen in pregnancy

Appendicitis

Appendicitis is the most common nonobstetric disease requiring surgery, occurring in 1 of 1500 pregnancies

Biliary tract disorders

Surgery for biliary disease occurs in 1 to 6 per 10,000 pregnancies. Symptoms of pain, nausea, and anorexia are the same as in nonpregnant patients

Bowel obstructions

Bowel obstructions are much less common, occurring in about 1 or 2 per 4000 deliveries

33

(2)Acute Abdomen in the Critically Ill


Many of the underlying diseases and treatments

encountered in the intensive care unit can predispose to

acute abdominal disease

Critically ill patients are often unable to appreciate

symptoms to the same degree as healthy peers because

of nutritional or immune compromise, narcotic

analgesia, or antibiotic use

34

(3) Immunocompromised Patients With Acute Abdomen


Most common Immunocompromised Patients

Immunocompromised patients have variable presentations with acute abdominal diseases. The variability is highly correlated to the degree of immunosuppression

Elderly, malnourished, and diabetic patients

Transplant recipients on routine maintenance therapy

Cancer patients; renal failure patients

HIV patients

35

(4) Acute Abdomen in the Morbidly Obese


Alterations in the signs and symptoms of

peritonitis in the morbidly obese

Exam findings can also be difficult to confirm

distention or intra-abdominal mass because of

the size and thickness of the abdominal wall.

Abdominal imaging is also adversely affected

by obesity

36

Effective management of acute abdominal pain involves a careful history taking, ultrasound, electrocardiography and blood tests. Computed tomography of abdominal organs and visceral vessels is probably important already at the beginning of the diagnostic work up

Treatment for Acute Abdomen

37

Treatment Algorithms (1)

CT, computed tomography; NG, nasogastric tube; NL, normal study; OR, operation

Algorithm for the treatment of acute-onset severe, generalized abdominal pain

38

Treatment of gradual-onset severe, generalized abdominal pain.


CT, computed tomography;

ERCP, endoscopic retrograde cholangiopancreatography; LFTs, liver function tests

39

Algorithm for the treatment of right upper quadrant abdominal pain



ERCP, endoscopic retrograde cholangiopancreatography;

LFTs, liver function tests;

NL, normal study;

US, ultrasound. 40

Algorithm for the treatment of left upper quadrant abdominal pain


CT, computed tomography41

Algorithm for the treatment of right lower quadrant abdominal pain



hx, history;

OR, operation;

UTI, urinary tract infection42

Algorithm for the treatment of left lower quadrant abdominal pain


CT, computed tomography43

Preparation for emergency operation

IV access

Antibiotic infusions

Nasogastric tube

Foley catheter bladder drainage

Hydroelectrolytic equilibration

Crossmatched blood available

44

Summary

Acute abdomen remains a challenging part of a surgeon's practice

KEY: A patient with an acute abdomen is an EMERGENCY, and it is IMPERATIVE to get a correct diagnosis

Although advances in imaging techniques, a careful history and physical examination remain the most important part of the evaluation

Perform a laparoscopy or laparotomy for diagnosis with a good deal of uncertainty as to the expected findings

45

Case Study

20-Year-Old Male with Abdominal Pain for 18 Hours

Pain started in the Mid-Abdomen

Constant

Anorexia, Nausea, and Vomiting

First Episode

No Diarrhea, Dysuria

Pain Now Seems Worse in the Right Lower Abdomen

History

46

Case Study

Lying flat, avoids moving

Afebrile

Abdomen tender mostly in the RLQ

Significant guarding

Positive Roving's Sign

Physical Exam

47

Case Study

WBC 14*109/L

AST,ALT Normal

Amylase, Lipase Normal

Urine Culture Negative

CT scan

Lab Data

Further Testing

•Diagnosis?

48

Part Ⅱ Appendix

•Appendicitis

•Appendiceal Abscess

50

Appendicitis

Reginald Fitz first described acute and chronic appendicitis in 1886

It has been recognized as one of the most common causes of severe acute abdominal pain worldwide

Appendicitis is a condition characterized by inflammation of the appendix Vermiform appendix

All cases require removal of the inflamed appendix, either by Laparotomy or laparoscopy.

Untreated, mortality is high, mainly because of peritonitis and shock

51

Appendicitis

Anatomy and position

Pathophysiology

Diagnosis

Differential Diagnoses

Treatment

Outcome52

Anatomy and position

Anatomy A closed-ended, narrow tube up to several inches in length that attaches to the cecum like a worm

The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum

The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies

Position The vermiform appendix has no constant position

The appendix is more often found in the pelvic rather than the retrocaecal position

pelvic

Pre-ileal

post-ileal

retrocaecal

Para-caecal

53

Pathophysiology

Acute appendicitis is thought to begin with

obstruction of the lumen

Obstruction can result from food matter, adhesions,

or lymphoid hyperplasia

Mucosal secretions continue to increase

intraluminal pressure

54

Pathophysiology

Acute simple appendicitis

Acute purulent appendicitis

Acute gangrenous appendicitis

55

Diagnosis

History


Laboratory Studies

Radiography


56

History

Primary symptom: abdominal pain

Pain beginning in epigastrium or periumbilical area that is vague and hard to localize

Associated symptoms: indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting

Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific

Anorexia is the most common of associated symptoms

Vomiting is more variable, occuring in about ½ of patients

57


Findings depend on duration of illness prior to exam

Early on patients may not have localized tenderness

With progression there is tenderness to deep palpation over McBurney’s point

McBurney’s Point: just below the middle of a line connecting the umbilicus and the ASIS （ anterior superior iliac spine)

Rectal exam: pain can be most

pronounced if the patient has

pelvic appendix

58


Roving's sign

Pain in RLQ with palpation to LLQ

A sign of appendicitis. If palpation of the lower left

quadrant of a person's abdomen results in more pain in

the right lower quadrant, the patient is said to have a

positive Rovsing's sign and may have appendicitis

59


Psoas sign

Place patient in L lateral decubitus and extend R leg at

the hip. If there is pain with this movement, then the sign

is positive.

Occasionally, an inflamed appendix lies on the

Psoas muscle and the patient will lie with the right hip

flexed for pain relief.

60


Obturator sign

Passively flex the R hip and knee and internally rotate the

hip. If there is increased pain then the sign is positive

If an inflamed appendix is in contact with the obturator

internus, spasm of the muscle can be

demonstrated by flexing and internally

rotating the hip. This maneuver

will cause pain in the hypogastrium

61

Laboratory Studies

WBC

The white blood cell count is elevated with more than 75% neutrophils in most patients

A completely normal leukocyte count and differential is found in about 10% of patients with acute appendicitis

A high white blood cell count (>20,000/mL) suggests complicated appendicitis with either gangrene or perforation

Urinalysis

Be helpful in excluding pyelonephritis or nephrolithiasis

Microscopic hematuria is common in appendicitis

Gross hematuria is uncommon and may indicate the presence of a kidney stone

62

Radiography

Plain abdominal radiographs

Ultrasonography

Computed tomography (CT)

CT ： best choice based on availability and alternative

diagnoses

CT ： greater sensitivity, accuracy, predictive value

63

CT scan of the abdomen or pelvis in a patient with acute appendicitis may reveal an appendicolith (arrow)

CT typically shows a distended appendix (arrow) with diffuse wall-thickening and periappendiceal fluid (arrowhead)

CT scanning

64


A direct examination of the appendix

A survey of the abdominal cavity for other possible causes of pain.

Primarily for women of childbearing age in whom preoperative pelvic ultrasound or CT scan

65

Diagnostic Algorithm

Algorithm for the evaluation and management of patients with possible acute appendicitis based on surgical assessment of clinical probability of the diagnosis66


Algorithm summarizing the treatment of acute appendicitis 67

Differential Diagnoses

Two type : A: required surgery B: not required surgery

Required surgery

Perforation of gastrointestinal tract ulcer, tumor, diverticulitis

Obstetrics and gynecologic disease: ectopic pregnancy, ovarian torsion

Meckel’s diverticulitis

Tumor

Not required surgery

Pelvic inflammation

Mesenteric adenitis: at exploration a normal appendix and enlarged lymph nodes in the mesentery

Viral &bacterial gastroenteritis

Pneumonia, pleurisy68

Treatment

Surgical removal of appendix is definitive treatment

Incision Incision over the point of maximal tenderness,generally at McBurny point McBurney’s incision, tansvers skin incision , 3—6cm long

Process The taenia of the colon are followed to the base of the appendix

Mesoappendix is divided between clamps and ligated

The base of appendix is divided and ligated 0.5cm from caceum and inverted using a purse-string

Suspected case

Admit the patient to hospital for further observation 12-24hrs

69

Open Appendectomy (OA)

Location of possible incisions for an open appendectomy

Division of the mesoappendix

cecum

Anterior cecal artery

70

B. Ligation of the base and division of the appendix

C. Placement of purse-string suture or Z stitch

D. Inversion of the appendiceal stump

Open Appendectomy (OA)

71

Location of port sites for laparoscopic appendectomy

Division of the mesoappendix

using the harmonic scalpel

Laparoscopic Appendectomy (LA)

72

Placement of an absorbable Endoloop encircling the base of the appendix

Placement of an absorbable Endoloop encircling the base of the appendix

Division of the appendix between Endoloops Division of the appendix between Endoloops

Placement of the appendix into a specimen bag before removal of the appendix with

the umbilical port

Placement of the appendix into a specimen bag before removal of the appendix with

the umbilical port

Laparoscopic Appendectomy (LA)

73

Antibiotic thearpy

The differentiation between simple appendicitis and gangrenous appendicitis/perforated appendicitis with peritonitis should determine the length of antibiotic administration

Simple appendicitis

ONLY preoperative antibiotic prophylaxis

Gangrenous appendicitis and perforated appendicitis

with peritonitis

A therapeutic course

74

Appendiceal Abscess An abscess in the peritoneal cavity resulting from the spread of

infection in acute appendicitis, especially with perforation of the appendix.

Also called periappendiceal abscess.

Imaging studies are useful both in confirming the diagnosis and in

evaluating the size of any abscess present

Those patients with smaller abscesses or phlegmon and who are not

sick may be successfully managed initially with antibiotics alone.

Patients who continue to have fever and leukocytosis after several days

of nonoperative treatment are likely to require appendectomy during the

same hospitalization, whereas those who improve promptly may be

considered for interval appendectomy

75


Algorithm for the management of appendiceal abscess

76

Outcomes

The mortality rate after appendectomy is less than 1%.

Surgical site infections are the most common complications seen after appendectomy.

Small bowel obstruction occurs in less than 1% of patients after appendectomy for uncomplicated appendicitis and in 3% of patients with perforated appendicitis who are followed for 30 years.

The risk for infertility following appendectomy in childhood appears to be small.

There are rare reports of appendicocutaneous or appendicovesical fistulas after appendectomy, typically for perforated appendicitis.

77

Thanks !Thanks !78

Acute Abdomen and Appendix Xu Xiao M.D. Ph.D. Department of Hepatobiliary and Pancreatic Surgery The...

Documents

Transcript of Acute Abdomen and Appendix Xu Xiao M.D. Ph.D. Department of Hepatobiliary and Pancreatic Surgery The...