ER The Acute Abdomen
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THE ACUTE ABDOMENTHE ACUTE ABDOMEN
Mr. MOUSTAFA ABOU_ELKHEIRMr. MOUSTAFA ABOU_ELKHEIR
CONSULTANT SURGEON KFHUCONSULTANT SURGEON KFHU
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Anatomical considerationAnatomical consideration
True AbdomenTrue Abdomen Thoracic partThoracic part Pelvic partPelvic part Retroperitoneal spaceRetroperitoneal space
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Clinical assessmentClinical assessment
Initial assessmentInitial assessment ReassessmentReassessment
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Does the patient need admission?Does the patient need admission?
The risk factors necessitating admission are:The risk factors necessitating admission are:
1.1. Abdominal pain of less than 48 hours duration.Abdominal pain of less than 48 hours duration.
2.2. Abdominal pain followed by vomiting.Abdominal pain followed by vomiting.
3.3. History of trauma, operation or haemorrhage.History of trauma, operation or haemorrhage.
4.4. History of loss of or impairment of consciousness.History of loss of or impairment of consciousness.
5.5. Extremes of age.Extremes of age.
6.6. Abnormal physical signs.Abnormal physical signs.
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The important abdominal findings are:The important abdominal findings are:
DistentionDistention Guarding/rigidityGuarding/rigidity Tenderness/reboundTenderness/rebound Tender massTender mass Tender external herniasTender external hernias Absent /tingling/hyperactive bowel soundsAbsent /tingling/hyperactive bowel sounds Rectal tenderness/mass Rectal tenderness/mass
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InvestigationsInvestigations
Routine investigation in patients with acute Routine investigation in patients with acute abdomen are:abdomen are:
CBC, urea and electrolytes, PT, PTT, Urine CBC, urea and electrolytes, PT, PTT, Urine analysisanalysis
LFT, serum amylase, lipaseLFT, serum amylase, lipase
urineurine
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InvestigationsInvestigations
Radiology:Radiology:
1. Plain abdominal film (erect/ supine)1. Plain abdominal film (erect/ supine)
2.Contrast study2.Contrast study
GastrografinGastrografin
BariumBarium
IVPIVP
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InvestigationsInvestigations
EndoscpyEndoscpy
1. Upper GIT endoscopy1. Upper GIT endoscopy
2. Sigmoidoscopy2. Sigmoidoscopy
3. Colonoscopy3. Colonoscopy
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InvestigationsInvestigations
Emergency UltrasoundEmergency Ultrasound Emergency CTEmergency CT Isotope ScintiscanningIsotope Scintiscanning
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InvestigationsInvestigations
Abdominal LavageAbdominal Lavage Emergency LaparoscopyEmergency Laparoscopy
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Is the patient underlying condition a of Is the patient underlying condition a of surgical or medical nature?surgical or medical nature?
Medical causes of acute abdominal pain:Medical causes of acute abdominal pain:*Myocardial infarction*Myocardial infarction*Lobar pneumonia*Lobar pneumonia*Acute hepatitis*Acute hepatitis*Diabetic ketacidosis*Diabetic ketacidosis*Sickle cell disease*Sickle cell disease*Congenital spherocytosis*Congenital spherocytosis*Henoch-Schonlen purpura*Henoch-Schonlen purpura*Congenital erythropoietic hepatic porphyrias*Congenital erythropoietic hepatic porphyrias*Erythrohepatic porphyria*Erythrohepatic porphyria*Herpes Zoster*Herpes Zoster*Lead poisoning*Lead poisoning*Campylobacter infections*Campylobacter infections
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Common Septic ConditionsCommon Septic Conditions::
Acute AppendicitisAcute Appendicitis Acute cholycistitisAcute cholycistitis Acute diverticulitisAcute diverticulitis
All Can lead toAll Can lead to
PERITONITISPERITONITIS
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PERITONITISPERITONITIS
1.1. Acute secondary bacterial peritonitisAcute secondary bacterial peritonitis
2.2. Primary bacterial peritonitisPrimary bacterial peritonitis
3.3. Acute non-bacterial peritonitisAcute non-bacterial peritonitis
4.4. Chronic bacterial peritonitis (TB)Chronic bacterial peritonitis (TB)
5.5. Chronic non-bacterial peritonitis Chronic non-bacterial peritonitis (granulomatous)(granulomatous)
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PNEUMOPERITONEUMPNEUMOPERITONEUM
Free air after laparotomy, abdominal Free air after laparotomy, abdominal paracentesis and peritoneal dialysis.paracentesis and peritoneal dialysis.
Gynaecological causes.Gynaecological causes. After gastrointestinal endoscopy.After gastrointestinal endoscopy. Escape of air from tracheobronchial tree.Escape of air from tracheobronchial tree. Pneumatosis cystoides intestinalis.Pneumatosis cystoides intestinalis.
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HAEMOPERITONEUMHAEMOPERITONEUM
TraumaTrauma Abdominal surgeryAbdominal surgery Pelvic fracturesPelvic fractures Ectopic pregnancyEctopic pregnancy Secondary peritoneal carcinomatosisSecondary peritoneal carcinomatosis Abdominal aneurysmsAbdominal aneurysms Haemorrhagic or clotting disorderHaemorrhagic or clotting disorder
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ASCITESASCITES
Serous (yellow/ green)Serous (yellow/ green) Chylous ( milky)Chylous ( milky) Pseudochylous (opalescent and/or turbidPseudochylous (opalescent and/or turbid Blood stainedBlood stained MyxomatousMyxomatous
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ASCITESASCITES
Liver DiseaseLiver Disease Inflamatory DiseaseInflamatory Disease Malignant DiseaseMalignant Disease Lymphatic obstructionLymphatic obstruction
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ASCITESASCITES
INTRACTABLE ASCITESINTRACTABLE ASCITES
a) Advanced Ch liver diseasea) Advanced Ch liver disease
b) Budd-Chiari syndromeb) Budd-Chiari syndrome
c) Peritoneal carcinomatosisc) Peritoneal carcinomatosis
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MESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIA
OcclusiveOcclusive
a) Arterial 90%a) Arterial 90%
b) Venousb) Venous
Non-occlusiveNon-occlusive
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INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTION
Mechanical obstructionMechanical obstruction
a) Intraluminala) Intraluminal
b) Intramuralb) Intramural
c) Extramuralc) Extramural
Paralytic or adynamic ileus Paralytic or adynamic ileus
II
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INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTION
Mechanical ObstructionMechanical Obstruction a) Simplea) Simple b) Strangulatedb) StrangulatedClinical presentation could be:Clinical presentation could be: a) Acutea) Acute b) Chronicb) Chronic c) Subacutec) Subacute d) Acute on chronicd) Acute on chronic
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INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTION
Paralytic IleusParalytic Ileus
It could be secondary to :It could be secondary to :
*Peritonitis*Peritonitis
*Mesenteric ischaemia*Mesenteric ischaemia
*Metabolic disturbance*Metabolic disturbance
*Drug induced*Drug induced
*Late stage of mechanical obstruction*Late stage of mechanical obstruction
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MANAGEMENTMANAGEMENT
1) 1) SUPPORTIVE MANAGEMENTSUPPORTIVE MANAGEMENT
2) SURGICAL MANAGEMENT2) SURGICAL MANAGEMENT
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Mr. MOUSTAFA ABOU-ELKHEIRMr. MOUSTAFA ABOU-ELKHEIR
THANK YOUTHANK YOU