The Acute Surgical AbdomenAda EkpeAmel Ibrahim

Contents Anatomy Adominal pain Management of the acute abdomen:

from history to exam Scars and surgeries Stomas Questions

Anatomy of the abdomen 9 regions and 2 flanks Surface:

Skin Linea alba and umbilicus Xiphisternum Symphysis pubis Pubic tubercle Costal margins Iliac crests

2 Hypochondria Epigastrium 2 Loins Paraumbilical Suprapubic 2 Iliac fossae 2 Flanks

Surface Anatomy Transpyloric plane of Addison:

Halfway between jugular notch and Symphysis pubis.

Contains: body and tail of pancreas, L1 body, 2nd part of duodenum, Hilum of L kidney, upper pole R kidney, pylorus, tips of 9th costal cartilages, fundus of GB, splenic and hepatic flexures, spleen and origins of SMA and portal vein.

McBurneys point: 1/3 of way between ASIS

and umbilicus. Appendix

Mid inguinal point: halfway between ASIS and

pubic tubercle. Site of deep ring.

Mid point of inguinal ligament: Half way between ASIS and

pubic symphysis. Site of femoral pulse.

Referred pain No plan for viscera Pain referred to

associated dermatome

Appendicitis: initially T10 then as peritoneum inflamed (richly innervated) pain localised to RIF

Pain Epigastric:

cardiac Lung Thoracic dissection/ruptured aneurysm pancreatitis Liver Gall bladder Gastric/duodenal ulcer Transverse/small bowel

RUQ: Gall bladder Liver Lung Bowel

LUQ: Spleen Bowel Lung Cardiac

RIF: Skin: cellulitis/sebaceous

cyst Subcut tissue: nec fasc Lymph nodes: mesenteric

adenitis/lymphoma/infection Bowel: large bowel (tumour,

colitis) Appendictis/appendix mass Constipation Strangulated hernia Ruptured iliac aneurysm OVARIAN Orchitis/undescended testis

LIF: Diverticultis Tumour Hernia Testicular Ovarian Colitis Lymphoma etc…

Q&A Paraumbilical? Flank? Suprapubic?

History Site Onset Character Radiation Associated symptoms Time Exacerbating/alleviating factors Severity

Change in bowels Appetite? Is pain associated with food? Nausea/vomiting Urinary symptoms/systems review Previous surgeries Medications Family history Social history

Examination ABC Observations OBSERVE:

Jaundice nutrition body habitus Discomfort Stigmata of ETOH use Position (mobilising/peritonitic)

Volunteer? Abdo exam: Hands (dupuytren’s/clubbing/asterixes/pulse/nails) Face (icteric/hydration) Neck (Virchow’s node) Chest (spider naevi/gynaecomastia) Abdomen: scars, lumps, erythema, tenderness,

guarding, peritonism, organomegalyand bowel sounds) PR: skin tags/fungating tumours/haemorrhoids, tender,

mass, blood and rectum empty/full (hard or soft stool). HERNIAL ORIFICES AND TESTES

Management Analgesia IV access Fluids/antibiotics (if necessary) AXR and/or USS Vs CT scan Optimise for theatre or manage conservatively Common emergencies:

appendicitis, diverticulitis, ischemic colitis, strangulated hernia and SBO.

Common emergency operations: appendicectomy, herniorraphy +/- resection,

Hartmann’s and (sub)total colectomy.

Stomas Ileostomy:

often RIF spouted, liquid contents

Colostomy: end/defunctioning Flush Solid contents

Urostomy: For cystectomy Ileal conduit Urine in bag