1. Presenter Muhammad Uzair Nik Ahmad Indera Supervisor Dr
Hilda
2. Outlines Introduction Pathophysiology of pain Approach
Common causes for acute abdomen Immediate life-threatening
diagnosis Management Take home message
3. Introduction repair Definition acute abdomen (Stedman's
Medical Dictionary, 27th Edition) Any serious acute intra-abdominal
condition Attended by Pain Tenderness muscular rigidity Emergency
surgery must be considered
4. Visceral Pain Somatic Pain Referred pain Comes from abd
visceral Comes from parietal peritoneum Perceived distant from its
source Autonomic nerve fibers Somatic nerve fiber Convergence of
nerve fibers at spinal cord Respond mainly to distension and muscle
contraction Respond to cutting, infectious, chemical or
inflammatory processes Examples: -Scapular pain biliary colic
-Groin pain renal colic -Shoulder pain blood or infection
irritating diaphragm Usually vague, dull and nauseating Usually
sharp and localized Pathophysiology
5. 1. Luminal obstruction (luminal, mural and extramural) with
features of Abdominal colic. Related to rate of peristalsis.
Vomiting. Common in high obstruction. Constipation. Common in
distal obstruction. Abd distention. Prominent in large bowel
obstruction. BO should not rule out obstruction Worsening symptoms
may indicate adynamic ileus, strangulation and perforation
6. 2. Inflammation Many visceral organs are potential source
for inflammation within abdomen. Patient usually present with Pain
Vomiting (vagal response to pain) Can be self limiting
(spontaneously resolved or treated with antibiotics) May progress
to gangrene and perforation causing peritonitis.
7. 3. Peritonitis Can be caused by bowel contents, bile, urine,
pus or blood from perforated viscus. Classical signs of guarding,
board like rigidity, rebound tenderness, abdominal distension and
absent bowel. Patients are often septic with/without shock
8. 4. Ischemia and infarction Classification: Arterial or
venous Intra/extraluminal Usually presented with abdominal pain out
of proportion to physical finding a/w anorexia, vomiting, diarrhea
or GIT bleed. Should be suspected in pt with vascular disease or
atrial fibrillation
9. 5. Non specific abdominal pain Diagnosis of exclusion In 40%
of cases causes is unknown Causes can be viral/parasitic infection,
gastroenteritis, mesenteric adenitis, ovulatory pain, IBS Most
cases require admission for observation and investigation
10. HISTORY: The main presenting complaint and the
characteristics of the abdominal pain. Site , Time and mode onset ,
Severity , Nature, Progression, Duration , Exacerbating and
relieving factors, Radiation Any associated symptoms distension
nausea, vomiting, fever, diarrhoea, constipation, PR bleeding,
anorexia, jaundice, gastrointestinal bleeding, dysuria, oliguria
Other important Hx Similar problems before? Underlying medical
illness? H/O surgical intervention before?Gynaecological hx LMP,
pregnant? Family Hx of malignancy? Clinical Assessment
11. INSPECTION Any abdominal swellings or distended due to
enlargement of the liver, kidneys or spleen, tumors of bowel. Scars
from previous surgery PALPATION Tenderness area, rebound
tenderness, voluntary guarding, involuntary guarding. Palpable
mass, lymphadenopathy, hernial orifices. PERCUSSION To determine
presence of fluid within the peritoneal cavity. ASCULTATION Bowel
sound, The absence of bowel sound over 30-s suggest peristalsis has
ceased (ileus) Examination
12. Investigation Baseline: FBC BUSE RBS Other investigation:
serum amylase, LFT, UPT, GSH/GXM, UFEME Abdominal x ray, CXR
Ultrasound abdomen Endoscopy Colonoscopy OGDS ERCP Laparoscopy /
laparotomy In cases where diagnosis in unclear May be the ultimate
diagnostic investigation, in addition to being therapeutic
13. Important Signs in Patients with Abdominal Pain Sign
Finding Association Cullen's sign Bluish periumbilical
discoloration Retroperitoneal haemorrhage Grey-Turner's sign
Discoloration of the flank Retroperitoneal haemorrhage Murphy's
sign Abrupt interruption of inspiration on palpation of right upper
quadrant Acute cholecystitis McBurney's sign Tenderness located 2/3
distance from anterior iliac spine to umbilicus on right side
Appendicitis Iliopsoas sign Hyperextension of right hip causing
abdominal pain Appendicitis Obturator's sign Internal rotation of
flexed right hip causing abdominal pain Appendicitis Rovsing's sign
Right lower quadrant pain with palpation of the left lower quadrant
Appendicitis
14. Common causes for acute abdomen Non-specific abdominal pain
(40%) Acute appendicitis (28%) Acute cholecystitis (10%) Bowel
obstruction (4%) Perforated PU (3%) Pancreatitis (3%) Diverticular
disease (2%) Others (13%)
15. Appendicitis - Definition Inflammation of the appendix
Pathophysiology Obstruction of the appendiceal lumen Lymphoid
hyperplasia Fecolith Sign and symtoms RIF pain Fever Anorexia
Nausea and Vomiting Rebound tenderness Alvarado score Lab &
radiology : TWBC & neutrofil high, Ultrasound Treatment
Appendicectomy
16. These images reveal a typical tubular structure with blind
end, showing total diameter more than 6mm.(12 x 15 mm.). These
sonographic images reveal hypoechoic content (purulent material)
distending the appendix with an echogenic focus floating within
it
17. Biliary colic / acute cholecystitis C/O RHC pain + nausea
and vomiting Difference between biliary colic and acute
cholecystitis: fever, usually lasted > 24 hrs, Murphys sign,
leukocytosis (in later) Charcoat triad fever, RHC pain and
jaundiceascending cholangitis Diagnostic Ix - ultrasound HBS and
ERCP Treatment Fluid resuscitation Antibiotics broad spectrum
(penicillin+aminoglycosides/ 3rd generation
cephalosporin+metronidazole) Decompression of biliary tree by ERCP,
drain stone in common bile duct by stenting
18. Ultrasound with thickened gallbladder wall and
pericholecystic collection
19. Acute pancreatitis H/O Sudden epigastric pain Radiates to
the back, exacerbated by movement Frequent vomiting Signs
Hypovolemia, Jaundice, severe abdominal tenderness, Grey Turners
sign, Cullens sign Lab and Ix Serum amylase - > 1000 units
AST/ALT deranged ? obstruction Plain abdominal x-ray Colon cut-off
sign
20. U/S of the pancreas Swollen pancreas, hypoechoic (d/t
edema), peripancreatic fluid collections & edema Treatment
conservative analgesic, bed rest and bowel rest Surgery is
indicated if : Patient fails to improve on conservative management
or deteriorates Gallstones are present - ERCP + sphincterostomy
When complications develop pseudocyst > 6 cm (wait for 3 weeks
to mature) Pancreatic abscess ? Glasgow (Imrie) prognostic score
(Mnemonic: PANCREAS) PO255y TWBC>15 x109/L Calcium16mmol/L
Enzymes AST>200U/L, LDH >600U/L Albumin10mmol/L
22. Perforated Viscus Pt Might c/o generalized abdominal pain
O/e tachycardic, profused sweating, abdominal guarding/rigidity,
tenderness aggravated by coughing Investigation Erect chest xray
must be done if perforated viscus is suspected to look for air
under diaphragm Treatment Definite treatment still surgical
intervention Exploratory laparotomy and proper lavage of peritoneum
is needed if the cause is unknown. Hydration correction of
electrolyte imbalance analgesic and If infection is suspected
antibiotics
23. Bowel Ischemia Caused by inadequate blood flow through the
mesenteric vessels, resulting in ischemia and eventual gangrene of
the bowel wall. The vascular supply of the small and large bowel is
provided by three arteries: 1. celiac trunk 2. superior mesenteric
artery (60%70% cases) 3. inferior mesenteric artery
24. c/0 : generalized abd pain and some have bloody stool Bowel
motility reduces abdominal bloating. o/e : Fever, hypotension,
tachycardia, tachypnea, and altered mental status,Tenderness
becomes severe. Bowel sounds range from hyperactive to absent.
Voluntary and involuntary guarding appears. Lab : Leukocytosis,
metabolic acidosis Abd xray : ileus, small bowel obstruction,
edematous or thickened bowel walls, and paucity of gas in the
intestines. Small bowel : >4cm Colon : > 6cm Caecum : >
8cm Ultrasonography is highly specific (92-100%), but its
sensitivity (70-89%) CT angiography has a sensitivity of 71-96% and
a specificity of 92- 94%
25. Colon Cutoff Sign-dilated transverse colon, usually to
splenic flexure, associated with pancreatitis or ischemic
colitis
27. Abdominal aortic anerysm Male: female ratio is 4 : 1 510%
of males over 65 years of age have AAA High incidence in patients
with peripheral arterial aneurysm (popliteal, femoral) Ruptured AAA
clinical suspicion Severe back or abdominal pain may radiate to
groin. sudden, together with sign and symptoms of shock
28. Sn & Sx: Pulsatile abdominal massin less than 30 % of
patients with significant AAA Tender abdominal mass is suggestive
of symptomatic aneurysm Sudden onset of lower limb numbness
Ruptured AAA Pulsatile mass + hypotension abdominal/back/groin pain
+ hypotension
29. Ultrasound Helpful only if aorta is clearly seen and
completely normal often not helpful due to bowel gas and patient
discomfort cannot rule out a leak from AAA CT scan Best test when
diagnosis of AAA is unclear Sensitivity nearly 100% Size aneurysm
(diameter), location, potential ruptured, Determining surgical
repair or endovascular repair (EVAR) Treatment for ruptured AAA
emergency surgery (but most of the time patient passed away before
surgical intervention)
30. Ectopic Pregnancy Early embryo (fertilized egg) that has
implanted outside of the uterus (womb), the normal site for
implantation. C/o Pain (abdominal or pelvic) Amenorrhea with
abnormal uterine bleeding Gastrointestinal symptoms Anaemic
symptoms may have a pelvic mass. beta-hCG level > 6000 mIU/mL,
the gestational sac should be visible in the uterus with an
abdominal probe. beta-hCG level : 1000-2000 mIU/mL, a gestational
sac should be seen in the uterus with a vaginal probe. UPT
positive
31. Ultrasound scans ultrasound does not show a pregnancy
inside the uterus in the first 3 to 5 weeks after conception . show
fluid or blood in the abdominal cavity, suggesting bleeding from an
ectopic pregnancy. Laparoscopy Treatment: methotrexate treatment
salpingectomy
32. Management Generally Secure airway and breathing put on
oxygen depends on oxygen status of the patient Circulation 2 large
bore branula both upper limb Run fluid Insert catheter to monitor
urine output Insert central venous line Ryles tube for
decompression Monitor BP, PR, urine output, CVP Keep patient nil by
mouth with IV drip maintenance Analgesia either intravenous or
subcutaneous
33. Take home message Knowing anatomy of abdomen is most
important to make diagnosis. Acute appendicitis is the commonest
cause for acute abdomen 4 life threatening condition ruptured
ectopic pregnancy, perforated viscus, leaking/ruptured AAA, bowel
ischemia. Air under diaphragm in erect CXR suspect perforated
viscus. Do UPT to rule out ectopic pregnancy in woman of
childbearing age Fluid resuscitation is important in acute abdomen
Always perform ABC, Resuscitate before Dx even of patient is toxic
and urgent surgery is required resusitation is essential
34. References Janette KS, Dileep NL. Investigation of acute
abdomen; Elsevier 2008; Surgery 26:3 O. James Garden, John
Forsythe, Andrew W. Bradbury, Principles and Practice of Surgery;
4th edition; 2007 Oxford textbook of Surgery 2nd edition Browses
Introduction to the Symptoms and Signs of the Surgical Disease; 4th
edition.
