ACUTE ABDOMEN(ABDOMINAL EMERGENCIES)

One of the most common causes for hospitalization

Meaning= acute abdominal symptoms which lead

patients to ER , excluding obvious

abdominal injuries

May or may not require immediate operations

Some aspect has been changed

Pathophysiology of Abdominal pain

Origins of intraabdominal visceral organs

Stomach to 2nd part of duodenum, including liver,

biliary trees, pancreas, and spleen are derived from

forgut

3rd and 4th part of duodenum, jejunum, ileum,

appendix, ascending colon to proximal 2/3 of

transverse colon are derived from midgut

Distal 1/3 of transverse colon to anal canal above

dentate line are derived from hindgut

Visceral pain from organs derived from foregut and midgut

is at midline and above or around umbilicus.

Visceral pain from organs derived from hindgut

is at midline and below umbilicus.

Peritoneum innervations

Visceral peritoneum

-Sympathetic and parasympathetic nerve innervations(C fibers)

dull or cramping pain

-character

insidious

sensitive to distension, ischemia, squeezing, torsion

insensitive to heat, cutting, or electrical shock

Parietal peritoneum

character

somatic nerve innervation (A fiber)

sharp and exquisite pain

somatic nerve distribution (T7-L2, umbilicus at T12)

sensitive to mechanical stimuli (stretching, pinprick,

pinch), heat, electrical shock, chemical stimulus,

infection-inflammation

ASSESSMENT

2 most important things in assessment of the patients are

Carefully and precise history taking, and

Physical examination

Basic History Taking

onset

sudden

insidious

Perforated PU,Gallstone,UC,Aortic

dissection,Rupture AAA, SMA

Embolism,Ruptured ectopic preg.,

Ruptured corpus luteal or follicular

cysts,Twisted ovarian cyst

Acute Appendicitis,Acute pancreatitis,

Intestinal obstruction,Acute pyelonephritis,

Acute gastritis or gastroenteritis

Age

Childhood:

Adults:

Middle to old age:

Constipation, Acute appendicitis

Intussusception, Viral enteritis

Infecion-inflammation,

Female reproductive organs

Malignancies,

Degenerative diseases

Sex

Nature of pain

Colicky: sharp shooting,intermittent,restless,

associated with vomiting

is likely from acute obstruction of hallow

viscus organs (small bowel,biliary trees,

ureter,or even appendix).

SMA occlusion maybe possible

Acute Gastritis, Gastroenteritis

sudden,sharp & persistent: Leakage of irritating fluid, i.e.

blood from Ruptured ectopic preg,

AAA, corpus luteal or follicular

cysts, Hepatoma

Fluid from ovarian cyst, Perforated

PU

Shearing or Tearing: Aortic dissection, Ruptured AAA

Dull aching: general

Associated symptoms Nausea,vomiting, respiratory

symptoms

Bowel habits

Gynecologic History menstruation,leucorrhea, sexual

intercourse

Concomitant History Underlying diseases

Family History

Drug usage

Substance exposure

Diarrhea,constipation,

mucous bloody stool

Physical Examination

posture

General physical exam.

anemia

jaundice

hypotension

hypertension

fever

tachypnea: Kussmal breathing, dyspnea

dehydration

Sepsis

Chronic illness

Abdominal Examination

Palpation : soft, repeated, reproducible tenderness,Fothergill’s sign

Signs of Peritonitis

Point of maximal tenderness

guarding

rigidity

rebound tenderness

Bowel sound

Increase, decrease

Borborygmi

high pitch

infrequent

loud

Relate with abdominal pain

Rectal examination : Cul de sac palpation

Pelvic examination

Investigations

Beware of misleading by investigations

CBC

In RLQ pain to rule in or rule out Acute Appendicitis

wbc count (n>70%) < 8,000 very unlikely

8,000-10,000 unlikely

10,000-12000 equivocal

12,000-15,000 suggestive

15,000-20,000 highly suggestive

>20,000 probably ruptured

Urine pregnancy test

Beta HCG

urinalysis

Blood chemistry

General: BS, BUN, Cr, Electrolyte

Specific: Amylase, Lipase LFT,

Imaging Investigations

Plain film

Chest X-Ray

Plain Abdomen

Ultrasonography

•Biliary trees

•Mass

•fluid

•Retroperitoneal organs

Ultrasound in Acute Appendicitis +

CT Scan

Similar benefit as in U/S but

more time consumed

more accurate

more expensive

more sophisticated

more risk

ACUTE APPENDICITIS

Most common cause of acute abdomen

The earlier the diagnosis is made, the less

complicated the outcome, the shorter hospital stay

and recovery ,and the less expense are.

Aim = earliest and most accurate

Makarathep Score

1 History

Typical = 2

Not typical = 1

Unusual = 0

2 Age 10-30 = 1

<2 or >70 = -1

others = 0

3 Gender Male = 2

Female

Virgin = 0

Not virgin= -1

Hx of PID,

Salpingitis, = -2

Endometriosis

4 tender RLQ

Definite just one point = 3

Definite with other area= 2

Vague = 1

5 Rebound

tenderness

definite = 2

not definite = 1

no = 0

6 Guarding present = 2

no = 0

7 Rectal exam definite tender = 1, 2

not definite = 0

No = 0,-1

8 Vaginal exam purulent leucorrhea = -1

cervical excitation

pain = -1,-2

definite tenderness

left adnexa = -2

definite tenderness

right adnexa = -1

9 Fever (T>37.5 C) present = 1

no = 0

10 CBC

WBC (N>70%) > 12,000 = 2

10,000-12,000 = 0

8,000-10,000 = -1

<8,000 = -2

11 Neutrophil count > 90% = 2

80-89% = 1

70-79% = 0

< 70% = -1

12 Urinalysis

wbc 5-15/HD = 0

wbc> 15/HD = -1

13 Hypovolemic shock without obvious cause

Female = -10

Male = -5

wbc<5/HD = 1

Total score

20 >95%

11-19 90-94%

5-10 50-89%

0-4 30-50%

possibility

Common Differential Diagnosis of Acute Appendicitis

Ureteric Stone

Acute Pyelonephritis

CA Caecum with perforation, Diverticulitis

Gynecologic conditions

•Ruptured corpus luteal cyst or follicular cyst

•Ectopic pregnancy

•Salpingitis and Acute PID

•Endometriosis

Non surgical causes of Acute Abdomen

Pleuritis and Basal Pneumonia

Acute MI

Congestive Heart Failure

Dengue (Hemorrhagic) Fever

Acute Hepatitis

Acute

Hepatomegaly

Acute Pyelonephritis and Ureteric stone

Uremia

DKA

Vasculitis (SLE, Henoch-Scholein Purpura)

Aortic dissection

AIDS with Abdominal Tuberculosis

Drug Withdrawal

Irritable Bowel Syndrome

Constipation

Acute Abdomen in Children

Constipation

Viral Enteritis

Acute Appendicitis

Mesenteric Adenitis

Intussusception

Specific Investigations for Diseases in Acute Abdomen

1.Acute Appendicitis CT Scan

2.Acute Gastritis, PU Gastroscopy

3.PU Perforation CXR, CT Scan for free air

4.Biliary Tract Disease U/S

5.Diverticulitis CT Scan

6.Acute Pancreatitis serum Lipase

7.Ectopic Pregnancy Pregnancy test, Beta HCG with Transvaginal U/S

8.Acute PID CT Scan

11.SMA Occlusion CT Scan, SMA Angiography

9. Ureteric Stone IVP, CT Scan, U/S

12.Rptured AAA, CT Scan, U/SAortic Dissection

10.Small Bowel GI Follow through, CT ScanObstruction

Management

1.Manage hemodynamic instability

2.Oxygenation

General Management

3.Analgecics

4.Nursing process

Specific Treatment

Superior Mesenteric Artery Occlusion

Embolism or Thrombosis

Severe intractable abdominal pain, not corresponding

to abdominal signs

In late stage Gangrene nearly the whole small bowel

Profound intractable shock

Investigation (tough to proceed) : Mesenteric angiography

CT scan

Mini-explore lap.

Thank you very much

makarathep@hotmail.com

http://makarathep.hi5.com