Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery...

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Acute Abdomen Acute Abdomen DR. David Swar DR. David Swar Department of General surgery - Department of General surgery - (Resident) (Resident) Stomach & Colorectal diseases Stomach & Colorectal diseases Qilu hospital, Shandong University Qilu hospital, Shandong University

Transcript of Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery...

Page 1: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Acute Acute AbdomenAbdomen

DR. David SwarDR. David Swar Department of General surgery -Department of General surgery -(Resident)(Resident)

Stomach & Colorectal diseases Stomach & Colorectal diseases

Qilu hospital, Shandong UniversityQilu hospital, Shandong University

Page 2: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

DefinitionDefinition

A group of life threatening intra-A group of life threatening intra-abdominal conditions that often abdominal conditions that often lead to peritonitis and require lead to peritonitis and require urgent surgical interventionurgent surgical intervention

Page 3: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Acute Abdomen

Page 4: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,
Page 5: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

EtiologyEtiology SurgicalSurgical

InflammatoryInflammatory obstructionobstruction IschemicIschemic PerforationPerforationInflammatory Inflammatory Bowel DiseaseBowel Disease

AppendicitisAppendicitis

DiverticulitisDiverticulitis

PancreatitsPancreatits

cholecystitischolecystitis

CholangitisCholangitis

Meckel’s Meckel’s diverticulum.diverticulum.

Intestinal Intestinal ObstructionObstruction

Biliary colicBiliary colic

Ureteric colicUreteric colic

Mesenteric Mesenteric ischemiaischemia

Torsion of Torsion of viscus (organ)viscus (organ)

Peptic Ulcerative Peptic Ulcerative Disease (PUD)Disease (PUD)

Diverticular Diverticular diseasedisease

AppendixAppendix

Toxic megacolonToxic megacolon

Page 6: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Etiology, cont…Etiology, cont…

MedicalMedical gynecologicalgynecological

Myocardial Myocardial InfarctionInfarction

GastritisGastritis

GastroenteritisGastroenteritis

HepatitisHepatitis

Urinary Tract Urinary Tract InfectionInfection

Ectopic pregnancyEctopic pregnancy

Ovarian cyst torsionOvarian cyst torsionEndometriosis Endometriosis (endometrial cells are deposited in (endometrial cells are deposited in areas outside the uterine cavity )areas outside the uterine cavity )

Page 7: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Common causes of abdominal pain

Page 8: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,
Page 9: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Clinical evaluationClinical evaluation

HistoryHistory AgeAgeCertain conditions occur in certain age groupsCertain conditions occur in certain age groupsE.g.E.g. diverticulitis in elderly diverticulitis in elderly Mesenteric adenitis Mesenteric adenitis (inflammation of mesenteric (inflammation of mesenteric

lymph nodes)lymph nodes) in children in children

PainPain– OnsetOnset sudden perforationsudden perforation gradual inflammatory causesgradual inflammatory causes

Page 10: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

WWW.SMSO.CCWWW.SMSO.CC

sitesite

SiteSite

Cholecystitis

cholangitis

Peptic Ulcerative Disease (PUD)

Peptic Ulcerative disease (PUD)

Pancreatitis

cholecystitis

Gastric ulcer

Perforated colon

Appendicitis

Salpingitis

Ruptured. Ectopic pregnancy

Diverticulitis

Salpingitis

Tubo-ovarian abscess

Page 11: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

History, cont…History, cont…

– NatureNature

colicky obstruction (cramping colicky obstruction (cramping pain)pain)

dull inflammation e.g. dull inflammation e.g. pancreatitis (constant pain) pancreatitis (constant pain)

– RadiationRadiation

to tip of the right shoulder in acuteto tip of the right shoulder in acute

cholecystitis (boa’s sign)cholecystitis (boa’s sign)

Page 12: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

History, cont…History, cont…

– Aggravating factorsAggravating factors breathingbreathing coughing peritonitiscoughing peritonitis changing positionchanging position fatty meal cholecystitisfatty meal cholecystitis

– Relieving factorsRelieving factors lying still peritonitislying still peritonitis leaning forward pancreatitis (prayer’s leaning forward pancreatitis (prayer’s

signsign passing flatus Intestinal Obstructionpassing flatus Intestinal Obstruction

Page 13: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

History, cont…History, cont…

– Associated factorsAssociated factors

1.1. vomitingvomiting Precedes the pain medical conditionPrecedes the pain medical condition Follows the pain surgical conditionFollows the pain surgical condition ContentsContents

– Bilious Small Bowel ObstructionBilious Small Bowel Obstruction– Nonbilious pyloric stenosisNonbilious pyloric stenosis– Blood -bleedingBlood -bleeding

Page 14: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

History, cont…History, cont…

2. 2. Change in bowel habitsChange in bowel habits– constipationconstipation– Obstipation (constipation +no flatus)Obstipation (constipation +no flatus)– DiarrheaDiarrhea

3. 3. Anorexia (poor appetite)Anorexia (poor appetite)– e.g. appendicitise.g. appendicitis

4. 4. feverfever– Inflammatory causesInflammatory causes

Page 15: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Examination Examination

Note: physical signs may be less Note: physical signs may be less obvious in elderly, obese patients, obvious in elderly, obese patients, and those on steroidsand those on steroids

General examinationGeneral examination– Motionless peritonitisMotionless peritonitis– Writhing in agony colic Writhing in agony colic (to twist in (to twist in

pain)pain)

– Jaundice- obstructive jaundiceJaundice- obstructive jaundice– dehydrationdehydration

Page 16: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Examination, cont…Examination, cont… Vital signsVital signs

– PulsePulse– Respiratory rateRespiratory rate– Blood PressureBlood Pressure

High grade feverHigh grade fever Low grade feverLow grade fever

Acute cholangitis Acute cholangitis (Fever,jaundice,abdominal pain due (Fever,jaundice,abdominal pain due to bacterial proliferation to bacterial proliferation superimposed on obstruction of superimposed on obstruction of biliary tree due to gall stones)biliary tree due to gall stones)

PeritonitisPeritonitis

Acute cholecystitisAcute cholecystitis

AppendicitisAppendicitis

Page 17: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Abdominal Abdominal examinationexamination

InspectionInspection

What you seeWhat you see What it meansWhat it meansDistensionDistension

Rigidity Rigidity

Decreased movementDecreased movement

ScarsScars

HerniaHernia

Visible peristalsisVisible peristalsis

Intestinal Obstruction , AscitisIntestinal Obstruction , Ascitis

PeritonitisPeritonitis

PeritonitisPeritonitis

AdhesionsAdhesions

Intestinal ObstructionIntestinal Obstruction

Intestinal ObstructionIntestinal Obstruction

Page 18: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Abdominal Abdominal examination, cont…examination, cont… Palpation-(to Palpation-(to

feel)feel) signsign significancesignificance

Tenderness, Tenderness, guarding,guarding,

Rebound Rebound tendernesstenderness

Rigidity (board like)Rigidity (board like)

Pulsatile massPulsatile massSuccession splash Succession splash (splashing sound due to (splashing sound due to presence of air or fluid)presence of air or fluid)

Inflammation of Inflammation of parietal parietal

peritoniumperitonium

peritonitisperitonitis

Aortic aneurysmAortic aneurysm

Gastric outlet Gastric outlet obstructionobstruction

Page 19: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Abdominal Abdominal examination, cont…examination, cont… PercussionPercussion-(tapping on a -(tapping on a

surface)surface)

signsign significancesignificance

ResonanceResonance

Loss of liver Loss of liver dullnessdullness

Shifting dullnessShifting dullness

Intestinal Intestinal ObstructionObstruction

PerforationPerforation

Ascitis, free fluidAscitis, free fluid

Page 20: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Abdominal Abdominal examination, cont…examination, cont…

Auscultation-Auscultation-listening to the internal listening to the internal soundssounds(stethoscope)(stethoscope)

signsign significancesignificance

Absent bowel Absent bowel soundssoundsIncreased sound, Increased sound, Borborygmi Borborygmi (rumbling (rumbling sound caused by gas moving)sound caused by gas moving)

Bruit Bruit (Abnormal sound (Abnormal sound over blood vessel)over blood vessel)

Paralytic ileusParalytic ileus etc etc

Mechanical Mechanical obstructionobstruction

Vascular diseaseVascular disease

Page 21: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Specific signsSpecific signssignsign indicationindication

Murphy’s signMurphy’s sign

Boa’s signBoa’s sign

Rovsing’s signRovsing’s sign

Obturator signObturator sign

Psoas signPsoas sign

Grey turner & Grey turner & cullen’s signcullen’s sign

Acute cholecystitsAcute cholecystits

AppendicitisAppendicitis

Retrocecal Retrocecal appendicitis, appendicitis,

Hemorrhagic Hemorrhagic pancreatitispancreatitis

Page 22: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Murphy’s sign, Psoas sign –if positive where is the appendix? Retrocecal

Page 23: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Obturator sign,Cullen’s sign

Page 24: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Abdominal Abdominal examination, cont…examination, cont… Rectal examinationRectal examination Per vaginal examination Per vaginal examination

Page 25: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Digital rectal examination,Per Vaginal Examination

Page 26: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

InvestigationsInvestigations To assess patients condition in To assess patients condition in generalgeneral

1.1. Complete Blood Count (Blood Routine)Complete Blood Count (Blood Routine)2.2. Electrolytes-Na ,K ,ClElectrolytes-Na ,K ,Cl3.3. Blood Urea Nitrogen (BUN) & CreatinineBlood Urea Nitrogen (BUN) & Creatinine4.4. Arterial Blood Gas (ABG)Arterial Blood Gas (ABG)5.5. UrinalysisUrinalysis6.6. Liver Function Test (LFT)Liver Function Test (LFT)7.7. Prothrombin Time (PT)11 to 13.5 Prothrombin Time (PT)11 to 13.5

sec,PTT –25 to 35 secsec,PTT –25 to 35 sec(Partial thromboplastin time)(Partial thromboplastin time)(blood test that tells how long it takes for plasma to clot?)(blood test that tells how long it takes for plasma to clot?)

8.8. Blood grouping and cross matchingBlood grouping and cross matching

Page 27: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Investigations, Investigations, cont…cont…2. Serum Beta HCG 2. Serum Beta HCG (human chorionic (human chorionic

gonadotrophin hormone)gonadotrophin hormone)

– In female of child bearing ageIn female of child bearing age– To rule out ectopic pregnancyTo rule out ectopic pregnancy

Page 28: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Investigations, Investigations, cont…cont… Specific investigationsSpecific investigationsA. Lab A. Lab 1.1. Amylase & lipase Amylase & lipase

– Lipase elevation is specific for Lipase elevation is specific for pancreatitispancreatitis

– Amylase elevation confirms the diagnosis Amylase elevation confirms the diagnosis of Pancreatitis, but also seen in:of Pancreatitis, but also seen in:

Perforated viscus (Internal organs)Perforated viscus (Internal organs) Intestinal.ObstructionIntestinal.Obstruction Acute cholecystitisAcute cholecystitis

Page 29: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Investigations, Investigations, cont…cont…

B. RadiologicalB. Radiological1.1. Chest x-rayChest x-ray

Air under the diaphragm Air under the diaphragm in perforated viscus in perforated viscus (duodenal perforation)(duodenal perforation)

Elevated diaphragm in Elevated diaphragm in abdominal distentionabdominal distention

Page 30: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Investigations, Investigations, cont…cont…

2.2. Abdominal x-rayAbdominal x-ray air fluid levels in intestinal obstructionair fluid levels in intestinal obstruction

Stones (90% of kidney stones can be Stones (90% of kidney stones can be seen in x-ray and 10% can’t be seen seen in x-ray and 10% can’t be seen but 10% of gallstones can be seen in but 10% of gallstones can be seen in x-ray but 90% can’t be seen) why ? x-ray but 90% can’t be seen) why ? Calcium .Calcium .

Page 31: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Investigations, Investigations, cont…cont…

Page 32: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Kidney stone, Gall stones

Page 33: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Investigations, Investigations, cont…cont…

3.3. USG-Ultra sound ScanUSG-Ultra sound Scan GallstonesGallstones AppendicitisAppendicitis Ectopic pregnancyEctopic pregnancy Torsion of ovarian cystTorsion of ovarian cyst empyemaempyema

4.4. CT scanCT scan pancreatic pathologypancreatic pathology Acute aortic aneurysmAcute aortic aneurysm Severe diverticulitisSevere diverticulitis Abdominal abscessAbdominal abscess

Page 34: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Gall stones

Page 35: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Abdominal CT scan

Page 36: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Investigations, Investigations, cont…cont…

5.5. Duplex scan or angiography Duplex scan or angiography

for superior mesenteric for superior mesenteric embolus orembolus or

thrombosisthrombosis

6.6. ERCP (Endoscopic ERCP (Endoscopic retrograde cholangio-retrograde cholangio-pancreatography)pancreatography)

Page 37: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Investigations, Investigations, cont…cont…C. ParacentesisC. Paracentesis

– To assess Small Bowel Perforation in To assess Small Bowel Perforation in ascitis ascitis

– Free blood, bile, bowel contents Free blood, bile, bowel contents suggest Bowel perforation suggest Bowel perforation

D. Endoscopy & laparoscopyD. Endoscopy & laparoscopyE. Diagnostic peritoneal lavageE. Diagnostic peritoneal lavage

Page 38: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Peritoneal lavage, Paracentesis

Page 39: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

ManagementManagement

Initial management Initial management – Nil Per OralNil Per Oral– Intravenous fluids, Bolus Ringer Lactate Intravenous fluids, Bolus Ringer Lactate

solutionsolution– Monitor urine outputMonitor urine output– Nasogastric tubeNasogastric tube

DecompressionDecompression suctionsuction

– AnalgesiaAnalgesia PethidinePethidine

Page 40: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

CC

Management, cont…Management, cont…

– Antibiotics Antibiotics BroadspectrumBroadspectrum In case of sepsis or peritonititsIn case of sepsis or peritonitits

Page 41: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Management, cont…Management, cont…

Surgical managementSurgical management– IndicationsIndications

1.1. Physical findingsPhysical findings Localized peritoneal irritation with Localized peritoneal irritation with

guarding or rigidityguarding or rigidity Spreading tendernessSpreading tenderness Tense or progressive distensionTense or progressive distension Tender abdominal or rectal mass with Tender abdominal or rectal mass with

high fever or hypotensionhigh fever or hypotension

Page 42: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Indications for Indications for surgery, cont…surgery, cont…

Rectal bleeding with shock or acidosisRectal bleeding with shock or acidosis

Equivocal (uncertain)abdominal findings Equivocal (uncertain)abdominal findings with with

– Septicemia: high fever, leukocytosis, Septicemia: high fever, leukocytosis, mental status changesmental status changes

– Bleeding: shock, acidosis, falling Bleeding: shock, acidosis, falling hematocrithematocrit

– Suspected ischemia: acidosis, fever, Suspected ischemia: acidosis, fever, tachycardiatachycardia

Page 43: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Indications for Indications for surgery, cont…surgery, cont…2. Radiological findings2. Radiological findings

Pneumoperitonium –bowel perforationPneumoperitonium –bowel perforation Gross or progressive bowel distension-Gross or progressive bowel distension-

bowel obstructionbowel obstruction Free extravasation of contrast media-Free extravasation of contrast media-

bowel perforationbowel perforation Space occupying lesion –Mass or tumorSpace occupying lesion –Mass or tumor Mesenteric occlusion-IschemiaMesenteric occlusion-Ischemia

Page 44: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,

Indications for Indications for surgery, cont…surgery, cont…3. Endoscopic findings3. Endoscopic findings

Perforated lesionPerforated lesion Uncontrolled bleeding lesionUncontrolled bleeding lesion

4. Paracentesis4. Paracentesis Blood Blood bilebile bowel contentsbowel contents urineurine

Page 45: Acute Abdomen DR. David Swar Department of General surgery -(Resident) Department of General surgery -(Resident) Stomach & Colorectal diseases Qilu hospital,