PowerPoint Presentation

APPROACH TO ACUTE ABDOMENPain is the most common of all abdominal symptoms. This may be due to inflammatory, infective or obstructive pathology. Can arise from abdominal viscera or be referred from a site outside the abdomen, such as the lungs as in pneumonia or the heart as in angina.

TYPE OF PAINParietal painParietal peritoneum lines the abdominal wallInnervated by somatic nerves through spinal nerves in distribution of overlying dermatome:Xiphisternum (T7)Umbilicus (T10)Pubis (T12)Pain is sharply localized to the point of inflammation of the parietal peritoneumderived fromsomatic mesodermin the embryopain will appear to change in position and nature as the underlying pathology spreads from a local intraperitoneal structure to the parietal peritoneum

4

Skin and the muscles of the abdominal wall :the lateral and anterior cutaneous branches of the lower six intercostal nervesthe iliohypogastric and ilioinguinal nerveThe central part of the diaphragmatic peritoneum is supplied by the phrenic nerve (C4)pain arising in this region is referred to the tip of the shoulder as it has the same segmental supply.

The pain in the parietal peritoneum may radiate to back or front along the dermatome

When an inflamed organ touches the parietal peritoneum: pain is then localised to the segmental dermatome of the abdominal wall

The pain in the parietal peritoneum may radiate to back or front along the dermatomeVisceral painThe abdominal organ and visceral peritoneum innervated by autonomic nervous systemThis pain is transmitted via sympathetic fibres and so is referred to the appropriate somatic distribution of that nerve root from T1 to L2 Deep, poorly localized and usually ass. with sympathetic symptoms (nausea and vomiting)

It is derived fromsplanchnic mesodermin the embryo.8Localization depends on embryologic origin of the organ. The pain from:Foregutstructures are referred to theepigastricregionMidgutstructures are to the peri- umbilicalregion Hindgutstructures to thelower abdomen

EMBRYLOGICAL DISTRIBUTION OF GITForegutEsophagusStomachDuodenum (1st and 2nd part)PancreasLiverGallbladderMidgutDuodenum (3rd and 4th part)JejunumIleumAscending colonTransverse colonAppendixHindgutDescending colonSigmoid colonRectum CLINICAL APPLICATIONSReferred pain appendicitis:Initially, pain from the appendix (midgut structure) and visceral peritoneum is referred to theumbilical region.

As the appendix becomes inflamed and irritates the parietal peritoneum the pain becomes localised to theright iliac fossa.

Most causes of11Most causes of abdominal pain will involves both visceral and parietal pain which indicates the inflammation increases and spread

S:suprarenal (adrenal) glandA:aorta/IVCD:duodenum(second and third part)P:pancreas(except tail)U:uretersC:colon(ascendinganddescending)K:kidneysE:(o)esophagusR:rectum

13KEY POINTS IN HISTORYSiteOnsetRadiationNature and characterDurationIntensityPrecipitating and relieving factorsAssociated symptoms

Onset

SuddenUsually occur in perforation of an abdominal viscusRupture / perforation of viscous

Most common organ that perforate:AppendixStomach and duodenum (from PUD)Colon (from diverticular ds or severe constipation)

The gastrointestinal system also contains faeces, air and a high concentration of organisms. Trauma and ischaemia may cause perforation, leak of contents and peritonitis.GradualUsually involves intra abdominal inflammatory conditionsCholecystitis, Appendicitis, Diverticulitis, pancreatitis, mesenteric adenitis, pelvic inflammatory disease

The pain very non specific, gradually increasing in intensity over a period of several hours or even daysRadiationPain radiated to the back (pancreatitis)Pain initially at umbilical area then radiated to the RIF (appendicitis)Loin pain then radiating to ipsilateral iliac fossa and genitalia (ureteric colic)

Nature and character

Colicky painOccur in obstruction of all viscera except gallbladerIntermittent severe pain with pain free interval (resolves between short lived episodes)

Central colicky abdominal pain is a classical presentation of small bowel obstruction. The central distribution is because of the segmental nerve supply of the mid-gut.

The pain reaches a crescendo and then disappears in minutes when the peristaltic wave passesBiliary colicBiliary colic: obstruction of gall bladderContinous type of painPunctuated by acute exacerbation

Pain of biliary colic is insidious in onset, reaches the peak in half an hour or so and does not ease off completely between spasmsBurningSuggest PUD, GERDDull achingPancreatitisStabbingAbdominal aneurysmPleuriticIntensified by breathingSuggest lung/cardiac causesAggravating/relieving factorsPain made worse by moving and coughing: suggest peritoneal inflammation

Patients rolls around with painTypical of colic (suggest obstruction of viscus)Leaning forward may relieve the pain arising from retroperitoneal structuresRelieved by eating : suggest peptic ulcerASSOCIATED SYMPTOMSFeverIn cholangitis, hepatitis,liver abscessPyogenic: low grade Amoebic: high grade

In appendicitis: low grade feverPyelonephritisCystitisVomitingAcute appendicitis: vomiting follows abdominal painUsually ass. with nausea

Intestinal obstruction:Repeated vomiting of large amount early in high GI obstruction and late in low GI obstruction

ConstipationAbsolute (no faeces or flatus): complete bowel obstructionMore obvious in the initial phase of large bowel obstruction than in small bowel obstructionRisk factor for diverticulitis

History of melena/hematemesis

Urinary symptoms: Micturition (strangury)Painful and frequent attempts at micturition passing only small quantity each timeUTI symptomsIn bladder/ureteric stone or pelvic appendicitisCystitisOTHER HISTORIESPersonal histories:Alcohol intake/smoking (pancreatitis)Dietary intake which is fatty food (gallstone ds)In females, menstrual histories important to rule out ectopic pregnancyHigh risk behaviour

Drug history:NSAIDS leading to peptic ulcerOpiates causing constipation

Past history:Previous abdominal surgery: adhesion (intestinal obstruction)Hx of peptic ulcer: possible of perforation/recurrencediagnosis of a perforated peptic ulcer is supported by a past history of ulcer-type pain followed by sudden onset of upper abdominal pain

Family history:For carcinoma and inflammatory bowel diseaseI GET SMASHED(PANCREATITIS)IIdiopathic

GGallstoneEEthanolTtraumaSSteriodsMMUMPSAAutoimmuneSScorpion/SnakeHHyperlipidemiaEERCPDDrugsPHYSICAL EXAMINATIONGeneral examination:Pallor: due to intra-abdominal bleedingJaundice: CBD obstructionDehydrated: peritonitis, Small bowel obstructionRestless: colicky painMotionless: peritonitis (movement exacerbates pain)Leaning forward: suggest pancreatitisABDOMINAL EXAMINATIONGeneral inspection:See if the abdominal wall moves with respiration.If only the thorax moves: peritonitisLook for abdominal distension: suggest for intestinal obstruction, ascites or large intra abdominal tumourExpansile pulsation: abdominal aneurysmVisible peristalsis: in a thin/malnourished patient with obstructionPalpation:OrganomegalyTenderness according to the regionGuarding: contraction of the abdominal wall muscle over the area of painRebound tenderness Suggest peritoneal inflammationBoard like rigidity (abdominal wall rigid/tense all over)Suggest generalised peritonitis

Tender hepatomegaly: hepatitisLocalised tenderness + rebound tenderness + guardingappendicitisIn female patient:If mass palpable and unable to get, must be arising from the pelvis. If the mass can be moved in a transverse direction, then it is likely to be an uterine or ovarian mass Twisted ovarian cyst: presented with acute abdominal painPercussion:Intra abdominal fluid (ascites)Intra abdominal gas (intestinal obstruction/perforation)Obliteration of liver dullness: cardinal sign of free gas in the peritoneal cavity Air leaking from the bowel gets trapped between the liver and abdominal wall: loss of hepatic dullness, a physical sign that supports the diagnosis of perforation of a hollow viscus. Auscultation:Bowel soundsGurgling and high pitched (obstruction)Absent (peritonitis/ileus)

Abdominal bruit (vascular)

SPECIFIC SIGNSSignsDescriptionPathologyCourvoisierPalpable gall bladder and jaundiceCarcinoma of head of pancreasCullenPeri umbilical bruisingSevere acute pancreatitis, ruptured ectopic pregnancy or trauma to the liver.

blood tracks to the umbilicus along the ligamentum teresGrey turnerBruising of flankretroperitoneal haemorrhagesevere acute pancreatitis leaking abdominal aortic aneurysmRovsingRight lower quadrant pain with palpation with palpation of left quadrant painAppendicitisMcBurneyTenderness located 2/3 distance from ASIS to umbilicusAppendicitisMurphyRight upper quadrant tenderness exacerbated by inspirationAcute cholecystitisKehrSevere left shoulder painSplenic ruptureRupture ectopic pregnacyBLOOD TESTFBC: HB : anemiaTWC: leucocytosis (inflammatory), PLT : evidence of sepsis

BUSE Evidence of dehydrationVomiting and diarrhea can cause electrolyte imbalanceLFTSuspect hepatobiliary disordersHepatitis: high bilirubin and transaminase Obstructive pathology: high in ALP

AmylaseUseful marker for pancreatitis (3-4x > normal)

PT/APTT/INR: Look for evidence of sepsisacute pancreatitis, Liver ds

GSH/GXM: if planned for operation/GI bleed

Other testUPT: to exclude pregnancy (ectopic pregnancy)Urine FEME/Urine c+s

Urine diastaseCardiac enzyme and ECGIf clinically suggestive of cardiac causeIMAGING Erect CXRSub phrenic gas: sign of intestinal perforationConsolidation

AXR supineDilated bowel due to intestinal obstruction stones in the kidney (90% cases) or gallbladder (10% cases)

not diagnostic of acute pancreatitis, but are useful in the differential diagnosis. Non-specific findings in pancreatitis include a generalised or local ileus (sentinel loop), a colon cut-off sign and a renal halo

Occasionally, calcified gallstones or pancreatic calcification may be seen. A chest radiograph may show a pleural effusion and, in severe cases, a diffuse alveolar interstitial shadowing may suggest acute respiratory distress syndrome

Abdominal USGold standard ix for hepato biliary disorders. It can demonstrate biliary calculi, the size of the gall bladder, the thickness of the gall bladder wall, the presence of inflammation around the gall bladder, the presence of stones within the biliary tree

Ultrasound does not establish a diagnosis of acute pancreatitis. The swollen pancreas may be seen, but ultrasonography should be performed within 24 hours in all patients to detect gallstones as a potential cause, gynae pathology (ectopic pregnancy, twisted ovarian cyst)Urinary pathology (stone, pyelonephritis, pyonephrosis)

CT scan abdomenTo diagnose the cause of intestinal obstructionLook presence of intraabdominal mass

CTis not necessary for all patients, particularly those deemed to have a mild attack on prognostic criteria.

Flexible endoscopeFlexible endoscopy is the gold standard investigation of the upper gastrointestinal tract.