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Approach to acute abdomen
Supervised by ,
Dr.B.Faki
Presented by, Eman Al.harbi
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Introduction
defined as any clinical condition
characterized by severe abdominal pain
which develops over a period of 8 hrs.
In pt who have been previously well.
rapid and accurate diagnosis is essential for
morbidity and mortality process.
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Pathophsiology
Visceralpain; due to stimulation of visceral
afferent nerve plexus usually in midline
result from contraction or distension
against resistance & chemical irritation
usually colicky in nature.
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Pathophsiology
Parietalpain; 2dry to partial peritoneum
irritation perceived through segmental
somatic fibers reflex involuntary muscle
wall rigidity may result from irritation ofsegmental sensory nerves.
Hyperesthesia of the skin may be result
from ipsilateral peritoneal irritation usuallya sharp ache.
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Abdomen
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Epidemiology
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Abdominal quadrant
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Causes
Gastrointestinal tract*
Acute appendicitis
Meckls diverticulitis
bowelPerforated
ulcer Perforated pepticobstruction Small and large bowelherniaStrangulatedDiverticulitisGastritisGastroenteritisInflammatory bowel diseaselymphadinitis Mesenteric
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spleen. and, liverBiliaryTractsCholangiti acute Cholecystitis acuteHepatic abscess
tumor Ruptured hepaticspleen Rupturedbiliary colic, Hepatitis acute infarct Splenic
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PeritoneumIntra-abdominal abscess*Primary peritonitisTuberculosis peritonitis
PancreasPancreatitis, acuteca pancreases
UrinaryTractCystitis acute
Pyelonephritis acuteRenal infarctteral colicUre
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Gynecological;
ruptured ectopic pregnancy
Ruptured ovarian follicular cyst
Twisted ovarian tumorDysmenorrheal
Endometriosis
acute salpingitis.PIDs
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Male reproductive tract.
Prostatitis
Cystitis
Torsion of testes Vascular causes
Acute ischemic colitis .Mesenteric thrombosis*Ruptured arterial aneurysm*
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Medical causes
Pneumonia.
Myocardial infarction
Sickle cell crisis.
DKA
Leukemia
Herpes zoster
psychogenic
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Approach to acute abdomen
History.
1. pain
2. Associated symptoms, nausea, vomiting,Change of bowel habitus, jaundice,
anorexia,
Heamatemsis, melena, dyspepsia3.Menstruatin & sexual history.
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Cont..
4.ROS
5.past medical & surgical hx
6.hx /o medications
7.familay Hx
8.social Hx
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Eg
Acuteappendicitis,
constant ,progressive more severe start
per umbilical move toward RIF.+ nausea,
vomiting, low grade fever, anorexia &/orconstipation.
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Inflamed appendix
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Acute cholecytitis
Constant moderate pain in RUQ radiated
to Rt shoulder tip + nausea, bilious
vomitus, low grade fever & jundice
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Perforated peptic ulcer,
Sudden onset of pain in midepigastrium
that spreads and is aggravated by
movement; patient appears acutely ill and
is reluctant to move; rigid abdomen;
grunting respiration; bowel sounds absent
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Ectopic pregnancy,
Pain sudden, severe,persistent,following a
missed or abnormal period, typically epigastric;
associated with hypotension and tachycardia Ovariancyst
Pain constant with sharp, sudden onset, usually
in ipsilateral hypogastrium; may have nausea
and vomiting following the pain.
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Pelvic inflammatory disease.
Pain at end of or after normal menstrual
period, bilateral lower quadrant pain
aggravated by cervical manipulation;
anorexia, nausea, and vomiting rare;
possible cervical discharge; fever
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Urinarystone,
Pain location changes with movement of
stone, may radiate to testicle, groin of
involved side, pain very severe; patient
cannot get comfortable
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Physical examination
1.general appearance,
2. Vital signs.
3.abdomial exam
4.rectal exam
5.pelvic exam (female pt)
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?
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investigation
1.CBCs,
WBCs & differential.
RBC & hct, degree of anemia & hemocon.
Platelet count, evidence of cougalopathy.
2.electrolyte,
(G, Na, K, Cl, Ca ,Mg, Po) Indicative of volume status, GIT loss,
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.
3.ABG,
Indicate metabolic acidosis or alklosis.
M.acidosis with generalized abdominal
pain in elderly is ischemic colitis till proven
other wise.
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.
4.liver function test
Bilirubin (D or ID), ALP elevation in biliaryobstruction & transaminase elevation in
case of hepatocellular injury.5.RFT
Urea, creatinin elevation in renal
insufficiencySerum albumin decrease in edema /
ascitis.
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.
6. serum amylase
Seen in pancreatitis although non specific
may be elevated in mesenteric ischemia,
perforated peptic ulcer, rupture ovarian
cyst & renal failure. But lipase more
sensitive.
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.
7.serum B_HCG
Mandatory for all women in childbearing
period.
8.urinalysis
See WBC RBC & casts.
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Radiologicalevaluation
1.CXR,
Look for pneumonia, free gases under
diaphragm .pleural effusion suggest sub
diaphragmatic inflammatory process.
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.
2.abdominal Xray.
(Erect & supine position )
* bowel distension & air fluid level
*bowel gas cut off vs air through rectum.
*sentinel loop vs pancreatitis
*abn calcification vs ch.pancreatitis,stone*pnumatosis vs omnious sign of dead gut.
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Intestinal obstruction
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.
3.ultrasound,
*hepatobiliray tree(stones,mass,thickining
of the wall)
*pancreases
*kidney
*pelvic organ
*intrabdominal fluid collection
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Gallstone\ appendicolith
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.
4.CT_scan
Helpful in case of abdominal pain without
clear etiology better in evaluation of
abdominal oartic aneurysm.
5.helical CT_scan
Provide rapid cost effictive dignostic tool.
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Acute pancreatitis\dilated loop
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.
5.contrast study
A. barium study
*perforation,
*discering point of obstruction in small
bowel.
*avoid if colonic diverticuilitis is suspected
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Multiple stones in CBD
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.
B_ intravenous pyelogram
For dignosis of ureteral stone or obstuction
C_angiography
For mesenteric ischemia
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angiograph
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Other study
6.endoscopy,
EGE, for evaluation epigastric pain in non
acute setting.& git bleeding
Sigmoid\colonoscopy
*colonic obstruction
*dig IBD,ischimic colitis lower bleeding,
*nonstrangulated sigmidal volvulus
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ERCP
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.
7.paracentesis &\or peritoneal lavage
*spontaneous bacterial peritonitis in
cirrhotic pt
*peritoneal lavage may be useful bedside
test in diagnosis of mesenteric infarction in
critically ill pt.
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.
8.culdocentesis
Valuable in diagnosis of rupture ectopic
pregnancy.
9.laproscopy
*D & ttt of suspected gynec.cause
*appendectomy if appendicitis is found in awomen in childbearing period.
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laparoscopy
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Planoftreatment
*promote timely work up in first 4_6hrs.
*keep pt Npo till the diagnosis is firm & ttt
plan is formulated.
*IV fluid. based in expected fluid loss.
*heamodynamic monitoring.
*NGT bleeding ,vomiting ,sign ofobstruction or when urgent laparoscopy is
planned in pt not NPo.
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.
Foley catheter to monitor fluid out put
decisions
Immediate surgery
* what is the timing of operative
intervention( does pt need time for
resuscitation)
*what incision should be used?
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.
* what are the likely findings?
*develop primary operative plan.
* consider alternative diagnosis & plan.
* use appropriate pre-operative antibiotic
based on suspected pathology.
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.
2. admit & observe for possible operation.
*serial examination every 2-4 hrs duringthe first 12-24 hrs in case without definite
diagnosis; minimal use of narcotics &sedatives to avoid masking physical sign &symptoms.
*monitor vital signs frequently
*serial lab exam may be useful ;repeatCBC every 4-6hrs.
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.
3.no operation develop ttt plan for further
diagnostic workup or non operative
therapy.
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Case
36yrs old female pt status postoraticvalvereplacement who present with one week
hx of acute abdominal pain becoming
severe over last 24hrsO\E tachycardia, PR=145\min, B.P=100\45
temp=38. abd. Distended , rigidwith
moderate tenderness.wbc=23. amy=200LDH=1500.
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.
What is mostly like diagnosis?
What is the investigation of choice?
Management plane?
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.
Thanks
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