acute abdomen approach to managment-hazem
DESCRIPTION
Approach to initial assessment; resusscitation; and managment of acute abdominal painTRANSCRIPT
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ACUTE ABDOMENMANAGEMENT APPROACH
DR.M.HAZEM EL-FOLLFRCS-(UK)
Consultant General and Laparoscopic Surgery
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Acute AbdomenDefinition And Epidemiology
Undiagnosed Abdominal Pain of less than 7-10 days
duration.
Abdomino-thoracic Trauma is excluded from this
definition.
It accounts for 5-10% of ER visits
It accounts for 1% of all hospital admission.
Most Patients-(70-75%) Discharged after ER
Evaluation.
Only 7-10% of Patients will Require Urgent Surgery
for Life-Threatening Conditions.
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SURGICAL CAUSES—SURGICAL ABDOMEN
MEDICAL CAUSES---NON-SURGICAL
ABDOMEN
Acute Abdominal pain
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Etio-Pathological Classification:-
Inflammatory/Infective
• Acute Cholecystitis
• Liver Abscess
• Acute Pancreatitis
• Inflammatory Bowel Disease
• Acute Appendicitis
• Acute Diverticulitis
• Meckle's Diverticulitis
• PID-(Salpingitis)/Tubo-ovarian abscess.
• UTI-Acute Pyelonephritis/Acute Cystitis
Perforation
• Perforated Peptic Ulcer Disease
• Perforated Appendicitis/Cholecystitis
• Perforated Small Bowel
• Esophageal Perforation
• Perforated Colon
• Aortic Dissection
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Etio-Pathological Classification
Obstruction Infarction Thrombo-embolic
diseases• Acute Intestinal
Ischemia• Renal Infarction• Splenic Infarction GIT-Volvulus Omental Torsion Intussusception Torsion ovarian
cyst/sub-serous fibroid
Intestinal Obstruction
Biliary Colic
Renal Colic
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Etio-Pathological ClassificationSpontaneous intra-peritoneal bleeding
Rupture AAA.Rupture visceral A.Aneurysms in
mesenteric; hepatic and renal arteries.Rupture pathologically enlarged spleenRupture Hepatic Tumor.Gynecological causes:-• Ruptured Ectopic pregnancy• Ruptured Ovarian Cyst• Ruptured Graffian's follicles( mid-cycle)• Ruptured Endometriosis.
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Medial Causes of Acute Abdominal PainNon-Surgical Abdomen
Intra-Abdominal Conditions
• Gastro-Enteritis.
• Infective Colitis
• Mesenteric Adenitis
• Typhoid Fever
• UTI
• Acute Viral Hepatitis
• Congestive Hepatomegaly
• Liver Tumors
Intra-Thoracic Conditions
• MI
• Basal Lobar Pneumonia
and Lung Abscess
• Pericarditis.
• Spontaneous
Pneumothorax.
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Non-Surgical Abdomen
Metabolic Causes
• D-Ketoacidosis• Uremia• Adreno-cortical
Insufficiency• Hypercalcemia• Acute Intermittent
Porphyria.• Heavy Metals
Poisoning
Haematological Diseases
• Haemolytic Crisis of Chronic Haemolytic Anaemia.
• Polycythemia.• Henoch- Schonelein
Purpura.• Lymphoma.• Leukemia.
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Non-Surgical Abdomen
Neurological Causes Herpes Zoster-
commonly involving spinal nerves T3-L1.
Spinal cord Compression:-
• Degenerative-Disc Prolapse.
• Metastases. Nerve Entrapment:-• 2-3 localised areas just
medial to linea semilunaris of rectus muscle.
Collagen Diseases SLE.
Polyarteritis Nodosa.
• Abdominal Pain caused by thrombosis of visceral arteries lead to Visceral infarction.
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Management Approach
• (I)-Clinical Evaluation:
• Accurate History and Complete Physical
Examination are Essential for Diagnosis
• (II)-Resuscitation and Immediate Diagnostic Tools.
• (III)-Other Investigations-according to clinical
progress of the patient.
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History taking
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Abdominal pain
Onset; Progression of pain
Duration.
Site of pain: at onset, at present.
Severity.
• Type: intermittent colicky, sharp persistent
Radiation of Pain
Aggravating factors: movement, coughing, food
Relieving factors: position, drug, food
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Physiology of Pain-Visceral Pain
• Elicited by distention ;
inflammation of the serous
coat of hollow viscera and
in the capsules of solid
organs.
• Mediated by afferent
autonomic nerve fibres.
• Diffuse; felt in the midline
in regions related to the
embryological
development.
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Somatic(Parietal)Pain
• Elicited by direct
irritation/inflammation of
the somatically innervated
parietal peritoneum.
• Mediated by afferent
somatic nerve fibres.
• localised in the
dermatomes supplied by
segmental nerve roots
innervating the parietal
peritoneum.
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Referred Pain
• Pain Sensations perceived
at a site distant from that
of a strong primary
stimulus.
• Due to Confluence of
afferent nerve fibers from
widely disparate areas
within the posterior horn
of the spinal cord. This
may cause distorted
central perception of the
site of pain.
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In Most causes of Surgical Abdominal pain
• There is insidious onset of pain started diffuse;
dull ach/or gripping pain. In hollow viscus
obstruction; the pain is sever gripping associated
with nausea; vomiting; and sweating; causing the
patient to move around in bed and inability to lie
still. There is no aggravating of relieving factors.
• In Early Inflammatory Processes of Solid Viscera;
there is diffuse dull ache pain
Visceral pain.
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Progression of pain-In Inflammatory and Obstructed Causes
• There is progression of pain over several hours;
and change character of pain into sharp localised
stabbing pain. The pain is aggevated by moving;
coughing and relieved by lying still.
Somatic Pain
• There will be associated Abdominal localised
tenderness; rebound; and involuntary muscle
guarding. (Localised Peritonitis.)
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In perforation; Strangulation(Infarction);and Spontaneous Bleeding
• The pain is sudden in onset with progression over
minutes to 1-2 hours; into sharp localised
stabbing pain. There will be Localised (Early) / or
Generalised Abdominal tenderness; rebound and
rigidity.
• Shoulder tip and sub-scapular pain; is common
due to blood/or pus in sub-phrenic space.
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In Most of Non-Surgical causes of Abdominal Pain
• There will be Diffuse mild dull-ach/or vague
discomfort.
• Vomiting usually precedes the onset of
pain; especially in metabolic causes.
• There will be Diffuse; non-specific
abdominal tenderness. However there will
be NO Rebound tenderness and NO Muscle
Guarding.
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Associated symptoms
• Nausea and vomiting
• Indigestion
• Anorexia and weight loss
• Bowel habit
• Urinary Symptoms
• Gynecological Symptoms
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Menstrual History-in women in Reproductive age
• Sexual Activity and IUD
• Amenorrhea(Missed period)
• Vaginal Bleeding
• Vaginal Discharge
• Mid-Cycle
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Medical History
• Medical Diseases; HTN ; CAD ; AF ; Vascular
Diseases ;Pulmonary Diseases.
• Previous Surgery.
• Current Medications.
• Alcohol and Smoking.
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Physical examination
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General Examination
• Vital Signs: Pulse ; Temp.; BP.
• Pallor ; Jaundice ; Cyanosis.
• Tongue:-Dry ; Coated ; acetone smell.
• Examination of Cervical LNs.
• Examination of Chest and Heart.
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Abdominal Examination General Inspection
• Patient is agitated; the patient moves around in
bed and inability to lie still.= visceral pain.
In hollow viscus obstruction and Strangulation
• Patient is lying motionless in bed=Parietal pain
In Localised/Generalised Peritonitis.
• Patient is Drowsy with decrease
responsiveness .
Haemodynamic Collapse/Sepsis.
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Abdominal ExaminationInspection
• Patient should be exposed from nipple to mid-
thigh.
• Abdominal Distension.
• Obvious Abdominal Swelling
• Scar ; Fistula ; Sinus.
• Distended Superficial Veins
• Ecchymosis,Cullen”s and Gray-Turner”s Signs
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• Cullen sign Grey-Turner sign
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Palpation and PercussionLight and deep palpation.
Start gently and away from reported area of pain. Palpation with pulp of fingers NOT Tips of fingers.
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Palpation/Percussion
Rebound tenderness = “Peritoneal irritation can
be elicited by:-
Cough tenderness = Percussion tenderness.
Involuntary Muscle guarding=Peritonitis.
Areas of maximum tenderness.
Detect Organomegaly.
Tympanatic Abdomen.= gas in bowel loops.
Shifting dullness in Ascites.
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Auscultation
• High-pitch “tinkling” sound = mechanical
bowel obstruction.
• Hyperactive bowel sounds = Enteritis and
early intestinal ischemia
• No sound within 1-2 min = absent bowel
sounds.
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Do Not Forget
Examination of:-
• Hernial Orifices.
• External Genitalia-Testis and Scrotum.
• Examination of the Back of the patient.
PR and PV Examination.
Dip-stick testing of urine for sugar ;
ketone ; blood ; proteins and pus cells.
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Resuscitation and Immediate Investigations
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Resuscitation
• NPO
• NG-Tube in intestinal obstruction and if there is persistent vomiting.
• IV-Line and Start IV Fluids.
• Analgesia after initial assessment should be given for pain relief.
• Important:-Narcotic analgesia don't mask physical signs or obscure the diagnosis.
• Start broad spectrum IV Antibiotics if Inflammatory Conditions suspected.
• Correction of dehydration and electrolyte imbalance.
• Urinary catheter and monitor the urine output.
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Resuscitation-In Critically Ill-Patients
• Air Way and Oxygen Supplement.
• Oxygen Saturation Monitoring
• ABG
• CV-Line ; Volume Replacement.
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Laboratory studies
• CBC• Electrolytes• Blood urea nitrogen/creatinine• Amylase / lipase• Serum lactate levels• Liver function test• Pregnancy Test-In all Women in child-
bearing age.• Sickling Test• Blood Group and save the serum.• ECG.
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Emergency Abdominal Ultrasonography--:
Detection of acute Cholecystitis; pancreatitis; pancreatic pseudo-cysts; liver abscess Detection of appendicitis/ appendicular abscess; diverticular
abscess; mesenteric cysts; Tubo-ovarian abscess; PID and pelvic abscess.
Useful in pregnant and young female patient (detect pelvic pathology);ovarian cysts ; sub-serous fibroid ;PID.
Diagnosis of suspected AAA. Diagnosis of free intra-peritoneal blood/fluid.
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Contrast-enhanced CT-Scan (oral and IV Contrast)
• It is the secondary imaging modality of
choice in the patient with an acute abdomen,
following plain abdominal radiography; as
images not masked by bowel gas and most
surgeons can interpret the findings more
than US.• CT-Scan establishes the diagnosis of acute
abdominal pain in over 95% of cases.
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Thick-walled,fluid-filled appendix with surrounding inflammation
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Large Appendicular Abscess containing gas.
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Acute Pancreatitis--An enlarged pancreas with indefinite border and infiltration of the surrounding fat-(the peri-pancreatic stranding)
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Pancreatic Necrosis-- Lack of gland enhancement following IV contrast administration is diagnostic.
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Multiple splenic abscess
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CT-IV Contrast-Small Bowel Ischemia due to Strangulation
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After the initial assessment the patients with acute abdominal pain should be categorized into:
(I)Patients with immediately Life Threatening conditions :-
Patients who need immediate Laparotomy
( Abdominal Crises )
(1)—Massive intra-abdominal bleeding; (Ruptured AAA. or visceral
aneurysms, ruptured ectopic pregnancies, and spontaneous hepatic or
splenic ruptures).
(2)—Acute Intestinal Ischemia with hypovolemia and resistant
acidosis.
(3)-Intra-abdominal sepsis; (due to perforated viscus/or strangulation;
volvulus; Intussusception; strangulated hernia ) ; with high fever;
tachypnea; sweating; frank hypotension; deterioration of mental
state(agitation, disorientation); indicating impending septic shock.
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Medical life threatening conditions:-
Myocardial infarction.
Spontaneous tension Pneumothorax.
D-Ketoacidosis .
Acute AD.Cortical Failure.
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(II)– Patients with Rapidly Life Threatening conditions.Patients who need; Urgent laparotomy;(with in 4-6H.)
Perforated hollow viscera.
Strangulated Bowel.
Intra-abdominal Abscesses; (Appendicular; and Diverticular);
with free intra-peritoneal perforation and diffuse peritonitis.
Clinical; Laboratory; and Radiological indicators for Urgent
Laparotomy:-
Increasing severe localized tenderness.
Progressive tense abdominal distention.
Spreading Involuntary muscle Rigidity.
High fever, tachycardia, confusion.
Marked Leukocytosis with left shift.
Pneumoperitoneum
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(III)-Serious conditions:-that need early planned surgery/or need early supportive treatment and
close monitoring
Appendicitis/appendicular abscess; acute
Cholecystitis/peri-cholecystic abscess; acute
pancreatitis.
Diverticulitis/Diverticular abscess; PID /Tubo-
ovarian abscess; Localised intra-abdominal or
Pelvic abscess.
Small bowel obstruction.
Large bowel obstruction due to: diverticular abscess/ carcinoma
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(IV-)Less serious conditions which require conservative treatment
Biliary colic; renal colic.
Inflammatory bowel disease.
Non-specific abdominal pain.
Gastro-enteritis and infective colitis.
UTI.
Un-complicated ovarian cyst and fibroid; and
endometriosis. Mid-ovulatory pain.
Un-complicated Diverticulitis.
Most of Medical causes.
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Differential Diagnosis
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Differential Diagnosis of patients with Acute Abdominal Pain
Each List Represents > 90-95% of Causes in each Group)
Infants less than one year old
• Infantile Colic.
• Gastro-enteritis.
• Intussusception.
• Incarcerated congenital
hernia
• Constipation.
• UT-Infection.
• Hirschsprung disease.
• Volvulus neonatorum
Children 1-5 years old
Appendicitis.
Non-specific abdominal pain
Intussusception.
Incarcerated congenital
hernia
Gastro-enteritis
UT-Infection
Constipation
Sickle cell crisis
Henoch scheneloin Purpura
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Differential Diagnosis of patients with Acute Abdominal Pain
Young and middle age Adult• Appendicitis.
• Acute Cholecystitis.
• Acute Pancreatitis.
• Non-specific abdominal pain.
• Intestinal obstruction.
• Active/Perforated PU.
• UTI.
• Diverticulitis.
• Renal colic
Young and middle age Women• Salpingitis-PID.
• Appendicitis.
• Acute Cholecystitis.
• Acute Pancreatitis.
• Rupture ectopic pregnancy
• Rupture/Torsion Ovarian cyst.
• Mid-ovulatory Pain.
• UTI.
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Suppruative Appendicitis
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Meckle's Diverticulum
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Volvulus of Meckle's Diverticulum
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Torsion Ovarian Cyst
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Acute Cholecystitis
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Sigmoid Volvulus.
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Acute Abdominal Pain in Elderly Patients
In Elderly patients >60 years old; after exclusion of the commonest causes of Acute Abdominal Pain; as:-
Acute Cholecystitis ' Acute Pancreatitis; Acute Appendicitis; the patients should be investigated as; they may have colonic obstruction/ perforation due to Colo-rectal carcinoma; diverticular abscess
In patients >70 years old; 10% of patients with Acute Abdominal Pain will have Vascular Accident; Acute Intestinal Ischemia; or MI.
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Messages
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Accurate History and complete clinical Examination are essential
to put provisional diagnosis/or short list of DD; and to institute
diagnostic tests and to decide if the patient will need urgent
surgery.
It is NOT Important to make specific diagnosis but to detect
Urgent and immediate Life-Threatening conditions.
The diagnosis of acute abdominal pain; particularly in early
stage of presentation is often difficult and is accurate only in 45-
65% of patients. So the patient should be re-examined by the
same physician after resuscitation.
Define Surgical from non-surgical Abdomen. The term Acute
Abdomen should never equate with the invariable need for
surgery.
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Analgesia-Make the patient pain-free.
Opioids as (Morphine and Pethidine) don't mask the
physical signs or prevent accurate diagnosis.
The most common surgical diagnosis: -- acute
appendicitis, followed by acute Cholecystitis, small bowel
obstruction, and gynecologic disorders.
A useful rule is never to place appendicitis lower than
second in the differential diagnosis of acute abdominal
pain in a previously healthy person.
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Indications of Surgical Consultation:-
(A.)-Severe Progressive Abdominal Pain.
(B.)-Involuntary Abdominal Muscles Guarding/Rigidity.
(C.)-Bile-stained or Faeculent Vomiting.
(D.)-Haemodynamically Instability(Fluid/Blood Loss)-
Signs of hypoperfusion as un-explained acidosis.
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