ACUTE ABDOMEN Begashaw M ACUTE ABDOMEN Denotes any
ACUTE ABDOMEN Begashaw M
ACUTE ABDOMEN Ø Denotes any sudden condition with chief manifestation of pain of recent onset in the abdominal area which may require urgent surgical intervention
Sites of referred pain
Sites of Abdominal Pain
CLASSIFICATION Ø Ø Ø Obstruction Inflammation Hemorrhage Infarction perforation
CLINICAL FEATURES Symptoms _Colicky and Intermittent pain ( visceral) _Continuous pain ( somatic) _Vomiting _Fever _Tachycardia l Colic pain obstruction l Continuous pain infection, inflammation or ischemia Ø
Signs Abdominal distention, visible peristalsis Ø Direct and rebound tenderness, guarding Ø Anemia, hypotension Ø Toxic with Hippocratic faces Ø Absence of bowel sound ( peritonitis) Ø Psoas sign appendicitis Ø Murphy‘s sign acute cholecystitis Ø Dehydration sunken eyeballs Ø
DIFFERENTIAL DIAGNOSIS Surgical - Intestinal obstruction Ø Gynecologic & obstetric - Ectopic ruptured pregnancy Ø Medical - enteritis Ø
Surgical causes A- Inflammation Acute appendicitis Acute cholecystitis B- Obstruction Intestinal obstruction C- Infarction Mesenteric ischemia D-Strangulation volvulus E- Perforation perforated peptic ulcer
DIAGNOSIS l Clinical: Hx & p/E l Lab: CBC, cross match, urine analysis, serum amylase & electrolytes l Ultrasound l plain film of abdomen
MANAGEMENT A-Preoperative - Resuscitation with IV fluids - Antibiotics - Catheterization & NGT insertion - Analgesics after confirming the diagnosis B- Surgery Definitive laparotomy C Monitoring Follow up
INTESTINAL OBSTRUCTION Ø is partial or complete blockage of the intestine producing symptoms _Vomiting _Constipation _Distension _Abdominal pain
Causes of mechanical intestinal 0 bstruction
Intestinal Obstruction
CLASSIFICATION physical barrier blocks l Paralytic ileus disordered propulsive motility l High _Small bowel l Low _Large bowel l Simple -> adequate blood supply l Strangulated -> Mesenteric vessels occluded l Mechanical
Mechanical A- Luminal _Gallstone Ileus _Food bolus _Meconium Ileus _Malignancy _Inflammatory mass _Ascaris bolus B- Mural _Stricture _Congenital _Inflammatory _Ischemic _Neoplastic _Intussusception
Intussusception
C- Extra mural l Adhesions inflammatory/malignant l Hernia External/internal l Volvulus Small bowel large bowel -> Sigmoid volvulus
Small bowel obstruction
Adhesion
PATHOPHYSIOLGY dilatation disrupts peristalsis Ø Above the obstruction distended with fluid and gas Ø stimulates excessive peristalsis ->colicky pain Ø blood vessels-stretched & narrowed ischemia Ø Absorptive capacity decreases Ø increased vomiting depletion of extra cellular fluid hypovolemia & dehydration Ø Proximal
Pathophysiology
l. A strangulated loop dies and perforates to produce severe bacterial peritonitis which is often fatal l Grossly distended abdomen restricts diaphragmatic movement and interferes with respiration l A multiple organ failure
Clinical features Symptoms -Abdominal pain-colic -Vomiting -Constipatio-partial -absolute Ø Signs -Abdominal distension visible bowel loops -High pitched bowel sounds -Tenderness & guarding -Dehydration & hypotension -Empty rectum DRE Large bowel obstruction Ø
DIAGNOSIS Clinical: Hx & P/E Ø Lab: CBC, electrolytes Ø Plain abdominal film : - distension of bowel with air fluid level - Central located distended loops with multiple air fluid level small bowel - Peripherally located distended bowel with haustral marks Large bowel Ø
X-ray of intestinal obstruction
MANAGEMENT l Fluids resuscitation to restore the circulatory state l Early preoperative preparation l Attempt rectal tube deflation-simple sigmoid volvulus l Supportive measures l Early operation Laparotomy l Post operative care
NG tube suction
SIGMOID VOLVULUS Ø Sigmoid colon is the most frequent site of volvulus Ø Predisposing factors - A long redundant sigmoid with a narrow pedicle - High fiber diet - Chronic constipation_elderly _chronic mental pts
Sigmoid volvulus
PATHOPHYSIOLOGY Redundant sigmoid twists on its base in a clockwise direction l Mesocolic veins become occluded & arterial inflow into the twisted loop perpetuates the volvulus until it becomes irreversible l Twisted loop distends grossly l Perforation may occur due to either pressure necrosis at the base of the twist or to avascular necrosis at the apex l
DIAGNOSIS CLINICAL _Abdominal cramp & distension _Constipation (early) & vomiting (late) _Empty rectum on DRE Ø RADIOLOGIC FINDINGS l Two long fluid levels in the lower quadrant l Inverted U shape of the sigmoid lumen l “Coffee bean” appearance or the ‘Omega sign” Ø
MANAGEMENT Conservative l simple volvulus deflation with a well greased large bore rectal tube under the guide of a sigmoidoscope l Deflation fails laparotomy & derotation l Elective resection & anastomosis l Intravenous fluid - rehydrate if sign of dehydration Ø
Sigmoidoscopic deflation
Emergency Surgery _Complicated volvulus with signs of peritonitis _Resuscitative measures _Antibiotics _Resection of the gangrenous segment with Hartman’s colostomy Ø
Laparatomy
APPENDICITIS l is an inflammation of the appendix that results from bacterial invasion usually distal to an obstruction of the lumen
Appendix
Pathogenesis Luminal obstruction bacterial overgrowth lnflammation/swelling Increased pressure localized ischemia gangrene/perforation localized abscess (walled off by Omentum) or Peritonitis Ø Etiology: _Hyperplasia of lymphoid follicles _Fecolith, obstructing neoplasm _Parasites, foreign body Ø
CLINICAL PRESENTATION l Symptoms -Central abdominal colic which shifts to the right Iliac fossa -Anorexia, nausea, episodes of vomiting and low grade fever -High grade fever indicates perforation and peritonitis
Signs -Tenderness and localized rigidity in RLQ MC Burney’s point -Rovsing’s sign: Pain in RLQ on pressing in LLQ -Psoas sign: Pain on extension of right flexed hip -Obturator sign: Pain on passive internal or external rotation of the flexed right hip -Right sided tenderness on rectal examination. -Diminished bowel sounds indicating peritonitis
Appendicitis signs
Differential diagnosis IN CHILDREN -Intussusceptions -Mesenteric adenitis Ø FEMALE -PID -Twisted ovarian cyst( torsion) - ruptured ovarian follicle Ø GENERAL -Acute chlolecystitis -Perforated PUD -Renal or ureteric calculi -UTI -Early small bowel obstruction (volvulus) -Gastroenteritis Ø
Investigations Ø Labs l leukocytosis with left shift l beta-h. CG to rule out ectopic pregnancy l Urinalysis Ø Imaging: l Upright CXR, AXR-free air l Ultrasound: may visualize appendix
MANAGEMENT PREOPERATIVE -Resuscitation with fluids -Appropriate antibiotics (combination for coverage of gram positive, gram negative and anaerobes) -Correct all deficits ( dehydration) Ø SURGERY -Surgical removal of the appendix is the definitive treatment-Appendectomy Ø
COMPLICATIONS l Perforation - local or generalized peritonitis l Appendiceal mass and abscess formation l Death
APPEDECIAL MASS Inflammatory process walled off in the right iliac fossa by omentum and loops of bowel to form a mass l Management-Conservative -antibiotics -fluids _Drug of choice- metronidazole and ceftriaxone Ampicilline, Chloramphenicol & Gentamycin l
Follow up -Vital signs every 4 hourly -Mass size & consistency 12 hourly -Patient’s condition -Laboratory every other day Ø Interval appendectomy 6 weeks later
Appendiceal abscess l Increasing mass size l Fluctuation l persistence of systemic signs l Management - drainage of the abscess and appendectomy l Interval appendectomy after emergency drainage
Draining appendeceal abscess
PERITONITIS l is an inflammation of the peritoneum l is an acute life threatening condition caused by bacterial or chemical contamination of the peritoneal cavity
Peritoneum
Peritoneal abscess
Differential diagnosis l l l Perforated appendix Perforated PUD Anastomotic leak Strangulated bowel Pancreatitis Cholecystitis l Intra abdominal abscess l Typhoid perforation l Ascending infection e. g salpingitis l
CLASSIFICATION l Primary peritonitis: caused by bacterial spread via the blood stream l Secondary peritonitis: caused during perforation or rupture of abdominal organ allowing access of bacteria and irritant digestive Juices to the peritoneum
Classification l Acute peritonitis: rapid onset or brief duration l Chronic peritonitis: long duration l Localized peritonitis - confined to a limited space - pelvis l Generalized peritonitis - whole peritoneal cavity involved
ROUTES OF BACTERIAL INVASION 1 - Direct- contamination via perforation, a penetrating wound or during surgery 2 -Local Extension: contamination by migration from an infected organ - through gut wall, via the fallopian tube 3 -Blood stream: via the blood as consequence of general septicemia
CLINICAL FEATURES Sharp pain which is worse on movement Fever & tachycardia Abdominal distension Tenderness & guarding Diminished or absent bowel sounds Shoulder pain _referred pain -diaphragmatic irritation l Tenderness on rectal examination (pelvic peritonitis) l Abdominal distension & vomiting l l l
Generalized peritonitis
MANAGEMENT Resuscitation: intravenous fluids l Analgesia l Naso-gastric tube insertion (NGT) l Triple antibiotics (ampicilline , gentamycin and metornidazole or chloramphenicol) l Monitoring in put & out put by catheterization l Surgery l Drainage & peritoneal lavage l
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