Acute abdomen Dr Szathmri Mikls Semmelweis University First

Acute abdomen Dr. Szathmári Miklós Semmelweis University First Department of Medicine 29. nov. 2011.

The definition of acute abdomen • Life-threatening condition due to acute onset abdominal disease with typical symptoms and physical findings, which reqiures: – Prompt surgical intervention • • • Acute appendicitis Acute peritonitis Acute intestinal obstruction Acute mesenteric vascular insufficiency Rupture of the spleen, extrauterin gravidity, dissection of aortic aneurysm – Emergent admission to a monitored bed or intensive care unit • Acute pancreatitis • Acute cholecystitis • Purpura abdominalis

Physical findings in acute abdomen syndrome • Abdominal pain – The medication can influence. In case of shock the pain might be diminished • Vomiting – Mostly in cases of obstruction of intestine • Involuntary muscular rigidity – Inflammation(irritation) of parietal peritoneum • Distension – As a consequence of mechanic or paralytic ileus • Shock – Hypotension, sweating, pallor, tachycardy. In case of shock sometimes bradycardy because of the vagal (parasympathic) activation

Acute appendicitis • Pathogenesis: – Acute appendicitis occurs as a result of appendiceal luminal obstruction • Most commonly caused by a fecalith, or enlarged lymphoid follicles associated with a viral infection, or infection with Yersinia organisms • Clinical manifestations: – Pathognomic sequence od abdominal discomfort and anorexia • Periumbilical „visceral type” pain • Localized parietal pain according to the location of appendix – Anorexia is very common. Hungry patient does not have acute appendicitis – Nausea and vomiting in appr. 50 -60% of cases – Normal or slightly elevated temperature – Distension is rare unless severe diffuse peritonitis has developed – A mass may develop if localized perforation has occured. Perforation is rare before 24 h after the onset of symptoms, but the rate may be as high as 80% after 48 h.

Physical findings of acute appendicitis • Physical findings in acute appendicitis: – Typically, tenderness to palpation will occur at Mc. Burney’s point: located on a line one-third of the way between anterior iliac spine and the umbilicus (abdominal tenderness may be completely absent if a retrocecal or pelvic appendix is present) – Right-sided rectal tenderness (not specific) – Rebound tenderness: pain in the right lower quadrant during left-sided pressure (Rovsing’s sign) – Psoas sign: place your hand just above the patient’s right knee and ask the patient to raise thigh against your hand. Increased abdominal pain during the maneuver suggests irritation of the psoas muscle by an inflamed appendix. – Hyperaesthesia of the skin of the right lower quadrant • Diagnostic difficulties are mostly in infants, in elderly, and pregnants (appendititis occurs about one in every 500 -2000 pregnancies). – The diagnosis may be missed or delayed because of gradual shift of appendix from the right lower to the right upper quadrant during the pregnancy • Diagnosis: abdominal ultrasound, CT (positive predictive value of CT is 95 -97%)

Acute peritonitis • Pathogenesis: – Most often infectious and is usually related to a perforated viscus (secondary peritonitis) • Perforations of bowel (appendicitis, peptic ulcer disease, neoplasms, volvulus, ischemia, ingested foreign body, etc. ) • Perforations or leaking of other organs (pancreatitis, acute cholecystitis, urinary bladder rupture, etc. ) • Disruption of integrity of peritoneal cavity (trauma, peritoneal dialysis, perinephric abscess, etc. ) – When no intraabdominal source is identified, the infectious peritonitis is called primary or spontaneous peritonitis • Usually in patients with liver cirrhosis and ascites • Clinical manifestations: – Acute abdominal pain and tenderness, usually with fever. The location of the pain depends on the underlying cause and whether the inflammation is localized or generalized • Localized peritonitis is most common in uncomplicated appendicitis and diverticulitis – – – Distension of intestinal lumen with gas and fluid Boardlike muscular rigidity in cases of diffuse peritonitis Bowel sounds are usually absent Disappearance of liver span Tachycardy, hypotension, and signs of dehydration

Free air under the diaphragma P-A X-ray: Discoid shape free air under the diaphragma on both sides.

Acute intestinal obstruction • Etiology: – In 75% of patients, it results from previous abdominal surgery to adhesive bands or internal or external hernias. Other causes include lesions intrinsic to the wall of intestine, e. g. diverticulitis, carcinoma, regional enteritis, and luminal obstruction, as gallstone obstruction or intussusception • Pathophysiology – Distension of the intestine is caused by accumulation of gas and fluid proximal to the obstructed segment. – Massive loss of fluid from the circulation- hypovolemia, shock • • Marked depression of flux from lumen to blood (in the first 12 -24 h) Sodium and fluid move into the lumen Vomiting Sequestration of fluid into the edematous intestinal wall and peritoneal cavity as a result of impairment of venous return from the intestine • Impaired blood supply of intestine – necrosis of the intinal wall – peritonitis

Intussusception (the prolapse of one part of intestine into the lumen of an immediately adjoining part) intussuscipiens 1. Colic: involving segments of the large intestine 2. Enteric: involving only the small intestine intussusceptum 3. Ileocecal: the ileocecal valve prolapses into the cecum, drawing the ileum along with it 4. Ileocolic: the ileum prolapses through the ileocecal valve into the colon

Symptoms and physical findings in acute intestinal obstruction • Symptoms and physical findings – Cramping midabdominal pain, which tends to be more severe the higher the obstruction – The pain occurs in paroxysms – Audible borborygmi simultaneously with the paroxysms of the pain – Abdominal distension (most marked in colonic obstruction) – Presence of a palpable abdominal mass (closed-loop strangulating small bowel obstruction) – Vomiting is almost invariable, and it is earlier and more profuse the higher is the obstruction • Initially contains bile and mucus, and remains as such if the obstruction is high • With low ileal obtsruction, the vomitus is feculent (orange-brown in color with a foul odor – Obstipation and the failure to pass gas by rectum (indicating complete obstruction)

Roentgenographic image in acute intestinal obstruction Fluid- and gas-filled loops of small intestine arranged in a „stepladder” pattern with air-fluid levels in small intestine obstruction Frame-like arranged distanded gasfilled colonic bowels in colonic obstruction.

Inguinal és femoral hernia 1. Invaginate loose scrotal skin with your index finger. 2. Follow the spermatic cord upward to above the inquinal ligament, and find the opening of the external inquinal ring. 3. If possible, gently follow the inguinal canal laterally. 4. Ask the patient to strain down or cough. 5. Note any palpable herniating mass as it touches your finger. Palpate the anterior thigh in the region of the femoral canal…. . If the findings suggest a hernia, try to reduce it by sustained pressure with your finger. If the mass is tender or the patient reports nausea and vomiting, you have to finish this maneuver. Incarcerated hernia: when its contents can not be returned to the abdominal cavity. Strangulated hernia: when the blood supply is compromised (tenderness, nausea, vomiting)

Acut mesenterial ischemia • Risk factors: – include atherosclerosis, atrial fibrillation, recent myocardial infarction, valvular heart disease, and recent cardiac or vascular catheterization • Conditions: – – Arterial embolism (in >75% of cases originate from the heart) Arterial thrombosis Venous thrombosis Nonocclusive mesenteric ischemia (vasospasm, dehydration) • Clinical symptoms: – Severe acute, non remitting abdominal pain, initially without muscular rigidity (defense) – Minimal abdominal distension – Hypoactive bowel sounds – Nausea, vomiting, transient diarrhea, bloody stool – Later findings will demostrate peritonitis, adynamic ileus • Management: – The „gold standard for the diagnosis and management of acute arterial occlusive disease is laparotomy Surgical exploration should not be delayed if suspition of acute occlusive mesenteric ischemia is high.

Acute panreatitis • Risk factors: – Gallstone – Alcoholism – Hyperlipidemia • Clinical manifestations: – The abdominal pain is steady, and is located in the epigastrium and periumbilical region and often radiates to the back. The pain is frequently more intense when the patient is supine, and patients often obtain relief by sitting with the trunk flexed and knees drawn up. – Nausea, vomiting and abdominal distension are also frequent complaints – Hypomotoility, bowel sound are usually diminished or absent – Epigastric tenderness and rebound tenderness are usually present but the abdminal wall may be soft. – A faint blue discoloration around the umbilicus (Cullen’s sign) may occur as the result of hemoperitoneum, indicating the presence of a severe necrotizing pencraetitis – Disstressed anxious patient – In 10 -20% of cases, there are pulmonary findings (basilar rales, atelectasis, and pleural effusion, most frquently left-sided

Summary • Location of the abdominal pain. Rebound tenderness • Auscultation of bowel movement • Free air in the abdomen – percussion of liver span • Hernial orifices should always carefully examined for the presence of a mass • Rectal digital examination

Palpation of the abdomen • Light palpation (palpate the abdomen with light, gentle, dipping motion, moving your hand from place to place, raise it just off the skin) – Helpful in identifying abdominal tenderness, muscular resistance, and some superficial organs and masses • If muscular resistance is present, try to distinguish voluntary guarding from involuntary muscular spasm (relaxing methods). Persisting muscular rigidity indicates peritoneal inflammation. • Abdominal pain on coughing also suggest peritoneal inflammation. • Deep palpation – This usually required to delineate abdominal masses (use the palmar surface of your fingers). • Describing the location, size, shape, consistency, tenderness, pulsation and mobility of palpated mass