Acute Abdomen

Download as ppt, pdf, or txt
Download as ppt, pdf, or txt
You are on page 1of 59

*:Introduction

* The acute abdomen is a term used in Surgical,


Medical and Gynecological condition.
*The primary symptoms of the condition is
abdominal pain.
*The acute abd pain definition is taken as non
traumatic abd pain which does not subside for more
than one hour , require admission to hospital, which
has not been previously investigated or treated .
*Pt with acute abd pain have significant morbidity
and mortality.
;Anatomy
Abdominal wall .
Blood supp .
Nerve supp .
Blood supply of the viscera ;
1. Celiac artery
2. Superior mesenteric artery
3. Inferior mesenteric
:Aetiology*

-Surgical. -Medical.
-Gynecological.
*Surgically:
1-Inflammation. Peritonitis
2-Obstruction. Intestinal obs
3-Ischaemia.
4-Perforation.perforated PU .
:Site*
*The structure that cause pain in the upper
zone:-

Stomach
&
Gall
duodenum Pancreas
bladder
The structure that cause pain in the central*
:-zone

Small bowel

Caecum
Kidney

Kidney
Retroperitoneal
structure
The structure that cause pain in the lower*
:-zone

Transverse colon
Appendix Sigmoid
Ca & Bladder
ec Colon
&
um
uterus
:-Nature*
It divided into:-
1-condition associated with inflammation.
2-condition associated with obstruction.
Physiology of abd pain
Def :-
Pain is the physical adjunct of an imperative
protective reflex .
*pain has three component :-
1-motor reaction
2-emotional reaction .
3- autonomic reaction.
:-Pain qualities
Pricking pain Burning pain
1-fast acute pain 1-slow pain

2-occur with in 0,1 Sec 2-occur with in many Sec to


mints

3-usually superficial & not 3-both in skin and deeper


felt in most deeper tissues tissues

4-transmitted by type Adelta 4-trasmitted by type C fiber


fiber
*There are tow type of pain :
1-somatic 2- visceral
Supplied by somatic nerve -supplied by autonomic nerve

Sensitive to mechanical - As the same


,thermal &chemical
stimulation

-well localized Poorly localized

-sharp & or knife like -dull & deeply seated

Supplied by type A delta -supplied by type C fiber


:- The causes of true visceral pain*
1- Distention of hollow viscous.
2-Excessive contraction (colic).
3-Ischemia of visceral tissue.
4-Muscle spasm.
5-Nerve end irritation by chemicals.
Character of the pain
*referred pain
*dermatomal rule
Organ Site of referred pain

-heart -pericardium, inner aspect of


left arm, epigastrum
-appendix -umbilicus

-small intestine -umbilicus

-central part of -tip of shoulder


diaphragm
-pleura -abdomen
Organ Site of referred pain
-kidney -costo vertebral angle (loin
pain)
-ureter -testicle

-trig one of bladder -Tip of penis

-tongue -ear

-teeth -head

-hip -knee

-uterus -low back radiating to lower


abdomen
Hyper-alagesia

Psychological aspect of Abd.Pain


Clinical presentation of A-B :-
A-Symptoms :
1- age :
Certain condition are more likely to occur in certain
age groups ,eg. Mesenteric adenitis in children ,
diverticulitis in the older patient.
2- pain :
mode of onset
site
shifting of pain
character of pain
what relieves the pain?
What aggravates the pain ?
Relation to a natural act
3- vomiting:
a-relationship with pain : its start soon after pain in
acute appendicitis ,pancreatitis , biliary and renal
colic and in high small intestinal obstruction.
It starts after few hours in lower small intestinal
obstruction.
It occurs very late in colonic obstruction.
b- Frequency and quantity:
it is frequent and profuse in acute intestinal obstruction
and acute pancreatitis.
It occurs once or twice at the onset in acute
appendicitis and in perforated peptic ulcer.
c-characters:
it is projectile in high small intestinal obstruction.
It is effortless in peritonitis.
d- vomitus: in colic it is usually bilious.
In obstruction at first there are stomach content, then
becomes bilious and faeculent.
In peritonitis it is dark brown from altered blood.
4-Bowel action:
Absolute constipation in acute obstruction and
peritonitis.
Tenesmus with passage of mucus and blood in pelvic
appendicitis and pelvic abscess
In children intestinal obstruction associated with
passage of blood and mucus peranum suggest
intussusceptions.
6-Menstruation :
In rupture of ectopic gestation there is a history of
amissed period.
In acute salpingitis there is vaginal discharge
7- past history:
a- in acute perforation there may be a history of peptic
ulceration.
b- in colics there may be a history of previous attack.
C-in intestinal obstruction, a history of previous
abdominal operation will suggest the cause to be due
to band or adhesion.
B- Sings :
1- general Sings :
1) Facial expression :
Pallor and and gasping respiration in women of child
bearing age suggests rupture of ectopic gestation .
Cyanosis of lips is either may be observed in actual
present in terminal stage of intestinal obstruction and
peritonitis .
2) attitude :
In colics the patient is eather doubled –up or writhing in
agony .
In peritonitis the patient remain quit because movement
increase highly excitable .
3) pulse:
At the onset of many condition it is normal , then it
become rapid in internal haemorrhage and
peritonitis . it remain unchanged in obstruction for
som time exept in extensive strangulation where it
become rapid .
4) Temperature :
It may be low at onset then later rises gradually It does
not however reach a high level .
5) Tongue :
In acute appendicitis it is a bit dry and thinly coated
In dehydration the tongue becomes dry and toxaemias
it become also browen .
6) chest and heart :
They should be examined in every case so as not to
miss
conditions like diaphragmatic pleurisy , basal
pneumonia
and cardiac infarction .
7) Palpation of Femoral Arteries :
Absent pulsations of discrepancy between the two
sides in the presence of acute abdominal pain may
be the clue to a dissecting aneurysm of the aorta .
ABDOMINAL SINGS :
1) INSPECTION:
contour :
There is distention in well-established intestinal
obstruction and advanced peritonitis.
Respiratory movement :
Diffuse limitation occurs in diffuse peritonitis and
intraperitoneal haemorrahage .localized limitation
occurs over an inflamed organ e.g in appendicitis
and cholecystitis .
Hernial orifices :
All inspected for the presence of a strangulated hernia.
Peristaltic movement :
The aldder-step peristalsis of low small intestinal
obstruction may be present .
Pulsating swelling :
There is present in a leaking abdominal aortic aneurysem
Skin :
Patches of ecchymosis in the loins or bluish discoloration around
the umbilicus fmay be found in late cases of acute
pancreatities and ruptured ectopic pregnancy .
PLAPATION :
Tenderness:
It is present over inflamed organs e.g over McBurneys point in
acute appendicitis and over the right hypochondrium in acute
cholecysitis .
In diffuse peritonitis tenderness becomes wide spread over the
abdomen .
Tenderness in the renal angles is present in renal colic and
acute pyelonephritis
Rebound Tenderness :
It is diagnostic of peritonitis from any cause . N.B referred
abdominal pain from thoracic diseases can be diagnosed by
noticing that if pressure on the abdomen iss gradually
increased , there is no corresponding increased of pai n as
occurs in peritonitis
Rigidity :
It is present when there is irritation of the pareital peritoneum . In
perforated peptic ulcer it starts over the upper half of the right
rectus then spreads and become board –like ,
In acute appendicitis rigidity is localized over the right iliac
fossa .if the appendix is retrocaecal rigidity will be present in
the lion . if the appendix is pelvic in position there will be
rigidity .
In colics there is no rigidity in actual intestinal obstruction is also
absent except in internal strangulation .
In peritonitis with server toxaemia , rigidity is slight or absent
possibly due to exhaustion of the protective mechanism .
Swelling :
All appendicular mass may be palpable in the right iliac fossa .
Mucocele or empyema of the gall pladder may be palpated a
twisted overrian cyst may be palble in one iliac fossa . the
sausage – shaped swell ing in intussusception may be felt to
harden and soften alternately.
hernial orifices :
they should be palpated in order not to miss asmall strangulated
hernia specially in the femoral region
3) percussion :
a)Shifting dullness in the flanks : it is present in condition like
perforation of apeptic or typhoid ulcer , acute pancreatitis and
ruptured ectopic gestation.
b) diminution of liver dullness :
it indicates the presence of air under the diaphragm as occurs in
perforation of stomach , duodenum and intestine.
4) auscultation :
In intestinal obstruction , intestinal sounds become
frequent , loud and metallic tinkles can be heard in
peritonitis the abdomen is silent.
RECTAL EXAMINATION :
1)we may feel carcinoma of rectum causing colonic
obstruction .
2) in pelvic abscess the anterior wall of the rectum will
be bulging and very tender
3) in pelvic appendicitis the right wall of the pelvis is
extremely tendered
VAGINAL EXAMINATION :
tenderness in both fornices when associated with
vaginal discharge is suggestive of acute salpingitis
in ruptured ectopic gestation the cervix feels softer and
any movement of the cervix elicits pain .
SCROTAL EXAMINATION :
to exclude un descending Tests
to exclude testicular torsion
to exclude epididemo orcitis
D \D of acute appendicitis*
:-depending on age & sex
children Adult
Gastroenteritis Regional enteritis
Mesenteric adenitis Ureteric colic
Meckel`s diverticulitis Perforated ulcer
Intussusceptions Torsion testis
Henoch-schonlein purpura Pancreatitis
Lobar pneumonia Rectus sheath
haematoma
Adult female Elderly
Milte ischmerz Diverticulitis
Salpingitis Intestinal obstruction
Pylonephritis Torsion appendix
epiploicae
Ectopic gestation Colonic carcinoma
Torsion \rupture of an Mesenteric infarction
overian cyst
Endometriosis Aortic aneurysm
:-Differential Diagnosis*
*Acute appendicitis:-
1-condition in the chest.
2-condition in the upper abdomen .
3-condition in the lower abdomen .
4-condition in the pelvic.
5-retroprotoneal condition .
:-D\D of acute cholecystitis*
-Acute peptic ulcer disease.
-Acute pancreatitis .
-Acute appendicitis .
-Hepatitis .
-Pneumonia.
-Acute myocardial infarction .
D\D of perforated peptic*
:-ulcer
-Acute pancreatitis .
-Acute cholecystitis .

*D\D of acute pancreatitis:-


-Perforated peptic ulcer .
-Acute cholecystitis .
-Gall stone colic .
-Myocardial infarction .
-Dissecting aortic aneurysm .
:-D\D of peritonitis*
-Gastrointestinal perforation .
-Exogenous condition .
-Transmural bacterial .
-Female genital tract infection .
-Haemtogenous spread .
:-Investigation of acute abdomen
1-Blood test :-
TWBCs – Hb%
Serum amylase .
Glucose.
Serum calcium.
Arterial blood gases
Serum bilirubin
2-Urine general .
3- Stool general.
4 -Radiograohic investigation & I.V.U .
5-Ultra sound .
7- CT-scan & angiography .
;General treatment
A.B.C .
N.G suction .
Broad spectrum anti bio .
Analgesia .
Surgery
indication of surgery
Elective operation .
:Acute appendicitis
Pathology ;
Risk factors perforation of appendix
1. Extreme of age
2. Immunosuppretion .
3. Faecolith obs .
4. Pelvic appendix .
5. Previous abd surgery .
:-C\F of appendicitis*

-Preumbilical colic.
-Pain shift to the right iliac fossa.
-Anorexia.
-Nausea & vomiting
*C\s in appendicitis:-
-Pyrexia.
-Localized tenderness in right iliac fossa.
-Muscle guarding.
-Rebound tenderness.
:-signs to elicit in appendicitis*
-Pointing sign.
-Rovsing`s sign.
-psoas sign.
-obturater sign.
; Alverado score
Symptoms ; Score ;
1. Migratory RIF pain . 1
2. Anorexia . 1
3. Nausea and vomi . 1
Signs ;
1. Tenderness RIF .
2
2. Rebound T .
1
3. Elevated T .
1
Lab :
1. Leuk .
2
2. Shift to the left .
total 1
10
Management of acute appendicitis
Acute pancreatitis
Def;
Aetiology :
common ; gallstones , periampullary
carcinoma and alcohol .
uncommon ;
Pathology :
basicly enterokinase activation of
pancreatic enzymes autodigestion .
finally pancreas become swollen , hrrgis
,necrotic and suppurative
:-C\F of acute pancreatitis*
*Pain is cardinal Vomitting.
symptoms: Ab. tenderness and
-Site . guarding
-Nature. Temperature
-Severity. Jaundice 30%
-Radiation. Grey turner’s singe
-Aggravated factor.
Cullen’s singe .
-Reliving factor.
shock
:-O\E
-Pt look ill, tachypnea, tachycardia.
-Hypotension, mild jaundice.
-Temperature normal or abnormal.
-Grey turner sign.
-Cullen's sign.
-Red tender nodules on legs.
-Abdominal distension.
Complication
Investigation
Treatment
Prgnosis
:-Treatment of Acute pancreatitis*

Mild +Sever+
).Conserve. (Ranson criteria -
.ICU admission -
. analgesics + -
.N.B.M -
.Antibiotic -
.Chart -

. Deteriorate

.Laprotomy
Definition
C/F
O/E
D.D
Management
Complication
Investigation
;Perforated peptic ulcer

c\f
Investigation
Treatment
:-peritonitis*
Def of peritoneum ;
Types of the peritoneum ;
Causes of the peritoneal inflammatory exudate ;
1. Bacterial infection
2. Chemical injury
3. Ischemic injury
4. Direct trauma
5. Allergic reaction
:Acute peritonitis
Bacteriology ;
Route of infection
Clinical \F of localized perit
1. Initial symptoms and signs .
2. Fever
3. Abdominal pain .
4. Vomitting
5. Sings ; PR -- guarding and rigidity –
positive rebound tenderness
;Diffuse peritonitis
Symptoms
Signs
Investigation & management
Complications .
THANK
YOU

You might also like