Dr.J.S Lamba

8/9/2019 Dr.J.S Lamba

1/27

CLINICAL APPROACH TO

ACUTE ABDOMEN

DR. J. S. LAMBA

MBBS, MS, FICSSR CONSULTANT

DEPT. OF SURGERY,

PUSHPANJALI CROSSLAY HOSPITAL,

VAISHALI, GHAZIABAD


2/27

the general rule can be laid down that the majority of

severe abdomonal pain which ensue in patients who

have been previously fairly well, and which last aslong as six hours, are caused by conditions of

surgical import.

[zachary cope, 1881-1974]

Acute abdomen refers to severe abdominal pain of

short duration that requires fairly immediate

management and decision regarding an urgent

surgical intervention.

ACUTE ABDOMEN


3/27

ACUTE ABDOMEN

Frequent causes of acute abdomen

Clinical features

How to perform physical examination D/d upperabdominal pain

D/d lowerabdominal pain

Clinical patterns

Natural history of frequent causes Conclusion


4/27

FREQUENT CAUSES OFACUTE

ABDOMENLONG LISTDIAGNOSIS FROM A LIMITED MENU

1.Inflammatory

a) Bacterial --appendicitis, diverticulitis, PID

b) Chemical peptic perforation, ac. pancreatitis

2.Mechanical

Obstructionincarcerated hernia, adhesions, intussusception,large bowel obstruction -- CA or volvulus

3.Vascular

Ac mesenteric arterial thrombosis/embolism

Mesenteric venous thrombosis


5/27

ABDOMINAL PAIN

Visceral

Somatic

Referred


6/27

VISCERAL

stretching of peritoneum ororgan capsule by

distension oroedema

diffuse

Poorly localised

May be per

ceived atr

emote locationsr

elatedto organs sensory innervation


7/27

SOMATIC

Inflammation of peritoneum ordiaphragm

Sharp

Well localised

REFERRED

Perceived at distance from diseased organ

Pneumonia

Acute MI

Male GU problem


8/27

C/FOFACUTE ABDOMEN

PAIN

1) Origin & location

Epigastric - stomach, duodenum, pancreas, liver,biliary tree, associated parietal peritoneum, HEART

Periumbilical - small intestine, appendix, upperureter

Hypogastric - colon, bladder, lowerureter, uterus


9/27

2) Radiation

appendicitis, cholecystitis, renalcolic, pancreatitis,

peptic perf.,ruptured ectopic pregnancy, spleen. Pain

of abd aortic aneurysm radiates from lowerback toone orboth legs

3) Type of onset & Intensity

sudden & severe -- rupture of viscus,mesentericthrombosis,infarct,haemorrhage

gradual & moderate-- cholecystitis,appendicitis,

peritoneal irritation,hollow organ

distension


10/27

4) Quality

dull-- epig pain of appendicitis

sharp/colicky-- renal,biliary,int obstaching-- PID

pleuritic-- intensified by breathing

lancinating--pancreatitis

5) Special features

continuous-ac pancreatitis

pulsatile-abdominal aneurysm

colicky-int obst,gall /renal colic


11/27

6) Factors which intensify/relieve pain

relation to mealspeptic ulcer, cholecystitispostural-appendicitis, pancreatitis

movement-peritonitis

7) Associated symptomsnausea/ vomiting/ diarrhoea/ obstipation

haematochesia/ malaena/ change in urinary

habits /fever

MURPHYS

SYNDR

OME

8) EXTRA ABDOMINAL CONDITIONS WHICH

SIMULATE THE ACUTE ABDOMEN ARISE MOST

OFTEN IN HEART,LUNGS,URINARY TRACT AND

FEMALE REPR

ODUCT

IVEO

RGANS


12/27

COMPLETE PHYSICAL EXAMINATION

vitals

Anaemia, shock, haemorrhage, dehydration

Palpation must expose abdomen fully

pt on back&knees bent

warm handswork towards area of pain

tenderness, rigidity, guarding, masses

Percussion hyperresonant,liver dullness

Auscultation-- listen for1 minute in each quadrantMUST EXAMINE HEART & LUNGS

P/R

Bimanual pelvic exam

EQUIVO

CALFI

NDING

SRE EXAM

INE AT

FREQUENT INTERVALS


13/27

D/D OFDISEASES CAUSING UPPERABDOMINAL PAIN

Ac oesophagitis

Ac appendicitis

Ac cholecystitis

Perforated peptic ulcer

Ac panc

reatitis

Pleurisy / pneumonia

Ac coronary occlusion - considerpossible MI with

pain referred to abdomen in patient >30 years old


14/27

D/D OFDISEASES CAUSING

LOWER ABDOMINAL PAIN

Ac appendicitis

Ureteral obstruction

Ac diverticulitis

Ac salpingitis Ectopic pregnancy

Twisted ovarian cyst


15/27

OESOPHAGITIS

Inflammation of distal oesophagus

Usually from gastric reflux,hiatal hernia

Substernal burning pain

Worsened by supine position


16/27

PANCREATITIS

Sudden, severe,constant mid epigastric painradiating to back

Often worsened by food

Profuse vomiting

Less gua

rding than peptic pe

rf

Bluish flank discoloration[Grey Turnersign]

Bluish periumbilical discoloration[Cullen sign]

Absent bowel sounds


17/27

CHOLECYSTITIS

Sudden pain, often severe in RUQ

Radiating to right shoulder

Nausea,vomiting

Often associated with fatty food intake

Point tenderness underR costal margin

[Murphys sign]


18/27

APPENDICITIS

Periumbilical painRLQ Nausea, vomiting, anorexia

Low grade fever

Mc burneys sign

Aarons sign epig pain on palpation of RLQ Rovsings sign pain in LLQ on palpation of RLQ

Psoas sign pain when patient extends R leg whilelying on left side


19/27

PERFORATED PEPTIC ULCER

Sudden, intense & constant pain

Patient keeps abdomen immobile

Rapid shallow breathing

Tende

rness, gua

rding alove

rabd

Liverdullness masked

Absent bowel sounds


20/27

ULCERATIVE COLITIS

Crampy abdominal pain,nausea, vomiting

Bloody diarrhoea orstool containing mucus Ischaemic damage with perforation may occur

DIV

ERTICUL

ITIS

Olderpatient, Inadequate fibre in diet

Bright red blood in stools,alt consti/diarrhoea

Tenderness in LLQ

Rupture may cause peritonitis and sepsis


21/27

ECTOPIC PREGNANCY

In females of child bearing age abd pain or

unexplained shock

ECTOPIC PREGNANCY DOES NOT

NECESSARILY CAUSE MISSED PERIOD

TWISTED OVARIAN CYST

Sudden severe pain

sick looking,shock

Ischaemic nec

rosis-pe

rf & spillage


22/27

1) Abdominal pain & shock [apoplexy] catastrophic eventa. ruptured aortic aneurysm

b. ruptured ectopic pregnancy

c. fluid loss into third space eg: ac mesenteric

ischaemia, severe ac pancreatitis, int obst

2) Generalised peritonitis

a. ruptured viscus perf ulcer, colonic perf,

perforated appendicitis

b. ischaemic unruptu

red bowel st

rangulated he

rniamesenteric occlusion,volvulus

c. extension of infection liverabscess, PID

CLINICALPATTERNS


23/27

3) Localised peritonitis

RUQ,RLQ,LLQ,SILENT ZONE

POINT TENDERNESS

4) intestinal obstruction

Making diagnosis is not a big issue but important is

deciding approp

riate cou

rse of action

5) medical illness

Inf wall MI, basal pneumonia, porphyria,diabetic

ketoacidosis,HIV positive suffering from AIDS

TIME ISSUPERB DIAGNOSTICIAN

Clinical pattern contd


24/27

Clinical pattern contd.

6) gynaecological

ectopic preg, twisted ovarian cyst,PID

7) mixed pattern[obstruction & inflammation]

Int. distension & obstruction/inflammationeg; enteritis,colitis

MIMICS PERITONITIS


25/27

NATURAL HISTORY OFFREQUENT

CAUSES

Life Threatening Self Limiting

Aortic Aneurysm

rupture

pancreatitisBowel ischaemia

Perforated peptic

ulcer

Perforated

diverticulitis

Appendicitis

cholecysitis

signoiddiverticulitis

salpingitis

Gastroenteritis

mesenteric

lymphadenitisepiploic

appendigitis

omental infarction

caecal diverticulitis


26/27

CONCLUSION

It is as much an intellectual exercise

to tackle the problems of belly acheas to work on the human genome

[Hugh dudley]


27/27

Documents

Dr.J.S Lamba