acute abdomen 4 th year 2012 part ii dr abdulhakim al-tamimi, md assiss prof of suregry aden...
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Acute abdomen 4th year 2012
part IIDr Abdulhakim Al-Tamimi , MD
Assiss prof of suregry
Aden university
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What are your objectives?You should be able to address the following questions1. Is this bowel obstruction or ileus?2. Is this a small or large bowel obstruction?3. Is this proximal or distal obstruction?4. What is the cause of this obstruction?5. Is this a complex or simple obstruction?6. How should I start investigating my patient?7. What is the role of other supportive investigations?8. What is my immediate/ intermediate treatment plan?9. What are the indications for surgery?10. What are the medico-legal and ethical issues that I
should address?
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Introduction and Definitions Accounts for 5% of all acute surgical admissions Patients are often extremely ill requiring prompt
assessment, resuscitation and intensive monitoring
Obstruction A mechanical blockage arising from a structural abnormality that presents a physical barrier to the progression of gut
contents. Ileus is a paralytic or functional variety of
obstruction
Obstruction is: Partial or completeSimple or strangulated
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Epidemiology
Mechanical small-bowel obstruction is the most frequently encountered surgical disorder of the small intestine.
Although a wide range of etiologies for this condition exist, intra-abdominal adhesions related to prior abdominal surgery is the etiologic factor in up to 75% of cases of small-bowel obstruction.
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More than 300,000 patients are estimated to undergo surgery to treat adhesion-induced small-bowel obstruction in the United States annually.
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In contrast to colonic obstruction, small-bowel obstruction is uncommonly caused by neoplasms.
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Fewer than 3% of cases are caused by primary small-intestinal neoplasms.
Cancer-related small-bowel obstruction is
more commonly caused by extrinsic compression or invasion by advanced malignancies arising in organs other than the small bowel
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Patho-physiology I
8L of isotonic fluid received by the small intestines (saliva, stomach, duodenum, pancreas and hepatobiliary )
7L absorbed 2L enter the large intestine and 200 ml excreted
in the faeces Air in the bowel results from swallowed air ( O2 &
N2) and bacterial fermentation in the colon ( H2, Methane & CO2),
600 ml of flatus is released Enteric bacteria consist of coliforms, anaerobes
and strep.faecalis. Normal intestinal mucosa has a significant
immune role
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Patho-physiology I
Distension results from gas and/ or fluid and can exert hydrostatic pressure.
In case of BO Bacterial overgrowth can be rapid
If mucosal barrier is breached it may result in translocation of bacteria and toxins resulting in bactaeremia, septaecemia and toxaemia.
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Patho-physiology IIObstruction results in:
1. Initial overcoming of the obstruction by increased paristalsis
2. Increased intraluminal pressure by fluid and gas
3. Vomiting 4. sequestration of fluid into the lumen from the
surrounding circulation5. Lymphatic and venous congestion resulting in
oedematous tissues6. Factors 3,4,5 result in hypovolaemia and
electrolyte imbalance7. Further: localised anoxia, mucosal depletion
necrosis and perforation and peritonitis.8. Bacterial over growth with translocation of
bacteria and it’s toxins causing bacteraemia and septicaemia.
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Patho-physiology II
Decompress with NGT Replace lost fluid Correct electrolyte abnormalities Recognise strangulation and
perforation Systemic antibiotics.
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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
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Causes- Small BowelLuminal Mural Extraluminal
F. BodyBezoars
Gall stoneFood Particles
A. lumbricoides
Neoplasims lipoma polyps leiyomayoma hematoma lymphoma carcimoid carinoma secondary
TumorsCrohnsTBStrictureIntussusceptionsCongenital
Postoperative adhesions
Congenital adhesions
Hernia
Volvulus
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Small Bowel Adhesions Accounts for 60-70% of All SBO Results from peritoneal injury, platelet activation and fibrin
formation. Associated with starch covered gloves, intraperitoneal sepsis,
haemorrhage and wash with irritant solutions iodine and other foreign bodies.
As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years
• Colorectal Surgery 25%
• Gynaecological 20%
• Appendectomy 14% 70% of patients had a single band Patients with complex bands are more likely to be readmitted Readmission in surgically treated patients is 35%
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ADHESIVE INTESTINAL OBSTRUCTION
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ADHESIVE INTESTINAL OBSTRUCTION
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ADHESIVE INTESTINAL OBSTRUCTION
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ADHESIVE INTESTINAL OBSTRUCTION
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ADHESIVE INTESTINAL OBSTRUCTION
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Hernia Accounts for 20% of SBO Commonest 1. Femoral hernia
2. ID inguinal
3. Umbilical
4. Others: incisional and internal H.
The site of obstruction is the neck of hernia The compromised viscus is with in the sac. Ischaemia occurs initially by venous occlusion,
followed by oedema and arterial ompromise. Attempt to distinguish the difference between:
• Incaceration
• Sliding
• Obstruction
Strangulation is noted by: • Persistent pain
• Discolouration
• Tenderness
• Constitutional symptoms
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Incarcerated Inguinal Hernia
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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 gas-filled colonic bowels in colonic obstruction.
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Other causes
IBDGall stone IleusIntussusception
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F.B in the G.I.T
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F.B in the G.I.T
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Large Bowel Obstruction•Distinguishing ileus from mechanical obstruction is challenging
•According to Leplac’s law: maximum pressure is at the it’s maximum diameter. Cecum is at the greatest risk of perforation
•Perforation results in the release of formed feaces with heavy bacterial contamination
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Large Bowel Obstruction
Aetiology:1. Carcinoma: The commonest cause, 18% of colonic ca. present
with obstruction2. Benign stricture: Due to Diverticular disease, Ischemia,
Inflammatory bowel disease.3. Volvulus: 1. Sigmoid Volvulus: Results from long redundant,
faecaly loaded colon with a narrow pedicle 2. Caecal Volvulus4. Hernia.5. Congenital : Hirschusbrung, anal stenosis and agenesis
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Sigmoid VolvulusColonic Obstruction
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Volvulus Most commonly sigmoid,
also right colon and terminal ileum (cecal volvulus), cecum alone (due to a highly mobile cecum called a cecal bascule- mobile in caudad to cephalad direction), and rarely transverse colon
(photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)
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(photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)
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Large Bowel Obstruction
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Large Bowel Obstruction
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How to Understand the clinical findings
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Clinical Findings1. History
Persistent pain may be a sign of strangulation Relative and absolute constipation
The Universal FeaturesColicky abdominal pain, vomiting, constipation (absolute), abdominal
distension.
Complete HX ( PMH, PSH, ROS, Medication, FH, SH)
High•Pain is rapid
•Vomiting copious and contains bile jejunal content
•Abdominal distension is limited or localized
•Rapid dehydration
Distal small bowel•Pain: central and colicky
•Vomitus is feculunt
•Distension is severe
•Visible peristalsis
•May continue to pass flatus and feacus before absolute constipation
Colonic•? Preexisting change in bowel habit
•Colicky in the lower abdomin
•Vomiting is late
•Distension prominent
•Cecum ? distended
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Clinical Findings2. Examination
General
•Vital signs:
P, BP, RR, T, Sat
•dehydration
•Anaemia, jaundice, LN
•Assessment of vomitus if possible
•Full lung and heart examination
Abdominal
•Abdominal distension and it’s pattern
•Hernial orifices
•Visible peristalsis
•Cecal distension
•Tenderness, guarding and rebound
•Organomegaly
•Bowel sounds–High pitched–Absent
•Rectal examination
Others
Systemic examination
If deemed necessary.
•CNS
•Vascular
•Gynaecological
•muscuoloskeltal
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Radiological EvaluationNormal Scout
Always request: Supine, Erect and CXR
Gas pattern:• Gastric,
• Colonic and 1-2 small bowel
Fluid Levels:• Gastric
• 1-2 small bowel
Check gasses in 4 areas:1. Caecal
2. Hepatobiliary
3. Free gas under diaphragm
4. Rectum
Look for calcification
Look for soft tissue masses, psoas shadow
Look for fecal pattern
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Intestinal obstruction
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The Difference between small and large bowel obstruction
Large bowel Small Bowel
•Peripheral ( diameter 8 cm max)
•Presence of haustration
•Central ( diameter 5 cm max)
•Vulvulae coniventae
•Ileum: may appear tubeless
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Role of CT Used with iv contrast, oral and
rectal contrast (triple contrast). Able to demonstrate
abnormality in the bowel wall, mesentery, mesenteric vessels and peritoneum.
It can define
• the level of obstruction
• The degree of obstruction
• The cause: volvulus, hernia, luminal and mural causes
• The degree of ischaemia
• Free fluid and gas
Ensure: patient vitally stable with no renal failure and no previous alergy to iodine
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Role of barium gastrografin studies
As: follow through, enema Limited use in the acute setting Gastrografin is used in acute
abdomen but is diluted Useful in recurrent and chronic
obstruction May able to define the level and
mural causes. Can be used to distinguish
adynamic and mechanical obstruction
Barium should not be used in a patient with peritonitis
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How to initially investigate your patient
Lab:
• CBC (leukocytosis, anaemia, hematocrit, platelets)
• Clotting profile
• Arterial blood gasses
• U& Crt, Na, K, Amylase, LFT and glucose, LDH
• Group and save (x-match if needed)
• Optional (ESR, CRP, Hepatitis profile
Radilogical:• Plain xrays
• USS ( free fluid, masses, mucosal folds, pattern of paristalsis, Doppler of mesenteric vasulature, solid organs)
• Other advanced studies (CT, MRI, Contrast studies……senior decision)
ECG and other investigations for co-morbid factors
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Initial Management in the ER Resuscitate:
• Air way (O2 60-100%)
• Insert 2 lines if necessary
• IVF : Crytloids at least 120 ml/h. (determined by estimated fluid loss and cardiac function). Add K+ at 1mmmol/kg
Draw blood for lab investigations Inform a senior member in the team. NPO. Decompress with Naso-gastric tube and secure in position Insert a urinary catheter (hourly urinary measurements) and
start a fluid input / output chart Intravenous antibiotics (no clear evidence) If concerns exist about fluid overloading a central line should be
inserted Follow-up lab results and correction of electrolyte imbalance The patient should be nursed in intermediate care Rectal tubes should only be used in Sigmoid volvulus.
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Indications for Surgery
Immediate intervention: Evidence of strangulation (hernia….etc) Signs of peritonitis resulting from perforation or ischemia
In the next 24-48 hours Clear indication of no resolution of obstruction ( Clinical,
radiological). Diagnosis is unclear in a virgin abdomen
Intermediate stage
The cause has been diagnosed and the patient is stabalised
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Viable VS non viable intestine
Circulation: 1.Dark colour becomes lighter
2. Mesentry bleeds if pricked Peritoneum:
1.Shiny Intestinal musculature:
1.Firm
2.Peristalsis may be observed
3.Pressure rings may/may not disappear
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Non –viable
Circulation:1.Remains dark in colour
2. No bleeding if pricked Peritoneum:
1.Dull and lusterless Intestinal musculature:
1.Pressure rings persist 2.No peristalsis
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Differentiation between viable and non viable intestine
Intestine Viable Nonviable
Circulation -Dark color become lighter-mesentery bleed if pricked
-Dark color remained -No bleed if mesentery is pricked
Peritonium Shiny Dull and Lustreless
Intestinal musculature
-Firm-Peristalsis may be observed
-Flabby thin and friable-No peristalsis
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Legal issues and consent
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Paralytic Ileus Associated with the following conditions:
• Postoperative and bowel resection
• Intraperitoneal infection or inflammation
• Ischemia
• Extra-abdominal: Chest infection, Myocardia infarction
• Endocrine: hypothyroidism, diabetes
• Spinal and pelvic fractures
• Retro-peritoneal haematoma
• Metabolic abnormalities:
• Hypokalaemia
• Hyponatremia
• Uraemia
• Hypomagnesemia
• Bed ridden
• Drug induced: morphine, tricyclic antidepressants
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Is this an ileus or obstructionClinical features Is there an under lying cause? Is the abdomen distended but tenderness is not marked. Is the bowel sounds diffusely hypoactive.
Radiological features: Is the bowel diffusely distended Is there gas in the rectum Are further investigasions (CT or Gastrografin studies) helpful
in showing an obstruction.
Does the patient improve on conservative measures
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Example of ileus
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Intussusception (the prolapse of one part of intestine into the lumen of an
immediately adjoining part)
intussusceptum
intussuscipiens1. Colic: involving segments
of the large intestine
2. Enteric: involving only the small intestine
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
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Ileocolic intussusception
Intussusception: invagination of one segment of intestine into another
segment
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Etiology
1) idiopathic : 95%
hypertrophied Payer's patches secondary to
viral infection
30% : preceding illness(+)
viral gastroenteritis,
URI
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Red Currant jelly stool
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Bad Intussusception
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Intussusception
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Target sign in intussusception
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Double ring sign
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Coiled spring or filling defect
Ileocolic intussusception
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DiagnosisDiagnosis
Clinical diagnosisAccuracy = 50%
UltrasoundAccuracy = 100%
Contrast enemaAccuracy = 100%
- Undiagnosed mortality = < 1%- Overall mortality = rare
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Barium reduction
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Unsuccessful 10-15%
Successful 85-90%
Perforation <1 %
Recurrence (10 %)
Mortality 0 %
Radiologic Radiologic reductionreduction
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intussusception
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Intussusception
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Meckel’s diverticulum. diverticulitis
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Congenital hypertrophic pyloric stenosis
Age 3 weeks First born male baby Projectile vomiting non bilious Epigastic mass Gastric movement from left to right Abdominal US can diagnose the presence
of the mass even if not palpable
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Pyloromyotomy (Fredet- Ramstedt procedure)
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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)
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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
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Management:• The „gold standard for the diagnosis
and management of acute arterial occlusive disease is laparotomy Surgical exploration should not be delayed if suspision of acute occlusive mesenteric ischemia is high.
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Acute abdomen in pregnant women
Ectopic gestation Retroverted gravid uterus Threatened abortion Sepsis following abortion Torsion ovarian cyst/ fibroid Red degeneration fibroid Rupture uterus Appendicitis
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First and Foremost…
Female + ovaries = pregnancy When patients said…
• “My last period was on time.”
• “I don’t think I’m pregnant.”
• “I can’t possibly be pregnant.”
…10% were pregnant.Ramoska EA, et al. Ann Emerg Med. 1989 Ramoska EA, et al. Ann Emerg Med. 1989
Jan;18(1):48-50.Jan;18(1):48-50.
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ECTOPIC PREGNANCY
DEFINITION
Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.
21/04/23 03:24 Ectopic Pregnancy 109
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21/04/23 03:24 Ectopic Pregnancy 110
SITES OF ECTOPIC PREGNANCY
1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn 8)Secondary abdominal 9)Broad ligament 10)Primary abdominal
Ampulla (>85%)Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Abdomen (< 2%)
Cervix (< 2%)
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CLINICAL PRESENTATION Ectopic Pregnancy remains asymptotic until
it ruptures when it can present in two variations - Acute &. Chronic
SYMPTOMS-• Amenorrhea
• Abdominal Pain
• Syncope
• Vaginal Bleeding
• Pelvic Mass
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METHODS OF EARLY DIAGNOSIS Immunoassay utilising monoclonal
antibodies to beta HCG Ultrasound scanning – Abdominal &
Vaginal including Colour Doppler Laparoscopy Serum progesterone estimation not
helpful
21/04/23 03:24 Ectopic Pregnancy 112
A combination of these methods may have to be employed.
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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY
HospitalisationResuscitation -
• Treatment of shock
• Lie flat with the leg end raised
• Analgesics
• Blood transfusion
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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY
Laparotomy should be done at the earliest.
Salpingectomy is the definitive treatment.
No benefit from removing Ovary along with the tube
If blood is not available, auto-transfusion can be done.
21/04/23 03:24 Ectopic Pregnancy 114
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21/04/23 03:24 Ectopic Pregnancy 115
COMPARING LAPAROTOMY Vs LAPAROSCOPY
L’tomy L’scopyHospital cost More? Less?Post operative adhesions More LessRisk of future ectopic Same SameFuture fertility Same SameExperience of Surgeon Trained Special Instruments General Special
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Appendicitis in Pregnancy
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Acute abdomen in tropics
Amebiasis Malaria----- vivax Worm infestation Sickle cell anemia Pyomyositis (in HIV) Enteric fever
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Typhoid ulcer - perforated
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Typhoid ulcer - perforated
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Complications of ascariasis
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Diseases that simulate acute abdomen
Diabetic ketoacidosis Typhoid Malaria TB peritonitis Food poisoning Lead colic Porphyia Pleurisy/pneumonia Cardiac disease (eg. MI) Disease of spine affecting nerve roots Renal disease
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Conditions mimicking Acute Abdomen
1. Pneumonia
2. Angina or myocardial infarction
3. Obstructive uropathy
4. Acute hepatitis
5. Sickle cell crisis
6. Leukemia
7. Radiculopathy from spinal nerve involvement
8. Cystitis
9. Pyelonephritis
10.Ureteral obstruction
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Conditions mimicking Acute Abdomen
11. Abdominal wall hematoma
12. Pericarditis
13. Herpes Zoster
14. Diabetic ketoacidosis
15. Systemic lupus erythematosus
16. Uremia
17.Torsion of the testis
18. Acute intermittent porphyria
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Conditions mimicking Acute Abdomen
19. typhoid 20. Malaria 21. TB abdomen
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Acute Pancreatitis
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Obstruction
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Vascular Emergencies
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Imperforate Anus: Anal atresia
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JEJUNAL ATRESIA
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Anatomy on the
Abdominal X-Ray:
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Abdominal X-Rays:
AXR-1 AXR-2
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Abdominal X-Rays:
AXR-3 AXR-4
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“”“”Let the knife dispel the doubt and reveal the Let the knife dispel the doubt and reveal the truth…”” truth…””
AnonymousAnonymous
“”“”Let the Laparoscope dispel the doubt and Let the Laparoscope dispel the doubt and reveal the truth…””reveal the truth…””
Kim Shi Tan, MDKim Shi Tan, MD Chairman, Dept. Of SurgeryChairman, Dept. Of Surgery FEU-NRMF FEU-NRMF
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www.medtube.net
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SHOKRAN
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