Intraperitoneal & Intraperitoneal & retroperitoneal retroperitoneal haemorrhagehaemorrhage

Complex ethiologyany vascular lesion if big enough

Lesions of solid organs– Liver, spleen, kidney, pancreas

Lesions of hollow organs and mesentery Lesions of parietal vessels (cirrhosis) Genital lesions: extra uterine pregnancy Fractures of vertebral column Lesions of big retroperitoneal vessels (aorta,

IVC, etc) Postoperative

Many others

Symptoms

Hemorrhagic syndrome– Symptoms develop in hours– Cataclismic hemorrhage

Clinical presentations– Pale– Agitation, pseudo-psychotic manifestations– Hypotension– Oliguria/anuria

Abdominal evaluation

Inspection: may be enlarged, especially in massive haemorrhage

Sensibility: spontaneous and o palpation Ausculation: intestinal sound may be

diminished due to peritoneal irritation Percution:

– free liquid in the abdomen (movable dullness) – Increased liver or splenic dullness

Careful anamnesis: STRANGE SITUATION

Ectopic pregnancy – major cause of hemoperitoneum

Progression of a hematoma in sequences Pelvic griddle and vertebral fractures can

bleed in the free peritoneum Iatrogenic lesions

Progression with a FREE INTERVAL

Trauma Silent period – almost no symptoms

– SUBCAPSULAR HEMATOMA will form in this time

– Hematoma ruptures in the peritoneal cavity - hemoperitoneum

Lab work

Plain abdominal X-Ray Abdominal US

– Can demonstrate free liquid in the peritoneal cavity + specific character of blood

– Can show lesions and abnormalities in the structure of solid organs

– Can demonstrate pregnancy or signs associated with ectopic preganancy

Paracentesis + lavaj

Particular aspects of retroperitoneal hemorrhage

Frequently in the context of polytrauma “No room” closed space –possible

spontaneus hemostasis Clinical forms

– Small unnoticed hematoma– Large volume: “tumor like” appearance– Echimosis may appear due to blood migration

Special evaluation aiming for a retroperitoneal hematoma

US scan – special attention for kidney and large vessels

Intravenous urography Rx for vertebral column and pelvic griddle CT scan Paracentesis + lavaj

Upper GI bleedingUpper GI bleeding

SyndromeSyndrome: GROUP of diseases which may be unrelated

Upper GI bleeding - definition

Internal hemorrhage becoming exteriorized

Hematemesis – above the angle of Treitz Melena – above the ileo-cecal valve Hematochesis (fresh blood per anum) –

bellow splenic flexure Hypovolemic shock – the only

manifestation

Main causes

Duodenal ulcer 24% Erosive gastritis 23% Gastric ulcer 21% Esofageal varices 10% Esofagitis 8% Sdr. M-W 7% Erosive duodenitis 6% Tumors 3%

Large geographical variations

DIAGNOSTIC VS

TREATAMENT EMERGENCY Urgent treatment should precede

complete diagnostic Sequence

– Positive diagnostic - GI bleeding– Resuscitation – Empiric treatment– Ethologic diagnostic– Specific treatment

Homodynamic evaluation pulse + blood pressure

Shock – systemic blood pressure in decubitus <90mmHG – 50% din VC

No shock – BP and pulse checked in ortostatism– BP<90 lost = 25-50%– BP-10 or pulse >120/min = 20-25%

MONITOR PATIENTS -REBLEEDING MODELS

CONTINUOUS BLEEDING• No response to treatment

• No major rebleeding

• Clinical observation = ESSENTIAL

MAJOR REBLEEDING EPISODE• Sudden onset

• Most frequently in ICU

• Cases only with hypovolemic shock

Rebleeding – major prognostic factor

Definition: bleeding after a succesfull attempt to maintain hemodynamic stability

High mortality: 3x 3 major risk factors for morbidity and

mortalityMajor rebleeding in the hospitalOld ageTotal amount of transfused blood

WHAT IS THE CAUSE?

Clinical evaluation

X-Ray and US scan

endoscopy

“GOLD DIAGNOSTIC”

ANAMNESISpatient + relatives

Describe bleeding– Quantities can not be approximated

Other signs during or before onset PMH – suggestive for a medical problem that may cause

bleeding Hereditary problems Alcohol intake False bleeding, false upper GI bleeding Medication Coughing before hematemesis Mouth bleeding

CLINIICAL EVALUTATION

Hemodynamic evaluation Confirm upper GI bleeding

• HEMATEMESIS, MELENA or RECTAL• ENT evaluation.

Clinical signs suggestive for liver cirrhosis (liver and spleen size, ascites,colateral circulation, spider hemangioma,Dupuytren,etc)

Tumors Other diseases that can produce GI bleeding

IMAGISTICS Can be of major interest Rx thorax

• Pleuresia• Tuberculosis• Primary or secundary tumors

US abdominal• Liver cirrhosis• Abdominal tumors

Barium meal • Bad alternative when endoscopy is irrelevant

ENDOSCOPY

Establishes: SOURCE OR SOURCES OF BLEEDING

Evaluation of RISK OF REBLEEDING

THERAPEUTIC ACCES to lesion

FIRST LESION: “MIRAGE”

Esophageal causes

Varices Mallory-Weiss Hiatal hernia and reflux Esophageal tumors

Varices

Endoscopic diagnosis can be difficult• Massive bleeding

• Clots

• Gastric varices

• Portal encephalopathy

60% of cirrhotic pateintsbleed form varices

M-W SYNDROM

Diagnostic possible ONLY WITH EMERGENCY ENDOSCOPY

• Lesions are short lived

– Hypovolemic shoch is unlikely but not impossible

– Short hospital stay– Very small risk of rebleeding

Hiatus hernia and reflux

Stigmata of recent bleeding

HH is very frequent

TUMORS

Overt GI bleeding is rare, frequently occult bleeding

Gastric sources of bleeding

Hemorrhagic gastritis Gastric ulcer Benign tumors Malignant tumors

Hemorrhagic gastritis

DG: morphologic criteria Endoscopic aspect is not

diagnostic Barium meal: useless and

loss of money

Gastric ulcer

Diagnostic can be difficult

EDS: stigmata of recent bleeding

Risk of rebleedingevaluation

Benign tumors

Very unlikely, round circumscribed tumors with central ulcerations

Malignant tumors

Ex. endoscopicLocally advanced

tumorEndoscopic

hemostasis US scan

MTS + lymphnodes

Upper GI bleeding with duodenal origin

Very frequent Empiric treatment of upper

GI bleeding It is much to easy to say

that a bleeding originates from a duodenal ulcer without endoscopy

Erosive gastritis

Term misused for many unknown situations responsible for bleeding

Superficial ulcerations usually described as superficial ulcer – easier to comprehend

HP infection

Bleeding peptic duodenal ulcer

Relatively frequent although potent medication is on the market

53% previous diagnostic of ulcer 17% iterative:

More serious, high risk of rebleeding25% no previous cause!!!Known diagnostic-treat that

Rebleeding risk

INTESTINAL INTESTINAL OBSTRUCTIONOBSTRUCTION

SYNDROME, MANY DISEASES

Small bowell Small bowell obstructionobstruction

Essentials of diagnostic

Complete high obstruction– Vomiting– Abdominal discomfort– Rx changes

Low obstruction– Colicky pain– Vomiting– Abdominal distension– No intestinal transit– Hyperperistaltic

movements– A/F levels

2 major forms of obstruction

Simple– Mechanical– Paralitical

Strangulation– Vascular component

Causes

Postoperative adhesions – most frequent All hernias Tumors (intraluminal, parietal sor extraintestinal) Invagination Volvulus Foreign bodies Billiary ileus Inflammatory bowel disease Stenosis Hematoma Etc

Symptoms

Colicky abdominal pain (no in very high small bowell obstruction)– Crescendo-descrescendo– Seconds - minutes– No pain between

Vomiting– Dominant symptom– Intervals depending on localization of obstruction– More distal - fecaloid

Symptoms

No transit for feaces or gas per anum– Feaces can be present in large bowel. Initial normal defecation

General signs may be absent or minimal– Dehydration– No fever

Abdomen:– Abdominal distension (not in high obstruction)– Hyperperistaltic waves can be seen on the abdomen– Abdomen may be tender– NO signs of peritoneal iritation– Abnormal sounds– CHECK FOR HERNIA

Paraclinical

Lab: non-specific– Hemoconcentration (increased WBC,

hyperglicemia)– Electrolytic imbalance– High level serum amilase

Plain abdominal X-Ray– A/F levels and their position and form– Hydrosoluble contrast media

Particularities of strangulation

Shock develops very early Pain is less colicky and becomes

permanent Fever Vomiting + blood strikes Abdominal guarding

Particularities of strangulation

High WBC Rx:

– Loss of normal mucosal lining– Air in portal veins or in intestinal wall– F/A levels outside intestinal lumen: abscess or

pneumoperitoneum

LARGE BOWEL LARGE BOWEL OBSTRUCTIONOBSTRUCTION

Essentials of diagnostic

Constipation or no feaces or flatus per anum

Meteorism +/- guarding Abdominal pain Nausea and vomiting – late Important Rx findings

Frequent causes

Colonic malignant tumor

Volvulus Diverticulosis -

infected IBD

Benign tumors Fecal impactation Lesions outside

digestive tract

Symptoms

Dependent on the cometepence of ileo-cecal valve– Valvular lesion – similar with ileal obstruction– Competent valve – no vomiting– Incompetent valve - vomiting

Closed loop syndrome– Risk of cecal perforation

Symptoms Progressive onset (mechanical obstruction) Dull pain mainly in hypogastrium

– Fixed colonic lesion may produce localized pain

– Continuous pain - ischemia

Borborism associated with colicky pain No feaces no flatus Vomiting: changing character

Clinica examination Meteorism and timpanism Peristaltic waves on abdominal wall Specific sounds - obstruction Peritoneal irritation symptoms Rectal

– Bloos– Tumor– Invagination pseudotumor

Radiology

Colonic distention with gas F/A levels (colonic) Mixed A/F level signs if the ileo-cecal

valve is incompetent Barium enema (or water-soluble solution)

– Level of obstruction– Ethiology– Devolvulation

Differential diagnostic

Low/high obstruction Ileus (paralitic) Pseudo-obstruction

Signs in acute Signs in acute pancreatitispancreatitis

Abdominal drama

Essentials of diagnostic ABDOMINAL PAIN

– Sudden onset– Dull pain irradiating transverse and to the back

Vomiting, Sweating, Fever Distended abdomen High WBC, amilazemia, amilazuria,

lipazemia PMH: alcohol, billiary calculus

General data Severe inflammatory disease Abnormal activation of pancreatic enzymes Causes:

– Alcohol, billiary calculus– Hypercalcemia, hyperlipidemie, trauma,

reaction to medicines, vasculitis, infections

Inflamation: edema – hemorrhagic, necrotic severe form

Symptoms

PAIN Epigastric, severe, continuous, relieved in

genu-pectoral position ; IRRADIATION: TRANSVERSE Nauseam vomiting: CHARACTERISTIC –

impossibility to eat or drink PMH: alcohol or billiary colicky

Abdominal examination

Very few elements Diffuse sensibility in upper half of the abdomen Ussually no guarding and no signs of peritoneal

irritation Paralitic Ileus

– Abdominal distension – No bowel sounds– No flatus per anum

Abdominal pseudotumor in epigastrium and left upper quadran

General status

High fever>38 Septic state (tachycardia, hypotension,

septic shock, palor, could periphery) Jaundice (either compression, obstruction

or secondary liver failure) Renal failure

Lab

WBC 10.000-30.000 Hyperglicemia High billirubin High alkaline fosfataze Hypocalcemia (loss of albumin through

extraasation) ~ severity Amilaze si lipaze serum + pleural and

peritoneal effusion

Imagistic Plain abdominal X-Ray = MUST

– Differential dg. acute abdomen– Sentinel looop – left upper quadrant– Left pleural effusion + atelectasis– Incomplete F/A levels– Billiary stones– Fluid in the abdominal cavity

Imagistic

US– Standard procedure in screening– PROBLEM: air content– Pancreas: dimensions, edema, liquid collection

pseudocysts– Free fluid in the abdomen and pleura – Guided aspiration for diagnostic

Imagistic CT scan + contrast

– Best for diagnostic and follow up– Information on pancreatic structure and fluid

collections– Pancreatic tissue viability– Evaluation of peripancreatic collections– Free air in collections!!!!

Imagistic MRI

– No major advantages– Superior for the description of billiary duct– Not specifically indicated in acute pancreatitis

Differential diagnostic

Anything in acute abdomen Myocardial infarction After ERCP Urlian virus infection Intestinal obstruction Aortic dissection Mesenteric obstruction

Differential diagnosticSIGNIFICANCE

NO LAPAROTOMY NO LAPAROSCOPY IF DIAGNOSTIC – Sure– No billiary obstruction (except compression)– No suspicion of infection