Acute abdomen

Tamás Fenyvesi

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Tamás Fenyvesi November, 2016

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Acute abdomen is anabdominalemergency no temporizing is ever justifiable.temporizing is ever justifiable.

Patients present more likely in the evening hours

Never wait with your decision for the next

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Never wait with your decision for the next morning

Characteristics of acute abdomen

�has been present for less than 24 hours�Sudden and unexpected onset of

abdominal painabdominal pain�associated symptoms:

nausea, vomiting, abdominal dystension,diarrhea, constipations, anorexia

The pain may arise from intra-and extra-

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�The pain may arise from intra-and extra-abdominal structures

acute abdomen not invariable operation

Neural innervation of the gastrointestinal tract

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History

�allow the patient to give his/her entire allow the patient to give his/her entire current history before asking specific questions�the character and onset of pain are essential

–colicky pain: obstructive processes

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–colicky pain: obstructive processes–sustained pain :infectious processes

�Referred pain patterns may give a clue

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Abdominal pain onset patterns

�I. sudden(seconds)I. sudden(seconds)–A. perforation or rupture of a viscus:peptic ulcer, abdominal aortic aneurysm, esophagus, ectopic pregnancy,PTX

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–B. infarction:gut, heart, lung

P.D. White etc

Abdominal pain onset patterns

II. rapid(minutes)�II. rapid(minutes)–A. colic syndromes: biliary, ureteral, small

bowel obstruction(high)–B. inflammatory processes:

pancreatitis, diverticulitis,

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pancreatitis, diverticulitis,appendicitis, penetrating ulcer, cholecystitis

–C. ischemic processes: strangulation, torsion

Abdominal pain onset patterns

�III. Gradual(hours)�A. inflammatory :appendicitis, cholec.,

pancreat., divertic., salpingitis, ¤pancreat., divertic., salpingitis, ¤prostatitis, inflamm.bowel dis., intra-abdominal abscess

�B. obstruction:distal small bowel or colon,ectopic pregnancy,urinary retention,

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colon,ectopic pregnancy,urinary retention,incarcerated hernia

�C. neoplastic:perforating or penetratingtumors (colon, stomach, small intestine)

Physical examination

� Observation of the patients body habitus and facial expressionhabitus and facial expression

–peritonitis :unwillingness to change posture, hip flexion with the knees drawn up, shallow breathing

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drawn up, shallow breathing–colicky pain: intense movements to alleviate

Physical examination

�Inspection of the abdomen:localized or

generalized dystension, visible peristaltsis, hernial bulges, erythema

�Auscultation of bowel sounds, if nosounds are heard : paralytic ileus

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sounds are heard : paralytic ileus

� Percussion absence of hepatic dullness (!!) : perforation

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Physical examination�Palpation : superficial, gentle of all quadrants, first at the least painful areas,

after this deeperafter this deeper�classic rebound tenderness (deep

palpation followed by rapid release) is notspecific

�have the patient laugh, cough, distend ormaximally reduce his/her abdominal girth

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maximally reduce his/her abdominal girth�A very old and forgotten means to palpate

the abdomen in a bath tub (in only thepatient !!)

•A rectal digital examination is obligatory

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Characteristicscars,Now often laparoscopy

Laboratory evaluation�Complete blood count:WBC differential,

CRP, sed.rate�urinalysis:serum amylase (urine)�serum amylase (urine)

�beta human chorionic gonadotropin infemales

�serum electrolytes,BUN,creatinine andglucose

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glucose�liver function test in upper abdominal painuse only relevant laboratory

investigationsthe results of which effect therapy !!

X-ray evaluation

�upright PA and lateral film of the chestupright PA and lateral film of the chest�supine and erect plain film of theabdomen

–the upright film should include thediaphragm

� to detect free intraperitoneal air

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� to detect free intraperitoneal air� only horizontal beam films detect fluid

levels within the bowel

X-ray evaluation

�contrast study may be required (dangers!)abdominal ultrasound mandatory�abdominal ultrasound mandatory

in some instances endoscopic�CT , MRI, nuclear (PET scan if

cost/benefit !! O K)angiography

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�angiography� may add to diagnostic accuracy

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Causes of acute abdomen�Appendicitis �Acute cholecystitisAcute pancreatitis�Acute pancreatitis

�Diverticulitis�Perforated peptic ulcer�Bowel obstructionMesenteric ischemia

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�Mesenteric ischemia�Ruptured abdominal aortic aneurysm�Gynecologic causes

Appendicitis

History: tipically midabdomonal pain ¤History: tipically midabdomonal pain ¤onset of nausea and vomitingrelocation of pain to the right lower quadrantelevation of temperature

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elevation of temperature

23ZETA (Sir Zachary Cope)

.Appendicitis : bacterial infection with contributory factors:intraluminal obstruction -fecalith lymphoid obstruction -fecalith lymphoid hyperplasia, parasites, carcinoid tu.

–typical symptoms:midabdominal pain moving to the right lower quadrant- elicited by coughing

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quadrant- elicited by coughing laughing or bumping, nausea and vomiting, anorexia,fever.

.Appendicitis :

physical : tenderness and guarding over the right lower quadrant (McBurneypoint-1/3 distance superior iliac point-1/3 distance superior iliac spine-umbilicus)

– psoas sign, rebound tendernesslaboratory:WBC,CRP, urinalysis

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Differntial dg of appendicitis

Localization of the appendixascending:

cholec,perf pyonephrduodenal ulc pyelitisduodenal ulc pyelitisperinephr absc nephrolithhydronephr omental torsion

Iliacal penetrating duod ulc Meckel’s diverticulumCrohn diseas!! Psoas absc

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Crohn diseas!! Psoas abscIleocecal cc. hip !!Tbc muscle rupture uretolith typhlitis

�Appendicitis 2 :�abdominal X-ray rarely useful,

ultrasound(periappendicular fluid,edema,abscess,visualization of fluid,edema,abscess,visualization of the lumen) increasing significance

Peak incidence 15-24 years�choice of treatment ,surgery:10-20%

negative appendectomy

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�Keep in mind the danger of perforation in the elderly

Acute cholecystitis

obstruction of the bile duct by stone1. bacterial in 50-85% of cases2. Chemical agents : lysolecithin,

other tissue factors3. Inflammation from mechanical

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3. Inflammation from mechanicalstrech

Acalculous cholecystitis with dilated gallbladder and thickened gallbladder wall

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Diagnosis of stone disease by ultrasound

shadow

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Cholesterol stones gall bladder

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Appearance of gallstones

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Characteristic symptoms:colic, localized to the right upper

quadrantRUQ tendernessRUQ tendernesspatient suddenly stops inspiration

(Murphy ‘sign) irradiates to the right shoulder or

scapulavomiting , exsiccosis

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vomiting , exsiccosisfever usually moderate, but also

chills

The„convergence projection” :in thelateral spinothalamictract the fiberin thelateral spinothalamictract the fiber

number is less than the sensory fibers

somatic> visceralis

the brain “learns” that on the given tract

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the brain “learns” that on the given tract

the somatic signals are transmitted

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Acute pancreatitis

Increasing incidence: 36 to 44/100 000 adultsin California (1994-2001)

200 000 hospital admission/year in the USA200 000 hospital admission/year in the USA

Bile reflux is the trigger (1856 Claude Bernard)

2 enzymes are released from acinar cells

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2 enzymes are released from acinar cells amylase and lipase

Causes

gallstones 38%alcohol abuse 36%pancreas divisum ( congenital abnormality ofpancreas divisum ( congenital abnormality of

the pancreatic duct)intraductal papillary tumorsERCP (increase of serum amylase

after the procedure )

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after the procedure )Serum triglyceride >11mmol/Lsome drugsinfections

Diagnosis Symptoms of acute abdomen•Constant acute pain in the epigastric area or the

right upper quadrant•Nausea , vomiting•Nausea , vomiting•Tenderness in the upper abdomen•Cullen’s sign:

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20% severe (4% die)

Early developmentEarly developmentsequential organ failure

increased capillary permeabilitydecreased intravascular volume hypovolemia renal dysfunction

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renal dysfunctionpulmonary complication

Pancreatic necrosis a very severe complication

Severity is assessed by CT and contrast enhanced CT

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Treatment

Correct fluid lossesmonitor respiratory, cardiovascular and monitor respiratory, cardiovascular and

renal function. Multidisciplinary

Stop parenteral nutrition : a rule!??Infection

antibiotic prophylaxis is debated in

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antibiotic prophylaxis is debated in proven infection: imipenem

43Lancet 2008;371:143¤

44BMJ 2004;328:1407

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Causes of acute abdomen

Diverticulitis� prevalence 5% , increases with age� the sigmoid colon is most commonly involved� the sigmoid colon is most commonly involved� in 50% the only segment, right sided 0,1-2,5%� signs and symptoms protean� left lower quadrant pain, low grade fever,� leucocytosis,nausea, vomiting, distension� Sigmoidoscopy not indicated(perforation!!),nor

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� Sigmoidoscopy not indicated(perforation!!),nor� barium enema, not in acute phase ,only later

"elective "� X-ray or CT scanning

Causes of acute abdomen

Mesenteric ischemia: 0,4% of abdominal surgeryMesenteric ischemia: 0,4% of abdominal surgery�vascular disorders-usually catastrophic illness

–embolic occlusion or thrombosis:intestinal infarction--gangrenous bowel–mortality 40-70%

�abdominal pain,vomiting diarrhea, melena , distension,tendernessbowel sounds from hypoactivity to absent

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�bowel sounds from hypoactivity to absent�Bloody peritoneal transsudate,leucocytosis 20 t hemoconcentration�history of abdominal angina,atrial fibrillation�rapid visceral angiography

Causes of acute abdomen

Perforated peptic ulcer 10% of hospital Perforated peptic ulcer 10% of hospital admission for ulcer 7-10 pts/100000/year�undiagnosed pts die,duodenal 6-8x more often¤�sudden onset epigastric pain"hit with a knife"

–spreading to the entire abdomen:rigidity, diffuse tenderness-hypovolemia, shock

�upright or left lateral decubitus X-ray 55-85%

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�upright or left lateral decubitus X-ray 55-85% pneumoperitoneum:on physical disappearance of hepatic dullness, X-ray�may heal spontaneously,dudenal anterior wall ¤�surgery,broad spect.antibiot,fluid

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Succussion splash

Colonic perforation

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Causes of acute abdomen

Ruptured abdominal aortic aneurysmRuptured abdominal aortic aneurysm

�pain,sudden onset ,midabdominal,paravertebral�pulsatile abdominal mass,hypotension "triad"�risk: atheroscler.diameter and rate of increase

–5,5 cm threshold for elective surgery–Abdominal ultrasound

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–Abdominal ultrasound�X-ray (contrast iv.deviation of the ureters,aortic � wall,CT,angio time consuming

MR�emergency operation-high mortality

Classification of thoraco-abdominal aortic aneurysms

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Atherosclerotic abdominal aortic aneurysm after fatal rupture

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Bowel obstruction: ileus 20% of all acute

Causes of acute abdomen

surgical hospital admissions

causes: mechanical�extrinsic: adhesions,hernias,volvulus,masses

�intraluminal objects: fecal impaction,gallstone,

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gastric bezoars,foreign bodies

�intrinsic lesions:neoplasms,inflammation,

intussusception,hematoma

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Causes of acute abdomen

�Ileus 2 : adynamic(paralytic)�reflex inhibition:laparotomy,trauma�reflex inhibition:laparotomy,trauma�inflammation:peritonitis,toxic megacolon,�acute irradiation�infectious process:appendicitis,cholecystitis�ischemic processes:arterial insuff.�retroperitoneal :ureter,kidney

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�retroperitoneal :ureter,kidney�drug induced:opiates,anticholinergic drugs�metabolic:porphyria ,ketoacidosisX-ray diagnosis: air-fluid levels -small or large bowel

Causes of acute abdomen

�Gynecoligical:in reproductive age�Gynecoligical:in reproductive age� pelvic inflammatory, ectopic pregnancy, ovarian

cyst hemorrhage,adnexal or ovarian torsion�pain,delayed menstrual period,diffuse pelvic�tenderness, acute rupture of blood filled

fallopian tube�SYNCOPE,pelvic examination,pregnancy test

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�SYNCOPE,pelvic examination,pregnancy test

„A good eater must be a good man,

for a good eater must have good

digestion, and good digestion

depends upon good conscience”

Benjamin Disraeli

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Benjamin Disraeli1804-1881

Prime minister of Great-Britain: 1868, 1874-80

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Some reminder of anatomy and Some reminder of anatomy and pathophysiology

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The foregut,midgut and hindgut have andThe foregut,midgut and hindgut have andretain their own innervation and bloodsupply

�forgut : oropharynx to the duodenum (bile duct)

�midgut: distal duodenum,jejunum,

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�midgut: distal duodenum,jejunum,ileum,appendix, ascending colon,proximal 2/3 transverse colon

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hindgut: distal1/3 of transverse colon to�hindgut: distal1/3 of transverse colon toanus

�peritoneum: visceral autonomicinnervation dull,crampy or aching pain

:parietal somatic innervation

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:parietal somatic innervationsharp, severe and persistent pain

Acute abdomen

�Abdominal pain :visceral, somatic or referred�abdominal wall: anterior and lateral spinal T7-L1�abdominal wall: anterior and lateral spinal T7-L1�Two types of nociceptors

–A-delta fibers rapid : sharp well localized–C-fibers slow:dull, poorly localized

� :posterior L2-L5

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�pain fibers enter spinal cord ipsilaterally� visceral pain arises in the midline� fibers enter spinal cord bilaterally

“ To study the phenomenon of disease

without books is to sail an uncharted without books is to sail an uncharted

sea,

while to study books without patients

is not to go sea at all”

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is not to go sea at all”

William Osler

A University should be

a place of light,

of liberty, and of learning.Benjamin DISRAELI, 1873

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Benjamin DISRAELI, 1873

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Diagnosis:

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