the acute abdomen. major causes of the 'acute abdomen' acute cholecystitis acute...
TRANSCRIPT
The Acute AbdomenThe Acute Abdomen
Major causes of the 'acute Major causes of the 'acute abdomen'abdomen'
Acute cholecystitisAcute cholecystitis Acute appendicitisAcute appendicitis or or Meckel's diverticulitisMeckel's diverticulitis Acute pancreatitisAcute pancreatitis Peptic ulcer diseasePeptic ulcer disease Pelvic inflammatory diseasePelvic inflammatory disease Intestinal obstructionIntestinal obstruction, including paralytic ileus (adynamic , including paralytic ileus (adynamic
obstruction) obstruction) Acute intestinal ischaemia/infarctionAcute intestinal ischaemia/infarction or or vasculitisvasculitis Gastrointestinal haemorrhageGastrointestinal haemorrhage Non-surgical disease, e.g. Non-surgical disease, e.g. myocardial infarctionmyocardial infarction, , pericarditispericarditis, ,
pneumoniapneumonia, sickle cell crisis, , sickle cell crisis, hepatitishepatitis, inflammatory bowel , inflammatory bowel disease, opiate withdrawal, disease, opiate withdrawal, typhoidtyphoid, , acute intermittent porphyriaacute intermittent porphyria, , HIVHIV-associated lymphadenopathy or enteritis -associated lymphadenopathy or enteritis
Gallstones and CholecystitisGallstones and Cholecystitis
Gallstones Gallstones may cause no symptoms and may cause no symptoms and are occasionally discoveredare occasionally discovered
The second commonest presentation is The second commonest presentation is acute cholecystitisacute cholecystitis, caused by distension , caused by distension of the gallbladder with subsequent of the gallbladder with subsequent necrosis and ischaemia of the mucosal necrosis and ischaemia of the mucosal wall. wall.
Biliary colicBiliary colic
The pain starts The pain starts suddenlysuddenly in the in the epigastriumepigastrium,,
VVomitingomiting often accompanies the pain, often accompanies the pain,
InvestigationsInvestigations
Urinalysis, Urinalysis, chest X-raychest X-ray and ECG may and ECG may help exclude other diseases. help exclude other diseases.
Ultrasound Ultrasound is the best way to is the best way to demonstrate stones.demonstrate stones.
UltrasonographyUltrasonography can also allow can also allow measurement of the diameter of the measurement of the diameter of the common bile duct common bile duct
Investigations Investigations
Endoscopic retrograde cholangiopancreatEndoscopic retrograde cholangiopancreatographyography (ERCP) is currently the only reliable (ERCP) is currently the only reliable and widely available investigation for and widely available investigation for duct stones.duct stones.
CT mayCT may be useful when filling the bile be useful when filling the bile duct is unsuccessful duct is unsuccessful
Oral cholecystogramsOral cholecystograms (contrast given (contrast given orally is concentrated in a healthy GB orally is concentrated in a healthy GB
CholecystitisCholecystitis
The main difference from biliary colic is the The main difference from biliary colic is the inflammatory component inflammatory component
If the stone If the stone movesmoves to the common bile to the common bile duct (CBD) jaundice may occur duct (CBD) jaundice may occur
Ultrasonography confirms dilatation of the Ultrasonography confirms dilatation of the common bile duct (>7mm diameter common bile duct (>7mm diameter ))
Non-surgicalNon-surgical
Biliary colic and acute cholecystitisBiliary colic and acute cholecystitis - these - these conditions will usually respond to an conditions will usually respond to an opioid opioid such as morphine such as morphine
Pain Pain continuing for over 24 hours or continuing for over 24 hours or accompanied by fever usually accompanied by fever usually necessitates hospital admission. necessitates hospital admission.
RRequire antibioticsequire antibiotics
SurgicalSurgical
Laparoscopic cholecystectomyLaparoscopic cholecystectomy Early surgeryEarly surgery (within seven days of the onset of (within seven days of the onset of
symptoms) appears to be safe and shortens symptoms) appears to be safe and shortens hospital stay, but further studies are needed.hospital stay, but further studies are needed.
Postoperative complicationsPostoperative complications are rare but do are rare but do occur. The most significant is injury to the occur. The most significant is injury to the bile duct which occurs at a rate of 0.2% in bile duct which occurs at a rate of 0.2% in both open and laparoscopic surgery.both open and laparoscopic surgery.
Acute AppendicitisAcute Appendicitis
Sudden Sudden inflammationinflammation of the appendix of the appendix usually caused by obstruction of the lumen usually caused by obstruction of the lumen resulting in invasion of the appendix wall resulting in invasion of the appendix wall by the gut flora. by the gut flora.
Appendicitis is Appendicitis is more common in menmore common in men. . AppendicectomyAppendicectomy is is performed more performed more
often in womenoften in women
Classic symptomsClassic symptoms
Pain:Pain: Early peri-umbilical pain Early peri-umbilical pain movesmoves after after
hours or sometimes days to the right hours or sometimes days to the right iliac fossa iliac fossa
VVomiting, anorexia omiting, anorexia Temperature and pulse are normal at first Temperature and pulse are normal at first Rectal examinationRectal examination: : TR-TR-AppendicectomyAppendicectomy
Intestinal obstruction and ileusIntestinal obstruction and ileus
ObstructionObstruction to free passage of contents can to free passage of contents can occur at any level of the gut but problems such occur at any level of the gut but problems such as oesophageal stricture, oesophageal as oesophageal stricture, oesophageal carcinoma, carcinoma of stomach and pyloric carcinoma, carcinoma of stomach and pyloric stenosis will not be considered here but only stenosis will not be considered here but only obstruction beyond the duodenum. Ileus means obstruction beyond the duodenum. Ileus means intestinal blockage. The term intestinal blockage. The term paralytic ileusparalytic ileus is is used when the problem is inactivity of the bowel. used when the problem is inactivity of the bowel. IleusIleus is often used as a synonym. This may also is often used as a synonym. This may also be called be called intestinal pseudo-obstructionintestinal pseudo-obstruction..
Risk factors:Risk factors:
Small intestinal obstructionSmall intestinal obstruction is caused by is caused by adhesions in 60%, strangulated hernia in adhesions in 60%, strangulated hernia in 20%, malignancy in 5% and volvulus in 20%, malignancy in 5% and volvulus in 5%. 5%.
Large intestinal obstructionLarge intestinal obstruction is most is most often the result of colo-rectal malignancies often the result of colo-rectal malignancies
Sigmoid and caecal volvulusSigmoid and caecal volvulus describes describes rotation of the gut on its mesenteric axis rotation of the gut on its mesenteric axis
Paralytic ileusParalytic ileus Paralytic ileusParalytic ileus describes the condition in which describes the condition in which
the bowel ceases to function and there is no the bowel ceases to function and there is no peristalsis. peristalsis.
chest infection chest infection acute myocardial infarction acute myocardial infarction StrokeStroke,, trauma trauma acute renal failureacute renal failure severe hypothyroidism severe hypothyroidism electrolyte disturbance electrolyte disturbance diabetic ketoacidosisdiabetic ketoacidosis
CClinicallinical
CCentral entral abdominal abdominal painpain VomitingVomiting tends to be early in high level tends to be early in high level
obstruction obstruction Abdominal Abdominal distensiondistension Check Check hernial orificeshernial orifices Plain abdominal x-rayPlain abdominal x-ray is a very important is a very important
investigation investigation
Management:Management:
ResuscitationResuscitation is very important is very important NNasogastric tube will reduce vomitingasogastric tube will reduce vomiting Early surgery is required if there is local or Early surgery is required if there is local or
generalised peritonitis, generalised peritonitis, The management of patients with The management of patients with
obstruction due to malignancy who are obstruction due to malignancy who are unfit for unfit for surgery surgery
Prognosis:Prognosis:
The prognosis of advanced carcinoma The prognosis of advanced carcinoma of the colon remains poorof the colon remains poor. 25% have . 25% have distant metastases distant metastases
50% of sigmoid volvulus50% of sigmoid volvulus will recur in will recur in the next 2 years the next 2 years
60% of stomas60% of stomas are never reversed are never reversed Older patientsOlder patients are less able to are less able to
withstand the rigours of serious illness withstand the rigours of serious illness and major surgery and major surgery
Acute PancreatitisAcute Pancreatitis
PathogenesisPathogenesis
--Gallbladder disease and excess Gallbladder disease and excess alcohol consumptionalcohol consumption account for most account for most cases and typically cause periductal cases and typically cause periductal necrosinecrosis.s.
Biliary disease and alcohol abuse together Biliary disease and alcohol abuse together account for 70%-80% of cases, account for 70%-80% of cases,
SignsSigns
Take temperature to exclude Take temperature to exclude hypothermia hypothermia Probable Probable tachycardiatachycardia Epigastric or generalised Epigastric or generalised abdominal abdominal
tendernesstenderness, often with rigidity. , often with rigidity. In severe cases: In severe cases: gross hypotensiongross hypotension, ,
pyrexia, tachypnoea pyrexia, tachypnoea Hypoxaemia is characteristic of acute Hypoxaemia is characteristic of acute
pancreatitis pancreatitis
InvestigationsInvestigations
Serum amylase >4 x normal: Serum amylase >4 x normal: Raised bilirubin and/or serum Raised bilirubin and/or serum
aminotransferase suggest gall stones. aminotransferase suggest gall stones. Hypocalcaemia is relatively common. Hypocalcaemia is relatively common. CT withCT with contrast enhancement may be contrast enhancement may be
diagnostic where clinical and diagnostic where clinical and biochemical results are equivocal on biochemical results are equivocal on admissionadmission
ManagementManagement
PainPain relief with pethidine or relief with pethidine or buprenorphine ± IV benzodiazepines. buprenorphine ± IV benzodiazepines. Morphine relatively contraindicated Morphine relatively contraindicated because of possible spastic effect on because of possible spastic effect on sphincter of Oddi.sphincter of Oddi.
Nasogastric tubeNasogastric tube only for severe only for severe vomiting. vomiting.
AntibioticsAntibiotics for specific infections. for specific infections.
ComplicationsComplications
Pancreatic necrosisPancreatic necrosis Infected necrosisInfected necrosis Pancreatic abscessPancreatic abscess Acute pseudocystAcute pseudocyst Pancreatic ascitesPancreatic ascites Systemic complicationsSystemic complications Respiratory Respiratory, ,
CardiovascularCardiovascular, , Disseminated Disseminated intravascular coagulopathy (DIC)intravascular coagulopathy (DIC), , HypocalcaemiaHypocalcaemia