Abdominal Trauma

1. During the evaluation of a trauma patient, an upright CXR showed gastric bubble shifted to
the right. No free air is present. What is the main concern? splenic Injury
2. The major findings with injury of the solid abdominal organs are those of hemorrhagic
shock. Signs with solid organ injury include all of the following EXCEPT:
 Abdominal pain and tenderness.
 Early bacterial peritonitis.
 Development of rebound, guarding and rigidity.
 Hypotension and tachycardia.
 Palpable mass and radiographic mass effect (may result from confined hemorrhage).

3. Small bowel injury is the most common injury resulting from blunt abdominal trauma
4. The Classification of abdominal trauma: Blunt and penetrating abdominal trauma.
5. Which organ is the most common in blunt or closed abdominal trauma splenic rupture .
6. Peritoneal irritation signs: Tenderness; rebound tenderness; muscular tension
7. The liver is the second most commonly involved solid organ in the abdomen after the
spleen. However liver injury is the most common cause of death.
8. Gastric injury:
 Often result from penetrating trauma. rarely from blunt trauma.
 Any penetrating abdominal injury, particularly in the upper abdomen, should be
suspected of gastric injury.
 A nasogastric tube should be inserted and if the aspirate is positive for blood, an
gastric injury to should be suspected.
 Careful examination of the anterior and the posterior gastric wall during operation.
9. Colon rupture:
 Morbidity is lower than small intestine rupture.
 Peritonitis is later but more serious because bacteria is much and irritative fluid is
few.
 Enterostomy or intestinal exteriorization is applied to the majority of patients.
 Enterectomy is only suitable for patients with small rupture, fewer pollution and
good systemic condition.
10. Small intestine rupture:
 Small intestine takes up a large part of the abdomen and is likely to be damaged in
penetrating injury.
 It is not difficult to diagnose small intestine rupture because of early occurrence of
peritonitis.
 Pneumoperitoneum isn’t common manifestations in this disease.
 May be associated with complications such as infection, abscess, bowel obstruction,
and the formation of a fistula.
  Operations is necessary: Close perforation by suture or excise damaged intestine
and anastomosis.

11. Duodenal injury:

 Mostly caused by penetrating trauma, rarely by blunt trauma.
 Mostly accompanied by other abdominal injuries.
 A motor vehicle accident causing a steering wheel blow to the epigastrium is the
most common mechanism of blunt duodenal injuries.
 Injury of intra-abdominal duodenum is easy to diagnosis.
 Early diagnosis is difficult for injury of retroperitoneal duodenum (second and third
portions).
 Hyperamylasemia raise suspicion the duodenal injury.
 Diagnosis:
1) Requires plain films or CT.
2) Diagnostic peritoneal lavage is unreliable in detecting retroperitoneal injuries.
3) Intraoperative evaluation requires an adequate exposure of the second, the third
and fourth portions.
12. Rectal injury:
 Upper rectal injury (above peritoneal reflection) is familiar to colon rupture.
 Lower rectal injury (under peritoneal reflection) can’t cause peritonitis but severe
peripheral rectal infection.
 Sigmoid Colostomy.
 After 2-3 months, when rectal injuries heal, reduce the sigmoid

Acute Appendicites
1. Obstruction of the appendiceal lumen, by lymphoid hyperplasia, occasionally by a fecalith,
foreign body, or worms.
2. The obstruction leads to distention, bacterial overgrowth, ischemia, and inflammation, necrosis,
gangrene, and perforation.
3. If the perforation is contained by the omentum, peripheral appendiceal abscess results.
4. Diagnosis of acute appendicitis
 abdominal pain (shifting pain)
 gastrointestinal symptoms (Anorexia, nausea and vomiting).
 Localized abdominal tenderness in RLQ( most important)
 Lower fever
 Leukocytosis
5. Four stages：
 Acute simple appendicitis
1) Mucus accumulating
 2) Intestinal bacteria multiply
3) WBC accumulating
4) Edema of the appendix
 Acute purulent appendicitis
1) A further rise in intraluminal pressure
2) Venous obstruction
3) Further edema and ischemia in the appendix
4) Bacterial invasion through the wall of appendix
5) The formation of pus
 Perforation and gangrenous
1) Venous and arterial thrombosis
2) The area with poorest blood supply infarcted
3) Perforation
4) Spilling accumulating pus
5) Localized Peritonitis
6) Generalized Peritonitis
 Appendiceal abscess
1) Generalized peritonitis
2) Localized peritonitis
3) Healing
6. patient feels vague abdominal discomfort followed by slight nausea, anorexia. The pain is
persistent and continuous.
7. Essentials diagnosis:
 Abdominal pain (shifting pain).
 Gastrointestinal symptoms (Anorexia, nausea and vomiting).
 Localized abdominal tenderness in RLQ (most important).
 Lower fever.
 Leukocytosis.
8. Within several hours, the pain shifts to the right lower quadrant, becoming rather sharply
localized and causing discomfort on moving, walking or coughing.
9. Mcburney’s point, which is a point one-third of the distance between the right anterior
superior iliac spine and the umbilicus
10. Atypical Pain : At the onset of the appendicitis it never become localized and may remain
diffuses , more be found in old patient or child
11. Visceral Pain : It is because the appendix and the small bowel have the same visceral nerve
supply, the obstruction of appendix and the accumu-lation of fluid and mucus then pus lead
to higher intraluminal pressure which cause the pain, so the patient feel pain in the epi-
gastrium or periumbilical area
12. Somatic Pain : Inflammation stimulate the peritonium , leading to localized peritonitis, because
the peritoneum has somatic nerve supply, so the painful area can be exactly pointed
(McBurney point)
13. Differential Diagnosis : The essential differential diagnosis is to eliminate those illness
that do not need operative therapy and to decided suitable operation for those that
need operative therapy.
1) Inflammatory diseases of the right upper abdomen, Such fluids may come from a
perforated duodenal ulcer, gallbladder disease, or inflammatory diseases of the liver(a liver
abscess).
2) Ureteral stone :
 Suddenly sharp extreme pain
 Less tenderness and guarding
 The pain may spreads to the groin
 RBCs were detected in the urine
 B-ultrasound show dilation of ureter
3) Gynecologic diseases
 Pelvic inflammatory disease (PID) :(acute salpingitis , endometritis )
 Relationship to the last menstrual period
 No nausea and vomiting
 More often with bilateral tenderness
 Culdocentesis yield pus .
4) Acute mesenteric adenitis : It often happened in children or young patients, have
respiratory infection history, abdominal tenderness is not localized
5) The others : Gastroenteritis, Diverticulitis, Acute cholecystitis ,Perforating cecal carcinoma,
Torsion of An Ovarian Cyst
14. Acute gastroduodenal ulcer perforation
 An ulcer history
 The most painful area is at epigastrium .
 Tenderness and guarding more severe .
 Air under diaphragm is detected by x-ray.
15. Treatment:
 Early operation because treatment delay increases mortality: Surgical removal
(appendectomy).
 Acute simple appendicitis: appendectomy.
 Acute purulent and gangrenous appendicitis: appendectomy and/or drainage.
 Appendiceal abscess:
1) If local in right low quadrant: antibiotic therapy and general treatment.
2) If infection diffusion: incision and drainage.
 Operation: Appendectomy.
 Incision: incision over the point of maximal tenderness, generally at McBurney point, the
McBurney’s incision: 3—6cm.
 New method: Laparoscopy appendectomy.
16. Special types of appendicitis : Children and the elderly often have fewer symptoms, which
makes their diagnosis less obvious and the incidence of complications more frequent.
17. Appendicitis in pregnancy:
1) Appendix displaced superiorly: Tenderness site upper shift.
2) Elevation of abdominal wall: Inconspicuous of tenderness, rebound tenderness,
muscular rigidity.
3) Without adherent blanket of omentum: Peritonitis diffusion
18. Appendicitis in neonate
1) Seldom
2) Non-specific clinical manifestation
3) Anorexia, nausea, and vomiting diarrhea
4) dehydration
5) Difficult in early diagnosis
6) High rate of perforation
7) High mortality
8) Carefully physical exam
9) Early operation
19. Appendicitis in child
1) Quick onset and severe
2) High fever and vomiting present early
3) Non-typical tenderness at right low quadrant
4) High rate of perforation
5) High mortality
6) More complication
7) Early operation
8) Transfusion and correct dehydration, Broadspectrum antibiotics
20. Appendictis in the elderly
1) Less well-defined symptoms and signs
2) Severe pathologic type
3) Error diagnosis easily
4) High rate of perforation
5) Pay attention to tumor

21. Treatment :
1) Operation: appendectomy, early operation
2) To early and late pregancy: abortion, premature birth
 3) Superior Incision
4) Broad spectrum antibiotics
STOMACH AND DUODENUM DISEASES
1. Peptic ulcer: Any gastrointestinal ulcer caused by contact with acid-pepsin secretions.
2. Three main types of peptic ulcer:
 Duodenal ulcer diathesis (duodenal,pyloric channel,and synchronous gastric and
duodenal ulcer).
 Chronic gastric ulcer.
 Acute gastric mucosal ulcerations
3. Duodenal ulcer: Men are more frequently affected than women. Psychological factors
(chronic psychic stress) are accepted as the most common link in the genesis of
duodenal ulcers. Coffee drinking and excess alcohol intake might increase the incidence
of duodenal ulcer.
4. Essential diagnosis:
 Epigastric pain at hungry time or during midnight (relieved by food or antacids).
 Epigastric tenderness.
 Normal or increased gastric acid secretion.
 Ulcer on endoscopy, or Signs of ulcer disease on upper gastrointestinal X-rays.
 Evidence of Helicobacter pylori infection
5. Gastric ulcer: 3 to 4 times less common than duodenal ulcer. Occurs more frequently in
middle aged and elderly persons and about equally in men and women. Evidence points
to a defective mucosal barrier and back-diffusion of acid as the immediate cause. About
80% of gastric ulcers appear in stomachs that secrete normal or smaller amounts of acid.
Other 20% of gastric ulcer usually occur just inside the pylorus or are associated with
duodenal ulcer, arising in a hyperacidic environment, belong in the duodenal ulcer group.
6. Clinical findings of gastric ulcer:
 Compared with duodenal ulcer, the pain in gastric ulcer tends to appear earlier after
eating, often within 30 minutes.
 Vomiting, anorexia, and aggravation of pain by eating.
7. Differential diagnosis:
 The characteristic symptoms of gastric ulcer are often clouded by numerous
nonspecific complaints.
 Uncomplicated atrophic gastritis, chronic cholecystitis, irritable colon syndrome, and
undifferentiated functional problems are distinguishable forms peptic ulcer only
after appropriate radiologic studies and sometimes not even then.
 Gastroscopy and biopsy of the ulcer should be performed to rule out malignant
gastric ulcer.
8. Comparison of Duodenal and Gastric Ulcer.
Duodenal ulcer Gastric ulcer
Cause Inc. acid secretion, inc. Defective mucosal barrier
gastrin, defect in acid and back-diffusion of acid
 disposal
Age Younger (20 to45 years) Somewhat older (40-60)
Sex Male:female,7:1 Male:female,1:1
Symptoms Much the same. Pain appears Much the same. Pain
at the hungry time or during appears earlier after eating
the midnight
Malignancy Rare 5%
Free HCL 12 hour night 60 mEq (average), Normal or 12 mEq (average), lower
secretion Higher Than the normal
Medical treatment Excellent (successful in over Poor (successful in 50%)
90%)
Surgical treatment Vagotomy and antrectomy or Removal of the ulcer with
pyloroplasty,parietal cell limited partial gastrectomy
vagotomy,subgastrectomy
9. Essential diagnosis of gastric ulcer:
 Epigastric pain (appears earlier after eating).
 Epigastric tenderness.
 Decreased gastric acid secretion.
 Ulcer on endoscopy, or Signs of ulcer disease on upper gastrointestinal X-rays.
 Evidence of Helicobacter pylori infection.
10. Hemorrhage from Peptic Ulcer: Peptic ulcer is the most common cause of massive
upper gastrointestinal hemorrhage, amounting for over half of all cases. “Blind
subgastrectomy”. Bleeding occurs in 10% to 15% of patients with duodenal or gastric
ulcer. The diagnosis is unreliable when based on clinical findings, so endoscopy and
endoscopic therapy should be performed early (i.e, within 24 hours) in most cases.
11. Nonoperative treatment: This kind of treatment for perforated ulcer consists of
continuous gastric suction and the administration of antibiotics in high doses. Although
this has been shown to be effective therapy, with a low death rate, a peritoneal and
subphrenic abscess occasionally accompanies it, and side effects are greater than with
laparoscopic closure
12. Surgical treatment:
 The simplest surgical treatment, laparoscopy (or laparotomy) and suture closure of
the perforation solves the immediate problem.
 More aggressive treatment involves a definitive ulcer operation for most patient
with acute perforation, eg subgastrectomy, parietal cell vagotomy plus closure of the
perforation or truncal vagotomy and pyloroplasty. Now that eradicating H pylori can
cure ulcer disease, the value of anything more than simple closure will have to be
reexamined.
 Concomitant hemorrhage and perforation are most often due to two ulcers, an
anterior perforated one and a posterior one that is bleeding. Perforated ulcers that
also obstruct obvious cannot be treated by suture closure of the perforation alone.
Pyloro-plasty should be performed.
  Perforated anastomotic ulcers require a vagotomy or gastrectomy, since in the long
times, closure alone is nearly always inadequate.
13. Gastric carcinoma: Gastric cancer is one of the commonest malignant tumors. It often
be found in 40 to 60 years people. The ratio of male/female is 3/1.
14. Chemotherapy: Adjuvant chemotherapy after curative surgery for advanced disease,
doxorubicin or 5-fluorouracil alone, each of which results in a 20% response rate, is as
good as a combination of chemotherapeutic agents. Now, more new chemotherapic
medicine are discovered

PERFORATED PEPTIC ULCER

15. A. Symptoms and Signs:
1. The perforation usually elicits a sudden,severe upper ,abdominal pain whose
onset can be recalled precisely.
2. The patient may or may not have had preceding chronic symptoms of peptic
ulcer disease. Perforation rarely is heralded by nausea or vomiting, and it
typically, occurs several hours after the last meal. Shoulder pain, if present,
reflects diaphragmatic irritation.
3. The patient appears severely distressed , lying quietly with the knees drawn up
and breathing shallowly to minimize abdominal motion. Abdominal distention
and diffuse tympany may result if delay.
4. There are abdominal muscles rigid (owing to severe involuntary spasm),
Epigastric tenderness and rebound tenderness ,which may not be as marked as
expected in elder patients.
5. Escaped air from the stomach may enter the space between the liver and
abdominal wall, and upon percussion the normal dullness over the liver will be
tympanitic.
6. Peristaltic sounds are reduced or absent
7. Fever is absent at the start.
8. Lesser degrees of shock with minimal abdominal findings occur if the leak is small
or rapidly sealed.
9. A small duodenal perforation may slowly leak fluid that runs down the lateral
peritoneal gutter, producing pain and muscular rigidity in the right lower
quadrant and thus raising a problem of confusion with acute appendicitis.
10. Perforations may be sealed by omentum or by the liver, with the later
development of a subhepatic or subdiaphragmatic abscess
16. B. Laboratory Findings:
1. A mild leukocytosis in the range of 12,000/uL is common in the early stages. After
12-24 hours, this may rise to 20,000/uL or more if treatment has been inadequate.
2. The mild rise in the serum amylase value that occurs in many patients is probable
caused by absorption of the enzyme from duodenal secretions within the peritoneal
 cavity. Direct measurement of fluid obtained by paracentesis may show very high
levels of amylase.
17. C. Imaging Studies:
1. Plain x-rays of the abdomen reveal free subdiaphragmatic air in 85% of patients.
Films should be taken with the patient both supine and upright.
2. If the findings are questionable ,400mL of air can be insufflated into the stomach
through a nasogastric tube and the films repeated. Free air in the abdomen in a
patient with sudden upper abdominal pain should clinch the diagnosis.

18. Pathology of Gastric carcinoma:

1. Early gastric cancer: tumour is limited in the mucosa or submucosa,whether there is
lymphatic metastasis or not.
2. Advanced gastric cancer
BorrmannⅠ: Polypoid carcinoma
BorrmannⅡ: Ulcerating carcinoma
Borrmann Ⅲ: Invasived ulcerating carcinoma
Borrmann Ⅳ: Linitis plastica
Borrmann Ⅴ：(mixed)

INTESTINAL OBSTRUCTION
1. Intestinal obstruction: An interference in the normal movement of the bowel contents
through the intestinal tract. The small bowel is about 20 feet long, and the large bowel is
5 feet long. This 4 to 1 ratio parallels the ratio of mechanical obstruction that occur in
the small and large bowels; 80% occurs in the small bowel, and only 20% involve the
large bowel.
2. Mechanical obstruction:
 The “big three” causes of adult mechanical obstruction are hernias (incarcerated or
strangulated), adhesions, and tumors. Hernias and adhesions together account for
about 70%. Tumors cause about 15% of all bowel obstruction, but they are the most
common cause of large bowel obstruction.
 In the child,intestinal obstruction limited primarily to congenital defects and
intussusception.
1) Adhesions: Adhesions are by farther most common cause of mechanical small
bowel obstruction.
2) Hernia: Incarceration of an external hernia (including incisions) is the second
most common cause of intestinal obstruction. Inguinal, femoral, or umbilical
hernias may have been present for years.
3) Neoplasms: Neoplasms of the small bowel are rare cause of obstruction. In
contrast, neoplasms cause most obstructions of the colon. Left colon lesions may
cause tremendous dilation of the proximal colon when the ileocecal valve is
competent.
 4) Intussusception: It’s more often seen in children; an organic lesion is not
required, and the syndrome of colicky pain, passage of blood per rectum, and a
palpable mass is characteristic.
5) Volvulus: Twisting of a portion of gastrointestinal tract. Sigmoid vovulus is the
most common; cecal vovulus occurs when the cecal mesentery is long; vovulus of
the stomach is rare.
6) Obturation: Results when materials within the gut occlude the lumen. Such as:
fecal impaction, gallstone, bezoar, ingested foreign bodies, ascaris lumbricoides.
7) Inflammatory bowel disease: Disease often causes obstruction when the lumen is
narrowed by inflammation or fibrosis of the wall. Such as: tuberculosis, regional
eneritis,ulcerative colitis and amebiasis.
8) Paralytic ileus:
 Direct peritoneal irritation from any source: Acute cholecystitis, pancreatitis,
appendicitis, perforation of a hollow viscus, or any abdominal operation.
 Extraperitoneal irritation: hemorrhage, trauma to retroperitoneal nerve,
pneumonitis, etc.
 Systemic imbalances: Infections, electrolyte imbalance, shock, uremia,
myxedema.
 Neurogenic disorders: Severe strokes, central nervous system trauma ,or
spinal cord lesion.
9) Vascular obstruction is the reverse, pathologically, of stragulation obstruction;
primary blood vessel blockage precedes and causes bowel obstruction. Occlusion
of the superior mesenteric vessels produces vascular compromise of that
segment of small intestine distal to the point of occlusion. The causes are
embolism or thrombosis. Embolism originate within the left side of
heart,generally associated with auricular fibrillation. Thrombosis may be caused
by increased venous pressure (abdominal tumor, cirrhosis, congestive heart
failure), hypercoagulability (polycythemia, some cancers), or vascular diseases
(collagen diseases, vasospastic diseases, prolonged infections, or trauma).
 In the child, intestinal obstruction limited primarily to congenital defects and
intussusception.
3. Symptoms:
 Abdominal pain.
Pain is typically cramping and intermittent. Each episode of cramps has a crescendo-
decrescendo pattern, lasts for a few seconds to a few minutes, and recurs every few
minutes. Continuous pain usually signifies strangulation or perforation. Vomiting
temporarily relieves the pain from upper gastrointestinal obstruction.
 Vomiting: In high obstruction vomiting occurs as an early symptom. In low
obstruction feculent vomiting results from stagnation and bacterial putrefaction.
  Abdominal distention: In high (proximal small bowel) obstruction, distention is
minimal. In low obstruction, distention is massive because of the greater amount of
bowel that is filled with gas and liquid.
 Obstipation: Because intestinal obstruction may be only partial or intermittent.
However, complete obstruction usually produces eventual failure to pass either gas
or feces.
4. Signs:
 General signs:
1) Vital signs may be normal in the early stages, but dehydration is noted with
continued loss of fluid and electrolytes.
2) Temperature is normal or mildly elevated. When strangulation supervenes in
simple obstruction, high fever may develop.
3) Shock that appears early in the course of obstruction suggests a strangulated
closed loop.
 Abdominal signs:
1) Inspection:
 Abdominal distention is minimal to absent in proximal obstruction but is
pronounced in more distal obstruction.
 Peristalsis in dilated loops of small bowel may be visible beneath the
abdominal wall in thin patients.
 Incarcerated hernias should be sought.
2) Palpation: Mild tenderness may be elicited. When strangulation supervenes in
simple obstruction, abdominal tenderness and rigidity may appear.
3) Percussion: Later, there may be percussion dullness, moved with position, when
there is fluid in the peritonum.
4) Auscultation: Peristaltic rushes, gurgles, and high-pitched tinkles are audible in
coordination with attacks of cramping pain in distal obstruction.
5. Laboratory findings:
 X-ray findings:
1) Supine and upright plain abdominal films reveal a ladder-like pattern of dilated
small bowel loops with air–fluid levels. These features may be minimal or absent
in early obstruction, proximal obstruction, or closed loop obstruction or in some
cases when fluid-filled loops contain little gas.
2) Plain films of the abdomen may also show free air in the peritoneal cavity,calculi
in the biliary or renal areas,fecaliths,tumors,or radiopaque foreign bodies.
3) Barium enemas help to localize the area of colon obstruction.
4) In suspected cases of obstruction, radiologists use oral barium cautiously
because of the inspissation of the barium above the obstruction.
 Laboratory examinations:
 1) Blood studies: In the early stages, laboratory examinations may be normal; with
progression of disease, there are hemoconcetration, leukocytosis,and electrolyte
abnormalities. Serum amylase may be slightly elevated.
2) Urinalysis: Glycosuria or proteinuria should indicate the paralytic ileus caused by
diabetic acidosis or primary renal disease.
6. Partial intestinal obstruction can be treated expectantly as long as there is continued
passage of stool and flatus. Plain abdominal x-rays show gas in the colon, and small
bowel contrast x-ray proves the diagnosis. Decom-pression with a nasogastric or long
intestinal tube (ileus tube) is successful in 90% of such patients. Operation is required if
obstruction persists for several days even though it is incomplete
7. General treatment:
 Nasogastric suction: Nasogastric tube should be inserted immediately upon
admission to the emergency ward in order to relieve vomiting, avoid aspiration, and
reduce the contribution of further swallowed air to the abdominal distention.
 Fluid and electrolyte resuscitation: Depending upon the level and duration of
obstruction, fluid and electrolyte deficits are mild to severe. Losses of
gastrointestinal fluid also entail acid-base deficits.
 Antibiotics treatment: Antibiotics should be given if strangulation is even remotely
suspected.
8. Operation: Operation may commence when the patient has been rehydrated and vital
organs are functioning satisfactorily. Occasionally, the toxic effects of strangulation may
force operation at an earlier time. Details of the operative procedure vary according to
the cause of obstruction.
9. Is there intestinal obstruction or not? According to symptoms(abdominal
pain,vomiting,abdominal distention, obstipation), signs and X-ray,intestinal obstruction
can be diagnosed in most patients.
10. Is it mechanical obstruction or paralytic ileus?

11. Case maybe intestinal obstruction.

12. what cause intestinal obstruction? Adhesions?Hernias?Neoplasm?Others?