Surgical Unit (1)

4th bloc posting

Seminar

4th February, 2016

 Outline of presentation

 What is acute abdomen?

 Common causes

 How to get diagnosis?

 How to manage?
 Acute Abdomen
Synonym: Acute abdominal pain

• A condition of severe abdominal pain,

• causes by an acute disease or injury to the internal organ(s),
• usually requiring emergency surgery.

o Previously undiagnosed pain that arises suddenly

o less than 7 days (usually less than 48 hours duration)
o needs urgent surgical intervention.

o Abdominal pain of a non-traumatic origin

o with maximum duration of 5 days.
Common Causes
Surgical causes

1) Inflammation
2) Perforation
3) Obstruction
4) Strangulation
5) Ischaemia
6) Torsion
7) Abdominal wall
 Surgical causes
1) Inflammation

 Acute appendicitis 2) Perforation

 Acute pancreatitis
 Acute cholecystitis  PU perforation (DU>GU)
 Acute gastritis  Typhoid ulcer perforation
 Meckel’s diverticulitis  Traumatic colonic perforation
 Ruptured aortic aneurysm
 Gall bladder perforation
 Surgical causes

3) Obstruction

 Intestinal obstruction 4) Strangulation

 Ureteric obstruction/colic
 Biliary obstruction/colic  Strangulated hernia
 Intussusception
 Volvulus
 Surgical causes

5) Ischaemia
 Mesenteric thrombosis

6) Torsion
 Testicular torsion

7) Abdominal wall
 Rectus sheath haematoma
 Abdominal wall abscess
 Non-surgical causes
1) Medical causes
 Non-surgical causes
2) Obs & Gynae: causes

• Ruptured ectopic pregnancy

• Acute salpingitis/ acute PID
• Twisted ovarian cyst
• Endometriosis
• Mittelschmerz
• Uterine perforation due to septic induced abortion
 Older patients

• Myocardial infarction
• Lower-lobe pneumonia/pulmonary embolism causing pleurisy
• DKA/HONK
• Pyelonephritis
• Inflammatory bowel disease
How to get diagnosis?
 General appearance

• Looks ill, septic or shocked

• Lying still (peritonitis)
• Rolling around in agony (renal, biliary or intestinal colic)
 History
1) Personal identification: occupation, recent travel, recent abdominal trauma

2) PAIN
• Onset : including new pain or previously experienced
• Site : localized/ diffuse
• Nature : constant/intermittent/colicky
• Radiation
• Severity
• Aggravating factors : if worsened by movement/coughing  peritonitis
• Relieving factors : relieved by sitting forward  pancreatitis
 Associated symptoms
• Vomiting and the nature of vomitus
o undigested food/bile  upper GI pathology or obstruction
o faeculent vomiting  lower GI obstruction
• Haematemesis or melaena
• Stool/urine colour, urinary symptoms
• New lumps in the abdominal region/groins
• Eating and drinking - including when the patient's last meal occurred
• Bowels - diarrhoea, constipation and ability to pass flatus
• Fainting, dizziness or palpitations
• Fever/rigors
• Rash or itching
• Recent weight loss
 History
3) Past medical and surgical history
4) Gynaecological and obstetric history:
• Contraception
• LMP
• History of sexually transmitted infections/pelvic inflammatory disease
• Previous gynaecological or tubal surgery

• Previous ectopic pregnancy

• Vaginal bleeding
5) Drug history and allergies
 Physical Examination
• Temperature, BP, PR
• RR and pattern : patients with peritonitis  shallow, rapid breaths to reduce pain
• If there is altered consciousness, check GCS

Inspection
• Anaemia/jaundice.
• Visible peristalsis
• Abdominal distension.
• Signs of bruising
o around the umbilicus  Cullen's sign  haemorrhagic pancreatitis, ectopic
o flanks  Grey Turner's sign  retroperitoneal haematoma
 Physical Examination
Palpation

• Involuntary guarding, tenderness

• Masses, organomegaly (including the bladder)
• Tenderness at Mc Burney’s point
• Rebound tenderness
• Hernia +/- (strangulation)
• Men, scrotum : referred from unrecognized testicular pathology.
• Supraclavicular and groin lymph nodes
Alvarado’s scoring system
 Migratory RIF pain 1
 Anorexia 1
 Nausea, vomiting 1
1 – 4  very unlikely
 Tenderness at RIF 2
5 – 7  probable
 Rebound tenderness at RIF 1
8 – 10  definitive
 Elevation of Temperature 1
 Leucocytosis 2
 Shift to Left (immature WBC) 1
Total 10
 Physical Examination

Percussion

• Swelling/distension might be due to bowel gas or ascites

• Tenderness to percussion  generalized peritonitis (red flag)
• Shifting dullness
• Fluid thrill
• To determine the size of an abdominal mass/extent of organomegaly
 Physical Examination
Auscultation

• Auscultate the abdomen in all four quadrants.

• Absent bowel sounds  paralytic ileus, generalized peritonitis or
intestinal obstruction.

• Suspected aortic aneurysm  abdominal and iliac bruits.

 Further examination

• DRE or VE as needed
• Lower limb pulsations (abdominal aortic aneurysm)
• Dipstick urine, send for culture if needed
• In a woman of childbearing age, assume that she is pregnant until proven
otherwise - perform a pregnancy test (urine hCG)

• Examine any other system : respiratory, cardiovascular

How to manage?
 Emergency department care
• Nil by mouth
• Apply O2 as appropriate
• IV fluids
• Nasogastric tube
• Analgesia (e.g. morphine)
• Anti-emetics
• Antibiotics (mostly used: IV Cephalosporin + Metro)
• Arrange urgent surgical/ gynaecological review as appropriate
• ECG if suspect medical causes
• Admission
 Investigations

• Blood tests: FBC, U&E, LFT, amylase, glucose, arterial blood gas
(pancreatitis).
• Blood for G&M
• Blood cultures
• Urine pregnancy test in women of childbearing age.
• Urinalysis
• Consider ECG and cardiac enzymes
 Imaging

• Ultrasound abdomen***
• Abdominal X-ray (supine)
• CXR (erect) - gas under the diaphragm
• Intravenous pyelogram (IVP)
• CT scan
 Specific Treatment
Acute Appendicitis
• Treatment of choice is emergency appendicectomy.
1) Grid-iron incision – widely used incision, if the diagnosis is certain
2) Lower midline incision – if the diagnosis is uncertain
3) Rutherford Morison’s incision
4) Lanz incision (transverse skin crease incision)
5) Laparoscopic appendicectomy
• Grid-iron incision – at right angles to a line joining ASIS to umbilicus, its
centre being along the line at McBurney’s point

• Rutherford Morison incision – cutting the internal oblique & tranversus

muscles in the line of incision  better access, para/retro-caecal & fixed

• Lanz incision – transverse skin crease incision made app. 2 cm below the
umbilicus centered on the midclavicular-midinguinal line  better exposure
& easier extension

• Lower midline incision – if diagnosis is doubt, in presence of IO

 Post-operative management

• Ryle tube suction, nil by mouth until bowel sound returns

• IV fluids
• IV antibiotics
• Allow oral fluids & oral antibiotics when bowel sound returns
• Remove stitches at 6th or 7th post-op day
Acute pancreatitis
• Treatment of choice is conservative treatment if diagnosis is certain
• Emergency surgery if only severe pancreatitis does not respond to
conservative management

Acute cholecystitis
• Treatment of choice is conservative treatment followed by interval /early
cholecystectomy

DU perforation
• Treatment of choice is emergency surgery – suturing & omentoplasty
 References

• Bailey & Love’s Short Practice of Surgery, 26th edition, 2013

• Evaluation & management of acute abdominal pain in emergency
department; International Journal of General Medicine, 2012
• Guideline for diagnostic pathway in patients with acute abdominal pain;
Review article in Digestive surgery, December, 2014
• Acute abdomen – www.patient.info.com, last reviewed on October, 2014