Acute Abdomen and its management updates.pptx
- 1. Presentation on Acute Abdomen & its Management Presented by- • Naima Jahan • Marjana Jannat • Zannatul Mysha • Ashief Ahmed • Tafjul Islam • Sadiazzaman juthi • Samira Chowdhury • Joy Prokash • Tofayel Ahmed • Mustafizur Rahman
- 2. What is acute abdomen? Acute abdomen a clinical scenario in which a patient presents with an intra-abdominal pathology manifesting with abdominal pain or obstruction,which warrant urgent investigation and treatment,often including parental fluid and sometimes surgery. It is the most common presenting Surgical Emergency Prepared by marj
- 3. Regions of abdomen : Prepared by marjan
- 4. Fig: Nine sites of abdominal pain Prepared by
- 5. Pathophysiology of acute abdomen 1) Inflammation: localized or generalized inflammation causes pain due to irritation of the peritoneum Eg- appendicitis, cholecystitis, diverticulitis, PID,pancreatitis,acute pyelonephritis 2) Obstruction: central colicky abdominal pain is a classical presentation of small bowel obstruction. Eg- intestinal obstruction, volvulus,gallstone ileus,intussusception,ureteric stone, 3)Rupture & perforation of organ:Trauma,ischemia or tissue ulceration may cause perforation with resulting in severe abdominal pain. Eg- perforated peptic ulcer ,perforated diverticulum , rapture aortic aneurysm, 4)Trauma-blunt & penetrating abdominal trauma etc.
- 6. Clinical symptoms 1 . Abdominal Pain 2. Associated Gastrointestinal Symptoms- Nausea, vomiting, Diarrhoea,constipation, abdominal distention . 3. Systemic symptoms- Fever, tachycardia ,hypotension, shock,Malaise, chills. ■ The primary symptom of the "acute abdomen" is –Abdominal pain
- 7. Types of Abdominal Pain: 1. Visceral Due to stretching of fibers innervating the walls of hollow or solid organs. 2. Parietal Caused by irritation of parietal peritoneum. 3. Referred pain Pain is felt at a site away from the pathological organ
- 12. Management of acute abdomen • Initial assessment • History • Thorough physical examination Diagnosis can be made most of the time by a good history and a proper physical examination. An exact diagnosis often impossible to make after the initial assessment, and often relying on further investigation
- 13. 1. Initial assessment Airway: Ensure it's clear. Breathing: Check respiratory rate, oxygen saturation. Give O2 if needed. Circulation: Monitor pulse, BP. Start IV line, give fluids (usually normal saline or Ringer's lactate).
- 14. 2. History & clinical examination History of pain: ● Onset: Sudden: perforation of bowel. Rapid- inflammation like Appendicitis, cholecystitis. Slow insidious onset: obstruction,malignancy ● Duration: Less than 24 hours ● Characteristics: Aching-dull pain poorly localized Burning- peptic ulcer symptoms Stabbing-ureteric colic Gripping - smooth muscle spasm e.g. intestinal obstruction worse by movement
- 15. ● Intensity- Mild- Appendicitis, Severe- pancreatitis ● Localization & Migration Epigastric→ back: Pancreatitis, perforated ulcer RLQ → periumbilical : Appendicitis RUQ → scapula/back: Biliary colic/cholecystitis Flank → groin/testicle/ thigh: Renal (ureteric) colic LUQ → left shoulder/back: Splenic rupture, pancreatitis
- 16. ● Aggravating & relieving factors Movement/motion worsens parietal pain (peritonitis); lying still brings relief Colicky pain: Eased by vomiting or movement Pain relief patterns: Duodenal ulcer relieved by food Gastric ulcer worsened by food Biliary colic triggered by fatty meals
- 17. In females, abdominal pain = GYN problem until proven otherwise ● Females ○ Last menstrual period? ○ Abnormal bleeding? Associated symptoms •Nausea,vomiting,fever, bowel/bladder habits, bloody discharge, change in urinary habits, urine appearance,change in bowel habits, hematemesis, melena,regular food/water intake. Prepared by
- 18. Past history -previous surgery, trauma,any medical diseases. Drug history – corticosteroid: masking pain ,anti-coagulant: intra-mural hematoma, NSAIDS: gastritis, peptic ulcer. Family history -colon cancer,IBD.
- 19. General examination Local examination ● Inspection: look for abdominal distension, Position of the umbilicus, Flanks full or not, visible peristalsis, Pulsation, engorged vein,pigmentation. ● Palpation: Check for temperature, tenderness, guarding, rigidity, rebound tenderness, masses, organomegaly. ● Percussion: Assess tympany, shifting dullness (ascites), and percussion tenderness. ● Auscultation: Note bowel sounds - absent, decreased, or increased. 3.Examination:
- 20. 3. Investigations Blood: CBC, electrolytes, liver/renal function, amylase/lipase,serum creatinine, serum -hCG (in females). ẞ Imaging: •X-ray abdomen (erect): For air under diaphragm (perforation), obstruction signs. •Ultrasound (USG): Gallstones, ectopic pregnancy. •CT scan: If diagnosis unclear-more sensitive for appendicitis, pancreatitis, abscess. •MRI Urine Test: Routine exam, pregnancy test.
- 21. 4.Supportive management ● NPO (nothing per oral) until further instructions. ● IV Fluids: Maintain hydration. ● NG Tube: If vomiting/severe distension. ● Urinary Catheter: For monitoring urine output if needed. ● Analgesic: Usually opioids (e.g. tramadol, morphine). ● Antibiotic: Broad-spectrum IV antibiotics if infection suspected (e.g. ceftriaxone,penicillin etc). ● Antiulcerant ● Antiemetic
- 22. 5.Monitoring & follow up Monitor vitals, urine output, and lab values regularly. Reassess diagnosis if condition deteriorates.
- 23. Surgical treatment • Appendicitis: appendisectomy • Cholecystitis: open or laparoscopic cholecystectomy • Peptic ulcer disease/Duodenal ulcer: vagotomy; Billroth -2 gastrectomy; gastrojejunostomy • Pyloric stenosis: pyloromyotomy • Intestinal obstruction: bowelresection &end to end anastomosis •Trauma. : damage control surgery •Perforated peptic ulcer: closure& omental patch(graham’s patch Prepared by marjana
- 24. Symptoms Differential diagnosis Fever,vomiting, Diarrhoea Acute gastroenteritis Fever,dysuria,renal angle tenderness,hematuria Renal stone Fever,vomiting, abdominal distention, constipation Intestinal obstruction Fever,right iliac pain,vomiting Acute Appendicitis
- 25. Symptoms Differential diagnosis Fever,pain in epigastrium, radiate to back, relief by leaning forward. Acute pancreatitis Fever, Burning intermittent pain in epigastrium temporary relief by food and antacid Peptic ulcer disease Fever, vomiting, reffered pain in tip of the right shoulder Acute cholecystitis
- 26. Now let's discuss about some common causes of acute abdomen
- 28. Appendicitis : Inflammation of Appendix is called appendicitis. Acute appendicitis is the most common cause of acute abdomen in young adults
- 29. Etiology: There is no unifying hypothesis regarding the etiology of acute appendicitis.Decreased dietary fiber and increased consumption of refined carbohydrate may be important. The incidence of appendicitis is lowest in societies with a high dietary fiber intake. In resource- poor countries that are adopting a more refined western type diet, the incidence continues to rise.
- 30. Causes: ● Foreign body ● Fecolith (hard stool) ● Trauma ● Immunocompromised (infection) ● Unknown/Idiopathic Symptoms: ●Periumbilical colic ● Pain shifting to the right iliac fossa ● Anorexia ● Nausea ● Fever
- 31. Clinical signs in appendicitis : ● Pyrexia ● Localised tenderness in the right iliac fossa ● Muscle guarding ● Rebound tenderness Signs to elicit in appendicitis: ● Pointing sign ● Rovsing’s sign ● Psoas sign ● Obturator sign
- 33. Differential Diagnosis Children Adult Adult female Elderly Gastroenteritis Regional enteritis PID Diverticulitis Mesenteric adenitis Ureteric colic Ectopic pregnancy Intestinal obstruction Intussuception Perforated peptic ulcer pyelonephritis Colonic carcinoma Meckels diverticulitis Torsion of tetis Torsion/ rupture of ovarian cyst Mesenteric infarction Lobar pneumonia pancreatitis endometriosis Aortic aneurysm
- 34. Complications: 1) Appendicular lump 2) Appendicular abcess 3) Perforation 4) Peritonitis 5) Septicemia 6) Gangrenous Apenndicitis Investigation The diagnosis of acute appendicitis is essentially clinical.
- 37. Treatment : Conservative: ● NPO until further instructions ● IV fluids ● IV antibiotics ● Analgesic ● Oxygen supplemention ● Monitoring of vital sign Surgical: The main surgical treatment for appendicitis is appendectomy performed by either: ● Open surgery ● Laparoscopic surgery
- 39. Defination: Cholecystitis refers to the inflammation of the gallbladder. This condition may develop suddenly, known as acute cholecystitis, or persist over a longer period, termed chronic cholecystitis. Commonly, it occurs in a patient with pre-existing chronic cholecystitis but often also can occur as a first presentation. Usual cause is impacted gallstone in the Hartmann's pouch, obstructing cystic duct. Cholecystitis
- 40. Types Acute chelecystitis is two types: ● Calculus Cholecystitis Refers to gallbladder inflammation that is directly associated with the presence of gallstone. ● Acalculus Cholecystitis Refers to inflammation of the gallbladder occurring without the presence gallstone or any blockage in the cystic duct.
- 41. Clinical features: ● Pain in the right hypochondrium, initially colicky than constant. ● Pain reffered to back, right scapula or tip of right shoulder. ● Palpable, tender, smooth, soft gallbladder. ● Fever, nausea, palpable tender mass in GB region (25%). ● Muscle guard & muscle rigidity in abdomen. ● Area of hyperaesthesia between 9th and 11th ribs posteriorly on the right side (Boas's sign). ● Murphy's sign may be positive.
- 42. Location: Just below the 9th costal cartilage.
- 43. Investigation: ● Blood for TC,DC- Neutrophilic leucocytosis. ●Ultrasound abdomen-Very useful, reveals presence or absence of gallstones and thickening of gallbladder wall. Sonographic Murphy's sign may be positive. ●Plain X-ray abdomen-10% of gallstones are radio-opaque; also rules out other causes of acute pain abdomen. Gas is seen in emphysematous GB. ●CT scan is useful in identifying the perforation, impacted stone, gallbladder wall thickness and oedema.
- 45. Treatment: ●Initially conservative treatment- -Nasogastric aspiration. -IV fluids. -Analgesics and antispasmodics. -Broad spectrum antibiotics. ●Surgery -Cholecystectomy.
- 46. Cholecystectomy ●Open 》 Right subcostal incision (Kocher's) 》 Right paramedian; midine incision. 》 Horizontal incision. 》 Mayo-Robson incision ● Laparoscopic approach.
- 48. Definition: Acute inflammation of the pancreas is called acute pancreatitis. Pathogenesis of acute pancreatitis : Pancreatic duct obstruction edema Compression of blood vessel Ischemia ⇨ ⇨ ⇨ ⇨ acinar cell injury release of pancreatic & lysosomal enzymes activation of ⇨ ⇨ enzymes autodigestion of pancreas. ⇨ Pancreatitis.
- 49. Etiology: 1.Gall stone(most common) 2.Alcohol 3.Trauma(Blunt,Iatrogenic ERCP) ⇨ 4.Biliary tract disease 5.Drugs-Halothane,Steroids,antipsychotic drugs. Management of acute pancreatitis : 1) Clinical Features- i. Sudden severe epigastric pain radiating to the back. ii. Pain exaggerated after fatty meal & Relived by leaning forward position. iii. Nausea,Vomiting,Fever.
- 50. 2)Investigation - i. Biochemical test : Serum amylase-↑, *Serum lipase-↑ ii. Imaging : a. Ultrasonogram of whole abdomen special attention to hepatobiliary system with pancreas b. CT scan iii. Hematological : Complete Blood Count(CBC) ## To predict the severity of acute pancreatitis there is 2 types of scoring- Ranson & Glasgow scoring.
- 51. 3) Treatment- Conservative i. NPO(nothing per oral) until further instructions ii. IV fluid iii. Oxygen supplementation iv. Analgesic to relief pain v. Antibiotic to prevent secondary infections vi. Monitoring of the vital signs vii. Catheterization to measure intake & output **HDU transfer may be needed.
- 52. #Two clinical signs seen in severe(hemorrhagic) pancreatitis: 1)Cullen’s sign- discoloration around the central umbilicus. 2)Grey Turner's sign- discoloration in & around the flanks.
- 53. Differential diagnosis : 1) Peptic ulcer disease 2) Acute cholecystitis 3) Myocardial infarction Complications : 1) Local- • Peripancreatic fluid collection • Pancreatic abcess • Pancreatic ascites • Pseudocyst 2) Systemic- •CVS -Shock,arrhythmias •Pulmonary - ARDS •Kidney - Renal failure •Hematological - DIC
- 54. Intestinal obstruction Definition: Intestinal Obstruction is an interruption in the normal forward flow of intestinal content along the intestinal tract. Prepared by marja
- 55. Causes of Intestinal Obstruction A. Dynamic Intra luminal- Fecal infection, Foreign body, Gall stone, Bezoar Intra mural- Volvulus, Stricture, Malignancy Extra mural- Band, Adhesion, Obstruction B. Adynamic- Paralytic ileus, Pseudoobstruction, Mesenteric vascular occlusion
- 56. Symptom: -Pain -Vomiting -Distention -Constipation Sign: -Dehydration -Hypokalemia -Pyrexia -Abdominal tenderness -High pitched bowel sounds
- 57. Investigations: 1) Plain x-ray of abdomen in erect posture with both dome of diaphragm. 2) Ultrasonogram of whole abdomen 3) CT-scan 4) CBC 5) Serum electrolyte 6) Serum creatinine
- 58. Fig: X-ray of small bowel obstruction Prepared by SAMIRA In small bowel obstruction, Multiple gas fluid level in the centre of abdomen & Valvulae conniventes (multiple ring like radio opaque shadow) seen
- 59. Fig: X-ray of Large bowel obstruction Prepared by SAMIRA In large bowel obstruction,Mul tiple gas fluid at the periphery & haustral fold are seen.
- 60. Treatment: 1.Nothing by mouth until further instructions 2.Gastrointestinal drainage via nasogastric tube 3.Fluid & electrolyte replacement 4.Antibiotics 5.Catheter 6.Relief of obstruction: Usually surgical, surgical treatment is necessary for most cases of intestinal obstruction but should be delayed until resuscitation is complete, provided there is no sign of strangulation or evidence of closed-loop obstruction
- 61. • Steady, well-localized epigastric or LUQ pain • Described as a “burning”, “gnawing”, “aching” • Increased by coffee, stress, spicy food, smoking • Decreased by alkaline food, antacids Prepared by Pain due to - Duodenal ulcer relieved by food Gastric ulcer worsened by food Peptic Ulcer Disease
- 62. Fig- xray of a perforated peptic ulcer Cresentic gas shadow under right dome of diaphragm Prepared by marjana
- 63. Treatment of PUD: A) Lifestyle modifications : 1.Avoid spicy food,smoking,alcohol 2.Maintain hydration 3.Discontinue NSAIDs B)Medical management : 1.Proton pump inhibitors 2.H2 receptor antagonist 3.Antacid C) H.pylori eradication therapy: Tripple therapy
- 64. D) Surgical treatment: For gastric ulcer- 1.Bilroth-1 gastrectomy removal of distal ⇨ portion of the stomach 2.Bilroth-2 gastrectomy removal of lower ⇨ portion of the stomach For duodenal ulcer- 1.Truncal vagotomy 2.selective vagotomy 3.Highly selective vagotomy Prepared by SAMIRA
- 65. Ureteric colic ● Severe, sudden flank pain due to urinary tract obstruction, usually by a kidney stone. ● Felt in the flank (costovertebral angle/ renal angle) and radiates to groin, scrotum in males, or labia in females,thigh. Investigations: • Urinalysis: hematuria. •Non-contrast CT KUB (investigation of choice). •Ultrasound for hydronephrosis. •Plain xray of KUB region Prepared by marja
- 66. Management 1. Initial Management • Pain relief (first line): NSAIDs (e.g. diclofenac IM or IV). • If pain persists: Add opioids (e.g. morphine) if NSAIDs are insufficient. 2. Hydration 3. Medical Expulsive Therapy (for stones <10 mm) Drink plenty of water,joulting movement Alpha blockers: e.g. tamsulosin to facilitate stone passage. 4.definate Management ( if stone doesn't pass or complications arises) ESWL (Extracorporeal Shock Wave Lithotripsy): For stones <2 cm. URS (Ureteroscopy) + Laser lithotripsy: For mid/distal ureteric stones. PCL (Percutaneous urolithotomy): For large (>2 cm) renal stones. 5. Emergency Intervention - ureterolithotomy
- 67. Definition: Implantation of fertilized ovum outside uterus is called ectopic pregnancy Prepared by marja
- 68. Ectopic pregnancy ● Presents with sudden lower abdominal pain, amenorrhea, and vaginal bleeding. ● If ruptured, it can lead to hemoperitoneum and shock, mimicking other surgical emergencies. ● A common cause of acute abdomen in reproductive-age women. ● Investigation: i) Blood:Hb%,TC,DC,ESR ii) Blood grouping & Rh typing iii) Transvaginal sonography Treatment: Surgical (laparoscopic removal) or medical (methotrexate) if unruptured. ● Diagnosis: ○ Positive B-hCG, ○ transvaginal USG shows empty uterus.
- 69. ##Case Presentation: A 60-year-old woman presents to the emergency department with sudden onset of severe epigastric pain radiating to the back, which started 8 hours ago. The pain is constant and worsens when lying flat. She has had multiple episodes of vomiting and appears distressed. She reports no history of alcohol consumption, trauma, or recent medication changes. *On examination: •Pulse: 108 bpm •BP: 98/60 mmHg •Temperature: 101°F (38.3°C) •Abdomen: Epigastric tenderness, reduced bowel sounds •No hepatosplenomegaly, no guarding •Mild icterus present
- 70. ☞ Questions: 1)What is the most likely diagnosis? 2)What is the most probable underlying cause in this patient? 3)What are the signs & symptoms suggesting your diagnosis in this patient? 4)Mention two clinical signs that suggest severity of this disease. 5)Which investigations would you order to confirm the diagnosis and identify the cause? 6)How would you manage this patient initially? 7)What complications would you monitor for in the next few days?
- 71. Case presentation Suppose you are an intern/Mo in a busy hospital. You are referred to a 29 year old woman with a severe and unremitting periumbilical pain.The pain has been worsening for the past 2 days and now localised to the right illliac fossa. On examination: BP 105/64 mmHg; temperature 38.3° C; RR 18/mins and Saturation: 97%
- 72. ☞ Questions: 1)What is the most likely diagnosis? 2)What are the differential diagnosis in this patient? 3)What are the signs & symptoms suggesting your diagnosis in this patient? 4)Which investigations would you order to confirm the diagnosis and identify the cause? 5)How would you manage this patient initially? 6)What are the complications?
- 73. Thank You