Acute abdomen
Tamás Fenyvesi November, 2016 1
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Acute abdomen is an abdominal emergency no temporizing is ever justifiable. Patients present more likely in the evening hours Never wait with your decision for the next morning 3
Characteristics of acute abdomen has been present for less than 24 hours Sudden and unexpected onset of abdominal pain associated symptoms: nausea, vomiting, abdominal dystension, diarrhea, constipations, anorexia The pain may arise from intra-and extraabdominal structures acute abdomen not invariable operation 4
Neural innervation of the gastrointestinal tract
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History 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 –sustained pain :infectious processes Referred pain patterns may give a clue 6
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Abdominal pain onset patterns I. sudden(seconds) –A. perforation or rupture of a viscus:peptic ulcer, abdominal aortic aneurysm, esophagus, ectopic pregnancy,PTX –B.
infarction:gut, heart, lung
P.D. White etc 8
Abdominal pain onset patterns II. rapid(minutes) –A. colic syndromes: biliary, ureteral, small bowel obstruction(high) –B. inflammatory processes: pancreatitis, diverticulitis, appendicitis, penetrating ulcer, cholecystitis –C. ischemic processes: strangulation, torsion 9
Abdominal pain onset patterns III. Gradual(hours) A. inflammatory :appendicitis, cholec., pancreat., divertic., salpingitis, ¤ prostatitis, inflamm.bowel dis., intraabdominal abscess B. obstruction:distal small bowel or colon,ectopic pregnancy,urinary retention, incarcerated hernia C. neoplastic:perforating or penetrating tumors (colon, stomach, small intestine) 10
Physical examination Observation of the patients body habitus and facial expression –peritonitis :unwillingness to change posture, hip flexion with the knees drawn up, shallow breathing –colicky pain: intense movements to alleviate 11
Physical examination Inspection of the abdomen:localized or generalized dystension, visible peristaltsis, hernial bulges, erythema Auscultation of bowel sounds, if no sounds are heard : paralytic ileus
Percussion absence of hepatic dullness (!!) : perforation 12
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Physical examination Palpation : superficial, gentle of all quadrants, first at the least painful areas, after this deeper classic rebound tenderness (deep palpation followed by rapid release) is not specific have the patient laugh, cough, distend or maximally reduce his/her abdominal girth A very old and forgotten means to palpate the abdomen in a bath tub (in only the patient !!)
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•A rectal digital examination is obligatory
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Characteristic scars, Now often laparoscopy
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Laboratory evaluation Complete blood count:WBC differential, CRP, sed.rate urinalysis: serum amylase (urine) beta human chorionic gonadotropin in females serum electrolytes,BUN,creatinine and glucose liver function test in upper abdominal pain use only relevant laboratory investigations the results of which effect therapy !! 17
X-ray evaluation upright PA and lateral film of the chest supine and erect plain film of the abdomen –the upright film should include the diaphragm to detect free intraperitoneal air only horizontal beam films detect fluid levels within the bowel 18
X-ray evaluation contrast study may be required (dangers!) abdominal ultrasound mandatory in some instances endoscopic CT , MRI, nuclear (PET scan if cost/benefit !! O K) angiography may add to diagnostic accuracy 19
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Causes of acute abdomen Appendicitis Acute cholecystitis Acute pancreatitis Diverticulitis Perforated peptic ulcer Bowel obstruction Mesenteric ischemia Ruptured abdominal aortic aneurysm Gynecologic causes 21
Appendicitis History: tipically midabdomonal pain ¤
onset of nausea and vomiting relocation of pain to the right lower quadrant elevation of temperature
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ZETA (Sir Zachary Cope)
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Appendicitis : bacterial infection with .
contributory factors:intraluminal obstruction -fecalith lymphoid hyperplasia, parasites, carcinoid tu. –typical symptoms:midabdominal pain moving to the right lower quadrant- elicited by coughing laughing or bumping, nausea and vomiting, anorexia,fever. 24
Appendicitis .
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physical : tenderness and guarding over the right lower quadrant (McBurney point-1/3 distance superior iliac spine-umbilicus) – psoas sign, rebound tenderness laboratory:WBC,CRP, urinalysis
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Differntial dg of appendicitis Localization of the appendix ascending: cholec,perf duodenal ulc perinephr absc hydronephr Iliacal penetrating duod ulc Crohn diseas !! Ileocecal cc. Tbc uretolith
pyonephr pyelitis nephrolith omental torsion Meckel’s diverticulum Psoas absc hip !! muscle rupture typhlitis 26
Appendicitis 2 :
abdominal X-ray rarely useful, ultrasound(periappendicular fluid,edema,abscess,visualization of the lumen) increasing significance Peak incidence 15-24 years choice of treatment ,surgery:10-20% negative appendectomy Keep in mind the danger of perforation in the elderly 27
Acute cholecystitis obstruction of the bile duct by stone 1. bacterial in 50-85% of cases 2. Chemical agents : lysolecithin, other tissue factors 3. Inflammation from mechanical strech
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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 quadrant RUQ tenderness patient suddenly stops inspiration (Murphy‘sign) irradiates to the right shoulder or scapula vomiting , exsiccosis fever usually moderate, but also chills 33
The „convergence projection” : in the lateral spinothalamic tract the fiber number is less than the sensory fibers somatic> visceralis the brain “learns” that on the given tract the somatic signals are transmitted 34
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Acute pancreatitis Increasing incidence: 36 to 44/100 000 adults in California (1994-2001) 200 000 hospital admission/year in the USA Bile reflux is the trigger (1856 Claude Bernard) 2 enzymes are released from acinar cells amylase and lipase
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Causes gallstones 38% alcohol abuse 36% pancreas divisum ( congenital abnormality of the pancreatic duct) intraductal papillary tumors ERCP (increase of serum amylase after the procedure ) Serum triglyceride >11mmol/L some drugs infections 37
Diagnosis Symptoms of acute abdomen •Constant acute pain in the epigastric area or the right upper quadrant •Nausea , vomiting •Tenderness in the upper abdomen •Cullen’s sign:
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20% severe (4% die) Early development sequential organ failure increased capillary permeability decreased intravascular volume hypovolemia renal dysfunction pulmonary complication Pancreatic necrosis a very severe complication 40
Severity is assessed by CT and contrast enhanced CT
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Treatment Correct fluid losses monitor respiratory, cardiovascular and renal function. Multidisciplinary Stop parenteral nutrition : a rule!?? Infection antibiotic prophylaxis is debated in proven infection: imipenem 42
Lancet 2008;371:143 ¤
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BMJ 2004;328:1407
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Causes of acute abdomen Diverticulitis prevalence 5% , increases with age 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 barium enema, not in acute phase ,only later "elective " X-ray or CT scanning 46
Causes of acute abdomen Mesenteric 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,tenderness bowel sounds from hypoactivity to absent Bloody peritoneal transsudate,leucocytosis 20 t hemoconcentration history of abdominal angina,atrial fibrillation rapid visceral angiography
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Causes of acute abdomen 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% pneumoperitoneum:on physical disappearance of hepatic dullness, X-ray may heal spontaneously,dudenal anterior wall ¤ surgery,broad spect.antibiot,fluid 48
Succussion splash 49
Colonic perforation
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Causes of acute abdomen Ruptured 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 X-ray (contrast iv.deviation of the ureters,aortic wall,CT,angio time consuming
MR emergency operation-high mortality
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Classification of thoraco-abdominal aortic aneurysms
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Atherosclerotic abdominal aortic aneurysm after fatal rupture
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Causes of acute abdomen Bowel obstruction: ileus 20% of all acute surgical hospital admissions causes:
mechanical
extrinsic: adhesions,hernias,volvulus,masses intraluminal objects: fecal impaction,gallstone, gastric bezoars,foreign bodies
intrinsic lesions:neoplasms,inflammation, intussusception,hematoma 54
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Causes of acute abdomen Ileus 2 : adynamic(paralytic) reflex inhibition:laparotomy,trauma inflammation:peritonitis,toxic megacolon, acute irradiation infectious process:appendicitis,cholecystitis ischemic processes:arterial insuff. retroperitoneal :ureter,kidney drug induced:opiates,anticholinergic drugs metabolic:porphyria ,ketoacidosis X-ray diagnosis: air-fluid levels -small or large bowel 56
Causes of acute abdomen 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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„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 1804-1881 Prime minister of Great-Britain: 1868, 1874-80 58
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Some reminder of anatomy and pathophysiology
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. The foregut,midgut and hindgut have and retain their own innervation and blood supply forgut : oropharynx to the duodenum (bile duct) midgut: distal duodenum,jejunum, ileum,appendix, ascending colon, proximal 2/3 transverse colon 62
. hindgut: distal1/3 of transverse colon to anus peritoneum: visceral autonomic innervation dull,crampy or aching pain :parietal somatic innervation sharp, severe and persistent pain
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Acute abdomen Abdominal pain :visceral, somatic or referred 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 pain fibers enter spinal cord ipsilaterally visceral pain arises in the midline fibers enter spinal cord bilaterally 64
“ To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go sea at all” William Osler 65
A University should be a place of light, of liberty, and of learning. Benjamin DISRAELI, 1873
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Diagnosis:
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