Post on 29-May-2018
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CLINICAL APPROACH TO
ACUTE ABDOMEN
DR. J. S. LAMBA
MBBS, MS, FICSSR CONSULTANT
DEPT. OF SURGERY,
PUSHPANJALI CROSSLAY HOSPITAL,
VAISHALI, GHAZIABAD
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the general rule can be laid down that the majority of
severe abdomonal pain which ensue in patients who
have been previously fairly well, and which last aslong as six hours, are caused by conditions of
surgical import.
[zachary cope, 1881-1974]
Acute abdomen refers to severe abdominal pain of
short duration that requires fairly immediate
management and decision regarding an urgent
surgical intervention.
ACUTE ABDOMEN
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ACUTE ABDOMEN
Frequent causes of acute abdomen
Clinical features
How to perform physical examination D/d upperabdominal pain
D/d lowerabdominal pain
Clinical patterns
Natural history of frequent causes Conclusion
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FREQUENT CAUSES OFACUTE
ABDOMENLONG LISTDIAGNOSIS FROM A LIMITED MENU
1.Inflammatory
a) Bacterial --appendicitis, diverticulitis, PID
b) Chemical peptic perforation, ac. pancreatitis
2.Mechanical
Obstructionincarcerated hernia, adhesions, intussusception,large bowel obstruction -- CA or volvulus
3.Vascular
Ac mesenteric arterial thrombosis/embolism
Mesenteric venous thrombosis
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ABDOMINAL PAIN
Visceral
Somatic
Referred
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VISCERAL
stretching of peritoneum ororgan capsule by
distension oroedema
diffuse
Poorly localised
May be per
ceived atr
emote locationsr
elatedto organs sensory innervation
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SOMATIC
Inflammation of peritoneum ordiaphragm
Sharp
Well localised
REFERRED
Perceived at distance from diseased organ
Pneumonia
Acute MI
Male GU problem
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C/FOFACUTE ABDOMEN
PAIN
1) Origin & location
Epigastric - stomach, duodenum, pancreas, liver,biliary tree, associated parietal peritoneum, HEART
Periumbilical - small intestine, appendix, upperureter
Hypogastric - colon, bladder, lowerureter, uterus
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2) Radiation
appendicitis, cholecystitis, renalcolic, pancreatitis,
peptic perf.,ruptured ectopic pregnancy, spleen. Pain
of abd aortic aneurysm radiates from lowerback toone orboth legs
3) Type of onset & Intensity
sudden & severe -- rupture of viscus,mesentericthrombosis,infarct,haemorrhage
gradual & moderate-- cholecystitis,appendicitis,
peritoneal irritation,hollow organ
distension
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4) Quality
dull-- epig pain of appendicitis
sharp/colicky-- renal,biliary,int obstaching-- PID
pleuritic-- intensified by breathing
lancinating--pancreatitis
5) Special features
continuous-ac pancreatitis
pulsatile-abdominal aneurysm
colicky-int obst,gall /renal colic
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6) Factors which intensify/relieve pain
relation to mealspeptic ulcer, cholecystitispostural-appendicitis, pancreatitis
movement-peritonitis
7) Associated symptomsnausea/ vomiting/ diarrhoea/ obstipation
haematochesia/ malaena/ change in urinary
habits /fever
MURPHYS
SYNDR
OME
8) EXTRA ABDOMINAL CONDITIONS WHICH
SIMULATE THE ACUTE ABDOMEN ARISE MOST
OFTEN IN HEART,LUNGS,URINARY TRACT AND
FEMALE REPR
ODUCT
IVEO
RGANS
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COMPLETE PHYSICAL EXAMINATION
vitals
Anaemia, shock, haemorrhage, dehydration
Palpation must expose abdomen fully
pt on back&knees bent
warm handswork towards area of pain
tenderness, rigidity, guarding, masses
Percussion hyperresonant,liver dullness
Auscultation-- listen for1 minute in each quadrantMUST EXAMINE HEART & LUNGS
P/R
Bimanual pelvic exam
EQUIVO
CALFI
NDING
SRE EXAM
INE AT
FREQUENT INTERVALS
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D/D OFDISEASES CAUSING UPPERABDOMINAL PAIN
Ac oesophagitis
Ac appendicitis
Ac cholecystitis
Perforated peptic ulcer
Ac panc
reatitis
Pleurisy / pneumonia
Ac coronary occlusion - considerpossible MI with
pain referred to abdomen in patient >30 years old
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D/D OFDISEASES CAUSING
LOWER ABDOMINAL PAIN
Ac appendicitis
Ureteral obstruction
Ac diverticulitis
Ac salpingitis Ectopic pregnancy
Twisted ovarian cyst
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OESOPHAGITIS
Inflammation of distal oesophagus
Usually from gastric reflux,hiatal hernia
Substernal burning pain
Worsened by supine position
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PANCREATITIS
Sudden, severe,constant mid epigastric painradiating to back
Often worsened by food
Profuse vomiting
Less gua
rding than peptic pe
rf
Bluish flank discoloration[Grey Turnersign]
Bluish periumbilical discoloration[Cullen sign]
Absent bowel sounds
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CHOLECYSTITIS
Sudden pain, often severe in RUQ
Radiating to right shoulder
Nausea,vomiting
Often associated with fatty food intake
Point tenderness underR costal margin
[Murphys sign]
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APPENDICITIS
Periumbilical painRLQ Nausea, vomiting, anorexia
Low grade fever
Mc burneys sign
Aarons sign epig pain on palpation of RLQ Rovsings sign pain in LLQ on palpation of RLQ
Psoas sign pain when patient extends R leg whilelying on left side
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PERFORATED PEPTIC ULCER
Sudden, intense & constant pain
Patient keeps abdomen immobile
Rapid shallow breathing
Tende
rness, gua
rding alove
rabd
Liverdullness masked
Absent bowel sounds
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ULCERATIVE COLITIS
Crampy abdominal pain,nausea, vomiting
Bloody diarrhoea orstool containing mucus Ischaemic damage with perforation may occur
DIV
ERTICUL
ITIS
Olderpatient, Inadequate fibre in diet
Bright red blood in stools,alt consti/diarrhoea
Tenderness in LLQ
Rupture may cause peritonitis and sepsis
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ECTOPIC PREGNANCY
In females of child bearing age abd pain or
unexplained shock
ECTOPIC PREGNANCY DOES NOT
NECESSARILY CAUSE MISSED PERIOD
TWISTED OVARIAN CYST
Sudden severe pain
sick looking,shock
Ischaemic nec
rosis-pe
rf & spillage
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1) Abdominal pain & shock [apoplexy] catastrophic eventa. ruptured aortic aneurysm
b. ruptured ectopic pregnancy
c. fluid loss into third space eg: ac mesenteric
ischaemia, severe ac pancreatitis, int obst
2) Generalised peritonitis
a. ruptured viscus perf ulcer, colonic perf,
perforated appendicitis
b. ischaemic unruptu
red bowel st
rangulated he
rniamesenteric occlusion,volvulus
c. extension of infection liverabscess, PID
CLINICALPATTERNS
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3) Localised peritonitis
RUQ,RLQ,LLQ,SILENT ZONE
POINT TENDERNESS
4) intestinal obstruction
Making diagnosis is not a big issue but important is
deciding approp
riate cou
rse of action
5) medical illness
Inf wall MI, basal pneumonia, porphyria,diabetic
ketoacidosis,HIV positive suffering from AIDS
TIME ISSUPERB DIAGNOSTICIAN
Clinical pattern contd
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Clinical pattern contd.
6) gynaecological
ectopic preg, twisted ovarian cyst,PID
7) mixed pattern[obstruction & inflammation]
Int. distension & obstruction/inflammationeg; enteritis,colitis
MIMICS PERITONITIS
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NATURAL HISTORY OFFREQUENT
CAUSES
Life Threatening Self Limiting
Aortic Aneurysm
rupture
pancreatitisBowel ischaemia
Perforated peptic
ulcer
Perforated
diverticulitis
Appendicitis
cholecysitis
signoiddiverticulitis
salpingitis
Gastroenteritis
mesenteric
lymphadenitisepiploic
appendigitis
omental infarction
caecal diverticulitis
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CONCLUSION
It is as much an intellectual exercise
to tackle the problems of belly acheas to work on the human genome
[Hugh dudley]
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