Acute Abdomen 2025 Past Paper PDF

THE ACUTE ABDOMEN Dr. Alejandra Franco, MD General Surgery and GI Endoscopy Dr. Andres Aranda, MD, Nephrology. CSD Block 3 WE MAKE DOCTORS Objectives: After completing this workshop, learners will be able to: 1. Understand the dia...

THE ACUTE ABDOMEN Dr. Alejandra Franco, MD General Surgery and GI Endoscopy Dr. Andres Aranda, MD, Nephrology. CSD Block 3 WE MAKE DOCTORS Objectives: After completing this workshop, learners will be able to: 1. Understand the diagnostic approach to the various presentations of acute abdomen. 2.Identify the symptoms (medical questioning) and signs (physical examination) in a patient presenting with an acute abdomen. 3.Establish a primary diagnosis and propose at least two differential diagnoses. Definition: Acute abdomen is a condition requiring immediate attention and treatment, typically lasting from a few hours to a few days. signs and symptoms of abdominal pain and tenderness. The underlying pathology may originate from intra- abdominal, thoracic, or systemic causes. May require urgent surgical intervention. Acute Abdominal Pain Frederick H. Millham Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11, 144-157.e2  Acute abdomen. Surgical Non Surgical NON-SURGICAL CAUSES OF ACUTE ABDOMINAL PAIN Metabolic: Infectious: -Diabetic ketoacidosis. -Influenza. -Tetany. -Typhoid and paratyphoid fevers. -Poliomyelitis. Cardiovascular: -Malaria. -Heart (angina pectoris, coronary occlusion, pericarditis). Urinary: -Embolism and thrombosis -Pyelonephritis. (mesenteric occlusion, subacute -Acute urinary retention. bacterial endocarditis, polycythemia). Pulmonary. -Intra-abdominal arterial disease -Pleurisy. (periarteritis nodosa, dissecting -Pneumonia. aneurism, abdominal angina). (3) Abdominal wall disorders. Haematologic: -Herpes zoster. -Haemolytic anemia. -Neuralgia. -Purpura (Henoch, Osler). -Trauma. -Sickle-cell anaemia. -Splenic enlargements with perisplenitis or infarction. -Leukemia, Hodgkin's disease. Acute Abdomen Alessandra Landmann, Morgan Bonds and Russell Postier Sabiston Textbook of Surgery, Chapter 46, 1134 -1149 https://pmc.ncbi.nlm.nih.gov/articles/PMC1391121/ Anatomy and physiology Pain resulting from abdominal pathology is transduced in different ways by sensory afferent fibers that travel with the autonomic and somatic nervous systems. These two systems transduce pain in different ways, leading to different nociceptive sensations. Crosstalk between the two systems can result in yet more variation in the perception of abdominal distress. This unique neuroanatomy results in three distinct types of pain: visceral, somatic-parietal, and referred. Acute Abdominal Pain Frederick H. Millham Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11, 144-157.e2 Visceral pain. Dull, diffuse, poorly localized deep pain. Stretch, ,mechanical distention, inflammation, ischemia. the poor localization of the pain and the phenomenon of referred pain to areas distant from its origin Localization of visceral pain. Pain arising from organ areas depicted in 3 hypogastrium 1 epigastrium, 2 midabdomen, as shown in A. The arrow in A indicates biliary pain that is referred to the right scapular area.  Types of abdominal pain Visceral Pain Autonomic system. Somatic -Parietal Pain Referred pain Innervate all layers of the Mediated by A-δ fibers that Referred pain is felt in areas intestinal wall, serosa, and are distributed principally to remote from the diseased mesentery. skin and muscle. organ and results when 1. Mucosal chemonociceptors are sensitive to visceral afferent neurons and 1. Sharp, sudden, well-localized pain, such as noxious luminal contents. that which follows an acute injury. somatic afferent neurons 2. Tonic mechanoreceptors respond to rising wall from a different anatomic 2. Is more intense and more precisely tension with a linear increase in activity. localized than visceral pain region converge on second- 3. High-threshold mechanoreceptors, also known 3. Superficial somatic pain is due to order neurons in the spinal as “phasic” receptors, have low resting activity and respond to excessive mechanical distention nociceptive input from skin, subcutaneous cord at the same spinal tissues, and mucous membranes. only. segment 4. It is characteristically well localized and 4. Silent nociceptors are activated only in the described as a sharp, pricking, throbbing, or presence of inflammatory mediators. burning sensation Somatic-Parietal Pain An example of this difference occurs in acute appendicitis, in which early vague periumbilical visceral pain originating within the appendix is followed by localized somatic- parietal pain at McBurney’s point that is produced by inflammatory involvement of the parietal peritoneum adjacent to the appendix. Somatic-parietal abdominal pain is usually aggravated by movement or vibration. Travel in somatic sensory spinal nerves that correspond to the cutaneous dermatomes of the skin from the sixth thoracic (T6) to first lumbar (L1) vertebral segmen Somatic – parietal pain. The parietal peritoneum covers the anterior and posterior abdominal walls, the undersurface of the diaphragm and the pelvic cavity. The parietal peritoneum is sensitive to mechanical, thermal or chemical stimulation and therefore cannot be painlessly handled, cut or cauterised. As a result of its innervation, when the parietal peritoneum is irritated, there is reflex contraction of the corresponding segmental area of muscle, causing rigidity of the abdominal wall (guarding) and sometimes hyperaesthesia of the overlying skin. PATTERNS OF REFFERED ABDOMINAL PAIN https://www.researchgate.net/publication/348659904_APPROACH_TO_GENERAL_S URGICAL_EMERGENCIES-Chapter_5/figures?lo=1 https://musculoskeletalkey.com/pain-types-and-viscerogenic-pain-patterns/ Pain irradiation, refferred pain. This convergence may result from the innervation, early in embryologic development, of adjacent structures that subsequently migrate away from each other. As such, referred pain can be understood to refer to an earlier developmental state Acute Abdomen Alessandra Landmann, Morgan Bonds and Russell Postier Sabiston Textbook of Surgery, Chapter 46, 1134 -1149 The acute abdomen Hugh M. Paterson Principles and Practice of Surgery, 13, 162 -179 Acute Abdominal Pain Frederick H. Millham Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11, 144 -157.e2 Chronology of Pain Patterns of acute abdominal pain. A, Many causes of abdominal pain subside spontaneously with time (e.g., gastroenteritis). B, Some pain is colicky (i.e., the pain progresses and remits over time); examples include intestinal, renal, and biliary pain (colic). The time course may vary widely from minutes in intestinal and renal pain to days, weeks, or even months in biliary pain. C, Commonly, acute abdominal pain is progressive, as in acute appendicitis or diverticulitis. D, Certain conditions have a catastrophic onset, such as a ruptured abdominal aortic aneurysm. The acute abdomen Hugh M. Paterson Principles and Practice of Surgery, 13, 162-179 Acute Abdominal Pain Frederick H. Millham Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11, 144-157.e2 History pain. Chronology. Location. Irradiation. Character. Intensity. Agravating, alleviating factors. Ascotiated symptoms. Acute Abdominal Pain Frederick H. Millham Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11, 144-157.e2 Maneuvers for Ameliorating Abdominal Pain Medical questioning? “Where is the pain?” “Has the pain changed its location since it started?” “Do you feel the pain in any other part of your body?” “How long have you had the pain?” “Have you had recurrent episodes of abdominal pain?” “Did the pain start suddenly?” “Can you describe the pain? Is it sharp? Dull? Burning? Cramping?” “Is the pain continuous? Does it come in waves?” “Has there been any change in the severity or nature of the pain since it began?” “What makes it worse?” “What makes it better?” Medical questioning? “Is the pain associated with nausea? Vomiting? Sweating? Constipation? Diarrhea? Bloody stools? Abdominal distention? Fever? Chills? Eating? Menstrual cycle?” “Have you ever had gallstones? Kidney stones?” “When you have the pain in your abdomen, do you feel the pain in any other part of your body at the same time?” If the patient is a woman, ask this question: “When was your last period?” If the woman is of child-bearing age and is sexually active, ask the question: “Is there a possibility that you might be pregnant?” Medical history. Past medical history. Special groups. https://next.amboss.com/us/article/N50-4g?q=acute+abdomen Etiology: Hemorrhage. Infection. Ischemia. Obstruction. Perforation. Inflamation. Vascular. Urologic / testicular. Gyencologic. Causes of Acute Abdominal Pain in Patients Presenting to an Emergency Department From Irvin TT. Causes of abdominal pain in 1190 patients admitted to a British surgical service. Br J Surg 1989;76:1121–5. Acute Abdominal Pain Frederick H. Millham Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11, 144-157.e2 https://www.amboss.com/us/knowledge/Acute_abdomen https://www.amboss.com/us/knowledge/Acute_abdomen https://radiopaedia.org/articles/bowel-obstruction https://www.amboss.com/us/knowledge/Acute_abdomen https://radiopaedia.org/articles/bowel-obstruction https://www.researchgate.net/publication/273467005_Comparison_of_multislice_computed_tomography_and_clinical_scores_for_diagnosing_acu Thomas, Liza & Henn, Megan. (2021). Perfecting the Gastrointestinal Physical Exam. Emergency Medicine Clinics of North America. 39. 10.1016/j.emc.2021.07.004. Bickley, Lynn S. (2003). Bates' guide to physical examination and history taking. Philadelphia :Lippincott Williams & Wilkins Rebound tenderness. It refers to the presence of pain when pressure is removed from the abdomen, rather than when applied. Although rebound tenderness can be elicited when performing Rovsing’s sign, it is not the same thing. Rebound tenderness is often indicative of general peritonitis or inflammation of the peritoneum, the membrane that lines the inner abdominal wall and covers the abdominal organs Is not exclusive for appendcitis. Guarding Rigidity Rebound https://www.osmosis.org/answers/Rovsing-sign https://www.amboss.com/us/knowledge/Acute_abdomen https://medium.com/@usara872/peptic-ulcers-symptoms-causes-and-prevention-c55c5d688597 https://www.amboss.com/us/knowledge/Acute_abdomen https://www.medicoverhospitals.in/es/diseases/gastroenteritis/ https://www.amboss.com/us/knowledge/Acute_abdomen https://radiopaedia.org/cases/colonic-diverticulitis-2 https://www.fesemi.org/informacion-pacientes/conozca-mejor-su-enfermedad/diverticulitis https://karger.com/dig/article/99/Suppl.%201/1/105772/Guidelines-for-Colonic-Diverticular-Bleeding-and https://www.amboss.com/us/knowledge/Acute_abdomen https://www.osmosis.org/learn/Gallbladder_disorders:_Pathology_review https://radiopaedia.org/articles/acute-cholecystitis?lang=us (1) The examiner positions their hands in the RUQ underneath the right costal arch, while the patient exhales. (2) During inspiration both the liver and the gallbladder are pushed down towards the examiner's hand. If the patient experiences pain and therefore stops inspiration, the Murphy's sign is positive. A positive Murphy's sign may indicate acute cholecystitis. https://www.amboss.com/us/knowledge/Acute_abdomen https://jamanetwork.com/journals/jama/article-abstract/2789654 https://radiopaedia.org/articles/acute-cholecystitis?lang=us https://www.amboss.com/us/knowledge/Acute_abdomen https://www.osmosis.org/learn/Gallbladder_disorders:_Pathology_review https://radiopaedia.org/articles/choledocholithiasis?lang=us https://www.amboss.com/us/knowledge/Acute_abdomen https://x.com/medcomic/status/971519482584760321?lang=es https://www.facebook.com/FOAMfrat/posts/reynolds-pentad-signs-symtoms-of-obstructive-ascending-cholangitis-fever- jaundic/494185359621790/ https://www.amboss.com/us/knowledge/Acute_abdomen https://jamanetwork.com/journals/jama/article-abstract/331545 https://www.nejm.org/cms/10.1056/NEJMra1505202/asset/6a91697b-26d7-4d5a-bf57-7991916bedb2/assets/images/large/nejmra1505202_f1.jpg  They are often associated with acute hemorrhagic pancreatitis,