Acute abdomen .pdf

Acute Abdomen Dr. Nadeeja Samarasekara Dr. Niroshan Lokunarangoda GIT - MD 3340 Lesson learning outcomes 1. Define acute abdomen. 2. Outline the causes of acute abdomen 3. Describe the clinical features in relation to the anatomical sites 4. Recognize red flags in acute abdomen 5. Outline the comp...

Acute Abdomen Dr. Nadeeja Samarasekara Dr. Niroshan Lokunarangoda GIT - MD 3340 Lesson learning outcomes 1. Define acute abdomen. 2. Outline the causes of acute abdomen 3. Describe the clinical features in relation to the anatomical sites 4. Recognize red flags in acute abdomen 5. Outline the complications and relevant investigations of acute abdomen in relation with the clinical findings 6. Outline the surgical vs non-surgical management of acute abdomen What is an acute abdomen? Acute onset of severe abdominal pain Requires urgent medical or surgical evaluation and intervention Characterized by symptoms such as: Severe and persistent abdominal pain Tenderness and guarding on physical examination Possible signs of systemic illness, such as fever, vomiting, sweating and altered vital signs Mechanisms of Pain in the Abdomen Inflammation of Parietal Peritoneum: Pain is steady, localized, and worsens with movement. Obstruction of Hollow Viscera: Pain is colicky and less localized; may be steady if distention occurs. Vascular Disturbances: Can cause sudden or gradual pain, often severe. Referred pain Referred Pain From Thorax, Spine, or Genitalia: Can complicate diagnosis, requiring careful history and examination. ST-elevation myocardial infarction(STEMI) can present with gastrointestinal symptoms such as abdominal pain, nausea and vomiting, without concurrent chest pain. In extreme cases such a presentation can be mistaken for an acute surgical emergency. Performing an ECG in patients with high risk of atherosclerosis and ischemic type pain is crucial in the management. Referred Pain Pneumonia, Pleurisy can present as acute abdomen. Clues in history such as pain aggravating with inspiration and associated respiratory symptoms should be taken into account. Clinical features Pain Acute Onset: Typically begins abruptly and can be severe Location: Pain location may help localize the source Character: The nature of the pain can vary: colicky, constant, sharp/dull, burning, stabbing, etc… Radiation Severity Duration: from the time of Onset and course of pain over the time Aggravating or relieving factors Associated clinical symptoms: Nausea and Vomiting Sweating Anorexia / Loss of appetite Fever: Suggests an infectious or inflammatory cause. Bloating: Abdominal distension Changes in Bowel Habits: Diarrhoea, constipation – absolute or relative constipation Haematemesis or Maelena Urinary symptoms- Dysuria, frequency Physical examination Vital Signs: Tachycardia: indicate pain, fever, or hypovolemia. Hypotension: suggest significant fluid loss or septic shock. Tachypnea: in response to pain or metabolic acidosis Signs of Shock: Pale, clammy skin, rapid pulse, low blood pressure, and altered mental status  Clinical features of abdomen Abdominal Distension: Gas or fluids - bowel obstruction or ascites Tenderness:Anatomical locations Rebound Tenderness: Pain on sudden release of pressure, indicating peritoneal irritation Guarding: Involuntary contraction of abdominal muscles in response to palpation Rigidity: A stiff, board-like abdomen suggests peritonitis  Physical Signs of abdomen Absent or Hyperactive Bowel Sounds: Absence of sounds – ileus or peritonitis Hyperactive sounds – obstruction Masses : Palpable lumps may indicate tumors, abscesses Hernial orifices – anatomical sites / incisions Genital examination Digital rectal examination Underlying pathologies Inflammation / infection Ischaemia Haemorrhage Obstruction Perforation Abdominal organs – solid or hollow Surgical causes Perforated Peptic Ulcer: gastric or duodenal - sudden, severe epigastric pain, peritonitis, and signs of sepsis Mesenteric Ischemia: Acute reduction in blood flow to the mesentery, causing severe abdominal pain, often in elderly patients with cardiovascular disease Ischemic Bowel Disease: Severe abdominal pain, not in proportion to physical findings. Pancreatitis: Severe epigastric pain radiating to the back, nausea, vomiting, and elevated serum amylase and lipase levels. Surgical causes Appendicitis: right lower quadrant pain, tenderness, and often accompanied by fever and leukocytosis Cholecystitis: typically due to gallstones, presenting with right upper quadrant pain, fever, and possibly jaundice Bowel Obstruction: crampy abdominal pain, vomiting, distension, and constipation. Mechanical blockage of the intestines due to adhesions, hernias, tumors, and volvulus.  Surgical causes Diverticulitis: Inflammation or infection of diverticula , presenting with left lower quadrant pain, fever, and changes in bowel habits. Ectopic Pregnancy / Twisted ovary, ruptured ovarian cyst: Lower abdominal pain, vaginal bleeding, period of ameno and possibly signs of rupture (hypotension and shock) Abdominal Aortic Aneurysm (AAA) leak / rupture: sudden onset of severe abdominal or back pain, hypotension, and shock Hernia: Incarcerated or strangulated hernia : pain, vomiting, and possibly bowel obstruction. Surgical causes Trauma: Blunt or penetrating abdominal injury causing internal bleeding, organ perforation, or damage to the intestines, liver, spleen, or other abdominal structures Volvulus: Twisting of the intestine  obstruction and ischemia Seen in the sigmoid colon or cecum Intussusception: Telescoping of one part of the intestine into another: obstruction, commonly seen in children (in adults with a lead point of a tumour) Peritonitis: Inflammation of the peritoneum due to infection, perforation, or other causes Present with diffuse abdominal pain, tenderness, and signs of sepsis. Atypical presentations Elderly Immunocompromised – steroids, diabetics Pregnancy – 2nd to 3rd trimester Neuropathies : mask features of peritonitis Drugs : Beta -blockers – mask tachycardia Key Investigations FBC Creatinine CRP Electrolytes RBS / CBS ABG Amylase Liver function tests UFR Trponine Urine HCG Erect CXR Supine abdominal X – ray USS: abdomen and pelvis, KUB/P, Scrotum and groins CECT Acute Visceral Perforation Any part of the bowel Inflammatory markers Stomach, duodenum, jejunum, CRP illeum, appendix, colon, rectum FBC Features of localised peritonitis Erect CXR – PA  generalized peritonitis Imaging: USS / CECT Very ill patients Urgent resuscitation +/- surgical If late - Septic shock - high intervention laparotomy mortality Ureteric colic One of the commonest cause for surgical missions Typical loin to groin pain Haematuria +/- other urinary tract symptoms UFR – microscopic haematuria X ray KUB/P USS KUB/P Medical or surgical management Leaking Aortic Aneurysm Late middle age to elderly Risk factors for atherosclerosis / cardiovascular disease Severe abdominal or back pain Not relieved by routine analgesia Worsening haemodynamic instability & pallor Pulsating intra-abdominal mass Evaluation: USS/CECT Resuscitation and further management Acute scrotum In young – testicular torsion Present with abdominal or scrotal pain Clinical diagnosis or suspicion Can not diagnose radiologically – will support the diagnosis Needs urgent surgical exploration Delay  gangrene Other causes – epididymo-orchitis, inguinoscrotal hernia with obstruction Causes of acute abdominal pain – Medical/non-surgical Metabolic- DKA, Addison, uraemia, AIP, hypercalcaemia, pheochromocytoma, hypokalaemia… CVS/RS- MI, Aortic dissection, PE, Pneumonia Infectious- Dengue, viral hepatitis, malaria, viral/bac gastroenteritis Toxins- corrosives/salicylate, anticholinergics (obstruction), Pb/heavy metal poisoning…. Hematologic/immunological- Sickle cell crisis, food allergy, TTP, HUS, HSP, H angioneurotic oedema Neuropsychiatric- HZ, TL seizures, radiculopathy, abdominal migraine, IBS Renal- nephrolithiasis Vasculitis/connective tissue causes- SLE, SS, systemic vasculitis Gyn /Obs- threatened miscarriage/pregnancy related….. 1. Metabolic/endocrine causes DKA, Addison, uraemia, AIP, hypercalcaemia, pheochromocytoma, hypokalaemia… Polyuria, polydipsia, polyphagia history, weight loss, vomiting, abdominal pain, dehydration, weakness, confusion and as a result coma are the classical clinical observations of DKA. Metabolic and Other Causes Metabolic Disorders: Conditions like diabetes, hyperlipidemia, and porphyria can cause abdominal pain. Diabetic pseudoperitonitis has to be considered as a differential diagnosis of acute abdomen in diabetic patients with severe ketoacidosis. Toxic Causes: Lead poisoning, envenomation (e.g., black widow spider bites). Patients with acute viral hepatitis commonly present with symptoms such as fever, malaise, fatigue, loss of appetite, vomiting, diarrhoea, and abdominal pain. Patients may also report yellowish discolouration of their sclera (icterus) and /or skin (jaundice), dark-colour urine, and light-colour stools. Acute intermittent porphyria (very rare) Consider Acute intermittent porphyria in a young patient presenting with recurrent episodes of acute abdomen with neurological symptoms such as psychosis, peripheral neuropathy.  2. Cardiopulmonary/vascular/Respiratory causes MI, Aortic dissection, PE, Pneumonia 3. Infectious causes Dengue, viral hepatitis, malaria, viral/bac gastroenteritis 4. Drug/toxin causes corrosives/salicylate, anticholinergics (obstruction), Pb/heavy metal poisoning…. 5. Haematological/immunological causes 6. Neuropsychiatric causes HZ, TL seizures, radiculopathy, abdominal migraine, IBS 7. Renal causes Renal/ureteric stones 8. Vasculitis/connective tissue causes Acute Mesenteric Ischaemia Types of Mesenteric Ischaemia Embolic Secondary to acute SMA occlusion by an embolus that originated in the left heart (75% of the time) Thrombotic This is mesenteric venous thrombosis due to the presence of a hypercoagulable state Non-occlusive This is ischemia that occurs secondary to a low-flow state due to cardiac pathology The risk factors for Mes. Isch. Arterial Dysrhythmias (esp. AF) Atherosclerotic heart disease Valvular Heart disease Recent AMI Venous thrombosis Hx of prior VTE Hypercoagulable state (polycythemia vera, AT III def., chemotherapy, estrogen use) Non-occlusive Hypotension Sepsis CHF Acute mesenteric ischaemia Management Assessment of patient Assessment of the condition at 1. Assessment of presenting presentation condition Hydration History Haemodynamic status : pulse, Examination blood pressure, pulse oxymetry Respiratory rate 2. Assessment of the individual UOP – catheterise patient – co-morbidities, physical Temperature status  Initial Management Bed rest Oxygen – always check the flow rate Large bore cannula & fluid resuscitation – blood for investigation Catheterization Analgesia : adequate analgesia: Oral, suppository, intravenous or subcutaneous (morphine) Nil oral until further decision Antibiotics ( after blood culture) Antiemetics & acid suppression NG tube Preparation for imaging/ surgery Thromboprophylaxis – s/c enoxaparin, stockings Decision on further management Surgical Medical Gynecological Paediatric Psychological Decide on urgent evaluation and management of present condition of the patient Red flags in acute abdomen Severe pain Signs of shock (eg, tachycardia, hypotension, confusion) Signs of peritonitis – guarding, rigidity, silent abdomen Abdominal distention Further management Medical or conservative management - Serial evaluation Surgical intervention Depends on… Underlying pathology Severity of the underlying pathology Condition of the patient at presentation Underlying comorbidities/ physical status Surgical outcome Thank you!