ACUTE ABDOMEN

DEFINITION Any sudden non-traumatic disorder whose chief manifestations are in the abdomen , which definitely or possibly threatens life and for which urgent surgical interference may be necessary. Frequently there is a progressive underlying disorder. So undue delay in diagnosis and treatment may adversely affect the outcome. The surgeon may often have to perform a calculated gamble either to wait & see or look & see In 20% cases the decision to operate may be uncertain Many a times wait & see policy may be disastrous and

look & see policy ( even if incorrect ) is rewarding of no loss , examples wait & see- in ruptured ectopic pregnancy, dissecting aortic aneurysm etc look & see- in suspected appendicitis, acute exacerbation of ch. PUD. Frederick H. Marsh (1839-1915) a British surgeon said Happy is he who has no serious consequence of his erroneous diagnosis to regret.

Common causes A. Intra-peritoneal I. GIT*Appendicitis *Gut obstruction *Incarcerated hernia * Small/Large gut perforation in--- typhoid ulcer, intestinal TB ,Crohns diseases, round worm- ulcer, Burst appendix, Colonic diverticulitis, CA-colon, Meckels diverticulitis. * Boerhaaves syndrome * Acute GE * Mesenteric adenitis II. HBS & Pancreas *Acute cholecystitis *Acute cholangitis

III.

* Biliary colic- due to stone in biliary tree round worms, clots. * Hepatic abscesses * Hepatic tumor necrosis * Haemorrhage in hepatic cysts * Splenic infarcts * Acute hepatitis * Acute pancreatitis Urinary tract * Acute pyelonephritis * Acute cystitis * Renal infarcts * Acute haemorrhage in renal tumors.

IV.

V.

VI.

VII.

Gynaecological disorders * Ruptured ectopic pregnancy * Twisted ovarian cyst or tumor * Ruptured ovarian follicular cyst * Acute sulphingo-oophoritis * Dysmenorrhoea * Endometriosis Vascular disorders * Ruptured aortic or major vessels aneurysm * Acute ischemic colitis * Mesenteric vascular thrombosis Peritoneal disorders * Intra-abdominal abscesses * Peritonitis a. Pyogenic b. Tuberculous c. Chemical Retro-peritoneal disorders * Haemorrhage.

B.

I.

II.

III.

IV.

Extra peritoneal causes Cardiopulmonary * Pneumonia * Empyema thoracis * Acute MI * Acute RHD Genitourinary * Nephritis * Pyelitis * Perinephric abscess * Ureteric colic * Epididymitis *Prostatitis * Cystitis Vascular * Dissecting aortic aneurysm * Periarteritis Neurogenic * Spinal cord tumor * Osteomyelitis of spine * Tabes Dorsalis * Herpes Zoster * Abdominal epilepsy

Metabolic * Uremia * Acidosis * Poryphyria * Addisonian crisis VI. Toxins * Bacterial (eg: tetanus) * Insects bites * Venoms *Drugs * Lead poisioning VII. Abdominal wall intramuscular haematoma VIII. Psychogenic
V.

Assessment Approach- must be orderly & thoroughly. History & clinical exam should suggest the probable cause and guide the choice of lab. studies. The clinician must then decide correctly whether hospitalization is needed & non-operative treatment is needed. Harmful inaccurate diagnosis should not be >1% and harmless inaccurate diagnosis not >20% History a. Pain- points to note * time and mode of onset * duration * site

* shifting * radiation * referred pain * character of pain, change of the character. * effect of pressure * relation to food, movements, respiration, micturation, defecation * what makes the pain better or worse

Just the mode of onset of pain may dictate the diagnosis

Sudden onset

Gradual onset
Appendicitis Cholecystitis Pancreatitis Pyelonephritis Low intestinal obstruction Leaking aortic aneurism Splenic vein thrombosis Endometriosis

Perforated viscus Volvulus Mesenteric vascular thrombosis Ruptured aortic aneurysm Ruptured ectopic pregnancy Twisted ovarian cyst Mittelschmers Intra-peritoneal haemorrhage

Intermittent pain PUD Reflux oesophagitis Cholelithiasis Diverticulitis Ch. Pancreatitis Crohns diseases Endometriosis b. Vomiting

Constant pain with acute exacerbation Pancreatitis Alkaline reflux gastritis

Character Frequency Quality

Vomitus Relation with pain

c. Bowel movements

Absolute constipation Loose motion Spurious diarrhoea Passage of red currant jelly (in intussusceptions)

d. Micturition
Strangury (in ureteric or vesicle calculi) Increase frequency with dysuria e. In women Menstrual history H/O missed period

f. Past history
H/O PUD, Haematemesis, Melaena H/O similar attack in the past g. Drug history Anticoagulants, NSAIDS, Steroids, Aspirin h. Family history : Any other member having similar prblems. i. Traveling history : related to Amoebic liver abscess Hydatid cyst Malarial spleen Typhoid ulcer in ileum Worm infestation

Physical examination

Do not jump into exam. the abdomen Methodical & complete general examination must precede abdominal examination. Extreme pallor Hypothermia Tachycardia May suggest intra Tachypnoea abdominal haemorrhage Sweating (provided exta Cold & clammy extrimities abdominal bleeding excluded)

Fever Low grade: Appendicitis

Cholecystitis Diverticulitis High grade: Empyema GB Appendicular abscess Burst appendix with peritonitis Acute salphingo-oophoritis Pyonephrosis High fever with disorientation , lethargy, chills & rigorimpending septic shock.

Examination of abdomen 1. Inspection :

Scaphoid abdomen unlikely to have acute pathology. Tensely distended abdomen with old scar- suggest intestinal obstruction Central distention- suggest small gut obstruction In volvulus of sigmoid colon distention mostly in left side & part of central abdomen. Visible peristalsis indicates gut obstruction- direction & site is pathognomic . Ladder pattern gut loops distention with peristalsis- in central abdomen also indicates small gut obstruction.

Hernial orifices must be inspected for obstructed hernias. Movement with respiration * Sluggish or no movement indicates diffuse peritonitis due to visceral perforation, intra-peritoneal haemorrhage. * Localized limitation in respiratory movement occurs in acute appendicitis , acute cholecystitis etc. Localized swelling moving with breathing in * Empyema GB * Mucocele GB * Ca- stomach * Enlarged liver - not moving with breathing in * Retro-peritoneal tumor * Mesenteric cyst * Ca- colon

II.

Pulsatile swelling * Abdominal aortic aneurysm * Tumor lying over the aorta Palpation : assess * Local rise of temperature
* Muscle guard (exclude voluntary contraction by deep breathing with mouth open.) * Hyperesthesia Importance : 1. Hyperesthesia + Muscle guard in Sherrers triangle Gangrenous appendicitis In burst appendix hyperesthesia disappears

2. Boas sign --- hyperesthesia between 9th &11th ribs in right infrascapular region indicates acute cholecystitis 3. Hyperesthesia with extra abdominal cause * Herpes Zoster * Spinal root compression * other neuromuscular problems

Tenderness
* Always constant over inflamed organ. * Tenderness + muscle guard ---- most important finding in acute abdomen Tenderness with out muscle guard : Gastroenteritis, Intestinal inflammation with out peritonitis

Minimum tenderness but severe pain * Uncomplicated hollow viscera obstruction Specific point tenderness
1. Murphys sign --- Acute cholecystitis 2. McBurneys point --- Acute appendicitis 3. Rovsings sign --- Acute appendicitis 4. Duodenal point --- Duodenal ulcer 5. Renal angle --- Pyelonephritis, Renal calculi, Perinephric abscess Rebound tenderness --- Sign of peritonitis with inflamed organ underneath. Eg. Acute Appendicitis

Rebound Tenderness Bloombergs Sign rebound tenderness in Acute Intestinal Obstruction suggests strangulation Bed shaking test (of Bapat) +ve in early peritonitis (helpful test when early peritonitis is in doubt) Spread of tenderness indicates spreading peritonitis eg. Perforation of PUD, burst appendix. Pointing test if the point of pain shown by the patient is the point of tenderness it is certainly the site of the diseased viscus. Cough test pain in the abdomen with cough indicates the site of the diseased viscus

Appendicular tenderness best elicited in left lateral position Patience ususally gives the clinical Experience diagnosis in >90% of cases Repeated Exam. If still in doubt pt. must be hospitalized Rising pulse over hours is very significant 4 signs of maxm. Importance in acute abdomen Pointing test Cough test Rebound tenderness Bed-shaking test

Trigger pt. sensitivity Lateral costal rib tip tenderness Pain exacerbated by spinal motion

signify parietal abdominal wall pathologies.

Referred pain: -to shoulder tip (C4), subscapular area (T6-8) without local tenderness may indicate thoracic pathology Specific signs

Murphys Sign Ac. Cholecystitis McBurney;s Sign Ac. Appendicitis Copes Psoas Ac. Appendicitis (Retrocaecal appendix), Psoas abscess, Perinephric abscess Copes obturator Ac. Appendicitis (Pelvic abcess) -obstructed obturator hernia

Masses in Ac. Abd. Empyema GB -Pancreatic abscess -Liver abscess -appendicular lump -appendicular abscess -Haemorrhage in splenomegaly -Renal/perinephric abscess Hernial orifices

Inguinal Umbilical may reveal obstructed hernias Femoral

DRE without it, no abdominal exam is complete.

Ant. Wall tenderness

In

Ac. Appendicitis (pelvic app.) Ac. Salphingo-oophoritis Twisted ovarian cyst Ruptured ectopic pregnancy Pelvic abscess
Other

findings

Rectal

tumours Intussusception Thrombosed haemorrhoids Ischiorectal abscess

Percussion:
Less important in acute abdomen Because it may be painful If done, it differentiates fluid or gaseous distension Shifting dullness in ascites

Auscultation: BS not heard within 1 min. over several quadrants means absent. Absent BS means

Profound ileus Hypokalaemia Hypomagnesemia Narcotic overdosage Peritonitis Mesenteric thrombosis

Hypoactive BS (<3/min)
Hypokalaemia Peritonitis Bowel ischaemia

Hyperactive BS (>10/min)
Early gut obstruction Early diverticulitis Early mesenteric artery thrombosis/embolism Early GE

General survey in Acute abdomen:

Appearance: Peculiar Abdominal facies it can discriminate abdominal from extra-abd. cause

Facies Hippocrativa
Terminal stage of peritonitis Anxious look, bright eyes, pinched face with cold sweating forehead Once seen, will never be forgotten.

Facies

of dehydration

Sunken eyes, drawn cheeks & dry tongue.

Attitude:

In colics pt. tossing on bed, doubled-up or rolls in agony In peritonitis (early) calm & quiet. In terminal peritonitis & post-op. peritonitis highly excitable, throwing out bed clothes, tossing head, grumbling, ineffective movement of limbs

Pulse: Normal in early stage Ac. Abdomen, eg. Acute intestinal obstruction, haemorrhagic pancreatitis, perforation of PUD. Increased in Ac, appendicitis, internal haemorrhage, spreading peritonitis, advancing intestinal obstruction, dehydration.

Respiration: -seldom increased, except in internal haemorrhage & late peritonitis. Resp. rate, proportionately increases with increasing fever. RR with movements of alae nasi- indicates thoracic pathology, eg. Lobar pneumonia, basal pleurisy etc.

Temperature: -increases in any infective & inflammatory condition but the range varies Low grade -early Ac. Appendicitis, pancreatitis Moderate grade Ac. Cholecystitis The temp. rise is never an early sign in Ac. Abdomen. High temp (with fluctuations)

Empyema

GB App. Abscess Pancreatic abscess Residual intraperitoneal abscess Pyogenic liver abscess etc.

Tongue: the mirror of the GIT & many general conditions.

Dry tongue dehydration Dry, brown tongue toxaemia Dry, thinly coated early appendicitis Anaemia: Any haemorrhagic condition, chronic illness. Jaundice: often in
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Biliary colic Biliary pancreatitis Cholangitis Round worm in CBD Cyanosis: in haemorrhagic pancreatitis, massive lobar pneumonia etc.