From: King Primary Surgery
volume I
On the job training for COs in Malawi
Mlambe Mission Hospital 1973 – ’76
2002 Department of Surgery, CoM, Blantyre
2005 -2009 Start CO Trainings Project
On “Surgery” , Why?
“On the Job”, Why?
 - Huge shortahe human resources
 - To improve standard of care Hs
 2 COs
 In all DHs and MHs
 SR, NR
 2007: COM : Review
 International attention
2013 : 6 BSc courses for COs,
presented by CoM
Partly On the Job
Acute Abdomen
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Making a diagnose
1 CT scan
X ray facilities: not optimal
Lab facilities: not optimal
Which means:
YOU HAVE TO DO IT YOURSELF
Use your eyes, ears, hands, skills
In 60% , the right diagnose on
CLINICAL GROUNDS only!!
What does AA mean?

Medical slang for any acute condition within
the abdomen

The acute abdomen is one that may require
an acute operation

An acute abdomen requires acute attention
and care
WHY
?
The acute abdomen

The chest rarely needs an acute operation

But the abdomen does. Why….?
Acute abdomen

Because it contains GUT
Which can……….?
Acute abdomen
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Obstruct
Strangulate or
Perforate
Allows micro organisms to reach PERITONEAL CAVITY
Other sources of micro organisms from
- GALL - BLADDDER
- FEMALE GENITAL TRACT
Acute abdomen
MAIN SYMPTOM of an acute abdomen is.... ?
Making a diagnose
Sir, what is the trouble?
PAIN
3 main types of pain
- colic pain: OBSTRUCTION
PAIN: in
waves, patient moves
- peritonitis pain: INFLAMMATION
PAIN: sharp
continuous.
localized – generalized
- bowel ischaemia pain: STRANGULATION
PAIN: agonizing,
continuous
Bowel
Obstruction
Shock
Death
Making a DIAGNOSE in acute
abdomen
is based on:
1)
History
2)
General examination
IPPA
1, 2 and 3: 60% right diagnose
Lab tests
X ray
Special tests (if you have them)
3)
4)
5)
6)
Making a DIAGNOSE in acute abdomen
1)
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History: ask about
Pain !!! When start, where, cont. or colic pain, on
urination etc
why?
Vomiting, related to pain?
why?
Previous history
why?
Bowels
why?
Monthly periods
why?
Appetite, weight loss, fever, chance of fit of clothes
why?
PAIN and likely cause
VOMITING and likely cause
VOMITING and likely cause
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Abdominal Pain and vomiting later suggests AA
Vomiting followed by abd pain suggest GE
Vomiting sudden and soon after abd pain
suggests upper small bowel obstruction or
strangulation
Vomiting about 4 hrs after abd pain
obstruction ileum/appendicitis
Vomiting many hours after onset abd pain:
large gut obstruction
2) GENERAL EXAMINATION and the likely
cause in acute abdomen
LOOK FIRST
- malnourished ?
- bright or lethargic, restless ?
How is his:
- Face: grey/pale, gasping,
swetting, sunken eyes, tongue,
conjunctiva, smell breath ?
Is it changing in time?
- Nose and hands cold?
- Pulse? Again later: trend?
- Attitude in bed?
- Respiration rate, Temperature , Signs of dehydration ?
3) EXAMINATION abdomen: I. P. P. A.

Inspection: contour, scars, distention, peristalsis,
groins etc.
 Palpation: warm hands, be gentle, have patience,
- muscle rigidity, tenderness, rebound (Rovsing
positiv ?)
- guarding: local or generalized rigidity?
- masses: how does it feel? firm or soft, painful? Fluct?
- feel hernia sites, skin elasticity (why, where?)
 Percussion: liver, spleen, tumour, gas or dull, painfull?
Locally or generalized pain?
 Auscultation: Bowel sounds:
increased, decreased or absent? Loud with peristaltic
rushes (gastro-ent), High pitched tinkling together
with worsening abd. pain? (obstr)
still on Examination

The Pelvic cavity
- Rectal Examination: empty? faeces?
blood? pussy? mucous? painful?
- Vaginal Examination: pussy?
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Chest
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Spine
- Spinal tb/root pain, tumour?

Neck
- Stiff?
Mind you: Meningitis can cause
vomiting and abd. pain!
- Creps? Pneumonia?
Making a diagnose
4)
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5)
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6)
Laboraty tests
Blood: Hgb, Ht, WBC, ESR
Urine: RBC, WBC, pus, sugar
Xrays
X chest: lung, diafragm/subfrenic area
X abd.: erect and supine/horizontal
Look for abnormal signs: free air, fluid levels, air in
small gut?
Special investigations
Ultra sound, Tap
(CT, MRI usually not available in DHs/MHs)
special investigations
How useful are “Special Investigations”
in Acute abdomen?
USEFULNESS
Correct preliminary diagnosis on CLINICAL
grounds, unaltered by tests
60% !
Incorrect pl diagnosis on clinical grounds,
unaltered by tests
25%
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Incorrect pl diagnosis corrected by tests
14% !
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Correct pl diagnosis altered wrongly by tests
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CONCLUSION ??
%
1%
RADIOLOGICAL APPEARANCES IN THE
ACUTE ABDOMEN
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Sm. bowel obstruction: distended sm.bowel

Colon obstr:
distended large bowel
+ sometimes also small bowel

Perforated ulcer
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Appendicitis
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Cholecystitis
gas under diaphragm
signs of local ileus
calculus
X rays
Diagnose?
?
?
HOW TO MAKE A DIAGNOSE ?
Make a checklist
 Re-examine patient
 Know the most lileky diagnose in your
area

Make a checklist based on likely
diagnose in your area like:
1) Intestinal obstruction
2) Perforation
3) Tropical diseases:
- amoebic enteritis, liver abscess, typhoid,
ileocaelic tb with subacute obstruction
4) Appendicitis
5) Trauma: - ruptured spleen
- gut perforation
Checklist , continue
6)
Gynecological causes
-Ruptured ectopic pregnancy
-PID
-Tubo ovarian absces with peritonitis
-Torsion ovarian cyst
-Intermenstrual bleeding
Checklist , continue
7) Renal conditions
- Renal colic with reflex intestinal ileus
- Pyonephros (not common)
8) Gallbladder (rare)
- Biliary colic, stones
- Acute cholecystitis
- Empyema
9) Pancreas (rare)
- pancreatitis, alcohol
Checklist, continue
Medical diseases
10) Acute gastroenteritis (everywhere, very common)
- diarrhoea, vomiting, and fever, colicky pains
minimal abdominal tenderness, hyperactive but no
obstructive bowel sounds
11) Basal pneumonia and pleurisy (everywhere, common)
- usually in children
12) Virus infection causing muscular pain (common)
13) Sickle cell crisis (common in some areas)
- central abd.pain, vomiting, headache,
high fever.
How to diagnose sickle cell disease?
Most likely diagnosis in
acute abdomen ?
In Uganda:
1)
intestinal obstruction
93% !
2) appendicitis 3% (rising)
3) perforated peptic ulcer 2% (rising)
4) cholecystitis, renal calculi, pancreatitis 1%
These figures differ geographically
How are the percentages in your area ??
Most likely cause of

Intestinal obstruction?
External hernia (73%) !
Sigmoid volvulus (13%)
 Bands and adhesions (4%)
 Intussusception (4%) but higher in
Kilomanjaro
 Malignant diseases, adult pyloric
obstruction and congenital anomalies (1%)

Again: may differ geographycally
External hernia
73%
Sigmoid volvulus
13%
Intussusception 4% Adhaesions 4%
Acute abdomen
IN DOUBT ?
Better to “ LOOK AND SEE”
than to
“ WAIT AND SEE”
The end of
Diagnosing Acute Abdomen
Next time
Management