The Acute Abdomen
Raymond Yiu
Surgery Team 3
• Acute Life-threatening intra-abdominal
conditions
• Requires Emergency admissions
• Often requires Emergency surgery
Aetiology:
Abdominal Pain
• EXTRAABDOMINAL
– Cardiovascular
– Metabolic
– Abdominal wall
– Neurogenic
• INTRABDOMINAL
–
–
–
–
Imflammatory
Traumatic
Obstructive
Vascular
MI
DKA
rectus sheath
haematoma
referred pain
INTRABDOMINAL
– Imflammatory Conditions (Peritonitis)
Localised / Generalised
Primary / Secondary / Tertiary
– Traumatic
Blunt / Penetrating Injury
Bleeding / Peritonitis
– Obstructive
Gastric/ Small / Large Bowel
– Vascular
Mesenteric infarction
Strangulated hernias
Volvulus (small or large bowel)
Rupture AAA
Aortic dissection
Imflammatory Conditions
Peritonitis
Peritonitis
• Bacteria
primary/ secondary/ tertiary
spontaneous
• Chemical
Peritonitis: Bacterial
secondary: majority of cases
perforated viscus / GIT
primary:
very rare
healthy people in absence of surgery and
trauma (children and young adult females)
streptococcal pneumoniae/ gonococcus
laparotomy + washout + antibiotics
tertiary:
ICU patients
persistent/ recurrent sepsis following
adequate therapy of secondary peritonitis
poor prognosis
Spontaneous bacterial peritonitis
• Immunocompromised patients with ascites, cirrhosis,
renal failure on CAPD, nephrotic syndrome
• Gram negative organisms
E. Coli in ascites (bacterial translocation)
• Present with abdominal pain, fever, generalised
perionitis
• Ascitic fluid tapwhite cells, gm stain, culture
• Treatment by iv cephalosporins, intraperitoneal
antibiotics (vancomycin/netelmicin for gm +ve
organisms)
Peritonitis: Chemical
• Leakage of irritant fluids ie urine, bile, acid
leading to initial chemical peritonitis
• Later secondary infection occurs after a few
hours
• Clinical Examples: PPU, Bile leak from
cystic duct stump post cholecystectomy
Peritonitis
Clinical Features
• Abdominal pain (recent onset)
• Irritation of somatic nerves supplying parietal
peritoneum
• Constant, sharp, aggravated by movement
• May be referred to other parts of body (eg
shoulder-tip pain in acute cholecystitis)
Peritonitis
Clinical Features
• Systemic:
• Abdominal:
Generalised
Fever
Tachycardia
Leucocytosis
Chills/rigors
Dehydration
tenderness, guarding, rigidity,absent BS,
distention (ileus)
localised
Peritonitis
Localisation of signs and pathology
Peritonitis
Clinical Features
Pancreatitis
Liver abscess
PPU
Cholecystitis
Cholangitis
Appendicitis
Diverticultis
Meckels
diverticultis
Small
bowel perf
Acute abdomen
Common conditions
Appendicitis
Cholecystitis
Acute appendicitis: aetiology
Obstruction of lumen by:
Lymphoid hyperplasia
Faecolith
Parasites
Cancer/ carcinoid
Acute appendicitis:
Clinical Features
7% population
10-30 years
Mortality rate <1%
5% Elderly and young
(delay in diagnosis)
Acute appendicitis
• RLQ pain
• Pain migration
• Anorexia, nausea
•
•
•
•
•
RLQ tenderness
RLQ guarding
RLQ rebound
Fever
Leucocytosis (80%)
Mcburneys
point
Acute appendicitis: Signs
Rovsings sign: Pain in RLQ on pressing LLQ
Dumphys sign: Pain on coughing
Psoas sign:
Obturator
sign:
Acute appendicitis: Signs
Depends on where inflamed appendix is:
Retrocecal: Lumbar sign: Pain in right flank
Pelvic:
irritate bladder: dysuria
irritate rectum: diarhoea
Acute appendicitis: Ix
Acute appendicitis
Laparoscopic
Young women of child
bearing age
Open
Acute appendicitis:
appendiceal mass
• Usually reflects delayed presentation
• Patient presents with mass in RLQ
• +/- peritoneal signs
• Mass represents walling off of appendix by
surrounding structures
• Rx: Osler-schering regime in absence of clinical signs
• Conservative rx with IVF and iv antibiotics until sx
subside (follow by colonoscopy and interval
appendicectomy 4-6 weeks later)
Acute Cholecystitis
Remember 4 ‘F’s
Cholesterol
Pigment
Calcium
Acute Cholecystitis
Chemical peritonitis
initally
Acute Cholecystitis
clinical features
Short onset RUQ pain
Fever
RUQ peritoneal signs
Murphys signs
Acute Cholecystitis
Imaging
Acute Cholecystitis
Treatment
• Short duration of sx (<5days pain)
– Consider surgery (lap)
– Higher incidence of conversion
• Longer duration of sx (>5days)
–
–
–
–
conservative treatment by npo, iv antibiotics
Followed by lap cholecystectomy 6-8 weeks later
Any signs of perforation requires urgent surgery
Interval cholecystitis
• Unfit patients
– cholecystostomy
Intestinal Obstruction
Aetiology
• Extramural:
adhesions
hernias (int/ext)
tumor
• Intramural
tumor
stricture (radiation/crohns/tb)
• Intraluminal
Food bolus
GS
FB
Faecal impaction
Aetiology by incidence (SBO)
• Previous OT: adhesions
• “Virgin” abdomen: carcinoma, hernias
Questions to ask?
• Site: Stomach vs SB vs LB
• Presentation: Acute vs Subacute
• Urgency: simple mechanical vs strangulating
Site: Sx
Gastric
outlet
Small bowel Large bowel
Pain
Epigastric
Central colic
Lower colic
Vomiting
Early
Early/late
Late/none
BO/flatus
Normal
Normal/ none
none
Distension
upper
General
General/
localised (just
LB)
Hyperactive BS
Ausculatation Sucussion
splash
Hyperactive
BS
Site: X-ray
Large gastric
bubble
Mainly LB
dilatation (+SB if
competent ICV)
AXR
Mainly SB
dilatation (no LB
or rectal gas)
Gastric outlet
obstruction
SB
obstruction
RT decompression
OGD
Oral contrast study
Virgin
abdo
Ca caecum
hernias
Previous
OT
adhesions
LB
obstruction
Contrast enema
(Watersoluble)
Presentation:
Acute vs Subacute SBO
• Acute
short onset
May require laparotomy if does not resolve
• Subacute:
on/off symptoms that subside but does not
completely resolve
Investigate (eg colonoscopy) if subside
Repeated attacks may require laparotomy
Simple Mechanical
Obstruction
Can wait
vs
Strangulating
Cannot wait
Simple Mechanical Obstruction
Simple Mechanical Obstruction
Femoral hernias
Strangulating obstruction
Vascular supply compromised
Can occur in any type of obstruction
• Closed loop obstruction (eg
volvulus, LBO with competent ICV)
• Intussusception
• Stangulation of mesenteric blood
supply (adhesive band, hernias)
Sigmoid Volvulus
Example of close loop obstruction:
both ends of the bowel are blocked
and air enters in a one-way valve
Sigmoid Volvulus
Decompression :
bedside sigmoidoscopy or colonoscopy
failure
intussusception
Usually associated with
polyps acting as lead
point
Small bowel ischemia
Prolonged
strangulation
from adhesion
band, hernia
Small bowel
volvulus
Recognising bowel ischemia
• Awareness is the most important
• Pain out of proportion to abdominal signs
• Peritoneal signs (may be late)
• Sepsis (fever, high WCC, shock , acidosis)
Management
Hx and exam
Initial Mx
Baseline Ix
Special Ix
Preparation for OT
History and Examination
Discharge Diagnosis
Undifferentiated
GI causes
Gastroenteritis
Surgical GI
UTI
Pelvic Disorder
1972
41%
13%
7%
10%
11%
12%
1977
39%
19%
12%
18%
---
Brewer, Am J Surg, 1976; Jazon, AC Scand, 1982; Powers, AJEM,
History & examination and simple lab tests
have about a 50-60 % accuracy in giving a
diagnosis
1993
25%
18%
5%
8%
11%
12%
Pattern Recognition is very
important !
Pattern Recognition
Central colicky
Young
+ abdo pain +
male
shifts to RLQ
region
Elderly
+
Obese
female
RLQ
peritoneal = appendicitis
signs +
Temp 38 C
RUQ
RUQ pain + peritoneal = Acute
cholecystitis
signs
(Murphys)+
Temp 38 C
Initial Mx
NGT
analgesia
NPO
Resuscitation: IVF
Iv antibiotics
Monitoring
devices
Foley
(CVP)
Baseline Laboratory testing
Blood tests
Plain X-rays
ECG
WBC
Limited utility
WBC
> 11,000 LR+ = ~ 2
< 11,000 LR- = ~ 0.5
WBC alone doesn’t distinguish patients
with surgical disease from non-specific
abdominal pain
Liver function tests
• ↟ Bilirubin/ALP suggestive of biliary
obstruction
• ↟ Bilirubin/ ALT suggestive of hepatitis
• Normal LFT in up to 40% with acute
cholecystitis
• May be deranged in all types of sepsis. Not
specific for any disease entity
Amylase
– ↟ in acute pancreatitis
– May be normal in 40% cases of pancreatitis
– Raised in other intra-abdominal conditions eg
PPU, hyperamylassaemia, renal failure
Urinalysis
• Pregnancy test ------> Mandatory for all young females
(ectopic)
• WBC
UTI
• Haemuturia (RBC)
Renal colic (LR+ ~ 2 , LR- = 0.3)
Hematuria occurs in up to 30% with AAA
Most common misdiagnosis in AAA- kidney stone
Plain X-rays
Bowel obstruction70% sensitive
Sensitive for free air
90-95%
Aerobilia (RPC,
GS ileus)
Renal stones 90% radio-opaque
GS 10%
Normal X-rays does not exclude acute abdomen!
Special investigations
• History & examination and simple lab tests have
about a 50-60 % accuracy
• Technological advances in imaging are
responsible for our increased accuracy in
diagnosing patients with acute abdominal pain
– CT
– Ultrasound
Imaging-Ultrasound
Good first line investigation for
most intra-abdominal conditons
Non-invasive, no radiation
Imaging-Ultrasound
Biliary tract
Cholecystitis
Cholangitis
Appendicitis
Gynaecological conditions
Ovarian cysts (rupture, torsion)
Ectopic(TVS)
Urological conditions
(renal, ureteric stones, hydronephrosis)
CT scan
High accuracy in most acute abdominal
conditions
• GI
Small/ large bowel obstruction
Diverticulitis
(hinchey grading)
• Vascular
AAA (esp leaking)
Aortic dissection
Mesenteric ischemia
• Hepatobiliary
Biliary tract (stones)
Rupture HCC
Pancreatitis
Contrast Enema
LB
obstruction
Hx and exam
Baseline Ix
CBC, RFT, LFT, Amylase, AXR, CXR
Initial MX
peritonitis
Equivocal signs
Operation
peritonitis
Serial
Examination
Peritonitis or condition requiring
surgery
No peritoneal signs or
equivocal
Further Ix
CT/USS
Def
Diagnosis
RX
Preoperative preparation
Informed consent
IV antibiotics
X-match
Optimize comorbidities
Booking of emergency
OT