ACUTE ABDOMEN
Begashaw M
ACUTE ABDOMEN

Denotes any sudden condition with chief
manifestation of pain of recent onset in the
abdominal area which may require urgent
surgical intervention
Sites of referred pain
Sites of Abdominal Pain
CLASSIFICATION





Obstruction
Inflammation
Hemorrhage
Infarction
perforation
CLINICAL FEATURES

Symptoms
_Colicky and Intermittent pain ( visceral)
_Continuous pain ( somatic)
_Vomiting
_Fever
_Tachycardia
 Colic pain obstruction
 Continuous pain infection, inflammation or
ischemia
Signs

Abdominal distention, visible peristalsis
 Direct and rebound tenderness, guarding
 Anemia, hypotension
 Toxic with Hippocratic faces
 Absence of bowel sound ( peritonitis)
 Psoas signappendicitis
 Murphy‘s signacute cholecystitis
 Dehydrationsunken eyeballs
DIFFERENTIAL DIAGNOSIS

Surgical - Intestinal obstruction
 Gynecologic & obstetric - Ectopic ruptured
pregnancy
 Medical - enteritis
Surgical causes
A- InflammationAcute appendicitis
Acute cholecystitis
B- Obstruction Intestinal obstruction
C- Infarction
Mesenteric ischemia
D-Strangulation volvulus
E- Perforation perforated peptic ulcer
DIAGNOSIS

Clinical: Hx & p/E
 Lab: CBC, cross match, urine analysis,
serum amylase & electrolytes
 Ultrasound
 plain film of abdomen
MANAGEMENT
A-Preoperative
- Resuscitation with IV fluids
- Antibiotics
- Catheterization & NGT insertion
- Analgesics after confirming the diagnosis
B- Surgery
Definitive laparotomy
CMonitoring
Follow up
INTESTINAL OBSTRUCTION
 is
partial or complete blockage of the
intestine producing symptoms
_Vomiting
_Constipation
_Distension
_Abdominal pain
Causes of mechanical
intestinal 0bstruction
Intestinal Obstruction
CLASSIFICATION
Mechanical  physical barrier blocks
 Paralytic ileus disordered propulsive
motility
 High _Small bowel
 Low _Large bowel
 Simple -> adequate blood supply
 Strangulated -> Mesenteric vessels
occluded

Mechanical
A- Luminal
_Gallstone Ileus
_Food bolus
_Meconium Ileus
_Malignancy
_Inflammatory mass
_Ascaris bolus
B- Mural
_Stricture
_Congenital
_Inflammatory
_Ischemic
_Neoplastic
_Intussusception
Intussusception
C- Extra mural
 Adhesionsinflammatory/malignant
 Hernia External/internal
 Volvulus Small bowel
large bowel -> Sigmoid
volvulus
Small bowel obstruction
Adhesion
PATHOPHYSIOLGY
dilatation disrupts peristalsis
 Above the obstruction  distended with fluid
and gas
 stimulates excessive peristalsis ->colicky pain
 blood vessels-stretched & narrowed
ischemia
 Absorptive capacity decreases
 increased vomiting  depletion of extra
cellular fluid  hypovolemia & dehydration
 Proximal
Pathophysiology

A strangulated loop dies and perforates to
produce severe bacterial peritonitis which is
often fatal
 Grossly distended abdomen restricts
diaphragmatic movement and interferes
with respiration
 A multiple organ failure
Clinical features

Symptoms
-Abdominal pain-colic
-Vomiting
-Constipatio-partial
-absolute

Signs
-Abdominal distension
visible bowel loops
-High pitched bowel
sounds
-Tenderness & guarding
-Dehydration &
hypotension
-Empty rectum DRE
Large bowel
obstruction
DIAGNOSIS

Clinical: Hx & P/E
 Lab: CBC, electrolytes
 Plain abdominal film :
- distension of bowel with air fluid level
- Central located distended loops with
multiple air fluid levelsmall bowel
- Peripherally located distended bowel with
haustral marksLarge bowel
X-ray of intestinal obstruction
MANAGEMENT

Fluids resuscitation to restore the
circulatory state
 Early preoperative preparation
 Attempt rectal tube deflation-simple
sigmoid volvulus
 Supportive measures
 Early operationLaparotomy
 Post operative care
NG tube suction
SIGMOID VOLVULUS
 Sigmoid
colon is the most frequent site of
volvulus
 Predisposing factors
- A long redundant sigmoid with a narrow
pedicle
- High fiber diet
- Chronic constipation_elderly
_chronic mental pts
Sigmoid volvulus
PATHOPHYSIOLOGY

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Redundant sigmoid twists on its base in a
clockwise direction
Mesocolic veins become occluded & arterial
inflow into the twisted loop perpetuates the
volvulus until it becomes irreversible
Twisted loop distends grossly
Perforation may occur due to either pressure
necrosis at the base of the twist or to avascular
necrosis at the apex
DIAGNOSIS

CLINICAL
_Abdominal cramp & distension
_Constipation (early) & vomiting (late)
_Empty rectum on DRE
 RADIOLOGIC FINDINGS
 Two long fluid levels in the lower quadrant
 Inverted U shape of the sigmoid lumen
 “Coffee bean” appearance or the ‘Omega sign”
MANAGEMENT

Conservative
 simple volvulusdeflation with a well
greased large bore rectal tube under the
guide of a sigmoidoscope
 Deflation fails laparotomy & derotation
 Elective resection & anastomosis
 Intravenous fluid - rehydrate if sign of
dehydration
Sigmoidoscopic deflation

Emergency Surgery
_Complicated volvulus with signs of
peritonitis
_Resuscitative measures
_Antibiotics
_Resection of the gangrenous segment with
Hartman’s colostomy
Laparatomy
APPENDICITIS

is an inflammation of the appendix that
results from bacterial invasion usually distal
to an obstruction of the lumen
Appendix
Pathogenesis
Luminal obstruction bacterial overgrowth 
lnflammation/swelling Increased pressurelocalized
ischemiagangrene/perforationlocalized
abscess (walled off by Omentum) or Peritonitis
 Etiology:
_Hyperplasia of lymphoid follicles
_Fecolith, obstructing neoplasm
_Parasites, foreign body

CLINICAL PRESENTATION

Symptoms
-Central abdominal colic which shifts to the
right Iliac fossa
-Anorexia, nausea, episodes of vomiting and
low grade fever
-High grade fever indicates perforation and
peritonitis
Signs
-Tenderness and localized rigidity in RLQ MC
Burney’s point
-Rovsing’s sign: Pain in RLQ on pressing in
LLQ
-Psoas sign: Pain on extension of right flexed hip
-Obturator sign: Pain on passive internal or
external rotation of the flexed right hip
-Right sided tenderness on rectal examination.
-Diminished bowel sounds indicating peritonitis
Appendicitis signs
Differential diagnosis

IN CHILDREN
-Intussusceptions
-Mesenteric adenitis
 FEMALE
-PID
-Twisted ovarian cyst(
torsion)
- ruptured ovarian
follicle

GENERAL
-Acute chlolecystitis
-Perforated PUD
-Renal or ureteric
calculi
-UTI
-Early small bowel
obstruction (volvulus)
-Gastroenteritis
Investigations
 Labs

leukocytosis with left shift
 beta-hCG to rule out ectopic pregnancy
 Urinalysis
 Imaging:
 Upright CXR, AXR-free air
 Ultrasound: may visualize appendix
MANAGEMENT

PREOPERATIVE
-Resuscitation with fluids
-Appropriate antibiotics (combination for
coverage of gram positive, gram negative and
anaerobes)
-Correct all deficits ( dehydration)
 SURGERY
-Surgical removal of the appendix is the
definitive treatment-Appendectomy
COMPLICATIONS

Perforation - local or generalized peritonitis
 Appendiceal mass and abscess formation
 Death
APPEDECIAL MASS

Inflammatory process walled off in the right
iliac fossa by omentum and loops of bowel to
form a mass
 Management-Conservative
-antibiotics
-fluids
_Drug of choice- metronidazole and ceftriaxone
Ampicilline, Chloramphenicol & Gentamycin
Follow up
-Vital signs every 4 hourly
-Mass size & consistency 12 hourly
-Patient’s condition
-Laboratory every other day
 Interval appendectomy 6 weeks later
Appendiceal abscess

Increasing mass size
 Fluctuation
 persistence of systemic signs
 Management - drainage of the abscess and
appendectomy
 Interval appendectomy after emergency
drainage
Draining appendeceal
abscess
PERITONITIS

is an inflammation of the peritoneum
 is an acute life threatening condition caused
by bacterial or chemical contamination of
the peritoneal cavity
Peritoneum
Peritoneal abscess
Differential diagnosis

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Perforated appendix
Perforated PUD
Anastomotic leak
Strangulated bowel
Pancreatitis

Cholecystitis
 Intra abdominal
abscess
 Typhoid perforation
 Ascending infection
e.g salpingitis
CLASSIFICATION

Primary peritonitis: caused by bacterial
spread via the blood stream
 Secondary peritonitis: caused during
perforation or rupture of abdominal organ
allowing access of bacteria and irritant
digestive Juices to the peritoneum
Classification

Acute peritonitis: rapid onset or brief
duration
 Chronic peritonitis: long duration
 Localized peritonitis - confined to a limited
space - pelvis
 Generalized peritonitis - whole peritoneal
cavity involved
ROUTES OF BACTERIAL
INVASION
1- Direct- contamination via perforation, a
penetrating wound or during surgery
2-Local Extension: contamination by
migration from an infected organ - through
gut wall, via the fallopian tube
3-Blood stream: via the blood as consequence
of general septicemia
CLINICAL FEATURES


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Sharp pain which is worse on movement
Fever & tachycardia
Abdominal distension
Tenderness & guarding
Diminished or absent bowel sounds
Shoulder pain _referred pain -diaphragmatic
irritation
Tenderness on rectal examination (pelvic
peritonitis)
Abdominal distension & vomiting
Generalized peritonitis
MANAGEMENT

Resuscitation: intravenous fluids
 Analgesia
 Naso-gastric tube insertion (NGT)
 Triple antibiotics (ampicilline , gentamycin
and metornidazole or chloramphenicol)
 Monitoring in put & out put by catheterization
 Surgery
 Drainage & peritoneal lavage