Acute Abdomen

ACUTE ABDOMEN BY S/N JANET KHOO

Acute Abdomen

Acute abdomen is Peritonitis

• The term acute abdomen refers to a sudden, severe pain in the abdomen that is less than 24 hours in duration. • It is in many cases an emergent condition requiring urgent and specific diagnosis. • Treatment usually involves surgery.

Acute Abdomen • Acute abdomen can be defined as • Severe, persistent abdominal pain • Of sudden onset that is likely to

require surgical intervention to treat its cause. • The pain may frequently be associated with nausea and vomiting , abdominal distention, fever and signs of shock.

INDICATIONS OF AN ACUTE ABDOMEN

• Abdominal pain • Guarding (contraction of abdominal muscles and discomfort when the doctor presses on the abdomen)

• Rigidity (hardness) of abdominal muscles • Rebound tenderness (an increase in severe pain and discomfort when the doctor abruptly stops pressing on a localized region of the abdomen)

• Leukocytosis (increase in white blood cell count)

Traumatic Causes • • •

Blunt or Perforating trauma To the stomach, bowel, spleen, liver , or kidney

Mechanical Causes • Small bowel obstruction secondary to

adhesions caused by previous surgeries, intussusception, hernias, benign or malignant neoplasms • Large bowel obstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impaction or hernia

Inflammatory Causes • Infections such as appendicitis,

cholecystitis, pancreatitis, pyelonephritis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess • Perforation of a peptic ulcer, a diverticulum, or the caecum • Complications of inflammatory bowel disease such as Crohn's disease or ulcerative colitis

Vascular Causes • occlusive intestinal ischemia, usually caused by thromboembolism of the superior mesenteric artery

DIAGNOSTIC TESTS FOR EVALUATING ABDOMINAL PAIN •

Laboratory examinations of blood and urine specimens

•

X-rays of the chest and abdomen

•

Ultrasound (evaluation of abdominal organs and spaces with sound waves)

•

CT scans (x-ray technique using computer programming to provide detailed images)

•

Endoscopy (a tube passed into the mouth to inspect the upper gastrointestinal tract or inserted into the rectum to view the lower gastrointestinal tract)

•

Angiography (dye studies exploring major blood vessels)

•

Radionuclide scans (injected dyes that identify sources of intestinal bleeding)

Differential diagnosis of Acute Abdomen • • • • • • • • •

Causes Acute appendicitis. Acute peptic ulcer and its complications. Acute gall bladder pathology, such as an impacted gallstone. Acute pancreatitis. Acute intestinal ischemia (See Section Below.) Diabetic Ketoacidosis. Acute Diverticulitis. Ectopic Pregnancy with tubal rupture.

Appendicitis • Is a condition characterized by

inflammation of the appendix. While mild cases may resolve without treatment, most require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly due to peritonitis and shock

Signs & Symptoms • Pain starting centrally (periumbilical) before localising to the right iliac fossa • Loss of appetite (anorexia) and • Fever, although the latter isn't a necessary symptom.. • Nausea or vomiting may or may not occur.

Perforated appendicitis with formation of an abscess (arrows), with appendicolith (arrowhead) within the abscess.

Deep gastric ulcer

PUD • A peptic ulcer, or peptic ulcer disease is • an ulcer of an area of the gastrointestinal tract • that is usually acidic and thus extremely painful. • As much as 80% of ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach

A benign gastric ulcer

Signs and symptoms

• Abdominal pain, classically epigastric with

• • • •

• •

severity relating to mealtimes, after around 3 hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it); Bloating and abdominal fullness Nausea, and lots of vomiting Loss of appetite and weight loss; Hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting. Melena (tarry, foul-smelling faeces due to oxidized iron from hemoglobin) Rarely, an ulcer can lead to a gastric or duodenal perforation. This is extremely painful and requires

Gallbladder

Gall Bladder Disease • The gallbladder stores about 50ml of bile • Which is released when food containing fat enters • • • •

the digestive tract Stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, Increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.

• Acute or chronic inflammation of the

gallbladder (cholecystitis) causes abdominal pain. • 90% of cases of acute cholecystitis are caused by the presence of gallstones. • The actual inflammation is due to secondary infection with bacteria of an obstructed gallbladder • With the obstruction caused by the gallstone.

• When gallstones obstruct the

common bile duct ( choledocholithiasis) • The patient develops jaundice and liver cell damage. • It can be a medical emergency, requiring endoscopic • Or surgical treatment such as a cholecystectomy.

Acute Pancreatitis

Symptoms and Signs • Severe upper abdominal pain, with

radiation through to the back • Nausea and vomiting • Blood pressure may be high (when pain is prominent) or low (if internal bleeding or dehydration has occurred) • Abdominal tenderness is usually found but may be less severe than expected given the patient's degree of abdominal pain. • Bowel sounds may be reduced as a reflection of the reflex bowel paralysis (i.e. ileus) that may accompany any abdominal

Most common causes • A common mnemonic for the

causes of pancreatitis spells • "I GET SMASHED", • an allusion to heavy drinking (one of the many causes):

• • • • • • • • • •

I - idiopathic G - gallstone. E - ethanol (alcohol) T - trauma S - steroids M - mumps (paramyxovirus (Epstein-Barr virus, Cytomegalovirus) A - autoimmune disease (Polyarteritis nodosa, SLE) S - scorpion sting - Tityus Trinitatis - Trinidad/ snake bite H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and hypothermia E - ERCP (Endoscopic Retrograde CholangioPancreatography - D D- drugs (steroids & sulfonamides, azathioprine, NSAIDS,furosemide and thiazides, & didanosine)

Causes • The most common cause of acute pancreatitis is gallstones. • Excessive alcohol use is often cited as the second most • • • • • • • •

common cause of acute pancreatitis. Less common causes include hypertriglyceridemia (but not hypercholesterolemia) and only when triglyceride values exceed 1500 mg/dl (16 mmol/L), hypercalcemia, viral infection (e.g. mumps), trauma (to the abdomen or elsewhere in the body) including post-ERCP (i.e. Endoscopic Retrograde Cholangiopancreatography), vasculitis (i.e. inflammation of the small blood vessels within the pancreas) autoimmune pancreatitis. Pregnancy can also cause pancreatitis, but in some cases the development of pancreatitis is probably just a reflection of the hypertriglyceridemia which often occurs in pregnant women. Pancreas divisum, a common congenital malformation of the pancreas may underlie some cases of recurrent pancreatitis.

Treatment • 1. provision of pain relief. • 2. provision of adequate replacement fluids and salts (intravenously) • 3. limitation of oral intake (with dietary fat restriction the most important point) • 4. Start antibiotics with signs of infection

Acute intestinal ischemia • Vascular disorders are more likely to affect the •

• • • • • • •

small bowel than the large bowel. Arterial supply to the intestines is provided by the superior and inferior mesenteric arteries, (SMA and IMA respectively) both of which are direct branches of the aorta. Acute intestinal ischemia The SMA supplies: Small bowel. Ascending and proximal 2/3 of the Transverse colon. The IMA supplies: Distal 1/3 of the Transverse colon. Descending colon Sigmoid colon.

Small bowel obstruction caused by an anterior abdominal wall incisional hernia diagnosed by CT. Image demonstrates dilated loop of small bowel going into the hernia and collapsed loop of small bowel coming out, confirming a complete small bowel obstruction with the hernia as the cause. Surgical skin staple and left pelvic

transplant kidney are also noted on the image.

Causes • •

•

A thromboembolism from the left side of the heart, such as may be generated during atrial fibrillation, occluding the SMA. Nonocclusive ischemia, such as that seen in hypotension secondary to heart failure may also contribute, but usually results in a mucosal or mural infarct, as contrasted with the typically transmural infarct seen in thromboembolus of the SMA. Primary mesenteric vein thromboses may also cause ischemic acute abdomen, usually precipitated by hypercoagulable states such as polycythemia vera.

SIGNS & SYMPTOMS • Diffuse abdominal pain • Bowel distention • Bloody diarrhea. • Bowel sounds will be absent. • Neutrophilic leukocytosis • Increased serum amylase. • Abdominal XR will show many airfluid levels, as well as widespread edema.

• Acute ischemic abdomen is a surgical emergency. • Typically, treatment involves removal of the region of the bowel that has undergone infarction, • And subsequent anastomosis of the remaining healthy tissue.

Diabetic ketoacidosis • (DKA) is a life-threatening

complication in patients with untreated diabetes mellitus

Symptoms and Signs • Sluggish, extreme tiredness. • Fruity smell to breath/compare to nail polish • • • •

• •

remover, similar to peardrops. Extreme thirst, despite large fluid intake. Constant urination Extreme weight-loss. Oral Thrush may be present, or/ yeast infections that fail to go away, this is because the normal fungal/flora present in oral cavity/cervix in women, the balance is upset and bacterial began to feast on the high sugar from urine output/ dry mouth from extreme thirst. Muscle wasting. Agitation / Irritation / Aggression / Confusion

The basic principles of DKA treatment are:

• Rapid restoration of adequate circulation and perfusion with isotonic intravenous fluids • Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate • Insulin to reverse ketosis and lower glucose levels • Careful monitoring to detect and treat complications

Diverticulitis • A common digestive disease

particularly found in the large intestine. • Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. • Diverticulitis results if one of these diverticula becomes inflamed.

Diverticula (arrowheads) and inflammation around the sigmoid colon, indicating diverticulitis. A small, adjacent, early abscess (open arrow) is noted.

Causes • Blockage of a diverticulum, possibly

by a piece of faeces or food particles, leads to infection of the diverticulum

Symptoms • Abdominal pain • Tenderness around the left side of the lower abdomen • Fever, nausea, vomiting, chills, cramping, and constipation

Treatment • An initial episode of acute diverticulitis is usually • • • • •

treated with Conservative medical management, including bowel rest (ie, nothing by mouth), IV fluid resuscitation, and Broad-spectrum antibiotics which cover anaerobic bacteria and gram-negative rods. Recurring acute attacks or complications, such as peritonitis, abscess, or fistula may Require surgery, either immediately or on an elective basis.

What’s this ?

Ectopic pregnancy • A complication of pregnancy • In which the fertilized ovum is implanted in any • • • •

tissue other than the uterine wall. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), But implantation can also occur in the cervix, ovaries, and abdomen. The fetus produces enzymes that allow it to implant in varied types of tissues, and Thus an embryo implanted elsewhere than the uterus can cause great tissue damage in its efforts to reach a sufficient supply of blood.

Causes • •

• • • •

The causes of ectopic pregnancy are unknown After fertilization of the oocyte in the peritoneal cavity, the egg takes about nine days to migrate down the tube to the uterine cavity at which time it implants. Wherever the embryo finds itself at that time, it will begin to implant. Some speculative specific causes or associations: Smoking, Advanced maternal age and Prior tubal damage of any origin

Symptoms • Clinical presentation of ectopic pregnancy occurs • • • •

at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Pain and discomfort, usually mild. Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy.

• Pain while having a bowel movement • Patients with a late ectopic pregnancy

typically have pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms. • External bleeding is due to the falling progesterone levels. • Internal bleeding is due to hemorrhage from the affected tube.

• More severe internal bleeding may cause: • Lower back, abdominal, or pelvic pain. • Shoulder pain. This is caused by free blood tracking up the • • •

abdominal cavity, and is an ominous sign. There may be cramping or even tenderness on one side of the pelvis. The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse. Ectopic pregnancy is noted that it can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems.

Treatment • Nonsurgical treatment • Early treatment of an ectopic pregnancy with the

• • •

antimetabolite methotrexate has proven to be a viable alternative to surgical treatment[6] If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of pregnancy. Surgical treatment If hemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing blood loss.. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy).

Tubal Pregnancy showing a 1 month embryo

Tubal pregnancy (6 week old embryo)

Acute Abdomen • An elderly man with acute

abdominal pain • This 75 year old man presented to the Emergency Department with acute abdominal pain and bloody diarhoea. What does the plain abdominal film show?

Crohn's colitis with toxic megacolon

LEFT: Plain abdominal film in a patient with an acute abdomen, showing no abnormalities. RIGHT: Subsequent CT shows distended small bowel loops (arrowheads) that are not seen on plain abdominal film because they are filled with fluid only and do not contain intraluminal air.