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Acute abdomen (pain)

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Acute abdomen


(abdominal pain ) Acute abdomen
Acute abdominal pain( pathophysiology)
,
Anatomy and pathophysiology relate to abdominal pain
( abdominal cavity ) peritoneum 2 lining
(abdominal wall ) parietal peritoneum, peritoneum
Visceral peritonuem parietal peritoneum Visceral peritoneum
parietal peritoneum Somatic Nerve Spinal
cord A-delta fiber (localized , sharppy)
somatic pain visceral peritoneum (autonomic nerve)
parasympathetic Sympathetic bilaterallity, midline pain
Visceral peritoneum C- Fiber A-delta Fiber
localized visceral pain stretch , distension , compression torsion
visceral pain forgut epigastium area, midgut periumbilical
area, hindgut suprapubic area
visceral pain somatic pain acute
appendicitis , visceral pain umbilical area inflammation and
progression appendix irritate parietal peritoneum somatic pain
migratory pain

Refered pain

Sharp,persistent localized central pathway afferent neuron (1)

cervical nerve III-V
(Kehrs sign) referred pain
( 1 )
,
( 2)
Clinical consideration

mechanism pain

(history taking)

1. (site of pain) (maximum point of pain),
, (Initial location of pain) (migratory pain)
acute appendicitis (right
lower quadrant) 4
xiphoid cartilage pubic symphysis umbilicus 4 RUQ, LUQ,
RLQ, LLO 2
2. (onset inNature of pain) (sudden onset)
hallow viscus organ perforate , (gradual onset) inflammatory process
appendicitis, cholecystitis 3
3. progrssion of pain , (Intermittent)
4. Character of pain (dull) Inflammation process
( Colicky , crammy) hollow viscus organ obstruction gut obstruction, biliary colic, ueteric colic
5. aggravates or relives of pain 4

, pancreastitis ,
, pathology GI tract,
peritonitis
6. associated symptomp, visceral organ autonomic Nerve
pathology autonomic response ,, , ,

6.1 VOMITING
acute abdomen bowel obstruction, luminal irritant
visceral pain visceral afferent emetic center

peptic ulcer perforation acute appendicitis
3-4 gastroenteritis 2-3
bowel obstruction

pyloric obstruction bowel obstruction distal small bowel
large bowel
6.2 ANOREXIA

6.3 BOWEL HABITS

acute gastroenteritis mechanical bowel obstruction
hollow viscus peritoneal cavity diarrhea
7. PAST ILLNESS pain
PAST ILLNESS
-

( - )

FAMILIAL HISTORY
familial disease acute abdomen
Peutz Juaghers syndrome small bowel obstruction harmatoma small bowel leading
point
ORGAN SYSTEM REVIEW

Extraabdominal disease systemic disease
lower lung pneumonia, myocardial infarction, renal failure, diabetic ketoacidosis etc.
PHYSICAL EXAMINATION
VITAL SIGNS vital signs

third space loss
septic shock
POSTURE AND GENERAL APPEARANCE

localized
inflammation
colicky pain pancreatitis

cachexia

ABDOMINAL EXAMINATION
EXPOSURE

groin hernia

INSPECTION

contour, surgical scar, skin lesion, bulging mass, visible peristalsis,

inflammatory area groin perineum hernia acute abdomen
distension adynamic ileus


fibrous adheseion
Mc Burney Point right subcostal incision
hyperemia
herpes zoster pyomositis abdominal wall muscle

AUSCULATION

four quadrants
bruit bowel sound high pitch metallic
sound colicky pain bowel obstruction bowel sound
bowel ileus
PALPATION



(light palpation)

visceral pain (tenderness)

(tenderness)
? (pain) ( pain symptom,
Tenderness sign)
somatic pain ( tenderness)
( voluntary guarding ) parietal peritoneum
parietal peritoneal inflammation


reflex abdominal spasm
abdomial rigidity involuntary guarding
somatic pain
voluntary guarding somatic pain
visceral pain rebound tenderness
parietal peritoneum parietal peritoneum
peritoneum

(cough test)
somatic pain parietal peritoneum
inflammation
maximal tenderness
(mild) (moderate) (marked)


( location) , ( size ) ,
(shape) , ( border) , (consistency) , (skin covering ),
(tenderness)
incisional hernia
incarceration bowel obstruction

inguinal region perineum acute abdomen

acute abdomen hernia indirect inguinal hernia,
femoral hernia
paresthesia ( Howship Rombergs sign ) obturator
hernia small bowel obstruction

PERCUSSION

solid structure
loss of liver dullness
pneumoperitoneum bowel ileus hepatic flexor colon
loss of liver dullness pneumperitoneum bowel ileus hepatic flexor colon
loss of liver dullness tenderness
somatic pain ( percussion test ) fluid thrill shifting dullness

PER-RECTAL EXAMINATION

gynecologic disease

ABDOMINAL EXAMINATION IN PEDIATRIC PATIENTS

acute abdomen




sedate

3-7
(
5)

DIAGNOSTIC INVESTIGATION

confirm exclusion
, investigation
1. Laboratory test;
2 , pre-op evaluation lab
routine, CBC, LFT, antiHIV, BunCr electrolyte , Serum hCG, amylase acute abdomen
complete blood count , complete blood count Leukocytosis
leukopenia infection Leukocytosis specific marker Differential
PMN > 80%
Liver function test
pathology hepatobiliary organ Nutrition ,
acute pancreastitis ranson critiria
Serum amylase / urine amylase

Urine Beta-HCG
pregnancy
urinalysis
WBC, RBC, KUB Stone acute abdomen pain
Serum amylase
Ischemic bowel ,
infected diarrhea or colitis,
Electrolyte
electrolyte imbalance Fluid loss
Blood sugar
acute pancreastitis
Hemoculture
sepsis acute cholangitis, pyogenic liver abscess

IMAGING
PLAIN FILM
plain film abdomen supine upright position
chest X-ray upright
plain abdomen 1) air pattern
2) abnormal calcifcation 3) abnormal soft tissue density
pneumoperitoneum 5-10 cc.
upright free air right lobe liver
right lateral abdominal wall falciform ligament ligamentum teres
soft tissue free air
double wall sign
Abnormal air
liver abscess portal vein acute gastric distention
small intestinal obstruction circumferential mucosal fold
(step laddle pattern) up right multiple air-fluid
level bowel loops large intestinal obstruction
cecum diameter
mucosal fold haustration
incompetent ileocecal valve competent ileocecal valve
adynamic ileus
up right air-fluid level
abnormal calcification
ureter right upper quadrant gallstones
common bile duct stones pancreatic calcification chronic
pancreatitis acute abdomen
CONTRAST STUDY
water soluble contrast study barium study
plain film barium enema large bowel obstruction
pseudocolonic obstruction barium
emema infant intusseception barium reduction ( intusseceptum
)

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ULTEASONOGRAPHY
()
ultrasound hepatobiliary
system solid organs free fluid
ultrasound hollow viscus artifact
COMPUTERIZED TOMOGRAPHIC
ultrasound radiaion exposure ultrasound
ultrasound CT scan
space complicated pancreatitis
necrosis pancreas blunt abdominal trauma epuivocal sign

special investigation

PRINCIPLE OF MANAGEMENT
acute abdominal pain 4 working diagnosis

1.Need Immediate laparotomy
2.Believe to have and underlying surgical condition (suspected surgical abdomen)
3.Has an uncertain diagnosis
4.Believe to have an underlying non surgical condition
(reevaluation)
(response) Working diagnosis

immediate laparotomy (rupture) AAA visceral aneurysm,

ruptured ectopic pregnancy, spontanous hepatic splenic rupture abdominal
vascular catastrophe

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surgical abdomen 3
1. urgent laparotomy 1-2
peritonitis acute appendicitis,perforated
hollow viscus, strangulated hernia
2. early or elective laparotomy 24-48
(conservative)
(highly unlikely to become life threatening during prolonged preiods)
non
strangulated incarcerated hernia, diverticulutis, uncomplicated cholecystitis
3. (hospitallization and active
observation) surgical abdomen peritonitis definite
diagnosis
uncertain diagnosis
electrolyte imbalance, unezplained abdominal
symptoms 24 medical condition acute abdominal pain
surgical abdomen (suspected non surgical abdomen)
(unuecessary laparotomy) lead poisoning
acute porphyria intermittentpain hyperperistalsis
nonspecific abdominal pain (NSAP)
GENERAL MANAGEMENT
acute abdomen provisional diagnosis
management
1. NPO (nothing per oral) gastrointestinal
tract
NPO
2. Nasogastric tube decompression
adynamic ileus mechanical obstruction hollow viscus
3. Fluid and electrolyte resuscitation salt solution
Lactate Ringer Solution
plasma

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external loss
oral fluid intake vital sign internal loss abdominal
distension peritoneal cavity bowel lumen initial urine volume
urinary catheter
fluid resuscitation

4. Monitoring vital signs, urine output per hour, central venous pressure, oxygen saturation, arterial
blood gas, arterial pressure, pulmonary arterial wedge pressure

5. Antibiotics broad spectrum antibiotics
gram positive , gram negative anaerobic bacteria
6. Analgesics
hypotension narcotics peripheral vasodilatation

7. Surgical intervention
Peptic ulcer perforation, hollow viscus perforation, acute toxic cholangitis, acute
appendicitis, acute toxic cholangitis, acute appendicitis, acute mesenteric arterial occlusion, complete or
strangulated bowel obstruction, massive intrapetitioneal bleeding due to trauma, etc.
hypavolemia electroly, acid-base imbalance

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1
Possible Origins for Referred Pain
Right shoulder
Diaphragm
Gallbladder
Liver Capsule
Right-sided
Pneumoperitoneum
Right scapula
Gallbladder
Biliary tree
Groin/genitalia
Kidney
Ureter
Aorta/iliac artery
Back-midline
Pancreas
Duodenum
Aorta

Left shoulder
Diaphragm
Spleen
Tail of pancreas
Stomach
Splenic flexure
(colon)
Left-sided
pneumoperitoneum
Left-sided
Spleen
Tail of pancreas

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Diagnosis Related to the Mode of Onset of Abdominal Pain

Sudden Onset

Gradual Onset

Intermittent Pain

Perforated viscus
Volvulus
Passage of stone (kidney or
Gallbladder)
High intestinal obstruction
Mesenteric embolism/
Arterial thrombosis
Ruptured aortic aneurysm
Ruptured ectopic pregnancy
Ovarian torsion/ruptured cyst
Sickle cell crisis
Myocardial ischemia/
Infarction
Mittelschmerz
Abdominal wall
Intramuscular hematoma
Intraperitoneal bleeding
Intussusception

Appendicitis
Diverticulitis
Cholecystitis
Lower intestinal Obstruction
Mesenteric ischemia/
insufficiency
Leaking aortic aneurysm
Ectopic pregnancy
Endometritis
Gastroenteritis
Gastritis/peptic ulcer disease
Pancreatitis
Salpingitis
Regional enteritis/ ulcerative
colitis
Pyelonephritis
Pneumonia
Splenic vein thrombosis
Hepatitis
Diabetic acidosis
Addisonian crisis
Herpes zoster

Peptic ulceration
Alkaline reflux gastritis
Reflux esophagitis
Pancreatitis
Cholelithiasis
Crohns disease
Diverticulitis
Chronic pancreatitis
Chronic mesenteric ischemia
Pelvic inflammatory disease
Endometriosis

4 Bodily Functions that Aggravate or Relieve Pain

Posture
Lying still
Movement such as walking
Legs drawn up
Being upright
GI tract function
Drinking
Hot liquid
Cold liquid
Eating
Types of foods?
Fatty, fried, greasy
Cabbage, chocolate
Protein-containing foods
Eructation
Flatulence
Bowel movements
Vomiting
Other functions
Urination
Menstrual cycle

Constant Pain with Acute

Exacerbation

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2
Gastrointestinal and Intraperitoneal Causes of Abdominal Pain
I. Inflammation/Infection
II. Mechanical (obstruction, acute distention)
A. Peritoneum
A. Hollow intestinal organs
1.Chemical and nonbacterial peritonitis perforated
1.Intestinal obstruction-adhesions,
Peptic ulcer, gallbladder, ruptured ovarian cyst,
Hernia, tumor, volvulus, infussusception
Mittelschmerz
2.Biliary obstuction-calculi, tumor,
2.Bacterial peritionitis
choledochal cyst, hematobilia
a.Rrimary peritonitis-pneumococcal, streptococcal, B. Solid visera
tuberculous
1. Acute splenomegaly
b.Perforated hollow viscus-stomach, intestine,
2. Acute hepatomegaly- cardiac failure,
biliary tract
Budd-Chiara syndrome
B. Hollow intestinal organs
C. Mesentery
1. Appendiciis
1. omental torion
2. Cholecystitis
D. Pelvic organs
3. Peptic ulceration
1.Ovarian cyst
4. Gastroenteritis
2. Torsion or degeneration of fibroid
5. Regional enteritis
3. Ectopic pregnancy
6. Meckels diverticulitis
III. Vascular
7. Colitis- ulcerative, bacterial, amebic
A. Intraperitoneal bleeding
8. Diverticulitis
1. Ruptured liver
C. Solid viscera
2. Ruptured spleen
1. Pancreatitis
3. Ruptured mesentery
2. Hepatitis
4. Ruptured ectopic pregnancy
3. Hepatic abscess
5. Ruptured aortic, splenic, or hepatic
aneurysm
D. Mesentery
B. Intraperitoneal bleeding
1. Lymphadenitis
1. Mesenteric thrombosis
E. Pelvic organs
2. Hepatic infarction-toxemia, purpura
1. Pelvic inflammatory disease
3. Splenic infarction
2. Tuboovarian abscess
4. Omental ischemia
3. Endometritis

. Miscellaneous
A. Endometriosis

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5
Extraperitoneal Causes of Abdominal Pain
Cardiopulmonary
Pneumonia
Empyema
Myocardial ischemia
Active rheumatic heart disease
Blood
Leukemia
Sickle cell crisis
Neurogenic
Spinal cord tumors
Osteomyelitis of spine
Tabes dorsalis
Herpes zoster
Abdominal epilepsy
Genitourinary
Nephritis
Pyelitis
Perinephric abscesses
Ureteral obstruction (calculi, tumors)
Prostatitis
Seminal vesiculitis
Epidydimitis

Vascular
Dissection, rupture, or
expansion of aortic an eurysm
Periarteritis
Metabolic
Uremia
Diabetic acidosis
Porphyria
Addisonian crisis
Toxins
Bacterial (tetanus)
Insect bites
Venoms
Drugs
Lead poisoning
Abdominal wall
Intramuscular hematoma
Psychogenic

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1. : , . : 2548 .
100 108
2. . : , . . : 109-119
3. 1989 : 1061-1067
4. . : ,
, 2548 1-9
5. Norman L.Browse. The abdomen In : Introduction to the symptom and sign of surgical disease second edition 1991:363403
6. Helen Sweetland. Kevin Conway. Acute abdominal pain in Crush Course Surgery second edition 2004:1-7