ACUTE ABDOMEN Surgery (Dr.

Penserga) Acute Abdomen
February 18, 2008

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symptoms of intra-abdominal diseases best treated with surgery episodes of severe abdominal pain after caused by intra-abdominal condition requiring emergency treatment continuous pain without relief (1d/<12H) needs surgery pain anorexia, nausea and vomiting changes in bowel habits fever, chills PAIN most common symptom not all pain needs surgical treatment NON-SPECIFIC SYMPTOMS not all acute abdomen is surgical Pancreatitis o don’t need to operate , only if there are complications o can develop hemorrhage  spread and affect portal vein  “bangungot” disease proximal to duodenum (foregut derivative) stimulates celiac axis EPIGASTRIC PAIN
(duodenal ulcer, gastric ulcer)

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o localizes pain to site of stimulus Visceral peritoneum stimulation o nonlocalized pain o epigastric, periumbilical, shoulder, suprapubic Gradual periumbilical pain appendicitis, diverticulitis, inflammatory diseases beginning of inflammation  stim visceral peritoneum, has not touched parietal peritoneum

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 Sudden, severe pain
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perforation of hollow viscus stomach, perforated ulcer, int ↑ pain intensity ischemic bowel disease continuous, ↑ intensity, cannot be relieved

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 Pain initially localized  generalized
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perforated ulcer because acid sealed byomentum  abscess  cannot contain  rupture  spread

 Colicky, crampy (on/off) - hollow viscus obstruction
pain not off totally int obstructed (tendency of bowel to push) hyperperistaltic in area proximal hyperactivity sounds and pain ureteral stone: constant movement proximal to obstruction/pain

disease in cecum, appendix (midgut derivative) stimulates afferent nerve accompanying IMA PERIUMBILICALPAIN
*Appendicitis: visceral pain  umbi  stim parietal peritoneum  RLQ

disease in distal colon stimulate afferent nerve accompanying IMA SUPRAPUBIC PAIN phrenic nerve + C3-5 afferent fibers accompanying phrenic arteries innervates diaphragm and peritoneum on its underside stimulation of diaphragm SHOULDER PAIN
(referred pain)

ANOREXIA, NAUSEA AND VOMITING commonly when abdomen is surgical o pain  vomiting o ex. appendicitis - also seen in nonsurgical o vomiting  pain o ex. Gastroenteritis (not absolute) CHANGES IN BOWEL HABITS/CHARACTERISTIC OF STOOL - blood in stool o inflammation, infectious (amoebiasis, mucoid and blood), ischemic process - absence of flatus/bowel movement o complete int. obstruction o occurs hours before there is absence of flatus after int. obstruction  RESIDUAL FEVER, CHILLS 1 of 4

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Pariteal peritoneum stimulation SOLID and 2B

Surgery– Acute Abdomen by Dr Penserga

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contain typical patterns appendicitis o early: no fever o non-ruptured: ↓ fever o ruptured: ↑ fever cholangitis o biliary tree, stones obstructs bile flow  stress  bacteria (pus) o 3 common symptoms  pain  fever SPECIFIC SYMPTOMS  jaundice Hx is important o previous surgery o previous episodes of similar pain o previous illness Px movement/posture HISTORY prior surgery adhesions  obstructions surgery for malignancy  possible recurrence organ removal  eliminates organ as possible cause of disease status of prior surgery: success remnant PATIENT MOVEMENT/POSTURE Very still, minimal movement peritonitis visceral to somatic pain Frequent changes of position hollow viscus spasm, obstruction biliary, ureteral, stones, spasms PREVIOUS ILLNESSES Urinary tract o dysuria, hematuria Reproductive tract in female o LMP, PID, dysmenorrheal o PID mimics acute appendicitis  no surgery CV conditions o Atrial fibrillation o Embolus DM

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jaundice, dehydration, disorientation = cholangitis

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Abdominal findings Inspection o Abdominal distention  intra-peritoneal cavity problem o Rigidity  muscle spasms  involuntary muscle guarding  perforated peptic ulcer: “board-like” rigidity o Scaphoid abdomen  sdaphragmatic hernia o Bulges, protrusion, hernias  inguinal area

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*Surgery  inflamed condition  adhesions

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Auscultation o Silent abdomen  Gangrene, diffuse peritonitis, late obstruction  o Peristaltic rush synchronous with pain  Obstruction  Metallic high-pitch sound (hypersensitivity) Palpation o Tenderness - pain on palpation o Direct, rebound, referred o Direct  visceral stimulation o Rebound  Parietal stimulation  inflamed peritonitis o Rovsing sign – referred sign (opposite side) o Muscle guarding: voluntary/involuntary o Presence of masses  Which quadrant  due to organ involved Percussion o Tenderness, pt of max o Tympany (sabi nya tempani daw wahaha)  free-air in peritoneum (pneumoperitoneum)  abdominal distention

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Uncontrolled sugar  uncontrolled infection

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PHYSICAL FINDING Non-abdominal findings give due to the cause o change in vital signs

 Rectal findings - DRE localize area of tenderness
Acute appendicitis  Pain on the same side  Rt. Pararectal tenderness Blood in the stool o

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Surgery– Acute Abdomen by Dr Penserga

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Hemorrhoids, inflammatory

malignancy,

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Mass Malignancy, inflammatory abscesses

 Genital findings
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Scrotal mass, tenderness o Hernia, strangulated o Intra-abdominal abscess  There is communication between abdomen and scrotal sac  Pus: scrotal hernia

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Perforation + typhoid ileitis (fever 2-3 weeks, Peyer’s patch) Ruptured diverticulitis  Small and large bowel  Outpouching (Meckel’s diverticulum) Appendicitis Intestinal obstruction Hydrops  GB pear-shaped stone blocks the opening  ↑ mucus production, ↑ size (distention) develops infection (pus): Empyema Perforated GB

 Gynecologic findings
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Cervical tenderness o PID  Important because Pelvic mass o Inflammatory disease with abscess  Tubo-ovarian  Pelvic

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      COMMON SIGNS IN ACUTE ABDOMEN Kidney punch - pyelonephritis Iliopsoas sign - appendicitis Obturator sign - hernia, appendicitis Murphy’s sign - cholecystitis Cough tenderness - max. pt of tenderness Ecchymosis trauma, pancreatitis, aneurysm ACUTE NON-SURGICAL ABDOMEN lower lobe pneumonia (mistaken for cholecystitis) ,MI (epigastric pain), DKA, hepatitis, uremia polyserositis, RF, Pb poisoning hx and high index of suspicion differentiated from surgical abdomen in Approach detailed and systematic evaluation common diagnosis more likely if unclear, watchful observation

Ruptured solid organs ruptured spleen, liver o check for vital signs o blood is irritant  same in PID and ectopic pregnancy pancreas o pancreatic trauma, acute pancreatitis o blood or chemical (pancreatic juice) is irritant in the later phase o presence of bacteria/ food can activate pancreatic juice  irritation Inflammatory conditions hollow and solid organs o appendicitis  N&Vepiperiumbiparietal RLQ) cholecystitis  mimics duodenitis, gastritis; RUQ back liver abscess  ↑grade fever o diverticulitis  colon  SI: distal ileum appendicitis pelvic (reproductive) organs

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Guide -

mimics

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COMMON ACUTE SURGICAL ABDOMEN  Esophageal, gastric, int perforation - Esophagus o Perforation  instruments, caustic ingestions o Mediastinum: mediastinitis o Below diaphragm: peritonitis o Acid  coagulation (delayed perforation) o Alkali  liquefaction  inc. damage - Gastric and duodenum o Perforated PUD - Intestines o

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mesenteric adenitis (surgical?)  LN enlarged (viral)  Near appendix  RLQ pain and tenderness  Mimic appendicitis  On/off pain Pancreatitis (surgical?)  Not, tx medically

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Ischemic condition mesenteric thrombosis o clogged vessels  no blood supply o surgical

Surgery– Acute Abdomen by Dr Penserga

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torsions, strangulation o BV is compromised

BOTTOM LINE QUESTION: Do we need to do surgery? - Yes o Appendicitis o Int. obstruction  Partial – NGT first  Complete - No o Pancreatitis o Mesenteric adenitis o Duodenitis o Gastritis EQUIVOCAL SITUATION - watchful observation o tenderness o guarding o ↑intensity of pain - op vs non op - (-) finding vs disastrous finding - risk and benefit for operating - risk and benefit for not operating SHORT QUIZ: 1. appendicitisperiumbilical - VISCERAL 2. appendicitisRLQ - PERITONEAL 3. guarding in peritonitis - “BOARD-LIKE” RIGIDITY 4. Murphy’s sign - CHOLECYSTITIS 5. continuous pain in eary obs - FALSE 6. continuous pain in late obs - TRUE 7. cannot be reduced INCARCERATED HERNIA 8. BV compromised STRANGULATED HERNIA 9. empyema: pus in GB - TRUE 10. spreading periton: locgen -TRUE
Yey! Sana ito na ang last trans na gagawin ko…for this school year hehe.

Anong meron ang taong happy?

sana wala naman mag-ppirate ng trans na to diba kse andito ang pic ko. please lang DO NOT disseminate! (bumagsak sana kung sino man ang magbibigay ng walang permiso ko! Curse ito haha)