LEARNING OBJECTIVE

Explain of Acute abdomen

Appendicitis Peritonitis Intestinal Obstruction Ileus Ascaris Hernia Intussusception Perforation Malrotation
Definition Epidemiology Etiology Classification Pathophysiology Signs & symptoms Risk factor DD Complication Treatment Examination Prognosis Prevention

ACUTE ABDOMEN

Definition
Any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered

Epidemiology
Abdominal pain represents 5% of ER visits Only 10% of these evaluations require surgery Accounts for 10% of malpractice claims

Etiology
Inflammatory Mechanical Neoplastic Vascular Congenital Defect Traumatic

 Traumatic : range from stab and gunshot wounds to blunt abdominal injuries producing such conditions as splenic rupture Inflammatory Bacterial (acute appendicitis, diverticulitis) Chemical (a perforation of a peptic ulcer) Mechanical Such obstructive conditions (intussusception, carcinoma of the colon) Vascular : Mesenteric arterial thrombosis, embolism Congenital defects : Duodenal atresia, diaphragmatic hernia, chronic malrotation of the intestine

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)

Characteristic Of The Pain

Visceral Pain
Due to stretching of fibers innervating the walls of hollow or solid organs. It occurs early and poorly localized It can be due to early ischemia or inflammation. Caused by irritation of parietal peritoneum fibers It occurs late and better localized Can be localized to a dermatome superficial to site of the painful stimulus

Parietal Pain

Referred Pain
Pain is felt at a site away from the pathological organ Pain is usually ipsilateral to the involved organ and is felt midline if pathology is midline Pattern based on developmental embryology

High Risk Factor

Elderly > 65 y S/S of Shock Peritoneal sign (+) silent bowel sound Pulsatile mass Refractory pain post Tx The immunocompromised. (e.g. HIV) Women of childbearing age

Elevation of Band WBC Fever cause Hypothermia Acute renal failure

Not post-surgical obstruction

Five Major Categories of Acute Abdomen (BIOPI)

Bleeding or rupture of vessels or tumor Ischemia or Infarction Obstruction Perforation Inflammation

Signs and Symptoms

Blood in stool, or blood coming from rectum or vagina Changes in bowel movements Fever Pain Mass in the stomach or pelvic area Nausea, vomiting, or restlessness Fast or pounding heartbeat Headache, dizziness Irregular or fast breathing Loss of appetite Sweating or having pale

Examination
1. Laboratory tests

Complete blood count (CBC) WBC count suggests inflammation / infection Liver enzymes Gallstone attacks liver enzymes Pancreatic enzymes (amylase and lipase) Pancreatitis Pancreatic enzymes Urinalysis Blood in the urine suggest kidney stones

2. Plain x-rays of the abdomen

3. Radiographic studies
Abdominal ultrasound Computerized tomography (CT) of the abdomen Magnetic resonance imaging (MRI) Barium x-rays Capsule enteroscopy

4. Endoscopic procedures
Esophagogastroduodenoscopy (EGD) Colonoscopy or flexible sigmoidoscopy Endoscopic ultrasound (EUS) Balloon enteroscopy

Table 3. Recommended Imaging Studies Based on Location of Abdominal Pain

Location of pain
Right upper quadrant Left upper quadrant
Right lower quadrant

Imaging
Ultrasonography CT
CT with IV contrast media CT with oral and IV contrast media Ultrasonography

Left lower quadrant

Suprapubic

CT = computed tomography; IV = intravenous. Information from references 14 through 16.

PROGNOSIS
# surgery or antibiotics mortality > 50% With early surgery mortality < 1%, and convalescence is normally rapid and complete

With complications (rupture, development of an abscess / peritonitis) prognosis is worse repeat operations & a long convalescence may follow

Quadrants of Abdomen

Quadrants of Abdomen

Acute Abdomen
Anamnesis
Past history appendectomy, cholecystectomy, and so forth Medication corticosteroid, anticoagulants, cocaine Age Patients position Menstrual history

Examination of Acute Abdomen

Inspection Looking for scars, hernias, masses. Contour of the abdomen is scaphoid, flat or distended. Abdominal distended can mean intestinal obstruction, ileus or acites. Auscultation Inform the presence or absence of bowel sound Hyperactive bowel sound may occur in bowel obstruction Hypoactive bowel sound may occur in paralytic obstruction.

 Percussion Hyperresonance mean gaseous distention of the intestine. Shifting dullness mean acites. Palpation The examiner should asses the patients facial expression for sign of pain. Should begin in an area away from the pain site. Tenderness and rebound tenderness indicates inflammation in peritoneum Deep palpation can detect abdominal masses.

 Evaluation of the vital signs

Low fever (37.2 C 37.8 C) diverculitis, appendicitis, acute cholecystitis High fever (> 37.8 C) pneumonia, urinary tract infection, septic cholangitis, or gynecologic infection Rapid heart rate and hypotension complicated disease with peritonitis

LABORATORY TESTING
Intra-abdominal inflammation WBC Dehydration , vomitting, diarrhea, taking diuretic medicine -> measure the concentrations of serum sodium, potassium, blood urea nitrogen, creatinine, glucose, chloride, and carbon dioxide. Pancreatitis, perforated duodenal ulcer serum amilase Abdominal pain RUQ should have measurements of serum bilirubin, alkaline phosphatase, and serum transaminase

DIAGNOSIS ACUTE ABDOMEN

History: Acute appendicitis: periumbilical pain, low-grade fever, anorexia with/without vomiting followed by movement of the pain into the right lower quadrant McBurneys point. Constipation: obstructive conditions, inflammatory disorders produce ileus. Watery diarrhea: gastroenteritis, Bloody diarrhea: infectious colitis, inflammatory bowel disease, mesenterial ischemia. Jaundice: hepatic and pancreaticobiliary disease, sepsis. Urinary frequency, dysuria, hematuria, and suprapubic or flank pain : urologic disease.

DIAGNOSTIC IMAGING
USG -> Liver, gallbladder, bile ducts, spleen, pancreas, appendix, kidneys, ovaries, and uterus. Also detect and charaterizes the distribution of intraabdominal fluid. Color doppler USG -> evaluation of intra-abdominal adn retroperitoneal blood vessels. CT scan X-ray

APPENDICITIS

Definition
Appendicitis is a painful swelling and infection of the appendix.

Epidemiology
Acute appendicitis is the most common cause of the acute abdomen in the US and should be included in the differential diagnosis for every patient presenting with acute abdominal pain. About 250,000 appendectomies are performed in the United States annually, with 2000 deaths resulting from complications of the disease. One in 15 persons develops appendicitis during his or her lifetime.

Etiology
Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected.

Etiology
Sources of obstruction include: feces, parasites (eg, Schistosomes species, pinworms, Strongyloides stercoralis), or growths that clog the appendiceal lumen enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal tract or elsewhere in the body inflammatory bowel disease, including Crohn's disease and ulcerative colitis trauma to the abdomen An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the abdomena potentially dangerous condition called peritonitis.

Patophysiology
Mucus, stool, or parasites Inflammation
The blood supply to the appendix is cut off

Necrosis
I f

Reduced blood flow

Perforation Appendicular abcsess Peritonitis

Obstructs the appendix

Obstruction of mucus outflow

Pressure in appendix increases

Restricting blood flow to the organ

Multiplying bacteria, inflammation and pressure continue to increase

Appendix contracts

Severe abdominal pain

Inflame in mucosa

Inflame in whole appendix

Effort for limiting inflammation with covered by omentum, small intestine

Periappendicitis

Abcess in inside

perforation

Pathogenesis
Obstruction Mucous cant be drained Edema

Increase intraluminal pressure

Bacterial diapedesis Mucosal Ulceration Epigastric pain Appendicitis acute focal

Mucous >>

Pathogenesis

Intraluminal pressure >>

Bacterial invasion of the appendix wall

Vein obstruction
Peritonitis

Pain in RLQ

Appendicitis supurative acute

Pathogenesis
Bad arterial flow

Gangren Appendicitic gangrenosa Infark Appendicitis perforation

initial inflammation

Epigastric pain/in central, maybe cholic

mucosal appendicitis

Tenderness in RLQ

inflammation in the entire thickness of the wall

central pain moved to the RLQ, nausea, vomiting

inflammation of the parietal peritoneum

local peritoneal stimulation (somatic), pain on active and passive motion, local muscular defans

inflammation of the tool / tissue attached to the appendix

Internal genitalia, ureter, m.psoas, rectum

Appendicitis ganggrenosa

fever , tachycardia, ranging toxic, leukocytosis

Perforation

defense muscular pain and the whole stomach

Sign & Symptoms

The main symptom of appendicitis is abdominal pain. The abdominal pain usually: occurs suddenly, often causing a person to wake up at night occurs before other symptoms begins near the belly button and then moves lower and to the right is new and unlike any pain felt before gets worse in a matter of hours gets worse when moving around, taking deep breaths, coughing, or sneezing

Other symptoms of appendicitis may include: loss of appetite nausea vomiting constipation or diarrhea inability to pass gas a low-grade fever that follows other symptoms abdominal swelling the feeling that passing stool will relieve discomfort

Symptoms vary and can mimic other sources of abdominal pain, including: intestinal obstruction inflammatory bowel disease pelvic inflammatory disease and other gynecological disorders intestinal adhesions constipation

Physical Examination
Guarding
Guarding occurs when a person subconsciously tenses the abdominal muscles during an examination

Rebound tenderness
Pain felt upon the release of the pressure indicates rebound tenderness

Rovsing's sign
Pain felt on the lower right side of the abdomen upon the release of pressure on the left side indicates the presence of Rovsing's sign

Psoas sign
The right psoas muscle runs over the pelvis near the appendix. Flexing this muscle will cause abdominal pain if the appendix is inflamed

Obturator sign
The right obturator muscle also runs near the appendix.

Laboratory Tests
Blood tests are used to check for signs of infection, such as a high white blood cell count Blood tests may also show dehydration or fluid and electrolyte imbalances Urinalysis is used to rule out a urinary tract infection Doctors may also order a pregnancy test for women

Imaging Tests
CT scans, can help diagnose appendicitis and other sources of abdominal pain. Ultrasound is sometimes used to look for signs of appendicitis, especially in people who are thin or young. An abdominal x ray is rarely helpful in diagnosing appendicitis but can be used to look for other sources of abdominal pain. Women of childbearing age should have a pregnancy test before undergoing x rays or CT scanning. Both use radiation and can be harmful to a developing fetus. Ultrasound does not use radiation and is not harmful to a fetus.

Treatment
Appendicectomy: In early cases the operation is straightforward. An incision is made over McBurney's point. McBurney's point is centred along a line joining the umbilicus with the anterior superior iliac spine. It is situated at a point 2/3 of the way along this line - rather closer to the iliac spine than to the umbilicus.

Complication
Perforation
Perforation of the appendix can lead to a peri-appendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis)

Blockage or obstruction of the intestine

Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing

Sepsis
a condition in which infecting bacteria enter the blood and travel to other parts of the body

Prognosis
Acute appendicitis is the most common reason for emergency abdominal surgery The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to surgical intervention The mortality rate in children ranges from 0.1% to 1%; in patients older than 70 years, the rate rises above 20%, primarily because of diagnostic and therapeutic delay

Prognosis
Appendiceal perforation is associated with increased morbidity and mortality compared with nonperforating appendicitis. The mortality risk of acute but not gangrenous appendicitis is less than 0.1%, but the risk rises to 0.6% in gangrenous appendicitis. The rate of perforation varies from 16% to 40%, with a higher frequency occurring in younger age groups (40-57%) and in patients older than 50 years (55-70%), in whom misdiagnosis and delayed diagnosis are common. Complications occur in 1-5% of patients with appendicitis, and postoperative wound infections account for almost one third of the associated morbidity.

DD
Abdominal Abscess Cholecystitis and Biliary Colic Constipation Crohn Disease Diverticular Disease Ectopic Pregnancy Endometriosis Gastroenteritis Gastroenteritis, Bacterial Inflammatory Bowel Disease Meckel Diverticulum Mesenteric Ischemia Mesenteric Lymphadenitis Omental Torsion Ovarian Cysts Ovarian Torsion Pediatrics, Intussusception Pelvic Inflammatory Disease Renal Calculi Spider Envenomations, Widow Urinary Tract Infection, Female Urinary Tract Infection, Male

PERITONITIS

Peritonitis
Peritonitis is an inflammation (irritation) of the peritoneum, the tissue that lines the wall of the abdomen and covers the abdominal organs Causes A collection of pus in the abdomen, called an intraabdominal abscess, may cause peritonitis The specific types of peritonitis :
Peritonitis - spontaneous Peritonitis - secondary Peritonitis - dialysis associated

Symptoms Abdominal distention Abdominal pain or tenderness Fever Fluid in the abdomen Inability to pass feces or gas Low urine output Nausea and vomiting Point tenderness Thirst
Additional symptoms that may be associated with this disease include :
Cloudy dialysis fluid (if undergoing peritoneal dialysis) Nausea and vomiting Shaking chills Signs of shock

Classification
Primary
ie, from hematogenous dissemination, usually in the setting of immunocompromise most often spontaneous bacterial peritonitis (SBP) caused by chronic liver disease

Secondary
ie, related to a pathologic process in a visceral organ, such as perforation or trauma, including iatrogenic trauma

Tertiary
ie, persistent or recurrent infection after adequate initial therapy often develops in the absence of the original visceral organ pathology

Peritonitis - Spontaneous
Causes Spontaneous peritonitis is usually caused by ascites, a collection of fluid in the peritoneal cavity. This usually occurs from liver or kidney failure

Peritonitis - Dialysis Associated

Dialysis-associated peritonitis is inflammation of the lining of the abdominal cavity (peritoneum), which occurs in those who receive peritoneal dialysis Causes Dialysis-associated peritonitis may be caused by bacteria or fungi can cause the infection Approximately one infection occurs for every 15 months of peritoneal dialysis

Treatment
Open appendectomy
Appendectomy can be performed as open surgery using one abdominal incision that's about 2 to 4 inches (5 to 10 centimeters) long.

Laparoscopic appendectomy Draining an abscess before appendix surgery

INTESTINAL OBSTRUCTION

DEFINITION
Intestinal obstructions are a partial or complete blockage of the small or large intestine, resulting in failure of the contents of the intestine to pass through the bowel normally

ETIOLOGY
Mechanical obstructions The bowel is physically blocked and its contents can not pass the point of the obstruction. This happens when the bowel twists on itself (volvulus) or as the result of hernias, impacted feces, abnormal tissue growth, or the presence of foreign bodies in the intestines. Non-mechanical obstruction
Called ileus or paralytic ileus, occurs because peristalsis stops. Peristalsis is the rhythmic contraction that moves material through the bowel. Ileus is most often associated with an infection of the peritoneum (the membrane lining the abdomen). It is one of the major causes of bowel obstruction in infants and children.

CAUSES
Location
Colon Duodenum (Adults) Duodenum (Neonates) Jejunum and ileum (Adults) Jejunum and Ileum (Neonates)

Causes
Tumors (usually in left colon), diverticulitis (usually in sigmoid), volvulus of sigmoid or cecum, fecal impaction, Hirschsprung's disease
Cancer of the duodenum or head of pancreas, ulcer disease Atresia, volvulus, bands, annular pancreas Hernias, adhesions (common), tumors, foreign body, Meckel's diverticulum, Crohn's disease (uncommon), Ascaris infestation, midgut volvulus, intussusception by tumor (rare) Meconium ileus, volvulus of a malrotated gut, atresia, intussusception

EXAMPLES OF CAUSES OF INTESTINAL OBSTRUCTION

Obstruction due to adhesions

Obstruction due to mesenteric occlusion

Obstruction due to hernia

Obstruction due to intussusception

Obstruction due to tumor

Obstruction due to volvulus

PATOPHYSIOLOGY

SYMPTOMS
Small bowel

Large bowel
Increasing constipation leads to obstipation and abdominal distention. Vomiting may occur (usually several hours after onset of other symptoms) but is not common Lower abdominal cramps unproductive of feces occur No tenderness The rectum is usually empty. A mass corresponding to the site of an obstructing tumor may be palpable.

Abdominal cramps centered around the umbilicus or in the epigastrium, Vomiting Obstipation (in patients with complete obstruction) Diarrhea (partial obstruction) Severe, steady pain suggests that strangulation has occurred. In the absence of strangulation, the abdomen is not tender Hyperactive, high-pitched peristalsis with rushes coinciding with cramps is typical Dilated loops of bowel are palpable sometimes. With infarction, the abdomen becomes tender Auscultation reveals a silent abdomen or minimal peristalsis Shock and oliguria (serious signs that indicate either late simple obstruction or strangulation)

PHYSICAL EXAMINATION
Hyperactive bowel to overcome the obstruction (early) Hypoactive bowel sounds Proper genitourinary and pelvic examinations are essential Look for the following during rectal examination: Gross or occult blood, which suggests late strangulation or malignancy Masses, which suggest obturator hernia Check for symptoms commonly believed to be more diagnostic of intestinal ischemia, including the following: Fever (temperature >100F) Tachycardia (>100 beats/min) Peritoneal signs

LAB EXAMINATIONS
X-rays CT Scan MRI USG Sigmoidoscope CBC (Complete Blood Count) Electrolytes BUN (Blood Urea Nitrogen) Urinalysis Laboratory tests to exclude biliary or hepatic disease Phosphate level Creatine kinase level Liver panels

TREATMENTS
Non-Farmacologic :
Nasogastric tube Rectal tube Intravenous fluids Repair the hernia to correct the obstruction Surgery complete obstructions

Farmacologic :
Antibiotics : pre and post operation

COMPLICATIONS
Dehydration Kidney failure (severe dehydration) Irregular heartbeat Shock Systemic infection from perforation of the bowel

PROGNOSIS
Most intestinal obstructions can be corrected with prompt treatment and the affected child will recover without complications. Untreated intestinal obstructions can be fatal, however. The mortality rate for unsuccessfully treated infants is 12 percent.

PREVENTION
Most cases of intestinal obstruction are not preventable. Surgery to remove tumors or polyps in the intestines helps prevent recurrences.

ASCARIS LUMBRICOIDES

Ascaris lumbricoides
Mature female is 20-40 cm x 0.50.6 cm Mature male is 12-25 cm x 0.3-0.4 cm 240.000 eggs/ day The larvae then migrate via the venous circulation to the pulmonary circulation and to the lungs

Epidemiology
Ascariasis is the most helminthic infection with an estimated prevalence of 25% (0.8-1.22 billion people) Infection occurs worldwide and is most common in tropical and subtropical areas where sanitation and hygiene are poor

Pathophysiology Ascaris Infection

Clinical features
During the lung phase of larval migration, 912 days after egg ingestion, patients may develop an
Irritating nonproductive cough and burning substernal discomfort that is aggravated by coughing or deep inspiration. Dyspnea and blood-tinged sputum are less common Fever is usually reported Eosinophilia develops during this symptomatic phase and subsides slowly over weeks. Chest x-rays may reveal evidence of eosinophilic pneumonitis (Lffler's syndrome), with rounded infiltrates a few millimeters to several centimeters in size. These infiltrates may be transient and intermittent, clearing after several weeks. Where there is seasonal transmission of the parasite, seasonal pneumonitis with eosinophilia may develop in previously infected and sensitized hosts

 In established infections, adult worms in the small intestine usually cause no symptoms. In heavy infections, particularly in children, a large bolus of entangled worms can cause pain and small-bowel obstruction, sometimes complicated by perforation, intussusception, or volvulus. Single worms may cause disease when they migrate into aberrant sites. A large worm can enter and occlude the biliary tree, causing biliary colic, cholecystitis, cholangitis, pancreatitis, or (rarely) intrahepatic abscesses. Migration of an adult worm up the esophagus can provoke coughing and oral expulsion of the worm. In highly endemic areas, intestinal and biliary ascariasis can rival acute appendicitis and gallstones as causes of surgical acute abdomen.

Diagnosis
Most cases of ascariasis can be diagnosed by microscopic detection of characteristic Ascaris eggs (65 by 45 m) in fecal samples. Occasionally, patients present after passing an adult worm identifiable by its large size and smooth cream-colored surfacein the stool or through the mouth or nose. During the early transpulmonary migratory phase, when eosinophilic pneumonitis occurs, larvae can be found in sputum or gastric aspirates before diagnostic eggs appear in the stool. The eosinophilia that is prominent during this early stage usually decreases to minimal levels in established infection. Adult worms may be visualized, occasionally serendipitously, on contrast studies of the gastrointestinal tract. A plain abdominal film may reveal masses of worms in gas-filled loops of bowel in patients with intestinal obstruction. Pancreaticobiliary worms can be detected by ultrasound and endoscopic retrograde cholangiopancreatography; the latter method also has been used to extract biliary Ascaris worms.

Treatment
Mebendazole Piperazine Pyrantel pamoate Albendazole Thiabendazole Partial intestinal obstruction should be managed with nasogastric suction, IV fluid administration, and instillation of piperazine through the nasogastric tube, complete obstruction and its severe complications require immediate surgical intervention.

ILEUS OBSTRUCTION

Definition
Interruption in the passage of intestinal contents Classification
Small bowel Large bowel

Types of intestinal obstruction

Adynamic ileus (paralytic ileus) Mechanical ileus

Signs and Symptoms

Intermittent crampy abdominal pain Nausea Vomiting or diarrhea Constipation Inability to have a bowel movement or pass gas Swelling of the abdomen (distention) Abdominal tenderness Fever

Risk Factor
Abdominal or pelvic surgery Crohn's disease an inflammatory condition that can cause the intestine's walls to thicken, narrowing its passageway Cancer within your abdomen, especially if you've had surgery to remove an abdominal tumor or radiation therapy A history of constipation Malrotation, a condition present at birth (congenital) in which your intestine doesn't develop correctly

X-ray Finding

Air fluid level Stepladder Absent colonic gases

Complication
Bowel necrosis Bowel perforation Sepsis Shock hipovolemic Abscess Short bowel syndrome with malabsorption and malnutrition Decreased absorption Dehydration Kidney failure. Death

Treatment
Based on the cause : Operatif Medicamentosa Rehydration and nutrition

HERNIA

Definition
A hernia is an abnormal weakness or hole in an anatomical structure which allows something inside to protrude through. It is commonly used to describe a weakness in the abdominal wall.

 Hernias by themselves usually are harmless, but nearly all have a potential risk of having their blood supply cut off (becoming strangulated). If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency.

Etiology
Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia
Obesity Heavy lifting Coughing Straining during a bowel movement or urination Chronic ling disease Fluid in the abdominal cavity Hereditary

Classification
Groin Umbilicus Linea alba (epigastric) Surgical incisions Semi-lunar line Diaphragm Lumbar triangles Pelvis

Groin hernia
Men > women Right > left 10% of premature babies 5% of adult population

Classfication
Indirect inguinal
o scrotal

Direct inguinal Femoral

Indirect Hernia Anatomy

Dilated persistent processus vaginalis Within spermatic cord Follows indirect course Complete vs. incomplete sac Sliding hernia Cord lipoma

Direct Hernia Anatomy

Hesselbachs triangle
o Inguinal ligament (base), rectus (medial), inferior epigastric vessels (lateral)

Sliding hernia

Femoral Hernia Anatomy

Inferior to inguinal ligament Women> men Cloquets node Usually on medial aspect of femoral sheath

Diagnose
Groin swelling that resolves with supine position Precipitating factors
Increased intra-abdominal pressure Defects in collagen synthesis Smoking

Examine erect and supine Does not transilluminate

Differential Diagnosis
Hydrocele Varicocele Epididymoorchitis Torsion of testis Undescended testis Ectopic testis Testicular tumor Femoral artery aneurysm Lipoma Lymphadenopathy

Treatment
Expectant management Surgical repair
Mesh Open Laparoscopic

TEP (totally extra-peritoneal) TAPP (transabdominal pre-peritoneal)

Complications
Recurrence Neuralgia
Ilioinguinal Iliohypogastric Genitofemoral Lateral cutaneous

Ischemic orchitis Injury to vas deference Wound infection Bleeding

Umbilical Hernia
Women> men Risk factors
Obesity Pregnancy

May rupture with ascites Repair primarily or with mesh

Common in infants Close spontaneously if <1.5 cm Repair if > 2 cm or if persists at age 3-4 years Repair primarily or with mesh

Epigastric Hernia
Incidence 1-5% Men > women Pre-peritoneal fat protrusion through decussating fibers at linea alba Between xiphoid and umbilicus 20% multiple Repair primarily

Incisional Hernia
Risk factors
Technical Wound infection Smoking Hypoxia/ ischemia Tension Obesity Malnutrition

Laparoscopic vs open repair

Parastomal Hernia
Variant of incisional hernia Paracolostomy > paraileostomy Low rate if through rectus muscle Traditionally relocate stoma, repair defect Concern for mesh erosion Laparoscopic repair

Spieghelian Hernia
Rare Hernia through subumbilical portion of semi-lunar line Difficult to diagnose
Clinical suspicion (location) CT scan

Repair primarily or with mesh

Lumbar Hernia
Congenital, spontaneous or traumatic Grynfeltts triangle
12th rib, internal oblique and sacrospinalis muscle Covered by latissimus dorsi

Petits triangle
Latissimus dorsi, external oblique and iliac crest Covered by superficial fascia

Pelvic Hernia
Obturator hernia
Most commonly in women Howship-Romberg sign

Sciatic hernia Perineal hernia

Signs and Symptoms

The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomenpossibly a strangulated hernia.
Asymptomatic reducible hernia
New lump n the groin or other abdominal wall area May ache but is not tender when touched. Sometimes pain precedes the discovery of the lump. Lump increases in size when standing or when abdominal pressure is increased (such as coughing) May be reduced (pushed back into the abdomen) unless very large

 Irreducible hernia
Usually painful enlargement of a previous hernia that cannot be returned into the abdominal cavity on its own or when you push it Some may be long term without pain Can lead to strangulation

Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting

Strangulated hernia
Irreducible hernia where the entrapped intestine has its blood supply cut off
Pain always present followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting) You may appear ill with or without fever Surgical emergency All strangulated hernias are irreducible (but all irreducible hernias are not strangulated)

Diagnose
If you have an obvious hernia, the doctor will not require any other tests If you have symptoms of a hernia the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt.

Treatment
Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated
Reducible
Can be treated with surgery but does not have to be

Irreducible
All acutely irreducible hernias need emergency treatment because of the risk of strangulation An attempt to push the hernia back can be made

Strangulation
Operation

Prevention
You can do little to prevent areas of the abdominal wall from being or becoming weak, which can potentially become a site for a hernia.

INTUSSUSCEPTION

Intussusception
Intussusception occurs when one part of the intestine invaginates into the lumen of the adjoining bowel The mesentery is dragged along with the prolapsed bowel, causing venous compression, swelling, and edema of the bowel wall If untreated, the edema eventually will cause arterial obstruction, ischemia, and perforation

Intussusception
Most common cause of intestinal obstruction between 3 mo - 6 yrs 2/3 cases occur < 2 yrs Male/Female=4:1 75-95% Ileocolic > 90% idiopathic; Meckels, Peyers patches, tumors, polyps
Telescoping of proximal bowel into distal (Terminal Ileum into Cecum depicted in diagram)

Etiology
Intussusception may result from a lead point such as a polyp or diverticulum that is pulled distally by peristaltic activity, but 95% are idiopathic Idiopathic intussusception usually originates near the ileocecal junction, and it likely results from swollen hypertrophied Peyer patches in the ileum serving as a lead point Henoch-Schonlein purpura and meconium ileus equivalent may be associated with intussusception, usually in the small bowel

Sign and Symptoms

Clasically presents with the triad of abdominal pain, vomiting, and blood in the stools The infants awakens from sleep crying with severe, colicky abdominal pain, which is demonstrated by flexion of the knees and hips Vomiting is common

 Telescoping of one segment of bowel into another

Ileocolic most common 6 months 3 years old

Progressive course
Intermittent acute abd. pain Vomiting Bloody stools (currant jelly) Fever, lethargy Palpable sausage-shaped mass in upper abdomen

Diagnosis
Phys Exam: 25-89% may have variably tender sausage shaped mass; Dances sign: empty RLQ U/S: target, pseudokidney, radiologist dependent; if high suspicion, order the barium enema
films target sign, crescent, and obstruction, 30% may be normal
Plain

Physical Examination
Generally reveals a soft and nontender abdomen between episodes of pain with time, the abdomen will become distended and the examination more difficult In 75% patients, rectal examination reveals occult blood or may precipitate passage of a bloody bowel movement Occasionally, the intussusceptum may be palpable in the rectum

Radiology
An abdominal radiograph should be examined for a soft-tissue mass displacing loops of bowel A contast enema (a preferably using air as the contrast agent) with fluoroscopic guidance is required to exclude intussusception in a patient with a suggestive history

Management
Enema: diagnostic & therapeutic, coiled spring Surgery must be consulted prior to study. Barium vs. Air- 80% correction if within first 12-24 hrs. Air Enema- safer if perforation 5-10% recurrence rate in first 24-48 hrs after barium enema reduction If free air on films or signs of peritonitis, do not administer barium, prepare child for surgery

Management
Ultrasound :
intussusception
Hydrostatic pressure reduces the

Surgeon must be involved directly If enema reduction fails Small bowel intussusceptions require surgical reduction

PERFORATION

Perforation
Definition
Gastrointestinal perforation is a hole that develops through the entire wall of the stomach, small intestine, large bowel, or gallbladder. This condition is a medical emergency.

Etiology
Gastrointestinal perforation can be caused by a variety of illnesses, including appendicitis, diverticulitis, ulcer disease, gallstones or gallbladder infection, and less commonly, inflammatory bowel disease, including Crohn's disease and ulcerative colitis. It may also be caused by abdominal surgery.

Symptoms
Perforation of the intestine leads to leakage of intestinal contents into the abdominal cavity. This causes inflammation called peritonitis. Symptoms may include: Abdominal pain - severe Chills Fever Nausea Vomiting

Examinations
X-rays of the chest or abdomen may show air in the abdominal cavity (not in the stomach or intestines), suggesting a perforation. CT scan of the abdomen often shows the location of the perforation. The white blood cell (WBC) count is often higher than normal.

Treatments
Treatment usually involves surgery to repair the hole (perforation). Occasionally, a small part of the intestine must be removed. A temporary colostomy or ileostomy may be needed. In rare cases, antibiotics alone can be used to treat patients whose perforations have closed. This can be confirmed by a physical exam, blood tests, CT scan, and x-rays.

Prognosis
Surgery is usually successful, but depends on the severity of the perforation and the length of time to treatment.

Complications
Bleeding Infection ( including a widespread infection called sepsis, which can lead to death ) Intra-abdominal abscess

Preventions
Prevention depends on the cause. Diseases that may lead to intestinal perforation should be treated appropriately.

MALROTATION

 Malrotation is incomplete rotation of the intestine during fetal development Malrotation is the result of incomplete rotation of the gut and lack of attachments of the mesentery of the small intestine during intrauterine development. It may result in :
midgut volvulus obstruction

May be no symptoms.

Year of life

Symptoms and sign

The majority of patients present within the 1st year of life : acute or chronic obstruction
Infants (present within the 1st wk of life ) Older infants bilious emesis acute bowel obstruction

episodes of recurrent abdominal pain (that may mimic colic) recurrent vomiting reccurent abdominal pain reccurent of both
acute intestinal obstruction recurrent abdominal pain less frequent vomiting and diarrhea
develop volvulus

Older children

Adolescents Patients of any age (with a rotational anomaly )

without pre-existing symptoms

General consideration
Rotation of midgut is incomplete, the dorsal fixation of the mesentery is defective and shortened bowel from the ligament Treitz to the mid transverse colon may rotate around its narrow mesenteric root and occlude the superior mesenteric artery (volvulus)

Clinical Findings
Symptoms and signs Present in the first 3 weeks of life Bile-stained vomiting or overt small bowel obstruction Intrauterine volvulus intestinal obstruction or perforation at birth Neonate: Ascites or meconium peritonitis Later: Intermittent intestinal obstruction, malabsorption, protein-losing enteropathy or diarrhea

 Laboratory findings Hematocrit and rell blood cell elevated Slight leukocytosis suggest impeding gangrene Imaging Plain abdominals film may / may not show stomach / duodenum dilatation duodenal obstruction with a double-bubble sign Barium examination cecum and ascending colon displaced to the left Ultrasonography inversion of the superior mesenteric artery and vein

Treatment
Surgery
To relieve extrinsic compression in the duodenum by dividing the bands and straightening duodenal junction The duodenum and upper jejunum are freed and remain in the right abdominal cavity The colon placed in the right abdomen The cecum in the left lower quadrant Young infants should be performed even volvulus has not occurred

Laparoscopic repair
Technically difficult Never performed in the presence of volvulus

Complication
Extensive intestinal ischemia from volvulus produces the short-gut syndrome Occlusion of the superior mesenteric artery bowel necrosis

Prognosis
Reccurences after surgical corection are uncommon