An up to date on the management of the acute abdomen. Including case presentations of x-rays, CT scans & laparoscopy images and the highlights of their management. Mainly intended for surgical trainees preparing for their exams.

1. A C U T E A B D O M E N
C A S E P R E S E N TAT I O N S
D R . M O H A M A D A L - G A I L A N I F R C S
‫ي‬ ‫ن‬ ‫ال‬ ‫ي‬ ‫ك‬ ‫ل‬ ‫ا‬ ‫د‬ ‫م‬ ‫ح‬ ‫م‬ ‫ر‬ ‫و‬ ‫ت‬ ‫ك‬ ‫د‬ ‫ل‬ ‫ا‬
C O N S U L TA N T S U R G E O N
‫ي‬ ‫ر‬ ‫ا‬ ‫ش‬ ‫ت‬ ‫س‬ ‫ا‬ ‫ح‬ ‫ا‬ ‫ر‬ ‫ج‬
R I YA D H , K S A
‫ض‬ ‫ا‬ ‫ي‬ ‫ر‬ ‫ل‬ ‫ا‬,‫ة‬ ‫ي‬ ‫د‬ ‫و‬ ‫ع‬ ‫س‬ ‫ل‬ ‫ا‬ ‫ة‬ ‫ي‬ ‫ب‬ ‫ر‬ ‫ع‬ ‫ل‬ ‫ا‬ ‫ة‬ ‫ك‬ ‫ل‬ ‫م‬ ‫م‬ ‫ل‬ ‫ا‬
2 0 1 7

2. ACUTE ABDOMEN
• A potentially life threatening condition that requires urgent diagnosis
and management
• Associated with:
1. Pain that persists for more than 6 hours
2. Guarding
3. Rigidity
4. Leucocytosis
5. Fever
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
2

3. ACUTE ABDOMEN
• Linear relationship between delay in treatment and
mortality
• A patient with an acute abdomen is an EMERGENCY,
and it is IMPERATIVE to get correct diagnosis and
prompt treatment
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
3

4. ACUTE ABDOMEN:
CASE PRESENTATIONS
4
Dr. Mohamad Al-Gailani FRCS Acute Abdomen Case Presentations 2017

5. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
5
Case 1
Patient presented to the Casualty department with several
hours worsening abdominal and back pain. He had had mild
back pain for some weeks. What does the plain abdominal film show?

6. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
6
Answer 1
Abdominal Aortic Aneurysm
(AAA)
Micro
Calcifications
Loss of
Psoas
Shadow

7. Abdominal Aortic Aneurysm
• 1% of all men over 65 years
• Rupture mortality is over 50%
• Back pain and collapse in >65 years age
• Fatal if not operated upon urgently
• Best chance of survival is early detection
• Elective surgery better than treatment once
ruptured!
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
7

8. ACUTE ABDOMEN: History
• PAIN
1. Location
2. Onset and Progression: > 6 hours-surgical
3. Character and Severity
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
8

9. ACUTE ABDOMEN: History
• Associated symptoms: vomiting follows pain,
anorexia
• Menstrual history
• Drug history: anticoagulants, steroids, beta-
blockers
• Family history
• Travel history: dysentery, Salmonellosis,
Tuberculosis
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
9

10. ACUTE ABDOMEN: Examination
• Vital signs: Temp, Pulse, BP, RR
• Inspection: General appearance, movement
• Palpation: tenderness, rebound, guarding
• Percussion: liver dullness, ascites, rebound
• Auscultation: absent, exaggerated, bruits, succussion
splash
• PR, PV
• Murphy’s sign, Rovsing’s sign, Iliopsoas sign
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
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11. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
11
Case 2
75 year old man presented to the Emergency Department
with acute abdominal pain and bloody diarrhoea. What
does the plain abdominal film show?

12. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
12
Answer 2
Toxic Megacolon
Caecum
>12 cm
Transverse Colon
>6 cm

13. Toxic Megacolon
• Nonobstructive colonic dilatation (Caecum > 12 cm,
Transverse Colon > 6 cm) + signs of systemic toxicity
• Diagnostic criteria:
1. Radiographic evidence of colonic dilatation
2. Fever , tachycardia, leucocytosis, dehydration, altered
mental status, electrolyte abnormality or hypotension
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
13

14. Toxic Megacolon: Management
• Initiate intensive medical treatment with
systemic steroids
• Close observation; daily x-rays
• Surgical intervention if no improvement occurs
over 48-72 hours with medical therapy
• Subtotal colectomy and ileostomy
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
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15. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
15
Case 3
62 year old woman presented to the emergency department with
one week's history of increasing abdominal pain and distension.
She gave a long history of chronic constipation, but was otherwise
fit and well. What does the X-ray show?

16. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
16
Answer 3
Sigmoid volvulus
 Coffee Bean
Sign
 C-pointing to
LIF

17. Sigmoid Volvulus
• Most common form of volvulus
• Coffee Bean sign
• Decompression by a long soft tube +- colonoscopy
• Surgery; failure of tube deflation, ischaemia &
recurrence
• Double barrel colostomy
• Per Cutaneous Colotomy (PEC)
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
17

18. ACUTE ABDOMEN: INVESTIGATIONS
BLOOD:
• FBC, U & E , LFT,
Glucose
• Serum lipase
• Clotting studies
• Pregnancy test!
RADIOLOGY:
• Erect CXR
• Plain AXR
• Ultrasound
• C/T
• Other: Contrast,
Angiography,
Radionuclide, MMR
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
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19. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
19
Case 4
A 55 year old admitted with a one day history of epigastric pain and
an acute abdomen. What are the findings on this CT?

20. Answer 4
Severe Necrotizing Pancreatitis
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
20

21. Severe Necrotizing Pancreatitis
• Presents as Acute Abdomen
• Treatment is supportive
• Modified Glasgow scale:
• 3 or > Severe Pancreatitis (15% Mortality)  ITU
• Consider US percutaneous drainage for Abscess
• ERCP for impacted CBD stone
• Surgery: Necrosectomy, Emergency Cholecystectomy
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
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22. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
22
Case 5
Acute epigastric pain of sudden onset. What is the
diagnosis?

23. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
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Answer 5
Air under Diaphragm. Perforated Viscous

24. PERFORATED VISCOUS
• Peptic or Colonic?
• Laparoscopy and Proceed
• Over sewing perforated Peptic Ulcer
• Perforated Sigmoid Diverticulae:
1. Without peritonitis > Laparoscopic Washout with
Drainage
2. With Peritonitis > Hartmann’s procedure
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
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25. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
25
Case 6
37-year-old woman presenting with 2 week history of right iliac
fossa pain. What does the CT show?

26. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
26
Answer 6
Ectopic Pregnancy
Ectopic
Gestation Haematoma
around uterus &
Haemoperitoneu
m
Uterine Fundus

27. Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
27
ECTOPIC PREGNANCY

28. Ectopic Pregnancy
•Pain, Amenorrhea & Vaginal bleeding
•50% present with vaginal bleeding
•50% have a palpable adnexal mass
•75% may have abdominal tenderness
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
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29. ACUTE ABDOMEN: Gynaecological
• Mittelschmerz pain- mid cycle pain
• Ectopic pregnancy- missed period, anaemia, B-HCG
positive
• Ovarian cyst torsion- U/S
• Salphingitis- PV, High vaginal swab
• Endometriosis
• Diagnostic Laparoscopy?
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
29

30. ACUTE ABDOMEN:
Indications For Laparotomy
• When the diagnosis is certain
• Generalized peritonitis
• Equivocal abdominal findings, Suspected ischaemia
• Deterioration/Failure conservative treatment
• Pneumoperitoneum
• Free Intra Peritoneal Blood/Fluid
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
30

31. ACUTE ABDOMEN:
Pre-operative Optimization:
• ITU?
• Pain relief
• Resuscitation
• Fluid replacement
• Antibiotics
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
31
• Nasogastric tube
• Foley’s catheter
• Central and arterial lines
• Consent!

32. ACUTE ABDOMEN:
Summary
•Never forget to measure serum lipase!
•Premenopausal? Pregnancy test!
•Management starts with Preoperative
Optimization
•Mortality depends on age, co-morbidity &
proper urgent management
Dr. Mohamad Al-Gailani FRCS Acute Abdomen
Case Presentations 2017
32

33. D R . M O H A M A D A L - G A I L A N I F R C S
‫ي‬ ‫ن‬ ‫ال‬ ‫ي‬ ‫ك‬ ‫ل‬ ‫ا‬ ‫د‬ ‫م‬ ‫ح‬ ‫م‬ ‫ر‬ ‫و‬ ‫ت‬ ‫ك‬ ‫د‬ ‫ل‬ ‫ا‬
C o n s u l t a n t S u r g e o n
‫ي‬ ‫ر‬ ‫ا‬ ‫ش‬ ‫ت‬ ‫س‬ ‫ا‬ ‫ح‬ ‫ا‬ ‫ر‬ ‫ج‬
M e d i c a l E d u c a t i o n & T r a i n i n g D i r e c t o r
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A l H a m m a d i H o s p i t a l , S u w a i d i
‫ي‬ ‫د‬ ‫ا‬ ‫م‬ ‫ح‬ ‫ل‬ ‫ا‬ ‫ى‬ ‫ف‬ ‫ش‬ ‫ت‬ ‫س‬ ‫م‬,‫ي‬ ‫د‬ ‫ي‬ ‫و‬ ‫س‬ ‫ل‬ ‫ا‬
R i y a d h , K S A
‫ض‬ ‫ا‬ ‫ي‬ ‫ر‬ ‫ل‬ ‫ا‬,‫ة‬ ‫ي‬ ‫د‬ ‫و‬ ‫ع‬ ‫س‬ ‫ل‬ ‫ا‬ ‫ة‬ ‫ي‬ ‫ب‬ ‫ر‬ ‫ع‬ ‫ل‬ ‫ا‬ ‫ة‬ ‫ك‬ ‫ل‬ ‫م‬ ‫م‬ ‫ل‬ ‫ا‬
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