Emergency Assessment and managment of ACUTE ABDOMEN

1. By Dr. Afework

2. ACUTE ABDOMEN
Definition:-
* It is a condition that mainly
present by pain in the abdominal
area which may need urgent
surgical intervention.
 a Non-traumatic abdominal emergency
characterized by sudden onset of
abdominal pain

3. ORGANS IN THE ABDOMENAL CAVITY

4. PAIN DESCRIPTION
o Onset (eg, sudden, gradual)
o Provocative and palliating factors (eg, does pain
decrease after eating?)
o Quality (eg, dull, sharp, colicky, waxing and waning)
o Radiation (eg, to the shoulder, back, or flank)
o Site (eg, a particular quadrant or diffuse)
o Symptoms associated with pain
o Time course (eg, hours versus weeks, constant or
intermittent)
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5.  Cause of Acute Abdomen
* Intestinal Obstruction * Gyn
- SBO - PID
- LBO - Ovarian torsion
- SH - Ovarian cyst rupture
* Inflammatory * Hepato-billary
- Appendicitis - Amoebic Liver abscess
- Peritonitis - Empyma of gallbladder
- pancreatitis - Cholelitiasis
- Cholecystitis
* Perforation * Medical causes
- PUD -DKA
- TF -AGE

6. Dangerous and common diagnoses to
consider in the elderly include:
o Abdominal aortic aneurysm (AAA)
o Mesenteric ischemia
o Myocardial infarction
o Bowel obstruction
o Bowel perforation
o Gallbladder disease
o Diverticular disease
o Volvulus
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7. Right upper quadrant
o Hepatitis
o Cholecystitis
o Cholangitis
o Pancreatitis
o Budd-Chiari syndrome
o Pneumonia/empyema pleurisy
o Subdiaphragmatic abscess
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8. Right lower quadrant
o Appendicitis
o Salpingitis
o Ectopic pregnancy
o Inguinal hernia
o Nephrolithiasis
o Inflammatory bowel disease
o Mesenteric adenitis (yersina)
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9. Epigastric
o Peptic ulcer disease
o Gastroesophageal reflux disease
o Gastritis
o Pancreatitis
o Myocardial infarction
o Pericarditis
o Ruptured aortic aneurysm
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10. Periumbilical
o Early appendicitis
o Gastroenteritis
o Bowel obstruction
o Ruptured aortic aneurysm
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11. Left upper quadrant
o Splenic abscess
o Splenic infarct
o Gastritis
o Gastric ulcer
o Pancreatitis
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12. Left lower quadrant
o Diverticulitis
o Salpingitis
o Ectopic pregnancy
o Inguinal hernia
o Nephrolithiasis
o Irritable bowel syndrome
o Inflammatory bowel disease
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13. Diffuse
o Gastroenteritis
o Mesenteric ischemia
o Metabolic (eg, DKA, porphyria)
o Malaria
o Familial Mediterranean fever
o Bowel obstruction
o Peritonitis
o Irritable bowel syndrome
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14. Intestinal obstruction
Small bowel  80% of obstruction
20% of acute abdomen admissions
5% of all surgical admissions
Large bowel  20% of obstruction
Ethiopia → Acute abdomen in TAH; 2000 (Berhanu K.)
i. Acute Appendicitis=52%
ii. Intestinal obstruction=26%
Small bowel= 52.3 %
Large bowel= 46.7 %

15. INTESTINAL OBSTRUCTION
• Definition:-
* partial or complete blockage of
intestine.
• Common cause
Developed Developing
- Adhesion - Volvulus
- Carcinoma of colon - Hernia
- Hernia - Ascarias bolus
- Faecal impaction - Intussusception

16. Ileo-sigmoid
knotting
(compound volvulus)
 Dramatic presentstion
with shock & gangrene
of bowl
 4th decade
Intussusception
 Commonest site -
ileocaecal junction
Sigmoid volvulus
Small Intestinal volvulus

17. CLASSIFICATION
1) High IO ( SOB)
Low IO (LBO)
2) Simple – has good blood supply.
Strangulated-impaired blood supply.
3) Dynamic/ Mechanical/- active
peristalsis.*
Adynamic/paralytic illus/- absence of
peristalsis.
4) *Close loop Obstruction -Competent
ileocaecal valve or Volvulus.

18. Pathophysiology
Obstruction leads
↓
Proximal distension gut by* gas & fluid
↓
Disrupt peristalsis → excessive peristalsis
↓
Impaired blood flow
↓
Ischemia
↓
Gangrene → G. Peritonitis
↓
Death

19. CLINICAL MANIFESTATION
* Colicky abd. Pain.
SBO LBO
* Vomiting early late
* DHN sever e mild/moderate
* Distension less more/ mass/
* Constipation relative absolute

20.  Cardinal feature of Obstruction
* Abdominal Pain
* Vomiting
* Distension
* Absolute constipation
 Clinical Feature of strangulation
◦ Severe continuous pain
◦ Tenderness with rigidity
◦ Shock
◦ Fever
◦ Tachycardia after resuscitation
Lab. →Leukocytosis

21. Plain abdominal X-ray
in SBO – triads of:
Dilated small bowl (>3cm)
Air-fluid level
Paucity of air in colon
• Sensitivity = 70-80% ;
Specificity is low ~60%
DDx: ileus, colonic
obstruction
• False negative- in high
small bowl obstruction
Erect abdominal
radiograph of a
47-year-old man
Supine
abdominal
radiograph in a
57-year-old man

23. Plain abdominal X-ray
in L BO
Dilation of the small and/or
large bowel and air fluid levels.
CXR →free air → perforation of
a hollow viscus
A dilated colon without air in
the rectum
Air in the rectum → obstipation,
ileus, or partial obstruction.
Dilation of the
colon in LBO
Massive dilation of
the colon due to
a sigmoid volvulus.

24. PRINCIPLES OF MANAGMENT OF IO
* Gastrointestinal drainage & decompression
NGT*
* Resuscitation with IV fluid *
* Catheterization
* Antibiotics if indication*
* Relieve Obstruction.
NB “ The sun should not be both rise and set on
case of unrelieved intestinal obstruction.”

25. Fluid and electrolyte
◦ Deficit, maintenance, continued third space losses
NGT decompression until return of bowel
function
Input / output monitoring
Antibiotics
Observation for complications

26. Sepsis
Intraabdominal abscess
Wound dehiscence
Aspiration pneumonia
Others
Recurrence of sigmoid volvulus
Electrolyte disturbance
Short-bowel syndrome

27. INTUSSUSCEPTION
 Definition:-
* Intussuscipeins become invaginated to
intussusceptum.
* Leading cause of IO in young children.
* Peak incidence 3-9 m.
 Causes:-
1) Primary/ idiopathic/ Intussusception
* Hypertrophy of peyer’s pathches in
terminal ileum.
* Antecedent to viral infection
. Rotavirus
. Adenovirus

28. 2) Secondary Intussusception
* Polyps, malignant tumour
* Meckel’s diverticulum
* After long period fasting
Symptom:-
*sudden screaming ass. With drowning
up legs.
* Intermittent vomiting
* Red current jelly stool
Signs:-
 Elongated mass in RUQ.
 Emptiness in R.ILLIAC F.

29.  Types
* ileocolic
* Colo-colic
* ileo-ileo-colic
* ileoileal
Diagnosis
Radiography
* Plain abd. Film
* Barium enema
U/s-

30. Parts
1. Intussuscipiens - Outer tube / distal
2. Intussusceptum – Inner tube / proximal
3. Apex – part further advanced
4. Neck – narrow part

31. Mgt
 Non Operative
* Hydrostatic reduction - Dx & Rx
* Pneumonic reduction*
 Operative*
* Exteriorization
* 10
R & A or stoma

32. SIGMOID VOLVULUS
- It is twisting or axial rotation of sigmoid colon about its
mesecolon.
- If it is complete, cause close loop obstruction.
Predisposing Factors
* Overloaded pelvic colon
* Long pelvic mesecolon
* Band of adhesion
* constipationSymptom/ Sign:-
- Colicky abd. Pain - Vomiting
- Distension - Absolute Constipation
- Empty rectum
DIAGNOSIS
Plain abd. Film
- Inverted U
- Coffee beam or Omega sign
- 2 long fluid level in LQ
- Barium Enema- bird’s beak

34. COMPOUND VOLVULUS
 known as Ileosigmoid knotting.
 Become gangrenous with in short period.
 Difficult to untie.
 Require decompression, resection &
anastomosis.

35. Mgt
 Uncomplicated / partial obs.
- *Deflate with a large bore rectal tube
under the direct guide of sigmoidoscopy.
- Elective surgery 0r resection to prevent
recurrence.
 Complicated/ Strangulated
* Urgent Laparotomy
* Exteriorization
* Hartmann’s Operation
NB “ If you even suspect strangulation, Urgently
refer or do Laparotomy”

36. APPENDICITIS
 Definition:-
* It is an inflammation of appendix that
results from bacterial invasion usually distal
to obstruction of lumen.
 Pathophysiology:-
*It began with the obstruction of the narrow
lumen by:-
- Lymphoid hyperplasia
- Faecal material (feclith)- the main
common cause.
- Foreign body ( seeds or worms)

37. Various position of Appendix

38.  The obstruction cause a closed loop
obstruction with continue distension &
bacterial proliferation.
 If not relived early, it ruptures & produce
peritonitis & sepsis.
CLINICAL MANIFESTATION
Symptoms:-
* central abdominal colicky pain which
shift to Rt iliac fossa.
* Anorexia, nausea & one episode of
vomiting.
* Low grade fever.

39. Signs:-
* Rovsing sign:- pain in the RLQ on pressing LLQ.
* Psoas sign:- pain on extension of the Rt
flexed hip.
* Obturator sign:- pain on passive internal &
external rotation of flexed Rt hip.
* Tenderness and localized rigidity on RLQ.
* Rt side tenderness on DRE.

40. DIAGNOSIS
 The likelihood of appendicitis can be approved by
using Alvarado scale based on S/S & Lab. results.
Alvarado scale/ MANTRELS
Manifestation
Value
 Symptom - Migration of pain 1
- Anorexia 1
- Nausea/ Vomiting 1
 Sign - Tenderness RLQ 2
- Rebound tenderness 1
- Elevated To 1

Lab. Values - Leukocytosis 2
- Left shift 1

41. * Scores 9- 10 Appendicitis
* Scores 7-8 Like hood of Appendicitis
* Scores 5-7 Not diagnostic
* Score 0-4 Unlikely
Mgt
- Adequate resuscitation & rehydration
- Per operative Antibiotics which cover Gm –ve,
Gm +ve, & anaerobes.
- Ampcillin + Metrondazole +
Gent/ceftriaxone
- Duration- 7-10d in perforated cases
- - 24- 48h in non perforated cases
- Surgery is definitive Rx- Appendectomy

42. o Appendiceal mass: Conservative
treatment, followed by ? elective
appendectomy after 6 weeks.
o Appendiceal abscess: Drain abscess,
leave appendix untouched if difficult to
identify, elective surgery after 6 weeks.
o Nonsurgical treatment: may be useful
when appendectomy is not accessible
or when it is temporarily a high-risk
procedure.
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43. o Perforation
o Sepsis
o Shock
o Dehiscence
o Wound infection
o Bowel obstruction
o Abdominal/pelvic abscess
o Death (rare)
o The prognosis is generally excellent
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44. PERFORATEDPEPTICULCERDISEASE
- It is one of the complication of PUD.
- Perforation occur commonly in anterior part of
duodenum.
- Common in males age 45-55yrs.
- Gastric contents spill over peritoneum & bring
about bacterial peritonitis.
CLINICAL MANIFESTATION
* V/s - increased pulse
* Abdomen - distended, tenderness
- board like rigidity
- do not move with respiration
- absence of liver dullness

45. Ix
*CXR- air under diaphragm
Mx
* Resuscitation
* Continuous NGT aspiration
* Analgesics
* Laparotomy - peritoneal toilet
- transverse closure of
perforation
* keep the pt NPO until 5 days.
* Anti helicobacter pylori Rx if +ve for H.
Pylori test

46. PERITONITIS
- It is an inflammation of the peritoneum.
- An acute life threatening condition cause by
bacterial or chemical contamination of the
peritoneal cavity.
CAUSE
* Perforation( PUD, Appendix, TF)
* Anastomosis leak after surgery.
* Pancreatitis, Cholecystitis
* Haematogenous spread. Eg -TB

47. 4
7

48. CLASSIFICATION
1) Based on route of bacterial invasion
* primary – hematologic spread
* secondary – contamination via
perforation
2) Based on site involved
* Localized – peritonitis confined to limited
space.
* Generalized - when it involves the whole
peritoneal cavity.
3) Based on onset of symptom
* Acute – with rapid onset.
* Chronic – with slow progression.

49. COMMON ETIOLOGIC AGENTS
* E. Coli * Staphylococcusocc
* Streptococcus * Clostridium
* Bacteroids * Klebsiella
C/ Manifestation
- sharp abd. Pain which is worse on
movement.
- Abd. Distension, fever & tachycardia
- Diminished or absence of bowel sound
- shoulder pain secondary to diaphragmatic
irritation.

50.  Ix
* increase WBC
* Erect CXR – free peritoneal gas
(In perforation)
* increase serum Amylase >4x.
o Mgt
* Resuscitation
* NGT
* Triple antibiotics
* surgery

52. Def:-
• is a protrusion of viscus or part of the
viscus through abnormal opining.
• The most common varieties of EAH are
 Paraumblical
 Umblical
 Inguninal
 Femoral
 Incisional

53. •Any thing that increase Intra-abdominal
pressure like
 Chronic cough
 Straining
 Obesity
 Intra abdominal malignance

54. •Sac
 Mouth , Neck, body & fundus
• Covering
• Content /Entrocele, Omentem/

55. 1. Reducible
2. Irreducible
3. Obstructed
4. Strangulated
Reducible ------Irreducible ------
Obstructed --------- Strangulated

56. •Hernias with NARROW NECK are responsible
for cause of Acute abdomen
 Femoral
>>
 Paraumblical
>>
 Indirect Inguinal

57. • Need urgent Surgical intervention for
Obstructed & strangulated Hernia
 Principles of general Mgt
 Herniotomy
 Herniorrhapy

58. Cholelithiasis
(Gallstone Disease)

59.  Formation of stones (calculi) within the gallbladder or
biliary duct system
 The most common pathology of the biliary tract
5
9

61. 1. Too much absorption of water from bile
2. Too much absorption of bile acids from bile
3. Too much cholesterol in bile
4. Inflammation of epithelium
61

62. 1. Cholesterol stone (<10%):
• usually single large stone, supersaturation of bile with cholesterol,
• Contain variable amounts of bile pigments and calcium, but are
always >70% cholesterol by weight
• Colors range from whitish yellow and green to black
2. Pigment stone (5%-10%)
◦ mainly composed of calcium bilirubinate
◦ They are usually small, multiple and black
3. Mixed stone (80%):
◦ cholesterol is the major component with others like
calcium bilirubinate
◦ These type of stones are multiple, faceted and usually
associated with infection
6
2

63.  Risk factor
◦ Female sex
◦ age > 40
◦ obesity
◦ maturity onset diabetes
 Complication
◦ In gallbladder: Biliary colic, Acute cholecystitis, Chronic
cholecystitis, Empyema of the gall bladder, & Perforation,
etc
◦ In the bile ducts: Biliary obstruction, Acute cholangitis, &
pancreatitis
◦ In the intestine: Intestinal obstruction (gallstone ileus)
6
3

64. ◦RUQ colicky pain
◦dyspepsia
◦fatty food intolerance (pain)
◦flatulence
◦symptoms of acute cholecystitis
◦nausea and sometimes vomiting
◦RUQ tenderness (PE)

65. • Blood Tests
◦ CBC & LFT
 elevated WBC (cholecystitis)
 elevation of bilirubin, alkaline phosphatase, and
aminotransferase (cholangitis)
 elevation of bilirubin (obstruction)
• In patients with biliary colic or chronic
cholecystitis, blood tests will typically be normal.
65

66. • Surgical mg’t
◦ Endoscopic Cholangiography,
◦ Laparoscopic Cholecystectomy,
◦ Open Cholecystectomy, and
◦ Transduodenal Sphincterotomy
• Conservative treatment followed by cholecystectomy
◦ Nil per mouth (NPO) and intravenous fluid
administration
◦ Administration of analgesics
◦ Administration of antibiotics
◦ Subsequent management
66

67.  Bile Duct Injury and Ligation
 Post cholecystectomy Pain
 Retained Biliary Stones
 Biliary Leak
 flatulence, belching, bloating, dietary fat
intolerance
67

68.  Risk Factors
◦ Alcohol
◦ Gallstones
◦ Drugs
 Amiodarone, antivirals,
diuretics, NSAIDs,
antibiotics, more…..
◦ Severe hyperlipidemia
◦ Idiopathic
 Clinical Features
◦ Epigastric pain
◦ Constant, boring pain
◦ Radiates to back
◦ Severe
◦ N/V
◦ bloating
 Physical Findings
◦ Low-grade fevers
◦ Tachycardia, hypotension
◦ Respiratory symptoms
 Atelectasis
 Pleural effusion
◦ Peritonitis – a late finding
◦ Ileus
◦ Cullen sign*
 Bluish discoloration around
the umbilicus
◦ Grey Turner sign*
 Bluish discoloration of the
flanks
*Signs of hemorrhagic pancreatitis

69.  Diagnosis
◦ Lipase
 Elevated more than 2
times normal
 Sensitivity and specificity
>90%
◦ Amylase
 Nonspecific
 Don’t bother…
◦ RUQ US if etiology unknown
◦ CT scan
 Insensitive in early or mild
disease
 NOT necessary to
diagnose pancreatitis
 Useful to evaluate for
complications
 Treatment
◦ NPO
◦ IV fluid resuscitation
 Maintain urine output of
100 mL/hr
◦ NGT if severe, persistent
nausea
◦ No antibiotics unless severe
disease
 E coli, Klebsiella,
enterococci, staphylococci,
pseudomonas
 Imipenem or cipro with
metronidazole
◦ Mild disease, tolerating oral
fluids
 Discharge on liquid diet
 Follow up in 24-48 hours
◦ All others, admit

70.  Bailey & Love”s short practice of surgery 25th edition.
 Schwartz's principle of Surgery, 9th edition.
 Sabiston Textbook of Surgery, 18th edition.
 Up-To-date 22.1
 Manual surgery