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Abdominal Pain
Department of Surgery A
Rabin Medical Center
Acute Abdomen -
Conundrum
• If I operate and the problem is not
surgical, patient exposed to unnecessary
risk, anesthetic, etc.
• Risks greater with concomitant illness,
older age
liver spleen
stomach
gallblader
• Indication
• suspected perforation
• suspected aspiration
• suspected foreign body
Chest X-ray
pneumoperitoneum
Plain Abdominal Film
• Indication
• intestinal obstruction
• calcification
• suspected ischemia
• intestinal transit study
• inflammatory bowel
disease
Plain Films
• Upright CXR
• “Free” air
• KUB (kidney/ureter/bladder)
• Calcifications
• Air/ Fluid levels
• Reactive bowel patterns
• Foreign bodies
Abdominal x-rays
• Valuable in diagnosis in only 10% of
cases
• 20% of perforated peptic ulcers do
not demonstrate “free air” in
abdominal films
• Up to 80% of AAA’s will show
calcium in the wall on plain film
• Diagnostic in 60% with sigmoid
volvulus
Hydropneumoperitoneum
Plain Abdominal Film
gallstone
CT Scans
• Better than plain films and US for
evaluation of solid and hollow organs
– Intravenous contrast
– Oral contrast
– Per rectal contrast
• High use in appendicitis, diverticulitis,
abscess, pancreatitis
CT Scan
• Unenhanced helical CT in the acute abdomen
for diagnosis of
- acute appendicitis
- renal colic
- sigmoid diverticulitis
- pancreatitis
- small bowel obstruction
- abdominal aortic aneurysms
• CT improves accuracy of diagnosis
• Reduces mortality and hospital stay
Abdominal CT
Acute diverticulitis
normal abdominal CT
MRI
Angiography
normal NOMI
Acute Abdomen and Peritonitis
• Symptoms linked to visceral distention
or ischemia
• Inflammation of the peritoneum
• Parietal component provides localization
• End result of a process involving viscera
• Early diagnosis means understanding
the patterns that lead up to peritoneal
irritation
Peritonitis
Peritoniti
• Primary: No obvious source
– E. coli and Klebsiella in adults, cirrhosis, ascites.
• Secondary:
– Fecal
– Chemical
– Infectious
• Tertiary:
Tertiary
• Peritonitis- like syndrome
– Disturbance in immune response
– No pathogens identified
Peritoneal cavity
Acute peritonitis
any perforation,
pancreatitis
abdominal pain, tenderness
guarding, silent abdomen
shock
Treatment – underlying condition
Biliary colic/Cholecystitis
• Biliary colic when gallstones obstruct cystic duct or
pass into CBD
• Cholecystitis when cystic duct or CBD obstructed,
causing inflammation
• Bacterial infection a consequence of cholecystitis.
Common organisms are E. coli, Klebsiella,
enterococci
• CBD stones primary or secondary
• Perforation of GB in 3-15% of cholecystitis gives 60%
mortality
• USS best modality for cholecystitis and cholelithiasis
Gall bladder/Biliary Tract
Acute Cholecystitis
Presentation
Acute RUQ pain
+/- Pyrexia
+/- Rigors
Diagnosis – FBC, WBCC,
USS
Treatment – Antibiotics,
analgesics
Early surgery
Gall bladder/Biliary Tract
Obstructive Jaundice
Yellow skin, sclerae
Pale stools, dark urine
+/- Pain
+/- Courvoisier’s sign
CT – dilated bile ducts
Establish diagnosis
Gallstones
Ca Head of Pancreas
Appropriate treatment
ERCP
Small Intestine
Meckel’s Diverticulum
rare
diverticulum of terminal ileum
can be lined by gastric epithelium
can perforate
can present like appendicitis
Small Intestine
Intestinal obstruction
May arise due to
adhesions, hernia, tumour
Presentation
colicky abdominal pain,
vomiting, constipation
Treatment
resuscitate/operate
Small Intestine
Mesenteric infarct
Acute diverticulitis
Treatment
resuscitate, operate
Large Bowel
Ulcerative colitis
Presents – bloody
diarrhoea, pyrexia
leukocytosis
may develop toxic megacolon
Treatment – steroids
Surgery on failure
Inflammatory Bowel Disease
Recurrent regeneration
Increased risk of tumour formation
14.8 X
Appendicitis
• 7-12% lifetime risk of appendectomy
• ~500,000 performed yearly
• 15% misdiagnosed
• 47,000 appys/year
• 1 in 4 women will have a “negative
appendectomy”
• $740 million dollars spent/yr on
misdiagnosis
Pathophysiology
• Obstruction of the appendiceal lumen
• Lymphoid hyperplasia
• Fecalith
– Inspissated stool
– Not always present
• Foreign body
Pathophysiology of
Appendicitis
• obstruction • inflammation
• bacterial overgrowth • edema
• mucous secret • ischemia
• distention • necrosis
• Increased intraluminal • perforation
pressure • abscess or localized
• lymphatic obstruction peritonitis
• venous obstruction • diffuse peritonitis
History and Physical Exam
Table 6 --Clinical Features of Appendicitis
Symptoms
Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.
Distinguishing Appendiceal
Perforation
Appendicitis Appendicitis
With Perforation w/o Perforation
N=70 N=176
Duration of symptoms (hrs, 48.5 hrs 18.0 hrs
median)
Fever as presenting 34.3 11.4
complaint (% of cases)
Nausea or vomiting (% of 60.0 70.5
cases)
Anorexia (% of cases) 52.9 64.2
Urinary symptoms (% of 10.0 10.8
cases)
Rebound tenderness (% of 64.3 71.6
cases)
Rectal tenderness (% of 41.4 41.5
cases)
Impression of a mass (% of 21.4 6.2
cases)
Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann
Surg 1984;200:567.
Signs and Symptoms
• Umbilical then migrates towards the RLQ
• Tenderness, then rebound
• Rovsing
• Psoas
– Extension of leg-pt on left
• Obturator
– Rotation of flexed thigh-pt supine
• Rectal
• Perforation related symptoms
Differential Diagnosis
• Preschool-age
• Intussusception, acute gastroenteritis, Meckel’s diverticulum
• School-age
• Acute GE, constipation, Sickle cell
• Young males
• Crohn’s, UC, epididymitis
• Young females
• Crohn’s, PID, ovarian cysts, UTI, pregnancy
• Older adults
• Malignancies of GI and GU
• Diverticulitis
• Perforated ulcers
• Cholecystitis
Labs
• WBC: 12,000-18,000
• left shift important
• HCG negative
• UA
• mild pyuria possible
Radiographics
• Plain films
• fecolith, ileus
• CT scan
• Distention of appendix, thickened > 5-7
mm walls, target sign
• US
• Non-compressible, 7 mm, fluid, mass
• Nuclear MD: Tc 99 WBC Ig G
Appendicitis
U/S
Appendicitis
CT Scan
Treatment
• Urgent appendectomy
• Antibiotics
• Only preoperative abx needed for
uncomplicated cases
• For complicated appendicitis 7-10 days
Appendectomy
High mortality
Presentation –
abdominal pain
rigidity
peritonism, shock
Air under diaphragm on X-
ray
Treatment
antibiotics, resuscitate
repair
Management
• Acute perforation of a viscous requires
emergent exploration
• Delayed presentations are more
complex
• Can avoid operation if the perforation is
contained
• May require delayed interventions
Ischemic Bowel Dis
• 60% acute colonic ischemia
30% acute mesenteric ischemia
5% focal segmental small bowel ischemia
5% chronic mesenteric ischemia
• Arterial Anatomy of Gut
Celiac Axis- supplies Liver, Spleen, Biliary
tree,stomach, duodenum, and pancreas
SMA- duodenum, pancreas, entire small bowel,
ascending and partial transverse colon
IMA- partial transverse colon, descending colon
and rectum
Acute Mesenteric vs. Acute Colonic
Risk factors-cardioemboli, Risk Factors- Vasculitis(SLE,
hypotension, CHF, MI, PN), Sickle cell dis,
Digoxin, diuretics, hypercoag hypercoag, Dig, Gold,
states psychotropic drugs,
Cocaine, post surgical(AAA
repair, AVR), obstruction
due to CA, radiation, fecal
impaction,salmonella,
shigella, E.Coli O157:H7,
age >60
Presentation- sudden severe abd
pain in pt with risk factors. Presentation- sudden, crampy
Exam is nonspecific early mild LLQ pain with urge to
then right sided abd defecate and passage of
tenderness and maroon stool, BRB within 24hrs. Exam
and ultimatley peritoneal reveals mild tenderness
signs with infarction most common over sigmoid
or rectum.
X-ray- negative early then
thumbprinting of SI and Rt X-ray- normal to thumbprinting
Colon of colon
Dx- Angiography required Dx-colonoscopy for mucosal
bx; angio if Rt colon only
Rx- papaverine infusion vs
involved
surgery
Rx- supportive;infarction/toxi
Course-mortality 10% if Rx prior
megacolon rare
Volvulus
• 80% sigmoid
• Classic presentation in elderly with
chronic constipation that presents with 1-
2 day hx of anorexia, N/V, pain,
obstipation, distention
• Pain is often sudden in onset and crampy
• Prior episodes of similar pain that
resolved with BM is a common hx
• Plain film diagnostic in 60%
• Treatment includes BE or endoscopic
decompression vs surgery
• High risk of recurrence
Sigmoid and Cecal volvulus
• Caecal volvulus less than sigmoid volvulus
• Caecal volvulus 25% of volvulus cases
• Incomplete midgut rotation a predisposing factor
• Inadequate fixation of caecum to posterior abdominal
wall
• Caecal volvulus clockwise around ileocolic vessels
• Involves terminal ileum and ascending colon
• May attempt decompression by colonoscopy but
main treatment is laparotomy
LARGE BOWEL VOLVULUS
Acute pancreatitis(1)
• Inflammatory process in which pancreatic enzymes
autodigest gland
• Inflammatory process cause systemic effects due to
cytokines.
• Fat necrosis cause hypocalcaemia
• Pancreatic B cell injury cause hyperglycaemia
• In severe form manifest as ARDS, ARF, cardiac
depression, haemorrhage, hypotensive shock
• Causes: GET SMASHED
Acute pancreatitis(2)
• Serum amylase low sensitivity & specificity. Serum
lipase more sensitive
• 20% cases have normal amylase (alcohol cause)
• amylase raised in cholecystitis, hepatitis, peritonitis
• CT scan most reliable imaging modality
- Criteria for diagnosis divided into 5 grades
• Ranson’s criteria
Age>55, WCC>16, LDH>600, AST>120, Glu>10
• APACHE II score
Acute pancreatitis
Constant pain, vomiting,
shock
Pancreas
Causes
Gallstones, or
Alcohol
Diagnosis
Serum amylase
elevation, USS
complications
pseudocyst,
phlegmon
abcess
Ruptured AAA
• AAA result of degeneration in media of arterial wall,
resulting in slow and continuous dilatation of vessel
lumen
• AAA caused by mycotic aneurysms of
haematogenous origin in 5%.
• AAA fusiform or saccular
• Male >60 yrs
• Risk of rupture at >6cm
• >80% with rupture present without previous diagnosis
of AAA
• CT scan best modality. USS scan be useful
Gynecological acute
abdomen