THE ACUTE ABDOMEN

THE ACUTE ABDOMEN

 The term acute abdomen- acute onset of
symptoms that strongly suggest an abdominal
cause
 Many of causes are potentially life- threatening
unless treated promptly
 On the other hand simple conditions such as
constipation can produce acute symptoms
 Sometimes the diagnosis may become apparent
after a period of observation or after special
investigations (CT) or at laparotomy
 THE ACUTE ABDOMEN
CAUSES IN ADULTS
 1.Bowel obstruction
 2.Adinamic bowel obstruction
 3.Bowel strangulation
 4.Peritonitis
 5.Intraabdominal hemorrhage
 6.Intraabdominal abscess
 7.Perforation of an abdominal viscus
 8.Acute bowel ischemia
 BOWEL OBSTRUCTION
Causes
 Adhesions or bands from previous surgery
 Strangulated hernia
 Volvulus
 Obstructing gastric cancer, bowel tumors
 Inflammatory stricures: diverticular disease,
Crohn’s disease
 Bolus obstruction: impacted feces, foreign body,
solitary gallstones, phytobezoar
 Intussusception
 BOWEL OBSTRUCTION
CLINICAL FEATURES
 Obstruction leads to proximal dilatation and disrupts
peristalsis
 The presentation depends on the level of obstruction and
on the completeness of obstruction
 The more proximal the obstruction, the earlier the vomiting
develops
 The nature of the vomitus gives important clues to the level
of obstruction:
-semidigested food,no bile= GOO,
- bile-stained vomitus= USBO,
-foul-smelling vomitus= LBO
 BOWEL OBSTRUCTION
CLINICAL FEATURES
 Proximal distention causes pain, colicky in nature-
peristalsis tries to overcome the obstruction
 Excessive peristaltic activity is responsible for the
bouts of colicky pain
 Absolute constipation is pathognomonic of bowel
obstruction
 If the bowel is partially obstructed, the clinical
features are less clearly defined
 The pain is often accompanied by visible
peristalsis
 BOWEL OBSTRUCTION
PHYSICAL EXAMINATION
 Dehydration- dryness of the mouth, loss of skin turgor and
elasticity
 Abdominal distention (gas-filled loops); the more distal the
obstruction, the greater the distention
 Visible peristalsis in thin patients
 Signs of anemia or lymphadenopathy due to the primary
disorder
 The most striking feature- the lack of tenderness, except
strangulation
 An obstructing abdo. mass may be palpable if large
 Hyperresonance- percussion, high-pitch bowel sounds-
ascultation
 BOWEL OBSTRUCTION
INVESTIGATIONS
 The most useful- abdo.X- ray in the erect position
 Bowel proximal to the obstruction is distended by
gas
 Fluid levels may indicate the site of obstruction
 Cecum>10-12cm. in diameter= imminent danger
of perforation
 Instant barium enema for less acute symptoms
may be helpful in large bowel obstrction
ADINAMIC BOWEL OBSTRUCTION
 Temporary disruption of normal peristaltic activity
without mechanical blockage
 It arises after abdo.surgery
 Post.op paralytic ileus should not persist for more
than 4 days
 Persistent paralytic ileus is due to a complication:
anastomotic leakage, intraabdominal sepsis
 Hypokalemia- cause of ABO
 Bowel sounds are inaudible
 BOWEL OBSTRUCTION
PRINCIPLES OF MANAGEMENT
 Oral intake is discontinued,
 I.V fluids given- the volume and type, after
the severity of dehydration and electrolyte
disturbances
 Naso-gastric tube is passed- gastric
decompression
 Surgery required to relieve the obstruction
 BOWEL STRANGULATION
 Strangulation- a segment of bowel trapped so that:
-its lumen obstructed, -its blood supply disrupted
 If unrelieved this progresses to infarction and
perforation
 Strangulation can occur in external hernia, internal
hernia, volvulus (mass rotation of bowel)
 The trapped segment-dilates by gas
 The combination of gas pressure and venous-gas
pressure inhibit arterial inflow- ischemia, infarction
 BOWEL STRANGULATION
 Strangulation most commonly occurs when
small bowel is cought within a hernia
(inguinal, femoral, umbilical, incisional)
 The bowel undergoes necrosis and
perforates within the hernial sac
 Clinically, symptoms and signs of bowel
obstruction
 An irreducible, tender hernia can be found
 BOWEL STRANGULATION
 Strangulation within the abdominal cavity:
- a loop is trapped by fibrous bands or
adhesions from previous surgery,
- a loop is passed through an mesenteric
defect,
- a loop is twisted on its mesentery
(volvulus)
 BOWEL OBSTRUCTION
 Intraabdominal strangulation- symptoms and
signs of bowel obstruction+ abdominal
tenderness
 The patients with strangulation are more
unwell than those with uncomplicated bowel
obstruction, with tachycardia and
leukocytosis
 BOWEL STRANGULATION
SYMPTOMS

 Vomiting- onset and nature of vomitus

suggests the level of obstruction
 Abdominal pain- colicky and severe
 Absolute constipation (no flatus, no feces
passed rectally)- pathognomonic for
complete obstruction
 BOWEL STRANGULATION
PHYSICAL SIGNS
 Dehydration caused by vomiting, lack of
fluid intake, fluid sequestration
 Abdominal distension caused by gas-filled
loops of bowel
 Visible peristalsis- uncommon
 Abdominal resonance on percussion
 Abdominal tenderness on palpation
 Abdominal bowel sounds exaggerated
 BOWEL STRANGULATION
PRINCIPLES OF MANAGEMENT
 Strangulation diagnosed or suspected,
operation must be performed urgently
 Objective- to prevent infarction and
perforation
 If necrotic bowel found- resection in healthy
tissues,+/- abdominal drainage
 Large-spectrum antibiotics given i.v.
 The cause of strangulation (hernia) repaired
 PERITONITIS
 Inflammation of the peritoneal cavity: the
serosal covering of the bowel and mesentry,
the omentum and the lining of the abdominal
cavity
 Initially, peritoneal inflammation often
localized by omentum, adjacent bowel and
adhesions
 If untreated, the inflammation spreads within
peritoneal cavity
 LOCALIZED PERITONITIS
 Transmural inflammation of the bowel:
- appendicitis,
- Crohn’s disease,
- diverticulitis
 Transmural inflammation of other organs:
- cholecystitis,
- salpingitis
 Palpable inflammatory painful intraabdominal
mass
 LOCALIZED PERITONITIS
 Localized peritonitis occurs in the vicinity of
any primary inflammatory process
 The surrounding organs- adherent in an
attempt to avoid the spreading of infection
 Once the parietal peritoneum involved- pain
is localized to the affected area
 Guarding, rebound tenderness, PR exam.
 Fever, malaise, tachycardia, leukocytosis
 GENERALIZED PERITONITIS
 Sudden perforation of a viscus leads to life-
threatening generalized peritonitis
 Irritation of the peritoneum by noxious fluids:
bile, gastric and bowel contents
 Spreading intraperitoneal infection: rupture
of intraabdo.abscess, posttraumatic bowel
perforation, anastomotic leak
 GENERALIZED PERITONITIS
 The patient is seriously ill
 Massive exudation of inflammatory fluid into
the peritoneal cavity- hypovolemia
 The most severe peritonitis- widespread
contamination by feces, pus, infected bile
 Less severe peritonitis- early stage of
perforated peptic ulcer
 GENERALIZED PERITONITIS
SYMPTOMS

 Fever,
 Malaise,
 Loss of appetite,
 Vomiting
 Abdo. pain exacerbated by movements
 GENERALIZED PERITONITIS
PHYSICAL SIGNS

 The abdomen is tender

 The abdomen is rigid
 Generalized guarding
 Bowel sounds absent- paralytic ileus
 PR- anterior tenderness- pelvic peritonitis
 Low blood pressure, tachycardia
 PERITONITIS
PRINCIPLES OF MANAGEMENT
 Local peritonitis-according to the cause:
- appendicitis- appendicectomy,
- diverticulitis- antibiotics,
- salpingitis- antibiotics
Generalized peritonitis- urgent surgery
- broad-spectrum ab.
- i.v. fluids
 INTRA-ABDOMINAL
HEMORRHAGE

 Sourses:
- ruptured ectopic pregnancy,
- ruptured spleen,
- ruptured liver,
- ruptured mesentery,
- ruptured aortic aneurism
 INTRA-ABDOMINAL
HEMORRHAGE
 Blood in the peritoneal cavity- moderate
peritoneal irritation
 History, moderate abdo.pain,acute anemia,
low BP, tachycardia enough clues for
diagnosis
 Abdo USS, peritoneal lavage- retrieval of
blood-stained fluid is diagnostic
 Treatment-urgent laparotomy-hemostasis
 INTRA-ABDOMINAL ABSCESS
 Causes:
– Bowel perforation when omentum & gut can wall off the
defect
– Postop.- fecal contamination or anastomotic leak
– Appendiceal perforation:- local abscess or
pelvic abscess
– Perforated diverticulitis- pericolic abscess
– Perforated bowel tumor- pericolic abscess
– Gangrenous cholecystitis- subphrenic abscess
– Perforated peptic ulcer post.wall- lesser sac abscess
 INTRA-ABDOMINAL ABSCESS
CLINICAL DIAGNOSIS
 Increasing continuous abdo .pain
 Bowel irritation- diarhhea or ileus
 Swinging pyrexia
 Palpable tender inflammatory mass
appendicular or diverticular abscess
 PR exam.- Douglas tender mass, displacing
the rectum backwards
 INTRA-ABDOMINAL ABSCESS
INVESTIGATIONS
 Lab.tests:- leukocytosis,- high ESR,- anemia
 USS of the abdomen and pelvis- site, size of
the abscess
 CT of the abdomen and pelvis- better
informations but more expensive
 Radioisotope scanning, using the patient’s
own white cell labelled with indium
 INTRA-ABDOMINAL ABSCESS
TREATMENT

 Small abscess- i.v. antibiotics

 Large abscess:- CT guided drainage,
- laparotomy to drain the
abscess, resolve the sourse
- antibiotics after culture
and sensitvity
 INTRA-ABDOMINAL
PERFORATION

 The common sites:

– Stomach and duodenum (peptic ulcer)
– Sigmoid colon (diverticular disease)
– Appendix (appendicitis)
 PERFORATED VISCUS
SYMPTOMS AND SIGNS

 Depend on:
– the nature of its contents,
– the volume of spillage,
– the effectiveness of the local defenses
 PERFORATED VISCUS
SYMPTOMS AND SIGNS
 Perforated gangrenous appendicitis,if
neglected- generalized peritonitis
 Perforated diverticular disease- rarely may
result in generalized peritonitis
 Large colonic perforation- life-threatening
fecal peritonitis
 Perforated peptic ulcer- generalized
peritonitis at late stage
 PERFORATED VISCUS
SYMPTOMS AND SIGNS

 Abdo .pain, malaise, chills, fever,

 Vomiting, paralytic ileus
 Rigid abdomen
 Guarding
 Absent bowel sounds
 PERFORATED VISCUS
INVESTIGATIONS

PLAIN ABDOMINAL X RAY- MAY REVEAL

PNEUMOPERITONEUM

USS OF THE ABDOMEN- DEMONSTRATS

INTRA-ABDOMINAL FLUID
 PERFORATED VISCUS
TREATMENT
 PERFORATION IS A SURGICAL
EMERGENCY
 URGENT LAPAROTOMY
 RESOLVE THE CAUSE
 ABDOMINAL LAVAGE AND DRAINAGE
 EMPIRIC BROAD SPECTRUM
ANTIBIOTICS
 ACUTE BOWEL ISCHEMIA
 Occlusion of the SMA- acute midgut
ischemia (jejunum, ileum, right colon)-
infarction- fatal perforation.
 There are two types of acute SMA
occlusion:- embolism - AF or recent MI
- thrombosis- low output cardiac
failure on atherosclerotic vessels
 ACUTE BOWEL ISCHEMIA
DIAGNOSIS
 Lack of specific clinical features and
diagnostic tests
 The severity of abdominal symptoms and
signs often gives no clue to the catastrophy
within
 Diagnosis depends on history and clinical
examination
 Excruciating abdominal pain
 ACUTE BOWEL ISCHEMIA
DIAGNOSIS

 Diffuse tenderness
 Abdominal distension
 Absent bowel sounds
 Cardiovascular collaps
 Late stage- abdo X ray- gas within the bowel
wall
 ACUTE BOWEL ISCHEMIA
TREATMENT
 If intestinal ischemia is suspected,
laparotomy must be performed urgently
 Embolectomy to restore the mesenteric
arterial supply, before the bowel becomes
necrotic
 Resection of the necrotic bowel if not too
extensive
INFARCTUL ENTEROMEZENTERIC

CLINICA III CHIRURGICALA

1993-2003
 NUMAR DE PACIENTI 52
1993-2003

 Barbati 30
 Femei 22

 Urban 27
 Rural 25 U
R
B
A
N
R
 REPARTITIA PE ANI

10
9
8
7
6
5
4
3
2
1
0
93 94 95 96 97 98 99 0 1 2 3
 Media de virsta 66,8 ani
(28-89 ani)
16
14
12
10
8
6
4
2
0
20-30 31-40 41-50 51-60 61-70 71-80 >80
 Virsta medie-- barbati 62,3ani
-- femei 68,2ani

9
8
7
6
Barbati
5
4 Femei
3
2
1
0
20-30 31-40 41-50 51-60 61-70 71-80 >80
MORTALITATEA INTRASPITALICEASCA
30 PACIENTI -- BARBATI 17 (32,69% )
(57,69%) -- FEMEI 13 (25%)
9 PACIENTI EXTERNATI AGRAVATI --17,32%
 ANTECEDENTE PERSONALE

 FIBRILATIE ATRIALA CRONICA 42,8%

 CICD 23,2%
 SECHELE INFARCT DE MIOCARD 21,4%
 INSUFICIENTA CARDIACA 19,6%
 HIPERTENSIUNEA ARTERIALA 19,6%
 ARTERIOPATIE OBLITERANTA MEMBRE INF. 9%
 ALTE ARITMII 7,1%
 INSUFICIENTA RENALA 5,3%
 AFECTIUNI RESPIRATORII 5,3%
 DIABET ZAHARAT 3.5%
 Diagnostic clinic si paraclinic

CLINICE :
DURERI ABDOMINALE --Predominant
TULBURARI DE TRANZIT --Predominant
METEORISM ABDOMINAL 30%
HEMORAGIE DIGESTIVA INFERIOARA 25%
PARACLINICE :
LEUCOCITOZA 92%
ECOGRAFIC : -Distensie anse--Predominat
-Lichid liber intraperitonea 9,61%
RX ABDOMINAL -Nivele hidroaerice 48%
 Interventia chirurgicala

 Laparotomie exploratorie 15 cazuri

 Dezobstructie cu sonda Fogarty 3 cazuri
 Rezectie segmentara 34 cazuri
 CAUZE DE DECES

 Soc septic 14 (26,92%)

 Insuficienta cardiocirculatorie 12
(23,07%)
 MSOF 4 (7,69%)
 Infarct miocardic acut 3 (5,76%)
 Insuficienta renala acuta 1 (1,92%)
 CID 1 (1,92%)
 MAJOR GASTRO-INTESTINAL
HEMORRHAGE
 Presents as massive hematemesis or
melena
 Hematemesis indicates bleeding from
esophagus, stomach, duodenum
 Upper GI bleeding is often manifest by
melena
 MAJOR GASTRO-INTESTINAL
HEMORRHAGE
 Causes of major GI bleeding:
– Chronic gastric and duodenal ulcers
– Diverticular disease
– Esophageal varices
– Mallory-Weiss esophageal tears
– Bowel angiodisplasia
– Fulminant inflammatory bowel disease
– Malignant tumors
 MAJOR GI HEMORRHAGE
DIAGNOSIS

 History
 Clinical examination
 Lab. tests
 Endoscopy
 MAJOR GI HEMORRHAGE
MANAGEMENT
 Massive GI bleeding is a life-threatening condition
due to hypovolemic shock
 Fluid ressuscitation: plasma expanders or blood
monitoring BP, PR, CVP, UO/h
 History taking- PMH: peptic ulcer, gastric surgery,
diverticular disease, cirrhosis
 Abdominal exam.unremarkable
 Conservative management: antisecretory drugs,
hemostatics- usually efficient
 Endoscopic hemostasis
 Rebleeding- consider surgery for hemostasis