+

ACUTE ABDOMEN
- Department of Surgery -
PRECEPTOR : dr. Andanu Indratnoto, Sp.B-KBD
By : Soraya Olyfia (03010258)
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INTRODUCTION
 Abdominal pain is a common complaint in all settings of medical
practice.

 Abdominal pain may be symptom of severe, life threatening

disease or symptom of benign underlying condition.

 Many diseases with abdominal pain do not require surgical

treatment so the evaluation of patients with acute abdominal
pain must be methodical and careful.

 An acute abdomen must be suspected even if the patient has

only mild or atypical complaints.

 Proper management of patients with acute abdominal pain

requires a timely decision.
+
DEFENITION

“An acute abdomen” denotes any sudden, spontaneous, both traumatic

and non-traumatic disorder whose chief manifestation is in the
abdominal area and for which urgent operation may be necessary.

Because there is frequently a progressive underlying intra-abdominal

disorder, undue delay in diagnosis and treatment adversely affects
outcome.
+
History Taking
+Abdominal Pain
 Visceral
 Mediated primarily by afferent C fibers located in the walls of hollow
viscera and in the capsules of solid organ.
 Vague, deep-seated pain and poorly localized to the epigastrium,
periumbilical or hypogastrium region.
 Elicited by distention, inflammation or ischemia or by direct involvement of
sensory nerves
 Most often felt in midline because of the bilateral sensory supply to the
spinal cord.

 Parietal
 Mediated by both C and A delta nerve fibers
 Corresponds to the segmental nerve roots innervating the peritoneum
 The cutaneous distribution of parietal pain orresponds to the T6-L1 areas.
 The somatic afferent fibers are directed to only one side of the nervous
system.
 Acute, sharper, better-localized pain sensation.
+
 Referred
 Noxious (cutaneous) sensation perceived of the site distand from
that of a strong primary stimulus.
 Distorted central perception of the site of pain is due to the
confluence of afferent nerve fibers from widely disparate areas
within the posterior horn of the spinal cord.
 For example : pain due to subdiaphragmatic irritation by air,
peritoneal fluid, blood or mass lesion is referred to the shoulder
via the C4-mediated nerve. Pain may also be referred to the
shoulder from supradiafragmatic lesions such as pleurisy or lower
lobe pneumonia. Posterolateral right flank pain may be seen in
retrocecal appendicitis. Billiary pain may be perceived in the
right scapular reg
+Abdominal Pain
Visceral Mediated primarily
by afferent C fibers
located in the walls
of hollow viscera
and in the capsules
of solid organ. Sensory Levels Associated with Visceral Structures

Vague, deep-
seated pain and
poorly localized.

Solid organ visceral

pain in the
abdomen is
generalized in the
quadrant of the
involved organ.

Elicited by
distention,
inflammation or
ischemia or by
direct involvement
Visceral pain sites
of sensory nerves

Most often felt in

midline because of
the bilateral
sensory supply to
the spinal cord.
+Abdominal Pain
Parietal
Mediated by
both C and A
delta nerve
fibers

Corresponds to the
segmental nerve
roots innervating
the peritoneum

The cutaneous
distribution of
parietal pain
corresponds to the
T6-L1 areas.

The somatic
afferent fibers are
directed to only
one side of the
nervous system.

Acute, sharper,
better-localized
pain sensation
+Abdominal Pain
Referred

Noxious (cutaneous) sensation

perceived of the site distand
from that of a strong primary
stimulus.

Distorted central perception of

the site of pain is due to the
confluence of afferent nerve
fibers from widely disparate
areas within the posterior horn
of the spinal cord.

For example : pain due to

subdiaphragmatic irritation by
air, peritoneal fluid, blood or
mass lesion is referred to the
shoulder via the C4-mediated
nerve. Pain may also be
referred to the shoulder from
supradiafragmatic lesions such
as pleurisy or lower lobe
pneumonia. Posterolateral right
flank pain may be seen in
retrocecal appendicitis. Billiary
pain may be perceived in the
right scapular regio.
+
Spreading or shifting pain

Perforated peptic ulcer : Pain

almost always begins in the
Appendicitis : beginning in the epigastrium, but as the leaked
epigastric or periumbilical gastric contents tract down the
region that later shift to become right paracolic gutter, pain may
sharper in right lower quadrant descend to the right lower
quadrant with even diminution of
the epigastric pain.
+
Mode of Onset and Progression of Pain
 The mode of onset of pain reflects the nature and severity of the
inciting process.

 Onset may be :
Explosive (within seconds)

• Unheralded, excruciating generalized pain suggests an intra-

abdominal catastrophe such as perforated viscus, rupture of an
aneurysm, ectopic pregnancy or abcess.

Rapidly progressive (within 1-2 hours)

• Steady, mild pain becoming intensely centered in a well-defined

area. More typical in acute cholecystitis, pancreatitis, strangulated
bowel, mesentric infarction, renal or ureteral colic or high small
bowel obstruction.

Gradual (over several hours)

• Slight or vague abdominal discomfort that is fleetingly diffusely

throughout the abdomen. Eventually, the pain become more
pronounced, steady and localized. This condition includes acute
appendicitis, incarcerated hernias, low (distal) small bowel and
large bowel obstruction, uncomplicated PUD, etc.
+
Character of pain

 The nature, severity, and periodicity of pain provide useful

clues to the underlying cause
+

 Other symptoms associated with abdominal pain :

 Anorexia
 Nausea
 Vomitting
 Constipation
 Diarrhea
 etc

 Other specific symptom :

 Jaundice : Hepatobiliary disorders
 Hematochezia or hemtemesis : gastroduodenal lesion or Mallory-
Weiss syndrome
 Hematuria : Ureteral colic or cystitis
+

 Other relevant aspects of the history :

 Gynecologic history : menstrual history, vaginal discharge,
dysmenorrhea
 Drug and smoking history : analgetics,oral contracetive,
anticoagulants, corticosteroid, narcotics
 Family history
 Past History
 Travel history
 Operation history
PHYSICAL EXAMINATION

+
+
PHYSICAL EXAMINATION
• Patient with peritoneal irritation will typically
lie very still in the bed with the flexed knees
and hip to reduce the tension on the anterior
abdominal wall. • Check the quantity, quality, pitch and
• Disease without peritoneal irritation such as pattern.
ischemic bowel, biliary colic typically cause
patients to shift and fidget in bed continually to • Quiet abdomen suggests an ileus
find a position that lessens their discomfort. • Hyperactive bowel sounds are found in
• Distended abdomen with an old surgical scar enteritits and early ischemic intestine
suggests both the presence and the cause • High pitches tinkling sound that tend to come
(adhesions) of bowel obstruction. in rushes indicates mechanical bowel
• Scaphoid contracted abdomen is seen in obstruction
perforated ulcer. • Far away, echoing sound are often present when
• Visible peristaltis occurs in advanced bowel significant luminal distention exists.
obstruction • Bruits within abdomen reflects the turbulent
• Soft doughy fullness is seen in early paralytic blood flow in the vascular system (high grade
ileus or mesenteric thrombosis. arterial stenosis)
• Erythema or edema of skin may suggest
cellulitis of the abdominal wall, whereas
ecchymosis is observed in deeper necrotizing

Auscultation
infections of the fascia or abdominal
structures.

General
Inspection
 +
• Bowel obstruction or ileus : hyper-
tympany throughout the abdomen
except the right upper quadrant.
• Dullness indicate any abdominal
mass displacing the bowel
• When liver dullness is lost and
resonance is uniform throughout
the abdomen , free intra-
abdominal air shoul be suspected.
• Ascites is detected by looking for
fluctuance of the abdominal cavity.
Percussion
• Digital rectal
• Revealing the severity and exact
location of abdominal pain,
identify any organo-megaly and
sign of peritonitis.
• Pain on palpation when focal
examination,
suggests an early or well-
localized disease process,
whereas diffuse pain is present
Pelvic
with extensive inflammation or a
late presentation.
examination
• In voluntary guarding, abdominal
muscles will relax during the act
of inspiration; if involuntary, they
remain spastic and tense.
Palpation Others
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+
INVESTIGATIVE STUDIES

 Additional studies are worthwhile only if they are likely to

significantly alter or improve therapeutic decisions.

 A more liberal use of diagnostic studies is justified in elderly

or seriously ill patients, in whom the history and physical
findings may be less reliable and an early diagnosis vital to
ensure a successful outcome.
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 Laboratory Studies
+

 Imaging Studies
 Plain Chest X-Ray Studies :
 Preoperative assessment and may also demonstrate supra-diaphragmatic
conditions that simulate an acute abdomen (lower lobe pneumonia or
ruptured esophagus)
 An elevated hemidiaphragm or pleural effusion may direct attention to
subphrenic inflamamatory lesions.
 Plain Abdominal X-Ray Studies : bowel obstruction, peritoneal free air,
pneumoperitoneum in lateral decubitus positions, calcification 
apendicoliths, gallstones, renal stones , pancreatitis calcification, abdominal
aortic calcification, etc.
 Ultrasonography – detecting gallstones, diameter of extrahepatic and
intrahepatic bile ducts, abnormalities in adnexa, uterus and ovaries,
intraperitoneal fluid.
 CT-scan
 Endoscopy
 Paracentesis
 Diagnostic Laparoscopy
+
Differential Diagnosis
 Based on etiology acute abdomen is classified into :

Acute
Abdomen

Traumatic Atraumatic

Penetrating Blunt
Peritonitis Obstruction
Injury Trauma

Major
Gunshot Solid Organ Hollow Non-Hollow Intra-
Stab Wound Vessel Intra-Mural
Injury Injury Perforation Perforation Luminal
Injury

Mesentrial
Extramural
Injury

Strangulation
/ Vascular
Problem
+
Peritonitis
Pneumoperitoneum
Peritonitis is defined as inflammation of the serosal
membrane that lines the abdominal cavity and the organs
contained therein.

Depending on the underlying pathology, the resultant

peritonitis may be infectious or sterile (ie, chemical or
mechanical).

The inflammatory process may be localized (abscess) or

diffuse in nature.

Xray  thickened abdominal wall with or without free air.

Goal : target correction of the underlying process,

administration of systemic antibiotics and supportive
therapy to prevent secondary complication due to organ
system failure.
+
PATHOPHYSIOLOGY

Bowel develops
Increased blood
local or generalize
Introduction of An outpouring of flow, increased
paralysis. Fibrinous
bacteria or irritating fluid from the permeability and
surface and
chemicals into peritoneal formation of a
decreased intestinal
peritoneal cavity membrane fibrinous exudate
movement cause
on its surface
adherance
+

 Peritoneal infections are classified as :

 Primary (ie, from hematogenous dissemination, usually in the
setting of immunocompromise, most often spontaneous bacterial
peritonitis caused by chronic liver disease.
 Secondary (ie, related to a pathologic process in a visceral organ,
such as perforation or trauma, including iatrogenic trauma) – the
most common form
 Tertiary (ie, persistent or recurrent infection after adequate
initial therapy). Often develops in the absence of the original
visceral organ pathology.
+

 Based on etiology, peritonitis is classified into :

 Hollow viscus perforation
 Acute diverticulitis, perforated peptic ulcer/gaster perforation,
perforated appendicitis, IBD perforation, Meckel divertivulum,
etc
 Non-hollow viscus perforation
 Acute pancreatitis , ruptured spleen, TB peritonitis, Hepatic
abcess, ruptured aorta abdominalis, ruptured ovarium cyst, etc
+
Hollow Viscus Perforation 
free air under diaphragm
+ ACUTE DIVERTICULITIS
 80% of affected patients are older than 50 yo.

 Presents as a spectrum of disease from mild abdominal

discomfort to gross fecal peritonitis.

 Present with constant, dull, left lower quadrant pain and fever,
may complaint of constipation or obstipation.

 PF : left lower quadrant tenderness, a left lower quadrant mass,

localized peritoneal sign may be present. In severe cases,
generalized peritonitis may be present.

 CT is reliable in confirming the diagnosis (sensitivity of 97%),

can be used to determined the severity of diverticulitis by using
Hinchey grading system.
+
Hinchey Grading system

Localized pericolic absess or inflammation

• Frequently require hospitalization for intravenous antibiotics.

Pelvic, intra-abdominal or retroperitoneal abcess

• Should undergo CT-guided drainage of the abscess and receive a course of broad-
spectrum intravenous antibiotics

Generalized purulent peritonitis

• Required emergency surgery.

Generalized fecal peritonitis

• Required emergency surgery.
+
Perforated Peptic Ulcer

 Presents with : sudden onset of severe, diffuse, excruciating

abdominal pain.

 PF : reveals peritonitis, with rebound tenderness, guarding or

abdominal rigidity.

 Radiology :
 Xray : Pneumoperitoneum
 CT : edema in the regio of the gastric antrum and duodenum
associated with extraluminal air.

 Laparotomy is acceptable as the primary diagnostic

maneuver in such patients especially in patients with diffuse
peritonitis and hemodynamic collapse
+
Perforated appendicitis
 Appendicitis is an acute inflammatory process of the
appendix resulting from obstruction of the lumen with
subsequent bacterial invasion, distension, ischemia and
ultimate rupture.

Obstruction (due Peritonitis (At

to lymphoid Secretion of Bacterial invasion Perforation and times, the
Continued
hyperplasia, mucus within the of the spillage of infection is
Ischemic injury inflammation and
intraluminal appendix raises appendiceal inflammatory contained by the
to the mucosa bacterial
object), viral or intraluminal mucosa and cells and bacteri omentum and
proliferation
bacterial pressures submucosa into peritonium periappendicular
infection abcess forms)
+

 Present with : migrating pain, anorexia, nausea and vomiting.

 PF : Low grade fever, RLQ tenderness, positive Rovsing sign,

Blumberg etc with guarding and rebound as the process
progresses (perforation)

 Laboratory : leukocytosis with neutrophilia

 Most significant complication of acute appendicitis is

perforation which leads into peritonitis and sepsis

 The mortality rate of perforated appendicitis is 1.66%, 7

times greater than that of patients ongoing appendectomy
for simple acute appendicitis (0.24%) and 12 times greater
than that of appendectomy for a normal appendix (0.14%).
+  There are few reliable clinical features that distinguish non-perforated from perforated
appendicitis.

 Sign of perforated appendicitis :

The duration of symptom tends to

be longer in patients with
perforation (>48hours) Some perforation case has
lucid interval which refers to
Lower or generalized abdominal a period after perforation in
tenderness which pain is temporary
lessened.
Local or generalized rigidity over
the RLQ

The presence of a palpable RLQ

mass

Generalized rectal tenderness Suspected perforation Triple Antibiotics (ampicillin 2g,

gentamicin 2mg/kg, metronidazole
500mg) or 2nd generation
cephalosporin or quinolone
(ciproflaxaxin 500 mg ofr
levofloxacin 500 mg) with
metronidazole
+
Perforated Ileum et Causa Typhoid
Fever
 Typhoid fever, a severe febrile illness caused by a gram
negative bacillus Salmonella typhi.

 Complication : Intestinal perforation (on ilealcecal junction) 

high mortality and morbidity

 The most serious complications of typhoid fever are

gastrointestinal hemorrhage (2%–10%) and perforation (1%–
3%). They occur toward the end of the second week or during
the third week of the disease.

 Intestinal perforation is one of the principal causes of death.

 The clinical manifestations are indistinguishable from those of

acute appendicitis, with pain, tenderness, and rigidity in the
right lower quadrant.
+
Perforation of Inflammatory Bowel
Disease
 Inflammatory bowel disease (IBD) is an immune-mediated chronic intestinal
condition. Ulcerative colitis (UC) and Crohn's disease (CD) are the two major
types of IBD.

 The peak age of onset of UC and CD is between 15 and 30 years. A second

peak occurs between the ages of 60 and 80.

 Pathophysiology :

Exogenous and Atrophic ,

Severe
Endogenous Dysregulated Inflammation narrowed,
inflammation
host factors mucosal (erythematous shortened, thin
(hemorrhagic, Perforation
modified by immune and sandpaper bowel wall and
edematous and
environmental function surface) severe mucosa
ulcerated)
factors ulceration

 UC  involves rectum and extends proximally to involve all or part of colon

 CD  affect any part of GI tract from mouth to anus

+
Ulcerative Colitis

 Major symptoms : Diarrhea, rectal bleeding, tenesmus, passage of mucus, crampy abdominal pain. Colonic motility is
altered as the disease progressing. Severe condition  liquid stool containing blood, pus and fecal matter accompanied
by systemic symptom.

 Abdominal pain is not a prominent symptom, some just experience vague lower abdominal discomfort or mild central
abdominal cramping.

 Perforation  peritoneal signLaparotomy

 Diagnostic :
 Lab : rise CRP, platelet count, ESR and decrease in Hb, leukocytosis.
 Radiography : thickened mucosa, ulcer, collar button ulcer (deeper ulcer), edematous and thickeded haustral fold,
shorten and narrowed colon]
 CT scan : is not too helpful. Mural thickening, increase perirectal, presacral fat, adenopathy.
 Endoscopy :
 Mild : erythema, decrease vascular pattern, mild friability.
 Moderate : marked erythema, absent vascular pattern, friability and erosions.
 Severe disease : spontaneous bleeding and ulceration.

 Unlike with Crohn disease, surgery offers a therapeutic option in ulcerative colitis.
+
Crohn Disease

 Site of disease influence the clinical manifestation

 Ileocolitis : RLQ colicky pain, precedes and relived by defecation , diarrhea, fever, weight loss, palpated
inflammatory mass.
 Jejunoileitis : diarrhea, malabsorption and steatorrhea which lead to anemia, hypoalbuminemia, hypocalcemia,
hpomagnesemia, coagulopathy and hyperoxaluria.
 Colitis and Perianal disease : low grade fevers, malaise, diarrhea, crampy abdominal pain, hematochezia. Colonic
disease may fistulize into stomach or duodenum, causing feculent vomiting, malabsorption.
 Gastroduodenal disease : nausea, vomiting, epigastric pain may lead into chronic gastric

 Perforation  Peritoneal sign outlet obstruction  laparotomy

 Diagnostic :
 Lab : Elevated ESR, CRP,, if severe hypoalbuminemia, anemia and leukocytosis
 Endoscopic : rectal sparing, apthous ulceration, fistula and skip lesions
 Radiographic : thickened folds, apthous ulceration, cobblestoning, strictures, fistula, inflammatory
masses and abcesses may be detected.
 CT
 MRI

 Surgery in Crohn disease is frequently required to address complications of stricturing, penetrating, or

fistulizing disease. Because recurrence at anastomotic sites is common, surgery is not recommended
as a primary treatment strategy.
+
Meckel Diverticulum
 Meckel diverticulum is a congenital anomaly of the GI tract in which an outpouching portion of the intestine (> terminal
ileum), derived from the fetal yolk stalk, contains gastric or pancreatic tissue which can secrete enzyme that can erode
mucosal wall.

 Congenital anomaly of GI tract - failure or incomplete vitelline duct obliteration

 Bleeding associated with Meckel’s diverticulum is usually the result of ileal mucosal ulceration that occurs adjacent to
acid-producing, heterotopic gastric mucosa located within the diverticulum. Intestinal obstruction associated with
Meckel’s diverticulum can result from several mechanisms:
 1. Volvulus of the intestine around the fibrous band attaching the diverticulum to the umbilicus
 2. Entrapment of intestine by a mesodiverticular band
 3. Intussusception with the diverticulum acting as a lead point
 4. Stricture secondary to chronic diverticulitis

 Clinical presenting : asymptomatic abdominal pain, nausea, vomit, intestinal bleeding (<18yo), intestinal obstruction
(>30yo).

 Complication : diverticulitis, intussusception, perforation and obstruction.

 Diagnostic :
 Usually discovered incidentally, radiography, during endoscopy or during surgery.
 Radionuclide scans (99mTc-pertechnetate) can be helpful if the diverticulum consist .ectopic gastric mucosa that capable of uptake of the tracer.
(accuracy 90%), angiography to localize the site of bleeding.

 The surgical treatment of symptomatic Meckel’s diverticula should consist of diverticulectomy with removal of associated
bands connecting the diverticulum to the abdominal wall or intestinal mesentery.
+
NON-HOLLOW VISCUS
PERFORATION
+
Acute Pancreatitis
 Present with : acute pain in the episgastrium that is constant,
frequently described as boring pain through the back or left
scapular, fever, anorexia, nausea and vomiting.

 Patients usually more comfortable sitting upright, leaning

forward slightly .

 PF : tachycardia, tachypnea, hypoactive bowel sounds,

tenderness to percussion and palpation in the epigastrium,
abdominal rigidity. Rarely, patients + flank or periumbilical
ecchymoses  pancreatic necrosis with hemorrhage.

 Lab : Leukocytosis (12.000 to 20000/mm3), elevated serum and

urine amylase levels, abnormal serum electrolyte, calcium,
blood glucose levels, liver biochemical test and ABG.

 USG may identify gallstones as a cause of pancreatitis. CT is

reserved for severe or complicated pancreatitis.
+

 Although most cases of acute pancreatitis are self-limited, as

many as 20% of patients have severe disease with local or
systemic complications, including hypovolemia, and shock, renal
failure, liver failure and hypocalcemia.

 A minority of patients with severe acute pancreatitis present with

a profound intra-abdominal catastrophe, usually caused by
thrombosis of the middle colic artery or right colic artery, which
travels in proximity to the head of pancreas, with resulting
colonic infarction.

 This process may not be seen clearly on CT scans obtained

early in the course of disease and should be suspected in any
case marked by rapid hempdynamic collapse. Such patients
require immediate laparatomy.
+
+
Abdominal Aortic Aneurysm
 Rupture of an abdominal aortic aneurysm is heralded by the
sudden onset of acute, severe abdominal pain localized to
the mid-abdomen or paravertebral or flank areas. The pain is
tearing in nature and associated with prostration,
lightheadedness and diaphoresis.

 If the patient survives transit to the hospital, shock is the most

common presentation.

 Physical examination reveals a pulsatile, tender abdominal

mass in about 90% of cases. The classic triad of hypotension,
a pulsatile mass and abdominal pain is present in 75% of
cases and mandates immediate surgical intervention.
+Obstruction

An interruption in the forward flow of intestinal contents.

Etiology :
Intramural : chron’s disease, tumor,
carcinoma, limfoma, stricture, ileus, intussuception
Extramural : volvulus, adhesion, hernia,
tumor compression
Intraluminal : fecal impaction, ascarys ball,
gallstone ileus

The clinical presentation : nausea and emesis, colicky

abdominal pain, and a failure to pass flatus or bowel
movements.
The classic physical examination findings of abdominal
distension, tympany to percussion, and high-pitched bowel
sounds suggest the diagnosis

Management of uncomplicated obstructions includes fluid

resuscitation with correction of metabolic derangements,
intestinal decompression, and bowel rest.
Evidence of vascular compromise or perforation, or failure
to resolve with adequate bowel decompression is an
indication for surgical intervention.
+
Small Bowel Obstruction

 SBOs can be partial or complete, simple (ie,

nonstrangulated) or strangulated.

 Strangulated obstructions are surgical emergencies.

 SBO accounts for 20% of all acute surgical admissions.

 Etiology : post-surgical adhesion, incarcerated groin hernia,

malignant tumor, inflammatory bowel disease, volvulus, etc.

 Pain on central and mid abdominal that tends to be colicky

(cramping and intermittent), spasm lasting for a few minutes,
vomitting occurs before constipation.
+

 Some signs and symptoms associated with SBO include the following:
 Nausea
 Vomiting - Associated more with proximal obstructions
 Diarrhea - An early finding
 Constipation - A late finding, as evidenced by the absence of flatus or bowel movements
 Fever and tachycardia - Occur late and may be associated with strangulation
 Previous abdominal or pelvic surgery, previous radiation therapy, or both - May be part of the patient's medical history
 History of malignancy - Particularly ovarian and colonic malignancy

 Physical examination :
 Abdominal distention (>>distal bowel)
 Hyperactive bowel sound (early finding)
 Hypoactive bowel sound (late finding)
 Rectal Examination : Gross or occult blood Strangulation or malignancy, masses obturator
hernia
 Intestinal ischemia : fever (>1000F), tachycardia (>100bpm), peritoneal signs

 Radiology finding : Dilated small bowel, fighting loops, little gas in colon, esp
rectum
+
Large Bowel Obstruction
 The most common causes of adult LBO are as follows :
 Neoplasm
 Obstructions caused by tumors tend to have a gradual onset and result
from tumor growth narrowing the colonic lumen.
 Diverticulitis
 Diverticulitis is associated with muscular hypertrophy of the colonic wall.
Repetitive episodes of inflammation cause the colonic wall to become
fibrotic and thickened, leading to luminal narrowing.
 Volvulus
 A colonic volvulus results when the colon twists on its mesentery, which
impairs the venous drainage and arterial inflow. Symptoms of this
condition are usually abrupt. The cecum and sigmoid colon are most
commonly affected. Volvulus typically occurs in elderly, debilitated
individuals; patients living in an institutionalized setting; or patients with
a history of chronic constipation.Volvulus may also be seen during
pregnancy, most commonly occurring in the third trimester when the
gravid uterus displaces the colon.
+

 Intussusception
 Intussusception is primarily a pediatric disease; however, it is estimated that between 5% and 16% of
all intussusceptions in the Western world occur in adults. Two thirds of adult intussusception cases are
caused by tumors. Two main types of intussusception affect the large bowel: enterocolic and colocolic.
 Enterocolic intussusceptions involve both the small bowel and the large bowel. These are composed of
either ileocolic intussusceptions or ileocecal intussusceptions, depending on where the lead point is
located. Colocolic intussusceptions involve only the colon. They are classified as either colocolic or
sigmoidorectal intussusceptions

 In large bowel obstruction the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier
and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction.

 Radiologic finding : Dilated colon to point of obstruction, little or no air in sigmoid/rectum, little or no gas in small bowel if
ileocecal valve remains competent.
+
Vascular Problem
Volvulus
Ischemic mesenteric artery
Strangulated incarcerated hernia
+
Strangulated Hernia

 Hernia is the protrusion of a structure or organ through the

tissues that normally contain it.

 A strangulated hernia  the blood supply to the herniated

structure is compromised  Gangrene may occur if the
vascular compromised is not relieved.

 A strangulated hernia is a life-threatening situation requiring

emergency treatment and surgical intervention.

“All strangulated hernias are irreducible or incarcerated, but not

all irreducible or incarcerated hernias are strangulated”
+

 Hernia with a small neck or opening and a large sac have a

tendency to strangulate.

 Femoral hernia which has a narrow neck or opening are

frequently incarcerate. Umbilical hernias in adults often
incarcerate with strangulation occurring in 20% to 30% of
adult umbilical hernias. Ulceration and perforation can also
occur in adults with umbilical hernias.

 If strangulation is present , the patient may present with pain,

distention, peritonitis, vomiting, fever and sepsis.
+

 Physical examination may reveal for any bulges or masses.

 In such cases, leukocytosis with a left shift is often present,

although it may not occur in geriatric patients. Dehydration with
electrolyte abnormalities and an elevated blood urea nitrogen
also occurs frequently in incarceration or strangulation.

 The patients with strangulated hernia requires :

 Aggressive resuscitation with fluids and blood
 Emergent surgical consultation for operative intervention
 Gastric decompression with a nasogastric tube is appropriate if
bowel obstruction is present.
 Broad-spectrum antibiotics are also adviced in the acutely ill or
potentially septic patients.
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Acute Mesenteric Ischemia

 Acute mesenteric ischemia can result from occlusion of a

mesenteric vessel arising from an embolus, which may
emanate from an atheroma of the aorta or cardiac mural
thrombus or from primary thrombosis of a mesenteric vessel,
usually at a site of atherosclrerotic stenosis.

 >>superior mesenteric artery

 Nonocclusive mesenteric ischemia results from inadequate

visceral perfusion and can also lead to intestinal ischemia
and infarction. Such cases are usually consequent to
catastrophic systemic illnesses such as cardiogenic or septic
shock.
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 The hallmark of the diagnosis of acute mesenteric ischemia :

 Abrupt onset
 Intense cramping epigastric
 Periumbilical pain
 Other symptoms : diarrhea, vomiting, bloating, melena

 Shock is present about 25% of cases.

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 Diagnostic :
 CT best initial diagnostic test
 Mesenteric angiography useful for determining the cause of
intestinal ischemia and defining the extent of vascular disease

 Management :
 Patients with acute embolic or thrombotic intestinal ischemia should
be referred for immediate revascularization and bowel resection.
 Patients with nonocclusive mesenteric ischemia are best managed by
treatment of the underlying shock state.
 Transcatheter vasodilator therapy may be helpful for patients who are
found to have vasospasm on visceral arteriography.
 For those with persistent symptoms, laparotomy for resection of
infracted intestine may necessary
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Preparation for Emergency Operation

 IV access

 Antibiotic infusion (common bacteria in acute abdominal

emergencies are gram-negative enteric organism and
anaerobes).

 Nasogastric tube (for hematemesis or copious vomiting patients,

suspected bowel obstruction or severe paralytic ileus to prevent
aspiration)

 Foley catheter bladder drainage

Parenteral analgesics should not be withheld after initial assessment-

abdominal masses may become obvious once rectus spasm is
relieved. Pain that persists in spite of adequate doses of narcotics
suggests a serious condition often requiring operative correction.
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Indications for urgent operation in
Patients with an acute abdomen
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