acute abdomen and peptic ulcer

8/9/2019 Acute Abdomen and Peptic Ulcer

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Acute AbdomenAcute Abdomen

Presented byPresented by Dr.Dr. DeepankarDeepankar SrigyanSrigyan

Under guidance ofUnder guidance of Prof. AlekseevProf. Alekseev GennadiiGennadii IvanovichIvanovich

MOSCOW 2010MOSCOW 2010


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Visceral

Somatic

Referred


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Visceral pain

Stretching of peritoneum or organ capsules bydistension or edema

Diffuse

Poorly localized

May be perceived at remote locations relatedto organs sensory innervation


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Somatic pain

Inflammation of parietal peritoneum ordiaphragm

Sharp

Well-localized


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Referred pain

Perceived at distance from diseased organPneumonia

Acute myocardial infarction

Male genitourinary problems


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yy Gastrointestinal Causes:Gastrointestinal Causes:y Peritonitis

y Pancreatitis

y Early Appendicitis

y Mesenteric Adenitis

y Gastroenteritisy Colitis

y Intestinal Obstruction

yy Hematologic Causes:Hematologic Causes:

y Leukemia

y Sickle Cell Crisisyy Vascular Causes:Vascular Causes:

y Mesenteric Thrombosis

y Abdominal Aortic Aneurysm

y Splenic artery aneurysm

y Mesenteric Artery aneurysm


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Gastrointestinal Causes:Cholecystitis or Cholelithiasis

PericarditisGastritis or Peptic Ulcer Disease

Pancreatitis

Vascular Causes:Myocardial Infarction

Aortic Dissection

Mesenteric Ischemia


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yy Gastrointestinal Causes:Gastrointestinal Causes:

y Gastritis

y Pancreatitis

yy Miscellaneous Causes:Miscellaneous Causes:

y Splenic enlargement, splenic rupture, splenicinfarction, aneurysm

y Renal pain

yy Cardiopulmonary Causes:Cardiopulmonary Causes:y Myocardial Ischemia

y Pneumonia

y Empyema


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yy Acute Pelvic Pain CausesAcute Pelvic Pain Causes

yy Gastrointestinal Causes:Gastrointestinal Causes:y Gall Bladder or Billiary Tract Disease

y Hepatitis

y Hepatic Abscess

y Hepatomegaly due to Congestive Heart Failure

y Peptic Ulcer

y Pancreatitis

y

Retrocecal Appendicitisyy Miscellaneous Causes:Miscellaneous Causes:

y Renal pain

y Pneumonia

y Empyema


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yy Gastrointestinal Causes:Gastrointestinal Causes:y Intestinal Obstruction

y Constipation

y Diverticulitis

yy

Vascular Causes:Vascular Causes:y Leaking aortic aneurysm

yy Genitourinary Causes:Genitourinary Causes:y Acute Pelvic Pain Causes

y Ovarian Cyst or torsion

y Ureteral Calculus (Nephrolithiasis)

y Renal pain

y Seminal vesiculitis

yy Miscellaneous Causes:Miscellaneous Causes:y Psoas abscess

y Abdominal wall hematoma


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Gastrointestinal Causes:Gastrointestinal Causes:

Appendicitis (pain overMcBurney's Point)

Intestinal Obstruction

Regional Enteritis

Diverticulitis

Genitourinary Causes:Genitourinary Causes:

Acute Pelvic Pain Causes

Ovarian Cyst or torsion

Ureteral Calculus (Nephrolithiasis)

Renal pain Seminal vesiculitis

Miscellaneous Causes:Miscellaneous Causes:

Leaking Abdominal Aortic Aneurysm

Abdominal wall hematoma


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Inflammation of distal esophagus

Usually from gastric reflux, hiatal hernia

Signs and SymptomsSigns and Symptoms

Substernal burning pain, usually epigastric

Worsened by supine position

Usually without bleeding

Often temporarily relieved by nitroglycerin


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Inflammation ofstomach, intestine May lead to bleeding, ulcers

CausesCauses

acid secretion

Chronic alcohol abuse

Biliary refluxMedications (Aspirin, NSAIDs)

Infection


Epigastric pain, usually burning

Tenderness

Nausea, vomiting

Diarrhea

Possible bleeding


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Long-term mucosal changes or permanent

damage

Due primarily to microbial infections(bacterial, viral, protozoal)

Fecal-oral transmission

More common in underdeveloped countries

Nausea, vomiting, fever, diarrhea,

abdominal pain, cramping, anorexia,

lethargy


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Inflammation of pancreasin which enzymes autoInflammation of pancreasin which enzymes auto--digest gland.digest gland.

Causesinclude:Causesinclude:

Alcohol (80% of cases)

Gallstones obstructing ducts Elevated serum triglycerides

Trauma

Viral, bacterial infections


Mid-epigastric pain radiating to back Often worsened by food, alcohol

Bluish flank discoloration (Grey-Turner Sign)

Bluish periumbilical discoloration (Cullens Sign)

Nausea, vomiting

Fever


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Gall bladderinflammation, usually secondary to

gallstones (90% of cases).

Risk factors

Five Fs: Fat, Fertile, Febrile, Fortyish, Females

Heredity, diet, contraceptive pills use

Signs and Symptoms Sudden pain, often severe, cramping

Right upper quadrant, radiating to right shoulder Point tenderness under right costal margin (Murphyssign)

Nausea, vomiting

Often associated with fatty food intake

History ofsimilar episodesin past


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Inflammation of vermiform appendix.

Usually secondary to obstruction by fecalith.

May occurin older personssecondary to

atherosclerosis of appendiceal artery and

ischemic necrosis.


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Signs and Symptoms

Classic: Periumbilical pain RLQ pain/cramping

Nausea, vomiting, anorexia

Low-grade fever

Pain intensifies, localizes resulting in guarding

Patient on right side with right knee, hip flexed


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Signs and Symptoms

McBurneys Sign: Pain on palpation ofRLQ

Aarons Sign: Epigastric pain on palpation ofRLQ

Rovsings Sign: Pain in LLQ on palpation ofRLQ

Psoas Sign: Pain when patient:

Extends right leg while lying on left side

Flexes legs while supine


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Signs and Symptoms

Unusual appendix position may lead to atypicalpresentations

Back pain

LLQ pain

Cystitis

Rupture: Temporary pain relief followed by peritonitis


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Blockage of intestine

Common Causes

Adhesions (usually secondary to surgery)

Hernias

Neoplasms

Volvulus

Intussuception

Impaction


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Pathophysiology

Fluid, gas, air collect near obstruction site

Bowel distends, impeding blood flow/ haltingabsorption

Water, electrolytes collect in bowel lumenleading to hypovolemia

Bacteria form gas above obstruction further

worsening distensionDistension extends proximally

Necrosis, perforation may occur


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Signs and Symptoms Severe, intermittent, crampy pain

High-pitched, tinkling bowel soundsAbdominal distension

History of decreased frequency of bowelmovements, semi-liquid stool, pencil-thinstools

Nausea, vomiting

? Feces in vomitus


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Protrusion of abdominal contents into groin(inguinal) or through diaphragm (hiatal)

Often secondary to intra-abdominal pressure(cough, lift, strain)

May progress to ischemic bowel (strangulatedhernia)


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Signs and Symptoms

Pain by abdominal pressure

Past historyInguinal hernia may be palpable as

mass in groin or scrotum


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Idiopathic inflammatory bowel disease

Occurs anywhere from mouth to rectum

35-45%: small intestine; 40%: colon

Hereditary

High risk groups

White females Jews

Persons under frequent stress


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Pathophysiology

Mucosa ofGI tract becomes inflamed

Granulomas form, invade submucosa

Muscular layer of bowel become fibrotic,hypertrophied

Increased risk develops for

Obstruction

Perforation

Hemorrhage


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Idiopathic inflammatory bowel disease Chronic ulcers develop in mucosal layer of colon Spread to submucosal layer uncommon 75% of cases involve rectum (proctitis) or

rectosigmoid portion of large intestine Inflammation can spread through entire large

intestine (pancolitis)


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Severity of signs, symptoms depends on extent

Classic presentation

Crampy abdominal painNausea, vomiting

Blood diarrhea or stool containing mucus

Ischemic damage with perforation may occur


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Diverticulitis

Diverticula

Pouches in colon wall

Typically in olderpersons

Usually asymptomatic

Related to diets with

inadequate fiber


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Diverticula trap feces, become inflamed

Occasionally result in bright red rectalbleeding

Rupture may cause peritonitis, sepsis

Signs and Symptoms

Usually left-sided pain

May localize to LLQ (left-sidedappendicitis)

Alternating constipation, diarrhea

Bright red blood in stool


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Small masses of veins in anus, rectum

Most frequently develop when patients are in

age of 30s or 40s; common past 50Most are idiopathic, can be associated with

pregnancy, portal hypertension

Cause bright red bleeding, pain on defecation

May become infected, inflamed


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Inflammation of abdominal cavity lining

Signs and Symptoms

Generalized pain, tenderness

Abdominal rigidity

Nausea, vomiting

Absent bowel soundsPatient resistant to movement

Positive Blumberg's sign


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Peptic ulcer is a mucosal erosion (0.5 cm) of an

area of the gastrointestinal tract that is usually

acidic and thus extremely painful.

Gastric ulcer

Duodenal ulcer

Esophageal ulcer

Meckel's Diverticulum ulcer


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Helicobacter Pylori

Nonsteroidal Anti-inflammatory Drug (NSAID)

Tobacco Smoking

Stress

Caffeine

Alcohol


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Duodenal Ulcers

20 to 50 years old

High stressoccupations

Genetic predisposition

Pain when stomach isempty

Pain at night

Gastric Ulcers

> 50 years old

Work at jobsrequiring physical

activity

Pain after eating or

when stomach is full

Usually no pain at

night

Men are affected 3-4x more than women.


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Damage to mucosawith alcohol abuse,

smoking, use ofaspirin and NSAIDs

Acid and pepsinogenrelease with chronic

vagal response toincreased stress

Infection withHelicobacter Pylori

Damaged mucosal barrier

Imbalance of aggressive and

defensive factor

Low of mucosal cells; Lowquality of mucous; Lesstight

juntion between cells


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A damage mucosa could notsecrete enough mucus to act as

a barrier against gastric acid

Mucosal ulcerations, possiblebleeding and scarring

Erosive gastritis inflammation>> decreased acid and intrinsic

factor

Severe Ulcerations:

Signs and Symptoms: Epigastric pain Hematemesis Dsypepsia Pyrosis

Infection gives increasedgastrin and decreased

somatostation production


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Symptoms ofgastric ulcer disease:

epigastric pain after meal or during meal

upper dyspeptic syndrome loss of

appetite, nausea, vomiting, flatulencevomiting brings relief

reduced nutrition

loss of weight


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Symptoms of duodenal ulcer

disease:

epigastric pain 2 hours after meal or on aempty stomach or during night

pyrosis

good nutrition

obstipation

seasonal dependence (spring, autumn)


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NONPHARMACOLOGIC TREATMENT

Life style modifications

Patients with PUD should eliminate or reduce psychological stress,

cigarette smoking, and the use of Nonselective NSAIDs (including

aspirin). If possible, alternative agentssuch asacetaminophen, a

nonacetylated salicylate (e.g., salsalate), or aCOX-2selective

inhibitor should be used forpain relief.

Although there is no need for a special diet, patientsshould avoid

foods and beverages that cause dyspepsia or exacerbate ulcer

symptoms (e.g. spicy foods, caffeine, and alcohol).

PHARMACOLOGIC TREATMENT

acid-antisecretoryagents,

mucosal protective agents,

agents that promote healing through eradication of H pylori.


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Medicines forMedicines for peptic ulcer diseasepeptic ulcer disease

Drug type/mechanism Examples Dose

Acid-suppressing drugs

Antacids Maalox, Tums,

Gaviscon

100-140 mg 1

and 3 h aftermeals

H2 receptor antagonists Cimetidine,

Ranitidine,

Famotidine

800 mg/d

300 mg/d

40 mg/d

Proton pump inhibitors Omeprazole,

Lansoprazole,

Rabeprasole

20 mg/d

30 mg/d

20 mg/d


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Drug type/mechanism Examples Dose

Mucosal protective agents

Sucralfate Sucralfate 1 g qid

Prostaglandine analoque Misoprostol 200 mg qid

Bismuth-containing

compounds

Bismuth

subsalicylate

(BSS)


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Omeprasol 20 mg twice daily or Ranitidine 400 mg

twice daily.

Bismuth subcitrate (De-Nol) two tablets four times

daily.

Tetracyclin 500 mg four times daily.

Metronidazol 250 mg four times daily.

The most common triple therapy : Omeprasol (lanzoprazol) 20 m g bid

Clarithromycin 500 mg bid

Amoxicillin 1 g bid for 14 days.


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Gastrointestinal HemorrhageGastrointestinal Hemorrhage

IntraIntra--abdominal Hemorrhageabdominal Hemorrhage


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Dilated veinsin esophageal wall

Occursecondary to hepatic cirrhosis, common in

alcohol abusers

Obstruction of hepatic portal blood flow resultsin

dilation, thinning of esophageal veins

Portal hypertension

Hepatic scarring slows blood flow

Blood backs up in portal circulation

Pressure rises

Vesselsin portal circulation become distended


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Signs and Symptoms

Hematemesis (usually bright red)

Nausea, vomitingEvidence of hypovolemia

Melena (uncommon)


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Mallory-Weiss Syndrome

Longitudinal tears at

gastroesophageal junction

Occur as result ofprolonged, forceful

vomiting, retching

Common in alcoholics

May be complicated by

presence of esophageal

varices


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Localized dilation due to weakening of aortic wall

Usually older patient with history of hypertension,atherosclerosis

May occur in younger patients secondary to

Trauma

Marfans syndrome

Signs and SymptomsUnilateral lower quadrant pain; low back or leg pain

May be described as tearing or ripping

Pulsatile palpable mass usually above umbilicus

Diminished pulsesin lower extremities

Unexplained syncope

Evidence of hypovolemic shock


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Ectopic Pregnancy

Any pregnancy that takes

place outside of uterine

cavity Most common location is

in Fallopian tube

Pregnancy outgrows

tube, tube wall ruptures

Hemorrhage into pelvic

cavity occurs


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Suspect in females of child-bearing age with:

Abdominal pain, or

Unexplained shock

When was last normal menstrual period?

Ectopic pregnancy does

NOT necessarily causemissed period


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Where do you have pain?

Try to point with one finger

What does pain feel like? Steady pain = Inflammatory process

Cramping pain = Obstructive process

Onset of pain?

Sudden = Perforation or vascular occlusionGradual = Peritoneal irritation, distension of

hollow organ


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Does pain travel anywhere?

Gallbladder = Angle of right scapula

Pancreas = Straight through to back Kidney/ureter = Around flank to groin

Heart = epigastrium, neck/jaw, shoulders, upperarms

Spleen = Left scapula, shoulderAbdominal Aortic Aneurysm = low back radiating

to one or both legs


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How long have you been paining?

>6 hours = increased probability of surgicalsignificance

Nausea, vomiting

How much, How long?

Consider possible hypovolemia

Blood, coffee grounds?

Any blood in GI tract = emergency untilproven otherwise


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Urine

Change in urinary habits?

Frequency

Urgency

Color?

Odor?


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Bowel movements

Change in bowel habits? Color? Odor?

Bright red bloodMelena = black, tarry, foul-smelling stool

Dark stool

Suspect bleeding

Other causes possible (iron or bismuthcontaining materials)


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Last normal menstrual period?

Abnormal bleeding?

In females, lower abdominal pain = GYN

problem until proven otherwise

In females of child-bearing age, lower

abdominal pain = ectopic pregnancy untilproven otherwise


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Position and General Appearance

Still, refusing to move = Inflammation,

peritonitisExtremely restless = Obstruction

Gross appearance of abdomen

Distended

Discolored

Consider possible third spacing of fluids


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Vital signs

Tachycardia = more important sign of volumeloss than falling BP

Rapid, shallow breathing = possibleperitonitis

Consider performing tilt test


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Bowel sounds

Auscultate BEFORE palpating

One minute in each abdominal quadrant

Absent sounds = possible peritonitis, shock

High-pitched, tinkling sounds = possible

bowel obstruction


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Palpation

Palpate each quadrant

Palpate area of pain LAST

Do NOT check rebound tenderness inprehospital setting

ALL

abdominal tenderness significant untilproven otherwise


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for the diagnosis of rectal tumors and other forms of cancer; for the diagnosis of prostatic disorders, notably tumors and benign prostatic

hyperplasia;

for the diagnosis of appendicitis or other examples of an acute abdomen

(i.e. acute abdominal symptomsindicating a serious underlying disease);

for the estimation of the tonicity of the anal sphincter, which may be usefulin case of fecal incontinence or neurologic diseases, including traumatic

spinal cord injuries;

in females, for gynecological palpations ofinternal organs

for examination of the hardness and color of the feces (ie. in cases of

constipation, and fecal impaction); prior to a colonoscopy or proctoscopy.

to evaluate hemorrhoids

In newborns to exclude imperforate anus


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Oxygen therapy; keep airway clear

Intravenous opioids

Keep patient from losing body heat

Position of comfort

Monitor vital signs


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Monitor ECG

l Keep patient Nil Per Osl Analgesia controversial

l Demerol is preferred narcotic analgesic

Consider possible MI with

pain referred to abdomen inpatients >30 years old


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acute abdomen and peptic ulcer

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