Acuteabdomen

Department of surgical diseases for general practitioners

« I and my generation were breeding

by fear in front of God and peritonitis »

Wegner (1876).

«Illness – is a twice tragedy, one going on in a complete darkness and remains vague, another one going on by burned candlesas everything is clear, but nothing helpful»

Lerish

Abdomen regions

I. Epigastric

II. Mesogastric

II. Hypogastric

An abdominal cavity - cavity limited by the diaphragm above, by the pelvic diaphragm and iliac bones below, by backbone and lumbar muscles behind, rectus muscles in a front, internal oblique and transversal muscles from sides.

Anatomic and physiologic features of peritoneum

Peritoneum is a serous cover of abdominal walls (parietal part) and organs of abdominal cavity (visceral part). By crossing from abdominal walls to organs, also from organs to organs peritoneum forms folds, ligaments, frills, which generate spaces (spacium), sinuses (sinus), pockets (recessus).

Anatomically distinguished: bursa hepatica on the top floor where located a liver, a stomach and a spleen, bursa praegastrica, bursa omentalis. bursa hepatica is divided to upper and lower parts. Upper part of a bursa hepatica in the surgical literature more often called right underdiaphragmal space.

The bottom floor of an abdominal cavity can be examined after turning up of a large omentum and a colon transversum. Thus we can see left and right mesenteric sine (sinus mesentericus), lateral channels (canalis lateralis), which are connected with a small pelvic cavity.

Reasons of acute abdomen

• Acute myocard infarction;• Lung diseases;• Medications;• Insect stings;• Different poisonings;• Porphyria and others.

Often reasons of pains irradiated to abdomenLocalisation Illness

Chest Miocardial infarctionPneumoniaPleurisyPericarditisFractures of lower ribs

TELA

Retroperitoneal space Renal colicPyelonephritisKidney infarctionRupture of aneurism of abdominal aortaPsoas abscess

Pelvis Ovarian apoplexyEctopic pregnancyEndometriosisSalpingitis, pyosalpinx, pyovariumTorsion of ovarian cyst pedicle

Abdominal wall Intramuscular haematomaInjury and tensions of abdominal muscles

Systemic diseases and pathologic conditions which cause an abdominal pain

infectious Tuberculosis

metabolic uraemiaDiabetic ketoacidosisAddisonian crisisAcute porphyria

toxic Heavy metal poisoningsDrug diseasesReaction for insect sting

haematological leukosisSickle-cell anemia

Main causes of an abdominal pain (V.S.Savelyev , 2006)

1. Myocard infarction2. Lower lobular pleuropneumonia3. Renal colic, acute cholecystitis4. Perforated ulcer of a stomach

5. Perforated ulcer of a duodenum

6. Inflammation of a Meckel diverticulum

7. Perforated tumor of a colon8. Terminal ileitis9. Bowel obstruction10. Diverticulitis, ulcerative colitis11. Acute appendicitis12. Ovarian apoplexy, torsion or

rupture of an ovarian cyst, acute salpingitis

13. Ectopic pregnancy14. Abdominal injury,

haemoperitoneum15. Renal colic

Surgical diseases as are causes of an acute abdomen

1. Inflammation:•Bowl inflammatory diseases•Appendicitis•Cholecystitis•Pancreatitis•Salpingitis

2. Perforation: •Perforated ulcer of stomack and duodenum•Fecal peritonitis•Biliary peritonitis•Perforated appendicitis, peritonitis•Urinary peritonitis

4. Bleeding :•Rupture of ectopic pregnancy •Rupture of ovarian cyst•Rupture of liver and spleen•Rupture of aneurism of abdominal aorta

5. Ischemia: strangulationTorsion of ovarian cyst pedicleTorsion of testicle

3. Obstruction:Biliary colicSmall bowel obstructionObstruction of colonRenal colicAcute urinary retentionInfarction of bowel

Basic sources of contamination of an abdominal cavity

1. Vermiform appendage 30-65%2. Stomach and duodenum. 7-14%3. Female reproductive organs 3-12%4. Bowel 3-5%5. Gallbladder 10-12%6. Pancreatic gland 1%7. Postoperational peritonitis 1%8. Traumatic injuries 2,7%

Differential diagnosis of an pseudoabdominal syndrome

Abdomina syndrome Pleurapulmonary syndrome

Cardiac syndrome

Complaints and anamnesis

GI disorders, abdominal pain, constipation or diarrhea. Acute beginning, often without fever

chill, possibility of contamination, cold.

Acute beginning, almost by fever. Pain increases on breathing in

Anamnesis of cardiac patient. Often complains to pain which irradiates to left arm. Sometimes suddenly, often by gradual beginning, seldom by vomit

Objective examine

The face expression is normal or is similar to the person of the patient with peritonitis.

The pressure of muscles of a stomach is sharply expressed, does not disappear by palpation. The pain amplifies from pressure over a place of the primary focus.

Bright flush on cheeks. Sometimes movement of wings of a nose at each breath. The pressure of muscles of a stomach is clearly expressed, but disappears by palpation. The pain amplifies by cough and pressure on intercostal interval.

Expression of fear on the face. Cyanosis. The pressure is sharply expressed, amplifies by palpation.

Dynamics of a sharp pain in an abdomen at various pathological processes

0,010,020,030,040,050,060,070,080,090,0100,0

10 20 30 40 50 60

perforationobturationinflammation

intensity

Time,min

« acute abdomen » includes even one of distinctand obviously expressed manifestations:

Pain in a stomach and shock;diffuse peritonitis (pain on all stomach, pressure);Local peritonitis (limited by one of quadrants of an abdominal wall);The phenomena bowel obstruction;Various therapeutic disease./On this Lecture we are not going to discuss about an abdominal trauma./

COMPULSORY QUESTIONS to the PATIENTS with an abdominal pain, WHICH the GP SHOULD SET

• Pain: localization, irradiation, character, duration, intensity, time of occurrence, causal connection, provoking and the facilitating factors.

• Character of retching.• Character of a stool.• Whether the patient lost weight of a body.• Whether the faint or collapse was marked.• Endured diseases.• gynaecological anamnesis.• Medicinal anamnesis.

Methods of examination• Anamnesis(believe to nobobody, ask about everything)• physical methods of inspection: • General view of the patient;• Survey of a belly;• palpation;• Prcussion;• auscultation;• Per rectum examination, vaginal examination;• Laboratory researches:• The general analysis of blood;• The general urine analysis;• The biochemical analysis of blood etc.;• Tool researches:• X-ray examination;• Ultrasonography;• Endoscpic examinations• ECG;• Laparoscopy;• CT?• angiography

Acute phlegmonous cholecystitis

salpingoophoritis

Pus inside the pelvis cavity

Bowel infarction

Fallopian pregnancy

On the upright position gases accumulated under the diaphragm kind of linear enlightenment – symptom of «top» or

«sickle».

Small bowel obstruction: wide, multiple, centrally located cups of Cloyber, smooth levels, Cercking^s folds, аркады

(blowed up bowel loops)

Small bowel obstruction

Obstruction of colon: single narrow Cloyber^s cups on sides, rough levels, haustrations

Acute gangrenouse appendicitis.

Vermicular empyema.

Perforated gangrenous appendicitis

Phlegmon of stomach

Alien body.

Rupture of ovarian cyst.

Crohn^s diseases

Phlegmon of intestinum cecum

Reactionary strangulation Parietal strangulation

Strangulated hernia

Enterogenic cyst of duodenum

Abscess of pancreas

Thank you for paying attention!

!!

Thank you for paying attention!

!!