acute pain abdomen in surgical practice
TRANSCRIPT
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Dr. Mintu Borgohain, MS
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Acute abdomen means the presentation of abdominal
pain that may occur suddenly or gradually over a period
of several hours and presents as symptom complexwhich suggest a disease that possibly threatens life and
demands an immediate or urgent diagnosis for early
treatment .
It is one of the commonest causes of surgical
emergency
More than 1000 causes
20-40% admission rates
50-65% inaccurate initial diagnosis
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Common causes of acute abdomen :
Acute appendicitis (28%)
Acute cholecystitis (10%)
Small Bowel Obstruction (4%)
Perforated PU (3%)
Pancreatitis (3%)
Diverticular disease (2%)
Non specific causesOthers (13%) : intussuception, volvulus
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Common causes of pain abdomen in women
Pelvic Inflammatory Disease or PID
Ectopic pregnancy
Abortion and other pregnancy events
FibroidsEndometriosis
Endometritis
Ruptured ovarian cyst
Twisted ovarian cyst
Ovarian cancer
Mittleschmerz
Urinary Tract Infection
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Causes in different age group
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Etiology of Abdominal Pain
Three main categories of abdominal pain:
GI (Appendicitis, Diverticulitis, etc, etc, etc)
GU (Renal Colic, etc, etc, etc)
Gyn (Acute PID, Pregnancy, etc)
Vascular systems (AAA, Mesenteric Ischemia, etc)
Cardiopulmonary (AMI, etc)
Abdominal wall (Hernia, Zoster etc)
Toxic-metabolic (DKA, lead poisoning etc)
Neurogenic pain (Zoster, etc)Psychic (Anxiety, Depression, etc)
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Patho physiology
Three types of pain exist:
1. Visceral
2. Parietal
3. Referred
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1. Visceral painDue to stretching of fibers innervating the walls of hollow or solid organs.
It occurs early and poorly localized
Distention, inflammation or ischaemia in hollow viscous & solid organs
Localisation depends on the embryologic origin of the organ:Forgut to epigastrium
Midgut to umbilicusHindgut to the hypogastric region
2.Parietal pain
Caused by irritation of parietal peritoneum fibers.
It occurs late and better localized.
It is localised to the dermatome above the site of the stimulus.
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3. Referred painPain is felt at a site away from the pathological organ.
Pain is usually ipsilateral to the involved organ and is felt midline ifpathology is midline.
Gastric/duodenal
pain T5-8
Liver and biliary pain
Colonic painT11,12L1.2
Ureteric/ renal pain L1,2
Diaphragmatic irritation C5
Biliary pain T7-9
Pancreatic / renal pain
Uterine / rectal pain S2,3
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Causes of pain according to quadrants :
oPerforation
oAcute pancreatitis
oBilateral pleurisy
oEarly appendicitisoSmall Bowel Obstruction
oAcute gastritis
oAcute pancreatitis
oRuptured Abdominal Aorta
Aneurysm
oMesenteric thrombosis
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Epigastric pain
DU / GUOesophagitis
Acute pancreatitisAAA
RUQ pain
Gallbladder diseaseDU
Acute pancreatitisPneumoniaSubphrenic abscess
cont
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Left Upper Quad pain
Peptic UlcerPneumonia
Acute pancreatitisSpontaneous splenic rupture
Acute perinephritisSubphrenic abscess
Suprapubic pain
Acute urinary retentionUTIsCystitisPIDEctopic pregnancyDiverticulitis
cont
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Right Iliac Fossa pain
Acute appendicitis
Mesenteric adenitis (young)Perforated DUDiverticulitisPIDSalpingitisUreteric colicMeckels diverticulumEctopic pregnancyCrohns diseaseBiliary colic (low-lying gall bladder)
cont
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Left Iliac Fossa pain
DiverticulitisConstipationIBSPIDRectal CaUreteric CalculiEctopic pregnancy
cont
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colicy pain of acute intestinal obstruction
may change into constant burning type indicates strangulation
Deep inspiration in diaphragmatic irritation
Fatty food in cholecystitis
Spicy fried food, alcohol in peptic ulcer disease
Intake of food in duodenal ulcer
Gastric ulcer pain decrease after vomiting
Peritonitis pain marginally reduced on lying still
Fever/ vomiting/ jaundice/constipation/ passage of blood & putrid stool (in
mesenteric thrombosis) / burning micturition
Vomitus any be projectile : high intestinal obstruction, toxic enteritis
Non projectile : peptic ulcer perforation ,general peritonitis
Contd.
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Anxious look, bright eyes, pinched face and cold sweat k/a interminal stage of peritonitis
In colic- tossing and turning in bed
In pancreatitis- knee chest position
CBD obstruction
Peritonitis, Small Bowel obstruction
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Scaphoid or flat in peptic ulcer
Distended in ascitis or intestinal obstruction
Visible peristalsisladder pattern in small bowel obstruction
Discoloration of skin in left flank(Grey Turner sign) or bluish hue aroundumbilicus (Cullen sign) occasionally seen in acute hemorrhagic pancreatitis
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Check for Hernia sites
Tenderness
Rebound tenderness
Guarding- involuntary spasm of muscles duringpalpation
Rigidity- when abdominal muscles are tense &board-like. Indicates peritonitis.
Distensioncentral distension in acute intestinalobstruction
Lumpappendicular lump/ in cases of intussceptionsausage shaped lump in epigastric or left lumbar region
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Guarding
Rebound tenderness with (a) hand down (b)hand up
ab
Muscle guarding suggest irritation of parietal peritoneumRebound tenderness(Blumbergs sign)
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Copes Psoas test in retrocaecalappendicits
Obturator test in pelvic appendix
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Some Important Signs in Patients with Abdominal Pain
Sign Finding Association
Cullen's signBluish periumbilical discoloration Retroperitoneal haemorrhage
Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture
McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side Appendicitis
Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant
Acute cholecystitis
Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis
Obturator's sign Internal rotation of flexed right hip causingabdominal pain
Appendicitis
Grey-Turner'ssign
Discoloration of the flank Retroperitoneal haemorrhage
Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with palpation ofthe left lower quadrant
Appendicitis
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Percussion :Light percussion elicits tendernessShifting dullness presence of free fluid in some conditions like peptic ulcerperforation, ruptured ectopic pregnancy.
Obliteration of liver dullness - in hollow viscus perforation
Auscultation :Silent abdomen in peritonitisBorborygmi in acute intestinal obstruction
Rectal examination :very important
Gynaecological examination essential in female patients
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Investigations
CBC
LFT, Amylase/LipaseCreatinine, BUN, electrolytes
Urine R/E & culture
Pregnancy test
Cardiac enzymes if appropriate
Electrocardiogram
Erect/ Supine
Plain abdominal radiographs or abdominal series has several limitations and is
subject to reader interpretation.
CT scan in conjunction with ultrasound is superior in identifying any abnormality
seen on plain film.
IVU (renal/ureteric colic)
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Has good specificity and sensitivity in
picking up stones and common duct
obstructions.
Less invasive / less complications than
ERCP(ERCP can induce GI perforation, pancreatitis,
biliary duct injury)
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Gas under diaphragm
Appendicitis in USG
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GB stone on USG
CBD stone USG
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Multiple air fluid level in bowel obstruction
CT acute pancreatitis
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Ruptured ectopic Right side
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1. ABC
2. Start large bore IV with either saline or lactated Ringers solution IV
pain medication
3. Nasogastric tube if vomiting or concerned about obstruction
4. Foley catheter to follow hydration status and to obtain urinalysis
5. Antibiotic administration if suspicious of inflammation or perforation6
.
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ConclusionAcute abdomen is one of the commonest causes of surgicalemergency. It goes without saying that it is very important thatan early diagnosis is made. Any delay will worsen the condition
of the patient and may even lead to fatal outcome.Although etiologies are many, a careful and through clinicalevaluation with the help of different investigative procedurescan help us towards a diagnosis
Immediate resuscitation is most important.
Pain management is crucial
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And Happy New Year