Download - 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
Signs and SymptomsSigns and Symptoms
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
Signs and SymptomsSigns and Symptoms
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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