10Organ Location of Pain Pathology Liver Right Upper quadrant Hepatitis Common Causes of acute abdominal painOrganLocation of PainPathologyLiverRight Upper quadrantHepatitisLiver abscessCCF
11Organ Location of Pain Pathology Biliary Tract Right Upper quadrant Common Causes of acute abdominal painOrganLocation of PainPathologyBiliary TractRight Upper quadrantCholeycystitisCholelithiasisCholedocholithiasis
12Common Causes of acute abdominal pain OrganLocation of PainPathologyPancreasEpigastriumRight HypochondriumLeft HypochondriumAcute PancreatitisCa PancreasCa Oesaphagus
22Taking the history of a patient with acute abdomen Specific questionWhen did the pain start and was the onset sudden?What brought the pain on and are there any aggravating or relieving factors?Where did the pain start and where is it now? Does it radiate elsewhere?What is the character of the pain and how severe is it?
23Taking the history of a patient with acute abdomen Specific questionAre there any associated symptoms? (e.g. distension, nausea, vomiting, fever, diarrhoea, absolute constipation, anorexia, jaundice, pruritis, gastrointestinal bleeding, dysuria, oliguria, chest pain)Was there any similar episode in the past?When was your last period and is there any chance that you may be pregnant?
24Taking the history of a patient with acute abdomen General enquiriesHistory of alcohol intakeDrug historyHistory of previous surgeryHistory of Pre-existing diseaseHistory of travel (Especially foreign)Family history
32PathologyMinor, simple, acute with spontaneous resolution to supperactive necrosis and perforation.Bacteria (E Coli, Klebsilla, Proteus).Enter through ulcer (caused by faceolith).Edema purulent inflammation thrombosis, gangrene.
33Clinical Features Age can influence presentation. Clinical picture also dictated by position of appendix.Epigastric / periumblical pain .Shift to right iliac fossa.Colicky / dull pain.Aggravated by movement and coughing.Loss of appetite constipation nausea and vomiting.
34Clinical Examination Tachycardia. Mild Pyrexia Guarding in RIF Fetor orisTenderness on rectal / vaginal examination.Rovsings sign, psoas stretch sign.Obturater test
36Anatomical Feature influencing Presentation 1. RetrocaecalMuscular rigidity often absentRight hip in flexed position due to psoas spasmPsoas stretch sign.
372. Post ileal 3. Pelvic Diarrohea and Vomiting Prominent feature due to irritation of ileum.3. PelvicDiarrohea due to irritation of rectum.Increased frequency of micturation.Microspic haematuria.Tenderness on rectal and viginal examination.Obturator sign.
38Age Related features affecting presentation ChildrenDifficulty in obtainingProper historyDifficulty in differentiating from mesenteric adenitis and enteritis.
39Elderly Under developed omentum leading to early complications. Less prominent SymptomsAfebrileNormal white cell count.
40Pregnancy1 per / years in UK. Displacement of appendix by Gravid uterus can result in atypical presentation. Symptoms may be confused with onset of labor.Tenderness may not be marked due to gravid uterus.Less maternal mortality in case of simple appendix.Risk of featal death is about 10% .Complications both at risk.
51Amoebic liver Abscess It is common in indo-pak Caused by parasite entamoeba histolyticaCommon in alcoholicsInfection commonly occurs in caecum and rectosigmoid junction via superior and inferior mesentric veins and portal vein to liver.
52Right lobe of liver is commonly involved, size of right lobe, portaly vein is in direct continuation with right branch.Infection Leads to liquefaction necrosis and formation of pus (Anchovy Sauce) which is chocolate brown in colour odourless.Pus may be green if mixed with bile.Secondary infection is common in (30%)70% single abscess, 30% multiple.
53E. Histolytica Life Cycle 2 stages:-Infective cyst stage- Multiplying trophozite stage2 forms:- Active parasite (trophozite)- Dormant parasite (cyst)Infection begins when cysts are swallowedCysts hatch---releasing trophozites that multiplyTrophozites cause ulcers on the lining of intestine and produce diarrhea.Once the intestinal epithelium is invaded, extra intestinal spread to the peritoneum, liver, brain and other sites may follow.Some of the trophozites forms cysts which are excreted in the faeces along with trophozitesOutside the body, trophozites die but cysts remain.Merck Manual Home Edition 2003
55ComplicationsRupture of the abscess with extension into the peritoneum, pleural cavity, or pericardium.Extra hepatic amebic abscesses have occasionally been described in the lung, brain, and skinAmebiasis: Parasitic Infections: Merck Manual Edition 2007