Presentation is loading. Please wait.

Presentation is loading. Please wait.

DR.RAMATE WONGWILAIRAT. MD SOMDEJPHAJAOTAKSIN HOSPITAL.

Similar presentations


Presentation on theme: "DR.RAMATE WONGWILAIRAT. MD SOMDEJPHAJAOTAKSIN HOSPITAL."— Presentation transcript:

1 DR.RAMATE WONGWILAIRAT. MD SOMDEJPHAJAOTAKSIN HOSPITAL

2 OUTLIN E DIFINITION ACUTE ABDOMEN ANATOMY AND PATHOPHYSIOLOGY ABDOMINAL PAIN ETIOLOGY OF ACUTE ABDOMEN CLINICAL ASSESSMENT HISTORY TAKING PHYSICAL EXAMINATION LABORATORY INVESTIGATION IMAGING STUDY KEY FEATURES OF COMMON CAUSES OF ACUTE ABDOMINAL PAIN QUESTION

3 DIFINITION diagnosis and treatment immediately medical or surgical condition timimg 1-4 wk

4 Anatomy relate to abdominal pain Peritoneum visceral and parietal peritoneum abdominal organ intraabdominal and retroperitoneal organ Abdominal wall pathophysiology

5 Intraabdominal organ

6 NERVE 1.Parietal peritoneum Abdominal wall inferior epigastric a. somatic sipinal nerve T7-L2 2.Intraabdominal organ Visceral peritoneum celiac trunk, SMA, IMA autonomous system

7 Type of abdominal pain Visceral pain Somatic pain Refered pain Migratory pain

8 Visceral pain abdominal organ parasympathetic and sympathetic C-fiber,slow transmitter dull and crampy not localized midline pain (bilaterallity) Stretching, compression, torsion, distention

9 Visceral pain foregut epigasti um midgut periumb ilical hindgut suprapu bic

10 Somatic pain Irritate to Parietal peritoneum A-delta fiber, spinal nerve fast transmitters sharp and exquisite localized peritoneal sign : localized tender, guarding

11 Migratory pain Acute appendicitis

12 Migratory pain Peptic ulcer perforate

13 Refered pain pain felt at a site distant from a disease process Pathophysiology multiple pain afferents in the posterior horn of spinal cord

14 Common nerve root

15 Spinal nerve root C4 Right shoulder diaphragm gall bladder liver capsule peumoperitome un Left shoulder diaphragm spleen tail of pancrease stomach splenic flexure of colon

16 The thoracic affernt T6-T8 Right scapular gall bladder biliary tree Left scapular spleen tail of pancrease

17 Refered pain Groin/genitalia ureter kidney Back- midline pancrease duodenum aorta

18 ETIOLOGY OF ACUTE ABDOMINAL PAIN

19 1.INFLAMMATION /INFECTION A.PERITONEUM PRIMARY PERITONITIS ; ASCITES SCONDARY PERITONITIS: HOLLOW VICUS ORGAN PERFORATE TERTIALY PERITONITIS : TB B. HOLLOW VICUS ORGAN APPENDICITIS, CHOLECYSTITIS, GASTROENTERITIS DIVERTICULITIS, PEPTIC ULCER C. SOLID VISCERA PANCREATITIS, HEPATITIS D. MESENTERY LYMPADINITIS E. PELVIC ORGAN PID, ENDOMETRIOSIS, TUBOOVARIAN ABSCESS

20 2. MECHANICAL ( OBSTRUCTION /ACUTE DISTENTION) A.HOLLOW VISCUS ORGAN GUT OBSTRUCTION ; HERNIA,TUMOR INTUSSUSCEPTION BILIARY TRACT OBSTRUCTION: CALCULI TUMOR B.SOLID ORGAN ACUTE HEPATOMEGALY, SPLENOMAGALY C.MESENTERY OMENTAL TORSION D.PELVIC ORGAN OVARIAN CYST, ECTOPIC PREGNANCY

21 3. VASCULAR A.INTRAPERITONEAL BLEEDING RUPTURE LIVER AND SPLEEN RUPTURE AORTA, SPLENIC ANEURYSM RUPTURE ECTOPIC PREGNANCY B.INTRAPERITONEAL ISCHEMIA MESENTERY THOMBOSIS HEPATIC INFRACION : TOXIMIA, PURPURA SPLENIC INFRACTION OMENATAL INFRACTION

22 Abdominal pain pathway Inflammation Infection Obstruction Distention Bleeding infarction Intraabdominal organ Parietal peritoneum Spinothalamic tract vagus Spinal nerve sympathetic Somatic pain Visceral pain Refer pain History taking PE investigation

23 HISTORY TAKING CLINICAL ASSESSMENT

24 duration Site of pain 1. maximum point of pain 2. initial location of pain

25 Nature in onset of pain Sudden onset hollow viscus organ perforate ischemic process passage stone Gradual onset inflammmation process

26

27 Progression of pain Intermittent pain Colicky seconds( bowel) minutes (ureteric) tens of minutes (biliary) Constant pain peptic ulcer, pancreatitis Subside early colic More severe late colic

28

29 Characterist ic of pain Burning peptic ulcer Sharp or stabbing ureteric colic Crampy gut ostruction gastroenteritis

30 Aggravate or relieve of pain Posture lying still rolling around GI function type of food

31

32 Associated symptom Vomitting type of vomitus timing frequent Anorexia Bowel habits fever

33

34 HISTORY TAKING age menstruation past illness familial history organ systemic review medication

35 Physical examination CLINICAL ASSESSMENT

36 BASIC CONSIDERATION A large number of different structures Small abdominal cavity Pelvic cavity and dome of diaphargm Abdominal wall muscle The brain cannot distinguish depend on tecnique of examination

37 prepara tion The environment warm and private good daylight and oblique The bed hard bed with a backrest rest head on pillow and flex hip

38

39 preparati on Exposure uncover the patients from nipple to knees genitalia and hernia orifices Get the patients to relax rest his arm on his side breathe regularly and slowly

40 preparat ion The position of the examination right side, hand and forearm horizontal position clean and warm hand short nail

41 The routine of examination Inspectio n Auscultati on Percussio n palpation

42 INSPECTATI ON Look at the whole abdomen symmetry buldging : organomegaly, mass distended : gas, ascitis, fat, mass scaphoid abdomen: malnutrition

43 inspec tation Scar Spider nevi, superficial vien dilate Visible peristalsis Grey tunner and cullen sign Hernia umbilicus

44

45

46

47

48 Spider nevi

49 Bowels sound (all quadrants) peritalsis ; gurgling noise…mixture gas and air low pitched, every few seconds no bowel sound over a seconds paralytic ileus intestinal obtruction : high pitch, freqent Systolic bruit aortic or iliac aneurysm Splashing sounds gastric outlet obstruction

50 percussion

51 Percus sion Tympanic or hypotympanic (dullness) on percussion liver or spleen dullness (span) loss of liver dullness????? shifting dullness (ascites ) hypertympanic ( gut obstruction or ileus) Determining the extent of the tender area

52 Liver span

53 Shifting dullness

54 Fist test (tender on percussion)

55 palpation Pressing gently and lightly Symmetrical over all the abdomen Begin palpation on nontender area principle

56 Light palpation for tenderness Assess the degree mild tenderness moderate tenderness guarding severe tenderness rebound Localized or generallized Subcutaneous mass

57 Deep palpation Masses position tenderness shape fluctuation size, surface, edge, consistency pulsatile

58 deep palpation(bimanual)

59 Deep Palpate the normal solid organ liver Hand on the right side transvesely of abdomen Start at umbilicus Patient takes a deep breathe The inferior edge of enlarged liver bump The index finger.. Irregular or smooth When cannot palpate the liver, please move up the hand to the costal margin

60 Spleen normal spleen is not palpable palpate with the finger tips on the left and below the umbillicus the patients takes deep breathe move the right hand toward the left costal margin left hand lift the lower cage forwards

61 Kidneys puts left hand behind the right loin, between the 12 th rib and iliac crest lift the loin and kidney forwards puts the right hand on the right side of abdomen just above the level of the anterior superior iliac spine the patients take deep breathe

62 Palpati on donot forget Supraclavicula r fossa Hernial orifice Femoral pulse External genitalia

63 Special examination Murphy sign

64 OBTURATOR SIGN

65

66 Pitfall in physical examination Elderly, children Mask factor; analgesic, steroid Immuno- compromised host Repeatly in PE Reliability As a whole

67 DIFFERENTIAL DIAGNOSIS

68 Differential diagnosis

69

70

71

72

73 notic e Medical cause Site Solid or hollow viscus Congenital, trauma, tumor Infection incidence

74 INVESTIAGATION CLINICAL ASSESSMENT

75 Diagnosis investigation Confirm diagnosis Exclusion diagnosis Pre op evaluation depend on facility and policy Always required history taking physical examination

76 CBC Hct or Hb GI loss dehydrate leukocytosis infective condition ischemic process

77 LFT bilirubin alkaline phosphatase liver enzyme Urianalysis KUB stone infection Amylase pancreatitis BUN Cr e renal, e imbalance

78 Blood sugar DM., acute pancreatitis Urine pregnancy test ectopic pregnancy Hemoculture sepsis, cholangitis pyogenic liver abcess

79 Diagnosis imaging plain film abdomen; supine, CxR, upright free air PUP bowel gas pattern gut obstruct abnormal calcification gall stone KUB stone chro.pancreatitis

80

81

82

83

84 Ultra sound hepatobiliary system, solid organ gynecologic condition KUB system CT scan acute diverticulitis complication severe pancreatitis

85

86 Contrast media unnessary barium enema colonic obstruction pseudo obstruction intussusception

87 Laparoscope diagnosis treatment unidentify diag pelvic pain PID. Acute appendicitis endometriosis

88 KEY FEATURE COMMON CAUSE OF ACUTE ABDOMINAL PAIN

89 ACUTE APPENDICITIS Cilnical assesment HISTORY Gradual onset, fever,anorexia(90%), nuasea vomitting(70%) migratory pain, pelvic pain, dysuria, diaarhea, testicular pain Typical sequence : anorexia –abdominal pain – vomitting (95%) PE. Depend on antomical site fever,tenderness, guarding at RLQ guarding (Mac Burney) and rebound PR. Tenderness at right side rousing, obturator sign Lab investigation film acute abdomen is not helpful minimal WBC in urine leukocytosis

90 PEPTIC ULCER PERFORATE Clinical assessment HISTORY sudden onset,severe pain generalized abominal pain,migratory pain, risk factor to peptic ulcer PE abdominal distention decrease bowel sound, generalized guarding rebound tenderness ( broad like rigidity) Lab investigation film acute abdomne free air (70 %)

91

92 ACUTE PANCREATITIS Clinical assesssment HISTORY haevy alcohol drinking one of exlusion : same, PUP, acute cholecystitis gradual onset,severe pain after meal usually epigastric pain, dullness and radiate to the back relieved by the patient leaning forward PE mark tender, voluntary or involuntary guarding rebound tenderness positive Grey tunner and Cullen sign Investigate film acute abdomen. Colon cut off sign, Sentineal loop rising serum amylase(30 %), urine amylase rising lipase

93

94

95

96 DIVERTICULITIS Clinical assessment History : old age with chronic constipation, pain in left lower abdominalrefer suprapubic and goin or back dysuria (irritate bladder) PE : terderness, guarding, rebound at LLQ. mass palpable(phlegmon or abscess) pelvic peritonitis PR: trnderness at Cul de sac INVESTIGATE : clinical diagnosis CT (investigate of choice) and ultrasound

97 INTESTINAL OBSTRUCTION CLINICAL ASSESSMENT HISTORY intermittent onset, colicky abdominal pain frequent vomtting, constipation hernia, previous surgery PE abdominal distention,visible peritalsis, hyperactive bowel sound, hypertympanic on percussion localized tenderness, mass ?, surgical scar, incarcerated hernia Investigation film acute abdomen. Dilate bowel, air fluid level

98

99 MESENTERIC ISCHEMIA CLINICAL ASSESSMENT HISTORY hyperlipidemia, CVA, MI, AF intestinal angina, acute onset and constant Extrem pain unresponsive to narcotic PE abdominal distention, hypoactive bowel sound generalized tenderness, guarding, rebound (pain is out of porportion to PE ) INVESTIGATION leukocytosis film acute abdomen: non specific, bowel dilate

100 A 69-year-old woman presents with 3 day history of constipation and constant pain in left lower abdomen.The pain has suddenly become much worse and she has collapsed and been admitted to casualty. On examination she has a tachycardia and is hypotensive. There is severe lower abdominal pain with guarding throughout the mid-and lower abdomen

101 A. 42 –year-old woman with a history of biliary colic and intermittent faundice is admitted as an emergency with a 2-day history of more severe abdominal pain radiating into her back, associated with profuse vomiting. On examination she is morbidly obese, is dehydrated, has a tachycardia and generalized vague abdominal tenderness.

102 A.78-year-old man presents with a 3 – day history of vomiting faeculent fluid, He has a grossly distended abdomen and a palpable mass in the right groin.The mass is firm,slightly tender and lies below and lateral to the pubic tubercle

103 A. 60 year-old man presents with a 48-hour history of sudden onset epigastric pain radiating through to the back after an alcoholic binge. Examination reveals the patient to be apyrexial,tachycardic and normotensive.The patient is diffusely tender with guarding in the epigastrium.An erect chest x – ray is normal,but the blood gas analysis reveals hypoxia

104 A 22-year-old woman presents with pain in the right iliac fossa. The patient is anorexic,has not vomited,but had some dysuria and frequency.Her temperature is 37.5 c o The patient is flushed and has localized guarding in the right iliac fossa and suprapubic region.

105 A 50-year-old obese woman presents with epigastric pain. On examination her temperature is 38.5 c o She is tender in the upper abdomen and Murphy’s sign is positive.

106 CONCLUSION ABDOMINAL PAIN DIFFERENTIAL DIAGPROVISIONL DIAG CLINICAL ASSESSMENT HISTORY TAKING LAB INVESTIGATION PATHOPHYSIOLOGY ANATOMY KNOWLAGE

107 หนังสืออ้างอิง จุตพล วิลาสรัศมี ใน : สิโรจน์ กาญจนพัญจพล, บรรณาธิการ. ศัลยศาสตร์ ทั่วไป กรุงเทพฯ : กรุงเทพเวชสาร หน้า 100 – 108 ชวนรัฐ สุวิภะบภรณ์กุล. ใน : สิโรจน์ กาญจนปัญจพล, บรรณาธิการ. ศัลยศาสตร์ทั่วไป. กรุงเทพ : กรุงเทพเวชสาร : รังสรรค์ กุภพินิมิตร. การดูแลผู้ป่วยที่มาด้วยเรื่องปวดท้องเฉียบพลัน ใน : สุเทพ กลชาญ วิทธิ์, บรรณาธิการ โรคทางเดินอาหารและการรักษา กรุงเทพ ซ โรงพิมพ์จุฬาลงกรณ์ มหาวิทยาลัย, 2548 หน้า 1-9 Norman L.Browse. The abdomen In : Introduction to the symptom and sign of surgical disease second edition 1991: Helen Sweetland. Kevin Conway. Acute abdominal pain in Crush Course Surgery second edition 2004:1-7 Seymour I. Schwartz. Manifestations of gastrointestinal disease In ; Seymour IS, editor. Principle of surgery 5 th edition New York 1989:

108


Download ppt "DR.RAMATE WONGWILAIRAT. MD SOMDEJPHAJAOTAKSIN HOSPITAL."

Similar presentations


Ads by Google