Department of surgical diseases for general practitioners Acute abdomen Department of surgical diseases for general practitioners

« I and my generation were breeding by fear in front of God and peritonitis » Wegner (1876).

complete darkness and remains vague, «Illness – is a twice tragedy, one going on in a complete darkness and remains vague, another one going on by burned candles as 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 abdomen Localisation Illness Chest Miocardial infarction Pneumonia Pleurisy Pericarditis Fractures of lower ribs TELA Retroperitoneal space Renal colic Pyelonephritis Kidney infarction Rupture of aneurism of abdominal aorta Psoas abscess Pelvis Ovarian apoplexy Ectopic pregnancy Endometriosis Salpingitis, pyosalpinx, pyovarium Torsion of ovarian cyst pedicle Abdominal wall Intramuscular haematoma Injury and tensions of abdominal muscles

Diabetic ketoacidosis Addisonian crisis Acute porphyria toxic Systemic diseases and pathologic conditions which cause an abdominal pain infectious Tuberculosis metabolic uraemia Diabetic ketoacidosis Addisonian crisis Acute porphyria toxic Heavy metal poisonings Drug diseases Reaction for insect sting haematological leukosis Sickle-cell anemia

Main causes of an abdominal pain (V.S.Savelyev , 2006) Myocard infarction Lower lobular pleuropneumonia Renal colic, acute cholecystitis Perforated ulcer of a stomach Perforated ulcer of a duodenum Inflammation of a Meckel diverticulum Perforated tumor of a colon Terminal ileitis Bowel obstruction Diverticulitis, ulcerative colitis Acute appendicitis Ovarian apoplexy, torsion or rupture of an ovarian cyst, acute salpingitis Ectopic pregnancy Abdominal injury, haemoperitoneum Renal colic

Surgical diseases as are causes of an acute abdomen 1. Inflammation: 2. Perforation: Perforated ulcer of stomack and duodenum Fecal peritonitis Biliary peritonitis Perforated appendicitis, peritonitis Urinary peritonitis Bowl inflammatory diseases Appendicitis Cholecystitis Pancreatitis Salpingitis 3. Obstruction: Biliary colic Small bowel obstruction Obstruction of colon Renal colic Acute urinary retention Infarction of bowel 4. Bleeding : Rupture of ectopic pregnancy Rupture of ovarian cyst Rupture of liver and spleen Rupture of aneurism of abdominal aorta 5. Ischemia: strangulation Torsion of ovarian cyst pedicle Torsion of testicle

Basic sources of contamination of an abdominal cavity Vermiform appendage 30-65% Stomach and duodenum. 7-14% Female reproductive organs 3-12% Bowel 3-5% Gallbladder 10-12% Pancreatic gland 1% Postoperational peritonitis 1% 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 intensity Time,min

« acute abdomen » includes even one of distinct and 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./

Whether the patient lost weight of a body. 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

Strangulated hernia Reactionary strangulation Parietal strangulation

Enterogenic cyst of duodenum

Abscess of pancreas

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