3.  What is Acute Abdomen? ◦ It’s a term used to describe Surgical, Medical and Gynecological conditions that range from trivial to life- threatening, which require admission, investigations and treatment. ◦ The primary symptom of this condition is abdominal pain

4.  It is estimated that at least 50% of General Surgical admissions are emergencies, and of these, 50 % present with acute abdomen  Some conditions of severe abdominal pain need urgent surgery (e.g. ruptured aortic aneurysm, perforated diverticulitis), and some do not require surgery (e.g. biliary colic, ureteric colic, and pancreatitis) and some do not require urgent investigations and treatment (e.g. mild gastroenteritis and constipation)

5.  It is classified into Medical, Surgical and Gynecological causes.  Medical Causes: System AffectedDiseases Cardiovascular SystemMyocardial Ischemia Gastrointestinal SystemGastritis and Gastroenteritis Mesenteric Adenitis Hepatitis and Hepatic Abscess Primary Peritonitis Abdominal Wall ConditionsRectus Sheath Hematoma Genitourinary SystemUTI and Pyelonephritis Neurological SystemTabes Dorsalis Hematological SystemSickle Cell Anemia Hereditary Spherocytosis

6. System AffectedDiseases Endocrine SystemDiabetes Mellitus Thyrotoxicosis Addison’s Disease Metabolic CausesPorphyria Uremia DKA InfectiveHerpes Zoster Left sided Lobar Pneumonia Right sided Lobar Pneumonia

7. Ectopic Pregnancy Ovarian CystTorsion Rupture Hemorrhage Infarction Pelvic Inflammatory Disaese Fibroid Degeneration Salpingitis Endometriosis

8.  According to the site: Site of PainDisease Whole AbdomenGeneralized Peritonitis Mesenteric Infarction Right Upper QuadrantAcute Cholecystitis Cholangitis Perforated Peptic Ulcer Left Upper QuadrantPerforated Peptic Ulcer Acute Pancreatitis Right Lower QuadrantAppendicitis Right Ureteric Colic Left sided Lobar Pneumonia Meckel’s Diverticulitis Mesenteric Adenitis

9. Site of PainDisease Left Lower QuadrantSigmoid Diverticular Disease Left Ureteric Colic Radiating PainTo the BackPeptic Ulcer Disease Pancreatitis Aortic Aneurysm Acute Aortic Dissection Ureteric Colic To the Groin Testicular Torsion

12.  Is an inflammatory or suppurative response of the peritoneal lining to direct irritation mostly due to bacterial invasion but may be of chemical origin.

13.  A- Intra-abdominal viscera. ◦ Gangrene of viscous:  acute appendicitis, acute cholecystitis, diverticulitis & infarction of the intestine. ◦ Perforation of viscous:  e.g. perforated ulcers, perforated appendicitis, trauma in the intestines, and post operative leakage of an intestinal suture. ◦ Trans- mural bacterial translocation (no perforation)  e.g. inflammatory bowel disease, appendicitis, ischemic bowel.

14.  B- Exogenous contamination: ◦ Infection in laboratories, perforated dialysis, trauma.  C- Hematogenous spread: ◦ As part of septicemia- wrongly termed primary perforation [not common].  D- Female genital tract infection: ◦ e.g. pelvic inflammatory disease, acute salpingitis.

15.  Bacteria causing peritonitis;  Gastrointestinal : ◦ Mixed fecal flora –Escherichia coli, Streptococcus faecalis, Pseudomonas, klebsiela, Proteus, Staphylococcus and anaerobic Clostridium and Bacteroids.  Gynecological : ◦ Chlamydial, Gonococcal or Streptococcal.  Hematological : ◦ Streptococcal, Pneumococcal, Staphylococcal or Tuberculous.

16.  Peritonitis may be localized or diffused:  Localization is caused by adherence of peritoneum [omentum] and the intestine thus leaving a substantial barrier to infection spread.

17.  Widespread absorption of toxins from the large, inflamed surface is associated with: ◦ Paralytic illeus, loss of fluid, loss of electrolytes, & loss of proteins. ◦ Gross abdominal distention with elevation of the diaphragm, which produces a liability to lung collapse and pneumonia.

18.  First clinical features are usually those of the cause e.g. Acute appendicitis, sepsis, perforated duodenal ulcers.  Early peritonitis is characterized by : ◦ Severe abdominal pain aggravated by movement and coughing. ◦ Pain referred to the shoulder tip if diaphragm is irritated.  Vomiting is frequent. Pyrexia [usually but may be absent].  Pulse raises slowly.

19.  Generalized or localized tenderness.  Rigid abdominal wall with rebound tenderness.  Absent or reduced bowel sounds.  Rectal or vaginal examination detect tenderness in pelvic peritonitis.  Abdomen is distended and tympanic  Ascites may be present it becomes toxic with rapid feeble pulse  Vomiting is feculent

20.  Signs of circulatory failure  If not treated patient becomes unconscious

22.  Hb, PCV, WBC ( ↑ WBC )  Blood sample for culture and sensitivity  Urea and electrolytes  Serum amylase is more than four times above normal in acute pancreatitis  Erect CXR reveal free gas\under the diaphragm in case of perforated abdominal viscous

23.  Abd. x-ray may give a reason of peritonitis  CT would usually pinpoint the cause

24.  Pain relief: with opiates e.g. : I.V. Morphine  I.V fluids and electrolyte replacement  Gastric aspiration  Broad spectrum antibiotics e.g.: Penicillin +Gentamicin or Cephalosporin+ Metronidazol.

25.  Surgery (if source of infection can be removed) ◦ Drainage of localized abscess  Conservative treatment (in localized peritonitis e.g. Appendicular mass or irremovable primary focus).

26.  Systemic: ◦ Hypovolaemic shock ◦ Bacterimic or endotoxic shock ◦ Bronchopneumonia or respiratory failure ◦ Renal Failure ◦ DIC ◦ Bone marrow suppression ◦ Multisystem failure

27.  Abdominal ◦ Adhesional small bowel obstruction ◦ Paralytic ileus ◦ Residual or recurrent abscess ◦ Portal pyemia or liver abscess.

29.  Definition: is an inflammation of the vermiform appendix  Appendix is blind-ending hollow muscular tube that arise from cecum  The most common cause of Acute abdomen in young adult  Site: ( retrocecal - pelvic position -paracaecal- subcaecal-preileal)  Length: 7.5-10 cm  Blood supply: appendicle artery branch from ilocecal artery

31. 1. Obstructive type –solid feacal closure obstruction of lumen lead to stasis lead to bacterial inflammation. 2. Non obstructive through blood

32.  Usually affect younger age 2nd -3rd decade of age.  Not common after 60years  Male :female ratio is equal 1. classically presents with abdominal Pain ◦ pain is start around umbilicus which is dull aching pain then with 6-10 hours pain is shift to right iliac fossa ◦ Pain is aggravated with movement 2. Anorexia, nausea, vomiting 3. low grade fever 4. Fur coated tongue, pulse is usually normal

33. 1. Movement of abd. with respiration is normal 2. Tender right iliac fossa. 3. Rebound tenderness – if touch or press right iliac fossa when remove hand feel sever pain. 4. Guarding in muscle. 5. Reovsing sign. 6. Positive Psoas sign. 7. Positive Obturator sign

34. 1. Rupture of Graffian follicle(mid cyclic pain). 2. Twisted ovarian cyst. 3. Acute salpingitis. 4. Rupture of right ectopic pregnancy. 5. Perorated peptic ulcer. 6. Mesenteric lymphadenitis. 7. Acute cholecystitis. 8. Right lower lobar pneumonia. 9. Right renal ache or Ureteric colic.

35. 1. leukocyte count: mild leukocytosis. 2. Urine analysis: if suspicion of calculus. 3. Pregnancy test : if ectopic is suspected 4. Ultrasound of abdomen 5. Laparoscopy.

36.  Is urgent appendicectomy for fear of complication

37.  Appendicular mass: not indicated for surgery because: ◦ Carry hazard to injury the adherent intestine. ◦ Mass represent success of the body to isolate the danger.  The treatment is by conservative management ( Ochsner-Sherren regime):

38.  Nil by mouth.  Intravenous fluid  Antibiotics(combination of Ampicillin, Gentamycin, Metronidazol, second generation cephalosporin).  Analgesic for pain.  follow up size of mass and for vital sign.  Then after 3 months do interval appendectomy.

39.  Appendicular abscess ◦ Treatment is by drainage  Perforation: patient is look toxic, febrile, vomiting, distend abdomen,silent abdomen and is rigid not move with respiration all this is due peritonitis  Treatment is urgent laparotomy.

41.  Definition: it is a common clinical syndrome associated with inflammation of the GB  Aetiology: ◦ Calculous (but could be acalculous) ◦ Typhoid fever ◦ Acute-on-chronic

42.  Obstruction of the GB neck or cystic duct by a stone  Bacterial infection → empyema → GB becomes inflamed, edematous and gangrenous  Organisms: E. coli, Klebsiella, Strept. Fecalis

43. 1. PAIN: ◦ Sudden right hypochondrial pain radiating to the right subscapular region occasionally to the right shoulder; ◦ continuous lasting more than 6 hours. ◦ Nothing except analgesic drugs brings relief. ◦ It is exacerbated by moving and breathing ◦ Associated with nausea and vomiting and sometimes may be associated with obstructive jaundice

44. 1. Abdominal tenderness and rigidity especially over GB 2. Murphy’s sign is positive → catching of breath or pain when GB is palpated at the height of inspiration. 3. Right hypochondrial mass

45.  Pyrexia  Tachycardia  Nausea and vomiting  Leucocytosis  Jaundice

46.  Chronic cholecystitis  Perforated peptic ulcer  High retrocecal appendicitis  Acute pancreatitis  Hepatitis  Cholangitis  Duodenal ulcer  GERD  Gastritis  Liver abscess  CA stomach  Myocardial infarction  Basal pneumonia

47.  Resolution  Recurrence  Mucocele  Obstructive jaundice  Pancreatitis (acute)  Cholangitis  Gallstone ileus  Empyema

48.  CBC: Hb, WBCs (Neutrophilia)  Ultrasonography: ◦ Acoustic shadow of the stone ◦ GB thickness ◦ CBD (normal diameter 4 – 7 cm) ◦ Liver ◦ Paraortic lymph nodes  Liver function tests: ◦ Increased serum Bilirubin and Alkaline Phosphatase → bile stones

49.  Urine: Bilirubin, casts, Urobilinogen  CXR: concomitant myocardial pathology e.g. heart failure  Blood grouping and cross-matching

50.  Most cases usually resolve spontaneously  Hospital admission  Vital signs monitored: BP, pulse and T˚  Analgesia  IV fluids  Broad-spectrum antibiotics e.g. cephalosporin  Nil by mouth and NG tube if there is vomiting.

51.  When the pt is stable, he/she is sent home to return 6 weeks later for cholecystectomy (open or closed i.e. laporoscopic)  Emergency cholecystectomy is performed if the symptoms do not resolve conservatively  If the surrounding tissue is inflamed (mucocele), cholecystostomy may be performed

54.  It is an acute inflammation of pancreas presenting with abdominal pain and usually associated with raised pancreatic enzymes 100 blood or urine.

55.  Biliary calculi  Alcoholism.  Biliary or gastric surgery, especially:  Billroth II and Partial Mastectomy.  Trauma, e.g. Blow to the Pancreas.  Distortion of Ampulla of Vater due to peptic ulcer or Ampullary carcinoma  Generalized disorders e.g. hypercalcaemia, hyperlipidemia, diabetes mellitus and Prophyria.

56.  Drugs, corticosteroids.  Viral infection of pancreas as mumps virus  Auto immune disease, e.g. Polyarteritis Nodosa  Impaired pancreatic blood flow, e.g. after cardiopulmonary by pass and following hypothermia.

57.  impaction of small stone in Ampulla of Vater → ↑ intra- pancreatic pressure → reflux of bile into pancreas &mixture of bile with pancreatic juice → activation of pro-enzymes & formation of highly toxic lysolecthin. Activated enzymes leaks out into interstitium due increased intraductal pressure.  Inflammation, proteolysis, fat necrosis & hemorrhage occur the in interstitium of pancreas

58.  Impaction of gall stone in the Ampulla with subsequent passage into duodenum → damages of sphincter of Oddi → reflux of duodenal jaundice into pancreas & enterokinase activates pancreatic enzymes with in the substance of pancreas..  Inflammation,proteolysis, fat necrosis and hemorrhage.

59.  Chronic Alcoholism ◦ this cause secretion of protein rich pancreatic fluid → deposition of inspissations of protein plugs & obstruction of small pancreatic ducts followed by degeneration of acini and fibrosis.  Interstitial leak of activated enzyme ◦ inflammation, proteolysis, fat necrosis and hemorrhage incase of viruses, drugs and trauma ◦ direct injury to acini lead to intra-pancreatic release and activation of enzymes inflammation, proteolysis, fat necrosis and hemorrhage.

60.  Pain: ◦ sudden onset epigastric pain radiated to left and right and through to back, steadily increase in severity until it is very severe and makes the patient lie still and breath shallowly. no relieving factors except analgesics. The pain aggravates by movement.  Nausea and vomiting with trenching sweat.  Muscle twitches, cramps and spasms, and tetany ◦ caused by hypocalcaemia when there is extensive intra abdominal fat necrosis.

61.  General signs: ◦ patient lie still. ◦ Pale and sweaty (due to hypovolemia) ◦ Dyspnea and cyanosis (due to pan interfering with respiration). ◦ Jaundice. ◦ Pyrexia.

62.  local signs: ◦ Mild abdominal distension (as paralytic items may develop) ◦ Bruising and discoloration in left flank (Grey Turner’s sign) k and around umbilicus ( Cullen’s sign). ◦ Tenderness in upper abdomen ◦ Abdominal guarding but not as intense as the severity of pain. ◦ Bowel sounds may be reduced or absent.

63.  Serum amylase: ◦ elevated to about 1000somogyi units.  Plain abdominal X-ray may show: ◦ air containing, slightly dilated loop of small bowel over left upper quadrant, called a sentinel loop ◦ moderate distension of duodenum with an air fluid level. ◦ Mild distension of transverse colon with collapse of descending colon, called colon cut of f sign.  Ultrasonography ◦ confirms pancreatic edema and may demonstrate calculi in gall bladder or bile duct.

64.  Bed rest:  Supportive intravenous therapy:  restore adequate blood volume  A careful fluid balance  Daily serum electrolyte estimation are made together with acid- base studies.

65. ◦ Full water replacement is given by intravenous route. ◦ Calories are given as glucose. ◦ Na, K, and CL are given in appropriate amounts  Ca deficiency, is treated by Ca Gluconate IV.

66.  Nasogastric aspiration ◦ a. continuous suction removes gastric HCL From entering duodenum thus suppressing nominal stimulation of exocrine secretion of pancreas. ◦. it also brings relief from persistent nausea and vomiting  Relief of pain: ◦ Pethidin HCL 50 100 mg ◦ rarely Splanchnic block and epidural anesthesia for the relief of sever pain.

67.  Prophylactic antibiotics: ◦ Given as prophylactic against infection of necrotic retroperitoneal tissues, and also against bronchopneumonia. Abroad – spectrum antibiotic, e.g. Cefoperazone (Prontokef) should be given for 3–5days.  Endoscopic sphincterotomy ◦ Gall stone pancreatitis will be improved if a stone is obstructing the Ampulla of Vater.

68.  shock: due to fluid loss in GTT ◦ 3rd space collection in peritoneal and pleural cavities & intravascular space. ◦ Treatment is by: fluid replacement, in the form of whole blood, plasma expanders, or albumin. ◦ central venous pressure monitoring.  pulmonary insufficiency due to: ◦ elevation of diaphragm ◦ reduce ventilation due to pain. ◦ right to left arterial shunting of blood in lungs. ◦ Treatment is by early provision of supplementary O2

69.  Infection : secondary infection of necrotic tissue in pancreatic bed.  hypocalcaemia  colonic stricture

70.  Pseudocyst ◦ Symptoms  An epigastric swelling which a pear during conservative treatment of pancreatitis or in traumatic cases during or after convalescence. ◦ Signs:  there is swelling : control, above the umbilical, the swilling is variable in size some times as large as melon, it is fixed consistency may be so tense, that fluctuation cannot be elicited. ◦ The transmitted pulsation is very prominent from the abdominal aorta.

71. ◦ Diagnostic investigation:  x-ray with barium meal shows projection of cyst in to hallow viscera especially stomach  ultrasonography  CT scanning ◦ Treatment:  No action if the pseudocyst is acute or is less than 6 cm in size  Cystogastrotomy or cystojejunostomy if infection has supervened, if present for 2 to 3 months, or if over 6 cm in diameter.

73.  Def: An inflammation involving the Biliary tree  Etiology: Complete or partial Biliary tree obstruction  Clinically: Charcot’s triad (Jaundice, rigors and tender Hepatomegaly)  Investigations: WCC ( ), Blood Culture, USS, LFT MRCP.  Treatment: ◦ Antibiotics: (Cefuroxime/ Metronidazol and Gentamicine) ◦ Urgent Decompression in presence of pus: Endoscopically inserted cannula via the Ampulla of Vater or percutaneous transhepatic drainage

74.  Etiology: Spontaneous (in splenomegaly) or vascular (Occlusion or Embolism from SBE)  Clinical: ◦ asymptomatic or commonly LUQ abd. Pain ◦ Overlying guarding and a friction rub  Treatment: ◦ Rest and analgesics ◦ Splenectomy in cases of septic infarcts which causes abscess

75.  Etiology: ◦ Diseases spleen (Malaria, Infectious mononucleosis, lymphoma, typhoid) ◦ Splenomegaly: trivial trauma causes splenic distorsion  Clinical: ◦ Shock: pallor, weak and rapid pulse, low BP, and air hunger ◦ LUQ pain, tenderness, guarding and rigidity ◦ Special signs:  Balance’s sign: shifting dullness on the right flank and fixed dullness of the left side of the patient’s abdomen (due to blood in the peritoneal cavity in the right flank)

76. ◦ Kehr’s sign: pain in the left shoulder (diaphragm irritation) – especially when in Trendlenburg position or during pressure on the left hypochondrium. ◦ Fullness in the bladder on PR  Investigations (only if patient is stable): ◦ Blood: low Hb and Hematocrit (bleeding)

77. ◦ USS or CT abdomen (surrounding hematoma and hemoperitoneum) ◦ Plain Abd X-ray (obliteration of psoas shadow, fracture of lower ribs, elevate lt. hemidiaphragm, obliteration of the splenic outline and indentation of the left side of the gastric air bubble and free fluid between gas filled intestinal loops).  Treatment: ◦ Correction of the hemodynamic state of the patient. ◦ Spleen preservation (Vicryl mesh bag compression) ◦ Splenectomy

78.  Aortic Aneurysm: a permanent localized dilatation of the Aorta (95% of cases involves the abdominal Aorta)  Rupture: Anterior (Peritoneal - 20%), Posterior (Retroperitoneal - 80%) ◦ Posterior rupture is less serious because of retroperitoneal tissue resistance  Signs of AAA rupture: ◦ Acute upper abdominal, back or flank pain ◦ Pulsatile tender abdominal mass with weak femoral pulses ◦ Signs of shock and in some case a brief LOC

79.  Treatment:  Resuscitation ◦ Two IV lines, blood G&S (8 units) ◦ Saline or volume expanders infusion (raise BP to approx. 100mmHg never more) for fear of uncontrolled hemorrhage  Urgent surgery to repair the Aneurysm ◦ Open Surgery (Implant a synthetic graft) ◦ Endovascular repair (bilateral femoral arteriotomies through which an endoluminal stent is grafted

80.  Def: Inflammation of the mesenteric lymph nodes (primarily ileocecal) – common in childhood.  Etiology: Unknown, sometimes viral, Yersinia Enterocolitica (His. Of URTI)  Clinical features ◦ Severe upper abdominal pain which localizes to the umbilicus, colicky in nature and of a short duration ◦ Headache and mild photophobia (Never in acute Append.)

81.  Associated with nausea, vomiting, anorexia, malaise and fever (higher than acute appendicitis)  On Examination  there is guarding but not rigidity, tenderness and rebound tenderness  Shifting Tenderness: (Laying the patient to the left for a few minutes shifts the point of maximum tenderness towards the midline). ◦ Investigations: WCC is high but relative lymphocytosis. ◦ Management:  Surgery is done on the provisional diagnosis of Acute appendicitis. Perform appendicectomy  Otherwise treatment is symptomatic  Tuberculous mesenteric adenitis may be indistinguishable from acute appendicitis.

82.  Intestinal Diverticula: Blind ended pouches originating from the lumen of a hollow viscus (Meckel’s and Colonic).  Intestinal Diverticulitis: inflammation of intestinal Diverticula.

83.  Meckel’s Diverticulitis: simulates Acute Appendicitis and may become gangrenous, rupture and perforate. ◦ Result from obstruction by food residue ◦ Occurs in 2%, 2 inches long and 2 feet away from the ileocaecal junction. ◦ Treatment: resection if symptomatic. If it is discovered incidentally without symptoms, leave in situ (especially in older patients).

84.  Colonic Diverticulitis (mainly sigmoid) ◦ Inflammation of the neck of the diverticulum cause inflammation, perforation and consequently localized or generalized peritonitis. ◦ Bleeding could occur due to erosion of BV at the neck of the diverticulum. ◦ Presents with Lower abdominal colicky pain with localized somatic pain and tenderness in the LIF. Additionally there is diarrhea, constipation, abdominal distension and fever