1. 1 ACUTE ABDOMEN DR SAMEER A SOFTA MD,FRCSC ASSISTANT PROFESSOR OF SURGERY FACULTY OF MEDICINE UMM ALQUORA UNIVERSITY HOLLY MAKKAH.

2. 2 ACUTE ABDOMEN DEFINITION: ABDOMINAL PAIN THAT HAS SEVERE ILLNESS THAT IS A MAJOR PHYSIOLOGICAL STRESS. ABDOMINAL PAIN THAT HAS SEVERE ILLNESS THAT IS A MAJOR PHYSIOLOGICAL STRESS.APPROACH: IS NECESSARY TO MAKE THE DIAGNOSIS BEFORE INITIATING TREATMENT? IS NECESSARY TO MAKE THE DIAGNOSIS BEFORE INITIATING TREATMENT? IT IS AN EXERCISE OF CLINICAL SKILLS IT IS AN EXERCISE OF CLINICAL SKILLSHISTORY: CATASTROPHIC ILL & HISTORY CATASTROPHIC ILL & HISTORY PREVIOUS SURGERY & CHRONIC MEDICAL PROBLEM PREVIOUS SURGERY & CHRONIC MEDICAL PROBLEM PREVIOUS LABARATORY OR RADIOLOGICAL WORK-UP PREVIOUS LABARATORY OR RADIOLOGICAL WORK-UP

3. 3 ACUTE ABDOMEN CHARACTERISTIC OF PAIN: LOCATION ONSET (SUDDEN, RAPID, GRADUAL) COURSESEVERITY CHARACTER (STEADY, CRAMPY, EPISODIC) MODIFYING FEATURES (DIET,BOWEL, FUNCTION,ACTIVITY,POSITION, BREATHING)

4. 4 ACUTE ABDOMEN DIFFERENTIAL DIAGNOSIS: BY RATE OF ONSET IMMIDIATE: RAPID(MINUTES) GRADUAL(HOURS) ESOPHAGEAL PERFORATION BILIARY COLIC ULCER DISEASE JLCER PERFORATION RENAL OR URETERIC COLIC GASTRITIS PERFORATED CANCER SBO ULCERATIVE COLITIS PERFORATED DIVERTICULITIS PORPHYRIA CROHN`S DISEASE RUPTURED ANEURISM SICKLE CELL CRISIS SIGMOID DIVERTICULITIS RUPTURE SPLEEN LEAD INTOXICATION CYSTITIS RUPTRE HEPATIC ADENOOMA BLACK WIDOW ENVENOMATION PID RUPTURE KIDNEY ACUTE PANCREATITIS APPENDICITIS RUPTURED ECTOPIC PREGNANCY COCAINE ENTOXICATION PANCREATITIS INTESTINAL ISCHEMIC PERFORATION CHOLECYSTITIS SPLEENIC,HEPATIC, RENAL INFARCTION PYELONEPHRITIS NARCOTIC WITHDRAWAL NARCOTIC WITHDRAWAL

5. 5 ACUTE ABDOMEN DIFFERENTIAL DIAGNOSIS: BY ORGAN SYSTEM PERITONEAL : PANCREAS & BILIARY TREE ABSCESS ACUTE PANCREATITIS 1RY PERITONITIS ACUTE CHOLECYSTITIS CHOLANGITIS CHOLANGITIS RETROPERITONEAL: GYENECOLOGICAL: ABSCESS RUPTREED ECTOPIC PREGNANCY HEMORRHAGE RUPTERED TUBOOVARIAN ABSCESS GASTROINTESINAL: RUPTURED CYST APPENDICITIS SALPINGITIS INTESTINAL OR COLONIC OBSTRUCTION ENDOMETRITIS STRANGULATED HERNIA ENDOMETRIOSIS PUD PERFORATED PUD VASCULAR: INTESTINAL PERFORATION RUPTURED AORTIC,ILEAC OR VICERAL DIVERTICULITIS ANEURISM ACUTE GASTRITIS ACUTE MESENTERIC ISCHEMIA ACUTE GASTROENTRITIS LIVER & SPLEEN: HEPATITIS SEGMENTAL OR ORGAN ORGAN RUPTURE ABSCESS

6. 6 ACUTE ABDOMEN DIFFERENTIAL DIAGNOSIS: BY AGE CHILDHOOD ELDERLY COMMON COMMON APPENDICITIS BILIARY TRACT DISEASE NON SPESIFIC ABDOMINAL PAIN INTESTINAL OBSTRUCTION LESS COMMON PUD BOWEL OBSTRUCTION DIVERTICULITIS INTUSUSCEPTION APPENDICITIS OVARIAN CYST PANCREATITIS CHOLECYSTITIS HERNIA`S (INCARCERATED) SPONTANEUOS PERITONITIS LESS COMMON RUPTURED ANEURISM RUPTURED ANEURISM MESENTERIC ISCHEMIA MESENTERIC ISCHEMIA PERFORATED PUD PERFORATED PUD

7. 7 ACUTE ABDOMEN NON SURGICAL CAUSES OF ACUTE ABDOMEN INFECTION: ENDOCRINE, METABOLIC, HEMATOLOGIC 1RY PERITONITIS( TB, PNEUMOCOCCUS) ACUTE INTERMITTENT PORPHYRIA INFLAMATORY: MEDTERRANIAN FEVER PNEMONIA UREMIA PLEURISY DIABETIC CRISIS PERICARDITIS ADDISON`S DISEASE ESOPHAGITIS SICKLE CELL DISEASE HENOCH-SCHONLEIN PURPURA LEUKEMIC CRISIS ACUTE RHEUMATIC FEVER TOXIC RECTUS HEMATOMA COCAINE ENTOXICATION ISCHEMIA LEAD POISONING MYOCARDIAL INFARCTION ENVENOMATION(BLACK WIDOW SPIDER) PULMONARY EMBOLUS NARCOTIC WITHDRAWAL PULMONARY INFARCT NEUROGENIC HERPES ZOSTER HERPES ZOSTER TABES DORSALIS TABES DORSALIS SPINAL ROOT, CORD OR DISK DISEASE SPINAL ROOT, CORD OR DISK DISEASE

8. 8 ACUTE ABDOMEN CONDITIONS MODIFYING THE PRESENTATION OF ACUTE ABDOMINAL PAIN AGE:CHILDRENELDERLY CONDITIONS OF COMPROMIZED HOST DEFENSE: DMCUSHINGHIV MALIGNANCYPREGNANCYRECENT SURGERYSPINAL CORD INJURYMEDICATION

9. 9 ACUTE ABDOMEN PHYSICAL EXAMINATION: GENERAL INCLUDING VITAL SIGNS LOCAL EXAM LABORATORY EVALUATION: BLOOD WORKURINE IMMAGING STUDIES ABDOMINAL SERIES U/S CT CONTRAST STUDY ENDOSCOPY

10. 10 ACUTE ABDOMEN COMMONCAUSES OF ACUTE ABDOMINALPAIN TYPES OF EVALUATION PRESENTATIONDIAGNOSIS UPRIGHT CXR: FREEAIR DIFFUSE, SEVERE TENDERNESS; GUARDING, ABSENT BOWEL SOUND PERITONITIS GIT PERFORATION U/S, CT, BE LAPAROSCOPY MCBURNEY TENDERNESS, REBOUND;ANOREXIA APPENDICITIS U/S, AMYLASE ERCP UPPER ABD,TENDERNESS, ILEUS GREY TURNER SIGN ACUTE PANCREATITIS U/S MURPHY`S SIGN ACUTE CHOLECYSTITIS CT, INTERVAL BE LLQ TENDERNESS; REBOUND FEVER QUIET BOWEL SOUND DIVERTICULITIS ABDOMINAL SERIES, UGI NAUSEA & VOMITING ALKALOSIS BOWEL SOUND+- SMALL BOWEL OBSTRUCTION ABD, SERIES CT, ANGIOGRAPHY SEVERE PAIN BUT BENIGN ABDOMEN, BLOOD IN STOOL MESNTERIC ISCHEMIA U/S ERCP FEVER, JAUNDICE; RUQ TENDERNESS, GUARDING SEP CHOLANGITIS TRANS VAG U/S CULDOCENTESIS PREGNANCY TEST PERITONITIS; HYPOTENSION; ANEMIA, SHOCK ECTOPIC PREGNANCY U/S, CT ANGIOGRAPHY UPPER ABD TENDENESS BACK PAIN SHOCK RUPTURED AAA

11. 11 ACUTE APPENDICITIS EIDEMIOLOGY: 6-20% AT BIRTH 1 IN 5 BY AGE 50 1 IN 35 IN MEN 1 IN 50 IN WOMEN BY AGE OF 70 1 IN 100 BY AGE OF 70 1 IN 100 DISEASE OF ADOLESCENTS UNCOMMON UNDER 3 YEARS AND OVER 55 YEARS PATHOPHYSIOLOGY:APPENDICOLITHINFECTIONBACTERIOLOGY: POLYMICRIOBIAL POLYMICRIOBIAL GM – VE GM – VE ESCHERICHIA COLI 80 % ESCHERICHIA COLI 80 % PSUDOMONAS 40 % PSUDOMONAS 40 % ANNEROBES PEPTOSTRETOCOCCUS ( THE COMMONEST) ANNEROBES PEPTOSTRETOCOCCUS ( THE COMMONEST)

12. 12 DIFFERENTIAL DIAGNOSISI OF ACUTE APPENDICITIS BY AGE DIFFERENTIAL DIAGNOSISI OF ACUTE APPENDICITIS BY AGE CHILD HOOD ADULT & ELDERLY PATIENT MESENTERIC ADENITIS SIGMOID DIVERICULITIS GASTROENTRITIS (VIRAL, BACTERIAL) PERFORATED ULCER MEKELS DIVERTICULITIS CHOLECYSTITIS INTUSSUCEPTION PERFORATED NEOPLASM(CECUM, APP) HENOCH-SCHONLEIN PURPURA VASCULAR INSUFICIENCY 1 RY PERITONITIS ANEURISM OF AORTA & ILIAC HEPATITS YERSINIA ENTEROCOLITIS TYPHLITIS YERSINIA PSUDOTUBERCULOSIS YOUNG WOMEN URINARY TRACT INFECTION SALPINGITIS CECAL OR APPENDICEAL DIVERTICULITIS RUPTURED OVARIAN FOLLICLE RUPTURED ECTPIC PREGNANCY RARE CAUSES ENDOMETRIOSIS PANCREATITIS YOUNG MEN TUBERCULOUS ENTERITIS ACUTE REGIONAL ILEITIS FOREIGN-BODY PERFORATION TESTICULAR TORSION OMENTAL TORSION OR INFARCTION EPIDIDYMITIS INFARCTED APPENDIX EPIPLOICA COCCAINE WITHDRAWAL

13. 13 ACUTE ABDOMEN PATHOLOGY & PRESENTATION ACUTE NONE PERFORATING APPENDICITIS SYMPTOMES: ABD PAIN 95% LOCALIZING ANOREXIA 90% NAUSEA & VOMITTING 60-80% DIARRHEA 7-10 % FEVERCOMMON SIGNS: LOW GRADE TEMP TACHYCARDIA TENDERNESS & REBOUNDGUARDING, WHEN? ROFSING SIGNOBTURATOR SIGN PSOAS SIGN LAPARATORY EVALUATION: CBCELECTROLYEURINE ANALYSIS U/S?

14. 14 ACUTE ABDOMEN PATHOLOGY & PRESENTATION APPENDICITIS WITH PERFORATION OCCURS IN:20 % OF ACUTE APP IN CHILDREN LESS THAN 3 YEARS ADULT MORE THAN 50 YEARS WHY? DELAY IN DIAGNISIS SYMPTOMES: VERY ILL OR TOXIC PATIENTHIGH TEMP SIGNS: MARKED TACHY CARDIAHYPOVOLEMIA ? SEPTIC SHOCK LAPARATORY EVALUATION: CBCELECTROLYTEURINE ANALYSIS U/S CT SCAN?

15. 15 ACUTE ABDOMEN PATHOLOGY & PRESENTATION APPENDICEAL MASS OCCURS IN: 10 % OF ACUTE APP WHY? DELAY IN DIAGNISIS SYMPTOMES: VERY ILL OR TOXIC PATIENTHIGH TEMP SIGNS: MARKED TACHY CARDIAHYPOVOLEMIA ? SEPTIC SHOCK LAPARATORY EVALUATION: CBCELECTROLYTEURINE ANALYSIS U/S CT SCAN

16. 16 ACUTE ABDOMEN TREATMENT OF APPENDICITIS STRAIGHT FORWARD NONECOMPLICATED APPENDICITIS ADMISSIONREHYDRATION BLOOD CULTURE BROAD SPECTRUM ANTIBIOTIC INFORMED CONSENT FOR SURGERY APPENDECTOMY

17. 17 ACUTE ABDOMEN TREATMENT OF APPENDICITIS COMPLICATED APPENDICITIS PRFORATED APPENDIX COMPLICATED APPENDICITIS PRFORATED APPENDIX (NO MASS) ADMISSIONREHYDRATION BLOOD CULTURE BROAD SPECTRUM ANTIBIOTIC INFORMED CONSENT FOR SURGERY APPENDECTOMY

18. 18 ACUTE ABDOMEN TREATMENT OF APPENDICITIS COMPLICATED APPENDICITIS APPENDICEAL MASS (NO ABSCESS) ADMISSIONREHYDRATION BLOOD CULTURE BROAD SPECTRUM ANTIBIOTIC NATURAL HISTORY: WITHEN 24 HOURS IMPROVEMENT INTERVAL APPENDECTOM IN 6 WEEKS INTERVAL APPENDECTOM IN 6 WEEKS NO IMPROVEMENT LAPARATOMY & APPENDECTOMY IF SAVE V/S OPEN DRAINAGE

19. 19 ACUTE ABDOMEN TREATMENT OF APPENDICITIS COMPLICATED APPENDICITIS APPENDICEAL MASS & ABSCESS ADMISSIONREHYDRATION BLOOD CULTURE BROAD SPECTRUM ANTIBIOTIC INFORMED CONSENT FOR DRAINAGE NATURAL HISTORY: WITHEN 24 HOURS IMPROVEMENT INTERVAL APPENDECTOM IN 6 WEEKS INTERVAL APPENDECTOM IN 6 WEEKS NO IMPROVEMENT LAPARATOMY & APPENDECTOMY IF SAVE OR OPEN DRAINAGE

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