2. Dr. Abdul Ghani Soomro Associate Professor Surgery LUMHS Jamshoro

5. ACUTE ABDOMEN
1 .Pain
2.Vomiting
3.Constipation
4.Abdominal distention

6. Acute abdomen
Spectrum of medical and surgical conditions ranging from trivial to life threatening that requires hospital admission investigations and treatment .

7. Diffuse difficult to localize Referred pain
Somatic
Abdominal wall
Peritoneum
Visceral
Diffuse difficult to localize
Referred pain
Irritation of abdominal organ

8. Symptoms Luminal obstruction Inflammation. Appendicitis Cholecystitis
Pancreatitis
Peritonitis.
Perforated viscus
Strangulation
Intra peritoneal collection
Bile
Blood
Pus I

10. Organ Location of Pain Pathology Liver Right Upper quadrant Hepatitis
Common Causes of acute abdominal pain
Organ
Location of Pain
Pathology
Liver
Right Upper quadrant
Hepatitis
Liver abscess
CCF

11. Organ Location of Pain Pathology Biliary Tract Right Upper quadrant
Common Causes of acute abdominal pain
Organ
Location of Pain
Pathology
Biliary Tract
Right Upper quadrant
Choleycystitis
Cholelithiasis
Choledocholithiasis

12. Common Causes of acute abdominal pain
Organ
Location of Pain
Pathology
Pancreas
Epigastrium
Right Hypochondrium
Left Hypochondrium
Acute Pancreatitis
Ca Pancreas
Ca Oesaphagus

13. Common Causes of acute abdominal pain

14. Common Causes of acute abdominal pain

15. Common Causes of acute abdominal pain

16. Common Causes of acute abdominal pain

17. Common Causes of acute abdominal pain

18. Common Causes of acute abdominal pain

19. Common Causes of acute abdominal pain

20. Common Causes of acute abdominal pain

21. Common Causes of acute abdominal pain

22. Taking the history of a patient with acute abdomen
Specific question
When 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?

23. Taking the history of a patient with acute abdomen
Specific question
Are 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?

24. Taking the history of a patient with acute abdomen
General enquiries
History of alcohol intake
Drug history
History of previous surgery
History of Pre-existing disease
History of travel (Especially foreign)
Family history

25. Investigations
Blood CP
Urea Creatinine
Blood Sugar
Serum Amylase
LFTs
Pregnancy Test
Urine DR
ECG

26. Imaging
Radiography
Abdomen
Chest
Ultrasound Abdomen
CT Scan
MRI
Barium Studies
Endoscopy
Laparoscopy / Laparotomy

27. Acute abdomen in infants & Children
Congenital atresia
Volvulus
Meconieum ileus
Meckl’s diverticulum
Inguinal Hernia

28. Common Surgical Emergencies
Acute Appendicitis
Liver Abscess
Abdominal Tuberculosis
Typhoid Perforation
perforated peptic ulcer
Abdominal wall hernia

29. Acute Appendicitis Most common abdominal emergency.
Uncommon before the age of 2 years.
Peak incidence in twenties and thirties

30. Aetiology The vermiform appendix is a vestigial structure.
7-10 cm in length.
Exact cause is unclear but luminal obstruction, diet, familial factors have been suggested.

32. Pathology
Minor, 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.

33. Clinical 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.

34. Clinical Examination Tachycardia. Mild Pyrexia Guarding in RIF
Fetor oris
Tenderness on rectal / vaginal examination.
Rovsings sign, psoas stretch sign.
Obturater test

36. Anatomical Feature influencing Presentation
1. Retrocaecal
Muscular rigidity often absent
Right hip in flexed position due to psoas spasm
Psoas stretch sign.

37. 2. Post ileal 3. Pelvic Diarrohea and Vomiting
Prominent feature due to irritation of ileum.
3. Pelvic
Diarrohea due to irritation of rectum.
Increased frequency of micturation.
Microspic haematuria.
Tenderness on rectal and viginal examination.
Obturator sign.

38. Age Related features affecting presentation
Children
Difficulty in obtaining
Proper history
Difficulty in differentiating from mesenteric adenitis and enteritis.

39. Elderly Under developed omentum leading to early complications.
Less prominent Symptoms
Afebrile
Normal white cell count.

40. Pregnancy
1 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.

41. Complications
Perforation
Appendix mass
Appendix abscess

42. Differential Diagnosis
Thorax and Respiratory Tract
Tonsilltis
Pneumonia

43. Abdomem Intestinal Obstruction Intussusception Acute cholecystitis
Perforated Peptic ulcer
Mesenteric adenitis
Terminal ileitis
Meckel’s diverticulitis

44. PELVIS Ectopic Pregnancy Ruptured ovarian follicle
Torsion of ovarian cyst
Salpingitis
PID

45. URINARY SYSTEM
Right Pyelonephritis
Right Uretric Colic

46. OTHER Diabetic ketoacidosis Rectus sheath haematoma Pancreatitis
Pre Herpetic Pain

47. INVESTIGATIONS
Blood cp
Urine analysis

48. Faecolith 50% of children < 2 years
RADIOGRAPHY
Faecolith 50% of children < 2 years
Ultrasound abdomen
C.T Scan
Laparoscopy

49. TREATMENT
Appendicetomy
Open
Laparoscopic

51. Amoebic liver Abscess It is common in indo-pak
Caused by parasite entamoeba histolytica
Common in alcoholics
Infection commonly occurs in caecum and rectosigmoid junction via superior and inferior mesentric veins and portal vein to liver.

52. Right 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.

53. E. Histolytica Life Cycle
2 stages:
-Infective cyst stage
- Multiplying trophozite stage
2 forms:
- Active parasite (trophozite)
- Dormant parasite (cyst)
Infection begins when cysts are swallowed
Cysts hatch---releasing trophozites that multiply
Trophozites 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 trophozites
Outside the body, trophozites die but cysts remain.
Merck Manual Home Edition 2003

55. Complications
Rupture 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 skin
Amebiasis: Parasitic Infections: Merck Manual Edition 2007

57. Treatment Drugs Aspiration under ultrasound guidance Metronidazole
Tinidazole
Chloroquine
Diloxanate furoate
Iodoquinol
Paromycin
Aspiration under ultrasound
guidance

59. Surgery
Thick pus
Ruptured liver abscess

60. Common Surgical Emergencies
Acute Appendicitis
Liver Abscess
Abdominal Tuberculosis
Typhoid Perforation
perforated peptic ulcer
Abdominal wall hernia

71. THANK YOU