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    Evaluation of Acute Abdomen

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    This document provides an overview of evaluating patients presenting with acute abdomen. It discusses the importance of a thorough history and physical exam in making a diagnosis in most cases. Key elements to assess include characteristics of pain, associated symptoms, past medical and surgical history, and systemic exam findings. Common investigations include blood tests, urine analysis, imaging studies and more specialized tests depending on suspected conditions. The physical exam section describes assessment of vital signs, inspection, palpation techniques and specific examination maneuvers to evaluate for conditions like appendicitis, cholecystitis, intestinal obstruction and others.

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    Evaluation of Acute Abdomen

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    46 views38 pages
    This document provides an overview of evaluating patients presenting with acute abdomen. It discusses the importance of a thorough history and physical exam in making a diagnosis in most cases. Key elements to assess include characteristics of pain, associated symptoms, past medical and surgical history, and systemic exam findings. Common investigations include blood tests, urine analysis, imaging studies and more specialized tests depending on suspected conditions. The physical exam section describes assessment of vital signs, inspection, palpation techniques and specific examination maneuvers to evaluate for conditions like appendicitis, cholecystitis, intestinal obstruction and others.

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    This document provides an overview of evaluating patients presenting with acute abdomen. It discusses the importance of a thorough history and physical exam in making a diagnosis in most cases. Key elements to assess include characteristics of pain, associated symptoms, past medical and surgical history, and systemic exam findings. Common investigations include blood tests, urine analysis, imaging studies and more specialized tests depending on suspected conditions. The physical exam section describes assessment of vital signs, inspection, palpation techniques and specific examination maneuvers to evaluate for conditions like appendicitis, cholecystitis, intestinal obstruction and others.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPS, PDF, TXT or read online from Scribd
    Download as pps, pdf, or txt
    46 views38 pages

    Evaluation of Acute Abdomen

    Uploaded by

    أبو عبيدة
    This document provides an overview of evaluating patients presenting with acute abdomen. It discusses the importance of a thorough history and physical exam in making a diagnosis in most cases. Key elements to assess include characteristics of pain, associated symptoms, past medical and surgical history, and systemic exam findings. Common investigations include blood tests, urine analysis, imaging studies and more specialized tests depending on suspected conditions. The physical exam section describes assessment of vital signs, inspection, palpation techniques and specific examination maneuvers to evaluate for conditions like appendicitis, cholecystitis, intestinal obstruction and others.

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    of 38

    Evaluation of Acute Abdomen

    By Dr. Conrad DCosta, MS, DNB (Senior House Officer) Mr.Sudhir Jain,MS,FRCS,FACS, (Specialist Registrar Surgery) North Middlesex University Hospital,London

    Acute Abdomen
    Challenge to Surgeons & Physicians Most common cause of surgical emergency admission Clinical course can vary from from minutes to hours to weeks. It can be an acute exacerbation of a chronic problem e.g. Chronic Pancreatitis,Vascular Insufficiency.

    DEFINITION
    Acute Abdomen is a term used synonymously for a condition that needs immediate surgical intervention

    ASSESMENT
    Well elicited history Proper physical examination Diagnosis can be made most of the time by a good history and a proper physical examination.

    Assesment(cont.)
    Investigations are usually carried out : only to support the diagnosis. or to narrow down the differential diagnoses.

    History
    History of Present illness Family History Past Medical history History of drugs taken or Medication eg. ingestion of certain toxic drugs or Alcohol intake

    PAIN
    The Most Important Symptom History of pain should include: 1. Onset 2. Severity 3. Type of pain 4. Radiation of Pain 5. Change in nature of Pain 6. Associated bowel or urinary symptoms 7. Aggravating or relieving factors

    (i) Onset of Pain


    Sudden onset pain which wakes the patient from sleep eg. perforation or strangulation of bowel Slow insidious Onset a. Inflammation of visceral peritoneum. b. Contained process such as evolving abscess. Crampy or colicky pain Biliary colic, Ureteric colic or Intestinal colic

    (ii) Progression of Pain


    Progression from: Dull, aching, poorly localized character To: Sharp, constant & better localized pain
    indicates involvement of Parietal peritoneum

    (iii) Associated Bowel Symptoms


    CONSTIPATION
    a. Progressive intestinal obstruction from a neoplasm or inflammatory bowel disease b. Paralytic Ileus c. Post Operative d. Obstructed groin hernia

    (iv) Associated Bowel Symptoms


    DIARRHOEA
    Diarrhoea with pain is mainly medical. The following are the exceptions: a. b. c. d. Obstructed Richter's Hernia Gall Stone ileus Superior mesenteric vascular occlusion Intestinal Obstruction associated with pelvic abscess e. Spurious diarrhea in chronic faecal impaction

    DRUG HISTORY
    Corticosteroids mask pain Anticoagulants can lead to an intramural haematoma of the gut causing obstruction Oral Contraceptives - rupture of hepatic adenomas NSAIDs - erosive gastritis & peptic ulcers

    NAUSEA & VOMITING


    (i) Frequency of vomiting (ii) Character of vomiting: projectile, non-projectile or self-induced

    (iii) Nature of vomiting:


    a. Bilious vomiting of small bowel obstruction b. Non-bilious vomiting in obstruction proximal to ampulla of vater c. Faeculent vomiting in distal small gut obstruction, large bowel obstruction , strangulation

    NAUSEA & VOMITING


    Pain first, followed by Vomiting is usually surgical. The vomiting is due to reflex pylorospasm Nausea & vomiting first , followed by pain is usually due to a medical condition

    Vomiting (cont.)
    Vomiting is very prominent in a. Mallory-Weiss syndrome. b. Boerhaave syndrome(transmural esophageal tear) c. Acute gastritis d. Acute pancreatitis

    ANOREXIA
    Anorexia or decreased appetite with pain is usually seen in Acute appendicitis

    Urinary Symptoms with Pain


    Ureteric colic Cystitis

    FEVER & CHILLS/RIGORS

    Amoebic Liver Abscess Pygenic Liver Abscess Perinephric Abscess Intra-abdominal pus collection

    OTHER HISTORY
    Past Surgical history: previous operationsleading to adhesions Past Medical history: Sickle cell disease, Diabetes or Cancer or Renal failure Menstrual History in females (i) Missed period- ectopic pregnancy (ii) Mid of period-ovulation pain (Mittelschmerz) (iii) With heavy periods- endometriosis Family history of colon cancer, any other malignancy or inflammatory bowel disease

    Physical Examination
    General Appearance a. Anxious Patient lying motionless: (i) Acute appendicitis (ii) Peritonitis b. Rolling in bed & restless: (i) Ureteric Colic (ii) Intestinal colic c. Writhing in Pain: Mesenteric Ischemia

    Physical Examination (contd.)


    d. Bending Forward: Chronic Pancreatitis e. Jaundiced: CBD obstruction f. Dehydrated (i) Peritonitis (ii) Small Bowel obstruction

    Physical Examination (contd.)


    Vital Charting Temperature, Pulse, BP, Respiratory rate Ruptured AAA or ectopic pregnancy can lead to -Pallor -Hypotension -Tachycardia -Tachypnea

    Physical Examination (contd.)


    -

    Low grade temp. is seen with Appendicitis Acute cholecystitis High grade temp. is seen with Salpingitis Abscess Very High Grade Temp.with increasing lethargy seen in imminent septic shock Peritonitis Acute cholangitis Pyonephrosis

    Systemic Examination
    Cardiopulmonary examination Check for: - Possible MI - Basal Pneumonia - Pleural Effusion

    Systemic Examination
    Per Abdomen: Inspection - Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

    Systemic Examination
    Erythema or discolouration a. Peri-umbilical - Cullen sign b. Inguinal Fox sign c. Flanks - Grey Turner sign Seen in Hemorrhagic pancreatitis or any other cause of haemoperitoneum Any Visible masses Any visible cough impulse at hernia site

    Systemic Examination
    Per abdomen: Palpation Be gentle Start away from site of pathology then towards Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis.

    Systemic Examination
    Local Right Iliac Fossa tenderness: a. Acute appendicitis b. Acute Salpingitis in females c. Amoebiasis of Caecum Low grade, poorly localized tenderness: Intestinal Obstruction Tenderness out of proportion to examination: a. Mesenteric Ischemia b. Acute Pancreatitis Flank Tenderness: a. Perinephric Abscess b. Retrocaecal Appendicitis

    Systemic Examination
    Rovsings Sign in Acute Appendicitis Obturator Sign in Pelvic Appendicitis Psoas Sign - Retrocaecal appendicitis - Crohns Disease - Perinephric Abscess

    Systemic Examination
    Murphy's sign in Acute Cholecystitis Thumping tenderness over lower ribs in inflammation of -Diaphragm - liver or spleen

    Systemic Examination
    Pulsatile Abdominal Mass with Hypotension Leaking AAA Cutaneous Hyperaesthesia indicates involvement of Parietal Peritoneum

    Systemic Examination
    Per Rectal Examination: - tenderness - induration - mass (Blummers shelf) - frank blood

    Systemic Examination
    Per Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

    INVESTIGATIONS
    Complete Blood Count with differential C-reactive protein estimation Electrolyte ,Blood Urea , Creatinine Urine dipstick Amylase or Lipase Liver Function Test

    Radiology
    Upright X ray chest for - Basal Pneumonia - Ruptured Oesophagus - Elevated Hemi diaphragm - Free Gas under diaphragm

    Radiology
    Abdominal X ray film
    Air-Fluid Levels Stones Ascites Eggshell calcification in AAA Air in Biliary tree. Obliteration of Psoas Shadow in retroperitoneal disease - Right lower quadrant sentinel loop in acute appendicitis

    INVESTIGATIONS
    Other Investigations - USG - CT abdomen for AAA, Pancreatic disease, or ureteric colic (nonContrast) - IVU - Mesenteric Angiography for Ischaemia, Haemorrhage

    THANK YOU

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