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    Clinical aPPROACH TO Acute Abdomen: Dr. J. S. Lamba

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    Pushpanjali Crosslay Hospital
    This document discusses the clinical approach to acute abdomen. It begins by defining acute abdomen as severe abdominal pain of short duration requiring immediate management to determine if urgent surgery is needed. It then provides details on the frequent causes, clinical features, examination steps, differential diagnoses for upper and lower abdominal pain, clinical patterns, and natural history of common causes. The goal is to diagnose from a limited set of options and appropriately determine treatment.

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    Clinical aPPROACH TO Acute Abdomen: Dr. J. S. Lamba

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    Pushpanjali Crosslay Hospital
    108 views27 pages
    This document discusses the clinical approach to acute abdomen. It begins by defining acute abdomen as severe abdominal pain of short duration requiring immediate management to determine if urgent surgery is needed. It then provides details on the frequent causes, clinical features, examination steps, differential diagnoses for upper and lower abdominal pain, clinical patterns, and natural history of common causes. The goal is to diagnose from a limited set of options and appropriately determine treatment.

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    Dr.J.S Lamba

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    This document discusses the clinical approach to acute abdomen. It begins by defining acute abdomen as severe abdominal pain of short duration requiring immediate management to determine if urgent surgery is needed. It then provides details on the frequent causes, clinical features, examination steps, differential diagnoses for upper and lower abdominal pain, clinical patterns, and natural history of common causes. The goal is to diagnose from a limited set of options and appropriately determine treatment.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPS, PDF, TXT or read online from Scribd
    Download as pps, pdf, or txt
    108 views27 pages

    Clinical aPPROACH TO Acute Abdomen: Dr. J. S. Lamba

    Uploaded by

    Pushpanjali Crosslay Hospital
    This document discusses the clinical approach to acute abdomen. It begins by defining acute abdomen as severe abdominal pain of short duration requiring immediate management to determine if urgent surgery is needed. It then provides details on the frequent causes, clinical features, examination steps, differential diagnoses for upper and lower abdominal pain, clinical patterns, and natural history of common causes. The goal is to diagnose from a limited set of options and appropriately determine treatment.

    Copyright:

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    of 27

    Clinical aPPROACH TO

    ACUTE ABDOMEN

    DR. J. S. LAMBA
    MBBS, MS, FICS
    SR CONSULTANT
    DEPT. OF SURGERY,
    PUSHPANJALI CROSSLAY HOSPITAL,
    VAISHALI, GHAZIABAD
    ACUTE ABDOMEN
    “the general rule can be laid down that the majority of
    severe abdomonal pain which ensue in patients who
    have been previously fairly well, and which last as
    long as six hours, are caused by conditions of
    surgical import.”
    [zachary cope, 1881-1974]

    Acute abdomen refers to severe abdominal pain of


    short duration that requires fairly immediate
    management and decision regarding an urgent
    surgical intervention.
    ACUTE ABDOMEN
     Frequent causes of acute abdomen
     Clinical features
     How to perform physical examination
     D/d upper abdominal pain
     D/d lower abdominal pain
     Clinical patterns
     Natural history of frequent causes
     Conclusion
    Frequent causes of acute abdomen
    LONG LIST—DIAGNOSIS FROM A LIMITED MENU

    1.Inflammatory
    a) Bacterial --appendicitis, diverticulitis, PID
    b) Chemical– peptic perforation, ac. pancreatitis

    2.Mechanical
    Obstruction—incarcerated hernia, adhesions, intussusception,
    large bowel obstruction -- CA or volvulus

    3.Vascular
    Ac mesenteric arterial thrombosis/embolism
    Mesenteric venous thrombosis
    ABDOMINAL PAIN

    Visceral
    Somatic
    Referred
    VISCERAL
     stretching of peritoneum or organ capsule by
    distension or oedema
     diffuse
     Poorly localised
     May be perceived at remote locations related
    to organ’s sensory innervation
    SOMATIC
     Inflammation of peritoneum or diaphragm
     Sharp
     Well localised

    REFERRED
     Perceived at distance from diseased organ
     Pneumonia
     Acute MI
     Male GU problem
    C/F OF ACUTE ABDOMEN

    PAIN

    1) Origin & location


     Epigastric - stomach, duodenum, pancreas, liver,
    biliary tree, associated parietal peritoneum, HEART
     Periumbilical - small intestine, appendix, upper ureter
     Hypogastric - colon, bladder, lower ureter, uterus
    2) Radiation
    appendicitis, cholecystitis, renalcolic, pancreatitis,
    peptic perf.,ruptured ectopic pregnancy, spleen. Pain
    of abd aortic aneurysm radiates from lower back to
    one or both legs

    3) Type of onset & Intensity


    sudden & severe -- rupture of viscus,mesenteric
    thrombosis,infarct,haemorrhage
    gradual & moderate-- cholecystitis,appendicitis,
    peritoneal irritation,hollow organ
    distension
    4) Quality
    dull-- epig pain of appendicitis
    sharp/colicky-- renal,biliary,int obst
    aching-- PID
    pleuritic-- intensified by breathing
    lancinating--pancreatitis

    5) Special features
    continuous-ac pancreatitis
    pulsatile-abdominal aneurysm
    colicky-int obst,gall /renal colic
    6) Factors which intensify/relieve pain
    relation to meals—peptic ulcer, cholecystitis
    postural-appendicitis, pancreatitis
    movement-peritonitis

    7) Associated symptoms
    nausea/ vomiting/ diarrhoea/ obstipation
    haematochesia/ malaena/ change in urinary
    habits /fever

    MURPHY’S SYNDROME

    8) EXTRA ABDOMINAL CONDITIONS WHICH


    SIMULATE THE ACUTE ABDOMEN ARISE MOST
    OFTEN IN HEART,LUNGS,URINARY TRACT AND
    FEMALE REPRODUCTIVE ORGANS
    Complete physical examination
     vitals
     Anaemia, shock, haemorrhage, dehydration
     Palpation– must expose abdomen fully
    pt on back&knees bent
    warm hands
    work towards area of pain
    tenderness, rigidity, guarding, masses
    Percussion hyper resonant,liver dullness
     Auscultation-- listen for 1 minute in each quadrant
    MUST EXAMINE HEART & LUNGS
     P/R
     Bimanual pelvic exam
    EQUIVOCAL FINDINGS—RE EXAMINE AT
    D/d of diseases causing upper
    abdominal pain
     Ac oesophagitis
     Ac appendicitis
     Ac cholecystitis
     Perforated peptic ulcer
     Ac pancreatitis
     Pleurisy / pneumonia
     Ac coronary occlusion - consider possible MI with
    pain referred to abdomen in patient >30 years old
    D/d of diseases causing lower
    abdominal pain

     Ac appendicitis
     Ureteral obstruction
     Ac diverticulitis
     Ac salpingitis
     Ectopic pregnancy
     Twisted ovarian cyst
    OESOPHAGITIS

     Inflammation of distal oesophagus


     Usually from gastric reflux,hiatal hernia
     Substernal burning pain
     Worsened by supine position
    PANCREATITIS

     Sudden, severe,constant mid epigastric pain


    radiating to back
     Often worsened by food
     Profuse vomiting
     Less guarding than peptic perf
     Bluish flank discoloration[Grey Turner sign]
     Bluish periumbilical discoloration[Cullen sign]
     Absent bowel sounds
    CHOLECYSTITIS

     Sudden pain, often severe in RUQ


     Radiating to right shoulder
     Nausea,vomiting
     Often associated with fatty food intake
     Point tenderness under R costal margin [Murphy’s
    sign]
    APPENDICITIS

     Periumbilical pain—RLQ
     Nausea, vomiting, anorexia
     Low grade fever
     Mc burney’s sign
     Aaron’s sign epig pain on palpation of RLQ
     Rovsing’s sign pain in LLQ on palpation of RLQ
     Psoas sign pain when patient extends R leg while
    lying on left side
    PERFORATED PEPTIC ULCER

     Sudden, intense & constant pain


     Patient keeps abdomen immobile
     Rapid shallow breathing
     Tenderness, guarding alover abd
     Liver dullness masked
     Absent bowel sounds
    ULCERATIVE COLITIS

     Crampy abdominal pain,nausea, vomiting


     Bloody diarrhoea or stool containing mucus
     Ischaemic damage with perforation may occur

    DIVERTICULITIS
     Older patient, Inadequate fibre in diet
     Bright red blood in stools,alt consti/diarrhoea
     Tenderness in LLQ
     Rupture may cause peritonitis and sepsis
    ECTOPIC PREGNANCY

     In females of child bearing age abd pain or


    unexplained shock
     ECTOPIC PREGNANCY DOES NOT
    NECESSARILY CAUSE MISSED PERIOD

    TWISTED OVARIAN CYST


     Sudden severe pain
     sick looking,shock
     Ischaemic necrosis-perf & spillage
    clinical patterns
    1) Abdominal pain & shock [apoplexy] catastrophic event
    a. ruptured aortic aneurysm
    b. ruptured ectopic pregnancy
    c. fluid loss into ‘third space’ eg: ac mesenteric
    ischaemia, severe ac pancreatitis, int obst

    2) Generalised peritonitis
    a. ruptured viscus perf ulcer, colonic perf,
    perforated appendicitis
    b. ischaemic unruptured bowel strangulated hernia
    mesenteric occlusion,volvulus
    c. extension of infection liver abscess, PID
    Clinical pattern contd
    3) Localised peritonitis
    RUQ,RLQ,LLQ,SILENT ZONE

    POINT TENDERNESS

    TIME IS SUPERB DIAGNOSTICIAN

    4) intestinal obstruction
    Making diagnosis is not a big issue but important is
    deciding appropriate course of action

    5) medical illness
    Inf wall MI, basal pneumonia, porphyria,diabetic
    ketoacidosis,HIV positive suffering from AIDS
    Clinical pattern contd.

    6) gynaecological
    ectopic preg, twisted ovarian cyst,PID

    7) mixed pattern[obstruction & inflammation]


    Int. distension & obstruction/inflammation
    eg; enteritis,colitis
    MIMICS PERITONITIS
    Natural history of frequent causes

    Life Threatening Self Limiting

    Aortic Aneurysm Appendicitis Gastroenteritis


    rupture cholecysitis mesenteric
    pancreatitis signoid lymphadenitis
    Bowel ischaemia diverticulitis epiploic
    Perforated peptic salpingitis appendigitis
    ulcer omental infarction
    Perforated caecal diverticulitis
    diverticulitis
    Conclusion

    ‘It is as much an intellectual exercise


    to tackle the problems of belly ache
    as to work on the human genome’
    [Hugh dudley]

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