PROBLEM 4A GIT

Angeline 10178
LO1. Anatomi and Histology lower GIT
Ileum
LO2. Acute Abdomen
Definition
The acute abdomen refers to the clinical
clinical situation in which a situation in
which a sudden change in the condition
of the intra-abdominal organs, usually
related to inflammation or infection,
demands immediate and accurate
diagnosis and treatment.
Classification
Visceral pain
Characterized by dullness, poor localization, cramping,
or burning
Mediated by autonomic nerves (sympathetic and
parasympathetic)
Location corresponds to the dermatomes of the organs
involved
Sensory neuroreceptors for visceral pain are located in
the mucosa or muscularis of hollow viscera, on the
visceral peritoneum, and within the mesentery
These receptors respond to mechanical and chemical
stimuli
Stretch is the primary mechanical signal for pain
 Somatic pain
tends tends to be more intense to be more
intense and well-localized
The parietal peritoneum has an entirely
somatic innervation (mediated by the
spinal nerves)
A transition from transition from visceral
visceral (vague (vague dull) to , dull) to
somatic (focal, sharp) pain indicates
extension of the underlying process
 Referred pain
perceived at a site that is distant from the
involved organ or disease process
Due to a convergence of visceral afferent
neurons with somatic afferent neurons from
from different anatomic regions different
anatomic regions
Referred pain is well-localized
Historical Features
Surgical History/ Past
PQRST
medicine
Medications
Allergies
Past Surgical History
Precipitating or alleviating factors Previous abdominal or
Quality - bright, sharp, dull, achy
pelvic operations

Radiation- shoulder, groin, back

Prior work-up for
Severity - 1 to 10 scale
abdominal pain
Timing- sudden or gradual, crampy or
Past Medical History
continuous
Diabetes
Cardiovascular disease
Gastrointestinal disease
Diagnose
Vital Signs - Temp, Pulse, BP, Resp
General

Low grade temp:

Appearance appendicitis, acute
Patient is lying cholycystitis
High grade temp:
motionless acute
abscess
appendicitis, General Examination

peritonitis Conjunctival pallor

Rolling around in Cyanosis
bed ureteric colic, Jaundice
intestinal colic
Signs of dehydration
Cervical
Bending forward lymphadenopathy
chronic pancreatitis Mesenteric adenitis
Physical Examination

Inspection Palpation

Deep tenderness, rebound

tenderness, guarding, rigidity,
masses, hernial orifices,
organomegaly
Peritoneal Signs
Movement with respiration
Distension, peristalsis, pulsations,
Rebound
masses, scars
Guarding
Rigidity (board-
like abdomen)
Percussion Auscultation

Silent abdomen: peritonitis, ileus

Tympanic note: intestinal obstruction
abdomen: peritonitis, ileus
Dullness over bladder: acute Increased bowel sounds:
retention
obstruction
Lab and Imaging Diagnose
CBC with differential (infection
and inflammation)
Electrolyte, creatinine, glucose
(DKA)
LFTs US (ovarian cyst, ectopic pregnancy,
Amylase aortic aneurysm, gallstones)
Urinalysis IVU for kidney stones
CXR (basal pneumonia, gas
Angiography (mesenteric embolus or
thrombosis)
under diaphragm)
Sickling test
Abdominal plain XR
Pregnancy test
distended bowel with air fluid
level
stones
calcified aorta
air in biliary tree
DD

Site vs Condition Onset vs Condition

Whole abdomen Minutes

Peritonitis perforated ulcer or

Mesenteric infarction diverticulum, ruptured
Right upper quadrant
AAA, testicular or ovarian
torsion, ectopic pregnancy,
Acute cholycystitis
pancreatitis, mesenteric
Cholangitis infarct
Hepatitis Hours

biliary disease,
Peptic ulceration
Left upper quadrant
appendicitis, diverticulitis,
small bowel obstruction
Peptic ulceration Days
Pancreatitis inflammatory bowel
Splenic infarct disease, malignant
obstruction
LO3. Appendisitis

Epidemiology

Most common cause of the acute

abdomen
Vague periumbilical pain is the most 11 in 15 people will develop in 15
common initial symptom, moving to people will develop appendicitis
the right lower quadrant (McBurneys in their lifetime
point)
Peak incidence is from 10 30
Hyperesthesia of the abdominal wall years
Rovsings, psoas, and obturator signs
Diagnose
Retrocecal Retrocecal appendix occurs
64% of the time appendix occurs 64% of
the time
Ultrasound or CT Scan may be used
CT Scan with triple contrast and 5mm
cuts through the level of the appendix is
98% sensitive for appendicitis
A retrocecal or pelvic appendix or
abscess will NOT cause peritoneal signs
LO4. Peritonitis
Acute Peritonitis
inflammation of the peritoneum
Maybe localized or diffuse in location,acute and chronic in
natural history, and infectious or aseptic in pathogenesis
infectious(primary peritonitis or spontaneus) and is usually
related to a perforated viscus (and calledsecondary
peritonitis)
Associated :
with decreased intestinal motor activity
resulting in distention of the intestinal lumen with gas and fluid
(adynamic ileus)
Accumulation of fluid in the bowel and oral intakerapid
intravascular volume depletioncardiac, renal, and other
systems.
2 Major Types

Primary Secondary

Caused by the spread of an infection

Caused by the entry of bacteria or
enzymes into the peritoneum from
from the blood & lymph nodes to the
the gastrointestinal or biliary
peritoneum.Very rare < 1%
tract.

Usually occurs in people who have an This can be caused due to an ulcer
accumulation of fluid in their eating its way through stomach
abdomens (ascites). wall or intestine when there is a
rupture of the appendix or a
ruptured diverticulum.
The fluid that accumulates creates a
good environment for the growth of
bacteria. Also, it can occur due to an
intestine to burst or injury to an
internal organ which bleeds into
the internal cavity.
Conditions Leading to Secondary Bacterial
Peritonitis
Perforations of bowel Perforations or leaking of other
Trauma, blunt or penetrating organs
Inflammation Pancreaspancreatitis
Appendicitis Gallbladdercholecystitis
Diverticulitis Urinary bladdertrauma, rupture
Peptic ulcer disease Liverbile leak after biopsy
Inflammatory bowel disease Fallopian tubessalpingitis
Iatrogenic Bleeding into the peritoneal cavity
Endoscopic perforation
Anastomotic leaks Disruption of integrity of peritoneal
Catheter perforation cavity
Vascular Trauma
Embolus Continuous ambulatory peritoneal dialysis
Ischemia (indwelling catheter)
Obstructions Intraperitoneal chemotherapy
Adhesions Perinephric abscessIatrogenic
Strangulated hernias postoperative, foreign body
Volvulus
Intussusception
Neoplasms
Ingested foreign body, toothpick, fish
bone
SS
acute abdominal pain and tenderness, usually with fever
Bowel sounds are usually but not always absent.
Tachycardia, hypotension, and signs of dehydration are
common
Localized peritonitis is most common in
uncomplicated appendicitis and diverticulitis, and
physical findings are limited to the area of inflammation
Generalized peritonitis is associated with widespread
inflammation and diffuse abdominal tenderness and
rebound.
Rigidity of the abdominal wall is common in both
localized and generalized peritonitis
Clinical Features
Leukocytosis and marked acidosis are common
laboratory findings.
Plain abdominal films dilation of large and small
bowel with edema of the bowel wallFree air under
the diaphragm perforated viscus.
CT and/or ultrasonography presence of free fluid
or an abscess.
When ascites is present, diagnostic paracentesis
with cell count (>250 neutrophils/L is usual in
peritonitis), protein and lactate dehydrogenase
levels, and culture is essential.
In elderly and immunosuppressed patients, signs of
peritoneal irritation may be more difficult to detect.
Management
Rehydration
Correction of electrolyte abnormalities
Antibiotics
Surgical correction of the underlying
defect
Prognosis
Mortality rates are <10% for
uncomplicated peritonitis associated
with a perforated ulcer or ruptured
appendix or diverticulum in an otherwise
healthy person.
Mortality rates of40% have been
reported for elderly people, those with
underlying illnesses, and when
peritonitis has been present for >48 h.
LO5. Perforation
Perforated Ulcer
Perforated gastric/duodenal ulcer requires
immediate operative therapy
Anterior gastric perforations cause peritonitis
Posterior gastric and duodenal perforations
may not cause peritonitis, and after the acute
episode of pain, the leak may wall off, giving
the impression that the patient is improving
Free air (80% of perforated ulcers)
Etiology
Helicobacter Pylori
Smoking
NSAIDs
Patophysiology
X-ray - diagnose
Treatment
Immediate surgery
For a perforated duodenal ulcer,may include:
a highly selective vagotomy, a truncal vagotomy and
pyloroplasty, or vagotomy and antrectomy.
For a perforated gastric ulcerdepends on the
patient's condition:
If the patient is moribund, the ulcer is best excised by
grasping it with multiple Allis clamps and using a GIA-
60 linear stapler. Or,can be excised with
electrocautery
In a stable patient, the ulcer is excised and sent for
frozen section analysis to exclude malignancy
LO6. Ileus
a condition in which the bowel doesn't
work correctly but there is no structural
problem
Or hypomotility of the gastrointestinal
tract in the absence of mechanical bowel
obstruction
This lack of coordinated propulsive
action leads to the accumulation of gas
and fluids within the bowel.
Paralytic ileus(pseudo obstruction), is
one of the major causes of intestinal
Etiology of paralytic ileus

Older children
Chemical, electrolyte, or mineral
disturbances (such as decreased
potassium levels)
Complications of intra-abdominal
surgery Bacterial
Decreased blood supply to the viral
abdominal area (
mesenteric artery ischemia)
food poisoning (gastroenteritis),
which is sometimes associated
Injury to the abdominal blood supply with secondaryperitonitis and
Intra-abdominal infection appendicitis.
Kidney or lung disease
Use of certain medications,
especially narcotics
Etiology POI Pathophysiology of POI
Pathophysiology
Symptoms
moderate, diffuseabdominal discomfort
constipation
abdominal distension
nausea/vomiting, especially after meals
lack ofbowel movementand/or
flatulence
excessive belching
Risk Factor
gastrointestinal surgery or other GI procedures
electrolyte imbalance
diabetic ketoacidosis(DKA), and other causes
ofmetabolic acidosis
hypothyroidism
medications(e.g.opiatesorantimuscarinics)
severeillness(Inflammation with peritonitis)
spinal cord injury (SCI), those with injury
abovethoracic vertebrae 5(T5) will have
hypomotility problems within the bowel
Management
Traditional therapy has primarily
involved NG intubation and IV fluids.
The use of nonsteroidal anti-
inflammatory drugs (NSAIDs) potentially
has some benefit but will not block the
inhibitory effects of opioid
Epidural thoracic anesthetics, as
opposed to epidural thoracic opioids, can
have a benefit on postoperative
recovery.
Laparoscopy Surgery
Complication
increaseadhesionformation, because
intestinal segments have more
prolonged contact
allowing fibrous adhesions to form
intestinal distention causes serosal injury
and ischemiaadhesions in foals
LO7. Abscess