The abdomen pdf - مجموعة طلاب

Part:1

Surgery

Acute Abdomen

#Causes of acute abdomen:

1- Most common causes:



Acute appendicitis



Acute cholecystitis



Pancreatitis



Inflammatory disease



Ectopic pregnancy

2- Other causes:



Acute Small Bowel Obstruction



Mesenteric Vascular Occlusion



Perforated Duodenal Ulcer



Acute peptic ulcer



Peritonitis



Pyelonephritis



Abdominal aortic aneurysm

3- Extra abdominal causes:



pleurisy

4- Non-surgical causes:



Diabetic ketoacidosis



Uremia



SLE



Hematological disorders

#patient with acute abdomen need:



History taking



Physical examination



Investigations



Laparoscope : to see the cause of acute abdomen + for definitive diagnosis

#Peritonitis features:



Inspection: No abdominal movement on respiration



Palpation: Tenderness, rebound tenderness, guarding, and rigidity.



Percussion: tenderness on percussion



Auscultation: Absence of bowel sound.



Associated: Pyrexia and tachycardia

#Examination of Acute Abdomen:



Inspection:



Usual inspection of the abdomen



Ask the patient to cough (this elicits pain, you may find a hernia)



Palpation: only superficial, using 1 or 2 fingers to score pain;



Mild: tenderness



Moderate: guarding



Sever: rigidity



Auscultation for bowel sounds : rule of three (Auscultate 3 areas for 3 minutes)



Right iliac fossa for 1 minute



The right side of umbilicus for 1 minute



Lower abdomen for 1 minute



Percussion: At the end of procedure because it elicits pain that may decreases bowel
sounds.

#Investigations:

1- Investigations in acute Cholecystitis:



Hematological: TSB (total serum bilirubin) – WBC count – Alkaline phosphatase (
obstructive jaundice) – serum amylase (indicate acute pancreatitis) – GUE (general
urine examination)



Radiological: US (gold standard) – X ray ( erect and supine abdomen x-ray) – CT scan
(highly sensitive to peritonitis)

2- Biliary tree: gold standard investigations are U.S + X ray

3- Pancreatitis: gold standard investigations are CT scan + contrast test

#surgery:

Patient with acute abdomen need surgical intervention in the following conditions:
Tachycardia + Tachypnea + Hypotension + Fever + Abdominal distention

#Cardinal signs of some disease of acute abdomen:

1- Cardinal signs of intestinal obstruction:

Site of obstruction above the pyloric region:

1-  Pain
2-  Vomiting: watery and acidic
3-  Distention: no distention
4-  Absolute constipation: not absolute

Site of obstruction mid-intestinal region:

1-  Pain
2-  Vomiting: bile content
3-  Distention: mild distention
4-  Absolute constipation: little absolute

Site of obstruction left colon region:

1-  Pain
2-  Vomiting: little amount of vomiting
3-  Distention: obvious distention
4-  Absolute constipation: absolute

2- Cardinal signs of acute Cholecystitis:



Febrile



Nausea



Colic abdominal pain if there is biliary obstruction but if there is inflammation it will
spread to make constant referral pain



Post-meal pain (30 min)



Fatty meal will increase the pain



The pain is sudden, severe, continuous, radiated to tip of right scapula, aggravated
by moving and coughing, relieved by analgesics and the site is right hypochondrium.

3- Cardinal signs of chronic Cholecystitis:



Some signs of acute cholecystitis



Distention



Fibrosis seen in imaging studies like U.S



Thickness

4- Cardinal signs of acute on chronic Cholecystitis:



Picture of acute abdomen

Note:

Types of abdominal pain:

1- Constant griping pain: could
contracting pain, it is due to
inflammation

2- Colic pain: due to muscular
tube obstruction

Note:

The constipation could be
relieved easily without surgery
but the obstruction very
difficult to be relieved



Fever



Hypertension



Abdominal pain



Loss of apatite



Signs of septicemia

5- Cardinal signs of diverticulitis:

The most common type of diverticulitis is sigmoid diverticulitis and it is caused by fiber
full food and it is acquired type of diverticulitis and not occur in developing countries



Lead to inflammation  acute abdomen



Diarrhea



Bleeding per rectum



Nausea



Pain



Vomiting

6- Cardinal signs of sigmoid volvulus:



Sign of acute abdomen



Acquired or congenital



Occur in developing countries

7- Cardinal signs of Meckel's diverticulum:



Congenital



Sign of acute abdomen



Pain in right iliac fossa



Nausea



Vomiting

8- Cardinal signs of Acute appendicitis:



History: Nausea, vomiting, central abdominal pain which later shifts to the right iliac
fossa



Examination

Peritonitis features, palpable mass in the right iliac fossa. Rovsing’s sign

(Palpation in the left iliac fossa produces pain in the right iliac fossa). Iliopsoas test
(for Retroileal appendicitis, iliopsoas abscess): Ask the patient to flex the thigh
against the resistance of your hand; a painful response indicates an inflammatory
process involving the right psoas muscle.

9- Cardinal signs of Perforated peptic ulcer with acute peritonitis:



History: history of dyspepsia, ulcer disease, NSAIDs or corticosteroid therapy.
Vomiting at onset associated with severe acute onset abdominal pain, previous



Examination: Peritonitis features

10- Cardinal signs of Acute pancreatitis:



History: alcohol abuse/cholelithiasis, Anorexia, nausea, vomiting, constant severe
epigastric pain



Examination: Peritonitis features, epigastric tenderness, periumbilical bruising
(Cullen’s sign) or loin bruising (Grey

–Turner’s sign, fever)

11- Cardinal signs of Ruptured aortic aneurysm:



History: history of vascular disease and/or high blood pressure. Sudden onset of
severe, tearing back/loin/abdominal pain.



Examination: Shock and hypotension, pulsatile, tender, abdominal mass,
asymmetrical femoral pulses, Grey–Turner’s and Cullen’s sign.

12- Cardinal signs of acute mesenteric ischemia:



History: Anorexia, nausea, vomiting, bloody diarrhea, constant, abdominal pain,
previous history of vascular disease and/or high blood pressure



Examination: Atrial fibrillation, heart failure, asymmetrical peripheral pulses, absent
bowel sounds, variable tenderness

and guarding

13- Cardinal signs of Intestinal obstruction:



History: Colicky abdominal pain, vomiting, distention and constipation



Examination: Surgical scars, hernias, mass, distension, visible peristalsis, increased
bowel sounds

Murphy's sign

is tested for during an abdominal examination; it is performed by asking the patient
to breathe out and then gently placing the hand below the costal margin on the right
side at the mid-clavicular line (the approximate location of the gallbladder). The
patient is then instructed to inspire (breathe in). Normally, during inspiration,
the abdominal contents are pushed downward as the diaphragm moves down
(and lungs expand). If the patient stops breathing in (as the gallbladder is tender and,
in moving downward, comes in contact with the examiner's fingers) and winces with a
'catch' in breath, the test is considered positive. In order for the test to be considered
positive, the same maneuver must not elicit pain when performed on the left
side. Ultrasound imaging can be used to ensure the hand is properly positioned over
the gallbladder.

Part:2

Surgery

Acute appendicitis

Definition: defined as an inflammation of the inner lining of the vermiform appendix that
spreads to its other parts. Despite diagnostic and therapeutic advancement in medicine,
appendicitis remains a clinical emergency and is one of the more common causes of acute
abdominal pain.

Causes: Obstruction of the appendiceal lumen by:



lymphoid hyperplasia secondary to inflammatory bowel disease (IBD)



infections (bacteria, parasites)



fecal stasis and fecaliths



foreign bodies



neoplasms (carcinoid tumor)



strictures



swollen peyer's patches

History of acute appendicitis (clinical presentation)

1- shifting pain: start as visceral pain (around the umbilicus) then shift to parietal pain (

in the R.I.F )

2-  Sudden onset of sever pain in the R.I.F (( in 1/3 of patients ))
3-  Nausea
4-  Vomiting (( one or two times per day – and usually start after the pain ))
5-  Loss of appetite
6-  Diarrhea or constipation (( in 18% of patients ))

Investigations:



Acute appendicitis is diagnosed from history and clinical examination but we do
many investigations for differential diagnosis and complications



There are a lot of investigations in acute appendicitis like: WBC count, General urine
analysis, X-ray, U.S, C.T scan, Laparoscopy and pregnancy test.

Note:

There are two types of pain:

1- Viseral pain: ((generalized pain – not localized)) occur in the epigastric, suprapubic

regions and around the umbilicus.

2- Parietal or somatic pain: ((localized pain – not generalized)) occur when an inflamed

organ touch the parietal peritoneum. Like pain in the right iliac fossa (R.I.F)

1- Patient with R.I.F pain: we do WBC count and General urine analysis for differential

diagnosis of 1- Acute appendicitis 2- Urinary Tract Infection (UTI) 3- Stone formation
4- irritation of the urinary bladder wall

2- Use Ultra Sound (U.S) for differential diagnosis of:



ectopic pregnancy



overian cyst in female, and presented with: menstrual irregularity



salpingitis and hirsutism and obesity.



ureteric stone



Pyelonephritis in male

3- Use Abdominal X ray (A.X.R) for differential diagnosis of:



Intestinal obstruction



ureteric stone



Pyelonephritis (radio-opaque)

4- Use C.T scan for differential diagnosis of:



Tumor



Perforated appendix



Perforated viscous



Pancreatitis

5- Use laparoscopy ((diagnostic and therapeutic)) for differential diagnosis of:



Gynecological complications



Advantage for obese

Clinical signs of patient with acute appendicitis:

1- Rovsing's sign: pressure on left iliac fossa and the pain will appear in Right iliac fossa
2- McBurney's sign: deep tenderness at the McBurney's point
3- Obturator sign: pain due to contact between the inflamed appendix and obturator

muscle.

4- Psoas sign: The pain results because the psoas borders the peritoneal cavity, so

stretching (by hyperextension at the hip) or contraction (by flexion of the hip) of the
muscles causes friction against nearby inflamed tissues like appendix.

هام جدا

5- Aaron's sign: is a referred pain felt in the epigastrium upon continuous firm pressure

over McBurney's point. It is indicative of appendicitis

6- Blumberg's sign: A positive sign is indicated by presence of pain upon removal of

pressure on the abdominal wall. It is very similar to rebound tenderness

7- Cough sign: increase pain with cough because of parietal pain
8- Shifting pain
9- Shifting tenderness: pressure on left iliac fossa and the pain will appear in Right iliac

fossa

10- R.I.F Tenderness
11- Rebound tenderness: lead to sever pain after sudden release of the hand above

appendix

12- percussion tenderness: percussion on McBurney's point lead to sever tenderness
13- guarding sign: The tensed muscles of the abdominal wall automatically go into

spasm to keep the tender underlying tissues (apeendix) from being disturbed.

Right iliac fossa pain differentials:

1- For child:



Acute appendicitis



Cystitis (UTI)



Torsion of testes



Intestinal obstruction



Enteritis



Intussusception



Mesenteric lymphadenoma



Meckel's diverticulum



Gastroenteritis

2- For young adult male:



Acute appendicitis



Acute pyelonephritis



Ureteric stone



Cancer



UTI



Inflammatory bowel disease

3- For female:



Ectopic pregnancy



UTI



Complication of pregnancy



Sigmoid

Note:

To differentiate between acute
appendicitis and Meckel's diverticulum:



rotate the baby to the left side then
exam the pain if the pain is still in the
R.I.F it is acute appendicitis but if the
pain disappear it is Meckel's
diverticulum



both have the same clinical characters

Note:

To differentiate between acute
appendicitis and Mesenteric
lymphadenoma : via shifting pain

Umbilicus

Ant. Sup. Iliac spine

McBurney's point = base
of the appendix

4- For elderly:



Cancer



Inflammatory bowel disease



Sigmoid

Surgery:

1-  General anesthesia
2-  Appendectomy
3-  Type of surgery: conventional and laparoscopic
4-  Types of incisions:



Lanz incision



Gridiron incision



Muscle splitting incision



Rutherford incision



Middle line surgery



Right para-median

5- Size of incisions is 6-7 cm

Complications of acute appendicitis:

1-  Appendicular abscess
2-  Appendicular mass
3-  Generalized peritonitis
4-  Perforation:



Predisposing factors: delayed diagnosis – immunocompromised patient – two
extreme of age.



Site: occur in the tip of appendix  lead to appendicular abscess  pelvic
abscess  generalized peritonitis.



Need surgery + drainage of abscess + aspiration under U.S guide.

Note:

Ochsner sherren regimen:



Is an expected management giving to apatient with appendicular mass



Aim: treatment of infections + pain relief + fluids and electrolytes supplement



Period: 48-72 hours



The regimen is: Nothing by mouth + fluids and electrolytes supplement + antibiotics +
analgesics + chart ( contain pulse measure + pressure measure + general examination +
measure input and output of fluids )



For more information visit: http://www.medimag.com.ng/ochsner-sherren-regimen-
and-appendix-mass/

Differential diagnosis of appendicular mass:

1-  T.B peritonitis
2-  Hematoma
3-  Crohn's disease
4-  Tumor
5-  Abscess
6-  Ovarian cyst
7-  Ectopic kidney
8-  Lymphoma
9-  Tissue mass

Differential diagnosis of appendicular mass ( (مصدر آخر

1- appendicular mass
2- ileocaecaltuberculosis (hyperplastic type)
3- Intussusception
4- Crohn`s disease
5- carcinoma caecum
6- Tubo-ovarian mass, e.g. abscess
7- undescended testis
8- transplanted kidney
9- ectopic kidney
10- psoas abscess
11- non-Hodgkin lymphoma

Complications of appendectomy:

1-  Septicemia
2-  D.V.T
3-  Inconel hernia
4-  Respiratory complications
5-  Intestinal obstruction
6-  Infections

Part:3

Surgery

Intestinal obstruction

#Types of intestinal obstruction:

1-  complete (total blockage of the lumen) - incomplete (partial blockage)
2-  small intestine obstruction - large intestine obstruction
3-  Dynamic (mechanical) obstruction - Adynamic obstruction (paralytic ileus) due to loss

of transmission of peristalsis and hypokalemia

4- Acute intestinal obstruction - Chronic intestinal obstruction

#Causes of intestinal obstruction

1- In neonate:



Congenital anomalies (like congenital pyloric stenosis)



Atresia



Hirschberg disease



Hernia



Family history of intestinal obstruction

2- In infant:



Meconium ileus

Causes of Dynamic (mechanical) obstruction

Extra-mural

Intra-mural

Intra-luminal

Adhesions
Bands
Internal hernia
external hernia
tumor

Tumor (cancer-lymphoma)
Strictures
Inflammatory disease like
Crohn's disease

Fecal material
Foreign bodies
Bezoars
Gallstone

Acute and chronic intestinal obstruction

Duration

Site

Symptoms

Acute: less than
2 weeks
Chronic: more
than 2 weeks

Acute: in the small
and large intestine
Chronic: only in the
large intestine

Acute: start as abdominal
pain then vomiting then
distention then constipation
Chronic: start as
constipation then distention
then pain then vomiting



Perforated anus



Hirschberg disease



Congenital anomalies

3- In children:



Volvulus



Tumor



Adhesion



Intussusception

4- In adult and elderly:



Hernia



Tumor



Adhesion

#Clinical features of intestinal obstruction:

1- Vomiting: start green, yellow then feculent color. More proximal obstruction lead to

increase vomiting and distention

2- Abdominal pain: colicky (in paralytic ileus is less pain)
3- Abdominal distention: Gas Nitrogen (produced by swallow of air and bacterial

fermentation) Fluid (produced by secretions and dietary source)

4- Constipation : but in some condition there is diarrhea
5- Extra-intestinal features: fever – dehydration – electrolyte disturbance

#Management of intestinal obstruction:

resuscitation-investigations-treatment

=Resuscitation:



I.V fluid (wide bore cannula): ringer lactate ((lower intestinal obstruction is acidic but
upper intestinal obstruction is alkaline so not give ringer lactate in upper intestinal
obstruction like gastric outlet obstruction and give normal saline with potassium
instead))



Blood sample for investigations



Nasogastric tube



Foley's catheter

Note: هام

Intestinal obstruction with diarrhea:



Richter's hernia



Gallstone ileus: called ball valve mechanism يوم مسدود ويوم إسهال– called
aerobilia (air in the biliary tree)



Pelvic abscess



Fecal impaction



Mesenteric vascular occlusion



Antibiotics: against gram negative and anaerobic bacteria



Analgesia



Check vital signs

=Investigations:

X-ray:



Erect and supine  supine give earlier diagnosis



See air/fluid level  5cm is normal – above 5 cm is abnormal



Small intestine: central – small diameter- diameter more than 6 cm



Large intestine: peripheral – large diameter – diameter more than 8 cm. if more
than 10 cm it indicate perforation.

=Treatment:



Treat underlying cause



Surgery

#Closed loop syndrome:



Obstruction in two sides



May lead to dilatation and green vomiting and perforation



Occur in colon: CA colon or incompetent ileocecal valve



Occur in small intestine: volvulus of small intestine



Occur in sigmoid volvulus (anti clock wise obstruction)

#Sigmoid volvulus:



Resuscitation: like that of intestinal obstruction



Deflating rectal tube



Sigmoidoscope (diagnostic and therapeutic)

#Intussusception:



Occur in the ileum – cecum – colon



Occur from 9 months of age to 10 years



Clinical features: vomiting – abdominal pain – blood per rectum – palpable
abdominal mass – lethargy – red current jelly – scream



Etiology: idiopathic – viral gastrointestinal pathogens like rotavirus, echovirus,
reovirus



Diagnosis: history – physical examination– radiographic studies – abdominal plain X-
ray – abdominal films – U.S – barium or air contrast enema (gold standard –
therapeutic and diagnostic)

Note:

Sigmoid colon: is the
commonest site of
volvulus, tumor and
diverticulosis
because of its shape
and fecal material
storage



Differential diagnosis: rectal prolapse



Treatment: IV line + nasogastric tube + IV antibiotics + hydrostatic barium enema or
pneumatic enema + surgery

# Causes of chronic intestinal obstruction (Intestinal Pseudo-Obstruction

)

1- The 3 most common associations are the following:



Trauma (especially retroperitoneal)



Serious infection



Cardiac disease (especially myocardial infarction and congestive heart failure)

2- Other conditions commonly associated with colonic pseudo-obstruction are:



Recent surgery (abdominal, urologic, gynecologic, orthopedic, cardiac, or
neurologic)



Spinal cord injury



Old age



Neurologic disorders



Hypothyroidism



Electrolyte imbalances
(hyponatremia ,hypokalemia ,hypocalcemia,hypercalcemia ,
orhypomagnesemia )



Respiratory disorders



Renal insufficiency



Medications (eg, narcotics, tricyclic antidepressants, phenothiazines,
antiparkinsonian drugs, and anesthetic agents)



Severe constipation

3- The condition may also observed in patients with the following:



Intestinal hypoperistalsis syndrome



Megacystis megacolon



Amyloidosis



GI carcinoma



Guillain-Barré syndrome



Multiple myeloma



Alcohol abuse

#Mesenteric vascular occlusion:



Causes: High cholesterol - Blood clots - Cocaine and methamphetamine use –
surgery



Symptoms include: abdominal pain and tenderness - bloating or a sense of
fullness – diarrhea – nausea – vomiting - fever



Diagnosis: CT – U.S – MRI - MRA (magnetic resonance angiography) -
Arteriogram



Treatment: Angioplasty + Lifestyle adjustments + medications (antibiotics -
vasodilator drugs - heparin or warfarin)

#Hypokalemia:



Potassium normal range : 3.5-5.2 mmol/L



Causes: Decreased intake - Shift into cells - Extra-renal losses (GIT) - Renal losses -
Spurious



Clinical manifestations: Neuromuscular disorders (Muscle Weakness, flaccid
paralysis, respiratory arrest) GIT (nausea , constipation paralytic ileus)
Acquired Nephrogenic DI ( Polyuria,polydypsia) Heart (Arrhythmias, Postural
hypotension)



ECG Changes: Flat T-wave - appearance of U wave - Cardiac arrest



Management: treat underlying cause + correction of alkalosis + Oral KCL Tabs

#Notes#

History of jaundice:

1- Obstructive jaundice due to benign cause: painful + fluctuating jaundice like

gallstone

2- Obstructive jaundice due to Malignant cause: painless + constant jaundice like

cancer

How to ask patient about bowel motion:

Ask about: frequency – color – amount – content – odor – timing – blood – mucus)

Diarrhea



More than 3 bowel motion/day or more than 300 mg/day



It is important to ask the patient if there are changes in the bowel motion
because it differs from person to person



Early morning diarrhea = malignancy (like CA colon )

Part:4

Surgery

Splenomegaly

Causes

1- Infections:



Viral: infectious mononucleosis



Bacterial: brucellosis – syphilis – T.B



Protozoal: malaria - kala azar

2-  Hematological: leukemia, lymphoma
3-  Metabolic: Gaucher's disease
4-  Vascular malformations
5-  Liver disease: cirrhosis
6-  Portal hypertension
7-  Hemolytic anemia
8-  Tumor and secondary metastasis

Indications of splenectomy:

1-  Trauma
2-  Hereditary spherocytosis
3-  Portal hypertension
4-  Malignancy (CA stomach - lymphoma)

Complications of splenectomy

1- Respiratory complications:



Basal atelectasis: cough after splenectomy due to lung collapse



Plural effusion



Empyema

2- Increase susceptibility to infections like



H.influenzae (pneumonia) , N.meningitidis (meningitis)

3-  D.V.T
4-  Thrombocytosis ( can lead to thrombosis )
5-  Acute gastric dilatation
6-  Bleeding
7-  Injury to adjusent organs
8-  Pancratits
9-  Septicemina ( by streptococcus – haemophilus )

Note:

There is conservative
management instead
of splenectomy

Note:

After splenectomy
give antibiotics and
vaccines