Acute Abdomen pdf - كاظم الحمداني

Medical causes of acute abdomen

a-Endocrine &metabolic disorders Uraemia,diabetic crisis

,addisonian crisis ,acute intermittent porphyria, acute

hyperlipoproteinemia, hereditary medetran

an fever

b-lnfections and inflammatory disorders Tabes

dorsalis,herpes zoster,acute rheumatic fever, Henoch

Shonlein purpura ,SLE,polyarteritis nodosa

c-Hematolo2ical disorders Sickle cell crisis, acute

leukemia, other dyscrasias

d-Toxins and drugs: Lead and other heavy metal

poisoning, narcotic withdrawal ,black widow (spider

poisoning)

e-Referred pain from thoracic region: myocardial

infarction, acute pericarditis, pneumonia ,pleurisy,

pulmonary embolus ,pneumothorax ,empyema

Physical signs in

various causes of

Perforated viscus : Scaphoid tense abdomen, diminished bowel

sounds(late), loss of liver dullness , guarding or rigidity

Peritonitis : Motionless, absent bowel sounds(late) cough and

rebound tenderness , guarding or rigidity

Inflamed mass or abscess: Tender mass(abdominal,rectal or

pelvic),special signs (murphy 's,psoas or obturator)

Intestinal obstruction: Distension , visible peristalsis(late) ,

hyperperistalsis(early) or quiet abdomen (late),diffuse pain without

tenderness; hernia or rectal mass(some)

Paralytic i leus: Distension, minimal bowel sounds, no localized

tenderness

lschemia or strangulated bowel : Not distended(until late), bowel

sounds variable,sever pain but little tenderness, rectal bleeding

(some)

Bleeding: Pallor ,shock, Distension, pulsatile(aneurysm) or tender

mass(e.g ectopic pregnancy); rectal bleeding

Other Symptoms of acute abdomen

Anorex

9 ,na1Jsea ., vomiting ,constipati.on

or Sii:lrrhoe

t1ng pa1n 1n the acute surg1ca audomen

usually precedes vomiting, whereas the reverse

holds true in medical conditions . Vomiting is a

prominent symptom in upper gastrointestinal

diseases (acute gastritis, pancreatitis)

B-Diarrhea: Copious watery diarrhea is

characteristic o f gastroenteritis and other

medical causes of acute abdomen .blood stained

diarrhea suggest ulcerative colitis ,Crohn

disease, bacillary or amebic dysentery .

• B-

constipation

Reflux ileus is of ten induced by visceral

afferent fibers stimulating efferent fibers of

the sympathetic nervous system to reduce

intestinal peristalsis.

Opstipation (the absence of both stool and

flatus) strongly suggest mechanical bowel

obstruction if there is progressive painful

abdominal distention or repeated vomiting

Laboratory Investigations

a-blood studies Pcv, wbc,clotting specific tests

differential count, urea ,creatinine

( crossmatching * arterial gases*)

b- urine test Microscopy, dipstick testing ,culture

c- stool exam: Occult blood, warm smear,c ulture

d-imaging studies: chest -abd x ray , US,or CT

scan (,angiography, water soluble upper

gastrointestinal series,HIDA scan)

e-endoscopy, paracentesis

laparoscopy

Differential diagnosis

The age and gender of the patient help in the differential diagnosis:

Mesenteric adenitis mimics acute appendicitis in the young

gynecologic disorders complicate the evaluation of lower abdominal

pain in women of childbearing age, and malignant and vascular

diseases are more common in the elderly.

(1) Any patient with acute abdominal pain persisting for over 6 hours

shoul

be regarded as having a surgical problem requiring in-hospital

evaluation. Well

lized pain

nd tenderness usually inaicate a

surgical condition. Systemic hypoperfusion in conjunction with

generalized abdominal pain is seldom due to a nonsurgical problem.

(2) Acute cholecystitis, appendicitis, bowel obstruction, cancer, and

acute vascular conditions are the most common causes of the surgical

acute abdomen in older patients.

(3) Salpingitis, dysmenorrhea, ovarian lesions, and urinary tract

infections complicate the evaluation of the acute abdomen in young

women.

(4) Unusual types or atypical manifestations of

intestinal obstruction, especially early cases, are easily

missed. Emesis, abdominal distention, and air-fluid

levels on x-ray may be negligible in Richter hernia,

proximal or closed-loop small bowel obstructions, and

early cecal volvulus.

5) Elderly or cardiac patients with severe unrelenting

diffuse abdominal pain but without commensurate

peritoneal signs or abnormalities on plain abdominal

films may have intestinal ischemia. Arterial blood pH

should be measured and visceral angiography

perf armed expediently.

(6) Medical causes of the acute abdomen should be

considered and excluded if possible before exploratory

laparotomy is planned .

PERIOPERATIVE MANAGEMENT

• After initial assessment ,

parenteral analgesic for pain

relief should not be withhe

d. pain that persist in

spite of adequate doses of narcotics suggest a serious

condition often requiring operative correction.

• Resuscitation of acutely ill patients should proceed

based on their intravascular fluid deficits and

systemic diseases.

• Medications should be restricted to only

essentials;cardiac drugs, corticosteroids,& to control

diabetes.

• Antibiotics are indicated for some infectious

conditions or as prophylaxis during the perioperative

period.

questions

1- differentiate between parietal and

visceral pain.

2- enumerate 5 common medical causes of

acute abdomen

3- how the age can be of help in diagnosing

acute abdomen?

4- intestinal obstruction can be missed

explain why?