+

ACUTE ABDOMEN
- Department of Surgery PRECEPTOR : dr. W. Setiawan, SpB
By : Stifanny Yap (07120090009)

INTRODUCTION

Abdominal pain is a common complaint in all settings of medical

practice.

Abdominal pain may be symptom of severe, life threatening

disease or symptom of benign underlying condition.

Many diseases with abdominal pain do not require surgical

treatment so the evaluation of patients with acute abdominal pain
must be methodical and careful.

An acute abdomen must be suspected even if the patient has only

mild or atypical complaints.

Proper management of patients with acute abdominal pain

requires a timely decision.

DEFENITION

An acute abdomen denotes any sudden, spontaneous, both traumatic

and non-traumatic disorder whose chief manifestation is in the abdominal
area and for which urgent operation may be necessary.
Because there is frequently a progressive underlying intra-abdominal
disorder, undue delay in diagnosis and treatment adversely affects
outcome.

+
History Taking

+ Abdominal Pain
Visceral

Mediated primarily by
afferent C fibers
located in the walls of
hollow viscera and in
the capsules of solid
organ.

Parietal

Referred
Mediated by both C
and A delta nerve
fibers

Vague, deep-seated
pain and poorly
localized to the
epigastrium,
periumbilical or
hypogastrium region.

Corresponds to the
segmental nerve
roots innervating the
peritoneum

Elicited by distention,
inflammation or
ischemia or by direct
involvement of
sensory nerves

The cutaneous
distribution of parietal
pain orresponds to
the T6-L1 areas.

Most often felt in

midline because of
the bilateral sensory
supply to the spinal
cord.

The somatic afferent

fibers are directed to
only one side of the
nervous system.

Acute, sharper,
better-localized pain
sensation.

Noxious (cutaneous)
sensation perceived
of the site distand
from that of a strong
primary stimulus.

Distorted central
perception of the site
of pain is due to the
confluence of afferent
nerve fibers from
widely disparate
areas within the
posterior horn of the
spinal cord.

For example : pain

due to
subdiaphragmatic
irritation by air,
peritoneal fluid, blood
or mass lesion is
referred to the
shoulder via the C4mediated nerve. Pain
may also be referred
to the shoulder from
supradiafragmatic
lesions such as
pleurisy or lower lobe
pneumonia.
Posterolateral right
flank pain may be
seen in retrocecal
appendicitis. Billiary
pain may be
perceived in the right
scapular regio.

+ Abdominal Pain
Visceral

Mediated primarily
by afferent C fibers
located in the walls of
hollow viscera and in
the capsules of solid
organ.

Sensory Levels Associated with Visceral Structures

Vague, deep-seated
pain and poorly
localized.

Solid organ visceral

pain in the abdomen
is generalized in the
quadrant of the
involved organ.

Elicited by distention,
inflammation or
ischemia or by direct
involvement of
sensory nerves

Most often felt in

midline because of
the bilateral sensory
supply to the spinal
cord.

Visceral pain sites

+ Abdominal Pain
Parietal

Mediated by both C
and A delta nerve
fibers

Corresponds to
the segmental
nerve roots
innervating the
peritoneum
The cutaneous
distribution of
parietal pain
corresponds to
the T6-L1 areas.
The somatic
afferent fibers are
directed to only
one side of the
nervous system.

Acute, sharper,
better-localized
pain sensation

+ Abdominal Pain
Referred
Noxious (cutaneous)
sensation perceived
of the site distand
from that of a strong
primary stimulus.

Distorted central perception

of the site of pain is due to
the confluence of afferent
nerve fibers from widely
disparate areas within the
posterior horn of the spinal
cord.

For example : pain due to

subdiaphragmatic irritation
by air, peritoneal fluid, blood
or mass lesion is referred to
the shoulder via the C4mediated nerve. Pain may
also be referred to the
shoulder from
supradiafragmatic lesions
such as pleurisy or lower
lobe pneumonia.
Posterolateral right flank
pain may be seen in
retrocecal appendicitis.
Billiary pain may be
perceived in the right
scapular regio.

Spreading or shifting pain

Appendicitis : beginning in the

epigastric or periumbilical
region that later shift to become
sharper in right lower quadrant

Perforated peptic ulcer : Pain

almost always begins in the
epigastrium, but as the leaked
gastric contents tract down the
right paracolic gutter, pain may
descend to the right lower
quadrant with even diminution
of the epigastric pain.

Mode of Onset and Progression of Pain

The mode of onset of pain reflects the nature and severity of the
inciting process.

Onset may be :
Explosive (within seconds)
Unheralded, excruciating generalized pain suggests an intraabdominal catastrophe such as perforated viscus, rupture of an
aneurysm, ectopic pregnancy or abcess.
Rapidly progressive (within 1-2 hours)
Steady, mild pain becoming intensely centered in a well-defined
area. More typical in acute cholecystitis, pancreatitis, strangulated
bowel, mesentric infarction, renal or ureteral colic or high small
bowel obstruction.
Gradual (over several hours)
Slight or vague abdominal discomfort that is fleetingly diffusely
throughout the abdomen. Eventually, the pain become more
pronounced, steady and localized. This condition includes acute
appendicitis, incarcerated hernias, low (distal) small bowel and large
bowel obstruction, uncomplicated PUD, etc.

Character of pain

The nature, severity, and periodicity of pain provide useful

clues to the underlying cause

Other symptoms associated with abdominal pain :

Anorexia
Nausea
Vomitting
Constipation
Diarrhea
etc

Other specific symptom :

Jaundice : Hepatobiliary disorders

Hematochezia or hemtemesis : gastroduodenal lesion or Mallory-Weiss
syndrome
Hematuria : Ureteral colic or cystitis

Other relevant aspects of the history :

Gynecologic history : menstrual history, vaginal discharge,

dysmenorrhea

Drug and smoking history : analgetics,oral contracetive,

anticoagulants, corticosteroid, narcotics

Family history

Past History

Travel history

Operation history

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION
Patient with peritoneal irritation will typically
lie very still in the bed with the flexed knees
and hip to reduce the tension on the anterior
abdominal wall.
Disease without peritoneal irritation such as
ischemic bowel, biliary colic typically cause
patients to shift and fidget in bed continually
to find a position that lessens their
discomfort.
Distended abdomen with an old surgical scar
suggests both the presence and the cause
(adhesions) of bowel obstruction.
Scaphoid contracted abdomen is seen in
perforated ulcer.
Visible peristaltis occurs in advanced bowel
obstruction
Soft doughy fullness is seen in early paralytic
ileus or mesenteric thrombosis.
Erythema or edema of skin may suggest
cellulitis of the abdominal wall, whereas
ecchymosis is observed in deeper
necrotizing infections of the fascia or
abdominal structures.

General
Inspection

Check the quantity, quality, pitch and

pattern.

Quiet abdomen suggests an ileus

Hyperactive bowel sounds are found in
enteritits and early ischemic intestine
High pitches tinkling sound that tend to come
in rushes indicates mechanical bowel
obstruction
Far away, echoing sound are often present
when significant luminal distention exists.
Bruits within abdomen reflects the turbulent
blood flow in the vascular system (high grade
arterial stenosis)

Auscultation

Bowel obstruction or ileus : hypertympany throughout the abdomen

except the right upper quadrant.
Dullness indicate any abdominal mass
displacing the bowel
When liver dullness is lost and
resonance is uniform throughout the
abdomen , free intra-abdominal air shoul
be suspected.
Ascites is detected by looking for
fluctuance of the abdominal cavity.

Percussion

Revealing the severity and exact

location of abdominal pain, identify any
organo-megaly and sign of peritonitis.
Pain on palpation when focal suggests
an early or well-localized disease
process, whereas diffuse pain is present
with extensive inflammation or a late
presentation.
In voluntary guarding, abdominal
muscles will relax during the act of
inspiration; if involuntary, they remain
spastic and tense.

Palpation

Digital rectal examination, Pelvic

examination

Others

INVESTIGATIVE
STUDIES

INVESTIGATIVE STUDIES

Additional studies are worthwhile only if they are likely to

significantly alter or improve therapeutic decisions.

A more liberal use of diagnostic studies is justified in elderly or

seriously ill patients, in whom the history and physical findings
may be less reliable and an early diagnosis vital to ensure a
successful outcome.

Laboratory Studies

Imaging Studies

Plain Chest X-Ray Studies :

Preoperative assessment and may also demonstrate supra-diaphragmatic
conditions that simulate an acute abdomen (lower lobe pneumonia or ruptured
esophagus)
An elevated hemidiaphragm or pleural effusion may direct attention to
subphrenic inflamamatory lesions.
Plain Abdominal X-Ray Studies : bowel obstruction, peritoneal free air,
pneumoperitoneum in lateral decubitus positions, calcification apendicoliths,
gallstones, renal stones , pancreatitis calcification, abdominal aortic calcification,
etc.
Ultrasonography detecting gallstones, diameter of extrahepatic and intrahepatic
bile ducts, abnormalities in adnexa, uterus and ovaries, intraperitoneal fluid.
CT-scan
Endoscopy
Paracentesis
Diagnostic Laparoscopy

Differential Diagnosis

Based on etiology acute abdomen is classified into :

Acute
Abdomen

Traumatic

Penetrating
Injury

Stab Wound

Gunshot
Injury

Atraumatic

Blunt
Trauma
Solid Organ
Injury

Major Vessel
Injury

Peritonitis

Hollow
Perforation

Mesentrial
Injury

Non-Hollow
Perforation

Obstruction

IntraLuminal

Extramural

Strangulation
/ Vascular
Problem

Intra-Mural

+ Traumatic Acute Abdomen

-Blunt Trauma

Sentinel Loops

-Penetrating Injury
Xray :
Pneumoperitoneum (>penetrating)
Ground Glass appearance
Psoas shadow obliteration
Sentinel Loops

Pneumo peritoneum

Ground Glsss
appearance due to the
presence of fluid or pus
in peritoneal cavity

Blunt abdominal trauma

Blunt abdominal trauma usually results from motor vehicle

collisions (MVCs), assaults, recreational accidents, or falls.

The most commonly injured organs are :

Blunt force injuries to the abdomen can generally be explained

by 3 mechanism :
An injury resulting from a collision between a rapidly moving body part
and a stationary object.
Causes differential movement among adjacent structures and cause
shear forces.
Deceleration

Crushing

Intra-abdominal contents are crushed between the anterior abdominal

wall and the vetebral column or posterior thoracic cage which cause
crushing effect on vulnerable solid viscera.

Whether from direct blows or from external compression against a

fixed object.
External compressive forces result in a sudden and dramatic rise in
intra-abdominal pressure and culminate in rupture of a hollow viscous
External
Compression organ.

Clinical finding : pain, tenderness, hypovolemia, evidence of

peritoneal irritation, ecchymosis involving the flanks (Grey
Turner sign) or the umbilicus (Cullen sign), lap-belt mark
(correlate with small intestine rupture), steering wheel- shape
contusion, distention, auscultation of bowel sounds in thorax,
abdominal bruit, fullness and doughy consistency on palpation,
peritoneal sign, crepitation or instability of lower thoracic cage.

Large amount of blood can accumulate in the peritoneal and

pelvic cavities without any significant or early changes in the
PE.

Bradycardia may indicate the presence of free intra-peritoneal

blood.

Diagnostic :

FAST (Focused assessment with sonography for trauma)

CT standard for detecting solid organ injuries and can determine the source of
hemorrhage.

DPL (diagnostic peritoneal lavage)

DPL is indicated for the following patients in the setting of blunt trauma:

Patients with a spinal cord injury

Those with multiple injuries and unexplained shock

Obtunded patients with a possible abdominal injury

Intoxicated patients in whom abdominal injury is suggested

Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for
another procedure

Management :

Closely monitoring vital signs

Repeating the PE frequently

Blood transfusion

Laparotomy.

Indications for laparotomy in a patient with blunt abdominal

injury include the following:

Signs of peritonitis

Uncontrolled shock or hemorrhage

Clinical deterioration during observation

Hemoperitoneum findings on FAST or DP

Management of blunt trauma

Penetrating Injury

A gunshot wound GSW is caused by a missile propelled by

combustion of powder. These wounds involve high-energy
transfer and, consequently, can involve an unpredictable
pattern of injuries.

In penetrating abdominal trauma due to gunshot wounds, the

most commonly injured organs are as follows[4] :

40%

40%

30%

Stab wounds are caused by penetration of the abdominal wall

by a sharp object. This type of wound generally has a more
predictable pattern of organ injury. However, occult injuries can
be overlooked, resulting in devastating complications.

In penetrating abdominal trauma due to stab wounds, the most

commonly injured organs are as follows :

40%

30%

20%

15%

Signs and symptoms of penetrating injury depends on various

factors, including :

The type of penetrating weapon or object

The range from which the injury occurred

The location and number of wounds.

Immediate surgical exploration is warranted for evidence of

significant intra-abdominal injury, especially vascular trauma,
such as the following:

Narrow pulse
pressure

Hypotension
(with or
without
abdominal
distention)

Signs of
inadequate
end organ
perfusion

Peritoneal
signs (eg,
pain,
guarding,
rebound
tenderness)

Tachycardia

Diffuse and
poorly
localized
pain that
fails to
resolve

LABORATORY TESTING
CBC

Calcium

Electrolyte levels

Magnesium

BUN

Phosphate

Serum Creatinine

Urynalisis

Prothrombine time

Serum and urine toxicology

Activated partial thromboplastin time

ABG

Venous or arterial lactate level

Imaging :

Chest radiography: To rule out penetration of the chest cavity

Abdominal radiography in 2 views (anterior-posterior, lateral)

Chest and abdominal ultrasonography

Abdominal CT scanning: Most sensitive and specific study in identifying and assessing
liver or spleen injury severity[3]

Retrograde urethrogram/cystogram: To detect any urethral or bladder injury

Procedures :

Gastric decompression

Foley catheterization

Peritoneal Lavage

Tube thoracostomy

Local wound exploration

Laparoscopy (nearly
mandate in gunshot injury )

Pharmacotherapy :
Resuscitation with Crystalloid
infusion
Analgesics (eg, morphine
sulfate, fentanyl citrate)
Anxiolytics (eg, lorazepam,
midazolam hydrochloride)
Antibiotics (eg, cefotetan,
metronidazole hydrochloride,
gentamicin sulfate, vancomycin
hydrochloride, ampicillin
sodium-sulbactam sodium)
Immune enhancement (eg,
tetanus toxoid adsorbed or
fluid)

Algorithm for anterior abdominal stab

wound

Peritonitis
Pneumoperitoneum
Peritonitis is defined as inflammation of the serosal
membrane that lines the abdominal cavity and the organs
contained therein.
Depending on the underlying pathology, the resultant
peritonitis may be infectious or sterile (ie, chemical or
mechanical).
The inflammatory process may be localized (abscess) or
diffuse in nature.
Xray thickened abdominal wall with or without free air.
Goal : target correction of the underlying process,
administration of systemic antibiotics and supportive therapy
to prevent secondary complication due to organ system
failure.

PATHOPHYSIOLOGY

Introduction of
bacteria or irritating
chemicals into
peritoneal cavity

An outpouring of
fluid from the
peritoneal
membrane

Increased blood flow,

increased
permeability and
formation of a
fibrinous exudate on
its surface

Bowel develops local

or generalize
paralysis. Fibrinous
surface and
decreased intestinal
movement cause
adherance

Peritoneal infections are classified as :

Primary (ie, from hematogenous dissemination, usually in the

setting of immunocompromise, most often spontaneous bacterial
peritonitis caused by chronic liver disease.

Secondary (ie, related to a pathologic process in a visceral organ,

such as perforation or trauma, including iatrogenic trauma) the
most common form

Tertiary (ie, persistent or recurrent infection after adequate initial

therapy). Often develops in the absence of the original visceral
organ pathology.

Based on etiology, peritonitis is classified into :

Hollow viscus perforation

Acute diverticulitis, perforated peptic ulcer/gaster perforation,

perforated appendicitis, IBD perforation, Meckel divertivulum, etc

Non-hollow viscus perforation

Acute pancreatitis , ruptured spleen, TB peritonitis, Hepatic

abcess, ruptured aorta abdominalis, ruptured ovarium cyst, etc

Hollow Viscus Perforation

free air under diaphragm

+ ACUTE DIVERTICULITIS

80% of affected patients are older than 50 yo.

Presents as a spectrum of disease from mild abdominal discomfort

to gross fecal peritonitis.

Present with constant, dull, left lower quadrant pain and fever, may
complaint of constipation or obstipation.

PF : left lower quadrant tenderness, a left lower quadrant mass,

localized peritoneal sign may be present. In severe cases,
generalized peritonitis may be present.

CT is reliable in confirming the diagnosis (sensitivity of 97%), can

be used to determined the severity of diverticulitis by using
Hinchey grading system.

Hinchey Grading system

Localized pericolic absess or inflammation
Frequently require hospitalization for intravenous antibiotics.

Pelvic, intra-abdominal or retroperitoneal abcess

Should undergo CT-guided drainage of the abscess and receive a course of broadspectrum intravenous antibiotics

Generalized purulent peritonitis

Required emergency surgery.

Generalized fecal peritonitis

Required emergency surgery.

Perforated Peptic Ulcer

Presents with : sudden onset of severe, diffuse, excruciating

abdominal pain.

PF : reveals peritonitis, with rebound tenderness, guarding or

abdominal rigidity.

Radiology :

Xray : Pneumoperitoneum
CT : edema in the regio of the gastric antrum and duodenum
associated with extraluminal air.

Laparotomy is acceptable as the primary diagnostic maneuver

in such patients especially in patients with diffuse peritonitis
and hemodynamic collapse

Perforated appendicitis

Appendicitis is an acute inflammatory process of the appendix

resulting from obstruction of the lumen with subsequent
bacterial invasion, distension, ischemia and ultimate rupture.

Obstruction (due
to lymphoid
hyperplasia,
intraluminal
object), viral or
bacterial infection

Secretion of
mucus within the
appendix raises
intraluminal
pressures

Ischemic injury to
the mucosa

Bacterial invasion
of the
appendiceal
mucosa and
submucosa

Continued
inflammation and
bacterial
proliferation

Perforation and
spillage of
inflammatory cells
and bacteri into
peritonium

Peritonitis (At
times, the
infection is
contained by the
omentum and
periappendicular
abcess forms)

Present with : migrating pain, anorexia, nausea and vomiting.

PF : Low grade fever, RLQ tenderness, positive Rovsing sign,

Blumberg etc with guarding and rebound as the process
progresses (perforation)

Laboratory : leukocytosis with neutrophilia

Most significant complication of acute appendicitis

perforation which leads into peritonitis and sepsis

is

The mortality rate of perforated appendicitis is 1.66%, 7 times

greater than that of patients ongoing appendectomy for simple
acute appendicitis (0.24%) and 12 times greater than that of
appendectomy for a normal appendix (0.14%).

There are few reliable clinical features that distinguish non-perforated from perforated
appendicitis.

Sign of perforated appendicitis :

The duration of symptom tends to
be longer in patients with perforation
(>48hours)
Lower or generalized abdominal
tenderness

Some perforation case has

lucid interval which refers to a
period after perforation in
which pain is temporary
lessened.

Local or generalized rigidity over the

RLQ
The presence of a palpable RLQ
mass

Generalized rectal tenderness

Suspected perforation

Triple Antibiotics (ampicillin 2g,

gentamicin 2mg/kg, metronidazole
500mg) or 2nd generation
cephalosporin or quinolone
(ciproflaxaxin 500 mg ofr
levofloxacin 500 mg) with
metronidazole

Perforated Ileum et Causa Typhoid

Fever

Typhoid fever, a severe febrile illness caused by a gram negative

bacillus Salmonella typhi.

Complication : Intestinal perforation (on ilealcecal junction) high

mortality and morbidity

The most serious complications of typhoid fever are

gastrointestinal hemorrhage (2%10%) and perforation (1%3%).
They occur toward the end of the second week or during the third
week of the disease.

Intestinal perforation is one of the principal causes of death.

The clinical manifestations are indistinguishable from those of

acute appendicitis, with pain, tenderness, and rigidity in the right
lower quadrant.

Perforation of Inflammatory Bowel

Disease

Inflammatory bowel disease (IBD) is an immune-mediated chronic intestinal

condition. Ulcerative colitis (UC) and Crohn's disease (CD) are the two major
types of IBD.

The peak age of onset of UC and CD is between 15 and 30 years. A second

peak occurs between the ages of 60 and 80.

Pathophysiology :

Exogenous and
Endogenous
host factors
modified by
environmental
factors

Dysregulated
mucosal
immune function

Inflammation
(erythematous
and sandpaper
surface)

Severe
inflammation
(hemorrhagic,
edematous and
ulcerated)

Atrophic ,
narrowed,
shortened, thin
bowel wall and
severe mucosa
ulceration

Perforation

UC involves rectum and extends proximally to involve all or part of colon

CD affect any part of GI tract from mouth to anus

Ulcerative Colitis

Major symptoms : Diarrhea, rectal bleeding, tenesmus, passage of mucus, crampy abdominal pain. Colonic motility is altered as
the disease progressing. Severe condition liquid stool containing blood, pus and fecal matter accompanied by systemic
symptom.

Abdominal pain is not a prominent symptom, some just experience vague lower abdominal discomfort or mild central abdominal
cramping.

Perforation peritoneal signLaparotomy

Diagnostic :

Lab : rise CRP, platelet count, ESR and decrease in Hb, leukocytosis.

Radiography : thickened mucosa, ulcer, collar button ulcer (deeper ulcer), edematous and thickeded haustral fold, shorten
and narrowed colon]

CT scan : is not too helpful. Mural thickening, increase perirectal, presacral fat, adenopathy.

Endoscopy :

Mild : erythema, decrease vascular pattern, mild friability.

Moderate : marked erythema, absent vascular pattern, friability and erosions.

Severe disease : spontaneous bleeding and ulceration.

Unlike with Crohn disease, surgery offers a therapeutic option in ulcerative colitis.

Crohn Disease

Site of disease influence the clinical manifestation

Ileocolitis : RLQ colicky pain, precedes and relived by defecation , diarrhea, fever, weight loss, palpated inflammatory
mass.

Jejunoileitis : diarrhea, malabsorption and steatorrhea which lead to anemia, hypoalbuminemia, hypocalcemia,
hpomagnesemia, coagulopathy and hyperoxaluria.

Colitis and Perianal disease : low grade fevers, malaise, diarrhea, crampy abdominal pain, hematochezia. Colonic disease
may fistulize into stomach or duodenum, causing feculent vomiting, malabsorption.

Gastroduodenal disease : nausea, vomiting, epigastric pain may lead into chronic gastric

Perforation Peritoneal sign outlet obstruction laparotomy

Diagnostic :

Lab : Elevated ESR, CRP,, if severe hypoalbuminemia, anemia and leukocytosis

Endoscopic : rectal sparing, apthous ulceration, fistula and skip lesions

Radiographic : thickened folds, apthous ulceration, cobblestoning, strictures, fistula, inflammatory

masses and abcesses may be detected.

CT

MRI

Surgery in Crohn disease is frequently required to address complications of stricturing, penetrating, or

fistulizing disease. Because recurrence at anastomotic sites is common, surgery is not recommended as a
primary treatment strategy.

Meckel Diverticulum

Meckel diverticulum is a congenital anomaly of the GI tract in which an outpouching portion of the intestine (> terminal ileum),
derived from the fetal yolk stalk, contains gastric or pancreatic tissue which can secrete enzyme that can erode mucosal wall.

Congenital anomaly of GI tract - failure or incomplete vitelline duct obliteration

Bleeding associated with Meckels diverticulum is usually the result of ileal mucosal ulceration that occurs adjacent to acidproducing, heterotopic gastric mucosa located within the diverticulum. Intestinal obstruction associated with Meckels
diverticulum can result from several mechanisms:

1. Volvulus of the intestine around the fibrous band attaching the diverticulum to the umbilicus

2. Entrapment of intestine by a mesodiverticular band

3. Intussusception with the diverticulum acting as a lead point

4. Stricture secondary to chronic diverticulitis

Clinical presenting : asymptomatic abdominal pain, nausea, vomit, intestinal bleeding (<18yo), intestinal obstruction (>30yo).

Complication : diverticulitis, intussusception, perforation and obstruction.

Diagnostic :

Usually discovered incidentally, radiography, during endoscopy or during surgery.

Radionuclide scans (99mTc-pertechnetate) can be helpful if the diverticulum consist .ectopic gastric mucosa that capable of uptake of the tracer.
(accuracy 90%), angiography to localize the site of bleeding.

The surgical treatment of symptomatic Meckels diverticula should consist of diverticulectomy with removal of associated bands
connecting the diverticulum to the abdominal wall or intestinal mesentery.

NON-HOLLOW VISCUS
PERFORATION

Acute Pancreatitis

Present with : acute pain in the episgastrium that is constant,

frequently described as boring pain through the back or left
scapular, fever, anorexia, nausea and vomiting.

Patients usually more comfortable sitting upright, leaning forward

slightly .

PF : tachycardia, tachypnea, hypoactive bowel sounds,

tenderness to percussion and palpation in the epigastrium,
abdominal rigidity. Rarely,
patients + flank or periumbilical
ecchymoses pancreatic necrosis with hemorrhage.

Lab : Leukocytosis (12.000 to 20000/mm3), elevated serum and

urine amylase levels, abnormal serum electrolyte, calcium, blood
glucose levels, liver biochemical test and ABG.

USG may identify gallstones as a cause of pancreatitis. CT is

reserved for severe or complicated pancreatitis.

Although most cases of acute pancreatitis are self-limited, as

many as 20% of patients have severe disease with local or
systemic complications, including hypovolemia, and shock, renal
failure, liver failure and hypocalcemia.

A minority of patients with severe acute pancreatitis present with a

profound intra-abdominal catastrophe, usually caused by
thrombosis of the middle colic artery or right colic artery, which
travels in proximity to the head of pancreas, with resulting colonic
infarction.

This process may not be seen clearly on CT scans obtained early

in the course of disease and should be suspected in any case
marked by rapid hempdynamic collapse. Such patients require
immediate laparatomy.

Abdominal Aortic Aneurysm

Rupture of an abdominal aortic aneurysm is heralded by the

sudden onset of acute, severe abdominal pain localized to the
mid-abdomen or paravertebral or flank areas. The pain is
tearing in nature and associated with prostration,
lightheadedness and diaphoresis.

If the patient survives transit to the hospital, shock is the most

common presentation.

Physical examination reveals a pulsatile, tender abdominal

mass in about 90% of cases. The classic triad of hypotension,
a pulsatile mass and abdominal pain is present in 75% of cases
and mandates immediate surgical intervention.

+Obstruction
An interruption in the forward flow of intestinal contents.
Etiology :
Intramural : chrons disease, tumor,
carcinoma, limfoma, stricture, ileus, intussuception
Extramural : volvulus, adhesion, hernia, tumor
compression
Intraluminal : fecal impaction, ascarys ball,
gallstone ileus
The clinical presentation : nausea and emesis, colicky
abdominal pain, and a failure to pass flatus or bowel
movements.
The classic physical examination findings of abdominal
distension, tympany to percussion, and high-pitched bowel
sounds suggest the diagnosis
Management of uncomplicated obstructions includes fluid
resuscitation with correction of metabolic derangements,
intestinal decompression, and bowel rest.
Evidence of vascular compromise or perforation, or failure to
resolve with adequate bowel decompression is an indication
for surgical intervention.

Small Bowel Obstruction

SBOs can be partial or complete, simple (ie, nonstrangulated)

or strangulated.

Strangulated obstructions are surgical emergencies.

SBO accounts for 20% of all acute surgical admissions.

Etiology : post-surgical adhesion, incarcerated groin hernia,

malignant tumor, inflammatory bowel disease, volvulus, etc.

Pain on central and mid abdominal that tends to be colicky

(cramping and intermittent), spasm lasting for a few minutes,
vomitting occurs before constipation.

Some signs and symptoms associated with SBO include the following:

Nausea

Vomiting - Associated more with proximal obstructions

Diarrhea - An early finding

Constipation - A late finding, as evidenced by the absence of flatus or bowel movements

Fever and tachycardia - Occur late and may be associated with strangulation

Previous abdominal or pelvic surgery, previous radiation therapy, or both - May be part of the patient's medical history

History of malignancy - Particularly ovarian and colonic malignancy

Physical examination :

Abdominal distention (>>distal bowel)

Hyperactive bowel sound (early finding)
Hypoactive bowel sound (late finding)
Rectal Examination : Gross or occult blood Strangulation or malignancy, masses obturator
hernia

Intestinal ischemia : fever (>1000F), tachycardia (>100bpm), peritoneal signs

Radiology finding : Dilated small bowel, fighting loops, little gas in colon, esp
rectum

Large Bowel Obstruction

The most common causes of adult LBO are as follows :

Neoplasm

Diverticulitis

Obstructions caused by tumors tend to have a gradual onset and result from
tumor growth narrowing the colonic lumen.
Diverticulitis is associated with muscular hypertrophy of the colonic wall.
Repetitive episodes of inflammation cause the colonic wall to become
fibrotic and thickened, leading to luminal narrowing.

Volvulus

A colonic volvulus results when the colon twists on its mesentery, which
impairs the venous drainage and arterial inflow. Symptoms of this condition
are usually abrupt. The cecum and sigmoid colon are most commonly
affected. Volvulus typically occurs in elderly, debilitated individuals; patients
living in an institutionalized setting; or patients with a history of chronic
constipation.Volvulus may also be seen during pregnancy, most commonly
occurring in the third trimester when the gravid uterus displaces the colon.

Intussusception

Intussusception is primarily a pediatric disease; however, it is estimated that between 5% and 16% of all
intussusceptions in the Western world occur in adults. Two thirds of adult intussusception cases are
caused by tumors. Two main types of intussusception affect the large bowel: enterocolic and colocolic.

Enterocolic intussusceptions involve both the small bowel and the large bowel. These are composed of
either ileocolic intussusceptions or ileocecal intussusceptions, depending on where the lead point is
located. Colocolic intussusceptions involve only the colon. They are classified as either colocolic or
sigmoidorectal intussusceptions

In large bowel obstruction the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier and
vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction.

Radiologic finding : Dilated colon to point of obstruction, little or no air in sigmoid/rectum, little or no gas in small bowel if
ileocecal valve remains competent.

Vascular Problem
Volvulus
Ischemic mesenteric artery
Strangulated incarcerated hernia

Strangulated Hernia

Hernia is the protrusion of a structure or organ through the

tissues that normally contain it.

A strangulated hernia the blood supply to the herniated

structure is compromised Gangrene may occur if the
vascular compromised is not relieved.

A strangulated hernia is a life-threatening situation requiring

emergency treatment and surgical intervention.

All strangulated hernias are irreducible or incarcerated, but not

all irreducible or incarcerated hernias are strangulated

Hernia with a small neck or opening and a large sac have a

tendency to strangulate.

Femoral hernia which has a narrow neck or opening are

frequently incarcerate. Umbilical hernias in adults often
incarcerate with strangulation occurring in 20% to 30% of adult
umbilical hernias. Ulceration and perforation can also occur in
adults with umbilical hernias.

If strangulation is present , the patient may present with pain,

distention, peritonitis, vomiting, fever and sepsis.

Physical examination may reveal for any bulges or masses.

In such cases, leukocytosis with a left shift is often present,

although it may not occur in geriatric patients. Dehydration with
electrolyte abnormalities and an elevated blood urea nitrogen also
occurs frequently in incarceration or strangulation.

The patients with strangulated hernia requires :

Aggressive resuscitation with fluids and blood

Emergent surgical consultation for operative intervention
Gastric decompression with a nasogastric tube is appropriate if bowel
obstruction is present.
Broad-spectrum antibiotics are also adviced in the acutely ill or
potentially septic patients.

Acute Mesenteric Ischemia

Acute mesenteric ischemia can result from occlusion of a

mesenteric vessel arising from an embolus, which may
emanate from an atheroma of the aorta or cardiac mural
thrombus or from primary thrombosis of a mesenteric vessel,
usually at a site of atherosclrerotic stenosis.

>>superior mesenteric artery

Nonocclusive mesenteric ischemia results from inadequate

visceral perfusion and can also lead to intestinal ischemia and
infarction. Such cases are usually consequent to catastrophic
systemic illnesses such as cardiogenic or septic shock.

The hallmark of the diagnosis of acute mesenteric ischemia :

Abrupt onset

Intense cramping epigastric

Periumbilical pain

Other symptoms : diarrhea, vomiting, bloating, melena

Shock is present about 25% of cases.

Diagnostic :

CT best initial diagnostic test

Mesenteric angiography useful for determining the cause of intestinal
ischemia and defining the extent of vascular disease

Management :

Patients with acute embolic or thrombotic intestinal ischemia should be

referred for immediate revascularization and bowel resection.
Patients with nonocclusive mesenteric ischemia are best managed by
treatment of the underlying shock state.
Transcatheter vasodilator therapy may be helpful for patients who are
found to have vasospasm on visceral arteriography.
For those with persistent symptoms, laparotomy for resection of
infracted intestine may necessary

Preparation for Emergency Operation

IV access

Antibiotic infusion (common bacteria in acute abdominal

emergencies are gram-negative enteric organism and anaerobes).

Nasogastric tube (for hematemesis or copious vomiting patients,

suspected bowel obstruction or severe paralytic ileus to prevent
aspiration)

Foley catheter bladder drainage

Parenteral analgesics should not be withheld after initial assessmentabdominal masses may become obvious once rectus spasm is relieved.
Pain that persists in spite of adequate doses of narcotics suggests a
serious condition often requiring operative correction.

Indications for urgent operation in

Patients with an acute abdomen