Acute Abdomen RPS

8/10/2019 Acute Abdomen RPS

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Acute Abdomen

Preseptor:dr. Liza Nursanty, SpB, Mkes,

FINACS

Presentan :

Harum Binar .M 12100113016


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Acute abdomen difined generally as anintraabdominal process causing severe painand often requiring surgical intervention.


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4 quadrant

- Right Upper Quadrant

- Right Lower Quadrant

- Left Upper Quadrant

- Right Lower Quadrant


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1. Right hypocondrium

2. Epigastric

3. Left hypocondrium

4. Right Lumbar

5. Regio umbilical

6. Left lumbal

7. Right inguinal

8. Suprapubic

9. Left inguinal


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Acute abdominal pain is a common physicalcomplaint and prompted more than 7 millionemergency departement visits last year in the

united states.


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ASSESMENT

Well elicited history

Proper physical

examination

Investigations are usually carried out :

only to support the diagnosis.

or to narrow down the differential diagnoses.


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HistoryHistory of Present illnessFamily History

Past Medical history

History of drugs taken or Medicationeg. ingestion of certain toxic drugs or

Alcohol intake


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Free Peritoneal Air


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This plain abdominal radiograph of a 55-year-old woman presenting with

features of intestinal obstruction shows dilated loops of the small bowel

associated with thickened edematous valvulae conniventes and a strangulated

left inguinal hernia (arrow).


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http://www.ajronline.org/content/vol176/issue1/images/large/01_AA0350_04.jpeg


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(ii) Progression of PainProgression f rom :

Dull, aching, poorly localized character

To:

Sharp, constant & better localized pain

indicates involvement of Parietal peritoneum


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(iii) Associated Bowel SymptomsCONSTIPATION

a. Progressive intestinal obstruction from a

neoplasm or inflammatory bowel disease

b. Paralytic Ileus

c. Post Operatived. Obstructed groin hernia


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(iv) Associated Bowel SymptomsDIARRHOEA

Diarrhoea with pain is mainly medical.

The following are the exceptions :

a.Obstructed Richter's Hernia

b.Gall Stone ileusc.Superior mesenteric vascular occlusion

d.Intestinal Obstruction associated with

pelvic abscess

e.Spurious diarrhea in chronic faecalimpaction


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DRUG HISTORY

Corticosteroidsmask pain

Anticoagulantscan lead to an intramural

haematoma of the gut causing obstruction

Oral Contraceptives - rupture of hepaticadenomas

NSAIDs - erosive gastritis & peptic ulcers


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NAUSEA & VOMITING

i. Frequency of vomitingii. Character of vomiting:

projectile, non-projectile or self-induced

iii. Nature of vomiting:

a. Bilious vomiting of small bowelobstruction

b. Non-bilious vomiting in obstruction

proximal to ampulla of vater

c. Faeculent vomiting in distal small gutobstruction, large bowel obstruction ,

strangulation


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NAUSEA & VOMITINGPain first, followed by Vomiting is usuallysurgical.

The vomiting is due to reflex

pylorospasm

Nausea & vomiting first , followed by painis usually due to a medical condition

Vomiting is very prominent in

a.Mallory-Weiss syndrome.

b.Boerhaave syndrome(trans- mural

esophageal tear)

c.Acutegastritis


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ANOREXIAAnorexia or decreased appetite with pain is

usually seen in Acuteappendicitis

Urinary Symptoms with Pain

Ureteric colicCystitis

FEVER & CHILLS/RIGORSAmoebic Liver AbscessPygenic Liver Abscess

Perinephric Abscess

Intra-abdominal pus collection


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OTHER HISTORYPast Surgical history: previous operations-

leading to adhesions

Past Medical history: Sickle cell disease,

Diabetes or Cancer or Renal failure

Menstrual History in females(i) Missed period- ectopic pregnancy

(ii) Mid of period-ovulation pain (Mittel-

schmerz)

(iii) With heavy periods- endometriosisFamily history of colon cancer, any other

malignancy or inflammatory bowel disease


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Physical ExaminationGeneral Appearance

a.Anxious Patient lying motionless:

(i) Acuteappendicitis

(ii) Peritonitis

b.Rolling in bed & restless:(i) Ureteric Colic

(ii) Intestinal colic

c.Writhing in Pain:

Mesenteric Ischemiad. Bending Forward:

Chronic Pancreatitis


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Physical Examination (contd.)h. Low grade temp. is seen with

- Appendicitis

- Acutecholecystitis

i. High grade temp. is seen with

- Salpingitis- Abscess

j. Very High Grade Temp.with increasing

lethargy

seen in imminent septic shock- Peritonitis

- Acutecholangitis

- Pyonephrosis


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Systemic ExaminationErythema or discolouration

a. Peri-umbilical - Cullen sign

b. InguinalFox sign

c. Flanks - Grey Turner sign

Seen in Hemorrhagic pancreatitisor any other cause of haemoperitoneum

Any Visible masses

Any visible cough impulse at hernia site


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Systemic ExaminationPer abdomen:

Palpation

Be gentle

Start away from site of pathology then towards

Check for Hernia sitesTenderness

Rebound tenderness

Guarding- involuntary spasm of muscles

during palpationRigidity- when abdominal muscles are tense &

board-like. Indicates peritonitis.


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Systemic ExaminationLocal Right Iliac Fossa tenderness :

a. Acuteappendicitis

b. AcuteSalpingitis in females

c. Amoebiasis of Caecum

Low grade, poorly localized tenderness :Intestinal Obstruction

Tenderness out of proportion to examination:

a. Mesenteric Ischemia

b. AcutePancreatitisFlank Tenderness:

a. Perinephric Abscess

b. Retrocaecal Appendicitis


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Systemic ExaminationRovsings Sign in AcuteAppendicitis

Obturator Sign in Pelvic Appendicitis

Psoas Sign

- Retrocaecal appendicitis

- Crohns Disease- Perinephric Abscess

Murphy's sign in AcuteCholecystitis

Thumping tenderness over lower ribs in

inflammation of- Diaphragm

- Liver or spleen


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Systemic ExaminationPulsatile Abdominal Mass with Hypotension

Leaking AAA

Cutaneous Hyperaesthesia indicates

involvement of Parietal Peritoneum

Per Rectal Examination:- tenderness

- induration

- mass (Blummers shelf)

- frank blood


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Systemic ExaminationPer Vaginal Examination

- Bleeding

- Discharge

- Cervical motion tenderness

- Adnexal masses or tenderness- Uterine Size or Contour


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INVESTIGATIONS

Complete Blood Count with differentialC-reactive protein estimation

Electrolyte ,Blood Urea , Creatinine

Urine dipstick

Amylase or LipaseLiver Function Test

INVESTIGATIONS


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INVESTIGATIONSRadiology

Upright X ray chest for

- Basal Pneumonia- Ruptured Oesophagus

- Elevated Hemi diaphragm

- Free Gas under diaphragm

Abdominal X ray film- Air-Fluid Levels

- Stones

- Ascites

- Eggshell calcification in AAA

- Air in Biliary tree.

- Obliteration of Psoas Shadow in retro- peritoneal

disease

- Right lower quadrant sentinel loop in acute

appendicitis


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INVESTIGATIONS

Other Investigations-USG

-CT abdomenfor AAA, Pancreatic disease, or

ureteric colic (non- Contrast)

-IVU-Mesenteric Angiography for

-Ischaemia, Haemorrhage


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Acute Abdomen RPS

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