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Surgery > Non- Traumatic Acute Abdomen > Flashcards

Non- Traumatic Acute Abdomen Flashcards

1
Q

Acute abdomen =

A

Anabdominal condition of abrupt onset associated with severe abdominal pain ( resulting from inflammation, obstruction, perforation, infarction, rupture)
- requires urgent evaluation and diagnosis bc it may indicate a condition that requires urgent surgical intervention

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2
Q

Visceral pain=

A
  • comes from abdominal/ pelvic viscera
  • transmitted by visceral afferent nerves ( in response to stretching or excessive contraction)
  • dull in nature and vague
  • poorly localized
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3
Q

Somatic pain=

A
  • comes from parietal peritoneum ( which is innervated by somatic nerves )
  • sharp in nature
  • well localized
  • made worse by movement , better by lying still
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4
Q

Referred pain=

A
  • pain felt some distance away from its origin
  • mechanism not clear
  • ex. Gallbladder inflammation can irritate diaphragm which is innervated by C3,4,5. Dermatomes of these spinal cord segments supplies the shoulder, hence referred shoulder tip pain
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5
Q

Causes of acute abdomen=

A

1) intestinal : acute appendicitis, perforated peptic ulcer, diverticulitis, intestinal obstruction, strangulated hernia
2) hepatobiliary: biliary colic, cholecystitis , cholangitis , pancreatitis
3) vascular: Ruptured AAA, acute mesenteric ischemia , ischemic colitis
4) urological: renal colic , UTI, testicular torsion, AUR
5) gynecological: ectopic pregnancy, ovarian cyst pathology, salpingitis
6) medical : pneumonia, MI, DKA, sickle cell crisis

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6
Q

The history of acute abdomen:

A 
🔸abdominal pain - will help in diagnosis 
🔸SOCRATES : 
Site and duration
Onset
Character 
Radiation
Associated symptoms
Timing
Exacerbating and alleviating
Severity
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7
Q

Acute abdomen examination:

A 
🔸inspection: 
Scars / asymmetry/ distention
🔸palpation:
Point of maximal tenderness
Features of peritonitis 
Mass
Specific signs ( rovsing’s, murphy’s, cullen’s, grey turner’s) 
🔸percussion: 
Shifting dullness/ tympanic
🔸auscultation: 
Bowel sounds - absent , normal, hyperactive, tinkling
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8
Q

Investigations for acute abdomen:

A

▪️simple invest.:
Blood tests, urine dipstick, pregnancy test,ecg, e. Cxr/ AXR
▪️more complex invest:
Uss, contrast studies, endoscopy, CT, MRI

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9
Q

3 Emergency surgeries without waisting time on tests and investigations:

A

1) generalized peritonitis on examination
2) perforation
3) irreducible and tender hernia

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10
Q

PERITONITIS =

A
  • infection or rarely some other type of inflammation of the peritoneum ( may be localized or generalized)
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11
Q

Peritonism:

A

Refers to a specific features found on abdominal examination in those with peritonitis:
🔸tenderness with guarding, rebound/ percussion tenderness
🔸is eased by lying still & exacerbated by any movement
*generalized peritonitis is a surgical emergency

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12
Q

Causes of generalized peritonitis:

A

▪️infective( most common cause)- due to perforations of the viscus
▪️non infective - leakage of certain sterile body fluids into the peritoneum :
Gastric juice, bile , urine, pancreatic juice , blood ,

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13
Q

2 types of intra abdominal anfections :

A

1) caused by spread of an infection from blood or LNs

2) caused by entry of bacteria or enzymes into the peritoneum from GI of biliary tract

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14
Q

Clinical features of peritonitis:

A

1) pain - constant and severe , worse on movement , eased by lying still
2) signs of ileus : distention, vomiting, tympanic abdomen with reduced sounds
3) signs of systemic shock: tachycardia , tachypnea, hT, low urine output

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15
Q

Resuscitation of generalized peritonitis:

A
  • ABC
  • oxygen
  • fluid resuscitation
  • Iv anbtx
  • analgezia
  • surgery
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16
Q

Intestinal obstruction:

A

-significant mechanic impairment or complete arrest of the passage of contents through the intestine due to blockage

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17
Q

abdominal bowel sounds:

A

▪️present= mechanical obstruction

▪️not present = adynamic obstruction (no gas under the diaphragm)/ perforation ( gas under the diaphragm)

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18
Q

Dynamic vs adynamic obstruction:

A 
Dynamic= peristalsis, mechanical obstruction
Adynamic= paralytic ileus, non propulsive mesenteric vascular obstruction, pseudo obstruction
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19
Q

Dynamic obstruction causes=

Pain, distention, vomiting, absolute constipation

A

1) intraluminal- impaction, FB, bezoars gallstones
2) intramural- strictures , malignancy
3) extraluminal- bands/adhesions, hernia, volvulus , intussuception

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20
Q

Adynamic obstruction causes=

A

1) paralytic ileus
2) mesenteric vascular occlusion
3) pseudo obstruction

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21
Q

Pathophysiology of abdominal obstruction:

A
  • proximal gut- altered motility
  • below the obstruction: normal motility , immobile
  • dehydration and electrolyte imbalance ,reduced intake ,defective absorption ,vomiting ,sequestration in gut
22
Q

Strangulation:

A
  • blood supply compromised
  • venous return 1st affected , arterial
  • hemorrhagic infarction
  • translocation and systemic exposure to microbes/ toxins
23
Q

Closed loop obstruction :

A

Is a specific type of bowel obstruction

  • strangulation
  • perforation
  • necrosis
  • distention
24
Q

Vomiting in bowel obstruction:

A 
High obstruction (complete)- violent 
Low obstruction- slow onset nausea / vomit
25
Q

Distention in acute abdominal obstruction:

A
  • greater in distal obstruction
  • visible peristalsis
  • peristalsis delayed in colonic obst.
  • absent in mesenteric vascular obst
26
Q

Abdomen tenderness:

A

Localized- ischemia

Peritonitis - perforation or infarction

27
Q

Treatment acute abdominal obstruction:

A

1) intestinal drainage
2) fluid and electrolyte replacement
3) relief of obstruction

28
Q

Surgical Mx- acute abdominal obst:

A

1) Mx of segment at the site of obstruction
2) distended proximal bowel
3) underlying cause of obstruction
* supportive : NG tube drainage, na water replacement, antbx
* caecal perforation: caecostomy, ileostomy

29
Q

Special obstructions mx:

A

🔸int. Hernia- foramen of winslow, hole in the mesentery, defect in broad ligament, hole in transverse colon…
Mx= release the ring and reduction of the hernia

30
Q

Sausage shaped lump in the abdomen can be a feature of abdominal obstruction

A
31
Q

Volvulus:

Treatment=

A

Axial rotation of bowel on its mesentery
-congenital or secondary
-caecal: clockwise , resection of gangrene
-sigmoid: anticlockwise
✅treatment=
-flexible sigmoidoscopy/ rigid
-laparotomy -untwisting
-viable fixing to retro peritoneum
-resection : paul mickulikz gangrene
- sigmiod colectomy / hartmans procedure later re anastomosis

32
Q

mesenteric ischemia :

A

Interruption of intestinal blood flow bye :
Embolism
Thrombosis
A low flow state

33
Q

Classification of mesenteric ischemia :

A

🔸acute : 4 distinct mechanisms

🔸chronic: due to long standing atherosclerosis

34
Q

Causes of acute mesenteric ischemia:

A

1) MAE - embolus
2) MAT- thrombosis
3) MVT- venous thrombosis
4) NOMI- non occlusive mesenteric ischemia ( splanchnic vasoconstriction , low flow state )

35
Q

Sympt. And signs of mesenteric ischemia :

A 
Abdominal pain
Nausea , vomiting
Diarrhea /constipation
HR>100
Shock
Metabolic acidosis
Blood per rectum
36
Q

Blood tests in mesenteric ischemia:

A

⬆️ of : WCC, amylase, phosphate

Metabolic acidosis

37
Q

Late signs in plane xray of mesenteric ischemia:

A 
-thump printing 
Pneumatosis intestinalis (presence of gas) 
Portal venous gas
38
Q

Doppler USG in mesenteric ischemia : able to detect and not able to detect?

A

Able to detect= severe stenosis or total occlusion

Not able to detect = emboli beyond the proximal main vessel , NOMI

39
Q

Treatment of AMischemia :

A 
* fluid resuscitation, o2, NG tube, broad spectrum antbx, stop vasopressors and digitalis , treat arrhythmia/ HF 
✅If the pt is stable : 
Angiogram 
Consider vasodilator/ anticoagulation
Interventional radiology
✅If pt is unstable:
Laparotomy, 
-/+ revascularization
-/+ bowel resection
40
Q

Role of anticoagulation in AMI:

A

🔸arterial embolism: early post op and long term
🔸arterial thromb. : early post op
🔸venous thromb: immediate after dx and long term

41
Q

Role of vasodilators

A 
- mainly on Papaverine 
Others: tolazoline, glucagon, nitroglycerine , nitroprusside , prostaglandin E, phenoxybenzamine
▪️for NOMI: 
Mainstay of treatment 
▪️for occlusive MI: 
Adjunct
42
Q

Role of interventional radiology :

A
  • catheter directed infusion of vasodilators= primary TREATMENT of NOMI
  • catheter directed thrombolysis= Anecdotal use in occlusive MI,
  • angiolasty= AMI- scant , CMI-common
43
Q

Role of surgery:

A

▪️MAE: embolectomy
▪️MAT: bypass
▪️MVT: venous thrombectomy is not usually recommended
▪️NOMI: no

44
Q

Embolectomy:

A

A) exposure of superior mesenteric artery by reflection of lig. Of treitz
B) a transverse arteriotomy is performed transversely , proximal to the middle colic branch of the sup. Mesenteric art.
C) embolectomy is performed with 4-F embolectomy catheter
D) artery is closed with interrupted praline suture

45
Q

Fir non viable looking bowel:

A

Frankly necrotic bowel sigment: resection

Marginal viable bowel: may improve over hours, consider second look laparotomy

46
Q

Parietal vs visceral irritation:

A 
Parietal= rich somatic nerve, severe and accurately localized to affected area 
Visceral= poor nerve supply by autonomic , poorly localized , dull and felt in midline
47
Q

Causes of peritonitis:

A

1) bacterial
2) chemical
3) ischemic
4) trauma
5) allergic

48
Q

Clinical features of localized peritonitis:

A
  • 1)fever , tachycardia
    2) abd. Pain
    3) guarding, rigidity and rebound tenderness overlying the involved area ( the rest is not tender)
    4) special features; shoulder tip pain, suprapubic/ both iliac fossa tenderness
49
Q

Management of localized peritonitis :

A

*investigation: cbc, u/e, US, CT
✅treatment: NPO, iv fluid
Antbx: can help resolving it
- percutaneous / open surgical drainage if no resolution or abscess formation

50
Q

Clinical features of generalized peritonitis:

A

1) Abd pain ( the whole abd)
2) fever, tachcard
3) restricted abd wall movement
4) generalized tenderness , guarding, rigidity
5) absent bowel sound
6) late cases: septic shock, silent abd, increasing distention, anxious face

51
Q

Management of generalized peritonitis:

A
  • investigations: cbc, u/e, amylase, cxr, axr, us , ct , peritoneal aspiration
    ✅treatment:
    NPO, iv fluid
    Ng tube : aspiration and drainage
    Broad spectrum antibiotic therapy
    Analgesia
    Operative management: excision, repair, lavage and drainage
52
Q

Complications of peritonitis:

A

🔸systemic: septic shock , pneumonia, RF, multi system failure
🔸local: adhesions, paralytic ileus, abscess formation , portal pyaemia , liver abscess

Surgery (8 decks)

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