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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
Distention in acute abdominal obstruction:
- greater in distal obstruction - visible peristalsis - peristalsis delayed in colonic obst. - absent in mesenteric vascular obst
26
Abdomen tenderness:
Localized- ischemia | Peritonitis - perforation or infarction
27
Treatment acute abdominal obstruction:
1) intestinal drainage 2) fluid and electrolyte replacement 3) relief of obstruction
28
Surgical Mx- acute abdominal obst:
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
Special obstructions mx:
🔸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
Sausage shaped lump in the abdomen can be a feature of abdominal obstruction
31
Volvulus: | Treatment=
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
mesenteric ischemia :
Interruption of intestinal blood flow bye : Embolism Thrombosis A low flow state
33
Classification of mesenteric ischemia :
🔸acute : 4 distinct mechanisms | 🔸chronic: due to long standing atherosclerosis
34
Causes of acute mesenteric ischemia:
1) MAE - embolus 2) MAT- thrombosis 3) MVT- venous thrombosis 4) NOMI- non occlusive mesenteric ischemia ( splanchnic vasoconstriction , low flow state )
35
Sympt. And signs of mesenteric ischemia :
``` Abdominal pain Nausea , vomiting Diarrhea /constipation HR>100 Shock Metabolic acidosis Blood per rectum ```
36
Blood tests in mesenteric ischemia:
⬆️ of : WCC, amylase, phosphate | Metabolic acidosis
37
Late signs in plane xray of mesenteric ischemia:
``` -thump printing Pneumatosis intestinalis (presence of gas) Portal venous gas ```
38
Doppler USG in mesenteric ischemia : able to detect and not able to detect?
Able to detect= severe stenosis or total occlusion | Not able to detect = emboli beyond the proximal main vessel , NOMI
39
Treatment of AMischemia :
``` * 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
Role of anticoagulation in AMI:
🔸arterial embolism: early post op and long term 🔸arterial thromb. : early post op 🔸venous thromb: immediate after dx and long term
41
Role of vasodilators
``` - mainly on Papaverine Others: tolazoline, glucagon, nitroglycerine , nitroprusside , prostaglandin E, phenoxybenzamine ▪️for NOMI: Mainstay of treatment ▪️for occlusive MI: Adjunct ```
42
Role of interventional radiology :
- catheter directed infusion of vasodilators= primary TREATMENT of NOMI - catheter directed thrombolysis= Anecdotal use in occlusive MI, - angiolasty= AMI- scant , CMI-common
43
Role of surgery:
▪️MAE: embolectomy ▪️MAT: bypass ▪️MVT: venous thrombectomy is not usually recommended ▪️NOMI: no
44
Embolectomy:
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
Fir non viable looking bowel:
Frankly necrotic bowel sigment: resection | Marginal viable bowel: may improve over hours, consider second look laparotomy
46
Parietal vs visceral irritation:
``` 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
Causes of peritonitis:
1) bacterial 2) chemical 3) ischemic 4) trauma 5) allergic
48
Clinical features of localized peritonitis:
- 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
Management of localized peritonitis :
*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
Clinical features of generalized peritonitis:
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
Management of generalized peritonitis:
* 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
Complications of peritonitis:
🔸systemic: septic shock , pneumonia, RF, multi system failure 🔸local: adhesions, paralytic ileus, abscess formation , portal pyaemia , liver abscess

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