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ACUTE ABDOMEN

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الكلية كلية الطب     القسم  الجراحة     المرحلة 4
أستاذ المادة كاظم جلوب حسن اللامي       13/04/2018 14:01:05
An acute abdomen” denotes any sudden, spontaneous, nontraumatic 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.
The approach to a patient with an acute abdomen must be orderly and thorough. The history and physical examination should suggest the probable causes and guide the choice of initial diagnostic studies. The clinician must then decide if in-hospital observation is warranted, if additional tests are needed, if early operation is indicated, or if nonoperative treatment would be more suitable.All clinicians should be thoroughly familiar with the presenting pattern of the following most common causes of an acute abdomen.
a-Gastrointestinal tract disorders
Nonspecific abdominal pain, Acute appendicitis, Small and large bowel obstruction, Perforated peptic ulcer ,Incarcerated hernia, Bowel perforation, Inflammatory bowel disorders, Mallory weiss syndrome, Bowel perforation Mickel;s diverticulitis, Diverticulitis
b-Liver, spleen and biliary tract disorders: Acute cholecystitis, Acute cholangitis, Hepatic abscess, Ruptured hepatic tumour ,Splenic rupture, Splenic infarct ,Biliary colic, Acute hepatitis
c- Pancreatic disorders: acute Pancreatitis
d-Peritoneal disorders:Intra-abdominal abscesses, Primary peritonitis, Tuberculous peritonitis
e-Urinary tract disorders: Ureteral or renal colic, Acute pyelonephritis, Acute cystitis, Renal infarct

f-Vascular disorders; Ruptured aortic and visceral aneurysms, Acute ischemic colitis, Mesenteric thrombosis
g-Gynecological disorders:Ruptured ectopic pregnancy, Twisted ovarian tumour, Ruptured ovarian follicle cyst, Acute salpingitis, Dysmenorrheal disorder, endometriosis
HISTORY
Abdominal Pain Pain is the most common and predominant presenting feature of an acute abdomen. Careful consideration of the location, the mode of onset and progression, and the character of the pain will suggest a preliminary list of differential diagnoses.
Location of Pain
Because of the complex dual visceral and parietal sensory network innervating the abdominal area, pain is not as precisely localized as in the extremities.. Visceral pain is elicited by distention by inflammation or ischemia stimulating the receptor neurons,or by direct involvement (malignant infiltration) of sensory nerves, the centrally perceived sensation is generally slow in onset dull ,poorly localized and protracted. Different visceral structures are associated with different sensory levels in the spine
The location of the pain :typical description described only in two thirds of cases.this great variability is due to atypical pain patterns, a shift of maximum intensity away from the primary site, or advanced or sever disease. In cases presenting late with diffuse peritonitis, generalized pain may completely obscure the precipitating event. Pain confined to either upper quadrant may be evaluated by anatomical consideration of acute conditions that affect the underlying organ.
- Character of pain: the nature ,severity and periodicity of pain provide useful clue to the underlying cause. Steady pain is most common .sharp superficial constant pin due to sever peritoneal irritation. It is typical of perforated ulcer or rupture appendix, ovarian cyst or ectopic pregnancy the gripping mounting pain of small bowel obstruction ( and soon become sharper occasionally in early acute pancreatitis) is usually intermittent ,vague,deep seated and crescendo at first ,but soon become sharper and remitting and better localized. Pain caused by lesions occluding smaller conduits &bile ducts ,uterine tubes and ureters) rapidly becomes unbearably intense. Pain is appropriately referred as colic if there are pain free intervals that reflect intermittent smooth muscle contraction.
Medical causes of acute abdomen:
a-Endocrine &metabolic disorders Uraemia,diabetic crisis ,addisonian crisis ,acute intermittent porphyria, acute hyperlipoproteinemia, hereditary medetranian fever
b-Infections and inflammatory disorders Tabes dorsalis,herpes zoster,acute rheumatic fever,Henoch-Shonlein purpura ,SLE,polyarteritis nodosa
c-Hematological 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 Thoracic region: myocardial infarction, acute pericarditis, pneumonia ,pleurisy,pulmonary embolus ,pneumothorax ,empyema .
Physical signs in various causes of acute abdomen:
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 ileus: Distension,minimal bowel sounds,no localized tenderness
Ischemia 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 associated with acute abdomen Anorexia ,nausea ,vomiting ,constipation or diarrhoe often accompanying abdominal pain,but since these are non specific symptoms,they do not have much diagnostic value.
A –Vomiting When sufficiently stimulated by secondary visceral afferent fibers ,the medullary vomiting centers activate efferent fibers to induce reflex vomiting. Hence, pain in the acute surgical abdomen usually precedes vomiting, whereas the reverse holds true in medical conditions .Vomiting is a prominent symptom in upper gastrointestinal diseases (acute gastritis,pancreatitis) . the absence of bile in the vomitus is a feature of pyloric stenosis .When associated findings suggest bowel obstruction, the onset,and character of vomiting may indicate the level of the lesion .
B- constipation
reflux ileus is often induced by visceral afferent fibers stimulating efferent fibers of the sympathetic autonomic nervous system(splanchnic nerves) to reduce intestinal peristalsis. So, paralytic ileus undermines the value of constipation in the differential diagnosis of an acute abdomen. Opstipation (the absence of both stool and flatus) strongly suggest mechanical bowel obstruction if there is progressive painful abdominal distention or repeated vomiting
C-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.
• Supplementary laboratory & radiological examination: are indispensable for diagnosis of many surgical conditions, for exclusion of medical causes ordinarily not treated by operation, and for assistance in preoperative preparation. A more liberal use of diagnostic studies is justified in elderly or seriously ill patients in whom ,history & physical findings may be less reliable and an early diagnosis vital to ensure a successful outcome.
• 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,,paracetesis ,laparooscopy
The differential diagnosis:
• The age and gender of the patient :mesenteric adenitis mimics acute appendicitis in the young, gynecologic disorders complicate the evaluation of lower abdominal pain in women of child bearing age ,and malignant & vascular diseases are more common in elderly. The clinical picture in early cases is often unclear.the following should be borne in mind.
• a-any pt with acute abd. Pain persisting for over 6 hrs should be regarded as having a surgical problem requiring in hospital evaluation .well localized pain and tenderness usually indicate a surgical condition. Systemic hypoperfusion in conjunction with generalized abd. Pain is seldom due to a non surgical problem.
• b- acute cholecystitis ,appendicitis,bowel obstruction,cancer and acute vascular conditions are the most common causes of surgical abdomen in older patient. In children ,appendicitis accounts for one third of all cases and nonspecific abd. Pain for nearly all of the remainder. c- appendicitis is the commonest cause of bizarre peritoneal findings that produce ileus or bowel obstruction .Appendicits is less likely in previously healthy individuals if the history exceeds 3 days duration and the patient has no fever,appreciable tenderness, ileus or leukocytosis .Aypical presentations of appendicitis are encountered during pregnancy. Pelvic appendicitis are encountered during pregnancy. Pelvic appendicitis,with mild abd pain ,vomiting,and many frequent loose stools ,simulate gastroenteritis & the initial abd signs may be mild and the rectal and pelvic examinations may be unremarkable.
• The acute abdomen in women
• Pathology of the normal organs of reproduction is a common cause of abdominal pain in women.A careful history and pelvic examination are essential. Many of the conditions may be treated non operatively , and an accurate diagnosis may require confirmatory tests.ultrasonographic examination of the pelvic organs,transvaginally or transabdominally, is important tool.CT should only be used only when strictly indicated since it is associated with significant radiation exposure and other risks.some women may be not a ware of recent conception.Thus , a pregnancy test is mandatory for women of child bearing age with abdominal pain.
• PERIOPERATIVE MANAGEMENT
• -after initial assessment ,parenteral analgesic for pain relief should not be withheld. 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.


المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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