Acute abdomen 4th year 2012

part IIDr Abdulhakim Al-Tamimi , MD

Assiss prof of suregry

Aden university

What are your objectives?You should be able to address the following questions1. Is this bowel obstruction or ileus?2. Is this a small or large bowel obstruction?3. Is this proximal or distal obstruction?4. What is the cause of this obstruction?5. Is this a complex or simple obstruction?6. How should I start investigating my patient?7. What is the role of other supportive investigations?8. What is my immediate/ intermediate treatment plan?9. What are the indications for surgery?10. What are the medico-legal and ethical issues that I

should address?

Introduction and Definitions Accounts for 5% of all acute surgical admissions Patients are often extremely ill requiring prompt

assessment, resuscitation and intensive monitoring

Obstruction A mechanical blockage arising from a structural abnormality that presents a physical barrier to the progression of gut

contents. Ileus is a paralytic or functional variety of

obstruction

Obstruction is: Partial or completeSimple or strangulated

Epidemiology

Mechanical small-bowel obstruction is the most frequently encountered surgical disorder of the small intestine.

Although a wide range of etiologies for this condition exist, intra-abdominal adhesions related to prior abdominal surgery is the etiologic factor in up to 75% of cases of small-bowel obstruction.

More than 300,000 patients are estimated to undergo surgery to treat adhesion-induced small-bowel obstruction in the United States annually.

In contrast to colonic obstruction, small-bowel obstruction is uncommonly caused by neoplasms.

Fewer than 3% of cases are caused by primary small-intestinal neoplasms.

Cancer-related small-bowel obstruction is

more commonly caused by extrinsic compression or invasion by advanced malignancies arising in organs other than the small bowel

Patho-physiology I

8L of isotonic fluid received by the small intestines (saliva, stomach, duodenum, pancreas and hepatobiliary )

7L absorbed 2L enter the large intestine and 200 ml excreted

in the faeces Air in the bowel results from swallowed air ( O2 &

N2) and bacterial fermentation in the colon ( H2, Methane & CO2),

600 ml of flatus is released Enteric bacteria consist of coliforms, anaerobes

and strep.faecalis. Normal intestinal mucosa has a significant

immune role

Patho-physiology I

Distension results from gas and/ or fluid and can exert hydrostatic pressure.

In case of BO Bacterial overgrowth can be rapid

If mucosal barrier is breached it may result in translocation of bacteria and toxins resulting in bactaeremia, septaecemia and toxaemia.

Patho-physiology IIObstruction results in:

1. Initial overcoming of the obstruction by increased paristalsis

2. Increased intraluminal pressure by fluid and gas

3. Vomiting 4. sequestration of fluid into the lumen from the

surrounding circulation5. Lymphatic and venous congestion resulting in

oedematous tissues6. Factors 3,4,5 result in hypovolaemia and

electrolyte imbalance7. Further: localised anoxia, mucosal depletion

necrosis and perforation and peritonitis.8. Bacterial over growth with translocation of

bacteria and it’s toxins causing bacteraemia and septicaemia.

Patho-physiology II

Decompress with NGT Replace lost fluid Correct electrolyte abnormalities Recognise strangulation and

perforation Systemic antibiotics.

Acute intestinal obstruction

Etiology:• In 75% of patients, it results from

previous abdominal surgery to adhesive bands or internal or external hernias.

• Other causes include lesions intrinsic to the wall of intestine, e.g. diverticulitis, carcinoma, regional enteritis, and luminal obstruction, as gallstone obstruction or intussusception

Causes- Small BowelLuminal Mural Extraluminal

F. BodyBezoars

Gall stoneFood Particles

A. lumbricoides

Neoplasims lipoma polyps leiyomayoma hematoma lymphoma carcimoid carinoma secondary

TumorsCrohnsTBStrictureIntussusceptionsCongenital

Postoperative adhesions

Congenital adhesions

Hernia

Volvulus

Small Bowel Adhesions Accounts for 60-70% of All SBO Results from peritoneal injury, platelet activation and fibrin

formation. Associated with starch covered gloves, intraperitoneal sepsis,

haemorrhage and wash with irritant solutions iodine and other foreign bodies.

As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years

• Colorectal Surgery 25%

• Gynaecological 20%

• Appendectomy 14% 70% of patients had a single band Patients with complex bands are more likely to be readmitted Readmission in surgically treated patients is 35%

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

Hernia Accounts for 20% of SBO Commonest 1. Femoral hernia

2. ID inguinal

3. Umbilical

4. Others: incisional and internal H.

The site of obstruction is the neck of hernia The compromised viscus is with in the sac. Ischaemia occurs initially by venous occlusion,

followed by oedema and arterial ompromise. Attempt to distinguish the difference between:

• Incaceration

• Sliding

• Obstruction

Strangulation is noted by: • Persistent pain

• Discolouration

• Tenderness

• Constitutional symptoms

Incarcerated Inguinal Hernia

Roentgenographic image in acute intestinal obstruction

Fluid- and gas-filled loops of small intestine arranged in a „stepladder” pattern with air-fluid levels in small intestine obstruction

Frame-like arranged distanded gas-filled colonic bowels in colonic obstruction.

Other causes

IBDGall stone IleusIntussusception

F.B in the G.I.T

F.B in the G.I.T

Large Bowel Obstruction•Distinguishing ileus from mechanical obstruction is challenging

•According to Leplac’s law: maximum pressure is at the it’s maximum diameter. Cecum is at the greatest risk of perforation

•Perforation results in the release of formed feaces with heavy bacterial contamination

Large Bowel Obstruction

Aetiology:1. Carcinoma: The commonest cause, 18% of colonic ca. present

with obstruction2. Benign stricture: Due to Diverticular disease, Ischemia,

Inflammatory bowel disease.3. Volvulus: 1. Sigmoid Volvulus: Results from long redundant,

faecaly loaded colon with a narrow pedicle 2. Caecal Volvulus4. Hernia.5. Congenital : Hirschusbrung, anal stenosis and agenesis

Sigmoid VolvulusColonic Obstruction

Volvulus Most commonly sigmoid,

also right colon and terminal ileum (cecal volvulus), cecum alone (due to a highly mobile cecum called a cecal bascule- mobile in caudad to cephalad direction), and rarely transverse colon

(photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)

(photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)

Large Bowel Obstruction

Large Bowel Obstruction

How to Understand the clinical findings

Clinical Findings1. History

Persistent pain may be a sign of strangulation Relative and absolute constipation

The Universal FeaturesColicky abdominal pain, vomiting, constipation (absolute), abdominal

distension.

Complete HX ( PMH, PSH, ROS, Medication, FH, SH)

High•Pain is rapid

•Vomiting copious and contains bile jejunal content

•Abdominal distension is limited or localized

•Rapid dehydration

Distal small bowel•Pain: central and colicky

•Vomitus is feculunt

•Distension is severe

•Visible peristalsis

•May continue to pass flatus and feacus before absolute constipation

Colonic•? Preexisting change in bowel habit

•Colicky in the lower abdomin

•Vomiting is late

•Distension prominent

•Cecum ? distended

Clinical Findings2. Examination

General

•Vital signs:

P, BP, RR, T, Sat

•dehydration

•Anaemia, jaundice, LN

•Assessment of vomitus if possible

•Full lung and heart examination

Abdominal

•Abdominal distension and it’s pattern

•Hernial orifices

•Visible peristalsis

•Cecal distension

•Tenderness, guarding and rebound

•Organomegaly

•Bowel sounds–High pitched–Absent

•Rectal examination

Others

Systemic examination

If deemed necessary.

•CNS

•Vascular

•Gynaecological

•muscuoloskeltal

Radiological EvaluationNormal Scout

Always request: Supine, Erect and CXR

Gas pattern:• Gastric,

• Colonic and 1-2 small bowel

Fluid Levels:• Gastric

• 1-2 small bowel

Check gasses in 4 areas:1. Caecal

2. Hepatobiliary

3. Free gas under diaphragm

4. Rectum

Look for calcification

Look for soft tissue masses, psoas shadow

Look for fecal pattern

Intestinal obstruction

The Difference between small and large bowel obstruction

Large bowel Small Bowel

•Peripheral ( diameter 8 cm max)

•Presence of haustration

•Central ( diameter 5 cm max)

•Vulvulae coniventae

•Ileum: may appear tubeless

Role of CT Used with iv contrast, oral and

rectal contrast (triple contrast). Able to demonstrate

abnormality in the bowel wall, mesentery, mesenteric vessels and peritoneum.

It can define

• the level of obstruction

• The degree of obstruction

• The cause: volvulus, hernia, luminal and mural causes

• The degree of ischaemia

• Free fluid and gas

Ensure: patient vitally stable with no renal failure and no previous alergy to iodine

Role of barium gastrografin studies

As: follow through, enema Limited use in the acute setting Gastrografin is used in acute

abdomen but is diluted Useful in recurrent and chronic

obstruction May able to define the level and

mural causes. Can be used to distinguish

adynamic and mechanical obstruction

Barium should not be used in a patient with peritonitis

How to initially investigate your patient

Lab:

• CBC (leukocytosis, anaemia, hematocrit, platelets)

• Clotting profile

• Arterial blood gasses

• U& Crt, Na, K, Amylase, LFT and glucose, LDH

• Group and save (x-match if needed)

• Optional (ESR, CRP, Hepatitis profile

Radilogical:• Plain xrays

• USS ( free fluid, masses, mucosal folds, pattern of paristalsis, Doppler of mesenteric vasulature, solid organs)

• Other advanced studies (CT, MRI, Contrast studies……senior decision)

ECG and other investigations for co-morbid factors

Initial Management in the ER Resuscitate:

• Air way (O2 60-100%)

• Insert 2 lines if necessary

• IVF : Crytloids at least 120 ml/h. (determined by estimated fluid loss and cardiac function). Add K+ at 1mmmol/kg

Draw blood for lab investigations Inform a senior member in the team. NPO. Decompress with Naso-gastric tube and secure in position Insert a urinary catheter (hourly urinary measurements) and

start a fluid input / output chart Intravenous antibiotics (no clear evidence) If concerns exist about fluid overloading a central line should be

inserted Follow-up lab results and correction of electrolyte imbalance The patient should be nursed in intermediate care Rectal tubes should only be used in Sigmoid volvulus.

Indications for Surgery

Immediate intervention: Evidence of strangulation (hernia….etc) Signs of peritonitis resulting from perforation or ischemia

In the next 24-48 hours Clear indication of no resolution of obstruction ( Clinical,

radiological). Diagnosis is unclear in a virgin abdomen

Intermediate stage

The cause has been diagnosed and the patient is stabalised

Viable VS non viable intestine

Circulation: 1.Dark colour becomes lighter

2. Mesentry bleeds if pricked Peritoneum:

1.Shiny Intestinal musculature:

1.Firm

2.Peristalsis may be observed

3.Pressure rings may/may not disappear

Non –viable

Circulation:1.Remains dark in colour

2. No bleeding if pricked Peritoneum:

1.Dull and lusterless Intestinal musculature:

1.Pressure rings persist 2.No peristalsis

Differentiation between viable and non viable intestine

Intestine Viable Nonviable

Circulation -Dark color become lighter-mesentery bleed if pricked

-Dark color remained -No bleed if mesentery is pricked

Peritonium Shiny Dull and Lustreless

Intestinal musculature

-Firm-Peristalsis may be observed

-Flabby thin and friable-No peristalsis

Legal issues and consent

Paralytic Ileus Associated with the following conditions:

• Postoperative and bowel resection

• Intraperitoneal infection or inflammation

• Ischemia

• Extra-abdominal: Chest infection, Myocardia infarction

• Endocrine: hypothyroidism, diabetes

• Spinal and pelvic fractures

• Retro-peritoneal haematoma

• Metabolic abnormalities:

• Hypokalaemia

• Hyponatremia

• Uraemia

• Hypomagnesemia

• Bed ridden

• Drug induced: morphine, tricyclic antidepressants

Is this an ileus or obstructionClinical features Is there an under lying cause? Is the abdomen distended but tenderness is not marked. Is the bowel sounds diffusely hypoactive.

Radiological features: Is the bowel diffusely distended Is there gas in the rectum Are further investigasions (CT or Gastrografin studies) helpful

in showing an obstruction.

Does the patient improve on conservative measures

Example of ileus

Intussusception (the prolapse of one part of intestine into the lumen of an

immediately adjoining part)

intussusceptum

intussuscipiens1. Colic: involving segments

of the large intestine

2. Enteric: involving only the small intestine

3. Ileocecal: the ileocecal valve prolapses into the cecum, drawing the ileum along with it

4. Ileocolic: the ileum prolapses through the ileocecal valve into the colon

Ileocolic intussusception

Intussusception: invagination of one segment of intestine into another

segment

Etiology

1) idiopathic : 95%

hypertrophied Payer's patches secondary to

viral infection

30% : preceding illness(+)

viral gastroenteritis,

URI

Red Currant jelly stool

Bad Intussusception

Intussusception

Target sign in intussusception

Double ring sign

Coiled spring or filling defect

Ileocolic intussusception

DiagnosisDiagnosis

Clinical diagnosisAccuracy = 50%

UltrasoundAccuracy = 100%

Contrast enemaAccuracy = 100%

- Undiagnosed mortality = ＜ 1%- Overall mortality = rare

Barium reduction

Unsuccessful 10-15%

Successful 85-90%

Perforation <1 %

Recurrence (10 %)

Mortality 0 %

Radiologic Radiologic reductionreduction

intussusception

Intussusception

Meckel’s diverticulum. diverticulitis

Congenital hypertrophic pyloric stenosis

Age 3 weeks First born male baby Projectile vomiting non bilious Epigastic mass Gastric movement from left to right Abdominal US can diagnose the presence

of the mass even if not palpable

Pyloromyotomy (Fredet- Ramstedt procedure)

Acut mesenterial ischemia

Risk factors:• include atherosclerosis, atrial fibrillation, recent

myocardial infarction, valvular heart disease, and recent cardiac or vascular catheterization

Conditions: • Arterial embolism (in >75% of cases originate from

the heart)• Arterial thrombosis• Venous thrombosis• Nonocclusive mesenteric ischemia (vasospasm,

dehydration)

Clinical symptoms:• Severe acute, non remitting abdominal

pain, initially without muscular rigidity (defense)

• Minimal abdominal distension• Hypoactive bowel sounds• Nausea, vomiting, transient diarrhea,

bloody stool • Later findings will demostrate peritonitis,

adynamic ileus

Management:• The „gold standard for the diagnosis

and management of acute arterial occlusive disease is laparotomy Surgical exploration should not be delayed if suspision of acute occlusive mesenteric ischemia is high.

Acute abdomen in pregnant women

Ectopic gestation Retroverted gravid uterus Threatened abortion Sepsis following abortion Torsion ovarian cyst/ fibroid Red degeneration fibroid Rupture uterus Appendicitis

First and Foremost…

Female + ovaries = pregnancy When patients said…

• “My last period was on time.”

• “I don’t think I’m pregnant.”

• “I can’t possibly be pregnant.”

…10% were pregnant.Ramoska EA, et al. Ann Emerg Med. 1989 Ramoska EA, et al. Ann Emerg Med. 1989

Jan;18(1):48-50.Jan;18(1):48-50.

ECTOPIC PREGNANCY

DEFINITION

Any pregnancy where the fertilised ovum gets implanted & develops in a site other than normal uterine cavity.

21/04/23 03:24 Ectopic Pregnancy 109

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SITES OF ECTOPIC PREGNANCY

1)Fimbrial 2)Ampullary 3)Isthemic 4)Interstitial 5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn 8)Secondary abdominal 9)Broad ligament 10)Primary abdominal

Ampulla (>85%)Isthmus (8%)

Cornual (< 2%)

Ovary (< 2%)

Abdomen (< 2%)

Cervix (< 2%)

CLINICAL PRESENTATION Ectopic Pregnancy remains asymptotic until

it ruptures when it can present in two variations - Acute &. Chronic

SYMPTOMS-• Amenorrhea

• Abdominal Pain

• Syncope

• Vaginal Bleeding

• Pelvic Mass

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METHODS OF EARLY DIAGNOSIS Immunoassay utilising monoclonal

antibodies to beta HCG Ultrasound scanning – Abdominal &

Vaginal including Colour Doppler Laparoscopy Serum progesterone estimation not

helpful

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A combination of these methods may have to be employed.

MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

HospitalisationResuscitation -

• Treatment of shock

• Lie flat with the leg end raised

• Analgesics

• Blood transfusion

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MANAGEMENT OF ACUTE ECTOPIC PREGNANCY

Laparotomy should be done at the earliest.

Salpingectomy is the definitive treatment.

No benefit from removing Ovary along with the tube

If blood is not available, auto-transfusion can be done.

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COMPARING LAPAROTOMY Vs LAPAROSCOPY

L’tomy L’scopyHospital cost More? Less?Post operative adhesions More LessRisk of future ectopic Same SameFuture fertility Same SameExperience of Surgeon Trained Special Instruments General Special

Appendicitis in Pregnancy

Acute abdomen in tropics

Amebiasis Malaria----- vivax Worm infestation Sickle cell anemia Pyomyositis (in HIV) Enteric fever

Typhoid ulcer - perforated

Typhoid ulcer - perforated

Complications of ascariasis

Diseases that simulate acute abdomen

Diabetic ketoacidosis Typhoid Malaria TB peritonitis Food poisoning Lead colic Porphyia Pleurisy/pneumonia Cardiac disease (eg. MI) Disease of spine affecting nerve roots Renal disease

Conditions mimicking Acute Abdomen

1. Pneumonia

2. Angina or myocardial infarction

3. Obstructive uropathy

4. Acute hepatitis

5. Sickle cell crisis

6. Leukemia

7. Radiculopathy from spinal nerve involvement

8. Cystitis

9. Pyelonephritis

10.Ureteral obstruction

Conditions mimicking Acute Abdomen

11. Abdominal wall hematoma

12. Pericarditis

13. Herpes Zoster

14. Diabetic ketoacidosis

15. Systemic lupus erythematosus

16. Uremia

17.Torsion of the testis

18. Acute intermittent porphyria

Conditions mimicking Acute Abdomen

19. typhoid 20. Malaria 21. TB abdomen

Acute Pancreatitis

Obstruction

Vascular Emergencies

Imperforate Anus: Anal atresia

JEJUNAL ATRESIA

Anatomy on the

Abdominal X-Ray:

Abdominal X-Rays:

AXR-1 AXR-2

Abdominal X-Rays:

AXR-3 AXR-4

“”“”Let the knife dispel the doubt and reveal the Let the knife dispel the doubt and reveal the truth…”” truth…””

AnonymousAnonymous

“”“”Let the Laparoscope dispel the doubt and Let the Laparoscope dispel the doubt and reveal the truth…””reveal the truth…””

Kim Shi Tan, MDKim Shi Tan, MD Chairman, Dept. Of SurgeryChairman, Dept. Of Surgery FEU-NRMF FEU-NRMF

www.medtube.net

SHOKRAN