the acute abdomen. major causes of the 'acute abdomen' acute cholecystitis acute...

The Acute AbdomenThe Acute Abdomen

Major causes of the 'acute Major causes of the 'acute abdomen'abdomen'

Acute cholecystitisAcute cholecystitis Acute appendicitisAcute appendicitis or or Meckel's diverticulitisMeckel's diverticulitis Acute pancreatitisAcute pancreatitis Peptic ulcer diseasePeptic ulcer disease Pelvic inflammatory diseasePelvic inflammatory disease Intestinal obstructionIntestinal obstruction, including paralytic ileus (adynamic , including paralytic ileus (adynamic

obstruction) obstruction) Acute intestinal ischaemia/infarctionAcute intestinal ischaemia/infarction or or vasculitisvasculitis Gastrointestinal haemorrhageGastrointestinal haemorrhage Non-surgical disease, e.g. Non-surgical disease, e.g. myocardial infarctionmyocardial infarction, , pericarditispericarditis, ,

pneumoniapneumonia, sickle cell crisis, , sickle cell crisis, hepatitishepatitis, inflammatory bowel , inflammatory bowel disease, opiate withdrawal, disease, opiate withdrawal, typhoidtyphoid, , acute intermittent porphyriaacute intermittent porphyria, , HIVHIV-associated lymphadenopathy or enteritis -associated lymphadenopathy or enteritis

Gallstones and CholecystitisGallstones and Cholecystitis

Gallstones Gallstones may cause no symptoms and may cause no symptoms and are occasionally discoveredare occasionally discovered

The second commonest presentation is The second commonest presentation is acute cholecystitisacute cholecystitis, caused by distension , caused by distension of the gallbladder with subsequent of the gallbladder with subsequent necrosis and ischaemia of the mucosal necrosis and ischaemia of the mucosal wall. wall.

Biliary colicBiliary colic

The pain starts The pain starts suddenlysuddenly in the in the epigastriumepigastrium,,

VVomitingomiting often accompanies the pain, often accompanies the pain,

InvestigationsInvestigations

Urinalysis, Urinalysis, chest X-raychest X-ray and ECG may and ECG may help exclude other diseases. help exclude other diseases.

Ultrasound Ultrasound is the best way to is the best way to demonstrate stones.demonstrate stones.

UltrasonographyUltrasonography can also allow can also allow measurement of the diameter of the measurement of the diameter of the common bile duct common bile duct

Investigations Investigations

Endoscopic retrograde cholangiopancreatEndoscopic retrograde cholangiopancreatographyography (ERCP) is currently the only reliable (ERCP) is currently the only reliable and widely available investigation for and widely available investigation for duct stones.duct stones.

CT mayCT may be useful when filling the bile be useful when filling the bile duct is unsuccessful duct is unsuccessful

Oral cholecystogramsOral cholecystograms (contrast given (contrast given orally is concentrated in a healthy GB orally is concentrated in a healthy GB

CholecystitisCholecystitis

The main difference from biliary colic is the The main difference from biliary colic is the inflammatory component inflammatory component

If the stone If the stone movesmoves to the common bile to the common bile duct (CBD) jaundice may occur duct (CBD) jaundice may occur

Ultrasonography confirms dilatation of the Ultrasonography confirms dilatation of the common bile duct (>7mm diameter common bile duct (>7mm diameter ))

Non-surgicalNon-surgical

Biliary colic and acute cholecystitisBiliary colic and acute cholecystitis - these - these conditions will usually respond to an conditions will usually respond to an opioid opioid such as morphine such as morphine

Pain Pain continuing for over 24 hours or continuing for over 24 hours or accompanied by fever usually accompanied by fever usually necessitates hospital admission. necessitates hospital admission.

RRequire antibioticsequire antibiotics

SurgicalSurgical

Laparoscopic cholecystectomyLaparoscopic cholecystectomy Early surgeryEarly surgery (within seven days of the onset of (within seven days of the onset of

symptoms) appears to be safe and shortens symptoms) appears to be safe and shortens hospital stay, but further studies are needed.hospital stay, but further studies are needed.

Postoperative complicationsPostoperative complications are rare but do are rare but do occur. The most significant is injury to the occur. The most significant is injury to the bile duct which occurs at a rate of 0.2% in bile duct which occurs at a rate of 0.2% in both open and laparoscopic surgery.both open and laparoscopic surgery.

Acute AppendicitisAcute Appendicitis

Sudden Sudden inflammationinflammation of the appendix of the appendix usually caused by obstruction of the lumen usually caused by obstruction of the lumen resulting in invasion of the appendix wall resulting in invasion of the appendix wall by the gut flora. by the gut flora.

Appendicitis is Appendicitis is more common in menmore common in men. . AppendicectomyAppendicectomy is is performed more performed more

often in womenoften in women

Classic symptomsClassic symptoms

Pain:Pain: Early peri-umbilical pain Early peri-umbilical pain movesmoves after after

hours or sometimes days to the right hours or sometimes days to the right iliac fossa iliac fossa

VVomiting, anorexia omiting, anorexia Temperature and pulse are normal at first Temperature and pulse are normal at first Rectal examinationRectal examination: : TR-TR-AppendicectomyAppendicectomy

Intestinal obstruction and ileusIntestinal obstruction and ileus

ObstructionObstruction to free passage of contents can to free passage of contents can occur at any level of the gut but problems such occur at any level of the gut but problems such as oesophageal stricture, oesophageal as oesophageal stricture, oesophageal carcinoma, carcinoma of stomach and pyloric carcinoma, carcinoma of stomach and pyloric stenosis will not be considered here but only stenosis will not be considered here but only obstruction beyond the duodenum. Ileus means obstruction beyond the duodenum. Ileus means intestinal blockage. The term intestinal blockage. The term paralytic ileusparalytic ileus is is used when the problem is inactivity of the bowel. used when the problem is inactivity of the bowel. IleusIleus is often used as a synonym. This may also is often used as a synonym. This may also be called be called intestinal pseudo-obstructionintestinal pseudo-obstruction..

Risk factors:Risk factors:

Small intestinal obstructionSmall intestinal obstruction is caused by is caused by adhesions in 60%, strangulated hernia in adhesions in 60%, strangulated hernia in 20%, malignancy in 5% and volvulus in 20%, malignancy in 5% and volvulus in 5%. 5%.

Large intestinal obstructionLarge intestinal obstruction is most is most often the result of colo-rectal malignancies often the result of colo-rectal malignancies

Sigmoid and caecal volvulusSigmoid and caecal volvulus describes describes rotation of the gut on its mesenteric axis rotation of the gut on its mesenteric axis

Paralytic ileusParalytic ileus Paralytic ileusParalytic ileus describes the condition in which describes the condition in which

the bowel ceases to function and there is no the bowel ceases to function and there is no peristalsis. peristalsis.

chest infection chest infection acute myocardial infarction acute myocardial infarction StrokeStroke,, trauma trauma acute renal failureacute renal failure severe hypothyroidism severe hypothyroidism electrolyte disturbance electrolyte disturbance diabetic ketoacidosisdiabetic ketoacidosis

CClinicallinical

CCentral entral abdominal abdominal painpain VomitingVomiting tends to be early in high level tends to be early in high level

obstruction obstruction Abdominal Abdominal distensiondistension Check Check hernial orificeshernial orifices Plain abdominal x-rayPlain abdominal x-ray is a very important is a very important

investigation investigation

Management:Management:

ResuscitationResuscitation is very important is very important NNasogastric tube will reduce vomitingasogastric tube will reduce vomiting Early surgery is required if there is local or Early surgery is required if there is local or

generalised peritonitis, generalised peritonitis, The management of patients with The management of patients with

obstruction due to malignancy who are obstruction due to malignancy who are unfit for unfit for surgery surgery

Prognosis:Prognosis:

The prognosis of advanced carcinoma The prognosis of advanced carcinoma of the colon remains poorof the colon remains poor. 25% have . 25% have distant metastases distant metastases

50% of sigmoid volvulus50% of sigmoid volvulus will recur in will recur in the next 2 years the next 2 years

60% of stomas60% of stomas are never reversed are never reversed Older patientsOlder patients are less able to are less able to

withstand the rigours of serious illness withstand the rigours of serious illness and major surgery and major surgery

Acute PancreatitisAcute Pancreatitis

PathogenesisPathogenesis

--Gallbladder disease and excess Gallbladder disease and excess alcohol consumptionalcohol consumption account for most account for most cases and typically cause periductal cases and typically cause periductal necrosinecrosis.s.

Biliary disease and alcohol abuse together Biliary disease and alcohol abuse together account for 70%-80% of cases, account for 70%-80% of cases,

SignsSigns

Take temperature to exclude Take temperature to exclude hypothermia hypothermia Probable Probable tachycardiatachycardia Epigastric or generalised Epigastric or generalised abdominal abdominal

tendernesstenderness, often with rigidity. , often with rigidity. In severe cases: In severe cases: gross hypotensiongross hypotension, ,

pyrexia, tachypnoea pyrexia, tachypnoea Hypoxaemia is characteristic of acute Hypoxaemia is characteristic of acute

pancreatitis pancreatitis

InvestigationsInvestigations

Serum amylase >4 x normal: Serum amylase >4 x normal: Raised bilirubin and/or serum Raised bilirubin and/or serum

aminotransferase suggest gall stones. aminotransferase suggest gall stones. Hypocalcaemia is relatively common. Hypocalcaemia is relatively common. CT withCT with contrast enhancement may be contrast enhancement may be

diagnostic where clinical and diagnostic where clinical and biochemical results are equivocal on biochemical results are equivocal on admissionadmission

ManagementManagement

PainPain relief with pethidine or relief with pethidine or buprenorphine ± IV benzodiazepines. buprenorphine ± IV benzodiazepines. Morphine relatively contraindicated Morphine relatively contraindicated because of possible spastic effect on because of possible spastic effect on sphincter of Oddi.sphincter of Oddi.

Nasogastric tubeNasogastric tube only for severe only for severe vomiting. vomiting.

AntibioticsAntibiotics for specific infections. for specific infections.

ComplicationsComplications

Pancreatic necrosisPancreatic necrosis Infected necrosisInfected necrosis Pancreatic abscessPancreatic abscess Acute pseudocystAcute pseudocyst Pancreatic ascitesPancreatic ascites Systemic complicationsSystemic complications Respiratory Respiratory, ,

CardiovascularCardiovascular, , Disseminated Disseminated intravascular coagulopathy (DIC)intravascular coagulopathy (DIC), , HypocalcaemiaHypocalcaemia