surgical approach of acute abdomen

8/10/2019 Surgical Approach of Acute Abdomen

1/49

The Surgical Approach to the

Acute AbdomenAndi Djaja Pratama


2/49

The acute abdomen refers to the clinical situation in which an acute change in the

condition of the intraabdominal organs,usually related to inflammation orinfection, demands immediate and

accurate diagnosis.


3/49

The term acute abdomen should never beequated with the invariable need for

operation.

Zachary Cope, MD, 192


4/49

The Acute Abdomen

! Abdominal pain i" one o# the mo"t #re$uentrea"on" to %i"it phy"ician o##ice" and emergency

room"! Mo"t patient" are #ound to ha%e "el# limited

condition"! A "ub"et o# patient" harbor "eriou" intraabdominal

di"ea"e that re$uire" urgent "urgical or medicalinter%ention


5/49

The Acute Abdomen

! &arly diagno"i" i" the 'ey to impro%ing outcome"! An accurate hi"tory and complete phy"ical

e(amination are more important than anydiagno"tic te"t

! The hi"tory "hould be obtained )ith the abdomen bare, )ith attention to ho) the patient po"ition"him"el# and mo%e"


6/49

The Acute Abdomen

! &arly e%aluation by e(perienced phy"ician" i"important, a" once the initial e%aluation i" done

analge"ia may be gi%en! Antibiotic" "hould not be gi%en until a )or'ing

diagno"i" i" made! Serial e(amination" by the "ame phy"ician during

the patient*" )or' up determine" di"ea"e progre""ion or re"olution


7/49

Peritoneal Sign"

! Palpation and Percu""ion + & -&.T/&! 0ebound + plea"e do not per#orm thi" te"t

+ Cau"e" une(pected and unnece""ary pain + Doe" not add in#ormation to an e(amination

a#ter percu""ion

! 0igidity + not pre"ent in pel%ic in#lammation orob"truction


8/49

The Acute Abdomen

! 0e%ie) anatomy and phy"iology o#

abdominal pain! 0e%ie) "ome common cau"e" o# the acute

abdomen


9/49

Abdominal Pain

! Acute abdominal pain i" the hallmar' o# anacute abdomen

! t may originate #rom any organ in theabdominal ca%ity

! nder"tanding the mechani"m" o# pain

production and the phy"iology o# pain perception allo) #or more accuratediagno"e"


10/49


11/49

Abdominal Pain

! Pain may be %i"ceral, "omatic or re#erred! 3i"ceral pain i" characteri4ed by dullne"",

poor locali4ation, cramping, burning orgna)ing

! 3i"ceral pain i" mediated by autonomic

5"ympathetic and para"ympathetic6 ner%e"! The location o# the pain corre"pond" to the

dermatome" o# the organ" in%ol%ed


12/49


13/49

Abdominal Pain

! Sen"ory neuroreceptor" #or %i"ceral pain arelocated in the muco"a or mu"culari" o# hollo)

%i"cera, on the %i"ceral peritoneum and )ithin theme"entery! The"e receptor" re"pond to mechanical and

chemical "timuli! Stretch i" the primary mechanical "ignal #or pain


14/49

Abdominal Pain

! The parietal peritoneum ha" an entirely "omaticinner%ation

! Somatic pain i" more inten"e and )ell locali4ed! Somatic inner%ation i" mediated by the "pinal

ner%e"

! A tran"ition #rom %i"ceral to "omatic painindicate" e(ten"ion o# the underlying proce""


15/49

Abdominal Pain

! 0e#erred pain i" percei%ed a" pain di"tant #rom thein%ol%ed organ

! t i" due to a con%ergence o# %i"ceral a##erentneuron" )ith "omatic a##erent neuron" #romdi##erent anatomic region"

! 0e#erred pain i" )ell locali4ed


16/49

Common Cau"e"

! Appendiciti"! Cholecy"titi"

! Pancreatiti"! Di%erticuliti"! Per#orated lcer

! D! 7b"truction

! 3a"cular &mergencie"! -ynecologic Di"ea"e"! rinary Tract Di"ea"e


17/49

Appendiciti"


18/49

Appendiciti"

! 1 in 18 people )ill de%elop appendiciti" intheir li#etime

! t*" the mo"t common cau"e o# the acuteabdomen

! Pea' incidence i" #rom 1 + : year"


19/49

Appendiciti"

! ;i"tory may be cla""ic + i# you*re luc'y! 3ague peri


20/49

Appendiciti"

! 0etrocecal appendi( occur" =>? o# the time! ltra"ound or CT Scan may be u"ed! CT Scan )ith triple contra"t and 8mm cut"

through the le%el o# the appendi( i" 9@?"en"iti%e #or appendiciti"

! A retrocecal or pel%ic appendi( or ab"ce"")ill .7T cau"e peritoneal "ign"


21/49

Appendiciti" in Pregnancy

! Appendiciti" i" the mo"t common e(trauterine"urgical emergency

! 1 in = pregnancie"! Sign" and "ymptom" are unreliable! Derangement" in - phy"iology include decrea"ed

ga"tric acid "ecretion, increa"ed re#lu(, delayedga"tric emptying and decrea"ed peri"tal"i"! CT "can" in the third trime"ter are "a#e


22/49

Appendiciti" in Pregnancy


23/49

Acute Cholecy"titi"


24/49

Acute Cholecy"titi"

! iliary colic i" the mo"t common "ymptom! Pain may radiate to the right "houlder or "capula

! The pain i" colic'y and i" a""ociated )ith nau"eaand %omiting

! Murphy*" "ign acute abdomen

! ltra"ound


25/49

Acute Cholecy"titi"


26/49

Acute Pancreatiti"


27/49

Acute Pancreatiti"

! 7n"et i" acute! Abdomen i" tender, but rarely ha" true peritoneal

"ign"! -rey Turner*" "ign, Cullen*" "ign and Bo(*" "ignare in#re$uently "een

! Serum amyla"e and lipa"e are the biochemical

hallmar'"! 0an"on*" criteria i" u"ed to torture "urgical

hou"e"ta## + APAC;& Score


28/49

Acute Pancreatiti"

! Che"t (


29/49

Per#orated lcer


30/49

Per#orated lcer

! Per#orated ulcer re$uire" immediate operati%etherapy

! Anterior ga"tric per#oration" cau"e peritoniti"! Po"terior ga"tric and duodenal per#oration" maynot cau"e peritoniti", and a#ter the acute epi"ode o#

pain, the lea' may )all o##, gi%ing the impre""ion

that the patient i" impro%ing! Tympany o%er the li%er at the mid


31/49

Per#orated lcer

! Bree air 5@ ? o# per#orated ulcer"6 + -o to 70

! .o #ree air, no peritoniti" + -o to CT "can

! Subhepatic #luid collection


32/49

Di%erticuliti"


33/49

Di%erticuliti"

! Patient" may ha%e antecedent hi"tory o# thinning bo)el mo%ement"

! Patient" may 'no) they ha%e poc'et"E! All colonic pain i" hypoga"tric + "o bandli'e pain

acro"" the lo)er abdomen i" common! Di##erential include" per#orated colon cancer ! .o endo"copy or contra"t enema" in the acute

pha"e + CT Scan


34/49

Di%erticuliti"

CT Scan Diagno"tic criteria! MildF /ocali4ed )all thic'ening 5 G8 mm6,

pericolic #at in#lammation! Se%ereF ab"ce"", e(traluminal ga" contra"t#ecti%ene""!

Sen"iti%ityF 9:


35/49

Di%erticuliti"


36/49

Di%erticuliti"


37/49

Di%erticuliti"

! Patient" )ith peri


38/49

n#lammatory o)el Di"ea"e


39/49

n#lammatory o)el Di"ea"e

! Crohn*" Di"ea"e + Acute e(acerbation in patient" )ith

undiagno"ed ileocolic Crohn*" may be con#u"ed)ith appendiciti"

+ /aparo"copy may help determine the diagno"i"

+ "olated Crohn*" coliti" account" #or 28? o# allCrohn*" di"ea"e


40/49

Crohn*" Di"ea"e

7perati%e ndication"! Coliti" re#ractory to

medical therapy i" themo"t common cau"e #orurgent operation

! Per"i"tent hemorrhage and#ree per#oration are rare


41/49

lcerati%e Coliti"

! Di"ea"e Cour"eProctiti"F

! 8 ? pan


42/49

lcerati%e Coliti"

Di"ea"e Se%erityMild coliti"F 2 ?Moderate coliti"F 1?Se%ere coliti"F 9?

Acute di"ea"e complication"To(ic coliti" or megacolon

Per#oration;emorrhage

/anghol4 1991


43/49

To(ic Coliti"

Subjecti%e appearance7bjecti%e criteriaF

! Be%er ! Tachycardia! /eu'ocyto"i"

! ;ypoalbuminemia! Colonic diameter greater than =cm on To(ic coliti" may progre"" to to(ic megacolon


44/49

7b"truction


45/49

Small o)el 7b"truction

! ;i"tory + Prior "urgery + ;ernia"

! Sign" and Symptom" + Colic'y abdominal pain + .au"ea and %omiting

+ Abdominal di"ten"ion + 0ectal e(am

! .o peritoneal "ign"


46/49

Small o)el 7b"truction

! Diagno"i" + and upright abdominal #ilm"

+ :cm i" upper limit o# "mall bo)el diameter ! Partial S 7

+ Colonic ga" + Small bo)el "erie" i# needed

! Complete bo)el ob"truction + mmediate laparotomy


47/49

/arge o)el 7b"truction


48/49


! -reater than 8 ? are malignant + Colorectal cancer i" u"ually the primary + 3ol%ulu" and intu""uception are other cau"e"

! Sign" and Symptom" + -radual on"et + Pain i" not colic'y

+ 3omiting i" rare! Patient" )ith competent ileocecal %al%e" are at

highe"t ri"' o# per#oration


49/49


! Diagno"tic (

surgical approach of acute abdomen

Documents