ACUTE

ABDOMEN
ALL YOU NEED
TO KNOW

PRESENTED BYMehedi Bashar

Ashiqur Rahman
Parul Akhtar
Asif Sizu
Aniza Agnesh Mrong
Junayed Safar Mahmud

INTRODUCTION TO
ACUTE ABDOMEN

ANATOMY OF ABDOMEN

ANATOMY OF ABDOMEN (CONTD.)

ACUTE ABDOMEN

Definition:
Acute abdomen may be defined as any
sudden, spontaneous, non-traumatic
condition whose chief manifestation is pain in
the abdominal area which needs immediate
medical attention with or without surgical
intervention.

EPIDEMIOLOGY
The most Common causes of acute abdomen are:
Non-specific abdominal pain(NSAP)(33.0%)
Acute appendicitis(23.3%)
Acute billiary disease(8.8%)

The male : female ratio is 47:53

Although 15% of the patients are discharged without
hospitalization, 1.9% patients die of various causes
the most common of which is malignancy.
In conclusion 1/3 rd of the pts remain without any
specific explanation. Operative treatment is
necessary in almost half of cases and mortality rate
is very low.

RISK FACTORS
Extreme of ages
Low fiber high protein diet (Appendicitis)
Alcoholism (Acute pancreatitis)
Injudicial use of NSAID (pepctic Ulcer
Perforation)

CAUSES OF ACUTE ABDOMEN

INTRA ABDOMINAL CAUSES :

Gastrointestinal tract disorders:
Perforated peptic ulcer, Typhoid ulcer
perforation
Small and large bowel obstruction
Dynamic
Intraluminal

: Impaction, foreign body, gall stone,

bezoars, round worm, faecolith
Intramural: Stricture, Growth.
Extramural : Bands & adhession, Volvulus,
Intussusception, obstructed Hernia.
Adynamic
Paralytic

ileus
Mesentaric vascular occlusion

GASTROINTESTINAL TRACT DISORDERS

(CONTD.):
Acute appendicitis
Diverticulitis
Incarcerated hernias
Ulcerative colitis
Acute regional Ileitis

Liver, Spleen and Biliary tract disorders:

Acute cholecystitis
Acute cholangitis
Biliary colic
Liver abscess
Ruptured hepatic tumor
Spontaneous rupture of spleen

Pancreatic Disorders:
Acute pancreatitis
Genito-urinary Disorders:
Acute Pyelonephritis
Acute Ureteric or Renal Colic (Stone)
Testicular Torsion
Gynaecological Disorders:
Ruptured Ectopic Pregnancy
Twisted Ovarian Tumor

Vascular disorders:
Ruptured aortic aneurysms
Acute ischemic colitis
Mesenteric vascular occlusion
Peritoneal and retroperitoneal disorders:
Mesentaric Lymphadenitis
Intra abdominal abscess
Retroperitoneal hemorrhage

EXTRA ABDOMINAL CAUSE:

Parietal Causes:
Cellulitis, abscess, Gas gangrene of
abdominal wall
Herpes Zoster virus infection
Thoracic Conditions:
Myocardial Infarction, Angina
Lobar pneumonia
Diaphragmatic pleurisy

Spinal Disorders:
Potts disease
Gastric crisis in Tabes Dorsalis
Endocrine Disorders:
Diabetic ketoacidosis
General Diseases:
Sickle cell Crisis
Acute porphyria
Uraemia

MOST COMMON CAUSES OF ACUTE ABDOMEN :

Acute appendicitis
Perforation of gas containing hollow viscus
Acute cholecystitis
Acute pancreatitis
Acute intestinal obstruction
Urinary tract infections

Common causes for

Children:

Common causes for

Women :

Acute appendicitis
Intussusception
Mesentaric
Lymphadenitis
Meckels
diverticulitis

Ruptured ectopic
pregnancy
Twisted ovarian
tumor
Acute salpingitis
Acute cholecystitis
Torsion or
degeneration of
uterine fibroid.

HISTORY IN A CASE OF
ACUTE ABDOMEN

AGE
Infant: Intussusception, Meckels
Diverticulitis
Children: Acute appendicitis, mesentaric
lymphadenitis, round worm intestinal
obstruction.
Adult: Perforation of peptic ulcer, Acute
cholecystitis, Acute pancreatitis
Elderly: Sigmoid volvulus, Intestinal
obstruction from malignant growth

SEX

Male:
Peptic

ulcer perforation
Acute Pancreatitis
Volvulus
Intussusception

Female:
Acute

Cholecystitis
Acute appendicitis

CHIEF COMPLAINTS
Abdominal pain (Most Important)
Vomiting
Bowel habit
Jaundice
Haematemesis
Haematuria
Haematochezia

ABDOMINAL PAIN

Some general patterns of location of the pain

SITE OF PAIN
provide clues to diagnosis.

ONSET OF PAIN
Sudden, like a light switching on onset of
pain in, rupture ectopic pregnancy, torsion of
ovary or testis, ruptured aneurysms.
Less sudden onset; on most other cases.

CHARACTER OF PAIN

Colicky pain: sharp intermittent gripping pain

which comes suddenly and disappears
suddenly. It indicates obstruction of hollow
organ
Intestinal colic
Biliary colic
Renal or ureteric colic

Constant Burning pain in peritonitis

Sudden stabbing pain in perforation of hollow
viscus.
Severe agonising pain in acute pancreatitis or
torsion.
Throbbing pain is suggestive of inflamation, e.g.
cholecystitis.

MOVEMENTS OF PAIN

Radiation of Pain: extension of pain to

another site whilst the original pain persists at
its original site.

Referred Pain: Pain is felt at a distance from

its source and there is no pain the site of
disease.

Shifting of Pain: Pain is felt at one site in the

begaining then pain is shifted to another site
and the original pain disappears.

PAIN MIGRATION IN ACUTE APPENDICITIS, CHOLECYSTITIS,

PANCREATITIS

SENSORY LEVEL ASSOCIATED

WITH VISCERAL STRUCTURE
Structure

nervous
system

sensory level

Pain felt at

Liver, spleen and

central part of
diaphragm

Phrenic nerve

C 3-5

Tip of the shoulder

Stomach, gall
bladder, small bowl

celiac plexas &

greater splanchic
nerve

T 6-9

Epigastric region

Appendix, Colon

Mesentaric plexus
& lesser splanchic
nerve

T 10-11

Umbilical region

sigmoid colon,
rectum, kidney,
testes

Pelvic splanchic
nerve

T 11-12

Hypogastric region

S 2-4

Hypogastric region

bladder,rectosigmoi hypogastric plexus

d

AGGRAVATING AND RELIEVING

FACTOR
In acute cholecystitis and appendicitis pain is
worsen by walking or jolting.
In case of peritonitis pain is slightly relieved
by taking lying still.
In acute cholecystitis pain is aggravated by
taking fatty food, and lessens on taking
normal food.
In PUD pain increases upon taking spicy food
alcohol, NSAID and somewhat lessens on
vomiting

SEVERITY OF PAIN

Extremely severe pain in case of

Perforated

peptic ulcer

Peritonitis
Acute

Pancreatitis
Pyelolithiasis (Kidney stone)
Twisted ovarian tumor
Testicular torsion

RECURRENCE OF PAIN
It suggests recurrent problems such as ulcer
disease, gallstone colic, diverticulits

Character of the act:

Projectile

in case of gastric outlet obstruction

Quiet regurgitation of mouthfuls in perforation
or general peritonitis.

Vomitus:
Recently

taken food particles

Bile stained
Faeculent vomitus
Blood stained

Frequency and quantity of vomit:

Vomiting

is constant, frequent and profuse in

high intestinal obstruction & acute
pancreatitis.

Relationship with pain:

Vomiting

relieves pain in Peptic ulcer

Vomiting relieves pain temporarily in colics so
that it reappears immediately.

BOWEL HABIT

Absolute constipation:

Relative constipation:

In case of acute appendicitis

Diarrhoea:

Arrest of both flatus and faeces is seen on intestinal

obstruction and peritonitis.

Watery stool in gastroenteritis

In pelvic appendicitis, irritation of rectum may cause
diarrhoea or tenesmus.

Bloody stool:

Childrean with intestinal obstruction passing mucuous

and blood with stool is hightly suggestive of
intussusception

OTHER SYMPTOMS
Jaundice
Haematemesis
Haematuria
Haematochezia

PAST HISTORY

Previous abdominal surgery

Any

history of a previous abdominal, groin,

vascular or thoracic operation may be relevant to
the current illness.

Previous history of peptic ulcer

Typhoid fever
Intestinal tuberculosis

Treatment & Drug History:

NSAID
Steroid

intake

Personal History:
Smooking
Alcohol
Irregular

food habit
Drinking contaminated water (dysentery)

Menstrual History:
Ruptured

ectopic pregnancy

CLINICAL FINDINGS ON
ACUTE ABDOMEN

Appearance:
Abdominal facies: Abdominal cause of
acute abdomen
Facies hippocratica: Terminal stage of
peritonitis
Facies of dehydration: Intestinal
obstruction

 Dequibitus:
Lying

quiet: Peritonitis
Tossing on bed: Colicky pain
Mohamedan prayer position: Acute
pancreatitis

 Pulse:
Normal:

early stage of acute abdomen

Increased:
Acute appendicitis
Internal hemorrhage: Ruptured ectopic
pregnancy

Respiratory rate:
Increased:

Internal hemorrhage, late case of

peritonitis
Normal: other cases

Temp: Increased in acute appendicitis &

acute cholecystitis

Anaemia: Ruptured ectopic pregnancy

Cyanosis: Acute hemorrhagic pancreatitis

Jaundice: Acute cholangitis, acute

pancreatitis

Shape of the abdomen:

Distended

in acute intestinal obstruction, late

stage of peritonitis

Movement with respiration:

Sluggish

or no movement: Diffuse peritonitis,

hemorrhagic condition
Localized limitation of movement: Acute
cholecystitis, acute appendicitis

INSPECTION (CONTD..) :

Visible peristalsis:
Left

to right: small gut obstruction

Right to left: Large gut obstruction

Visible pulsation: Abdominal aortic

aneurism
Skin condition:

Discolouration

of left flank- Gray Turner sign

Bluish hue around umbilicus- Cullens sign
-- both are found in late case of acute
hemorrhagic pancreatitis

Hernial orifice

PALPATION :

Superficial palpation:
Temperature:

Increased over the inflamed

organ
Tenderness:
McBurney's point: Acute appendicitis
Boass sign: Acute cholecystitis
Sherrens triangle: Gangreneous
appendicitis
Muscle guard: Over inflamed organ
Muscle rigidity: Generalised peritonitis

PALPATION (CONTD...) :
Deep palpation:
Organ palpation : Liver,Spleen,Kidney,Bladder,

Genitalia

Special Attention:
Rebound tenderness
Rovsings sign
Cope psoas test
Obturator test
Murphys sign
Lump: Intussusception (sausage shaped lump in
left lumber region associated with empty right ilic
fossa)- sign of Dance
Palpation of hernial orifice

PERCUSSION :

Shifting dullness:
Perforation

of gas containing hollow viscus

Acute pancreatitis
Ruptured ectopic pregnancy

Obliteration of liver dullness:

Perforation

of gas containing hollow viscus

AUSCULTATION :
Silent

abdomen:

Diffuse

peritonitis

Increased peristaltic wave

(borborygmi):
Acute

intestinal obstruction

DIGITAL RECTAL EXAMINATION :

Right

wall tenderness:

Pelvic

appendicitis

Recto vesical pouch tenderness:

Perforated

peptic ulcer

Red currant jelly found over the finger:

Intussusception

PER VAGINAL EXAMINATION :

Forniceal

tenderness:

Ruptured ectopic pregnancy

Twisted ovarian tumor

OTHER SYSTEMIC EXAMINATION :

Respiratory system:
To

exclude lobar pneumonia, diaphragmatic

pleurisy

Cardiovascular system:
To

exclude angina, myocardial infarction

Neurological
To

examination:

exclude tabes dorsalis

Examination of spine:
Compression

disease

of intercostal nerve in potts

Perforated Hollow viscus:

Scaphoid,

tense abdomen (early)

Followed by distension
Shallow respiration (only thoracic)
Guarding or rigidity
Obliteration of liver dullness
Diminished bowel sound (late)

ACUTE APPENDICITIS :

Initially pain in the peri-umbilical region

which shifts to the right iliac fossa within
several hours.
Low grade fever with tachycardia.
McBurney's point tenderness with
Rebound tenderness (Blumbergs sign)
Rovsings sign positive
Copes psoas test- positive
Copes obturator test- positive

RETROCAECAL
APPENDIX

Pelvic
appendix

ACUTE PANCREATITIS
Severe,

agonizing, abrupt onset of

epigastric pain which is constant &
refractory to the usual dose of analgesic,
frequently radiates to the back.
Dehydration, tachycardia and postural
hypotension may be present
Decrease bowel sound and tenderness
in abdomen
Cullens sign and Gray-Turners sign
may be present (Acute Haemorrhagic
Pancreatitis)

Cullens sign

Gray Turners
sign

ACUTE CHOLECYSTITIS :
Acute right upper quadrant pain and
tenderness may radiate to the back and tip
of the right shoulder.
Temperature usually ranges from 38C to
38.5C.
Murphys sign will be positive.
Fever and leukocytosis (12,00015,000/L)
Palpable gallbladder in one third of the
cases

INTESTINAL OBSTRUCTION :
Colicky pain in the abdomen,
Vomiting,
Distention,
Constipation,
Visible peristalsis,
Hernia or rectal mass,

In case of small gut obstruction

pain > vomiting > distension .> constipation
Incase of large gut obstruction
constipation > distension > pain > vomiting

MALIGNANCY :
Unexplained weakness and anemia
Occult or fresh blood in feces
Palpable abdominal mass
Feature of obstruction may be present
Change in bowel habit, e.g: tenesmus
Sensation of incomplete evacuation

INVESTIGATION OF
ACUTE ABDOMEN

PURPOSE

For confirmation of diagnosis

For management purpose- Routine
investigation
To exclude other possible causes

GENERAL PLAN OF INVESTIGATION FOR ACUTE

ABDOMEN
Routine Examination:
Blood analysis :

Full blood count

Serum electrolyte
Blood suger and Urea level

Urine RME :

Haematuria
Pus cell

Special tests according to case suspicion:

Serum enzyme levels

Serum amylase, lipase

Liver function test

Pregnancy test

Imaging:

Ultrasonogram
X-ray (plain X-ray of abdomen on erect posture)
Contrast X-ray

Barium Swallow
Barium meal
Barium follow through
Small bowel enema
Intra Venous Urogram

Endoscopy & Colonoscopy

ERCP (endoscopic retrograde cholangiopancreatography)
MRCP
C.T scan
MRI

Exploratory Laperotomy (if all else fails)

ACUTE APPENDICITIS

Routine:
> Full blood count: Neutrophilic leucocytosis
Raised ESR
Urine analysis:
of pus cell, few RBC UTI
Plenty of RBC, few pus cell Stone
Plenty

Selective:
> Pregnancy test- Suspected ectopic pregnancy
> Blood urea and electrolyte
> Supine abdominal radiograph/Plain X-ray KUB regionHigh resolution focused USG of the abdomen or pelvisTo

rule out other conditions

> Contrast enhanced CT scan of the abdomen (Very

helpful)

ACUTE CHOLECYSTITIS
Blood Analysis- Neutrophilia, C-reactive protein.

Ultrasound abdomenvery useful,reveals presence

or absence of gall stones and
thicking of gall bladder wall.

Liver function test:

Serum bilirubin-Increased level often signifies

cholangitis or stone in the CBD
SGPT
Alkaline phosphatase

Plain X-ray abdomen

10% of gall stones are radio opaque, also rule out

other causes of acute pain abdomen eg-duodenal
ulcer perforation, peritonitis. Gas is seen in
emphysematous GB.

Urine analysis To rule out pyelonephritis

ECG To exclude MI
Serum amylase To exclude Pancriatitis
Chest X-ray To exclude Pneumonia.

HIDA( Hepatic Immune Diacetic Acid)most sophisticated. It is a radio isotope scanning of

gall bladder done with 99Tc(Technetium)

ACUTE PANCREATITIS
Routine blood investigationModerate leucocytosis around 12000 cumm
Haematocrit- High due to dehydration or low as a
result of haemorrhage in haemorrhagic pancreatitis
Coagulation profile
Blood Urea, Serum Creatinine
Blood Glucose - hyperglycemia
Serum Electrolyte- Hypocalcaemia

Serum Amylase -

Very high(>1000 somogyi unit) or rising

titre

Serum Lipase- More specific than amylase

Serum Trypsin More reliable.

Liver Function test

Serum bilirubin
Serum albumin
Alkaline phosphatase
Prothrombin time
Plain X-ray abdomen:
Sentinel loop of dilated proximal small bowel
Distention of transverse colon with collapse of
Descending colon(Colon cut off sign)
Air fluid level in duodenum
Renal halo sign
Obliteration of psoas shadow
Localised ground glass appearance

USG abdomen:
valuable in detecting free peritoneal fluid,
gallstones, dilatation of CBD and occasionally
abdominal aortic aneurysm
Contrast enhanced CT scan:
Indication:
If there is diagnostic uncertainty
In patient with severe acute pancreatitis, to
distinguish interstitial from necrotizing pancreatitis.
In the 1st 72 hours, CT may underestimate the
extent of necrosis
In patient with organ failure, signs of necrosis or
progressive clinical deterioration
Localised complications eg-fluid collection,
pseudocyst or pseudoaneurysm.

INTESTINAL OBSTRUCTION
Plain X-ray abdomen :

(Initially supine abdominal x-ray is taken, later if

needed x-ray in erect posture is taken if perforation is
suspected)

Radiological features of obstruction:

Multiple air fluid levels

Proximal the obstruction-lesser the air fluidlevel
Distal the obstruction-more the air fluid level
Normally, three fluid levels can be seen in plain X-ray
film- at fundus of stomach, at duodenum and often at
caecum.

Obstructed small bowel- characterized by

multiple gas distended loops of intestine that
are generally central and lie transversely. No
gas is seen in the colon.
Jejunum- characterized by
its valvulae conniventes
which completely pass
across the width of the
bowel and are regularly
spaced giving a
CONCERTINA or ladder effect.
Ileum- smooth and characterless

Caecum- rounded gas shadow in the right fossa

Large bowel obstructioncharacterised by haustral
fold which, unlike valvulae
conniventes, are spaced
irregularly, do not cross
the whole diameter of
the bowel.
Pneumobilia (gas in the biliary tree)- due to gall
stone ileus

Volvulus of sigmoid colonHuge pneumatic tire like

distention of the large gut
with convexity upwards in
a manner of inverted U
arising from left iliac fossa
IntussusceptionEvidence of small bowel or large bowel
obstruction with an absent of caecal gas shadow
PeritonitisGround-glass appearance with gas under
the diaphragm in presence of perforation

Barium (microbar solution) enema or

gastrograffin contrast enema X-ray: If
suspected for intussusception (Barium meal is
contraindicated in acute intestinal obstruction)
Haematocrit,blood urea and serum creatinine
LFT, platelet count( in severe sepsis, there will
be altered LFT with thrombocytopenia)
Serum electrolytes- Hypokalaemia is common
USG ABDOMEN- Useful to see dilated bowel
and fluid in the peritoneal cavity
CT scan- Show dilated loop, transition zone
and collapsed part which are definitive features
of intestinal obstruction

RENAL CALCULI
Blood-ESR,serum calcium, phosphate,
creatitine, blood urea, uric acid, PTH level
Urine- Calcium,urate, cysteine if suspected
only, pH, specific gravity
Plain X-ray KUB region- To see kidney
shadow, stones (90% of kidney stones are
radio opaque)
IVU-To see renal function
USG Abdomen- To detect even radiolucent
stones and give information about the
changes in renal parenchyma

USG OF KIDNEY

X-RAY OF KUB REGION

PNEUMOPERITONEUM

Plain X-ray abdomen in erect posture

including both domes of diaphragm: shows
cresentic gas shadow under right or both
domes of diaphragm.
30% cases, there is no gas under
diaphragm due to:
-Gas leakage < 1 ml
-Previous surgery causing
adhesions between liver
and diaphragm.
-Sealed peptic ulcer

USG abdomen: shows free fluid and gas

Total blood count, serum electrolytes
Blood urea, serum creatinine
CT scan abdomen:
very sensitive,indicated
when there is absence
of gas shadow under
diaghram and also to
rule out other condition
like pancreatitis.

Ruptured ectopic pregnancy, twisted ovarian

tumor.

Investigations :
Pregnancy test
USG
CT scan.
Examination under anaesthesia
Laparoscopy
Cytology

EXTRA ABDOMINAL CAUSE OF ACUTE

ABDOMEN
Lobar pneumonia:
CBC
Chest Xray PA View
Sputum for M/E & C/S

Acute myocardial infarction:

Chest X-ray PA view
ECG
Eco-cardiogram
Troponin I
CPK
AST
LDH

MANAGEMENT OF ACUTE
ABDOMEN

MANDATORY STEPS OF MANAGEMENT FOR

ACUTE ABDOMEN
Hospital admission
Prompt attendance of patient by doctor.
Rapid diagnosis by

sound history taking

Clinical examination
Laboratory investigations.
OR,

Urgent decision irrespective of diagnosis

To look and see (Explore) or
wait and see (conservative)

IS SURGICAL INTERVENTION
NEEDED IN ALL CASES OF ACUTE
ABDOMEN???

THE ANSWER IS NO
Here are some Medical Causes of an Acute
Abdomen for Which Surgery Is Not Indicated
Endocrine and metabolic
disorders

Infections & inflammatory

disorders

Uremia

Tabes dorsalis

Diabetic Ketoacidosis

Herpes zoster

Addisonian crisis

Henoch-Schnlein purpura

Acute intermittent porphyria

Referred pain

Haematological Disorders
Sickle cell crisis
Acute leukemia

Myocardial infarction,
Angina
Lobar pneuminia
Diaphragmatic pleurisy

INDICATION FOR URGENT OPERATION

Physical finding:
Bleeding

(unexpected shock or acidosis, falling

hematocrite)
Involuntary guarding or rigidity with severe
localized tenderness.
Tender abdominal and/or rectal mass with high
fever or hypotension
Suspected ischemia (acidosis, fever, tachycardia)
Distention : Tense and progressive
Deterioration on conservative treatment.

Radiologic finding:
Pneumoperitoneum
Gross or progressive bowel distention
Free extravasations of contrast material
Mesenteric occlusion on angiography
Space occupying lesion on imaging
Endoscopic findings:
Perforated or uncontrollably bleeding lesion

Paracentesis findings:
Blood, bile, pus, bowel contents, or urine

PRE-OPERATIVE MANAGEMENT

PRIOR TO SURGERY, SPECIFIC SURGICAL

EXAMINATION MUST BE PERFORMED
They are:
State of hydration
State of nutrition
Palpation for abdominal mass and
tenderness
Checking the hernial orifice
Rectal examination
Auscultation of bowel sound.

GENERAL MANAGEMENT:
Nothing

by mouth
Nasogastric suction If indicated
Correction of dehydration by Intravenous fluid
Prophylactic Antibiotics:
Cephalosporin/ Ciprofloxacin+Metronidazole
Correction of anemia by blood transfusion
Thromboprophylaxis (for high risk patient)
Urinary catheterization,if indicated
Consult to anesthetists before giving any
drugs prior to the surgery

Prior to surgery some investigations are

performed:

Full blood count

Serum creatinine & electrolytes
Urinalysis
Liver function tests
Clotting assay : BT, CT, Prothrombin time
Respiratory system evaluation & arterial blood
gasses
Chest X-ray
Electrocardiography & cardiac system evaluation
Pregnancy test : HCG level
HBS-Ag Screening, HIV screaning

SPECEFIC
MANAGEMENT

ACUTE APPENDICITIS

Appendicectomy is the treatment

of choice either by laparotomy or
laparoscopy

If there is formation of
Appendicular lump conservative
treatment is preferred, Ochsnersherren regimen.

If there is formation of
Appendicular abscess, treatment is
incision & drainage by
percuteneous drain, recovery is
followed by interval Appendectomy
after 3 months.

INCISIONS IN APPENDICECTOMY

Gridiron incision for appendicitis, at right

angles to a line joining the anterior
superior iliac spine and umbilicus, centred
on McBurneys point.

Transverse or skin crease (Lanz) incision for

appendicitis, 2 cm below the umbilicus,
centred on the mid-clavicularmidinguinal
line

Rutherford Morisons incision is useful if

the appendix is para or retrocaecal and
fixed. It is essentially an oblique musclecutting incision with its lower end over
McBurneys point and extending obliquely
upwards and laterally as necessary

Right lower paramedian incision

Lower midline incision

Figure1. Gridiron incision for

appendicitis, at right angles to a
line joining the anterior superior iliac
spine and umbilicus, centred on
McBurneys point

Figure 2.Transverse or skin crease

(Lanz) incision for appendicitis,
2 cm below the umbilicus, centred on
the mid-clavicular midinguinal line

Technique of appendectomy. A: Incision. B: After delivery of the tip of the

cecum, the mesoappendix is divided. C: The base is clamped and ligated
with a simple throw of the knot. The next stepinversion of the stumpis
optional. D: A clamp is placed to hold the knot during inversion with a
purse-string suture of fine silk. E: The loosely tied inner knot on the stump
assures that there is no closed space for the development of a stump
abscess.

Laparoscopic appendicectomy. (a) Mesoappendix displayed. (b) Ligation at the

base of the appendix. (c) Division of base. (d) Appendicectomy complete

ACUTE CHOLECYSTITIS:
Conservative

treatment and continuous

observation on the patient

Surgical

treatment after 6 weeks:

- Laparoscopic Cholecystectomy
- Open Cholecystectomy

CHOLECYSTECTOMY

Figure : Port sites for laparoscopic cholecystectomy:

(A) French approach; (B) North American approach

LAPAROSCOPIC CHOLECYSTECTOMY

Acute Pancreatitis:
Mainly conservative treatment
Gastric Suction
Fluid replacement
Calcium & magnesium
supplimentation
Oxygen
Peritonial lavage
Nutrition
Other drugs (octreonide,H2 blocker)

but surgical debridement may be needed in

advanced severe gangrenous pancreatitis

SURGICALLY REMOVED PANCREAS

PERFORATION OF GAS CONTAINING

HOLLOW VISCUS MOST COMMONLY
DUODENAL ULCER PERFORATION:

Immediate resuscitation
followed by laparotomy
for repair of perforation
with omental patch
reinforcement and
thorough peritoneal
toileting.

INTESTINAL OBSTRUCTION

Conservative treatment if there is no

indication for immediate surgical
intervention:
NPO with Nasogastric suction
Fluid and electrolyte replacement
Monitor the vital signs
Waiting for 72 hours for the obstruction
may resolve spontaneously within that time
frame.

Surgical treatment is necessary for most cases but

should be delayed until resuscitation is complete or if
obstruction persists beyond 72 hours.

Laparotomy: If site of obstruction is unknown

adequate exposure is achieved by a midline incision.

Assessment is directed to:

The site of obstruction

The nature of obstruction
The Viability of Gut.

After assessment of the obstruction

If gut is viable : relief of obstruction

If gut is non viable: excision of the non viable part and end
to end anastomosis.

RENAL AND URETERIC STONE:

Kidney Stone Removal :
Open surgery:
Pyelolithotomy
Extended Pyelolithotomy
Nephrolithotomy

Modern methods of stone removal:

Percutaneous Nephrolithotomy
Extracorporeal shockwave lithotripsy (ECSW)

On an extensively damaged kidney:

Nephrectomy

Ureteric stone removal:

Endoscopic Stone
removal:
Dormia Basket
Ureteric meatotomy

Ureteroscopic Stone
removal :

Push Bang

Lithotripsy in situ
Ureterolithotomy (Open)

Figure Ureteroscopy.
Radiograph showing a
ureteroscope and guidewire
in the lower ureter.

Figure Dormia Basket

Figure 1 Oxalate calculi

Figure 2 Staghorn calculus

POSTOPERATIVE MANAGEMENT
Physiological support:
Ventilation and supplementary oxygenation.
Intravenous fluid administration
First nothing by mouth followed by fluid by mouth and
gradually returning back to normal diet.
Monitoring of urinary output.

Give analgesic for adequate pain relief:

Non-steroidal anti-inflammatory drugs(NSAID)
Morphine/ Pethidine

Anticipate and take early action on complication:

Prophylactic antibiotic administration.

High risk patient must be determined and put them
in the Intensive Care Unit (ICU).
Sterile precaution should be maintained

CONCLUSION
The abdomen is like
a magic box.
And among the surgical
disorders Acute
Abdomen is the most
urgent which should be
managed as soon as
possible to reduce the
mortality and morbidity of
the patient.

THANK YOU