ACUTE ABDOMEN

Urgessa (Integrated E.Surgeon,Msc)

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 Contents
Causes
Definition

DDX
Pathophysiology

Investigation
Classification

Mx
C/F
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 INTRODUCTION
 The term acute abdomen generally refers to previously
undiagnosed non-trauma abdominal pain that arises
suddenly and is of less than 7 days' (usually less than 48
hours') duration.
 It is a term used to encompass a spectrum of surgical,
medical and gynecological conditions, ranging from the
trivial to the life-threatening, which require hospital
admission, investigation and treatment.
 It is the most common presenting surgical emergency.

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 Pathophysiology
Abdominal pain arises from irritation of visceral &
parietal peritoneum,
Visceral pain-
Results from tissue injury or inflammation, OR fro
m distension of hollow
Vague & poorly localized ,
– To the epigastrium, periumbalical or hypogastriu
m–origion from fore/mid/hind gut pubis

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 Cont…
Solid organ visceral pain- generalized in the quadr
ant involved- liver→ RUQ pain
Parietal pain
Involvement of parietal peritoneum
Corresponding segmental N roots innervating the
parietal peritoneum allow for focal & intense sens
ation,
Sharper & better localized.

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 Cont….
Referred pain
Pain perceived at a site distant from the source of the stimu
lus,
Because of shared innervation;
– Liver & diaphragm→ referred pain to C3-C5 , to right s
houlder
– GU symptoms, 1⁰rly in the flank, originating from spla
nchnic N of T11-L1, pain often radiates to labia & scrot
um thru hypogastric plexus of S2-S4

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 Causes
The pathological causes are:
o Obstruction
o Inflammation
o Hemorrhage
o Infarction
o Perforation

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 Cont…
A. Gastrointestinal-
1-GIT 2-Liver and biliary tract
 Acute exacerbation of peptic ulcer  Biliary Colic
 Acute appendicitis  Cholecystitis
 Diverticulitis  Cholangitis
 Gastroenteritis  Hepatitis
 Intestinal obstruction
3-Pancreas
 Inflammatory bowel disease
 Acute pancreatitis
 Mesensteric adenitis
 Meckel’s diverticulitis 4-Spleen
 Perforated peptic ulcer  Splenic infarct and
spontaneous rupture

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 Cont…
B. Urinary tract D. Abdominal wall
 Acute pyelonephritis conditions
 Acute retention Rectus sheath haematoma
 Cystitis
 Ureteric colic E. Peritoneum
Primary peritonitis
C. Vascular Secondary peritonitis
Ruptured aortic aneurysm
Mesenteric embolus
Mesenteric venous thrombosis
Ischemic colitis
Acute aortic dissection

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 Cont….
F. Retroperitoneal
Hemorrhage e.g anticoagulants

G. Gynecological
Torsion of ovarian cyst
Ruptured ovarian cyst
Fibroid denegeration
Ovarian infarction
Salpingitis
Pelvic endometriosis
Severe dysmenorrhea
Endometriosis

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 Cont….
H. Extra-abdominal causes
Lobar pneumonia
Pleurisy –infl of pleura.
MI
Sickle cell crisis
Uremia –excess of urea & nitrogenous waste cpd in blood.
Hypercalcemia
DKA
Addison’s disease
Acute intermitent porphyria

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 Classification of causes with age
Children Adult female
Gastroenteritis Salpingitis
Mesentric adenitis Pyelonephritis
Meckel’s diverticulitis Ectopic pregnancy
Intussusception
Elderly
Adult Diverticulitis
Regional enteritis Intestinal obstruction
Ureteric colic Colonic carcinoma
Perforated ulcer Mesentric infarction
Testicular torsion Aortic aneurysm
Pancreatitis

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 Relation of pain to embryology
Intestine and its outgrowths (the liver, biliary system and
pancreas)-> midline.

Irritation of foregut structures

(oesophagus to the second part of the duodenum)
->epigastric area.

Midgut structures
(the second part of the duodenum to the splenic
flexure) ->umbilicus.

Hindgut structures (the splenic flexure to the rectum)->

>hypogastrium.

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 Management
History
Physical examination
Management

History-
– Identification data
Age:
• Mesenteric adenitis in children
• Diverticulitis in elderly
Gender

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 Characteristics of abdominal pain

Site
Time and mode of onset
Severity
Nature/Character
Progression
Radiation
Duration
Cessation
Exacerbating/relieving factors
Associated symptoms

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 Site-pain
Whole abdomen
Peritonitis or mesentric infarction

Right upper quadrant

Acute cholycystitis
Cholangitis
Hepatitis
Peptic ulceration

Left upper quadrant

Peptic ulceration
Pancreatitis
Splenic infarct

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 Right lower quadrant
Appendicitis
Ovarian cyst
Ectopic pregnancy
PID
Right ureteric colic

Left lower quadrant

Sigmoid diverticular disease
Ovarian cyst
Ectopic pregnancy
PID
Left ureteric colic

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 Symptoms--Pain
Onset
sudden: perforation of bowel, smooth muscle colic
slow insidious onset: inflammation of visceral peritoneum

Severity
Patient asked to rate pain from 1-10
Ureteric colic is one of worst pains

Character
Aching-dull pain poorly localised
Burning- peptic ulcer symptoms
Stabbing-ureteric colic
Gripping-smooth muscle spasm e.g. intestinal obstruction
worse by movement ; wringing of cloth
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 Cont…
Progression
-Constant e.g. peptic ulcer
-Colicky e.g. seconds(bowel), minutes(ureteric colic) or tens of
minutes (gallbladder
-may change character completely from dull poorly localized
pain to sharp pain indicates involvement of parietal peritoneum
e.g.appendicitis
Radiation of the pain
Back: duodenal ulcer, pancreatitis, aortic aneurysm
Scapula: gall bladder
Sacroiliac region: ovary
Loin to groin: ureteric colic
Groin: testicular torsion

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 Cont…
Cessation-
abrupt ending- colicky pains
resolving slowly-inflammatory pain, biliary pain

Exacerbating/relieving factors-
Movement/Rest-inflammatory conditions
Food- peptic ulcers

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 Cont…
Past history
previous surgery
trauma
any medical diseases

Drug history
corticosteroid: mask pain
anti-coagulant: intra-mural hematoma
NSAIDS: gastritis, peptic ulcer

Family history
colon cancer

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Physical Examination
General appearance
-Patient is lying motionless
acute appendicitis, peritonitis

-Rolling in bed
ureteric colic, intestinal colic

-Bending forward
chronic pancreatitis

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Cont…
Vital signs
Temp.
low grade: appendicitis, acute cholycystitis
high grade: abscess
Pulse, BP, Resp rate
General examination(HEENT-CNS)-
Conjuctival pallor
cyanosis
jaundice
Signs of dehydation
Cervical lymphadenopathy
-mesentric adenitis

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 Cont…
Cardio-pulmonary examination
-MI
-basal pneumonia
-pleural effusion

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Cont…
Abdomen
*Inspection
-movement with respiration
-distension, peristalsis, mass, scars and any obvious cough
impulse at hernia site
Palpation
*superficial palpation
-tenderness, rebound tenderness, guarding,
rigidity, masses, hernial orifices
*deep palpation
-organomegaly

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 Cont…
*percussion
tympanic note: intestinal obstruction
-dullness over bladder: acute retention
Auscultation
-silent abdomen: peritonitis
-increase bowel sound: intestinal obstruction
**Don’t forget to examine rectum for tenderness, mass,
blood and vaginal examination for discharge,
tenderness( PID).

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Investigation
CBC with differential (infection and inflammation)
Urea, electrolyte, creatinine, glucose (DKA)
LFT
Amylase ( high in acute pancreatitis)
urinalysis
CXR ( basal pneumonia, gas under diaphragm)
AXR
-distended bowel with air fluid level
-stones
-calcified aorta
-air in biliary tree

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CONT….

U/S (ovarian cyst, ectopic pregnancy)

IVP for stones
Angiography (mesentric embolus or thrombosis)
Pregnancy test

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Treatment
1. Relieve the pain
2. IV fluids and nasogastric suction
3. Antibiotics in case of peritonitis or sepsis
4. Surgery if indicated

*Indication for surgery:

If patient has guarding or rigidity with peritoneal irritation
spreading tenderness
Progressive distension or generalized peritonitis
Shock with bleeding or sepsis
Free gas on x-ray
Mesentric occlusion on angiography
Blood, pus or bile on paracentesis

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 Intestinal
Obstruction
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 Definition
When the intestinal contents are prevented
from travelling distally as a result of either i
ntrinsic or extrinsic compression

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 Cont… One of the common cause of
… acute abdomen
May lead to high morbidity and
mortality if not treated correctly
It can be classified into two
types:
Dynamic (mechanical)
Adynamic

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 Causes of dynamic IO
1.Intraluminal: impacted faeces, foreign bodies, gallstones,
worms

2.Intramural: tumours, inflammatory strictures, congenital

atresia, schemia

3.Extramural: adhesion, hernias, volvulus, intussusception,

tumours, Meckel’s diverticulitis

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 Dynamic
*also can be divided into:
1. Small bowel obstruction (SBO)
-high ->early perfuse vomiting
rapid dehydration
-low->predominant pain, and central distention
Vomiting delayed
air-fluid levels seen on AXR

2. Large bowel obstruction (LBO)

early pronounced distension, mild pain
vomiting, dehydration late
e.g. -carcinoma
-diverticulitis or volvulus

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 Obstruction can be-
Simple: blockage without interfering with vascular
supply
Strangulation: significant impairment of blood supply
most commonly associated with hernia, volvulus,
intussusception and vascular occlusion
-surgical emergency

Closed loop obstruction: bowel is obstructed at both the

proximal and distal end)

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 Pathophysiology
Irrespective of etiology or acuteness of onset:
Proximal to obstruction
Increased fluid secretion  abdominal distention
Accumulation of gas  abdominal distention
Increased intraluminal pressure
Decreased reabsorption with time and flaccidity to prevent vascular damage from
high pressure
Vomiting
Dehydration
Dilatation of bowel
Reflex contraction of smooth muscle  colicky pain
Increased peristalsis to overcome obstruction  increased bowel sounds
If obstruction not overcome  bowel atony
Distal to obstruction: nothing is passed & bowel collapse  constipation

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 Symptoms
The four cardinal features of intestinal obstruction:
-abdominal pain
-vomiting
-distension
-constipation

Vary according to:-

location of obstruction
age of obstruction
underlying pathology
intestinal ischemia

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 Cont…
Abdominal pain
colicky in nature, around the umbilicus in SBO while in the
lower abdomen in LBO
if it becomes continuous, think about perforation or
strangulation
Vomiting
-starts early in SBO and late in LBO
-vomitus starts with clear color then becomes thick, brown and
foul ( faeculent)
-more with lower or complete obstruction
-diarrhea may be present with partial obstruction
Distension
-more with lower obstruction

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 Cont..
Constipation
-more with lower or complete obstruction
-diarrhea may be present with partial obstruction
-either absolute (no feces or flatus)<-cardinal in absolute
IO or relative (flatus passed)

Distension
-more with lower obstruction

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 Strangulation
Viability of the bowel is threatened secondary t
o a compromised blood supply
Features of obstruction + shock
Causes:- -closed loop obstruction –fast in the
hernia, volvulus , acute appendicitis,
urgessa Soressa (IE. carcinom
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a of right colon, intussusception& mesenteric i
nfarction eg.

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 Symptoms of strangulation

severe constant abdominal pain

distended abdomen
fever
tachycardia
tender abdomen

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 Cont….
Evidence of strangulation from radiography:
-
Thickened small bowel loops
Mucosal thumb printing
Pneumatosis cystoides intestinalis or
Free peritoneal air

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 Adhession
Common in western country
Classification
Fibrinous –early
Fibrous-late
Practically:- ‘ easy’ filmsy ones
-’difficult’ dense ones
Bands
-congenital –obliterated VI duct
-string- previous bacteria peritonitis
-a portion of greater omentum

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 Cont…
Prevention:-
-Good surgical technique
-Washing of peritoneal cavity with N/S
- Minimize contact with gauze
-Instilling substances in to peritoneal cavity like;
hydrocortisone, dextran, antihistamine, hyaluronidase,
streptokinase, anticoagulants Or NSAID etc.

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 Cont…
Treatment
 Conservative-NPO,NG tube, IV fluid
-analgesics
-wait for 48-72 hrs
 Success rate  90% in early adhesive

Surgically-Adhessiotomy (Release of adhes

ion)

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 Small intestine volvulus
Usually occurs in lower ileum
Maybe primary or secondary
May occur in African following consumption o
f a large volume of vegetable matter
western –usually secondary to adhesion passin
g to the parietes or females pelvic organ
Treatment-reduction of the twist

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 Mechanical LBO
Causes:-
 Tumor
 Volvulus
 Hernia
 Diverticulitis
 Intussusception
 Fecal impaction

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 Intussusceptions

It is an "internal prolapse" of the bowel

Most common in children(peak age 3-9 mon.)
Primary or secondary to intestinal pathology
Iliocolic –commonest
Aetiology :-Idiopathic-70-90%
-gastroentritis ,UTI-30%
-hyperplausia of peyer’s patches
Peak incidence-in spring&summer

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 Pathologic cause
These include
polyps,
malignant tumors such as lymphoma, enteric dupli
cation cysts, or
Meckel's diverticulum.
Such intussusceptions are rarely reduced by air or
contrast enema, and thus the starting point is
identified when operative reduction of the
intussusception is performed

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 Clinical features
Sudden onset of creaming &drawing up leg
s
Episodic attack
Vomiting
Red current jelly stools
Abdominal distension
PR-blood stained mucus

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 Cont…
On p/E an elongated mass is detected in the right upper q
uadrant or epigastrium, with an absence of bowel in the r
ight lower quadrant (Dance's sign)
The mass may be seen on plain abdominal x-ray, but is
more easily demonstrated on air or contrast enema.
Abdominal X-ray- evidence SBO/LBO with absent caec
al gass shadow(ileo-ileal or ileocolic)

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 Treatment
Patients should be assessed for the presence of peritoni
tis and for the severity of systemic illness.
Following resuscitation and administration of intraven
ous antibiotics, the child is assessed for suitability to pr
oceed with radiographic versus surgical reduction.
In the absence of peritonitis, the child should undergo r
adiographic reduction. If peritonitis is present, or if the
child appears systemically ill, urgent laparotomy is ind
icated

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 Cont…
In the stable patient, the air enema is both diagnostic and often
curative.
It constitutes the preferred method of diagnosis and nonoperat
ive treatment of intussusception. Air is introduced with a man
ometer, and the pressure that is administered is carefully moni
tored. Under most instances, this should not exceed 120 mm
Hg.
Successful reduction is marked by free reflux of air into multi
ple loops of small bowel, and symptomatic improvement as th
e infant suddenly becomes pain free. Unless both of these sign
s are observed, it cannot be assumed that the intussusception i
s reduced

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 Cont…
If reduction is unsuccessful, and the infant remains stable, the
infant should be brought back to the radiology suite for a repe
at attempt at reduction after a few hours.
This strategy has improved the success rate of nonoperative re
duction in many centers.
In addition, hydrostatic reduction with barium may be useful i
f pneumatic reduction is unsuccessful.
The overall success rate of radiographic reduction varies base
d on the experience of the center, and is typically between 60
and 90%.

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 Caecal volvulus
Results from inadequate fixation of caecum
to posterior abdominal wall

Usually also involves terminal ileum and as

cending colon

Majority of patients have a similar presentat

ion to those with small bowel obstruction.

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 Cont….
Occurs as part of volvulus neonatorum
Usually clockwise twist
More common in females
Middle aged
Rare
Mobile caecum is the cause
Kidney shaped gass shadow with single fluid l
evels on the left side, occasionally distended ca
ecum
RX-only surgery

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Surgeon,Msc)
Surgeon,Msc)
Plain film :
Dilated cecum located anywhere in the a
bdomen, usually in the epigastrium , or L
UQ,

A ‘comma’ or ‘bean’- shaped

caecal shadow in mid abdomen

The terminal ileum may be air filled and

visualized in an abnormal position to the
right of the distended cecum.

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 72
Surgeon,Msc)
Surgeon,Msc)
 Management
Viable colon =» right hemicolectomy + ileo-tran
sverse anastomosis
Perforation or gangrene

=» resection with end ileostomy and colonic

mucus fistula; or

=» right hemicolectomy + ileo-transverse

anastomosis.
Cecopexy - recurrence rate of 30%.
Not recommended

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 73
Surgeon,Msc)
Surgeon,Msc)
 Sigmoid volvulus
More common in eastern Europe&Africa
Rare in USA
Rotation –always anticlock direction
More common in males
More common in rural population
Common in middle age&>60 years
It can occur during pregnancy

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 74
Surgeon,Msc)
Surgeon,Msc)
 Precipitating factors
Long mesentery of pelvic colon
Narrow attachment at base
Long redundant, pendulous sigmoid
Loaded colon due to higher residue diet
Diverticulitis with a band or adhesion
 Occurs in mentally disturbed ,hypothyroidism, Parkinson‘s disease
symptoms:-abdominal distention, absolute constipation
vomiting-late

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 75
Surgeon,Msc)
Surgeon,Msc)
 urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 76
Surgeon,Msc)
Surgeon,Msc)
 urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 77
Surgeon,Msc)
Surgeon,Msc)
 Plain abdominal x-ray
Shows hugely dilated sigmoid loop
-Bent inner tube sign

Omega sign –two fluid levels+dilated loops

 Contrast enema-bird’s beak sign

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 78
Surgeon,Msc)
Surgeon,Msc)
 urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 79
Surgeon,Msc)
Surgeon,Msc)
 Contrast Enema(BE)

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 80
Surgeon,Msc)
Surgeon,Msc)
 Treatments
Non operative-rectal tube deflation &elective
resection after 7 days
Operative :-
-Single stage resection
. if pt condn is good
-Hartman’s procedure
-Sigmiodopexy
.if loop is not gangrenous
- Exteriorization
.if pt condn is poor

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 81
Surgeon,Msc)
Surgeon,Msc)
 Compound volvulus
Also known as ileosigmoid knotting
The patient presents with acute intestinal obstru
ction
Distension is mild
At operation decompression ,resection &anasto
mosis are required
Plain abdominal film:-distended ileal loops in di
stended sigmoid colon

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 82
Surgeon,Msc)
Surgeon,Msc)
 urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 83
Surgeon,Msc)
Surgeon,Msc)
 Paralytic ileus (Adynamic IO)
Is failure of transmission of peristaltic waves 2ry to ne
uromuscular failure
Paralytic ileus can be localized or generalize
Peristalsis is absent or
Peristalsis may present in a non-propulsive form e.g.
mesentric vascular occlusion

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 84
Surgeon,Msc)
Surgeon,Msc)
 C/F
Marked abdominal distension
Pain is not a features
Effortless vomiting may occurs
Tinkling bowel sound
Relative constipation
Common in post op. within 24-72hrs

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 85
Surgeon,Msc)
Surgeon,Msc)
 causes
Intra-abdominal causes
- Intestinal ischemia: arterial or venous,
- Intraperitoneal problems
- Peritonitis or abscess - Retroperitoneal problems
- Inflammatory condition - Pancreatitis
- Mechanical: operation, foreign bod - Retroperitoneal hematoma
y - Spine fracture
- Chemical: gastric juice, bile, blood - Aortic operation
- Autoimmune: serositis, vasculitis - Renal colic
-Pyelonephritis
- Metastasis

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 86
Surgeon,Msc)
Surgeon,Msc)
 Extra-abdominal causes
Thoracic problems
Myocardial infarction
Pneumonia
Congestive heart failure
Rib fractures
Metabolic abnormalities
Electrolyte imbalance (e.g., hypokalemia)
Sepsis
Lead poisoning
Porphyria

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 87
Surgeon,Msc)
Surgeon,Msc)
 Hypothyroidism Alpha agonists
Hypoparathyroidism Antihistamines
Uremia Catecholamines
Medicines Spinal cord injury or o
Opiates perations
Anticholinergics Head, thoracic, or retr
operitoneal trauma
Chemotherapy, radiati
on therapy

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 88
Surgeon,Msc)
Surgeon,Msc)
 Radiological:-
- Gass filled loops of intestine with
multiple fluid levels

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 89
Surgeon,Msc)
Surgeon,Msc)
 Localized Ileus
Key Features

 One or two persistently

dilated loops of large or
small bowel
 Gas in rectum or
sigmoid

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 90
Surgeon,Msc)
Surgeon,Msc)
 Localized Ileus
Pitfalls

 May resemble early

mechanical SBO
 Clinical course
 Get follow-up

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 91
Surgeon,Msc)
Surgeon,Msc)
 Generalized Ileus
Key Features

 Gas in dilated small bowel and large

bowel to rectum
 Long air-fluid levels
 Only post-op patients have generalized
ileus

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 92
Surgeon,Msc)
Surgeon,Msc)
 Generalized Adynamic Ileus

Supine Erect

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 93
Surgeon,Msc)
Surgeon,Msc)
 Treatment of paralytic ileus
IV fluid &NG tube insertion –basic principles
Keep NPO
Electrolyte study
Treat causes eg.hypokalemia;K supplement
Laparotomy
When ileus is prolonged and threatens life to excl
ude a hidden cause and facilitate decompression.

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 94
Surgeon,Msc)
Surgeon,Msc)
 Investigations for IO
CBC- WBC (neutrophilia-strangulation)
Hgb
U/A
S/E
Plain AXR
Sigmoidoscopy (carcinoma, volvulus)
Ultrasound
Abdominal CT scan

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 95
Surgeon,Msc)
Surgeon,Msc)
 Large vs. Small Bowel By x-ray
 Large Bowel
 Peripheral
 Haustral markings don't extend
from wall to wall
 Small Bowel
 Central
 Valvulae extend across lumen
 Maximum diameter of 2"

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 96
Surgeon,Msc)
Surgeon,Msc)
 Mechanical SBO
Key Features

 Dilated small bowel

 Fighting loops
 Little gas in colon, especially rectum
 Key: disproportionate dilatation of SB

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 97
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Surgeon,Msc)
 cont….
Most specific for SBO-tri
ad of
Dilated small bowl (>3cm)
Air-fluid levels >2
Paucity of air in colon

Either erect or supine

films

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 98
Surgeon,Msc)
Surgeon,Msc)
 Small bowel obstruction

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 99
Surgeon,Msc)
Surgeon,Msc)
 Supine Prone

LBO

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 100
Surgeon,Msc)
Surgeon,Msc)
 Treatment of mechanical Obstruction

Three main measures-

- GI drainage(NG tube insertion)
- Fluid & Electrolyte replacement
- Relief of obstruction; usually surgical

urgessa
urgessa Soressa
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(IE.
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Surgeon,Msc)
 Cont…
Conservative:
-Nasogastric aspiration by Ryle or Salem tube
-IV fluids- volume varies depending on dehydration
-NPO
-urinary catheter
-check temp. and pulse 2 hourly
-abdominal examination 8 hourly
-Broad spectrum antibiotics initiated early-reduce bacterial
overgrowth

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 102
Surgeon,Msc)
Surgeon,Msc)
 Cont….
Some cases will settle by using this conservative regimen, other need
surgical intervention.

Surgery should be delayed till resuscitation is complete unless signs of

strangulation and evidence of acute or closed-loop obstruction.

Cases that show reasons for delay should be monitored continuously for
72 hours in hope of spontaneous resolution e.g. adhesions with
radiological findings but no pain or tenderness

“The sun should not both rise and set” in cases of unrelieved
obstruction.

urgessa
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Surgeon,Msc)
 Cont…
Indication for surgery:
- failure of conservative management
- tender, irreducible hernia
-strangulation

o Type of surgery depends upon the nature of the

cause.
o Laprotomy is usually done Decompression of
obstruction ( by repair of hernia, complete lysis of
adhesion)

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 104
Surgeon,Msc)
Surgeon,Msc)
 Surgical treatment
Operative decompression required-
If dilatation of bowel loops prevent exposure,
 If bowel wall viability is compromised, or
If subsequent closure will be compromised.
Savage’s decompressor used within seromuscular purse-
string suture.
Or large-bore NG tube maybe used for milking intestinal
contents into stomach.

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 105
Surgeon,Msc)
Surgeon,Msc)
 Cont…
*Once obstruction relieved, the bowel is inspected
for viability, and if non-viable, resection is
required.

Indication of non-viability
1.absent peristalsis
2.loss of normal shine
3.loss of pulsation in mesentry
4.green or black color of bowel

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 Cont….
If in doubt of viability, bowel is wrapped in hot
packs for 10 minutes with increased oxygen and
reassessed for viability.
Sometimes a second look laprotomy is required in
24-48 hours e.g. multiple ischemic areas.
Right sided large bowel lesion is treated by right
hemicolectomy with covering colostomy

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 107
Surgeon,Msc)
Surgeon,Msc)
 Prognosis
Simple small bowel obstruction has a very low
mortality rate but increases in case of strangulation

Reaches up to 15% in case of large bowel

obstruction mainly due to perforation

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
Surgeon,Msc)
 Acute Appendicitis
Anatomy of Appendix
Embryologically starts to develope at 8th weeks of pr
egnancy
Position:- -Retrocecal (12 oclock)-70-75%
-pelvic (4 oclock) -20%
-subceca (6 oclock)
-pre/post ileal (2 oclock)
-paraceacal
-sub hepatic
*It is an immunologic organ;secrets immunoglobulin A

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 109
Surgeon,Msc)
Surgeon,Msc)
 urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 110
Surgeon,Msc)
Surgeon,Msc)
 Congenital anomalies

1.Subhepaticappendix
2.Congenital absence & duplication
3.Situs inversus viscerum -in Lt lower
abdomen quadrant

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 Surface location
1/3 from ASIS&2/3 from umbilicus
*Mcburny point
Found at 2cm posteromedial to ileoceacal junction
* Length-3-30 cm(8-10cm)
* Layers-mucosa, submucosa,musculars,serosa
*Blood supply-appendicular aa
-accessory appendicular aa.of
sheshaculum;branch of posterior caecal aa.
It has mesoappendix

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 112
Surgeon,Msc)
Surgeon,Msc)
 urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 113
Surgeon,Msc)
Surgeon,Msc)
 urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 114
Surgeon,Msc)
Surgeon,Msc)
 Pathophysiology
Acute appendicitis is thought to begin with
obstruction of the lumen
Obstruction can result from food matter,
adhesions, or lymphoid hyperplasia
Mucosal secretions continue to increase
intraluminal pressure

urgessa
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Cont….
Eventually the pressure exceeds capillary
perfusion pressure and venous and
lymphatic drainage are obstructed.
With vascular compromise, epithelial
mucosa breaks down and bacterial invasion
by bowel flora occurs.

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 Cont….
Increased pressure also leads to arterial
stasis and tissue infarction
End result is perforation and spillage of
infected appendiceal contents into the
peritoneum

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 Cont….
Initial luminal distention triggers visceral
afferent pain fibers, which enter at the 10th
thoracic vertebral level.
This pain is generally vague and poorly
localized.
Pain is typically felt in the periumbilical or
epigastric area.

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 Cont….
As inflammation continues, the serosa and
adjacent structures become inflamed
This triggers somatic pain fibers,
innervating the peritoneal structures.
Typically causing pain in the RLQ

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 119
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Surgeon,Msc)
 Cont….
The change in stimulation from visceral to
somatic pain fibers explains the classic
migration of pain in the periumbilical area
to the RLQ seen with acute appendicitis.

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 120
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Surgeon,Msc)
 Cont….
Exceptions exist in the classic presentation
due to anatomic variability of the appendix
Appendix can be retrocecal causing the pain
to localize to the right flank
In pregnancy, the appendix can be shifted
and patients can present with RUQ pain

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 Cont…..
In some males, retroileal appendicitis can
irritate the ureter and cause testicular pain.
Pelvic appendix may irritate the bladder or
rectum causing suprapubic pain, pain with
urination, or feeling the need to defecate
Multiple anatomic variations explain the
difficulty in diagnosing appendicitis
Incidence of appendicitis is less after age of 30
yrs due to lymphatic tissue decreases as age
increases.

urgessa
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Surgeon,Msc)
 Etiology
Obstruction of the lumen is the dominant etiolo
gic factor in acute appendicitis.
-Causes of appendiceal obstruction
*faecoliths-the most common
*hypertrophy of lymphoid tissue
*tumors
*vegetable &fruit seeds
*intestinal parasites

urgessa
urgessa Soressa
Soressa(IE.
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Surgeon,Msc)
 Predisposing factors:-
Racial & dietary factors

Familly susceptability

Socioeconomic status

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Surgeon,Msc)
 Two theories of appendicitis
Obstructive theory
-Abrupt sxs
-More vomiting, tenderness & serious
gangrene, perforation, peritonitis followed
by local abscess occurs.

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 Non obstructive theory
Slow & gradual inflammation
Caused by :-
-E.coli
-Bacteriodes fragilis
-facultative & anaerobic bacteria
-mycobacteria

urgessa
urgessa Soressa
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(IE.
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Surgeon,Msc)
 Clinical manifestations
Symptoms:-
 Abdominal pain
 Anorexia the most common of associated symptoms
 Vomiting occurring in about ½ of patients
 fever-low grade
 Nausia
 Hematuria
 constipation
 Murphy’s triad; 1st Abdominal pain then vomiting then fever

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 Cont…
Sign
Findings depend on duration of illness prior to
exam.
Early patients may not have localized
tenderness
With progression there is tenderness to deep
palpation over McBurney’s point

urgessa
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Surgeon,Msc)
 Cont….
Rovsing’s: pain in RLQ with palpation to
LLQ
Rectal exam: tenderness on rectal wall (more
pronounced if pelvic appendix)
Rebound tenderness,
Voluntary guarding,
Muscular rigidity,

urgessa
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Surgeon,Msc)
 Cont…
Psoas sign
Obturator sign
Fever: another late finding (uncommon in fi
rst 24 hr)

urgessa
urgessa Soressa
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(IE.
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Surgeon,Msc)
 Modified Alvarado scoring system
Migratory RIF(1 point)
Anorexia (1 point)
Nausea/vomiting (1 point)
Tenderness in the RIF (2 points)
Rebound tenderness in the RIF(1 point)
Fever >37.5°C (1 point)
Leukocytosis (2 points)

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Surgeon,Msc)
 Cont….
Management guide based upon total points i
ncludes
 A patient with a score of 0 to 3 could be considere
d to have a low risk of appendicitis
 A patient with a score of 4 to 6 would be admitted
for observation and re-examination. If the score re
mains the same after 12 hours, operative interventi
on is recommended.

urgessa
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Cont…..
A male patient with a score of 7 to 9 would proc
eed to appendectomy.
A female patient who is not pregnant with a scor
e of 7 to 9 would undergo diagnostic laparoscop
y, then appendectomy if indicated by the intraop
erative findings.

urgessa
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(IE.
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Surgeon,Msc)
 Diagnosis
Acute appendicitis should be suspected in
anyone with epigastric, periumbilical, right
flank, or right sided abd pain who has not
had an appendectomy

Women of child bearing age need a pelvic

exam and a pregnancy test.

urgessa
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Surgeon,Msc)
 Special Populations
Very young, very old, pregnant, and HIV
patients present atypically and often have
delayed diagnosis
High index of suspicion is needed in these
groups to get an accurate diagnosis

urgessa
urgessa Soressa
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Surgeon,Msc)
 Appendicitis is dangerous b/c:-
It is closed at one end & blocked easily
Gangrene can occur fast b/c appendicular artery
is end artery
Perforates easily b/c appendix doesn’t have well
developed muscular coat
Blocked easily b/c the lumen is narrow-1-3mm

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 Complications of appendicitis
Generalized peritonitis
Appendicular mass
Appendicular abscess-(Extra/Retroperitoneal approa
ch)
 Retrocaecal abscess-Drained by extra peritoneal approa
ch
 Preileal or postileal abscess-drained by laparatomy
 Pelvic abscess-drained via rectum
 Lumbar abscess-drained by loin incision

urgessa
urgessa Soressa
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(IE.
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Surgeon,Msc)
DDX
 LOWER ABDOMINAL PAI  UPPER ABDOMINAL PAIN SYN
N SYNDROMES DROMES
 Diverticular disease  Biliary disease( Biliary colic)
 Kidney stones  Acute pancreatitis
 Bladder distension  Dyspepsia
 Pelvic pain  Hiatus hernia
 DIFFUSE ABDOMINAL PAI  Pneumonia
N SYNDROMES  Myocardial infarction
 Mesenteric ischemia and  Splenic abscess or infarction
infarction  ABDOMINAL PAIN IN SPECIAL
 Ruptured aneurysm POPULATIONS
 Peritonitis  PID
 Intestinal obstruction  Ectopic pregnancy etc
urgessa
urgessa Soressa
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Surgeon,Msc)
 Investigations
CBC, WBC
U/A
S/E
Imaging studies like
U/S,CT scan (best choice based on availabil
ity), x-ray (have limited use)

urgessa
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Surgeon,Msc)
 Management
Appendectomy is the standard of care
Patients should be NPO, given IV fluid, and
preoperative antibiotics
Antibiotics are most effective when given
preoperatively and they decrease post-op
infections and abscess formation

urgessa
urgessa Soressa
Soressa(IE.
(IE.
13/5/2015 140
Surgeon,Msc)
Surgeon,Msc)
 Management options
Early appendicitis –Appendectomy
Appendicial mass(no peritonitis ,no abscess) –
Non operative management &interval appende
ctomy(6-8wk)
Abscess-drain
Peritonitis –Remove appendix

urgessa
urgessa Soressa
Soressa(IE.
(IE.
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Surgeon,Msc)
 PERITONITIS
Is an inflammation of the peritoneum.

It is an acute life threatening condition cause

d by bacterial or chemical contamination of t
he peritoneal cavity.

urgessa
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Surgeon,Msc)
 Causes of peritonitis
Perforated appendix
Perforated peptic ulcer disease
Anastomotic leak following surgery
Strangulated bowel
Pancreatitis
Cholecystitis

urgessa
urgessa Soressa
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(IE.
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Surgeon,Msc)
 Cont…
Intra abdominal abscess
Haematogenous spread of infective agent such
as typhoid or tuberculosis
Typhoid perforation
Ascending infection (e.g. salpingitis) etc

urgessa
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Surgeon,Msc)
 CLASSIFICATION
Primary peritonitis
Secondary peritonitis
Or
Localized peritonitis
Generalized peritonitis
Or
Acute Peritonitis
Chronic peritonitis
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 Cont…
Primary peritonitis
Caused by bacterial spread via the blood str
eam.
Secondary peritonitis
Caused during perforation or rupture of abd
ominal organ allowing access of bacteria an
d irritant digestive Juices to the peritoneum

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 Cont…
Acute peritonitis:
Rapid onset or brief duration with several sy
mptoms
Chronic peritonitis:
Long duration since the onset involving ver
y slow changes

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 Cont….
Localized peritonitis:
peritonitis confined to a limited space e.g. p
elvis.
Generalized peritonitis:
the whole peritoneal cavity involved.

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ROUTES OF BACTERIAL INVASION
1. Direct: contamination via perforation, a penetrating
wound or during surgery
2. Local Extension: contamination by migration from an
infected organ
e.g. -through gut wall, via the fallopian tubes
3. Blood stream: via the blood as consequence of general
septicemia.
The infection can remain limited to a local area of the p
eritoneum or become generalized.

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 Factors which favor localization of the
infection include:

Anatomical factors (e.g. subphrenic spaces)

Pathological factors (e.g. adhesions )
Surgical factors (e.g. drains) Etc.

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 ETIOLOGY

The commonest bacterial invaders in peri

tonitis are :-
o Escherichia coli
o Streptococci
o Bacteroids

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 CLINICAL FEATURES
 Sharp pain which is worse on movement
 Fever and tachycardia
 Abdominal distension
 Tenderness and guarding
 Diminished or absent bowel sounds
 Shoulder pain due to referred pain from diaphragmatic
irritation
 Tenderness on rectal examination (pelvic peritonitis)
 Abdominal distension and vomiting, etc

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 DIAGNOSIS

History
P/E
Investigation like WBC, Plain Film, U/S

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MANAGEMENT
Resuscitation: general patient care with intravenous fluids
Analgesia
Naso-gastric tube insertion (NGT)
Triple antibiotics (ampicilline , gentamycin and metornidazole
or chloramphenicol)
Monitoring in put and out put by catheterization
Surgery to control source of infection and do drainage and perit
oneal lavage
Supportive treatment and close follow up etc.

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Reference
Oxford primary surgery vol.one
Bailey & Love’s
Upto Date 20.1
ACS surgery:Principles & practice 6th edition
Maingot’s abdominal operations 11th edition
Schwartz’s principles of surgery 8th edition
Manipal Manual of Surgery 2nd edition
Gray’s Anatomy
Moore clinical Anatomy

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 urgessa
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