ACUTE ABDOMEN &PERITONITIS.

Presenter-Dr Clemence Haule.

Facilitator- Dr Maleko.
Headlines.
Introduction
History
Surgical acute abd. Conditions.
Physical examination
Labararory investigations
Intra-abd pressure monitoring
Differential diagnosis
Peritonitis.
Introduction
• The term Acute abdomen-refers to signs & symptoms of abdominal
pain and tenderness, a clinical presentation that often requires
emergence surgical therapy.

• It requires thorough work up, to determine the need for operative

intervation and initiate appropriate therapy.
• The diagnosis varies according to age and gender, e.g Appendicitis is
common in young people where as biliary disease, bowel obstruction,
intestinal ischemia and infarction and diverticular are common in the
old people.

• Thorough history and careful physical examination is the most

important part of the evaluation.
• Lab and imaging studies are needed, but are directed by findings on
history and physical examination.
History.
• History should be detailed and well organized to formulate differential
diagnosis, and proper treatment regimen.
• History should be able to disclose the following.
Location of pain
Onset
Character
Duration
Radiation
Chronology of pain experienced
• The specific YES/NO style of questions is not advised as they don't
allow pts to narrate and can lead to missing of vital details.

• Ask the pt HOW she /he feels pain or if anything makes the pain
better /worse.

• Pain identified by the finger-pointing, is more localized and typical of

parietal inervation/peritoneal inflammation as compared with pain
identified by Palm.
• The intensity of pain is related with the underlying tissue damage.

Sudden onset of severe pain suggest conditions like:

 Intestinal perforation
Arterial embolism with ischemia
Biliary colick.
Pain which develops and worsens over several hrs, is a typical condition
of progressive inflammation or infection such as:
Cholesystitis
Colitis
Bowel obstruction.
• Small bowel pain presents as poorly localized peri-umbilical pain,
where as colonic pain is centered btn the umbilicus and the pubis
symphysis.
Reffered pain.
• This is the pain which may extend beyond the disease site.

The locations and causes of reffered pain include the following.

Right shoulder pain→Liver, gall bladder and R- hemidiaphragm.
Left shoulder pain→Heart, tail of pancrease & L-
hermidiaphragm.
Scotal and testicles→Ureters.
Aggraviating/ releaving factors
These are some of the activities may exacerbate/ reliave pain. Eg

Eating will often worsen the following types of pain.

Pain of the bowel obstruction
Pain of the biliary colick
Pancreatitis
Diverticulatis/ bowelperforation.
Food can provide relief from pain of:
Non-perforated peptic ulcer disease.
Gastritis

Associated symptoms can be important diagnostis clues like the

following, Nausea, vomiting, constipation, diarrhea, pruritis , malena,
hematochezia / hematuria etc.
History of medications and gynaecological history of a female patient
are also important.

Medications can both create acute abdominal conditions or

alternatively mark their symptoms.
E.g NSAIDs.
Surgical Acute abdominal conditions:
There are different acute abdominal conditions, as follows:
Hemorrage.
Infection
Perforation
Blockage
Ischemia
Common causes of acute Hemorrhage:
• Solid organ trauma
• Leakage/ ruprured arterial aneurysm
• Ruptured ectopic pregnancy
• Bleeding ectopic pregnancy
• Bleeding GI- diverticulum
• Arteriovenous malformation of GIT
• Hemorrhagic pancreatitis
• Mallory Weiss syndrome
• Spontaneous rupture of spleen
Infectious causes:
• Appendicitis
• Cholecystitis
• Meckel's diverticulum
• Hepatic abscess
• Diverticular abscess
• Psoas abscess.
Perforation causes.

• Perforated GI-ulcer
• Perforated GI-cancer
• Perforated diverticulum
• Boerheave's syndrome(spontaneous rupture of esophagus) common
after forceful emesis.
Blockage causes.
Adhesion induction (small/large bowel obstruction)
Sigmoid volvulus
Cecal volvulus
Incarcerated hernias
Inflammatory bowel diseases(Crohn's disease, Ulcerative colitis)
GI- malignancy
Intussusception
Ischemic conditions
Buerger's disease
Mesenteric thrombosis/embolism
Ovarian torsion
Ischemic colitis
Testicular torsion
Strangulated hernia.
 Common signs and symptoms of acute
abdomen.
Abdominal pain(colick in nature)
Abdominal distension
Bloating
Muscle guarding
Rebound tenderness
Ascites
Jaundice
Mallet Guy sign-Is the technique to detect signs of pancreatitis. It is pain
elicited by deep palpation of the left subcostal and epigastric region.
Physical examination:

• It should begin with -general examination

-Abdominal local examination(IPPA)

Abdominal examnation(inspe, palpa, percu & auscul)

Inspection.
Look for the following:
• Abd. Contours(distension or scarfoid, localized mass)
• Scars(local or surgical marks.
• Hernias
• Erythema/edema of the skin(may suggest Cellulitis of the abd. wall)
• Echymosis-if observed may mean Deeper necrotizing infections of the
fascia or abdominal structurs e.g pancrease.
Auscultation
Check for bowel sounds( Evaluate for quality &quantity.

Quiet abd→suggest Illeus.

↑bowel sounds→Enteritis/ early ischemic intestine.
High pitched sounds→mechanical obstruction, ass with
abdominal pain & Distension.
Bruits→tublent blood flow in the vascular system which is
common in arterial stenosis & artriovernous fistula.
Percussion
Used to assess gaseous distention of the bowel(intra abdominal air),
degree of ascites and presence of peritoneal inflammation.

Hyper-resonance→gas filled loops of bowel.

Also pain can be elicited in this procedure.
Palpation:

• Final major step in abdominal examination(more informative step)

• Can be used to show the severity of the illness, location of abd pain,
can identify organomegally/abnormal mass lesion.
• Begin gently and away from the site of reported pain, going ant-
clockwise.
• Involuntary gurding or abdominal wall muscle spasm, is a sign of
Peritonitis.
Special Physical signs.
• Different unique physical findings the come to be ass with specific
disease conditions, as follows:

Bassler sign, if positive→Chronic appendicitis.

Sharp pain created by compressing appendix btn abdominal wall
and iliacus muscles.
Charcot triad, if positive→Choledocholithiasis.
Intermittent RUQ-pain, Jaundice and fever.
Courvoisier sign, if positive→Periampullary tumor.
Palpable gall bladder in presence of jaundice.

Cullen sign if positive→Hemoperitonium

Periumbilical bruising.

Ilopsos sign if positive→Appendicitis with retrocecal abscess.

Elevation and extension of the leg against resistance crates pain.
Murphy sign if positive→Acute cholecystitis
Pain caused by inspiration while applying pressure to right
upper abdomen.

Obturator sign if positive→Pelvic abscess/ inflammatory mass

in the pelvis.
Flexion and external rotation of the right thigh, while supine
creates hypogastric pain.
Rovsing sign if positive→Acute appendicitis.
Pin at Mc Burner's point when compressing the left lower
abdomen.

Ten Horn sign if positive→Acute appendicitis

Pain caused by gentle traction of the right testicle.
Management.
Laboratory investigation.
Hematological investigations.
FBP-Hb level
-Complete blood count with differentials→Leucocytosis

Biochemistry investigations.
-Serum electrolytes, blood urea & creatinine-will help in
evaluating the effect of factors(vomiting or 3rd space fluid loss)
-↑Serum amylase & lipase levels, may suggest pacreatitis.

However, normal serum amylase and lipase levels, do not exclude

Pancreatitis as a possible diagnosis caused by effects of chronic
inflammation on enzyme production.
LFTs – Bilirubin (totol & direct, Serum aminotransferase & Alkaline
phosphatase level)s→Help to know biliary truct causes of acute
abdominal pain.

Urynalysis-Will help to diagnose bacteria cystitis, pyelonephritis,

and other enedocrine abnormalities eg. DM & Renal diseases.

HCG-Can suggest pregnancy as a confounding factor.

Radiological investigatigation.
Note: No any imaging technique can replace a careful history and
Physical examination.

Abdominal U/S, can detect- gall stones, gallbladder wall thickness,

diameter of extrahepatic and intrahepatic bile ducts.

Abdominal pelvic X-Ray (Erect & Supine)

Erect-will show gas under the diaphragm & Supine will show dilated
bowels.
CT-scan
Others-Barium swallow, Barium meal.
Intra- abd pressure monitoring.
An ↑ intraabdominal pressure can be a symptom of acute
abdominal process or can be the caurse of the process.

Anbnormally ↑ intra-abdominal pressure→↓blood flow to

abdominal organ, and ↓venous return to the heart, while ↑venous
stasis.
↑Presure in the abdomen can also press the diaphragm→↑peak in
inspiratory pressures and ↓ventilator efficiency.
Risk of esophageal reflux and pulmonary aspiration has also been
associated with abdominal HTN.

The normal Intra abdominal pressure is 5-7mmHg. Obesity and

elevation of the head of the bed can ↑the normal resting abdominal
pressure.
• Intra-abdominal pressure are measured via the bladder, by pressure
transducer attached to a folley catheter.
• Pressure readings are obtained at the End of expiration, following
instillation of 50mls of Saline into an empty bladder.
• Abnormally elevated pressure is higher than 11mmHg.

• It is graded I to IV, by severity. Follow the next table.

 Table: Abdominal hypertension.
Dedree of HTN Mesenteric Pressure Preatment
Normal 5-7mmHg Non
Grade 1 HTN 12-15mmHg Maintain euvolemia
Grade 2 HTN 16-20mmHg Non surgical decompression
Grade 3 HTN 21-25mmHg Surgical decompression
Grade 4 HTN >25mmHg Surgical decompression; reexplore
• Abd HTN grade I &II, are treated adequately by medical intervention,
by -Maintaining Euvolemia
-Gut decompression(NGT, Laxatives or enemas)
-Withholding entero-feeding
-Catheter aspiration of ascitic fluid.
-Use of hypotonic i/v fluids.
Grade III & IV, Require surgical decompression via Laparotomy, with
open packing of abdomen if the severe HTN and organ dysfunction do
not respond to medical intervation.
Differential Diagosis
Acute abdomen has a wide range of differential diagnosis as follows:

RUQ-pain.
Peumonia -Biliary colic
Hepatic tumor -Cholangitis
Hepatic abscess -Cholesystitis
Hepatitis -Pyelonephritis
Retrocaecal appendicitis -Renal colic & renal infarction
Epigastric pain
Esophagitis
Duodenal ulcer
Gastritis
Gastric ulcer
Pancreatitis
LUQ-Pain
Pneumonia
Splenic infarction
Pancreatitis
Pyelonephritis
Renal colic Renal infarction
Umbilical Pain
Meckel's diverticulitis
Aortic aneurysm
Intussusception
Small bowel obstruction
Enteritis
Small bowel infarction
Crohn's disease
RIF-Pain
Renal colic -Infected ovarian cyst
UTI -Salpingitis
Meckel's diverticulitis -Ectopic pregnancy
Crohn's disease
Acute appendicitis
Perforated caecal carcinoma
Suprapubic pain
Pelvic appendicitis
Salpingitis
Cystitis
Diverticulitis
Uterine Fibroid
Infected ovarian cyst
LIF
Renal colic
UTI
Sigmoid volvulus
Colitis
Diverticulitis
Infected ovarian cyst
Salpingitis
Ectopic pregnancy
Treatment
• As seen from the differential diagnosis, acute abdomen has various
different causes.
• It is treated according to specific cause
• Most of the causes are surgical ones, hence surgical intervention is
indicated
• For non surgical causes, eg Pneumonia, hepatitis and UTI, are
managed medically.
Note: Acute abdomen is an emergency condition, hence intervention
should be done without delay.
Pre Op preparation include
Establish an iv Line
Set NGT
Insert Urethral catheter
Prepare blood if indicated
Stabilise the patient before surgical intervention.
Peritonitis.
• Is an inflammation of the peritoneum and peritoneal cavity usually
caused by localized / generalized infection.

Primary peritonitis
• Results from bacteria, chlamydia, fungal or mycobacterial infection, in
the absence of perforation of the GIT.

Secondary Peritonitis
• Occurs in the settings of GI-Perforation.
Frequent causes of 2nd bacterial peritonitis are.

Peptic ulcer disease

Acute appendicitis
Colonic diverticulitis
Pelvicinflammatory disease
Spontaneous bacterial peritonitis(SBP)
• This is bacterial infection of ascetic fluid, in the absence of an intra
abdominal, surgically tretable source source of infection.

• Usually ass. with cirrhosis, nephrotic syndrome and less common pts
with CCF.

• It is rare for pt with ascetic fluid containing high protein conc (Exudates)
eg pt with Peritoneal carcinomatosis, TB-peritonitis, Pancreatic ascites
and Merg's syndrome(involuntary muscle contractions, that cause
twisting movements)
• The most common causes are the aerobc enteric flora (E.coli &
klebsiella pneumonia)

• In chidren with nephrogenic or hepatogenic ascites, Group A

streptococcus( Staphylococcus aureus & streptococcus pneumonia)
are common isolates.
• So bacteria peritonitis
GIT- Source-E. coli, Streptococcal, clostridium, Klebsiella pneumoniae &
Staphylococcus.
Routes of infection:
Infectious organisms may reach the peritonial cavity via a number of
routes.
GI-Perforation (perforated PUD, Diverticular perforation)
Exogenous contamination eg Drains, open surgery & Trauma.
Transmural bacterial translocation(inflammatory bowel disease,
appendicitis & ischemic bowel)
Female genital truct infection eg PID
Hematogeneous spread (rare ) eg Septicaemia.
Clinical features
• Abd. Pain, worse on movement
• Pyrexia
• Gurding/rigidity of the abd wall
• Pain /tenderness on rectal or vaginal examination
• ↑pulse rate
• Absent/ reduced bowel sounds
• Septic shock
Diagnosis
• Depends on careful history taking and proper physical examination.

• La investigations
-FBP→↑WBC
-↑Serum amylase→Pancreatitis
• Radiographs
-CXR –Erect may show free peritoneal gas→Perforation.
-Abd U/S or CT are diagnostic.
Treatment
Genaral care

Correct fluid and electrolyte imbalance

Insert NGT-keep it in situ until paralytic iileus is resolved
Broad spectrum antibiotics
Give analgesia
Specific treatment
• Surgery as soon as possible
• After treating the cause, explore the whole peritoneal cavity, mop &
dry it, until all seropurulent exudates are removed.
Complications.
Systemic complications

Bacteremic/ endotoxinc shock

Bronchopneumonia/ respiratory failure
Renal failure
Bone marrow suppression
Multisystem failure
Intra abdominal complication

Adhesional small bowel obstruction

Paralytic ileus
Reduced recurrent abscess
Portal pyaemia/Liver bscess.
Refference

• Sabiston 19th edition

• Schwartzs Principles of surgery 10th edition.
Thank you for Listernig.