Deals with Acute appendicitis, Pancreatitis, Cholecystitis, Peritonitis, Abdominal Aortic Aneurysm/ AAA

1. EMERGENCY DISORDERS
OF ACUTE ABDOMEN
Presented By:
By Lehulu T, Lecturer & Researcher @ WU, Dep’t of
Emergency & Ophthalmic H.

2. ACUTE APPENDICITIS
• Inflammation of the vermiform appendix.
Pathophysiology
• Obstruction of the lumen typically with fecalith!
• Mucosal secretion continues, leading to an increase in intraluminal
pressure and result with appendiceal vascular insufficiency.
• Which in turn allows bacterial invasion & inflammation.
• Last perforation if not treated.

3. Clinical Features
History
• Abdominal pain
• Anorexia, vomiting classic presentation
• Fever
 Bear in mind Retrocecal and pregnancy.
P/E
 Tenderness over McBurney's point.
 Rebound tenderness, voluntary guarding
 fever
 Rovsing sign
 +ve psoas sign
 +ve obturator sign

5. Diagnosis Treatment
• Hx & P/E NPO
• CBC, U/A IV fluids
• U/S, CT scan antibiotics
appendectomy

6. ACUTE PANCREATITIS
• Inflammation of pancreas
• Could be
Biliary pancreatitis/gall stone: most common form
– commonly in female 80%
– Alcoholic pancreatitis: commonly in male
 Other factors: drugs, infection/inflammation, trauma.
Pathophysiology
• Activation of digestive zymogens in the pancreatic acinar cells instead of the
small intestine and subsequent autodigestion of the pancreas.
• Extension of the localized process into a generalized systemic inflammatory

7. CLINICAL FEATURES
o Midepigastric or left upper quadrant pain.
o Abdominal bloating
o Nausea and vomiting
• moderate distress.
• Low-grade fevers /tachycardia /hypotension
• Respiratory symptoms! due to atelectasis, pleural effusion and ARDS.
• +ve Cullen sign:
• +ve Grey Turner sign:
Diagnosis
• Laboratory : amylase, lipase
• Radiographic investigations: plain radiograph, U/S and CT

8. RANSON’S CRITERIA
On admission After 48hrs
 Glucose>200 mg/dL; Calcium <8
 AST >250 units/L HCT decrease > 10%
 LDH >350 IU/L ;. Oxygen PaO2 <60
 Age >55 years; BUN increase >5
 WBC >16,000/L Base deficit > 4
Sequestration of fluid > 6L
Shows poor prognosis
Treatment
• Iv fluids
• NPO
• Pain medications like morphine

9. CHOLECYSTITIS
 Is inflammation of the gallbladder

10. DIAGNOSIS
ACUTE CALCULOUS
CHOLECYSTITIS
• Dull, aching, epigastric, or right
upper quadrant (RUQ) pain:
– Radiation to tip of right scapula,
acromion, or thoracic spine
– sharp, localized pain : as
inflammation progresses (parietal
peritoneal irritation)
• Nausea, vomiting, fever, and chills
• Jaundice (in 20%)
• Prior attacks of biliary colic or
known gallstones.
ACALCULOUS
CHOLECYSTITIS
• Often presents with symptoms
of generalized sepsis.
• Localized pain and tenderness
frequently absent

11. Clinical Features
RUQ or epigastric pain
oRadiation to the
back/shoulders
olasting >6 hours
N/V/anorexia
Fever, chills
Physical Findings
 Epigastric or RUQ tenderness
 Murphy’s sign
 Patient appears ill
 Peritoneal signs suggest perforation

12. Diagnosis
CBC, LFTs
 Elevated alkaline phosphatase
 Elevated lipase suggests gallstone
pancreatitis
 RUQ US
 Thicken gallbladder wall
 Pericholecystic fluid
 Gallstones
o HIDA scan
 more sensitive & specific than US
H&P and laboratory findings have
a poor predictive value – if you
suspect it, get the US
Treatment
IV fluids
Correct electrolyte abnormalities
Analgesia
Antibiotics
Ceftriaxone 1 gram IV
NGT if intractable vomiting
Surgical consult

13. PERITONITIS
 Inflammation of the peritoneum which maybe localised or generalised
 Generalised peritonitis is a surgical emergency – requires resuscitation
and immediate surgery.
 Peritonism – shows specific features found on abdominal examination.
i.e
 Characterised by tenderness with guarding,
rebound tenderness
 Eased by lying still and exacerbated by any
movement

14. CAUSES
 Infective – bacteria cause peritonitis e.g. due to gangrene or
perforation of a viscus (appendicitis/diverticulitis/perforated ulcer).
– is the most common cause of peritonitis.
 Non-infective – leakage of certain body fluids into the peritoneum
can cause peritonitis.
 Gastric juice (peptic ulcer)
 Pancreatic juice (pancreatitis)
 Bile (liver biopsy, post-cholecystectomy)
 Urine (pelvic trauma)
 Blood (endometriosis, abdominal trauma)
Note: although sterile at first these fluids often become infected
within 24-48 hrs of leakage from the affected organ resulting in a
bacterial peritonitis

15. CLINICAL FEATURES
 Pain
 Constant and severe (site will give clue as to cause, or maybe
generalised)
 Worse on movement
 Eased by lying still
o If localised– peritonism is in a single area of the abdomen
o If generalised– peritonism is all over abdomen with board
like rigidity

16.  Signs of ileus (generalised peritonitis > localised peritonitis)
 Distention
 Vomiting
 Tympanic abdomen with reduced bowel sounds
 Signs of systemic shock
 Tachycardia, tachypnoea, hypotension, low urine output
 More prominent with generalised than localised
peritonitis

17. INVESTIGATIONS
 If localised peritonitis
All patients get simple investigations
 If generalised peritonitis
Bloods: CBC, U/A, LFT, Amylase!!
AXR CT scan
– Only if this can be performed urgently and
patient is stable

18. MANAGEMENT
 ABC
 Oxygen
 Fluid resuscitation (IVF, bloods)
 IV antibiotics (Augmentin and metronidazole)
 Analgesia
 Surgery (with or without preceeding CT depending on availability
and stability of patients)

19. ABDOMINAL AORTIC
ANEURYSM/ AAA
• is a localized dilatation of the aorta caused by
weakening of its wall; it involves all three layers
(intima, media, and adventitia) of the arterial wall
• Dissections produce chest or upper back pain that can
migrates to abdomen as the dissection extend distally.
• <50% of pts with AAA present with hypotension,
abdominal/back pain, and/or pulsatile abd mass.

20. – Dilation of the aortic wall with an increase in diameter
by at least 50% (>3 cm)
• Average growth rate of 50% die before they reach
the hospital.
• 50% of patients who reach the hospital alive survive.
– 95% are infrarenal.
– Rupture can occur into the intraperitoneal or
retroperitoneal spaces.
• Intraperitoneal rupture is usually immediately fatal.
– 5-year survival after repair is 67%.

21. Risk factors:
 Advancing age.
 HTN,
 DM,
 smoking,
 COPD, and
 CAD

22. Presentation:
 Often asymptomatic until dissection or rupture.
 Pain can be abdominal with radiation to the back
or present as back pain.
• Pain can radiate to the groin or testes.
• . Pain often associated with syncope or signs
of shock
• Pain can mimic renal colic.

23. Unruptured:
– Most often asymptomatic
– Abdominal, back, or flank pain:
• Vague, dull quality
• Constant, throbbing, or colicky
– Abdominal mass or fullness
– Palpable, non tender, pulsatile mass
– Intact femoral pulses

24. Ruptured:
Classic triad:
 Pain
 Hypotension
 Pulsatile
abdominal mass
o Present in only
30 to“50% of
patients
Systemic:
 Hypotension
 Syncope
 Tachycardia
o Abdomen:
o Abdominal, back, or flank
pain
• Acute, severe, constant
• Radiates to chest, thigh,
inguinal area, or
scrotum
o Pulsatile, tender abdominal
mass
o Only 75% of aneurysms >5
cm are palpable
o Gastrointestinal (GI)
bleeding
Extremities:
• pain
• Diminished/asym
metric pulses in
the lower
extremities

25. PHYSICAL EXAM:
 Vital signs: be normal (in 70% of patients) to severely
hypotensive.
 Palpation: possible in aneurysms 5 cm or greater.
 imaging test (CT , FAST U/S) : augments P/E
ED intervention:
– Vascular surgeon consultation.
– Administering of blood products: with type and cross
matching.

26. Important Signs in Patients with Abdominal Pain
Sign Finding Association
Cullen's sign Bluish periumbilical
discoloration
Retroperitoneal haemorrhage
Kehr's sign Severe left shoulder pain Splenic rupture
Ectopic pregnancy rupture
McBurney's sign Tenderness located 2/3 distance from
anterior iliac spine to umbilicus on right side Appendicitis
Murphy's sign Abrupt interruption of inspiration on palpation
of right upper quadrant
Acute cholecystitis
Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis
Obturator's sign Internal rotation of flexed right hip causing
abdominal pain
Appendicitis
Grey-Turner's
sign
Discoloration of the flank Retroperitoneal haemorrhage
Chandelier sign Manipulation of cervix causes patient to lift
buttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with palpation of
the left lower quadrant
Appendicitis

27. GENERALLY: AS MANAGEMENT
• Hemodynamically unstable pts or those with life
threatening cases should be triaged immediately to
acute care area of ED
• Careful attention to A, B , C
• Supplemental O2, cardiac monitoring
• NPO
• Volume repletion with NS, RL and then blood if
necessary
• Consider ED U/S

28. • NG tube suction for Obstruction, retracted vomiting
• Analgesia
• Antibiotics: gram –ve and anaerobic coverage is
required
• Antiemetic
• Supportive nutrition
• Re-assess
• Early consultation to seniors/surgeons

29. REFERENCES
Tintinalli's Emergency Medicine,
Internet
Canada manual Emergency