ACUTE ABDOMEN

Dr. Abdulelah Shugaa Addin

Consultant general Surgery

Acute abdomen:
Sudden onset of severe abdominal pain developing over a short period of time.

Common causes includes:

1. Acute appendicitis
2. Acute peptic ulcer and its complications
3. Acute cholecystitis
4. Acute pancreatitis
5. Acute intestinal ischemia
6. Acute diverticulitis
7. Ectopic pregnancy
8. Ovarian torsion
9. Acute peritonitis (including hollow viscus perforation
10.Acute ureteric colic
11.Bowel volvulus
12.Intestinal obstruction
13.Acute pyelonephritis
14.Biliary colic
15.Abdominal aortic aneurysm dissection
16.Hemoperitoneum
17.Rupture spleen
18.Meckel s diverticulitis

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 Acute appendicitis
Appendix is blind ended tubular structure that arises from cecum.
Position:
 Retrocecal 74%
 Pelvic position 21%
 Paracecal 2%
 Subcecal 2%
 Preileal1%
 Postileal 0.5%

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Blood supply
 Supplied by one or two appendicular arteries arising from ileacolic artery
 Venous drainage by tributaries of the ileocolic vein to SMV then to portal
vein.
Clinical features
Symptoms
 Periumbilical pain shifting to the right iliac fossa
 Anorexia and nausea
 Constipation is usual
Signs
 Tenderness and cough tenderness
 Rebound tenderness at McBurney s point
 Rovsing sign
 Psoas sign
 Obturator sign
 Rigidity indicates perforation
 Tender appendicular mass

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Modified Alvarado score criteria

Investigations
 CBC …..leucocytosis
 Urine analysis
 Pregnancy test to rule out ectopic pregnancy

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 Abdominal US helps in diagnosis of acute appendicitis and exclude other
causes of acute abdomen such as renal or ureteric stones , gynecological
problems
 CT scan
 Diagnostic laparascopy

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Target sign

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Treatment
According to the situation
 Uncomplicated acute appendicitis
 Appendicular mass
 Appendicular abscess
 Perforated appendicitis with generalized peritonitis
 Chronic appendicitis

INTESTINAL OBSTRUCTION

Defination: Arrest of downward propulsion of intestinal content.

Classifications : four types of classifications
 According to the pathological nature of cause:
1. Simple mechanical
2. Strangulation
3. Closed loop obstruction.
4. Paralytic ileus
Outside the wall In the wall In the lumen Adynamic
Hernia—25% Tuberculous Gallstones Cessation of peristalsis
stricture
Adhesions—40% Crohn’s disease Roundworm Postoperative period
Volvulus Malignancy Inspissated faeces Electrolyte imbalance
Intussusception Meconium ileus Spinal injuries
Uraemia
Diabetes mellitus
Retroperitoneal—
haematomas and
surgeries
Renal surgeries
Mesenteric ischaemia

 According to the level of obstruction:

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1. High small bowel obstruction
2. Low small bowel obstruction
3. Large bowel obstruction

 According to the onset of the course of obstruction

1. Acute obstruction

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 2. Chronic obstruction
3. Acute on top of chronic obstruction

 Fourth classification
1. Congenital
2. Acquired

A. Congenital.
 Anorectal malformation
 Congenital megacolon
 Adhesions
 Deudenal atresia
 Intestinal atresia (ileal)
 Bands and adhesions
 Malrotaion
 Volvulus neoatorum
B. Acquired
 Hernias (commonest)
 Postoperative
 Intussusception
 Round worms
 Gall stones
 Tuberculosis
 Malignancy
 Internal hernia

Acute mechanical obstruction

Causes
1. In the lumen e.g. faecal impaction. Gallstone and parasitic infestation.
2. In the wall e.g. congenital atresia, tumors, stricture( Crohns,diverticulitis, tuberculos)

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 3. Outside the lumen e.g. adhesions, strangulated hernia and volvulus.
Common causes according to age
o Neonates. Congenital atresia, volvulus neonatrum, anoretal malformation, and
Hirschsprung s disease.
o Infants
Ileocecal intussusception, Hirschsprung s disease and strangulated hernia.
o Adult
Adhesions and strangulated hernia.
o Elderly Colon cancer and strangulated hernia.
o Strangulated hernia is a common cause in different age groups

Pathology

 Simple obstruction
Distal to obstruction the intestine empties and become collapsed.
Proximally the intestine becomes distended by gas and fluid.
Stretched smooth muscles undergo hyperperistalsis to overcome the obstruction.
Distension impairs blood supply and may end in ulceration and perforation.

 Strangulated obstruction
In addition to the previous events in simple obstruction bacteria and toxins in the lumen can
transgress ischemic bowel to the peritoneal cavity and unrelieved strangulation can lead to
septicaemic shock.
The mucosa is the first layer to suffer from ischemia producing acute ulceration and
intraluminal bleeding .
Unrelieved strangulation is followed by gangrene of the ischemic bowel with perforation and
peritonitis.

 General lethal effects

Fluid and electrolyte loss from vomiting and from accumulation in the proximal bowel.
Septicemia from peritonitis.

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Clinical features
 Pain
 Distension
 Absolute constipation
 Vomiting

Examination
 General examination (evidence of dehydration as tachycardia , oligouria, dry tongue or
even hypotension may be present)

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  Abdominal inspection (distension and visible peristalsis , hernias , scars )
 Abdominal palpation (mass)
 Auscultation ( exaggerated bowel sounds )
 Rectal examination (empty rectum or impacted stool).
Assessment should be answer the following questions
1. Is there intestinal obstruction?
2. What is the pathological type of obstruction ? paralytic ileus ? strangulation ? impacted
stool
3. What is the level of obstruction ?
a. In high small bowel obstruction vomiting and dehydration are early, slight abdominal
distension.
b. In low small bowel obstruction vomiting is delayed for about 12hours and there is
central abdominal distension.
c. In colonic obstruction constipation is early while vomiting may be absent or occurs after
few days. Distension is marked especially in the flanks.
4. What is the cause of obstruction?

Investigations
1. Plain x-ray
Multiple air-fluid level at least 3 in erect position, Centrally located in small bowel
obstruction while peripherally located in colonic obstruction.
Small bowel full of gas shows valvulae conniventes while haustrations in colonic
obstruction.
Air under diaphragm is seen in cases of perforated viscus.

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2. CBC
3. Renal function test
4. Electrolytes
5. Ultrasound
6. CT Scan

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 Treatment:
The treatment is urgent relief of obstruction, usually by surgery,
after adequate preoperative preparation.
Pre-operative preparation “ Drip and Suck”
1. Intravenous replacement of fluid and electrolytes.
2. Gastric aspiration by a nasogastric tube to decompress the
bowel and to reduce the risk of inhalation duiring inducktion
of anaethesia.
3. Antibiotics are given if there is a possibility of strangulation.
4. A Foley catheter is inserted to check the urine output.
Conservative treatment may be successful in certain situations provide
that the case is early and no evidence of intestinal ischemia.
1. Adhesive IO may be relieved by IV fluid and NG tube. Failure of
conservative treatment and the suspicion of strangulation are
indications for surgery.
2. Ileoceal intussusception may be reduced by the hydrostatic effect
of barium enema and the reduction is radiologically monitored on
the screen.
3. Sigmoid volvulus. Untwisting may attempted using a rectal tube
passed through a sigmiodoscope.
4. Fecal impaction is treated by enema to dissolve the obstructing
fecal mass as well as laxative drugs.
Surgery
Exploration and the first step to look at the cecum.
Treatment then according to situation
 Reduction and repair of hernia
 Untwisting volvulus
 Relief adhesive bands
 Non-viable bowel resection

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Non-viability is known by:
 Loss of peristalsis
 Loss of normal lustre
 Color change, greenish or black is non-invasive , while purple
bowel may still recover.
 Loss of pulsation in the mesentery
Intussusception
Defination
Invagination of an intestinal segment (intussusceptum) into the lumen of an
adjacent one (intussuscepiens).
Types
1. Ilioileal
2. Iliocecal
3. Ileocolic
4. Colocolic
Causes
 Idiopathic
 Evident cause at the head of intussusceptum e.g polyp, mass, meckles
diverticulum, submucosal hematoma in patients with Henoch-Schonlein
purpura…..etc
Clinical picture
 Severe intermittent colicky abd. Pain
 Lethargy, apathy
 Vomiting
 Bloody stool
 Distension
 Abdominal mass ?

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Any infant having colicky abdominal pain with passage of blood stained mucous
per rectum should be suspected of having intussusception.
Investigation
 CBC
 Abdominal US
 Barium enema
 Abdominal CT scan

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Treatment
1. Resuscitation
2. Hydrostatic reduction
3. Surgery when hydrostatic reduction is failed

VOLVULUS
Defination
Twisting of a bowel loop around its mesenteric axis.
Combination between closed loop obstruction and occlusion of main vessel
leading to ischemia (strangulation)

Types:

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  Sigmoid volvulus commoner in elderly males
 Cecal volvulus
 Midgut volvulus common in infants
 Stomach volvulus
 Small bowel volvulus
Investigations
 Plain X-ray
 CBC
 Urea, electrolyte
 Abdominal US
 Abdominal CT scan

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 Paralytic ileus (adynamic intestinal obstruction )
Defination
Failure of the peristaltic waves of the intestine due to failure of the
neuromuscular mechanism
Causes :
 Postoperative

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  Infective..pus, blood, bile, toxins, enteritis
 Uremia
 Hypokalemia
 Spinal surgery or spinal injury
 Retroperitoneal hemorrhage
 Drugs
Clinical features
 Abdominal distension
 Absolute constipation
 Effortless vomiting
 Abdominal discomfort and fullness
 NO abdominal colicky pain
 Absent bowel sound
Investigations
 Plain X-ray
 Blood urea and electrolyte
 CBC
Prevention
 Gentle bowel handling during surgey
 Correction of hypokalemia
 For major surgery NG tube
Treatment
 IV fluid replacement of the lost fluids and electrolytes
 NG tube
 Correction of underlying metabolic abnormalities and hypoproteinaemia
 If postoperative ileus is prolonged ….you should think of peritonitis or early
fibrinous adhesions
 Occasionally parasympathomimetic may be useful e.g. prostgimine.

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 Intestinal ischemia
Types
1. Acute intestinal ischemia
VERY SERIOUS SURGICAL EMERGENCY
Causes :
 Mesenteric arterial embolism
 Mesenteric arterial thrombosis
 Mesenteric venous thrombosis

2. Chronic intestinal ischemia

Narrowing of the superior mesenteric artery mostly due to atherosclerosis
Main symptom is postprandial abdominal pain … and this pain is called abdominal
angina.
The patient is usually afraid to eat.

3. Non occlusive intestinal ischemia

Associated with low cardiac output states as arrhythmias and major sepsis.

Investigations
 Abdominal US
 CT angiography
 Aortography

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HIRSCHSPRUNG’S DISEASE (CONGENITAL MEGACOLON)

 It is a congenital, familial condition, occurring in newborn due to the absence of

ganglion cells—Auerbach’s and Meissner’s plexus in anorectum, which may extend
proximally either a part or full length of the colon.
 It always involves the anus, internal sphincter and rectum (partly or entirely).
 There is narrow, spasmodic, non relaxing pathological segment.
 Transitional zone proximal to it contains only few ganglion cells with formation of
cone.
 It is one of the causes of neonatal intestinal obstruction.
 Severe enterocolitis can occur which may be fatal. Perforation, peritonitis and
septicaemia can occur.
 Often there will be a chronic course of the disease with malnutrition, abdominal
distension.

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Types
1. Ultra-short segment HD—only anal canal and terminal rectum is aganglionic
2. Short-segment HD—anal canal and rectum is completely involved (80%).
3. Long-segment HD—anal canal, rectum and part of the colon is involved (10%).
4. Total colonic HD—anal canal, rectum and full length of the colon is involved -
10%.

IT HAS THREE ZONES

I. Distal immobile spastic segment, i.e. aganglionic zone.
II. Proximal, middle transitional zone of about 1–5 cm length with less, sparse number of
ganglions (cone)
III. A still more proximal, hypertrophied dilated segment is actually the normal ganglionic
area.

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Clinical features
 Presentations: Acute, recurrent, chronic.
 It is common in males (80%).
 Its incidence is 1 in 5000 live births.
 It is common in infants and children, occasionally it occurs in adults also.
 Often it is associated with Down’s syndrome (10%). (Commonest association).
 In 90% of cases, symptoms appear in early neonatal period, i.e within three days of
birth. The child fails to pass meconium. Distension of the abdomen with features of
intestinal obstruction is seen.

Diagnosis

 Plain X-ray abdomen—shows intestinal obstruction. Useful in case of perforation.

 Barium enema is done to look for the extent of disease and three zones. Radiographs
of the abdomen and lateral pelvis should be repeated after 24-48 hours. The contrast
agent is will be retained for prolonged period. The delayed films are important and
more clear than the initial study.and clear Foley’s catheter should not be used while
doing barium enema in case of Hirschsprung’s disease.

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 Biopsy from all three zones to study the ganglions and hypertrophic nerve terminals
in spasmodic segment. Starting from 2 cm above the dentate line, a full thickness
rectal biopsy is ideal and definitive diagnosis.
 Anorectal manometry—shows the absence of rectoanal reflex in Hirschsprung’s
disease, which is diagnostic but rarely performed.

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Complications
 Colitis (Intramucosal gas in plain X-ray). Enterocolitis may be fulminant and fatal.
 Intestinal obstruction.
 Growth retardation.
 Perforation.
 Peritonitis.
 Septicaemia.

Treatment
 Initially, colostomy is done either transverse or transitional, so to have normal bowel
function.
 Nutritional supplementation.
 Once the child attains 10 kg of weight, definitive procedure is done, i.e.

a. Excision of aganglionic segment (spasmodic segment).

b. Maintenance of continuity by doing coloanal anastomosis.
c. Closure of colostomy later.

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 Acquired megacolon
 No contracted segment in rectum
 Seen in children with faulty toilet training
 Rectum and sigmoid colon are dilated
 Normal ganglions in all levels
 Improper bowel habit causing chronic bowel dilatation
 Repeated enemas, manual evacuation, toilet training, educating the parents are
required
 Should be differentiated from Hirschsprung’s disease

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