Acute abdomen

• acute abdomen ?
– New pain
– Exacerbation of chronic pain
– Intra-abdominal pathology need intervention
(surgical abdomen)
• Evaluation
– Acute or Not
– Need operation?
• death
 Characteristic of abdominal pain
Visceral pain Parietal pain
• Dull cramping • Sharp constant
• Colicky • More severe
– Rapid increase pain then • Precise location
resolving
• Location
– Foregut
– Midgut
– Hindgut
• Ass Nausea
 Characteristic of abdominal pain
Pain Characteristic Localized Tender

Visceral Dull & aching -- Poor +/-

distention
Colicky – spasm hollow
organ
Parietal Sharp – inflam Well ++
paritoneum
Refer Aching – Nerve root Poor -
รู ป refer pain
 Mechanism acute abdomen
• Perforation
– Chemical  inflammation  infection
– Sudden onset – Max intensity
– Rupture organ ex HCC, AAA
• Perforation + hypovolemic shock
 Mechanism acute abdomen
• Inflammation
– Infection
– Chemical ex bile
– Ex cholecystitis, abdominal abscess
 Mechanism acute abdomen
• Torsion
– Twist organ
– More pain if ischemic
– Sudden & severe
– tender at effected organ
• 180 degree – less severity, partial obstruction
• 360 degree -- complete obstruction & ischemia
 Mechanism acute abdomen
• Bowel obstruction
– Cardinal sign 4
• Abdominal distention
• Colicky pain
• Vomit
• ไม่ถ่าย, ไม่ผายลม
– Colicky pain due to peristalsis (visceral pain) 
parietal pain = bowel ischemia
• จะฟั ง bowel sound เป็ น absent เมื่อไหร่
 Mechanism acute abdomen
• Ischemia
– Vascular lesion
• Arterial or venous thrombosis
– Low flow state ex any type of shock
– External compression
• Strangulation hernia
– Visceral pain but more severe – pain out of proportion
• Progression – parietal pain
• End up perforation
• During observe
– Visceral pain –> parietal pain ให้ คิดถึง surgical
abdomen unless proven otherwise
 History taking
• location & refer pain &Characteristic
• Onset, severity -- rapid/ gradual
• aggravating and alleviating factors
• associated symptoms
– fevers, chills, weight loss or gain, nausea,
vomiting, diarrhea, constipation,
– hematochezia, melena
– Jaundice, change in the diameter of stool
 Examination
• Normal conscious – septic shock
– Monitor VS, respiration
– SIRS or sepsis
• Tachycardia or labile blood pressure
– B blocker
– Antihypertensive drug
• Urine output
• Cool cyanotic skin
• Bowel ileus
– General appearance
– อาจจะเป็ น secondary surgical abdomen
– มีคำตอบ อธิบาย อาการของคนไข้ หรื อเปล่า ?
– ex aculculous cholecystitis c GB perforation –
secondary bowel ileus
 PE
• Position
– เดินมาตรวจ
• facial expression
• Jx, pale
• inspected
– skin color, bruise
– scar
– Respiration movement หายใจสะดุด
– Distention
– Groin hernia
• Auscultation
– Decrease bowel sound
– Hyperactive & high pitch
– Chest – pneumonia
• Palpation
– Gentle & away from pain
– Deep palpation for mass
• Usually chronic setting
• hepatosplenomegaly
• Percussion
– Ascites
– Tampanic
– Liver span

• PR **
 Peritoneal sign
• Parietal pain
– Guarding
• Voluntary
• Involuntary = rigidity
– Superficial palpation, percussion
– Voskresensky sign – skin hypersensitivity
– Pointing sign
– Cough test
• Bed-shaking sign
• Heel tapping sign
• Percussion rebound
• Rebound tenderness (Blumberg sign)
– Sudden release deep palpation
– Guarding more severe than rebound
• Obturator sign
– Flex hip & internal rotate knee
• Psoas sign
– Hyperextensive thigh
• Butov manuver
– Simultaneous palpation in symmetrical area – ดู
ความต่างของ muscle tone
• มีโรคจริ ง แต่ ไม่มี sign หน้ าท้ อง
– elderly
– Immunocompromised
– Morbid obesity
• Laboratory surgical abdomen
– Leukocytosis c PMN predominant
– ESR CRP raising
– Lactic acid & metabolic acidosis
• Coliky pain -- bowel, Gall bladder, ureter
• mesenteric ischemia usually starts within one
hour of eating
• peptic ulcer disease is relieved by eating and
recurs several hours after a meal when the
stomach is empty
• pancreatitis is classically relieved by sitting up
and leaning forward
• Peritonitis often causes patients to lie motionless
• ผญ ถามประวัติทางสูติ
 acute gastritis
• Mucosal inflammation
– Variable degree pain
– N/V
– ถ้ าเป็ นสาเหตุ infection – gastroenteritis
• Diarrhea after few days
– PE : tender epigastrium but no peritoneum sign
• NSAIDs or alcohol – mild degree, resolve few days
• Caustic ingestion, HP infection or high amount chemical
– erosive gastritis
 Acute gastric erosion
• Cause
– Large amount of NSIADs, alcohol
– Any type of shock
– Stress ulcer
• TBI
• Extensive burn
• PE : epigastrium pain + peritoneum sign +/-
UGIH
 Peptic ulcer
• multifactorial disease
• imbalance secretory VS defense system
– HP & NSAIDs
– Smoking, alcohol, Genetic & diet

• Symptom ขึ ้นกับ location

• Classic
– vague crampy discomfort
– Burning
– Epigastrium > RUQ or LUQ

• Radiation to back
– Retroperitoneum pathology
• GU
– Precipitate by meal
– Relieve by vomit & lying down
• Non-bilious vomiting
– Benign GOO
• Chronic ulcer
• DU
– ปวดก่อนอาหาร
– Meal relief symptom
• Food buffer + acid from stomach
• Gastric emptying time 2-3 hours but acid secretion longer
– Reoccur pain 2-5 hour after meal
– around Midnight

• Chronic peptic ulcer

– Non classic symptom
• Complication peptic ulcer
– Perforation
• Erode all layer
– Hemorrhage
• Erode into blood vessel
– Obstruction
• Edema
• Malignant GOO
 Perforated peptic ulcer
• Hx peptic ulcer may be present
• Acid from Gut into peritoneum
– Location, adhesion affect abdominal sign
• MC DUP
– อาการ & PE ได้ เหมือนกัน
 3 phase of PUP
• Chemical phase
– Sudden onset severe upper abdomen
• Occasional vomiting
– Tampanic percussion
• Dilutional phase
– Inflammation – tachycardia
– Symptom improve
• Infection phase
– Board like rigidity
– Bowel ileus
• PR
• Confirm by film
• DUP may mimic appendicitis !!
– Fluid may irritation along Rt paracolic gutter
– Peritoneum sign at RLQ
• Tenderness more generalized & higher than Mcburney
point
• Perforation posterior ulcer
– Lesser curve
– Posterior DU
– No peritoneum sign
– present with back pain or radiation to back
– Mimic pancreatitis, aortic dissection
 Treatment
• Aggressive fluid resuscitation
• OR for simple closure +/- omental patch
• Gastric cancer perofration -- gastrectomy
 Esophageal perforation
• MC secondary
– Iatrogenic, trauma, FB, corrosive
• Borehavve
– Forceful vomiting
– alcohol abuse
– Partial tear to submucosal  upper
gastrointestinal bleeding (Mallory–Weiss
syndrome)
• Symptom depend location
– SubQ emphysema
– Cervical : dysphagia, neck pain, less contamination
less severity
– Thoracic : chest pain, tachypnea
– Abdominal : like PUP
• Non acute pain
– Severe reflux
– Infection ex candidal esophagitis
– Esophageal motility
– May be severe pain but not same intensity as
perforation
 Gastric volvulus
• Basic volvulus : two fixed part
– Stomach : gastrophrenic ligament & duodenum
fixed to retroperitoneum
• Typical > 50 yr
– May seen in infancy
• 2 type
– Organoaxial > mesenteroaxial
รู ป gastric volvulus
• Organoaxial
– Usually Ass large paraesophageal hiatus hernia +
Diaphragmatic defect
• Mesenterioaxial
– Partial volvulus
• อาการ ขึ ้นกับ degree obstruction
– Complete – emergency condition
– Complain abdominal pain or thoracic
• Radiation to back
– Vomitting
• EGJ obstruction
• Early vomiting followed by unproductive retch
• PE
– Abdominal distension but minimal tenderness
– อาการยิ่งน้ อย ถ้ า stomach ขึ ้นไปสูงกว่า diphragm
– Classic Borchardt’s triad
• Sudden epigastric pain
• Intractable retching (inability vomit)
• Inability to pass NG to stomach
• Delay Mx – ischemia + perforation
 GIH
• present
– Anaemia
– haematemesis
– coffee-ground-like material
– melaena
– Haematochezia
– Maroon stool
– bright red blood or blood clots in the stool
• Divide UGIH & LGIH
– duodenojejunal junction
– Ligament treitz
• NG tube
– Bile + blood = UGIH
– Only bile = R/O active UGIH
– Clear lavage = useless
• May be active bleed Distal to pylorus
• PUD is MC in UGIH
– GU จะเป็ น hematemesis มากกว่า DU
– DU จะเป็ น melena มากกว่า GU
• LGIH
– Diverticulosis
• meckel
– Bowel ischemia
– Tumor
– Vascular
• Angiodysplasia
– Colitis
• Inflammatory bowel
• radiation
 Cholelithiasis

• MC cholesterol stone • Black stone

– Inc prevalence by age – Hemolysis
– Predisposing factor
• Obesity • Brown stone
• Female
– Bacterial colonization
• Parity
• High fat diet
• Biliary colic
– 1-2 hr after fatty meal
– GB force stone against cystic duct
• Inc intraluminal pressure – visceral pain
• When stone fall back – GB relax -- pain subside
• Colic midleading ** since pain consistant
– Location : RUQ, epigastrium
– Radiate to scapula
– N/V – may consider acute cholecystitis
• May be unrelated meal *
– Circadian pattern – peak in evening
– Biliary dyskinesia – absent stone
• PE : minimal peritoneum sign
 Acute cholecystitis
• Persistance biliary colic few hours
– Inflammation & edema
– Bacterial infection -- fever
• Severe pain c peritoneum sign
– Transmural = more severity
• PE : murphy sign
– Deep breath & palpated GB – pt hold breath
– Positive test need to negative at Lt side *
• Mass
– Tense GB
– Omentum wall-off
• Result disease
– Persistance obstruction
• Gangrenous  Perforation
• Hydrops GB
– Inflammation resolve but still obstruction
– bile was absorb – clear fluid
– Resolute obstruction
• Acute aculculous cholecystitis
– Critical illness, bile stasis
– Ass TPN

• Ddx RUQ
– Hepatitis
– Pyelonephritis, KUB stone
– PUP, erosive gastritis
– pancreatitis
 Choledocholithiasis
• Large stone cholangitis
– ใหญ่พอที่จะติด ampulla และออกจาก cystic duct ได้
• Small stone = pancreatitis
– Passing stone
• Mirizzi’s syndrome
http://www.intern
ationalsurgery.org/
doi/pdf/10.9738/C
C13.1
https://link.springer.com/chapter/10.1007/978-3-319-63884-3_13
• Cholangitis = systemic Dz
– Less peritoneum sign
• Charcot triad
– RUQ pain
– Jx
– Fever
– + mental status & hypotension = Reynold pentad
• Emergency drainage
 Acute pancreatitis
• 2 MC cause : alcohol, stone
– Hyperlipid, hypoCa
– Virus, vascular, pancreas divisum
– Tumor * เจอน้ อย Dx ยาก
• severe abdominal pain radiation to back
– relieve by sitting + lean forward, lying + knee-
chest position
– Frequent N/V
• PE : limit peritoneal sign
– Severe visceral pain – voluntary guarding
– CXR : Reactive Lt pleural effusion
• Con-comitant with cholecystitis or cholangitis
• Severe pancreatitis
– Hypovolemic shock
– Grey turner sign : bruising flank
– Cullen sign : bruising periumbilical
• Ongoing inflammation – mass (pseudocyst)
– Complication pseudocyst
• Bleeding
• GOO
• Organ erosion
• Mx
– Ddx mimic pancreatitis
– Resuscitation
– monitor complication
 Chronic pancreatitis
• Need necrosis
– Repeat alcohol – atrophy gland + stricture duct
• Recurrent abdominal pain
– Anorexia
– Steatorrhea
– DM
– +/- Jx due to stricture ampulla
 Liver abscess
• Pyogenic abscess
– MC biliary infection – from iatrogenic
– Portal vein from intra-abdominal infection
• Diverticulitis, appendicitis
– Less : Hematogenous
• Endocarditis, pyelonephritis
– Intermittent spiking fever, malaise, RUQ pain
• +/- Jx if concomitant biliary cause
• Tender RUQ +/- CVA tender
• Amoebic liver abscess
– Entamoeba histolyticum
– Intestinal – portal vein – liver
– Usually solitary
– Similar sign but less prominent from pyogenic
• เนื่องจากอาการน้ อย จึงทนได้ นาน -- onset Longer
– Inadequate Tx – abscess may be rupture
• Granulomatous reaction – mimic CA colon
appendicitis
 obstruction
• Clinical
– Abd pain coliky
– N/V
– Abd distention
– Obstipation
 RUQ
• Cause : Biliary tree >>>> hepatic pain (เพราะเกิด
จาก stretched capsule)
• Lab : LFT, Amylase lipase
• Ix : U/S แต่ไม่เห็น distal bile duct
• CBD stone/ cholangitis -- ERCP
 Epigastric pain
• PUP / pancreatitis
• Pancretitis สาเหตุ GS/ Alcohol , ERCP, hyperTG
• Dx : Amylase, lipase
• พวก transaminitis + pancretitis บ่งบอกว่าสาเหตุมาจาก
GS (?? Alcohol ล่ะ)
 PUP
• Duodenal, antral/pyloric, and gastric body 60,
20, and 20 %
• In the first phase (within two hours of onset),
abdominal pain is usually sudden epigastric at
onset, but it quickly becomes generalized.
• Pain may radiate to the top of the right
shoulder or to both shoulders. Abdominal
rigidity begins to develop.
 PUP
• In the second phase (2 to 12 hours after onset),
– Pain is usually generalized, and is often markedly
worse upon movement.
– board-like rigidity.
– Loss of liver dullness
– The pelvic peritoneum, palpated at rectal
examination, is often tender due to irritation from
collected inflammatory fluid.
– Right lower quadrant tenderness may develop from
fluid moving down the gutter.
 PUP
• In the third phase (>12 hours after onset)
• increasing abdominal distention but abdominal
pain, tenderness, and rigidity may be less
evident.
• Temperature elevation and hypovolemia due to
third-spacing develop.
• Acute cardiovascular collapse
• Perforated gastric ulcers appear to have a poorer
prognosis than duodenal ulcers
 PUP
• CXR : free air * Rt
• CT c water soluble contrast
• Mx : NG , IV , PPI, and broad spectrum
intravenous antibiotics (cef-3 + PGS)
• Sx : omental patch
• Duodenal : acid reducing precodure
• Peptic R/o malignancy + H pylori
Alarm symptom dyspepsia
 Dyspepsia
• < 40 yr + no waring sign can Tx PPI ก่อน
• ถ้ าไม่ดีขึ ้น ควรทำ EGD
• ถ้ าทำไม่ได้ อาจทำ barium swallowing
 Nonsurgical RUQ pain
• Pneumonia : CXR
• MI inferior wall : EKG
 LLQ
• Pain + diarrhea = colitis
• Diverticulitis (WBC ขึ ้น)
• Inflammatory bowel
• CA
• Non Abd : renal colic, cystitis, PID
• Pt diarrhea > 1 wk ส่ง C/S, parasite
• Pt diarrhea > 2 wk ส่ง colonoscope
 Generalized pain
• pain out of proportion to physical findings or
risk factors : bowel ischemia (AF, Heart valve)
• DKA
• Hyper Ca