Approch to acute abdomen and appendicitis

by DR.SAMER BUSTAME
 Acute abdomen
 Definition :
•The term acute abdomen refers to a sudden, severe abdominal
pain of unclear etiology that is less than 24 hours in duration.
• It is in many cases a medical / surgical (non trauma) emergency,
requiring urgent and specific diagnosis.
•Several causes need surgical treatment.
 Epidemiology
•Can be simple or life threatening
•About 10-15% of Casualty visit
•Almost 40% of them need surgical intervention
•The challenge we face here : - Misdiagnosis, Atypical
presentation, and mortality if given wrong treatment
 The Physiology Of Abdominal Pain
•There are three types of Abdominal pain : Visceral Pain, Somatic
(Parietal) Pain and Referred Pain
•Several factors modify the expression of pain :
•Extremes of age, pain tolerance
•Vascular compromise (pain out of proportion)
•Pregnancy / CNS pathology / Neutropenia
 Visceral pain
•Deep, Dull, Aching or Cramping and poorly localised
•Stimulated by Stretching, Distension or Contractions of the gut or
other hollow abdominal organ
•Traction on the bowel mesentry
•Inflammation or Ischemia
•Usually felt in the midline, unaccompanied by tenderness
 Parietal (Somatic) Pain
•Sharper and better localised and easily described
•Aggravated by Stimulation or Irritation of the parietal peritoneum
with movement, coughing or walking
•Cardinal signs : Pain, Guarding, Rebound and Absent bowel
sounds
•A true parietal pain is the Surgical cause of abdominal pain
 Referred Pain
•Pain felt over the site other than that of the primary noxious
stimulus
•Occurs in an area supplied by the same neurosegment as the
involved organ
•Most visceral pain is of this type
•Its usually intense and most often secondary to an inflammatory
lesion
•Eg: Subdiaphragm – shoulder pain / Biliary tract – right shoulder
pain / Small bowel – back pain / Appendicitis – Umbilical
region
Differential Diagnosis By Location
 Epigastrium
•Acid / Peptic Disease (Ulcer, GERD, Gastritis)
•Angina / Myocardial Infarction
•Aortic Aneurism Cholelithiasis, Choledocholithiasis
•Diaphragmatic Defect (Acquired / Congenital) & Hernias
•Paraesophageal Hernia, Gastric Volvulus, Perforated Oesophagus
•Gastroenteritis, Pancreatitis
•Carcinoma ( Gastric / Pancreatic / etc…)
 Right Upper Quadrant
• Cholelithiasis, Choledocholithiasis
•Liver Related ( Hepatitis / Hepatomegaly / Abcess /
Malignancy)
• Renal Related ( Pyelonephritis / Nephrolithiasis /
Ureterolithiasis )
• Sub-diaphragmatic Abscess
•Appendicitis ( Reterocecal / Malrotated)
• Right side Pneumonia
 Left Upper Quadrant
•Pancreas Related ( Pancreatitis / Malignancy)
•Gastric Ulcer / Intestinal Obstruction / Mesentric Thrombosis
•Colonic Ischemia / Perforation
•Spleen Related (Infarct/ Rupture/ Abcess)
•Renal Related (Pyelonephritis/ Nephrolithiasis/ Ureterolithiasis)
•Subdiaphragmatic Abscess •Left side Pneumonia
 Peri-Umbilical / Mid-Abdomen
Aortic Aneurysm
Appendicitis
Small Bowel Obstruction
Ischemia (Interstinal Angina)
Gangrene
 Right / Left Lower Quadrant
•Appendicitis ( only for right lower quadrant)
•Colon Related - Colitis (Ulcerative / Pseudo Membranous) /
Diverticulitis (Meckel’s) / Carcinoma / Perforated Caecum /
Colonic Ischemia
•Sigmoid Volvulus / Diverticulitis ( only for left lower quadrant)
•Crohn’s Disease
•Hernia ( Inguinal / Femoral / Incarcerated)
•Psoas Abscess
•Mesentric Adenitis (Ctd..)
 RLQ & LLQ Continued…
• Renal Related - Pyelonephritis / Nephrolithiasis /
Ureterolithiasis
• Gynaecological : Ruptured Ectopic (Tubal) Pregnancy / Ovarian
Tortion / Cyst / PID / Tubo ovarian pathologies / Infections /
Abcess / Endometriosis / Salpingitis / Malignancies / etc…
• Typhilitis
• Rectus / Retroperitoneal Hematomas
 Supra – Pubic Region
Urinary Tract Infection
Diverticulitis
Gynecological - Endometriosis, Endometritis, Pelvic
Inflammatory Disease
Prostitis
Important Extra Abdominal Causes Of Abdominal Pain

• Systemic Causes:
• Diabetic Ketoacidosis • Alcoholic Ketoacidosis • Uremia •
Sickle cell disease • Porphyria (Acute Intermittent) • SLE •
Vasculitis • Acute Leukemia • Hyperthyroidism • Addisonian
crisis
• Abdominal Wall :
• Muscle Spasm • Muscle Hematoma • Herpes Zoster
• Thoracic :
• Myocardial Infarction • Unstable Angina • Pneumonia •
Pulmonary Embolism • Herniated Thoracic Disc (Neuralgia)
 Continued….
• Genito – Urinary :
• Testicular Tortion • Renal Colic
• Infectious / parasitic :
• Tuberculosis • Streptococcal infections • Infectious
Mononucleosis • Malaria / Dengue / Chikungunya • Hydatid
cysts, Worm infestations
• Toxic:
• Methanol Poisoning • Narcotic Withdrawal • Volatile drugs /
substance abuse • Scorpion Bite • Black widow spider bite •
Other poisons
 History Of Presenting Illness
•Pain : When? Where? How?
•Onset : Abrupt / Gradual / How often / How Long?
•Character : Dull / Sharp / Burning / Steady / Intermmitant
•Radiation / Quality / Severity / Timing
•Previous Occurrence
•Accompanied by: Vomiting, Nausea, Anorexia
•Aggravating and Relieving factors
 High Yield Questions
What is your Age? : Advanced age means more risk
Describe the position, character and migration of the pain :
• Sudden coupled with weakness or fainting / Less acute but still
abrupt onset / began gradually and maximised slowly
• Is the pain constant or intermittent? ( constant pain is worse)
• Have you had it before? ( no prior episodes is worse )
• Did the pain start centrally and migrate to the right lower side?
(Appendicitis)
 More questions….
 Have you noticed specific aggravating or relieving factors?
( eating/ defecation/ flatus/ movement/ exercise/ coughing….)
 Have you ever had abdominal surgery before? ( consider
obstruction / adhesions / rupture / volvulus / destention/
perforation in patients who report prior surgery)
 • Do you have nausea, vomiting, diarrhoea, change in colour or
blood in stool, any disturbed bowel movement? Any sleep
disturbances? Poor appetite?
 • Do you have HIV? ( consider occult or unusual infection )
 More questions….
• How much alcohol do you drink per day? ( consider pancreatitis,
hepatitis or cirrhosis) when was your last meal?
• Are you pregnant? ( test for pregnancy – consider ectopic
pregnancy) menstrual history, sexual exposure (history for STD)
• Are you taking any antibiotics or steroids? ( may mask
infections)
• Do you have any history of vascular or heart disease,
hypertension or atrial fibrillation? ( consider mesenteric
ischemia/ myocardial ischemia/ aortic aneurysm)
 Physical Examination
 Physical Examination • Overall appearance : Facial expression,
diaphoresis, pallor, mental status and degree of agitation
 • Position: Sitting, recumbent or constantly moving around
 • Vitals : Temperature (< 97F or >101F – consider abdominal sepsis),
Tachycardia, Hypotension
 • Inspection : Scars, hernias, distention, discolouration or visible
masses
 • Auscultation: Hyper active or hypo active bowel sounds, silent BS
or pulsatile bruit, borborygmi (stomach rumble)
 • Percussion: Dull (fluid filled) / shifting dullness / liver or spleen
dullness
 Continued….
Palpation:
•Tenderness
 Rigidity and guarding
 Board like abdomen
Rebounding pain
•Rectal digital examination
•Per vaginal examination
Careful examination of Heart, Lung and Skin
 Lab Investigations
• Complete blood count (including differentials, ESR, CRP, platelet
count, peripheral smear) & Blood Culture
• BUN, Creatinine, Serum electrolytes ( sodium, potassium,
bicarbonate)
• Complete urinalysis (with culture)
• Beta HCG – woman of child bearing age
• LFT – Bilirubin, ALP, ALT, AST, GGT – for RUQ pain & jaundice
• Amylase, Lipase – for epigastralgia
• PT, APTT, bleeding time, clotting time
• ECG, CK – epigastralgia with aged patient
 Diagnostic Imaging
• X-Ray – Standing CXR, upright and supine Abdominal X-ray ( helpful for
obstruction – free air visible)
• X-ray KUB – for Calcifications, air fluid levels, reactive bowel patterns.
Foreign bodies
• Ultrasound : rapid, safe & low cost, shows fluid, inflammation, air in
walls, masses, better for specific injuries( appendix, spleen, liver, gall
bladder, CBD, pancreas, kidney, aneurysm, prostate, ovaries, uterus and
other pathologies)
• CT Scan: useful for diagnosis of bowel obstruction, diverticulitis, colitis,
sepsis, abscess, free air, vessels, malignancies and ischemic bowel (gold
standard for acute pancreatitis/ appendicitis) and other fishing
expeditions as its better for a more generalised abdominal survey …
 Other specialised testing….
•Radiographic: Nuclear medicine ( for malignancies), Angiography
(for ischemic bowel/aneurysms), etc…
•Endoscopy : used judiciously
•Laparoscopy : Diagnostic and Treatment
•Exploratory Laparotomy
 Identifying High Risk Patients
• Elderly > 65years
• S/S of Shock, clammy patient, pallor, fainting
• Peritoneal signs
• Silent bowel sound
• Pulsatile mass
• Refractory pain post Rx
• Immunocompromised
• Women of child bearing age
•Elevation of Band WBC
• High grade fever
• Hypothermia
• Hypotension, Tachycardia – Spleen, aortic rupture, ectopic
pregnancy, ruptured ovarian cyst
• Acute Renal Failure
 Peritonitis
•Primary : caused by spontaneous bacterial seeding from states
such as cirrhosis. No GI leak.
•Secondary: caused by GI / GU leak ( PID, ulcer rupture, etc..)
•Tertiary: Secondary turning into chronic infection after closure of
the leak.
 Immediate Management
• Immediate insertion of a large bore IV and start with rather Saline
or Ringer Lactate solution (for fluid and electrolyte correction)
• IV / IM pain medication / Analgesics (Pro: can get more accurate
history and do examination / Con: Surgeons don’t suggest it and
prefer consultation immediately)
• Nasogastric tube if vomiting or concerned about obstruction
• Foley’s catheter to follow hydration status and to obtain urinalysis
• Antibiotic administration if suspicious of inflammation or
perforation
• Definitive treatment or procedure (varies with diagnosis)
• Reassess patient on a regular basis and Refer to concerned
surgeon when indicted.
 When to Operate – Surgical consult
•Peritonitis : Excluding primary peritonitis
•Abdominal pain + Tenderness + Sepsis + Shock
•Acute Intestinal Ischemia
•Pneumoperitoneum / Hemoperitoneum
•Exclude Pancreatitis
•Operable Tumour / Malignancies
 When not to operate….
• Cholangitis • Appendicial abscess
• Acute diverticulitis + abscess • Acute pancreatitis /
hepatitis
• Ruptured ovarian cyst • Long standing
perforated ulcer
• Diabetic ketoacidosis • Myocardial infarction,
• Pulmonary infarction, pneumonia • GE reflux, adrenal
insufficiency
• Acute porphyria • Rectus muscle hematoma
• Pyelonephritis, sickle cell crisis
THE APPENDIX
 EMBRYOLOGY
 In the sixth week the appendix and cecum appear as outpouchings from the caudal limb of the midgut .

 The appendiceal outpouching , initially noted in the eighth week , begins to elongate at about the fifth month to
achieve a vermiform appearance .

 The appendix maintains its position at the tip of the cecum throughout development .

 The subsequent unequal growth of the lateral wall of the cecum causes the appendix to find its adult position on
the posterior medial wall, just below the ileocecal valve .
 The base of appendix can be located by following the
longitudinally oriented taenie coli to their confluence on the
cecum .

 The tip of appendix can be located anywhere in the right lower

quadrant of the abdomen , pelvis , or retroperitoneum .

 In patient with midgut malrotation the appendix will remain in

the left upper quadrent of the abdomen . In situs inversus the
appendix is found in the left lower quadrent of the abdomen .
 ANATOMY
 In the adult , the average length of the appendix is 6 to 9 cm ;
however , it can vary in length from <1 to > 30 cm .
 The outer diameter varies between 3 and 8 mm , whereas the luminal
diameter varies between 1 and 3 mm .
 Th appendix receives its arterial supply from appendicular branch of
the ileocolic artery . This artery originates posterior to the terminal
ileum , entering the mesoappendix close to the base of the appendix .

 Innervation of the appendix is derived from sympathetic elements

contributed by the superior mesenteric plexus (T10 – L1 )** and
afferent from the parasympathetic elements via the vagus nerves .
HISTOLOGY
The histologic features of the appendix are
contained within the three following layers :
the outer serosa , which is an extention of
the peritoneum ; muscularis layer , which is
not well defined and may be absent in
certain locations ; and finally , the
submucosa and mucosa .
LYMPHATIC DRAINAGE
Lymphatic fluid from the appendix
drains into lymph nodes within the
mesoappendix and into the ileocolic
lymph nodes (which surround the
ileocolic artery) .
 PHYSIOLOGY
 For many years , the appendix was wrongly believed to be a
vestigial organ with no known function .

 Its now well recognized that the appendix is an immunologic

organ that actively participates in the secretion of
immunoglobulins , particularly immunoglobulin A .

 Other relation still not clear .

ACUTE APPENDICITIS
 EPIDEMIOLOGY
 The lifetime risk of developing appendicitis is 8.6% for males and 6.7%
for females , with highest incidence in the seconed and third decades .

 The rate of appendectomy has been decreasing since 1950s in most

countries . In US , it reached its lowest incidence rate of about 15 per
10,000 inhabitants in the 1990s .

 Since then , there has been an increase in the incidence rate of

nonperforated appendicitis . Increased used of diagnostic imaging has
led to higher detection rate of mild appendicitis that would otherwise
resolve undetected .
 ETIOLOGY AND PATHOGENESIS
 The etiology and pathogenesis of appendicitis are not completely
understood . Obstruction of the lumen due to fecaliths or hypertrophy of
lymphoid tissue is proposed as the main etiologic factor in acute
appendicitis .

 The frequency of obstruction rises with the severity of the inflammatory

proccess . Fecalith and calculi found in 40% of simple ,in 65% of
gangrenous without rupture , in 90% of gangrenous with rupture .

 The proximal obstruction of the appendiceal lumen produces a closed

loop obstruction > increase intraluminal pressure > stimulation of
visceral afferent nerve fibers at T8-T10 > initial diffuse periumbilical pain
> inflammation extends to serosa and irritates parietal peritoneum .
 NATURAL HISTORY
 The natural history of appendicitis is unclear , but it appears that
progression to perforation is not predictable and spontaneous
resolution is common , suggesting that nonperforated and
perforated appendicitis may , in fact be different diseas .
 Clinical presentation
 The inflammatory process in the appendix presents as pain , which
initially is often diffuse visceral type and later becomes more
localized as the peritoneal lining gets irritated .
 Symptoms of appendicitis start with periumbilical and diffuse pain
that eventually localizes to the right lower quadrant (sensitivity 81%;
specificity 53% )
 Appendicitis is also associated with gastrointestinal symptoms like :
 nausea (sensitivity 58% , specificity 36% ).
 Vomiting (sensitivity 51% , specificity 45% ) .
 Anorexia (sensitivity 68% , specificity 36% ) .
 Signs. Early in presentation , vital sign may be minimally altered
.

 The body tempreture and pulse rate may be normal or slightly

elevated .

 Changes of great magnitude may indicate that a complication

has occurred or that another diagnosis should be considered .
 Physical examination
 Physical findings are determined by the presence of peritoneal
irritation and are influenced by whether the organ has already
ruptured when the patient is first examined .
 Patient with appendicitis usually move slowly and prefer to lie
supine due to the peritoneal irritation .
 On abdominal palpation , there is tenderness with maximum at
or near McBurney’s point .
 On deep palpation, one can feel a muscular resistance
(guarding ) in the right iliac fossa , wich more evident when
compared to the left side .
 LABORATORY FINDINGS
 Appendicitis is very unlikely if the WBC , proportion of
neutrophils , and CRP are all normal
CLINICAL SCORING SYSTEM
 IIMAGING STUDY
 X-RAY

 Technetium 99m labeled leukocyte scan

 US & CT SCAN are the most commonly used imaging test in

patiens with abdominal pain , particularly in evaluation of
possible appendicitis .
Multiple meta analyses have been performed
comparing the two imaiging modalities (shows
below ) . Overall , CT scan is more sensitive and
specific than ultrasonography in diagnosing
appendicitis .
Multiple meta analyses have been performed comparing the two imaiging modalities
(shown above )
Overall , CT scan is more sensitive and specific than ultrasonography in diagnosing
appendicitis .
 DDX
 In adult : IBD , pancreatitis ,cholecystitis , gastroenteritis ,
nephrolithiasis , valentino's syndrome , pyelonephritis , simoid
diverticulitis , cecal diverticulitis , meckel's diverticulitis .

 In female : PID , overian torsion , mittelschmerz , ruptured

ectopic .

 In children :mesentric lymphadenitis , yersina enterocolitica

(pseudo appendicitis ) pneumococcal pneumonia ,
gastroenteritis , intussusception .
 MANAGEMENT
 Patient without complication

 Patien with complication

THANK YOU