Acute Abdomen Is the Most Common Cause for Admission in the Surgical Department. Acute

Acute Abdomen Is the Most Common Cause for Admission in the Surgical Department. Acute

6.
7
8 / Brief resume of the intended work:
6.1 Need for the study:
  • Acute abdomen is the most common cause for admission in the surgical department. Acute abdomen has always remained a challenge to surgeons and physicians all over the world
  • The etiology of acute abdomen varies from a trivial cause to serious life threatening conditions which need early intervention
  • The varied etiology differs according to the age ,sex and pre-existing conditions.
  • The management varies from passive observation to the most radical surgery. Thus decision making is based on good clinical skills and interpretation of the signs and investigations.
  • In cases which need surgical intervention , the most limiting factor is time. The time frame to surgery will have great implications on morbidity and mortality.
  • This study tries to analyse the spectrum of Acute Abdomen based on the above variables.
6.2 Review of literature:
The term acute abdomen inherently implies a suddenness of onset where the clinical course of abdominal symptoms ranges from minutes to weeks. The term is synonymously used for conditions that require immediate operation, but the patients who require surgery represent only a subset of patients of acute abdomen1.
Hippocrates in 477BC recognized the importance of peritonitis and acute abdomen and was the first to use the term ‘ileus’ to describe intestinal obstruction2.
Cope has laid down a rule ‘majority of patients of severe abdominal pain which ensue in patients who have been fairly well previously and which last as long as six hours are caused by conditions of surgical import’3.
The range of disease extends from relatively trivial to immediate life threatening conditions. Attempts to reach a diagnosis must sometimes be curtailed in the interest of immediate treatment.
Surgery of acute abdomen varies from a simple procedure to a highly complex procedure stretching the abilities of even highly skilled surgeons4.
Pathological processes causing acute abdomen are
i)Inflammation and infection : Acute appendicitis; acute cholecystitis, acute diverticulitis, acute pancreatitis, acute salpingites, mesenteric adenites etc.,
ii)Perforation: Peptic ulcer perforation, typhoid ulcer, perforation due to diverticular disease, perforation of caecum due to large bowel obstruction.
iii)Obstruction : Bowel obstruction
  • Small bowel : due to bands, meconium ileues, adhesions, hernias, intususseption, gall stones, tumor etc.,
  • Large bowel: Tumors, volvulus, inflammation, strictures etc.,
  • Renal colic
  • Biliary colic.
iv)Infarction: Torsion of testis, torsion of ovarian cyst, torsion of appendices epiploicae, occlusion of arteries due to thrombosis and embolism.
v)Haemorrhage: Blood in peritoneal cavity can lead to acute abdomen. Excluding trauma; rupture of aneurysm, rupture of ectopic pregnancy etc., can cause haemoperitoneum.
vi)Medical causes: Many causes which are non-surgical can cause symptoms mimicking acute abdomen.
a)Intra abdominal causes:
Primary peritonism : Bacterial, Tuberculosis
Infection: Acute viral gastroenteritis, acute food poisoning, Fitz Hugh Curtis syndrome.
b)Abdominal wall conditions: Rectus sheath haematoma.
c)Retroperitoneal causes : Pyelonephrites, acute hydronephrosis
d)Intra-thoracic causes: Myocardial infarction, pluerisy, pericarditis, dissection of aorta.
e)Neurological causes: Tabes dorsalis.
f)Metabolic causes: Acute intermittent porphyria, uraemia, Addisons disease.
g)Immunological diseases : PAN, SLE
h)Haemotological disease: Sickle cell anemia, HSP, Polycythemia, anticoagulant therapy.
i)Drug induced : Quinine, Chlorpromazine, OCP
j)Manchausen disease2
All the causes of acute abdomen cause various clinical signs and symptoms.
Symptoms are subjective manifestations and represent the pathophysiologic processrather than the specific cause. The common symptoms are pain abdomen, dysphagia, anorexia, weight loss, nausea, vomiting, distension, constipation, flatulence and diarrhea.
Signs are objective findings of the pathophysiologic process. Common signs are tenderness, rigidity, mass in abdomen, altered bowel habits bleeding, jaundice and stigmata of hepatic dysfunction5.
The need for surgical intervention is the most important decision to be taken and its best taken as early as possible.
The indications for urgent surgical intervention in acute abdomen can be enumerated under following headings:
Physical Signs:
1)Involuntary guarding or rigidity, if it is spreading.
2)Increasing or severe localized tenderness.
3)Tense and progressive distension.
4)Tender abdominal or rectal mass with high fever or hypotension.
5)Equivocal abdominal findings with
a)Septicemia
b)Bleeding
c)Suspected ischemia
d)Deterioration on conservative management.
Radiological findings:
1)Pneumoperitoneum
2)Gross / progressive bowel distension.
3)Free extravasation of contrast
4)Space occupying lesion with fever.
5)Mesenteric occlusion on angiography.
Endoscopic findings:
Perforated or uncontrollable bleeding lesion
Paracentesis finding:
Blood
Bile
Pus
Bowel content
Urine6
Plain X ray film can be used as screening modality in the diagnosis of acute abdominal emergencies as it is universally available, cheaper and is diagnostic in GIT perforation, obstruction and urolithiasis7.
In diagnosing hepatobiliary and gynecological disorders USG is more accurate, whereas in diagnosing acute appendicitis, ureteric colic and acute pancreatitis it has high specificity but low sensitivity. USG is also helpful in diagnosing alternative disease and to reduce negative laparotomy rate8.
Computed tomography has established itself as a sensitive study for patients with a wide variety of diagnoses, including appendicitis, diverticulitis, intestinal ischemia, pancreatitis, intestinal obstruction and perforated viscus9.
6.3 Aims and objectives of the study:
  1. To study the various causes of acute abdomen and their manifestations
  2. To study the distribution of varied aetiologies in different age groups
  3. Differentiate surgical causes of acute abdomen from various non-surgical causes
  4. To correlate various clinical signs and intra-operative findings and assess the reliability of the signs
  5. To assess the role and reliability of the investigations
  6. To study the outcome of patients depending on different aetiologies and the time frame to surgery
Materials and methods:
7.1 Source of data:
Cases for the study will be sourced from admissions to BapujiHospital, ChigateriHospital attached to J.J.M.MedicalCollege, Davangere.
7.2 Method of data collection:
A minimum of 100 consecutive cases presenting with acute abdomen in BapujiHospital, ChigateriHospital will be selected for the study.
  • This is a prospective study of 100 cases giving history of acute abdomen.
  • The period of study is from June 2007 to May 2009
  • Obtaining a detailed history and clinical examination.
  • Relevant investigations performed on the patient.
A detailed structured proforma will be used to collect this information.
Inclusion criteria :
  • Patients admitted with history of acute abdomen and subsequently diagnosed as cases with surgical causes of acute abdomen
  • Unconcious patients with guarding or rigidity or distension of abdomen
Exclusion criteria :
  • Patients with acute abdomen due to Gynecological causes, traumatic causes, non-surgical causes.
  • Pediatric cases with acute abdomen.
7.3 Does the study require any investigations or interventions to be conducted on patients, other humans or animals? If so, please describe briefly.
YES.
  • Hb% , TC, DC, ESR, BT, CT
  • Blood grouping, cross matching
  • S. Electrolytes
  • S. Amylase
  • Urine Sugar, Albumin, Microbiology
  • Chest X Ray,
  • Erect X Ray Abdomen
  • ECG
  • USG abdomen
  • Paracentesis and ascetic fluid analysis
  • CT scan abdomen
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES.
References:
  1. Martin RF, Rossi RL. The acute abdomen: an overview and algorithms. Surgical clinics of North America; Philadelphia: W B Saunders company; 77 (6): Dec 1997. p. 1227-1242
  2. Paterson-Brown S. The Peritoneum, The Mesentry, The Greater Omentum and the acute abdomen. In: Burnand KG, Young AE, edts. The New Aird’s companion in surgical studies. 2nd edn. London: Churchill Livingstone; 1998. p. 693-762
  3. Shepherd JA. Principles and methods of diagnosis. In: A concise surgery of the acute abdomen. Edinburgh: Churchill Livingstone; 1975. p. 1-13
  4. Britton J. The acute abdomen. In: Morris PJ, Malt RA, edts. Oxford textbook of surgery. Vol 1. OxfordUniversity Press; 1994. p. 1375-1397
  5. Liu CD, McFadden DW. Acute abdomen and appendix. In: Greenfield LJ, edts. Surgery- scientific principles and practice. 2nd edn. Philadelphia: Lippincott Raven publishers. p. 1246-1262
  6. Boey JH. The acute abdomen. In: Way LW, edtr. Current Surgical Diagnosis and Treatment. 10th edtn. New Jersey: Prentice-Hall International Inc; 1994. p. 440-452
  7. Gupta K,Bhandari RK, Chander R. Comparative study of plain abdomen and ultrasound in non_traumatic acute abdomen. Indian Journal of Radiology and Imaging. 2005;15(1):109-115.
  8. Prasad H, Rodrigues G, Shenoy R. Role Of Ultrasonography In Non Traumatic Acute Abdomen. The Internet Journal of Radiology. 2007; 5 (2).
  9. Gupta H, DupuyDE. The acute abdomen: an overview and algorithms. Surgical clinics of North America; Philadelphia: W B Saunders company; 77 (6): Dec 1997. p 1245-1265

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