Acute abdomen

RUQ pain
• Liver abscess
• Duodenal ulcer
• Renal calculi
• Gall stone
• Acute cholecystitis
• Pyelonephritis
Liver abscess
 ้ พบบ่
• เชือที ่ อย amoeba & pyogenic liver abscess
• Multiple abscess สัมพันธ ์กับ biliary disease
• มักอาการมาด ้วย
▫ fever +- chill
▫ RUQ pain
▫ Anorexia
▫ Malaise
▫ ถ ้า abscess ใกล ้ diaphragm ทาให ้ cough, pleuritic
chest pain, Rt. Shoulder pain
 ALA PLA
Age Younger Older

Sex Male>female Male=female

Presentation Acute Subacute

Jaundice Less common Common

Multiple abscess Less common Common

Pus สีกะปิ , Greenish-

Charcotleyden’s yellowish, foul
crystal, necrosis smell, numerous
tissue PMN, bacteria
• Investigation
▫ CBC, LFTs, H/C, CXR, Serology, U/S, CT scan,
Needle aspiration

• Treatment
▫ Antibiotic
 Gram +ve cocci : Cloxacilin, Cefazolin
 Gram –ve rod : Cephalosporin, Fluoroquinolone
 Mixed : Cephalosporin+Metronidazole,
Fluoroquinolone
 Amoebic : Metronidazole
▫ Drainage
Duodenal ulcer
• Peptic ulcer disease (PUD) may be due to any of
the following:
▫ H pylori infection
▫ Drugs : NSAIDs
▫ Lifestyle factors
▫ Severe physiologic stress
• PE
▫ Epigastric tenderness (usually mild)
▫ Right upper quadrant tenderness
▫ Guaiac-positive stool resulting from occult blood
loss
▫ Melena resulting from acute or subacute
gastrointestinal bleeding
• Complication : Duodenal perforate
• Sudden onset of severe, sharp abdominal pain. Most
patients describe generalized pain; a few present with
severe epigastric pain. As even slight movement can
tremendously worsen their pain, these patients assume a
fetal position.

• Abdominal examination usually discloses generalized

tenderness, rebound tenderness, guarding, and
rigidity.

• signs and symptoms of septic shock, such as

tachycardia, hypotension, and anuria.
• Investigations
▫ CBC, UA, Serum amylase, Serum electrolyte, CT
abdomen

• Treatment
▫ Resuscitation
▫ Surgery
Renal calculi
Signs and symptoms
• Sudden onset of severe pain originating in the
flank
• N/V
• infection, or hematuria.
• Asymptomatic
• Ureteropelvic junction stone : Mild to severe deep
flank pain without radiation to the groin; irritative
voiding symptoms, suprapubic pain, urinary frequency.

• Ureter stone : Abrupt, severe, colicky pain in the flank

and ipsilateral lower abdomen; radiation to testicles or
vulvar area; intense nausea with or without vomiting

• Upper ureteral stones: Radiate to flank or lumbar

areas

• Midureteral calculi: Radiate anteriorly and caudally

• Distal ureteral stones: Radiate into groin or testicle

(men) or labia majora (women)

• Stones passed into bladder: Mostly asymptomatic;

rarely, positional urinary retention
• Investigations
▫ UA & Urine culture
▫ Plain film KUB
▫ IVP
▫ CT
▫ U/S
• Treatment
▫ Ultrasonic lithotripsy
▫ Percutaneous nephrostomy
▫ Surgery
Gall stone
 Characteristics of biliary colic include the
following:
• Sporadic and unpredictable episodes

• Pain that is localized to the epigastrium or right upper

quadrant, sometimes radiating to the right scapular tip

• Pain that begins postprandially, is often described as

intense and dull, typically lasts 1-5 hours, increases steadily
over 10-20 minutes, and then gradually wanes

• Pain that is constant; not relieved by emesis, antacids,

defecation, flatus, or positional changes; and sometimes
accompanied by diaphoresis, nausea, and vomiting

• Nonspecific symptoms (eg, indigestion, dyspepsia, belching,

or bloating)
 Risk factors include the following:

• Obesity
• Pregnancy
• Gallbladder stasis
• Drugs
• Heredity
Investigation
• CBC : leucocytosis
• LFT :
▫ Mild hyperbilirubinemia ต่ากว่า 4 mg/ml
▫ alkaline phosphatase, tranaminase สูง
▫ severe jaundice แสดงว่ามี common bile duct stone
หรือ obstruction of bile duct จาก pericholecystitis
หรือ stone impact ที่ infundibulum
• Serum amylase : อาจจะสูง
 ่
• ECG : เพือแยกโรค myocardial injury หรือ ischemia
• Film abdomen
• Ultrasound

Treatment
• Endoscopic Cholangiography + sphicterotomy
ก่อนการทา lapraoscopic cholecystectomy
• Laparoscopic Common Bile Duct Exploration
Acute cholecystitis
 Characteristics may be reported:
• Signs of peritoneal irritation may be present,
and the pain may radiate to the right shoulder or
scapula

• Pain frequently begins in the epigastric region

and then localizes to the right upper quadrant
(RUQ)

• Pain may initially be colicky but almost always

becomes constant

• Nausea and vomiting are generally present, and

fever may be noted
The physical examination may reveal the
following:

• Fever, tachycardia, and tenderness in the RUQ

or epigastric region, often with guarding or
rebound

• Palpable gallbladder or fullness of the RUQ (30-

40% of patients)

• Jaundice (~15% of patients)

Diagnostic imaging
• Radiography

• Ultrasonography

• Computed tomography (CT)

• Magnetic resonance imaging (MRI)

• Hepatobiliary scintigraphy

• Endoscopic retrograde cholangiopancreatography

(ERCP)
Treatment
• Cholecystectomy
• Laparoscopic Cholecystectomy
Pyelonephritis
 Signs and symptoms
• Fever the temperature to exceed 103°F (39.4°C)

• Costovertebral angle bilateral discomfort may be

present

• Nausea and/or vomiting

Investigation
• Urinalysis

• Computed tomography (CT) scanning

• Magnetic resonance imaging (MRI)

• Ultrasonography

• Scintigraphy

• CT and MR urography
Management
Supportive care
• Monitoring of urine and blood culture results
• Monitoring of comorbid conditions for deterioration
• Maintenance of hydration status with IV fluids until
hydration can be maintained with oral intake
• IV antibiotics until defervescence and significant
symptomatic improvement occur; convert to an oral
regimen tailored to urine or blood culture results

Surgery
 Appendicitis
Cause :
• เกิดจากการมี obstruction ของ appendiceal lumen
• เกิดจากการกดเบียดของอวัยวะภายนอกไส ้ติง่ : lymphadenopathy
• เกิดจากการอุดตันภายใน : fecalith,parasite,FB
Pathogenesis :
่ การอุดตันใน lumen มีผลทาให ้แรงดันสูงขึน้ เกิดการร ับรู ้ที่ visceral afferent
เมือมี
stretch fiber
มีผลทาให ้ปวดท ้องแบบทีต่ าแหน่ งกลางท ้อง มี bacterial overgrowth เกิดการสะสม
ของหนองภายในไส ้ติง่ และบางส่วนลุกลามเข ้าสูก่ ระแสเลือด ทาให ้เกิด systemic
่ ่ ่
symptom เช่น ไข ้ คลืนไส ้ ปวดเมือย เมือลุกลามถึง serosa จะทาให ้ปวด right lower
่
quadrant pain เมือเวลาผ่ ้
านไปแรงดันสูงขึนจนไส ่
้ติงขาดเลื
อด เน่ าแตกในทีสุ ่ ด เกิด
หนองกระจายออกจากตัวไส ้ติง่

- ถ ้า defense mechanism ดี : appendical mass / appendiceal abscess

- ถ ้า defense mechanism ไม่ดี : generalized peritonitis
Appendicitis
Symptom :
• ปวดท ้องรอบสะดือหรือกลางท ้อง ปวดแบบแน่ นๆเสียดๆไม่มรี ้าวไปทีใด ่
• ่
4-6 ชมต่อมา อาการจะเลือนมาปวดที ่ ้องน้อยด ้านขวา
ท
้ อาการไข ้ เบืออาหาร
ในช่วงนี จะมี ่ ่ ้อาเจียนได ้
คลืนไส
• ่
เมืออาการเป็ ้ ้ติง่ จะเริมมี
นนานขึนไส ่ การเน่ า แตกทะลุ ทาให ้เกิดเชือแพร่
้ มาในท ้อง
เกิด appendiceal abscess หรือ generalized peritonitis

Type :

• ่ ่ใต ้ลาไส ้ Ileum (retroileal type) : testicular pain

ไส ้ติงอยู
• ่ ่ใต ้ลาไส ้ cecum (retrocecal type) : flank or back pain
ไส ้ติงอยู
• ่ ้ติงชี
ปลายไส ้ติงไส ่ เข้ ้าไปใน pelvic (pelvic type) : suprapubic pain
• ่
ปลายไส ้ติงยาวไปถึ งด ้านซ ้ายของท ้อง : ปวดท ้องน้อยด ้านซ ้าย
Appendicitis
Physical Examination :
• GA : นอนหงายช ันเข่าขวา
• V/S : มีไข ้ต่าๆ มักปกติ ยกเว ้นรายที่ perforation โดยเฉพาะ
ในคนสูงอายุ อาจเกิดภาวะช็อกได ้
• Abdomen : ปวดแสบทีผนั ่ งหน้าท ้อง bowel sound มัก absence
• Tender at McBurney’s point
• Rebound tenderness , guarding
• Rovsing sign positive : กด LLQ แล ้ว tender ที่ RLQ
• Psoas’s sign positive (retrocecal type): นอนตะแคงซ ้ายทา extension of right leg
เวลายืดจะปวด
่
• Obturator sign (pelvic type) : เมือนอนหงายช ันเข่าขวาขึน้ (flex hip,flex knee)
แล ้วทา internal rotation of leg จะทาให ้ปวด
่
• Dunphy’s sign : เมือไอหรื อขยับตัวแล ้วจะมีอาการปวดท ้อง
 Appendicitis
LAB :
-CBC : leukocytosis shift to the left
- Blood chemistry : serum amylase
- Urinalysis : normal ( ถ ้าพบนึ กถึง UTI )
- Chest film ( นึ กถึงโรค Pneumonitis )
- Urine pregnancy test ( หญิงเจริญพันธ ์ นึ กถึง ectopic pregnancy )
- Acute abdominal series : ปกติไม่จาเป็ น อาจจะเห็น localized ileus หรือเห็น
fecalith ที่ RLQ
- Ultrasound

Treatment :
- ี่
Preoperative preparation แก ้ไขโรคประจาตัว ความผิดปกติทพบก่
อน
- ให ้ยาแก ้ปวดระหว่างรอการผ่าตัด
- ่ มทัง้ gram negative และ
ให ้ยาปฏิชวี นะทีครอบคลุ
anaerobe bacteria
: Augmentin Cefolexin Unasyn หรือ
Gentamycin + metronidazole
 Colitis
• Colitis is inflammation of the inner lining of the colon
• Can be associated with diarrhea, abdominal pain,bloating,
and blood in the stool
• This inflammation may be due to a variety of reasons
- Infection
- Loss of blood supply to the colon
- IBD
- Invasion of the colon wall with
lymphocytic white blood cells or
collagen
 Colitis : Infectious colitis
• Infectious colitis :
- Common most common bacteria that cause colitis include:
Campylobacter , Shigella ,E.coli ,Yersinia , Salmonella
- The patient has eaten contaminated food
• Symptoms :
- diarrhea with or without blood , abdominal cramps and
dehydration from water loss because of numerous watery, bowel
movements.
• Treatment : Supportive care .
- Most infections will resolve with or without specific treatment and often
do not require antibiotics.
- Those decisions depend on the patient's diagnosis.
 Colitis : Ischemic colitis
• Ischemic colitis :
- loses supply of blood and becomes ischemic
• Symptoms : pain, fever, and diarrhea
• Cause : Risk factors for narrowed arteries are the same as
atherosclerotic heart disease, peripheral artery disease (PAD),
and include diabetes , high blood pressure , high cholesterol ,
smoking
• Treatment : controlling high blood pressure, diabetes, and
high cholesterol and stopping smoking
• Patients with severe ischemia that leads to a dead
(gangrenous) colon require surgery to remove the gangrenous
segment
 Colitis : Inflammatory bowel disease
• Ulcerative colitis : moving from the rectum to the sigmoid, descending,
transverse, and finally ascending colon. It is consisdered an autoimmune
disease and symptoms include abdominal pain , and bloody, diarrheal
bowel movements.
• Crohn's disease : may occur anywhere in the gastrointestinal tract (GI),
including the esophagus, stomach, small intestine, and colon.
• In Crohn's disease there may be "skip lesions," that is, abnormal segments
of the GI tract interspersed with normal segments
 Irritable Bowel Syndrome
• Irritable bowel syndrome (IBS) is a common intestinal condition characterized
by abdominal pain and cramps; changes in bowel movements (diarrhea,
constipation, or both) at least 3 days/month in last 3 months

• Signs and Symptoms

– Cramping or cramp-like, Stabbing, Sharp, A ‘migraine’ in the stomach

– anywhere in the abdomen

– improvement with defecation

– associated with a change in frequency, form of stool

 Diverticular disease
-Abnormal sac or pouch protruding from the wall of a hollow organ.
-The sigmoid colon, the most common site of diverticula formation.
-Further evidence that a diet low in fiber and high in carbohydrates and meat
- A true diverticulum is composed of all layers of the intestinal wall.
- A false diverticulum or pseudodiverticulum is the mucosa and
muscularis mucosa have herniated through the colonic wall.
Diverticulosis refers to the presence of diverticula without
inflammation.
Diverticulitis refers to inflammation and infection associated with
diverticula.
- Uncomplicated Diverticulitis
- Complicated Diverticulitis :
Abscess
Fistula
Generalized Peritonitis
Obstruction
Diverticular-Associated Colitis(DAC)
*The Hinchey staging system is often used to describe the
severity of complicated diverticulitis
 Symptoms
- left lower quadrant abdominal
- Pain that may radiate to the suprapubic area, left groin, or back.
- Alterations in bowel habits
- fever,chills
 Physical examination
-tenderness of the left lower abdomen.
-There may be voluntary guarding of the left abdominal musculature
and a tender mass in the left lower abdomen is suggestive of a phlegmon
or abscess.
-Abdominal wall distention may be detected if there is associated
ileus or small bowel obstruction secondary to the inflammatory process.
 Investigations
-CBC: leukocytosis
-A limited sigmoidoscopic examination
-computed tomography(CT) of the abdomen
-magnetic resonance imaging (MRI)
-abdominal ultrasound
-water-soluble contrast enema
 Treatments
Non-operative
-antibiotic
-percutaneous drainage(PCD)
Operation
-peritonitis
-recurrence
-failed antibiotic
 Meckel’s diverticulum
-incomplete closure of the omphalomesenteric or vitelline duct.
-Meckel’s diverticula are designated true diverticula
- Meckel’s diverticula contain gastric mucosa and pancreatic acini .
others include Brunner’s glands, pancreatic islets, colonic
mucosa,endometriosis, and hepatobiliary tissues.
Meckel’s diverticula is the “rule of two’s”
-2% prevalence
-2:1 male predominance
-location 2 feet proximal to the ileocecal valve in adults
-half of those who are symptomatic are under 2 years of age.
 Symptoms
-Meckel’s diverticula, is associated with a clinical syndrome that
is indistinguishable from acute appendicitis.
-bleeding, intestinal obstruction,and diverticulitis.
-Bleeding is the most common presentation in children
-Intestinal obstruction is the most common presentation in
adults.
Diagnosis
-radiographic imaging, during endoscopy, or at the time of surgery.
-Radionuclide scans (99mTc-pertechnetate) this test is positive only when the
diverticulum contains associated ectopic gastric mucosa

Treatment
-diverticulectomy
 Volvulus

-Volvulus occurs when an air-filled segment of the colon twists about

its mesentery.
-The sigmoid colon is involved in up to 90% of cases, but volvulus can
involve the cecum (<20%)or transverse colon.
 symptoms
-abdominal distention
-nausea and vomiting.
-abdominal pain and tenderness.
-Fever and leukocytosis
 Investigation
plain X-rays of the abdomen
• characteristic bent inner tube or coffee bean appearance, with

Gastrografin enema
• narrowing at the site of the volvulus and a pathognomonic bird’s beak
Sigmoid volvulus: (A) Illustration and (B) Gastrografin enema showing “bird-beak” sign (arrow). (B: Reproduced
with permission from Nivatvongs S, Becker ER. Colon, rectum, and anal canal. In: James EC, Corry RJ, Perry JCF Jr,
eds. Basic Surgical Practice.Philadelphia: Hanley & Belfus; 1987. Copyright Elsevier.)
 Treatment
-Unless there are obvious signs of gangrene or peritonitis:
endoscopic detorsion.
-Clinical evidence of gangrene or perforation :surgical exploration.
 Hernia
-abnormal protrusion of an organ or tissue through a defect in its
surrounding walls.
- Although a hernia can occur at various sites of the body, these
defects most commonly involve the abdominal wall.
- A incarceration : contents of hernia sac not reducible into
peritoneal cavity.
-A strangulated hernia has compromised blood supply to its
contents.
Types of abdominal wall hernias. (From Dorland’s
illustrated medical dictionary, ed 31, Philadelphia,
2007, WB S aunders,Plate 21.)
Anatomy of the important preperitoneal structures in
the right inguinal space.(From Talamini MA, A re C:
Laparoscopic hernia repair. I n Zuidema GD, Yeo CJ
[eds]: hackelford’s surgery of the alimentary tract, ed
5, vol 5, Philadelphia, 2002, WB S aunders, p 140.)
 Signs and symptoms
Characteristics of asymptomatic hernias are as follows:
• Swelling or fullness at the hernia site
• Aching sensation (radiates into the area of the hernia)
• No true pain or tenderness upon examination
• Enlarges with increasing intra-abdominal pressure and/or standing
Characteristics of incarcerated hernias are as follows:
• Painful enlargement of a previous hernia or defect
• Cannot be manipulated (either spontaneously or manually) through the fascial defect
• Nausea, vomiting, and symptoms of bowel obstruction (possible)
Characteristics of strangulated hernias are as follows:
• Patients have symptoms of an incarcerated hernia
• Systemic toxicity secondary to ischemic bowel is possible
• Strangulation is probable if pain and tenderness of an incarcerated hernia persist
after reduction
• Suspect an alternative diagnosis in patients who have a substantial amount of pain
without evidence of incarceration or strangulation
Investigation
-Ultrasonography

Treatment
-Nonoperative -Hernia reduction
-Surgical options depend on type and location of hernia.
herniotomy
herniorrhaphy
hernioplasty
 Pelvic inflammatory disease
Acute PID : ภาวะอุ ้งเชิงกรานอักเสบ
acute salpingitis , Tuboovarian absess , hydrosalpinx
ภาวะอักเสบในอุ ้งเชิงกรานเกิดจากการติดเชือร่ ้ วมกัน polymicrobial infection เชือโรคผ่
้ ้
านขึนไปจากอวั ยวะสืบพันธ ์
้ ่ ่
ส่วนล่างขึนไปยังอวัยวะสืบพันธ ์ส่วนบนโดยไปตามเยือบุผวิ ทีปกคลุมช่องคลอดและปากมดลูก ผ่านขึนไปยั ้ งโพรงมดลูก
ท่อนาไข่ และเข ้าสูช ้ ยกว่า canalicular spreading ปกติเชืออสุ
่ อ่ งท ้อง กระบวนการนี เรี ้ จ ิ สี และเลือดระดูสามารถ
้
ผ่านเข ้าไปอยู่ในช่องท ้องทางท่อนาไข่ จากการทดลองพบว่าเชือโรคสามารถผ่านเข ้าไปได ้ แต่ไม่ได ้ทาให ้เกิดการติด
้
เชือเสมอไป ้ ขึ
ทังนี ้ นกั
้ บความรุนแรง จานวนและ viability ของตัวเชือ้ และกลไกต่อต ้านเฉพาะทีของสตรี ่ ผู ้นั้นเอง
• Risk :
่ นอ้ ยกว่า 20 ปี
- ผู ้ป่ วยหญิงวัยเจริญพันธ ์ทีอายุ
- Multiple sexual partners
- Multiparity
- Previous PID
• ้ อโรคทีพบบ่
เชือก่ ่ อย : N.gonorrhea , Chlamydia
 Pelvic inflammatory disease
• Symptoms :
้
ปวดท ้องน้อยด ้านขวา แต่สว่ นใหญ่จะปวดท ้องน้อยทังสองด ้าน
่
อาการปวดไม่มาก ปวดตลอดเวลา ร่วมกับมีอาการเบืออาหาร
่ ้อาเจียน
คลืนไส
• Classical symptom : fever, lower abdominal pain
with pelvic tenderness, purulent vaginal discharge
่ าคัญอาการมักจะเกิดหลประจาเดือนภายใน 7 วัน โดยมีประวัตก
ทีส ิ ารร่วมเพศในช่วง
ประจาเดือน
Physical Examination :

• ไข ้ 38-39 c
•Abdomen : guarding , rebound tenderness
•PV : fluid จาก cervix ส่งตรวจ C/S , gram stain จะได ้
gonococcal , Culture จะได ้ Chlamydia
 Pelvic inflammatory disease
• Investigation :
laparoscopy , pelvic ultrasonography , pelvic CT scanning

• Treatment :
การร ักษาด ้วยยา : Ofloxacine / Levofloxafine +metronidazole
ในรายทีรุ่ นแรง : Cefotetan / Cefaxoitin + doxycycline
่
การร ักษาด ้วยการผ่าตัด เมือ
- Intraperitoneal rupture of tuboovarian abscess
- Persistence of pelvic abscess despite antibiotic therapy
- Chronic pelvic pain
ปัจจุบน ่ ้ผลดี จึงมักทา unilacteral salpingoophorectomy ในรายที่
ั มี antibiotic ทีได
ยังไม่มล
ี ก
ู
 Ectopic Pregnancy

• the conceptus implant and mature outside the endometrial cavity, which
ultimately ends in the death of the fetus.
 Ectopic Pregnancy

• Signs and Symptoms

– Abdominal pain

– Amenorrhea

– Vaginal Bleeding

– Symptoms of early pregnancy - Nausea, Breast fullness

– Abdominal rigidity, Involuntary guarding, Severe tenderness,

hypovolumic shock - may need emergency surgery
 Ectopic Pregnancy

• Investigations

– Pelvic examination

– Serum β-HCG

• 700-1000 mIU/mL, a gestational sac should be seen within the

uterus on transvaginal ultrasonographic images.

– Ultrasonography

• Visualization of an intrauterine sac, with or without fetal cardiac

activity, is often adequate to exclude ectopic pregnancy.
 Ectopic Pregnancy

• Treatment
– Methotrexate Therapy
– Salpingostomy and Salpingectomy
 Endometriosis

• presence of normal endometrial mucosa (glands and stroma)

abnormally implanted in locations other than the uterine
cavity.

• Patient History

– ages of 25-40

– Use contraceptive pill

– symptom improve during pregnancy and after menopause

 Endometriosis

• Signs and symptoms

– Dysmenorrhea (Painful menstruation)

– Heavy or irregular bleeding

– Pelvic pain

– Lower abdominal or back pain

– Dyspareunia (painful when having sexual inthercourse)

 Endometriosis

• Investigations

– Laparoscopy

• sensitivity 97% and specificity 77%

• classic lesions are blue-black or have a powder-burned appearance

• Treatment

– Medical treatment

• minimal or mild endometriosis

• GnRH agonists, progestins, oral contraceptive pills, and androgens.

• interrupts the normal cyclic production of reproductive hormones.

 Endometriosis

• Surgery
– Moderate to severe endometriosis
– removal of the endometrial implants and correction of anatomic distortions.
– hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO).
 Ovarian torsion
-Torsion of an ovarian cyst often causes cramping lower abdominal
pain.
-Ovarian cysts can become very large and produce visible abdominal
swellings
-Ovarian torsion is a surgical emergency