ACUTE ABDOMEN CASES EVALUATION

acute abdomen Case 1: 35-year-old male who complained of abdominal pain and collapsed.
Etiology of Acute Pancreatitis
• Metabolic
- alcohol, hyperlipidemia, hypercalcemia, hereditary pancreatitis, kwashiorkor
• Mechanical
- gallstones, post-operative, trauma, duct anomalies, iatrogenic, neoplasm, gastric ulcers
• Vascular
- vasculitis, atherosclerotic embolism
• Drugs
- steroids, aspirin, sulfonamides, tetracycline, opiates, cholinergics
• Infection
- mumps, measles, HIV, CMV

Acute Pancreatitis
• Clinical
- abdominal pain, nausea, vomiting, abdominal distension, shock
- flank ecchymosis (Grey Turners sign), periumbilical hematoma (Cullens sign)
• Laboratory Evaluation
- amylase, lipase
• Radiologic Evaluation

Why Order Imaging Studies?
• Exclude other abdominal disorders that may mimic pancreatitis
• Confirm clinical diagnosis of acute pancreatitis
• Evaluate extent of pancreatic injury and inflammation
• Evaluate for complications
- pseudocyst, abscess, intestinal obstruction, vascular complication

acute abdomen Case 2: 55-old-male with right lower quadrant pain, fever, malaise, and poor appetite
Normal Appendiceal Anatomy
• Posteromedial cecum at the convergence of the taenia coli
• 8 to 10 cm long (range 4 to 25 cm)
• Mesoappendix
• Appendiceal artery and vein

Acute Appendicitis
• Pathogenesis: luminal obstruction followed by infection
- stones, food, mucus, adhesions, mucosal edema, parasites, tumors, endometriosis, foreign objects, lymphoid hyperplasia
• Appendiceal Stones (appendicolith)
- 7-12% adults
- 50% children

Why Order Imaging Studies?
• Confusing clinical picture
• Pregnancy
- ultrasound is modality of choice
• Older age patient
- Suspect neoplasm as etiology
• Suspected complication

Acute Appendicitis
• Most common surgical emergency
• Peak incidence second and third decades of life
• Complications
- Perforation 20%
- Abscess/phlegmon 5%
- Septic thrombophlebitis (rare)

Differential Diagnosis: RLQ Pain
• Appendicitis
• Inflammatory bowel disease
• Right-sided diverticulitis
- ileal, cecal
• Complications of GI tumors
- intussusception
- perforation
- obstruction
• Meckels diverticulitis
• Small bowel obstruction
• Epiploic appendagitis
• PID
• Complications of ovarian cysts
- Hemorrhage
- Rupture
- Torsion
• Ectopic pregnancy
• Ureteral obstruction
- Stones, tumors, inflammatory disease
• Mesenteric adenitis
• Peritoneal carcinomatosis
• Omental infarction
• Peritonitis/abscess

acute abdomen Case 3: 9-year-old female with abdominal pain, vomiting, diarrhea, and abdominal distension
Inflammatory Conditions of the Colon
• Clinical
- diarrhea, nausea, vomiting, fever, malaise
• Laboratory evaluation
- stool culture, WBC count
- abdominal radiograph, computed tomography

Etiology of Inflammatory Conditions of the Colon
• Bacterial Infections
- salmonella, shigella, campylobacter, yersina, E. coli, tuberculosis, actinomycosis
• Viral Infections
- CMV
• Parasitic Infections
- amebiasis, schistosomiasis, trichuriasis
• Fungal Infections
- histoplasmosis, mucormycosis
• Noninfectious colitis
- ulcerative colitis, Crohn's disease, ischemia
• Exogenous Causes
- radiation, drug-induced, pseudomembranous colitis

Why Order Imaging Studies?
• Exclude other intra-abdominal processes
• Evaluate for complications
- toxic megacolon
- pneumatosis
- perforation
- abscess formation

Toxic Megacolon
• Transmural inflammation
• Serosal inflammation
• Vasculitis
• Destruction of neural plexuses
• Disintegration of normal tissue cohesiveness
- wet tissue paper
• Diagnosis made on abdominal radiograph
• Colonic dilatation
- >5cm
• Transverse colon
• Colonic wall thickening
- thumbprinting
• Loss of haustral pattern
• Fluid levels
• Ileus

acute abdomen Case 4: 65-year-old female with abdominal pain and rigidity of the abdominal wall
Intestinal Perforation
• Gastric or duodenal ulcer
• Intestinal obstruction
- Adhesions
- Neoplasm
- Inflammation
• Tumor
• Severe inflammation
- diverticulitis, appendicitis
• Severe colitis
- Ischemia, infection, ulcerative colitis

Acute Abdomen Cases
- abdominal pain that persists for more than a few hours
- abdominal tenderness
- evidence of inflammatory reaction or visceral dysfunction

Patient Evaluation
• History
- past medical history
- history of the present illness
• Physical examination
- pelvic examination in females
• Laboratory examination
• Radiologic evaluation

Five Principle Signs and Symptoms
• Pain
• Collapse
• Vomiting
• Muscular rigidity
• Abdominal distension

Radiologic Evaluation
• Abdominal Radiographs
- Supine (KUB) and upright abdominal films
• Ultrasound
• Computed Tomography

Summary
• Clinical signs and symptoms of an acute abdomen
- pain, collapse, vomiting, muscular rigidity, abdominal distension
• Why order radiological studies?
• Common disorders causing an acute abdomen
- appendicitis, pancreatitis, severe gastroenteritis/colitis, intestinal perforation