ACUTE ABDOMEN

From Big Medical Encyclopedia

ACUTE ABDOMEN — the clinical symptom complex developing at damages and acute diseases of abdominal organs and retroperitoneal space; at the same time it is required or the help can be required urgent medical (more often surgical). Lake., without being the final diagnosis, serves as the alarm signal forcing the doctor or the average medic to take immediate measures for the emergency hospitalization of the patient in profile establishment where in the nearest future after its receipt necessary diagnostic shall be carried out and lay down. actions. Sometimes in medical literature, especially pediatric, use the term «abdominal syndrome», the Crimea all patol combine, the states which are followed by acute abdominal pains, including and not subject to surgical treatment (see. Pseudoabdominal syndrome ). Thus, an abdominal syndrome — wider concept, than the Lake.

Reasons emergence of the Lake. are numerous and can be grouped as follows.

1. Injuries of abdominal organs and retroperitoneal space, to-rye it is accepted to divide on closed and opened (see. Stomach, damages ; Retroperitoneal space, damages ). The most frequent reason of the Lake. damages of hollow bodies are went. - kish. path and bladder. Symptoms of the Lake. often arise at changes of pelvic bones, and also nizhnegrudny and lumbar departments of a backbone that is caused by education in these cases of a retroperitoneal hematoma. Reason of the Lake. sometimes there is a through damage of a wall of a stomach arising in some cases at its chemical burns. Rather seldom the rupture of a large intestine arising at hit in its gleam of air under big pressure can be the cause.

2. Inflammatory diseases, including and peritonitis (see). The most frequent reason of the Lake. — acute inflammatory processes in a worm-shaped shoot, a gall bladder, a pancreas. Less often phlegmon of one of departments can be its cause went. - kish. a path, the diverticulitis, epiploit, etc.

3. Perforation of hollow body (see. Perforation ). Most often it arises owing to various diseases of abdominal organs and retroperitoneal space (e.g., acute cholecystitis, an acute appendicitis, ulcers and tumors went. - kish. path, diverticulums of a small and large intestine, bladder, etc.). In some cases perforation can result from hit in went. - kish. path of foreign bodys (bones, needles, etc.).

4. Internal bleedings went to a gleam. - kish. a path (see. Gastrointestinal bleeding ), in an abdominal cavity (e.g., at a rupture of a pipe at pipe pregnancy) and retroperitoneal space (e.g., a rupture of a kidney or the stratifying aneurism of a ventral aorta).

5. The impassability of intestines resulting from torsion of guts, nodulation, infringement of a gut in internal or outside hernia, obturation of a gut from the outside or from within, invaginations, prelums of a gut commissures (see. Impassability of intestines ).

6. The acute disorders of mezenterialny blood circulation (arterial and venous) leading to a heart attack (gangrene) of intestines. At the same time the symptomatology of dynamic impassability of intestines usually prevails. As a rule, disorders of mezenterialny blood circulation arise against the background of the expressed changes of a vascular wall and coagulant system of blood.

7. Inflammatory processes in appendages of a uterus, an extrauterine pregnancy, an apoplexy of an ovary, torsion of a leg of a tumor or an oothecoma, a necrosis of a myomatous node of a uterus or a tumor of ovaries.

8. Number of diseases cardiovascular, respiratory and other systems, nek-ry inf. diseases. Wedge, a picture at these diseases can serve as the reason of diagnostic mistakes (see. Pseudoabdominal syndrome ).

9. Children have a birth trauma (with injury of a liver, spleen and other bodies), the inborn and acquired impassability of intestines, perforation of a gut at ulcer nonspecific colitis, etc.

Symptomatology and diagnostic actions

the Leading symptom practically in all cases of the Lake. the pain localized or on all stomach is. Accurate dependence between dynamics of a disease, character and intensity of pain, and also its localization usually is not observed. At the extensive and severe defeats which caused emergence of the Lake. (e.g., at nek-ry types of mechanical impassability of intestines, a widespread hemorrhagic pancreatonecrosis), the pain syndrome can be sharply expressed and be followed by development shock (see).

Frequent symptom of the Lake. — vomiting, edges can arise during the first hours and even minutes of a disease. Emetic masses usually consists of the remains of the eaten food, a gastric juice, bile. The vomiting which arose in later terms of a disease, as a rule, happens to impurity of congestive contents, and in late stages of a disease accepts fecal character. At gastric bleeding emetic masses usually has an appearance of a coffee thick or contains scarlet blood.

The persistent painful hiccups is sometimes observed that it is usually connected with irritation of a phrenic nerve. So-called. frenikus-symptom (see) usually arises owing to irritation inflammatory exudate, to the streamed contents went. - kish. a path or blood of nerve terminations on the peritoneum covering a diaphragm. The same origin, obviously, has also a so-called symptom of a vanki-vstanka, at Krom of an abdominal pain sharply amplify in attempt of the patient to accept horizontal position in this connection he aims to sit down. As a rule, at the Lake. disturbances of a passage of contents of intestines develop.

The delay of a chair and gases is usually connected with existence of mechanical or dynamic impassability of intestines. More rare there is a liquid chair (e.g., at invagination of a gut). Important symptom of the Lake. change of character a calla is. So, melena (see) it is characteristic for went. - kish. bleedings, and impurity of scarlet blood is often observed at invagination of a gut and acute disorders of mezenterialny blood circulation.

From diagnostic actions an essential role is played by studying of the anamnesis of a disease and its complications, to-rye can lead to emergence of symptoms of the Lake., and also data on existence in the past of attacks of abdominal pains, on character and results of the diagnostic and medical events held in the past. Important data can be obtained at survey of the patient and overseeing with his behavior. So, at injury of abdominal organs, peritonitis, internal bleeding motionless situation in a certain pose (often on one side with the legs given to a stomach) is characteristic as the slightest movement causes sharp strengthening of pains. At a row patol, the processes which are followed by periodic colicy pains in a stomach (e.g., at hepatic or renal colic, nek-ry forms of impassability of intestines), the patient can be excited, groans, shouts, rushes about. The suffering look is often characteristic, and at diffuse peritonitis, strangulyatsionny impassability of intestines — a so-called Hippocratic face (see. Hippocrates person ). At survey of the patient pay attention to a shape of a stomach and a type of a front abdominal wall: the pulled-in stomach of a carinate form is most characteristic of perforation of hollow body, blown up and asymmetric — of impassability of intestines, sharp inflation of an upper half of a stomach — of an acute gastrectasia. Changes of language usually happen at severe forms of the Lake., especially at the phenomena of intoxication and dehydration. It becomes dry, on its surface the white, yellow or brown plaque is formed, color to-rogo is not specific to any form of the Lake.

Assessment of weight of a condition of the patient requires a research of pulse and the ABP. During the first hours after hit went to an abdominal cavity of contents. - kish. a path reflex bradycardia is usually observed. In process of development of peritonitis pulse rate increases, its filling decreases. The expressed tachycardia is characteristic of intra belly bleeding; it, as a rule, is followed by decrease in the ABP that can bring to to a collapse (see).

A palpation of an abdominal wall at the Lake. begins with poverkhnostnooriyentirovochny. The deep palpation should be applied very carefully since it can cause sharp pain reaction and protective tension of an abdominal wall that will not allow to gain clear idea of a condition of abdominal organs. The frequent symptom revealed at a palpation is morbidity of all front abdominal wall or its various areas.

At bleeding in an abdominal cavity Kulenkampff's symptom — a soft, but sharply painful stomach in all departments is characteristic. The palpation of a stomach helps to reveal a muscle tension of a front abdominal wall (see. Muscular protection symptom ) and Shchetkin's symptom — Blyumberg (see. Shchyotkina — Blyumberg a symptom ).

At children for identification of a muscle tension of a front abdominal wall resort to a research of a stomach during natural or medication sleep. These symptoms are considered to be signs of irritation of a peritoneum, i.e. peritonitis; identification has them major importance in the solution of a question of need of the emergency operative measure.

Percussion of an abdominal wall allows to find reduction of borders or disappearance of hepatic dullness that is characteristic of perforation of hollow body, and also the availability of free liquid in an abdominal cavity observed usually at bleeding, tumors of abdominal organs (a carcinomatosis of a peritoneum), cirrhosis (ascites); the expressed tympanites caused by accumulation of gases in intestines.

Auscultation of an abdominal cavity gives the chance to estimate character of a shfistaltika of intestines (on lack of intestinal noise or their strengthening) that allows to suspect impassability of intestines.

The rectal research helps to find a number of diseases of distal department of a rectum, patol, processes in a pararectal fat, to reveal Promp-tov's symptom — sharp morbidity at a palpation of a neck of uterus through a rectum (at acute inflammatory diseases of internal generative organs). Sharp morbidity of a front wall of a rectum at a rectal research demonstrates accumulation of an inflammatory exudate in a cavity of a small pelvis. Decrease in a tone of a sphincter of an anus and expansion of an ampoule of a rectum (a symptom of the Obukhovsk hospital) — a characteristic sign of impassability of intestines.

Vaginal examonation, including and tool, allows to estimate a condition of internal generative organs and to carry out the differential diagnosis with acute diseases of other abdominal organs.

Laboratory researches help to specify the nature of the changes happening in an organism and to estimate weight of a condition of the patient. So, at blood test it is possible to find a high leukocytosis with shift of a formula to the left (at inflammatory diseases), decrease in hemoglobin, quantity of erythrocytes, a hematocrit (at internal bleedings) etc. At the serious condition of the patient caused went. - kish. bleeding or inflammatory process, apply additional methods of a research, napr, determination of the central venous pressure, volume of the circulating blood, indicators of acid-base equilibrium, water and electrolytic balance etc.

Rentgenol, conduct a research by a certain technique: survey roentgenoscopy of chest and belly cavities, a X-ray analysis of an abdominal cavity in vertical, horizontal position of the patient and lateroposition (see. Polyposition research) . At serious condition of the patient the research is begun with survey roentgenograms of chest and belly cavities in horizontal position of the patient on a trokhoskopa and in lateroposition, and it is necessary to reach the image of both half of a diaphragm, side channels of an abdominal cavity and area of a small pelvis.

At rentgenol, a research of a chest cavity study a condition of lungs, the provision of a diaphragm and degree of its mobility at breath. At a number of acute diseases of abdominal organs (acute cholecystitis, acute pancreatitis, peritonitis) quite often there are discal atelectases in basal departments of lungs and reactive pleurisy, usually on the party, the corresponding localization of the struck body.

Only at diffuse peritonitis, late stages of mechanical impassability of intestines bilateral changes prevail. On the survey roentgenograms of an abdominal cavity made in vertical position of the patient and on lat-rogrammakh it is possible to define free gas in an abdominal cavity, Kloyber's bowls, intestinal arcades and other changes. In the pictures made in horizontal position of the patient on a trokhoskopa it is possible to reveal sometimes signs of free liquid in an abdominal cavity, concrements in a projection of kidneys, a gall bladder, etc.

Radiodiagnosis of an acute disease of an abdominal organ is based on identification of a complex rentgenol, the symptoms directly or indirectly indicating to localization and the nature of pathology.

According to survey roentgenograms, the symptoms which are directly indicating the acute disease of abdominal organs which is followed by perforation or impassability and also damage of hollow bodies are: gas out of a gleam went. - kish. a path (free gas in an abdominal cavity or in retroperitoneal space); free liquid in an abdominal cavity; accumulation of gas and liquid in intestinal loops with formation of characteristic classical bowls of Kloyber.

Gas in retroperitoneal space on roentgenograms comes to light at perforation of an ulcer or a rupture of a duodenum, the right half of a large intestine, and also at a pancreatonecrosis and phlegmon of retroperitoneal cellulose. In these cases gas is found in the form of accumulation of bubbles against the background of blackout of the relevant department of retroperitoneal space more often.

Reflex swelling belongs to the indirect rentgenol, symptoms indicating existence of acute inflammatory process in an abdominal cavity went. - kish. path. So, at acute pancreatitis inflation of one or several loops of a small bowel at the left, lack of gas in a poperechnoobodochny gut is observed.

At an acute appendicitis it is possible to find sometimes the isolated inflation of the loops of a small bowel which are located in the right ileal area.

At impossibility to make the diagnosis according to survey roentgenograms, and also according to special indications (e.g., at went. - kish. bleeding) use contrast methods of a research: a stomach and a duodenum by means of water-soluble contrast means or the cooled suspension of barium (at suspicion of acute pancreatitis); administration of gas via the probe in intestines (children have a hl. obr. at diagnosis of invagination of intestines, at the same time sometimes it is possible to eliminate impassability).

Main symptoms of the Lake. at contrast methods of a research are: a vykhozhdeniye of a contrast agent and gas at perforated stomach ulcers and a duodenum in an abdominal cavity; a vykhozhdeniye of the gas entered into a stomach, into an abdominal cavity; a pushing off of a stomach of a kpereda and drawing apart a duodenum (at acute pancreatitis).

According to special indications apply additional more difficult rentgenol, methods of a research — tseliakografiya (see), mezenterikografiya (see), splenoportografiya (see), etc.

Are very valuable in diagnosis of a number of the diseases which were the reason of the Lake., endoscopic methods of a research (see. Endoscopy ), to-rye allow to find an ulcer, a tumor, diverticulums of various departments went. - kish. a path to establish character of the arisen complications, and in some cases to make to lay down. manipulations, napr, a stop of bleeding by means of diathermocoagulation or the laser, a rekanalization at a tumor of the large intestine causing impassability. Finds broad application in hard diagnostic cases laparocentesis (see), to-ry allows to find blood or liquid in an abdominal cavity.

The special place in diagnosis of the Lake. belongs to a laparoscopy (see. Peritoneoskopiya ), indications to a cut, as a rule, arise also only at not clear a wedge, a picture. Allowing to find inflammatory exudate or blood, and also other straight lines or indirect symptoms of an acute disease of abdominal organs in an abdominal cavity, the laparoscopy is especially valuable also the fact that it allows to exclude unnecessary operation.

Among other methods of objective diagnosis there is a Lake. in a wedge, the electromyography of a front abdominal wall sometimes finds for practice application, termografiya (see), thermovision, local thermometry (see), etc. However in some cases, when the listed above methods to diagnose or reject an acute disease or injury of abdominal organs do not work well, resort to a diagnostic laparotomy. The differential and diagnostic characteristic of diseases and others patol, the processes causing emergence of the Lake., are presented in the table" the Differential and diagnostic characteristic of some damages, diseases and morbid conditions causing a symptom complex «acute abdomen» ".

Medical tactics

the Patient with the diagnosis of the Lake. it has to be immediately hospitalized in profile establishment. Transportation of the patients who are in a serious condition shall be carried out carefully, taking into account a possibility of carrying out in the course of its necessary resuscitation actions. Character to lay down. actions at the Lake. depends first of all on a cause of illness. At the nek-ry inflammatory processes which are not followed by development of peritonitis carry out the complex conservative treatment including a diet, antiinflammatory, disintoxication and other actions. However in most cases Lake. (at peritonitis, perforation of hollow bodies, mechanical impassability of intestines, internal bleedings, etc.) operational treatment is necessary. At serious condition of the patient with the expressed intoxication, dehydration carrying out intense preoperative training during 2 — 3 hours for the purpose of correction of the arisen disturbances is necessary. In difficult cases character and volume to lay down. actions shall be defined by a consultation of specialists (the surgeon, the resuscitator, the therapist, etc.). In nek-ry cases of critical condition of the patient (e.g., at massive went. - kish. bleeding) an operative measure is made at once after arrival of the patient in a hospital, in parallel carrying out resuscitation actions.

The issue of need of an immediate surgery is not resolved yet, it is necessary to refrain from use of analgetics, drugs, hypnotic drugs, neuroleptics, tranquilizers, purgatives, enemas since they can distort considerably symptomatology of a disease that can serve as the reason of a diagnostic mistake. To some extent it belongs to antibiotics, use to-rykh can temporarily create a deceptive picture of relative improvement and cause an unreasonable delay of an operative measure.

The forecast

the Forecast depends on character and weight patol, the process which was the reason of the Lake., and also from the term which passed from the beginning of a disease before arrival of the patient in a hospital, its age and existence of associated diseases. The forecast is adverse at common forms of peritonitis, impassability of intestines with its extensive necrosis, fibrinferment of mezenterialny vessels, especially at advanced and senile age. Than quicker at the Lake. the patient is hospitalized, the exact diagnosis is made earlier and treatment is carried out adequate (including and operational), the lethality and higher than a percent of patients are lower, at to-rykh working capacity is completely recovered.



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A. V. Gulyaev, M. I. Kuzin; S. M. Krivo-rak (it is put. hir.), V. P. Smetnik (gin.), M. K. Shcherbatenko (rents.), author of the tab. V. M. Buyanov.

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