The concept of acute abdomen in surgery. a history of chronic diseases. Palpation in the diagnosis of the disease

Acute abdomen is a syndrome that occurs when organs are damaged abdominal cavity. Accompanied by intense abdominal pain.

Pain occurs as a result of irritation of the peritoneum - thin shell covering the digestive organs and the walls of the abdomen from the inside, forming a closed cavity. The peritoneum is rich in nerve endings, therefore it sensitively reacts to any disorder in the abdominal cavity, signaling danger. Symptoms of an acute abdomen indicate a catastrophe in the abdominal cavity and require urgent surgical care.

The most common causes of an acute abdomen are: appendicitis, pancreatitis, strangulated hernia, intestinal obstruction, perforation of a stomach or intestinal ulcer, abdominal trauma.

Symptoms of an acute abdomen

• Sharp pain in the abdomen of high intensity. To reduce it, a person takes forced position: Lies on your side or sits with your knees drawn up to your chest. Any movement deep breathing, cough increase suffering.
• The localization of pain and its prevalence depend on the cause of the acute abdomen. In the first minutes, the pain is concentrated in the epicenter, which is easy to feel with your hand. However, the condition quickly worsens, and the pain covers the entire abdomen. Then the point of greatest pain is difficult to detect. The source of inflammation can be established by lightly tapping the anterior abdominal wall with the phalanges of the fingers: the point of the highest pain corresponds to the affected organ (Mendel's symptom).
• Most characteristic of an acute abdomen diagnostic sign- Shchetkin-Blumberg symptom. Pain occurs with gentle pressure on the abdominal wall and intensifies with a sharp withdrawal of the hand.
• Muscle tension in the anterior abdominal wall. This symptom cannot always be identified. Its expression depends on individual features person - weight, age, muscle mass. The extreme degree of the symptom is a plank-shaped abdomen: the muscles are tense to the limit, the abdomen looks flat, it is not possible to probe the internal organs. Most often, this indicates a rupture of a hollow organ - perforation of an ulcer of the stomach, intestines.
• Dry mouth, nausea, vomiting, lack of stool. May accompany an acute abdomen, but are not specific features. In addition, manifestations of the underlying disease are usually superimposed on the clinic of an acute abdomen.

What is the danger

Life-threatening diseases lead to an acute abdomen. In the absence of timely qualified assistance severe intoxication develops, join infectious complications, dehydration, shock . Possible death.

Diseases that do not require emergency can mimic the picture of an acute abdomen. surgical intervention: exacerbation of gastritis, peptic ulcer, intestinal colic, acute intestinal infection, food poisoning . However, if there is doubt about the diagnosis, the condition should still be regarded in favor of an acute abdomen.

What do we have to do…

Call an ambulance. If qualified health care unavailable, evacuate the person to the nearest settlement as soon as possible.

First aid for acute abdomen:

1. Provide the patient with peace - in a prone or half-sitting position, depending on the condition.
2. Put cold on the stomach. This will slow down the processes of inflammation and destruction, will help stop internal bleeding. This will save you time.
3. At intense thirst wet lips, rinse mouth.

What Not to Do

• eat and drink;
• warm the stomach
• take antibiotics and painkillers;
• do an enema or gastric lavage.

Nota Bene!

An exception to the rule is the situation when medical care is far away and a long evacuation is ahead. Such circumstances may arise during research expeditions, during field and sports camps, hikes, and in other cases of separation from civilization. AT similar situations allowed to use antibiotics a wide range action, painkillers. If there is confidence in the absence of internal bleeding, it is allowed to give a drink. Similar actions prolong the life of the patient at the stage of transportation.

Created from:

1. Komarov F. I., Lisovsky V. A., Borisov V. G. Acute abdomen and gastrointestinal bleeding in the practice of a therapist and surgeon. - L .: Medicine, 1971.
2. Nyhus L. M., Vitello D. M., Conden R. E. Abdominal pain. - M.: Binom, 2000.
3. Sinenchenko G. I., Kurygina A. A., Bagnenko S. F. Surgery of the acute abdomen: a guide. - St. Petersburg: ELBI, 2007.

The term " acute abdomen» combines a number of surgical diseases of the abdomen that have common clinical signs that indicate inflammation of the peritoneum: acute onset of the disease, abdominal pain, tension of the anterior abdominal wall up to a board-like state, symptoms of peritoneal irritation. "Acute abdomen" leads to the development of peritonitis with all its consequences. This term indicates the need for urgent measures to provide emergency care to the patient.

The cause of an "acute abdomen" may be an injury to the abdomen, acute appendicitis, acute cholecystitis, strangulated hernia, acute intestinal obstruction and all surgical diseases of the abdomen with perforation internal organs.

Symptoms. The clinical symptoms of an "acute abdomen" are: sudden severe abdominal pain, symptoms of peritoneal irritation (be sure to check the Shchetkin-Blumberg symptom!), symptoms of intoxication and muscle defense (tension of the muscles of the anterior abdominal wall).

Palpation examination of the abdomen

The outcome of the disease depends on the correct diagnosis, correct first aid, the time before the start of the operation.

When providing first aid, it must be remembered that the cause of the "acute abdomen" could be perforation of the wall of the stomach or intestines, so the patient it is forbidden:

ü give food and drink;

ü wash the stomach;

ü to put enemas;

ü use heating pads;

o give painkillers.

Only needed urgent hospitalization on stretchers.

Treatment of "acute abdomen" - only surgical!

1. Listen to the patient's complaints (pain, stool, vomiting, etc.).

2. Collect anamnesis of the disease: the onset of the disease (acute or gradual); how much time has passed since the disease; whether the symptoms have changed over this period.

3. Find out the circumstances preceding the disease: trauma, diet violations, fainting, etc.

4. Find out if the patient has surgical diseases of the abdomen: stomach ulcer, cholecystitis, hernia, etc.

5. Find out if there have been similar attacks before.

6. Assess the pain: their presence, localization, nature, intensity, irradiation.

7. Evaluate vomiting: its presence, frequency, presence of impurities (blood, etc.), whether it brings relief.

1. Rate general state patient (consciousness, pulse, temperature): satisfactory, moderate, severe.

2. Conduct an external examination: position (forced or not), color and condition of the skin and mucous membranes (pale, yellow; dryness).

3. Assess the condition of the tongue: wet or dry, clean or coated (color of plaque), cracks.

4. Conduct an external examination of the abdomen: assess its shape (whether there is swelling, asymmetry), the presence of protrusion, participation in breathing.

5. Palpate the abdomen: determine pain (what is its localization, strength), tension of the anterior abdominal wall (localization, strength), check the Shchetkin-Blumberg symptom and other symptoms of peritoneal irritation, evaluate peristalsis (absent or increased).

In surgical clinics for fast and accurate diagnosis acute diseases of the abdominal organs, formalized case histories are used, the data are entered into them by the doctor, examining the patient, and nurse enters this data into a computer for processing. In addition to the sheets for diagnosing diseases of the gastrointestinal tract, sheets for diagnosing the causes of bleeding from upper divisions Gastrointestinal tract with determination of the severity of blood loss and choice best method treatment, diagnostic list of complications after abdominal surgery.

Surgical diseases of the abdominal wall are associated with inflammation of the peritoneum (peritonitis) or with the presence of a hernia orifice (hernia)

Acute peritonitis is an inflammation of the peritoneum, and a serious surgical disease of the abdomen. The cause of peritonitis is often surgical diseases of the abdomen, especially in perforated processes. Diffuse purulent peritonitis gives a lethality of 20 to 70%.

Peritonitis is distinguished:

ü by etiology- aseptic and infectious;

ü by pathogen- staphylococcal, streptococcal, etc.;

ü because of– traumatic, postoperative, etc.;

ü by area- local and spilled.

Symptoms. Clinical picture consists of common and local symptoms. The general ones include: the type of the patient, his behavior, body temperature indicators, pain and its nature, pulse characteristics, blood pressure indicators, blood test data, etc. The local ones include the condition of the abdominal wall, the result of its palpation, pain points, data on flatulence and peristalsis .

By clinical symptoms There are 3 stages of development of peritonitis: reactive, toxic and terminal.

Stages of development of peritonitis

The outcome of the disease depends.

The term " acute abdomen" is a collective term. It is one of the most generalized syndromes, widespread in medical practice. This term denotes a clinical symptom complex that develops with injuries and acute diseases of the abdominal organs. AT in general terms it reflects the clinical situation associated with an acute, sudden onset intra-abdominal catastrophe, which usually requires urgent surgical care.

The term " acute abdomen" should not be considered as medical jargon (A.A. Grinberg, 1988). It is considered quite acceptable as preliminary diagnosis, working hypothesis especially on prehospital stage always requiring decisive action from the doctor, immediate hospitalization of the patient in a surgical hospital, quick diagnosis clarification, urgent resolution of the issue of surgical intervention, the timing of its implementation, etc. Although it is required, or rather, it is customary to strive to clarify the diagnosis before surgical intervention, however, in diagnostically difficult cases, it is not permissible to waste precious time.

The time spent by the patient in the hospital should not exceed the time required for his preoperative preparation. In some cases, to clarify the diagnosis, you have to resort to ultrasound(ultrasound), computed tomography(CT), laparocentesis, laparoscopy. Sometimes the diagnosis can be established only in the process of diagnostic abdominal surgery. In such cases, urgent surgical intervention has to be performed not according to the diagnosis, but according to urgent, vital indications, tactically.

The basis of the symptom complex of an acute abdomen in all cases, as a rule, is pathological process in the abdominal cavity, requiring surgical treatment. The most common cause of an acute abdomen is damage to the abdominal organs, acute inflammatory diseases, including peritonitis; mechanical NK; bleeding into the abdominal cavity; violation of the blood supply to the abdominal organs as a result of compression or torsion of the mesentery, embolism or thrombosis of the mesenteric vessels; acute inflammatory processes in the uterine appendages; interrupted ectopic pregnancy; ovarian apoplexy; torsion of the leg of a cyst or tumor of the ovary; necrosis of the myomatous node of the uterus, etc.

The clinical picture of an acute abdomen can often be observed in diseases of the abdominal organs that do not require surgical intervention. The symptom complex of an acute abdomen can simulate injuries and diseases of extraperitoneal organs: fractures of the spine, ribs, pelvic bones, retroperitoneal hematoma, myocardial infarction, pleuropneumonia, etc. All these injuries and diseases can create a clinical picture resembling an acute abdomen, the so-called pseudo-abdominal syndrome.

Diagnosis of an acute abdomen based on anamnesis data, objective and additional methods research, laparocentesis, laparoscopy, etc.

The task of the first medical examination of the patient, which takes place outside the hospital, is to recognize dangerous situation and understanding the need for emergency hospitalization and surgical treatment. The prognosis of an acute abdomen depends on the time elapsed from the moment of its development to the undertaken surgical intervention. The more time passes since the acute abdomen, the worse its prognosis.

Taking into account this circumstance, the doctor is obliged, if possible, to quickly hospitalize the patient in a surgical hospital, where as much as possible a short time necessary diagnostic and medical measures. One suspicion of an acute abdomen is the basis for urgent hospitalization of the patient.

In the diagnosis of an acute abdomen, anamnesis plays an important role. When taking anamnesis, attention should be paid to past illnesses and operations on the abdominal organs, chronic diseases complicated by an acute abdomen, predisposing to the occurrence of acute surgical diseases of the abdominal organs, etc.

In women, when collecting a gynecological history, attention should be paid to past gynecological diseases, the menstrual cycle, time last menstrual period. Cause of abdominal pain in the middle menstrual cycle may be ovarian apoplexy. With a delay in menstruation, there is reason to suspect an ectopic pregnancy.

With a closed abdominal injury great importance has a clarification of the mechanism of injury, the state of the organ at the time of injury. In case of injury, a violation of the integrity of the filled hollow organ is more likely.

Acute surgical diseases of the abdominal organs usually begin unexpectedly, against the background of apparent complete well-being.

Clinical picture very diverse flowing acute abdomen depends on the nature of the disease or injury, the initial state and age of the patient, the reactivity of the organism, concomitant diseases and other factors.

The main clinical symptoms of an acute abdomen are: abdominal pain, nausea, vomiting, anemia, shock, etc.

Pain — persistent symptom observed in all acute surgical diseases and injuries of the abdominal organs. In all cases, it is necessary to find out the beginning, nature, localization, irradiation and change in its nature in dynamics. Perforation of a hollow organ is characterized by the appearance of sudden, very severe pain, which then becomes permanent, aggravated by movement of the patient, physical exertion, etc.

Inflammation of one or another organ of the abdominal cavity is accompanied by severe constant, often localized pain. intensive cramping pain occurs with a sharp muscle contraction of the wall of hollow organs in the presence of an obstacle in the way of their emptying. In this case, attacks of pain may alternate with periods of subsidence of varying duration.

Of great importance in the clinical picture of an acute abdomen is irradiating pain (irradiation of pain). It is quite typical for various clinical forms acute surgical diseases of the abdominal organs. Due to the peculiarities of innervation, abdominal pain, other symptoms of an acute abdomen can also be observed in patients with injuries and diseases of extraperitoneal organs - pseudo-abdominal syndrome.

The next most common symptom of an acute abdomen is vomit which always follows pain. The presence and nature of vomiting do not always have an independent diagnostic value, except in cases of high NC, when intestinal contents appear very quickly in the vomit.

An important symptom of an acute abdomen is no stool and flatulence that are indicative of mechanical or functional NK. It should be remembered that with small bowel obstruction, especially at the beginning of the disease, the stool may be normal, and with peritonitis, diarrhea (septic diarrhea) is often noted. Black or crimson coloring of feces, an admixture of fresh blood are of some importance in the diagnosis of gastrointestinal bleeding (GIB).

Objective research. It begins with an external examination of the patient. At the same time, attention is paid to the general condition of the patient, forced position, anxiety, change in posture, adynamia, lethargy; signs of dehydration (dry mucous membranes (SO), pointed facial features); pallor, jaundice, discharge (vomiting, stool, blood). With perforation of hollow organs, embolism mesenteric arteries and strangulation NK, OP patients at the very beginning of the disease are often in a state of pain shock.

With peritonitis, they lie on their back or on their side, often with their legs pulled up to their stomachs, avoiding movements that lead to increased pain. On the contrary, with intense pain of another etiology (OP, NK), patients are restless, often change position. Most important symptoms observed on abdominal examination. With rigidity of the muscles of the anterior abdominal wall, bloating, there may be no abdominal breathing.

For peritonitis, intestinal paresis is characterized by uniform bloating. At certain types NK belly is asymmetrical. In the presence of a large number fluid in the abdominal cavity, the stomach seems to be spreading to the sides (“frog belly”). For perforation of a hollow organ, the disappearance of hepatic dullness is characteristic, with NK - high tympanitis of percussion sound, in the presence of fluid in the abdominal cavity in sloping areas of the abdomen, dullness of percussion sound is detected. With thrombosis or embolism of the mesenteric vessels, the absence of peristaltic noises is noted already in the early stage of the disease, with peritonitis - intestinal paresis, and with NK, on ​​the contrary, increased peristaltic noises, splashing noise.

One of the main symptoms of peritonitis is limited or diffuse stiffness of the muscles of the anterior abdominal wall. Localized muscle tension often corresponds to the position of the affected organ. The tension of the entire abdominal wall is noted with diffuse peritonitis. It is especially pronounced with perforation of a hollow organ. The degree of tension in the abdominal muscles largely depends on the nature of the contents that have entered the abdominal cavity.

The most dramatic tension of the abdominal wall is observed during perforation of a gastroduodenal ulcer, when acidic gastric contents enter the abdominal cavity; significantly less muscle tension is noted in the presence of blood in the abdominal cavity, perforation of the stomach tumor, even when the contents of the TC or OK enter the abdominal cavity.

An important symptom is also limited or diffuse pain on palpation of the abdomen. Localization of maximum pain big share probability indicates damage to the organ located in this area.

Blumberg-Shchetkin's symptom is characteristic of peritonitis, which can be local or diffuse (in all parts of the abdomen).

The presence of blood in the abdominal cavity is characterized by the Kulenkampff symptom (sharp abdominal pain and the presence of symptoms of peritoneal irritation with a soft abdominal wall).

One of the most valuable results objective research in patients with acute abdomen syndrome, palpation reveals any formation in the abdominal cavity (inflammatory infiltrate). A mandatory component of the examination of patients with acute abdominal syndrome should be considered a digital examination of the PC and vaginal examination. It is necessary for the diagnosis gynecological diseases, which are the cause of an acute abdomen, as well as to detect the spread of the inflammatory process to the pelvic peritoneum.

At digital examination PC should pay attention to the tone of the sphincter, the presence or absence of dark feces or blood in it, soreness and overhanging of its anterior wall. Through the PC you can feel inflammatory infiltrates or tumors in lower section abdominal cavity, intussusceptions.

During a vaginal examination, the size of the uterus and appendages is determined, the presence of blood or fluid in the pelvic cavity is detected, which is manifested by a shortening of the vaginal arches; soreness of the vaginal vaults, Douglas space with peritonitis, soreness and enlargement of the uterine appendages and painful formation in fallopian tube at tubal pregnancy. The overhang of the vaults of the vagina occurs when blood or exudate accumulates in the cavity of the small pelvis. In many cases, vaginal examination makes it possible to differentiate acute surgical diseases of the abdominal organs from gynecological ones.

To determine the indications for urgent hospitalization, it is enough to establish whether there is peritonitis, inflammation or blockage of the organ, or bleeding. In the diagnosis of an acute abdomen, do not administer narcotic analgesics, antibiotics.

In the study of the SS system, along with percussion and auscultation of the heart, determining the pulse rate, blood pressure, if myocardial infarction is suspected, an electrocardiogram (ECG) is done. With bleeding, dehydration, to determine the deficit in the volume of fluid circulating in the vascular bed, you can focus on the shock index - the ratio of pulse rate and systolic blood pressure. Normally, this indicator is 0.5.

The loss of circulating fluid volume up to 30% increases the shock index to 1, while the pulse rate and systolic blood pressure are about 100. With a pronounced picture of shock, the pulse is 120 bpm and systolic blood pressure is about 80 mm Hg. Art., the shock index rises to 1.5 and indicates a danger to the life of the patient. A shock index of 2 (pulse 140 bpm, systolic blood pressure 70 mm Hg) corresponds to a 70% decrease in circulating fluid volume.

Additional research methods. The need for clinical analyzes blood and urine, KOS, liver and pancreas enzymes, etc. is beyond doubt. However, on the other hand, it should be noted that the diagnostic value of laboratory research methods in acute abdomen, with the exception of acute pancreatitis (AP), is rather relative.

One of important components examination of patients with acute abdomen is x-ray examination . Plain fluoroscopy of the abdomen (diaphragm to pubic symphysis) or on plain radiographs of the abdominal cavity, the mobility of the diaphragm is determined, free gas is detected under the diaphragm during perforation of a hollow organ, fluid in the abdominal cavity with peritonitis or bleeding, fluid levels in the intestine (Kloiber's bowl) with NK, darkening (exudate); if perforation of the stomach and duodenum is suspected, an X-ray contrast study with water-soluble contrast is performed; if colonic obstruction is suspected, irrigoscopy is performed. Ultrasound of the gallbladder, pancreas, liver, spleen is performed to detect inflammation or damage to the organ.

One of the simplest and informative methods diagnostics closed injury abdomen is laparocentee. Laparocentesis is indicated in all doubtful cases when, according to the clinical picture, damage to the abdominal organs cannot be excluded. Relative contraindication to laparocentesis are transferred earlier surgical interventions on the abdominal organs.

Preparation of the patient for the study is the same as for emergency surgery: gastric lavage, emptying Bladder, toilet anterior abdominal wall. The study is carried out in the operating room. With the patient in supine position local anesthesia 2 cm below the navel, a skin incision up to 1.5 cm long is made. In the upper corner of the wound, an aponeurosis is pierced with a single-toothed hook and the abdominal wall is pulled up in the form of a sail. By rotating the trocar at an angle of 45°, the anterior abdominal wall is pierced from front to back towards the xiphoid process.

After removing the stylet through the trocar sleeve into the abdominal cavity in different directions(small pelvis, lateral canals, subdiaphragmatic spaces) a polyethylene tube or a rubber catheter of the appropriate diameter is inserted - the so-called rummaging catheter. At the same time, the contents of the abdominal cavity are constantly aspirated with a syringe. Upon receipt of pathological fluid from the abdominal cavity, a laparotomy is performed. If the result is negative (dry puncture), 500 ml of isotonic sodium chloride solution is injected through the catheter into the abdominal cavity, which is aspirated from the abdominal cavity after a few minutes.

With questionable results of laparocentesis and the absence of contraindications, as well as to determine the nature of acute surgical disease or damage to the organs of the abdominal cavity and, therefore, resolution in most cases of diagnostic difficulties in acute abdomen produce laparoscopy. Contraindications to laparoscopy are severe cardiac and pulmonary insufficiency, hernia of the anterior abdominal wall and diaphragmatic hernia, suspected diaphragmatic rupture.

patient preparation and operating field to laparoscopy, sedation is the same as before surgery.

It is considered preferable general anesthesia. The latter allows for muscle relaxation, duration and completeness of the study. A purse-string or U-shaped suture is applied to the navel area, capturing the aponeurosis. Pulling up the suture threads, lift the abdominal wall and pierce it 2 cm below the umbilicus at an angle of 45° with a special needle for applying pneumoperitoneum. Oxygen, nitrous oxide or air is injected into the abdominal cavity in a volume of 3 to 5 liters. The gas is insufflated using a Janet syringe or anesthesia machine through a reducer and a special filter valve.

Before introducing the bulk of the gas, it is considered necessary to introduce a test portion and with the help of percussion (high tympanitis, disappearance of hepatic dullness) make sure that it is in the abdominal cavity. After the skin is incised 2 cm above and to the left of the navel, a laparoscope trocar is inserted into the abdominal cavity: the stylet is replaced with an optical tube with a lighting system and a sequential examination of the abdominal organs is performed.

If perforation of a hollow organ is suspected, intraperitoneal bleeding, not detected by other methods, diagnostic peritoneal lavage is performed - washing the abdominal cavity isotonic saline sodium chloride. The admixture of blood in the washing fluid indicates intraperitoneal bleeding, and the gastrointestinal contents indicate perforation of a hollow organ.

Depending on the clinical forms of the syndrome, certain general and local signs acute abdomen. In case of trauma and peritonitis, muscle tension and soreness of the anterior abdominal wall are locally noted, and from the general symptoms - the phenomena of shock, bleeding and intoxication. With bleeding, a soft but painful anterior abdominal wall is noted, dullness of percussion sound in sloping areas of the abdomen, general symptoms of bleeding; with NK, the abdomen is soft, swollen, localized pain is more often noted, among the general phenomena - symptoms of dehydration, etc.

With penetrating wounds of the abdomen, diagnosis, as a rule, is not difficult. The solution of diagnostic problems is facilitated by the type of wounding weapon, the localization and nature of the wound and its edges, the type of wound discharge, the assumption of a possible projection of the wound channel, presentation to the wound or prolapse of any organ. With penetrating wounds of the abdomen, manipulations in the wound itself (probing) performed for the purpose of diagnosis should be completely excluded. The diagnosis is finally specified during the revision of the abdominal organs.

The most common causes of bleeding into the abdominal cavity are disturbed ectopic pregnancy and ovarian cyst rupture. Spontaneous bleeding is relatively rare (spontaneous rupture of the spleen, mesenteric arteries, aneurysm rupture, splenic artery).

differential diagnosis. When conducting differential diagnosis, first of all, diseases that mimic the clinical picture of an acute abdomen should be excluded: myocardial infarction, basal pleuropneumonia, spontaneous pneumothorax, renal colic, Shenlein-Genoch capillary toxicosis, as well as pseudo-abdominal syndromes.

Acute surgical diseases of the abdominal organs should be differentiated from non-surgical diseases, often accompanied by a clinical picture of an acute abdomen. Non-surgical diseases include: hepatitis, splenic infarction, nonspecific or tuberculous mesadenitis, intestinal and biliary colic, infectious diseases(dysentery, food poisoning, acute enterocolitis).

The clinic of an acute abdomen can be simulated and create certain difficulties in diagnosing a number of diseases and injuries of extra-abdominal organs, as well as systemic diseases.

Depending on the cause that caused abdominal pain, two groups of diseases are conventionally distinguished. The first includes diseases and injuries of the anterior and rear walls abdomen, when pseudo-abdominal syndrome is a consequence of local factors. These are hernias, abscesses, hematomas of the anterior abdominal wall, abdominal muscle ruptures, retroperitoneal hematomas and tumors, abdominal aortic aneurysm.

It should be noted that intra-abdominal formations under tension abdominals the patient ceases to be determined, and the formation of the abdominal wall continues to be palpated. It is possible to exclude intraperitoneal bleeding with the help of laparocentesis.

The second group includes numerous diseases, in which reflex pain or pain radiating to the abdomen, other symptoms of acute diseases of the abdominal organs are often observed.

Shingles (Herpes zoster) is recognized by the area of ​​skin hyperesthesia, tingling, burning, itching, and then rashes in the area of ​​distribution of the affected nerve. When conducting differential diagnosis, it must be borne in mind that an acute abdomen is characterized by the presence of abdominal symptoms- indigestion, abdominal pain, constipation or diarrhea, acute onset, often without fever; the face of Hippocrates (with peritonitis), a sharp tension in the muscles of the anterior abdominal wall, which does not disappear on palpation (unlike pleuropulmonary and cardiac syndrome), increased pain on palpation and pressure on the site primary focus etc.

In the differential diagnosis of injuries and diseases of the abdominal cavity and chest along with a clinical study, X-ray plays a leading role, and in heart diseases (myocardial infarction) - ECG.

In the diagnosis of kidney diseases, which are common cause pseudo-abdominal syndrome, urinalysis and radiological data are of great importance.

List of main systemic diseases, often accompanied by the development of pseudo-abdominal syndrome, are:

1) acute infections- influenza, tonsillitis, scarlet fever, Infectious mononucleosis, brucellosis;
2) neurological diseases- dorsal tassel, tetanus;
3) metabolic disorders - diabetes, uremia, hypercalcemia, hypokalemia;
4) blood diseases - hemolytic anemia, leukemia, Werlhof's disease, Schonlein-Genoch's disease, hemophilia;
5) medicinal disease- anticoagulants (bleeding); corticosteroids (perforations, bleeding); diuretics (hypocholesterolemia), barbiturates - porphyrias (A.A. Grinberg, 1988).

Treatment. If an acute abdomen is suspected, immediate hospitalization of the patient in a surgical hospital is necessary. It is prohibited to administer drugs and analgesics, which can contribute to an imaginary improvement in the patient's well-being and thereby complicate diagnosis. The introduction of these drugs is permissible only in those extremely rare cases when it is necessary to reduce or prevent shock phenomena before transporting the patient to a surgical hospital.

In the hospital, the diagnosis is based on clinical trial and application of additional research methods. The prognosis of an acute abdomen largely depends on the time elapsed from the moment of its development to the surgical intervention. If it is impossible to establish a diagnosis and after applying all diagnostic tools within 6 hours, the issue is resolved in favor of diagnostic laparotomy, because further waiting, dynamic monitoring of the patient is much more dangerous than abdominal surgery. It is performed after appropriate preoperative preparation.

For this purpose, anti-shock measures are carried out (correction of violations of EBV and CBS, replenishment of blood loss during bleeding, the introduction of antibiotics and antibacterial agents with a refined diagnosis of the inflammatory process, organ perforation, NK, etc.). In unclear cases, the median laparotomy is the optimal approach for surgical intervention.

Lecture No. 22. Acute abdomen syndrome

Acute abdomen syndrome

The term "acute abdomen" combines a number of surgical diseases of the abdomen that have common clinical signs that indicate inflammation of the peritoneum: acute onset of the disease, abdominal pain, tension of the anterior abdominal wall up to a board-like state, symptoms of peritoneal irritation. "Acute abdomen" leads to the development of peritonitis with all its consequences. This term indicates the need for urgent measures to provide emergency care to the patient.

The cause of "acute abdomen" may be abdominal trauma, acute appendicitis, acute cholecystitis, strangulated hernia, acute intestinal obstruction and all surgical diseases of the abdomen with perforation of the internal organs.

Symptoms. The clinical symptoms of an "acute abdomen" are: sudden severe abdominal pain, symptoms of peritoneal irritation (be sure to check the Shchetkin-Blumberg symptom!), symptoms of intoxication and muscle defense (tension of the muscles of the anterior abdominal wall).

Palpation examination of the abdomen

The outcome of the disease depends on the correct diagnosis, the correct first aid, the time before the start of the operation.

When providing first aid, it must be remembered that the cause of the "acute abdomen" could be perforation of the wall of the stomach or intestines, so the patient it is forbidden:

ü give food and drink;

ü wash the stomach;

ü to put enemas;

ü use heating pads;

o give painkillers.

Only urgent hospitalization on a stretcher is necessary.

Treatment of "acute abdomen" - only surgical!

1. Listen to the patient's complaints (pain, stool, vomiting, etc.).

2. Collect anamnesis of the disease: the onset of the disease (acute or gradual); how much time has passed since the disease; whether the symptoms have changed over this period.

3. Find out the circumstances preceding the disease: trauma, diet violations, fainting, etc.

4. Find out if the patient has surgical diseases of the abdomen: stomach ulcer, cholecystitis, hernia, etc.

5. Find out if there have been similar attacks before.

6. Assess the pain: their presence, localization, nature, intensity, irradiation.

7. Evaluate vomiting: its presence, frequency, presence of impurities (blood, etc.), whether it brings relief.

1. Assess the general condition of the patient (consciousness, pulse, temperature): satisfactory, moderate, severe.

2. Conduct an external examination: position (forced or not), color and condition of the skin and mucous membranes (pale, yellow; dryness).

3. Assess the condition of the tongue: wet or dry, clean or coated (color of plaque), cracks.

4. Conduct an external examination of the abdomen: assess its shape (whether there is swelling, asymmetry), the presence of protrusion, participation in breathing.

5. Palpate the abdomen: determine pain (what is its localization, strength), tension of the anterior abdominal wall (localization, strength), check the Shchetkin-Blumberg symptom and other symptoms of peritoneal irritation, evaluate peristalsis (absent or increased).

In surgical clinics, for quick and accurate diagnosis of acute diseases of the abdominal organs, formalized case histories are used, the data is entered into them by the doctor, examining the patient, and the nurse enters this data into a computer for processing. In addition to the sheets for diagnosing diseases of the gastrointestinal tract, sheets have been developed for diagnosing the causes of bleeding from the upper gastrointestinal tract with the determination of the severity of blood loss and the choice of the optimal method of treatment, a sheet for diagnosing complications after abdominal surgery.

Surgical diseases of the abdominal wall are associated with inflammation of the peritoneum (peritonitis) or with the presence of a hernia orifice (hernia)

Acute peritonitis is an inflammation of the peritoneum, and a serious surgical disease of the abdomen. The cause of peritonitis is often surgical diseases of the abdomen, especially in perforated processes. Diffuse purulent peritonitis gives a lethality of 20 to 70%.

Peritonitis is distinguished:

ü by etiology- aseptic and infectious;

ü by pathogen- staphylococcal, streptococcal, etc.;

ü because of– traumatic, postoperative, etc.;

ü by area- local and spilled.

Symptoms. The clinical picture consists of general and local symptoms. The general ones include: the type of the patient, his behavior, body temperature indicators, pain and its nature, pulse characteristics, blood pressure indicators, blood test data, etc. The local ones include the condition of the abdominal wall, the result of its palpation, pain points, data on flatulence and peristalsis .

According to clinical symptoms, there are 3 stages of development of peritonitis: reactive, toxic and terminal.

Stages of development of peritonitis

The outcome of the disease depends on:

ü on how timely the diagnosis of a surgical disease of the abdomen (acute appendicitis, acute cholecystitis, perforated stomach ulcer, etc.) was made, which caused peritonitis;

ü from the time between the onset of the disease and the admission of the patient to the hospital;

from possible errors when providing first aid.

Treatment. The patient must be urgently hospitalized with transportation on a stretcher. An emergency operation is performed with revision of the abdominal organs and drainage. Antibiotics are administered intramuscularly and through microdrainages. The fight against flatulence and intestinal paresis is carried out (gastric contents are removed with a thin probe, proserin is administered as prescribed by the doctor, hypertonic solution sodium chloride).

Implemented infusion therapy up to 4-5 liters of fluid per day (plasma, polyglucin, protein blood substitutes, gemodez, polydez, etc.) for several days with diuresis control. Parenteral nutrition. Hormonal and cardiovascular drugs, vitamins, oxygen are prescribed. Hemosorption is used. Prevention of bedsores and congestive pneumonia is necessary.

It's a sharp belly strong pain in the abdomen in diseases of the internal organs. Often immediately identify the source of pain and put accurate diagnosis difficult, in connection with which this collective concept is used. The place of greatest pain is not necessarily associated with the location of the diseased organ.

Pain can vary in character. Cramping pain is characteristic of spastic contractions of the muscles of the stomach or intestines. If the pain increases gradually, then you can think about inflammatory process. When the pain appeared suddenly, like a blow, this means that an intra-abdominal catastrophe has occurred. Breakthrough of a stomach or intestinal ulcer, abscess, inside abdominal bleeding, blockage of the vessels of the spleen, kidney.

Causes of an acute abdomen.

Pain in the abdomen appears when there is a violation of blood supply, spasms of the muscles of internal organs, stretching of the walls of hollow organs, and an inflammatory process in the tissues. Pain in the upper right side of the abdomen appears with damage to the liver, gallbladder and biliary tract, duodenum, right kidney. When the biliary tract is affected, pain spreads to the right shoulder.

Acute abdomen with pain in the upper left side of the abdomen occurs with diseases of the stomach, spleen, pancreas, colon, left kidney and hiatal hernia. An acute abdomen with pain in the right lower abdomen is associated with the development of appendicitis, occurs when the iliac, blind and colon, with diseases of the right kidney and genital organs. Acute abdomen with pain in the left lower abdomen is caused by diseases of the transverse colon and sigmoid colon, damage to the left kidney and diseases of the internal genital organs.

Symptoms of an acute abdomen.

Sudden constant or cramping pain in any one place or in the whole abdomen. If it is very strong, shock can develop. Quite often, vomiting also appears, sometimes already in the first minutes of the disease. There is a painful persistent hiccups.

When constipation occurs and intestinal gases stop leaving, one can think about the development of intestinal obstruction. Rarely in this case is noted liquid stool. When probing the abdomen, pain and tension of the muscles of the anterior abdominal wall are determined. When listening to the abdomen, it is possible to detect weakening of bowel movements.

First urgent care with an acute abdomen.

With symptoms of an acute abdomen, the patient should be immediately hospitalized in surgery department clinics. The patient is forbidden to eat, drink, an ice pack is placed on the stomach. Before hospitalization and clarification of the diagnosis, in no case should you use painkillers and antibacterial agents, give laxatives or do enemas. In some cases, during transportation, patients are given a gastric tube, for example, when frequent vomiting due to intestinal obstruction.

At low blood pressure as a result of bleeding, blood-substituting solutions are transfused intravenously, cardiac agents are administered (2 ml of cordiamine, 1–3 ml of 10% sulfocamphocaine). In many cases they produce emergency operation. At serious condition carry out preliminary preparation of the patient for surgery. Sometimes (when profuse bleeding) are operated immediately, simultaneously carrying out resuscitation.

According to the book " Quick Help in emergency situations."
Kashin S.P.