Chapter 5: Abdomen

Overview

The abdomen is a module made up of four regions:

• i) Anterior abdominal wall

  

• ii) Inguinal region

  

• iii) Posterior abdominal wall

  

• iv) Abdominal cavity

  

The multiplicity of systems represented here make for a potentially wide and frustrating differential diagnostic analysis of symptoms and signs. Accurate diagnosis of common abdominal surgical conditions requires detailed knowledge of anatomical layers, good clinical skills and a weighted analysis of the likely pathological processes involved. This will enable the correct choice of ordered investigations (if any), reducing the differential diagnosis to a manageable number that may be able to be narrowed to just one.

Treatment may begin broadly but becomes focused as the diagnosis does.

The most common (and confusing) presenting complaint is pain (often associated with referral). It is important to be aware that the presentation may be atypical.

When assessing pain, the clinician must begin with an open mind and a good technique.

Acute Cholecystitis

Acute cholecystitis involves obstruction of the cystic duct plus sepsis. It is the most common consequence of cholelithiasis. There is often a history of similar episodes.

The symptoms are pain, nausea and vomiting. The signs are general and local.

The differential diagnosis is extra-abdominal and abdominal diseases.

Investigations include blood tests, urine tests and imaging.

The treatment is conservative or operative.

Surgery requires good knowledge of variations in biliary anatomy.

Cholelithiasis with obstruction of the bile duct plus sepsis may lead to ascending cholangitis.

Acute Appendicitis

Acute appendicitis occurs due to the particular appendiceal anatomy, (a narrow lumen with submucosal lymphoid follicles) in conjunction with two other (predisposing) factors - infection alone or with obstruction.

The clinical presentation is usually that of acute appendicitis but the condition may be ...