c l i n i c a l f o l i o s : n a r r a t i v e





A D V E R T I S E M E N T

 

The Acute Abdomen: 4

A D V E R T I S E M E N T

   
 

Pancreatitis most commonly results from biliary tract disease and alcohol abuse. Because of its retroperitoneal position, the pancreas presents with deep mid-epigastric tenderness and back pain. Patients will often sit and lean forward to ease the posterior pressure of the pancreas on the spinal column. Release of pancreatic enzymes results in necrosis of surrounding structures. Pancreatitis can be complicated by abscess formation from superinfection and pseudocyst which may bleed or rupture. Pyelonephritis can mimic an acute abdomen with localized (often flank) tenderness, fever and high white count. The colicy pain of a kidney stone can be differentiated from surgical conditions by the radiating pattern, lack of peritoneal signs and the patient writhing around rather than lying still.    

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The Acute Abdomen: 5

A D V E R T I S E M E N T

   
 

The position of the pancreas beneath posterior parietal peritoneum of the lesser sac and beneath the root of the transverse mesocolon explains the pattern of pancreatitis complications. Pseudocysts may form in the lesser sac (see endoscopic transgastric pseudocyst drainage) or dissect upward or downward in the retroperitoneum. Infiltration of pancreatic enzymes into the transverse mesocolon may reach and necrose the colon wall. The splenic artery, lying along the cephalad border of the pancreas, can be eroded and cause bleeding into an adjacent pseudocyst (see hemorrhage into a psedocyst.)    

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The Acute Abdomen: 6

A D V E R T I S E M E N T

   
 

An obstructive series includes flat and upright abdominal films. Bowel obstruction (see intestinal obstruction with bowel resectionsmall bowel obstruction, and laparoscopic lyis of adhesions (recurrent obstruction)), most commonly caused by surgical adhesions, can deteriorate into an acute abdomen. A great deal of information can be derived from an obstructive series. The presence of jejunal plicae semicircularis differentiates those loops of bowel from smooth walled ileum and tells if the obstruction is high or low. A “ground-glass” mass effect may signal the presence of tumor or a closed loop obstruction in which there is no air. Separation of loops may indicate free peritoneal fluid, and bowel wall thickness can be seen at the interface of adjacent loops. Air in the bowel wall (pneumatosis, see pneumatosis cystoides intestinalis and pneumoperitoneum) may signal necrosis.   

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This page was last modified on 4/28/2006.