“A CORRELATIVE STUDY OF CLINICAL, BIOCHEMICAL, RADIOLOGICAL, DIAGNOSIS WITH OPERATIVE DIAGNOSIS OF ACUTE ABDOMEN” A DISSERTATION SUBMITTED TO THE TAMILNADU DR MGR MEDICAL UNIVERSITY CHENNAI In partial fulfillment of the requirement for the degree of M.S. (GENERAL SURGERY) BRANCH – I Register No: 221711366 DEPARTMENT OF GENERAL SURGERY TIRUNELVELI MEDICAL COLLEGE TIRUNELVELI- 11 MAY 2020 CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A CORRELATIVE STUDY OF CLINICAL, BIOCHEMICAL, RADIOLOGICAL, DIAGNOSIS WITH OPERATIVE DIAGNOSIS OF ACUTE ABDOMEN” is a bonafide research work submitted by Dr. PREETHI KRISHNARAJ, Postgraduate student in Department of General Surgery, Tirunelveli Medical College and Hospital, Tirunelveli to the Tamilnadu Dr MGR Medical University, Chennai, in partial fulfillment of the requirement for M.S. Degree (Branch - I) in General Surgery. DR. B.M. PABITHA DEVI M.S., Associate Professor, Department of General Surgery, Tirunelveli Medical College, Tirunelveli. Date: Place: CERTIFICATE BY THE HEAD OF THE DEPARTMENT This is to certify that the dissertation entitled “A CORRELATIVE STUDY OF CLINICAL, BIOCHEMICAL, RADIOLOGICAL, DIAGNOSIS WITH OPERATIVE DIAGNOSIS OF ACUTE ABDOMEN” is a bonafide research work submitted by Dr. PREETHI KRISHNARAJ, Postgraduate student in Department of General Surgery, Tirunelveli Medical College and Hospital, Tirunelveli, under the guidance of DR. B.M. PABITHA DEVI M.S., Associate Professor, Department of General Surgery, Tirunelveli Medical College & Hospital, in partial fulfillment of the requirement for M.S. Degree (Branch - I) in General Surgery. PROF. Dr.D.ALEX ARTHUR EDWARDS, M.S., Professor and HOD of General Surgery Tirunelveli Medical College, Tirunelveli CERTIFICATE BY THE HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “A CORRELATIVE STUDY OF CLINICAL, BIOCHEMICAL, RADIOLOGICAL, DIAGNOSIS WITH OPERATIVE DIAGNOSIS OF ACUTE ABDOMEN” is a bonafide research work carried out by Dr. PREETHI KRISHNARAJ, Postgraduate student in Department of General Surgery, Tirunelveli Medical College and Hospital, Tirunelveli. DR. S.M. KANNAN M. S, M.Ch (Uro) DEAN Tirunelveli Medical College Tirunelveli DECLARATION BY THE CANDIDATE I hereby declare that the dissertation titled “A CORRELATIVE STUDY OF CLINICAL, BIOCHEMICAL, RADIOLOGICAL, DIAGNOSIS WITH OPERATIVE DIAGNOSIS OF ACUTE ABDOMEN” is a bonafide and genuine research work carried out by me at Tirunelveli Medical College hospital, Tirunelveli under the guidance of DR. B.M. PABITHA DEVI M.S., Associate Professor, Department of General Surgery, Tirunelveli Medical College, Tirunelveli. The Tamil Nadu Dr MGR Medical University, Chennai shall have the rights to preserve, use and disseminate this dissertation in print or electronic format for academic / research purpose. Date: Dr. PREETHI KRISHNARAJ Postgraduate Student, Place: Tirunelveli Register No: 221711366 M.S.General Surgery, Department of General Surgery, Tirunelveli Medical College, Tirunelveli. ACKNOWLEDGEMENT First and foremost I would like to thank almighty for blessing me throughout my work, without whose presence nothing would be possible. I am obliged to record my immense gratitude to Dr.S.M.Kannan M.Ch., (Uro) Dean, Tirunelveli Medical College, Tirunelveli for all the facilities provided for the study. I express my deep sense of gratitude and indebtedness to my respected teacher and guide Dr. B.M. Pabitha Devi M.S., Associate Professor and Prof Dr. D.Alex Arthur Edwards, M.S, HOD, Department of General Surgery whose valuable guidance and constant help have gone a long way in the preparation of this dissertation. I am also thankful to Assistant Professors Dr. Rakesh Fernando M.S., Dr. Sivanu Pandian M.S., Dr. Bethsy Priscilla M.S., for their help. I express my thanks to all Assistant Professors, Staff members of the Department of General Surgery and all my Postgraduates colleagues, C.R.R.I s and friends for their help during my study and preparation of this dissertation and also for their co-operation. I wish to acknowledge my parents and family members for their everlasting blessings and encouragement. I thank all my patients who participated in this study for their extreme patience and kind co-operation. Above all I thank the Lord Almighty for his kindness and benevolence. CERTIFICATE – II This is to certify that this dissertation work titled “A CORRELATIVE STUDY OF CLINICAL, BIOCHEMICAL, RADIOLOGICAL, DIAGNOSIS WITH OPERATIVE DIAGNOSIS OF ACUTE ABDOMEN” of the candidate Dr. PREETHI KRISHNARAJ with registration Number 22171166 for the award of M.S. Degree in the branch of GENERAL SURGERY. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 8 Percentage of plagiarism in the dissertation. Guide & Supervisor sign with Seal. CONTENTS l. N Title Page No. 1 INTRODUCTION 1 2 AIM AND OBJECTIVES 2 3 REVIEW OF LITERATURE 3 4 MATERIALS AND METHODS 66 5 RESULTS 67 6 DISCUSSION 79 7 CONCLUSION 86 8 BIBLIOGRAPHY 9 ANNEXURE i. PROFORMA ii. CONSENT FORM iii. MASTER CHART INTRODUCTION The term acute abdomen refers to signs and symptoms of abdominal pain and tenderness, a clinical presentation that often requires emergency surgical therapy. This challenging clinical scenario requires a thorough and expeditious workup to determine the need for operative intervention and to initiate appropriate therapy. The acute abdomen may be caused by an infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of abdominal pain with associated nausea or vomiting. The approach to a patient with an acute abdomen should include a thorough history and physical examination. Many diseases, some of which are not surgical or even intra-abdominal can produce acute abdominal pain and tenderness. Therefore, every attempt should be made to make a correct diagnosis so that the chosen therapy is appropriate. 1 AIM AND OBJECTIVES 1. This study is aimed to correlate the clinical examination, biochemical investigations and radiological findings with operative diagnosis of acute abdomen. 2. To estimate the sensitivity, specificity and accuracy of biochemical diagnosis in acute abdomen. 3. To estimate the sensitivity, specificity and accuracy of radiological diagnosis in acute abdomen. 4. To know the importance of clinical examination in acute abdomen. 2 REVIEW OF LITERATURE HISTORICAL ASPECTS OF ACUTE ABDOMEN : Hippocrate’s observations of manifestations of acute abdominal conditions has been a master piece about life and its meaning. Among the conditions that relate peculiarly to small intestine is intestinal obstruction recognized as early as eighth century BC. At that time sushrutha recommended that obstruction be treated by incision of intestine, replacement of organs after moistening them with honey and butter and sewing up of the intestine. Sir Zachary Cope in his book ‘The history of acute abdomen’ reports that William Ballonius in his consiliorum Medicinalium (Geneva 1934), recorded a case of gangrenous appendicitis. In 1893 Roentgen described x-rays and diagnostic significance of gas shadows by Schwartz (1911). Schwartz in Vienna was the first to give a description in 1911 of gas distended bowel loops in intestinal obstruction and also noted that fluid levels could be seen in films taken with horizontal tube. Beniwal Udai Singh et al 2003 concluded that repair of typhoid perforation is better than temporary ileostomy in enteric perforation. Ileostomy and ileotransverse bypass should be considered as the treatment option in patients with unhealthy gut. 3 SURGICAL ANATOMY : Under normal conditions, the peritoneal cavity is a potential space that has a lining consisting of mesothelial layer, the serosal surface and subserosal layer which contains blood vessels and lymphatics. There are two major divisions of peritoneal cavity, the general peritoneal cavity which contain intra-abdominal viscera and lesser peritoneal cavity or lesser omental bursa. The foramen of Winslow is the opening through which these cavities communicate. For descriptive purposes the anterior abdominal wall is divided into four quadrants, with imaginary horizontal and vertical lines crossing at umbilicus. This permits the examiner to indicate that patient complained of pain in right upper quadrant or that tenderness was felt in left lower quadrant etc. The use of quadrants of abdomen for topographic location of pain, tenderness, or masses is helpful for the clinician, but it is important to recall that this external division of abdominal wall has little anatomic basis. The anatomic relationships of abdominal viscera and visceral attachments have a significant influence upon the localization of signs and symptoms of acute abdominal diseases. The visceral attachments influence the location of spread of blood, purulent material and intra abdominal fluid within peritoneal cavity. The abdomen is divided into 9 regions by 2 horizontal and 2 vertical lines. 4 The upper horizontal line or transpyloric runs midway between xiphisternum and umbilicus. Lower horizontal or trans tubercular line lies at the level of tubercles on iliac crests about 2” behind the anterior superior iliac spines. The vertical lines are drawn on either side, through midpoint between anterior superior iliac spine and pubic symphysis. 5 The different regions are: 1. Right hypochondrium 2. Epigastric 3. Left hypochondrium 4. Right lumbar 5. Umbilical