The acute abdomen
This presentation is the property of its rightful owner.
Sponsored Links
1 / 65

The Acute Abdomen PowerPoint PPT Presentation


  • 120 Views
  • Uploaded on
  • Presentation posted in: General

The Acute Abdomen. Acute Abdomen Definition. Intraabdominal process causing severe pain and often requiring surgical intervention . 2 considerations Surgical or non surgical causes. General Causes. Divided into 6 broad categories Inflammatory - ie appendicitis

Download Presentation

The Acute Abdomen

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


The acute abdomen

The Acute Abdomen


Acute abdomen definition

Acute Abdomen Definition

  • Intraabdominal process causing severe pain and often requiring surgical intervention.

  • 2 considerations

    • Surgical or non surgical causes


General causes

General Causes

  • Divided into 6 broad categories

    • Inflammatory - ie appendicitis

    • Mechanical - ie acute small bowel obstruction

    • Neoplastic - ie cancer

    • Vascular - ie mesenteric vascular occulsion

    • Congenital defects - ieIntussusception

    • Traumatic - ie mesenteric bleeds due to trauma


Red flags in acute abdomens

Red Flags in Acute Abdomens

  • › Signs of impending shock

  • › Hypotension, tachycardia, tachypnea

  • › Septic appearance

  • › Confusion

  • › Signs of dehydration

  • › Rigid abdomen

  • › Absent bowel sounds

  • › Patient lying still or writhing

  • › Involuntary guarding

  • › Tenderness to percussion

  • › Hematemesis, hematochezia

  • › Abdominal pain prior to vomiting

  • › Abdominal pain localized to the periphery

  • of the abdomen or pelvis


Pathophysiology

Pathophysiology

  • Visceral

    • From abdominal viscera

    • innervated by autonomic nerve fibers

    • Responds to sensation of distention & muscular contraction

    • Poorly localized


Pathophysiology con t

Pathophysiology con’t

  • Parietal

    • From parietal peritoneum

    • Innervated by somatic nerves

    • Responds to irritation from infectious, chemical or other inflammatory processes.

    • Sharp and well localized


Pathophysiology con t1

Pathophysiology con’t

  • Referred

    • Perceived distant from source

    • Results from convergence of nerve fibers at spinal cord

    • Eg. Scapular pain due to biliary colic or groin pain due to renal colic


Abdominal p e

Abdominal P/E

Inspection

Auscultation

Percussion

Palpation


Abdominal p e1

Abdominal P/E

  • Looking for

    • Distension

    • Rigidity

    • Guarding

    • Eviseration/Ecchymosis

    • Rebound tenderness

    • Rebound tenderness

    • Masses


Acute abdominal pain

Acute Abdominal Pain


Acute abdomen non rigid

Acute Abdomen Non-Rigid


Acute upper abdomen

Acute Upper Abdomen


Acute lower abdomen

Acute Lower Abdomen


Review

Review

  • Right lower quadrant pain, fever, leukocytosis, McBurney’s point localization of pain is most associated with:

    • Diverticulitis.

    • Ulcerative colitis.

    • Appendicitis.

    • Tubo-ovarian abscess.

    • Cholecystitis.


Review answer

Review - ANSWER

  • Right lower quadrant pain, fever, leukocytosis, McBurney’s point localization of pain is most associated with:

    • Diverticulitis.

    • Ulcerative colitis.

    • Appendicitis.

    • Tubo-ovarian abscess.

    • Cholecystitis.


Review1

Review

  • A complete small bowel obstruction might be suspected in a patient with:

    • Hypoactive bowel sounds.

    • Pain out of proportion to physical exam findings.

    • Crampy abdominal pain that waxes and wanes.

    • Diarrhea.

    • A flat, rigid abdomen.


Review answer1

Review - ANSWER

  • A complete small bowel obstruction might be suspected in a patient with:

    • Hypoactive bowel sounds.

    • Pain out of proportion to physical exam findings.

    • Crampy abdominal pain that waxes and wanes.

    • Diarrhea.

    • A flat, rigid abdomen.


Liver infections

Liver Infections

Hepatic Abscess

uncommon

3 major forms

- pyogenic, aerobes & anaerobes(80%)

- amebic, Entamoeba histolytica(10%)

- fungal, Candida species(10%)


Liver infections1

Liver Infections

1. Pyogenic Liver Abscess

usually gram (-) aerobic bacteria

from appendicitis or diverticulitis

ascension in biliary tree

systemic source from dental procedures

trauma

biliary instrumentation (iatrogenic)


Liver infections2

Liver Infections

1. Pyogenic Liver Abscess

fever, chills, pain, weight loss

tender liver, jaundice, hepatomegaly

Ultrasound

CT scan

percutaneous drainage

antibiotics


Liver infections3

Liver Infections

2. Amebic Liver Abscess

parasitic Entamoeba histolytica

tropical climates

young men account for 90% of cases

RUQ abdominal pain

fever, chills, nausea, vomiting, anorexia,

weight loss


Liver infections4

Liver Infections

2. Amebic Liver Abscess

percutaneous drainage

amebicidal agents-paromomycin-luminal agent.

metronidazole-tissue agent

chloroquine and emetine


Liver infections5

Liver Infections

3. Fungal Liver Abscess-Hepatosplenic Candidiasis or Chronic Disseminated Candidiasis

Candida albicans

multiple abscesses

immunocompromised

leukemia, HIV

systemic antifungal therapy (Amphotericin B)


Abdominal wall hernias

Abdominal Wall Hernias

Classification:

inguinal hernia (direct or indirect)

femoral hernia

umbilical hernia

epigastric hernia

Spigelian hernia (lateral ventral hernia)

ventral / incisional hernia


Groin hernias

Groin Hernias

Inguinal Hernia (96%)

more common in men than women

indirect (80%) [Internal inguinal ring]

direct (20%) [Hesselbach’s triangle]

Femoral Hernia (4%)[medial femoral canal]

Lifetime risk of developing a groin hernia is

- 25% for men

- 5% for women


Inguinal hernia presentation

Inguinal Hernia Presentation

  • Soft non-tender mass in the groin.

  • Local burning or aching.

  • Enlargement of the mass by coughing (any maneouver that increase intra-abdominal pressure).


Inguinal hernia repair

Inguinal Hernia Repair

Indications for Elective Surgery

pain / discomfort

limits / restrictions on activity

increasing size of hernia

small risk of incarceration & strangulation

cosmetic

Indications for Emergency Surgery

incarceration & strangulation


Ventral hernia

Ventral Hernia

11 – 20% of laparotomies

incarceration 5 – 15%

risk of strangulation 2%

recurrence rates = 50% with tension repair

50% of incisional hernias appear in the first

6 months following laparotomy

most occur within 2 years


Appendicitis

Appendicitis

Clinical Presentation

intermittent, crampy, periumbilical pain

obstruction of appendiceal lumen with

a fecalith

nausea follows the pain

anorexia

low grade fever

pain migrates to RLQ within 24 hrs and

changes to constant & sharp pain


Appendicitis1

Appendicitis

Physical Examination

RLQ tenderness & localized peritonitis

Rovsing’s sign (RLQ pain with LLQ palpation)

obturator sign suggests a pelvic appendix

psoas sign suggests a retrocecal appendix

in females, must do pelvic exam to rule out adnexal mass or tenderness.


The acute abdomen

Possible Positions

of the Appendix


The acute abdomen

P/E

  • McBurney's point tenderness:1.5 to 2 inches from ASIS to the umbilicus.

  • Rovsing's sign: pain in the RLQ w/ palpation of LLQ (rt-sided local peritoneal irritation).

  • Psoas sign: (retrocecal appendix) RLQ pain with passive right hip extension.

  • Obturator sign: (pelvic appendix) RLQ pain with rt hip/knee flexion and internal rotation.


Appendicitis2

Appendicitis

Laboratory Examination

WBC count

urinalysis

urine β-HCG to rule out pregnancy


Appendicitis3

Appendicitis

Imaging Studies

Ultrasound

- may be useful (sensitivity 80%, spec 90%)

- highly operator dependent

- useful to rule out gynecologic pathology

CT scan

- more accurate than U/S for appendicitis, sens and spec 95%.


Appendicitis4

Appendicitis

Treatment of Nonperforated Appendicitis

laparoscopic vs open appendectomy ASAP

fluid & electrolyte imbalance usually minor

prophylactic IV antibiotics to prevent wound infection.

post-op hospital discharge 24-48 hrs


Appendicitis5

Appendicitis

Treatment of Perforated Appendicitis

may be acutely ill

significant dehydration & electrolyte

disturbance

CT scan – appendiceal abscess or phlegmon

percutaneous drainage of abscess

may choose to delay surgery for months

interval appendectomy


Break

BREAK


Vascular emergencies

VASCULAR EMERGENCIES


Vascular emergencies1

Vascular Emergencies

Mesenteric Ischemia

low blood flow to bowel

embolic event to SMA (atrial fibrillation)

thrombosis of SMA

nonocclusive mesenteric ischemia (low flow

states in critically ill patients) - vasoconstriction


Vascular emergencies2

Vascular Emergencies

Mesenteric Ischemia

Diagnosis

angiography

CT scan with contrast

Treatment

operative attempts to restore mesenteric flow

need to resect any nonviable bowel

thrombolytic therapy an option


Vascular emergencies3

Vascular Emergencies

Ruptured Abdominal Aortic Aneurysm (AAA)

common surgical emergency

many pts do not know they have an aneurysm until it ruptures

risk factors include smoking, >60 yrs, HTN, CAD, dyslipidemia, FmHx.


The acute abdomen

AAA


Vascular emergencies4

Vascular Emergencies

Clinical Presentation Ruptured AAA

acute abdominal or back pain

usually sudden onset

lightheadedness or collapse due to sudden hypotension

immediate CT scan if pt hemodynamically stable.

if unstable, diagnosis with Hx, P/E, ultrasound


Vascular emergencies5

Vascular Emergencies

Ruptured Abdominal Aortic Aneurysm (AAA)

Treatment

immediate OR

laparotomy with X-clamp proximal aorta &

repair aneurysm with interposition tube graft

fluid & blood resuscitation

ICU post-op


The acute abdomen

Bifurcated Tube

Graft for

AAA Repair


Abdominal trauma

Abdominal Trauma


Principles of the initial assessment

Principles of the Initial Assessment

ATLS®

Airway, Breathing, Circulation

prioritizing life-threatening injuries

assessment & resuscitation simultaneous


Abdominal trauma1

Abdominal Trauma

Purpose of Diagnostic Work-up

most important decision is to determine

whether or not the patient requires an

emergent laparotomy


Diagnosis of abdominal trauma

Diagnosis of Abdominal Trauma

history & physical exam

FAST (Focused Assessment with

Sonography for Trauma)

CT scan

DPL (diagnostic peritoneal lavage)


Diagnostic test of choice

Diagnostic Test of Choice ?

ALL PATIENTSFAST

If FAST is not available, then in general:

unstable patientsDPL

stable patientsCT scan


Fast trauma ultrasound

FAST( Trauma Ultrasound )

Advantages

portable

inexpensive

rapid assessment

can be easily repeated during work-up

accurate for the presence of intraperitoneal free fluid

can be performed by trained non-radiologist


Fast technique

Look for free fluid

in 4 places:

perihepatic

perisplenic

pelvis

pericardium

FAST Technique


Ct scan

CT Scan

hemodynamically stable patients only

very specific and sensitive for solid organs

quantify / grade severity of organ injury

contrast extravasation (implications)

CT scan not needed if indication for

laparotomy exists

may miss bowel injury, ruptured diaphragm


The acute abdomen

DPL

sensitive for presence of intraperitoneal

blood

open or closed technique

positive =gross blood

red cell count > 100,000/mm3

rarely used in blunt trauma if FAST available


Approach to penetrating abdominal trauma

Approach to Penetrating Abdominal Trauma

Categorization of the anatomical site of injury:

stab wound to anterior abdomen

GSW to anterior abdomen

thoracoabdominal penetrating trauma

tangential GSW

back & flank penetrating trauma

transpelvic GSW


Stab wound to abdomen

Stab Wound to Abdomen

Anatomy (anterior abdomen)

costal margin

anterior axillary line

inguinal ligament


Stab wound to abdomen1

Stab Wound to Abdomen

Indications for laparotomy

hemodynamic instability

peritonitis

blood in NG, foley, rectal exam

evisceration

retained stabbing implement

positive FAST or DPL (100,000 RBCs)


Management of gsw abdomen

Management of GSW abdomen

ABC

IV lines above & below diaphragm

log roll early to find all bullet wounds

plain film X-rays to localize bullets

determine need for surgery

tetanus / antibiotics

communicate with blood bank


Gsw abdomen indications for laparotomy

GSW Abdomen - Indications for Laparotomy

hemodynamic instability

peritonitis

path of bullet

blood in foley, NG, rectal exam

pneumoperitoneum

evisceration

positive FAST or DPL (RBC count > 5,000)


Summary

Summary

history & physical exam of acute abdominal

conditions

diagnostic tests

resuscitation

surgical treatment


Red herrings

Red Herrings

Nerve root impingement


Red herrings1

Red Herrings

Herpes Zoster


  • Login