The Acute Abdomen

1. The Acute Abdomen

2. Acute Abdomen Definition • Intraabdominal process causing severe pain and often requiring surgical intervention. • 2 considerations • Surgical or non surgical causes

3. 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

4. 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

5. Pathophysiology • Visceral • From abdominal viscera • innervated by autonomic nerve fibers • Responds to sensation of distention & muscular contraction • Poorly localized

6. 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

7. 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

10. Abdominal P/E Inspection Auscultation Percussion Palpation

11. Abdominal P/E • Looking for • Distension • Rigidity • Guarding • Eviseration/Ecchymosis • Rebound tenderness • Rebound tenderness • Masses

12. Acute Abdominal Pain

13. Acute Abdomen Non-Rigid

14. Acute Upper Abdomen

15. Acute Lower Abdomen

16. 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.

17. 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.

18. 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.

19. 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.

20. Liver Infections Hepatic Abscess uncommon 3 major forms - pyogenic, aerobes & anaerobes (80%) - amebic, Entamoeba histolytica (10%) - fungal, Candida species (10%)

21. 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)

22. Liver Infections 1. Pyogenic Liver Abscess fever, chills, pain, weight loss tender liver, jaundice, hepatomegaly Ultrasound CT scan percutaneous drainage antibiotics

23. 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

24. Liver Infections 2. Amebic Liver Abscess percutaneous drainage amebicidal agents-paromomycin-luminal agent. metronidazole-tissue agent chloroquine and emetine

25. Liver Infections 3. Fungal Liver Abscess-Hepatosplenic Candidiasis or Chronic Disseminated Candidiasis Candida albicans multiple abscesses immunocompromised leukemia, HIV systemic antifungal therapy (Amphotericin B)

26. Abdominal Wall Hernias Classification: inguinal hernia (direct or indirect) femoral hernia umbilical hernia epigastric hernia Spigelian hernia (lateral ventral hernia) ventral / incisional hernia

27. 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

29. 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).

30. 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

31. 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

32. 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

33. 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.

34. Possible Positions of the Appendix

35. 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.

36. Appendicitis Laboratory Examination WBC count urinalysis urine β-HCG to rule out pregnancy

37. 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%.

38. 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

39. 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

40. BREAK

41. VASCULAR EMERGENCIES

42. 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

43. 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

44. 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.

45. AAA

46. 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

47. 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

48. Bifurcated Tube Graft for AAA Repair

49. Abdominal Trauma

50. Principles of the Initial Assessment ATLS® Airway, Breathing, Circulation prioritizing life-threatening injuries assessment & resuscitation simultaneous