Acute abdomen
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Acute Abdomen. Acute Abdomen. Anatomy review Non-hemorrhagic abdominal pain Gastrointestinal hemorrhage Assessment Management. Abdominal Anatomy. Review. Abdominal Cavity. Superior border = diaphragm Inferior border = pelvis Posterior border = lumbar spine

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Acute Abdomen

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Acute abdomen

Acute Abdomen


Acute abdomen1

Acute Abdomen

  • Anatomy review

  • Non-hemorrhagic abdominal pain

  • Gastrointestinal hemorrhage

  • Assessment

  • Management


Abdominal anatomy

Abdominal Anatomy

Review


Abdominal cavity

Abdominal Cavity

  • Superior border = diaphragm

  • Inferior border = pelvis

  • Posterior border = lumbar spine

  • Anterior border = muscular abdominal wall


Peritoneum

Peritoneum

  • Abdominal cavity lining

  • Double-walled structure

    • Visceral peritoneum

    • Parietal peritoneum

  • Separates abdominal cavity into two parts

    • Peritoneal cavity

    • Retroperitoneal space


Primary gi structures

Primary GI Structures

  • Mouth/oral cavity

    • Lips, cheeks, gums, teeth, tongue

  • Pharynx

    • Portion of airway between nasal cavity and larynx


Primary gi structures1

Primary GI Structures

  • Esophagus

    • Portion of digestive tract between pharynx and stomach

  • Stomach

    • Hollow digestive organ

    • Receives food from esophagus


Primary gi structures2

Primary GI Structures

  • Small intestine

    • Between stomach and cecum

    • Composed of duodenum, jejunum and ileum

    • Site of nutrient absorption into body

  • Large intestine

    • From ileocecal valve to anus

    • Composed of cecum, colon, rectum

    • Recovers water from GI tract secretions


Accessory gi structures

Accessory GI Structures

  • Salivary glands

    • Produce, secrete saliva

    • Connect to mouth by ducts


Accessory gi structures1

Accessory GI Structures

  • Liver

    • Large solid organ in right upper quadrant

    • Produces, secretes bile

    • Produces essential proteins

    • Produces clotting factors

    • Detoxifies many substances

    • Stores glycogen

  • Gallbladder

    • Sac located beneath liver

    • Stores and concentrates bile


Accessory gi structures2

Accessory GI Structures

  • Pancreas

    • Endocrine pancreas secretes insulin into bloodstream

    • Exocrine pancreas secretes digestive enzymes, bicarbonate into gut

  • Vermiform appendix

    • Hollow appendage

    • Attached to large intestine

    • No physiologic function


Major blood vessels

Major Blood Vessels

  • Aorta

  • Inferior vena cava


Solid organs

Solid Organs

  • Liver

  • Spleen

  • Pancreas

  • Kidneys

  • Ovaries (female)


Hollow organs

Hollow Organs

  • Stomach

  • Intestines

  • Gallbladder and bile ducts

  • Ureters

  • Urinary bladder

  • Uterus and Fallopian tubes (female)


Right upper quadrant

Right Upper Quadrant

  • Liver

  • Gallbladder

  • Duodenum

  • Transverse colon (part)

  • Ascending colon (part)


Left upper quadrant

Left Upper Quadrant:

  • Stomach

  • Liver (part)

  • Pancreas

  • Spleen

  • Transverse colon (part)

  • Descending colon (part)


Right lower quadrant

Right Lower Quadrant

  • Ascending colon

  • Vermiform appendix

  • Ovary (female)

  • Fallopian tube (female)


Left lower quadrant

Left Lower Quadrant

  • Descending colon

  • Sigmoid colon

  • Ovary (female)

  • Fallopian tube (female)


Acute abdomen2

Acute Abdomen


Abdominal pain

Abdominal Pain

  • Visceral

  • Somatic

  • Referred


Abdominal pain1

Abdominal Pain

  • Visceral pain

    • Stretching of peritoneum or organ capsules by distension or edema

    • Diffuse

    • Poorly localized

    • May be perceived at remote locations related to organ’s sensory innervation


Abdominal pain2

Abdominal Pain

  • Somatic pain

    • Inflammation of parietal peritoneum or diaphragm

    • Sharp

    • Well-localized


Abdominal pain3

Abdominal Pain

  • Referred pain

    • Perceived at distance from diseased organ

    • Pneumonia

    • Acute MI

    • Male GU problems


Non hemorrhagic abdominal pain

Non-hemorrhagic Abdominal Pain


Esophagitis

Esophagitis

  • Inflammation of distal esophagus

  • Usually from gastric reflux, hiatal hernia


Esophagitis1

Esophagitis

  • Signs and Symptoms

    • Substernal burning pain, usually epigastric

    • Worsened by supine position

    • Usually without bleeding

    • Often temporarily relieved by nitroglycerin


Acute gastroenteritis

Acute Gastroenteritis

  • Inflammation of stomach, intestine

  • May lead to bleeding, ulcers

  • Causes

    •  acid secretion

    • Chronic EtOH abuse

    • Biliary reflux

    • Medications (ASA, NSAIDS)

    • Infection


Acute gastroenteritis1

Acute Gastroenteritis

  • Signs and Symptoms

    • Epigastric pain, usually burning

    • Tenderness

    • Nausea, vomiting

    • Diarrhea

    • Possible bleeding


Chronic infectious gastroenteritis

Chronic Infectious Gastroenteritis

  • Long-term mucosal changes or permanent damage

  • Due primarily to microbial infections (bacterial, viral, protozoal)

  • Fecal-oral transmission

  • More common in underdeveloped countries

  • Nausea, vomiting, fever, diarrhea, abdominal pain, cramping, anorexia, lethargy

  • Handwashing, BSI


Peptic ulcer disease

Peptic Ulcer Disease

  • Craters in mucosa of stomach, duodenum

  • Males 4x > Females

  • Duodenal ulcers 2 to 3x > Gastric ulcers

  • Causes:

    • Infectious disease: Helicobacter pylori (80%)

    • NSAIDS

    • Pancreatic duct blockage

    • Zollinger-Ellison Syndrome


Peptic ulcer disease1

Duodenal Ulcers

20 to 50 years old

High stress occupations

Genetic predisposition

Pain when stomach is empty

Pain at night

Gastric Ulcers

> 50 years old

Work at jobs requiring physical activity

Pain after eating or when stomach is full

Usually no pain at night

Peptic Ulcer Disease


Peptic ulcer disease2

Peptic Ulcer Disease

  • Complications

    • Hemorrhage

    • Perforation, progressing to peritonitis

    • Scar tissue accumulation, progressing to obstruction


Peptic ulcer disease3

Peptic Ulcer Disease

  • Signs and Symptoms

    • Steady, well-localized pain

    • “Burning”, “gnawing”, “hot rock”

    • Relieved by bland, alkaline food/antacids

    • Worsened by smoking, coffee, stress, spicy foods

    • Stool changes, pallor associated with bleeding


Pancreatitis

Pancreatitis

  • Inflammation of pancreas in which enzymes auto-digest gland

  • Causes include:

    • EtOH (80% of cases)

    • Gallstones obstructing ducts

    • Elevated serum triglycerides

    • Trauma

    • Viral, bacterial infections


Pancreatitis1

Pancreatitis

  • May lead to:

    • Peritonitis

    • Pseudocyst formation

    • Hemorrhage

    • Necrosis

    • Secondary diabetes


Pancreatitis2

Pancreatitis

  • Signs and Symptoms

    • Mid-epigastric pain radiating to back

    • Often worsened by food, EtOH

    • Bluish flank discoloration (Grey-Turner Sign)

    • Bluish periumbilical discoloration (Cullen’s Sign)

    • Nausea, vomiting

    • Fever


Cholecystitis

Cholecystitis

  • Gall bladder inflammation, usually 2o to gallstones (90% of cases)

  • Risk factors

    • Five Fs: Fat, Fertile, Febrile, Fortyish, Females

    • Heredity, diet, BCP use


Cholecystitis1

Cholecystitis

  • Acalculus cholecystitis

    • Burns

    • Sepsis

    • Diabetes

    • Multiple organ systems failure

  • Chronic cholecystitis (bacterial infection)


Cholecystitis2

Cholecystitis

  • Signs and Symptoms

    • Sudden pain, often severe, cramping

    • RUQ, radiating to right shoulder

    • Point tenderness under right costal margin (Murphy’s sign)

    • Nausea, vomiting

    • Often associated with fatty food intake

    • History of similar episodes in past

    • May be relieved by nitroglycerin


Appendicitis

Appendicitis

  • Inflammation of vermiform appendix

  • Usually secondary to obstruction by fecalith

  • May occur in older persons secondary to atherosclerosis of appendiceal artery andischemic necrosis


Appendicitis1

Appendicitis

  • Signs and Symptoms

    • Classic: Periumbilical pain  RLQ pain/cramping

    • Nausea, vomiting, anorexia

    • Low-grade fever

    • Pain intensifies, localizes resulting in guarding

    • Patient on right side with right knee, hip flexed


Appendicitis2

Appendicitis

  • Signs and Symptoms

    • McBurney’s Sign: Pain on palpation of RLQ

    • Aaron’s Sign: Epigastric pain on palpation of RLQ

    • Rovsing’s Sign: Pain in LLQ on palpation of RLQ

    • Psoas Sign: Pain when patient:

      • Extends right leg while lying on left side

      • Flexes legs while supine


Appendicitis3

Appendicitis

  • Signs and Symptoms

    • Unusual appendix position may lead to atypical presentations

      • Back pain

      • LLQ pain

      • “Cystitis”

    • Rupture: Temporary pain relief followed by peritonitis


Bowel obstruction

Bowel Obstruction

  • Blockage of intestine

  • Common Causes

    • Adhesions (usually 2o to surgery)

    • Hernias

    • Neoplasms

    • Volvulus

    • Intussuception

    • Impaction


Bowel obstruction1

Bowel Obstruction

  • Pathophysiology

    • Fluid, gas, air collect near obstruction site

    • Bowel distends, impeding blood flow/ halting absorption

    • Water, electrolytes collect in bowel lumen leading to hypovolemia

    • Bacteria form gas above obstruction further worsening distension

    • Distension extends proximally

    • Necrosis, perforation may occur


Bowel obstruction2

Bowel Obstruction

  • Signs and Symptoms

    • Severe, intermittent, “crampy” pain

    • High-pitched, “tinkling” bowel sounds

    • Abdominal distension

    • History of decreased frequency of bowel movements, semi-liquid stool, pencil-thin stools

    • Nausea, vomiting

    • ? Feces in vomitus


Hernia

Hernia

  • Protrusion of abdominal contents into groin (inguinal) or through diaphragm (hiatal)

  • Often secondary to  intra-abdominal pressure (cough, lift, strain)

  • May progress to ischemic bowel (strangulated hernia)


Hernia1

Hernia

  • Signs and Symptoms

    • Pain  by abdominal pressure

    • Past history

    • Inguinal hernia may be palpable as mass in groin or scrotum


Crohn s disease

Crohn’s Disease

  • Idiopathic inflammatory bowel disease

  • Occurs anywhere from mouth to rectum

  • 35-45%: small intestine; 40%: colon

  • Runs in families

  • High risk groups

    • White females

    • Jews

    • Persons under frequent stress


Crohn s disease1

Crohn’s Disease

  • Pathophysiology

    • Mucosa of GI tract becomes inflamed

    • Granulomas form, invade submucosa

    • Muscular layer of bowel become fibrotic, hypertrophied

    • Increased risk develops for

      • Obstruction

      • Perforation

      • Hemorrhage


Ulcerative colitis

Ulcerative Colitis

  • Idiopathic inflammatory bowel disease

  • Chronic ulcers develop in mucosal layer of colon

  • Spread to submucosal layer uncommon

  • 75% of cases involve rectum (proctitis) or rectosigmoid portion of large intestine

  • Inflammation can spread through entire large intestine (pancolitis)


Ulcerative colitis1

Ulcerative Colitis

  • Severity of signs, symptoms depends on extent

  • Classic presentation

    • Crampy abdominal pain

    • Nausea, vomiting

    • Blood diarrhea or stool containing mucus

  • Ischemic damage with perforation may occur


Diverticulitis

Diverticulitis

  • Diverticula

    • Pouches in colon wall

    • Typically in older persons

    • Usually asymptomatic

    • Related to diets with inadequate fiber


Diverticulitis1

Diverticulitis

  • Diverticula trap feces, become inflamed

  • Occasionally result in bright red rectal bleeding

  • Rupture may cause peritonitis, sepsis


Diverticulitis2

Diverticulitis

  • Signs and Symptoms

    • Usually left-sided pain

    • May localize to LLQ (“left-sided appendicitis”)

    • Alternating constipation, diarrhea

    • Bright red blood in stool


Hemorrhoids

Hemorrhoids

  • Small masses of veins in anus, rectum

  • Most frequently develop when patients are in 30s or 40s; common past 50

  • Most are idiopathic, can be associated with pregnancy, portal hypertension

  • Cause bright red bleeding, pain on defecation

  • May become infected, inflamed


Peritonitis

Peritonitis

  • Inflammation of abdominal cavity lining

  • Signs and Symptoms

    • Generalized pain, tenderness

    • Abdominal rigidity

    • Nausea, vomiting

    • Absent bowel sounds

    • Patient resistant to movement


Hemorrhagic abdominal problems

Hemorrhagic Abdominal Problems

Gastrointestinal Hemorrhage

Intraabdominal Hemorrhage


Esophageal varices

Esophageal Varices

  • Dilated veins in esophageal wall

  • Occur 2o to hepatic cirrhosis, common in EtOH abusers

  • Obstruction of hepatic portal blood flow results in dilation, thinning of esophageal veins


Esophageal varices1

Esophageal Varices

  • Portal hypertension

    • Hepatic scarring slows blood flow

    • Blood backs up in portal circulation

    • Pressure rises

    • Vessels in portal circulation become distended


Esophageal varices2

Esophageal Varices

  • Signs and Symptoms

    • Hematemesis (usually bright red)

    • Nausea, vomiting

    • Evidence of hypovolemia

    • Melena (uncommon)


Mallory weiss syndrome

Mallory-Weiss Syndrome

  • Longitudinal tears at gastroesophageal junction

  • Occur as result of prolonged, forceful vomiting, retching

  • Common in alcoholics

  • May be complicated by presence of esophageal varices


Peptic ulcer disease4

Peptic Ulcer Disease

  • Ulcer erodes through blood vessel

  • Massive hematemesis

  • Melena may be present


Aortic aneurysm

Aortic Aneurysm

  • Localized dilation due to weakening of aortic wall

  • Usually older patient with history of hypertension, atherosclerosis

  • May occur in younger patients secondary to

    • Trauma

    • Marfan’s syndrome


Aortic aneurysm1

Aortic Aneurysm

  • Usually just above aortic bifurcation

  • May extend to one or both iliac arteries


Aortic aneurysm2

Aortic Aneurysm

  • Signs and Symptoms

    • Unilateral lower quadrant pain; low back or leg pain

    • May be described as tearing or ripping

    • Pulsatile palpable mass usually above umbilicus

    • Diminished pulses in lower extremities

    • Unexplained syncope, often after BM

    • Evidence of hypovolemic shock


Ectopic pregnancy

Ectopic Pregnancy

  • Any pregnancy that takes place outside of uterine cavity

  • Most common location is in Fallopian tube

  • Pregnancy outgrows tube, tube wall ruptures

  • Hemorrhage into pelvic cavity occurs


Ectopic pregnancy1

Ectopic Pregnancy

  • Suspect in females of child-bearing age with:

    • Abdominal pain, or

    • Unexplained shock

  • When was last normal menstrual period?

Ectopic pregnancy does NOT necessarily cause missed period


Assessment of acute abdomen

Assessment of Acute Abdomen


History

History

  • Where do you hurt?

    • Try to point with one finger

  • What does pain feel like?

    • Steady pain = Inflammatory process

    • Cramping pain = Obstructive process

  • Onset of pain?

    • Sudden = Perforation or vascular occlusion

    • Gradual = Peritoneal irritation, distension of hollow organ


History1

History

  • Does pain travel anywhere?

    • Gallbladder = Angle of right scapula

    • Pancreas = Straight through to back

    • Kidney/ureter = Around flank to groin

    • Heart = epigastrium, neck/jaw, shoulders, upper arms

    • Spleen = Left scapula, shoulder

    • Abdominal Aortic Aneurysm = low back radiating to one or both legs


History2

History

  • How long have you been hurting?

    • >6 hours = increased probability of surgical significance

  • Nausea, vomiting

    • How much, How long?

      • Consider possible hypovolemia

    • Blood, coffee grounds?

      • Any blood in GI tract = emergency until proven otherwise


History3

History

  • Urine

    • Change in urinary habits?

      • Frequency

      • Urgency

    • Color?

    • Odor?


History4

History

  • Bowel movements

    • Change in bowel habits? Color? Odor?

      • Bright red blood

      • Melena = black, tarry, foul-smelling stool

      • Dark stool

        • Suspect bleeding

        • Other causes possible (iron or bismuth containing materials)


History5

History

  • Last normal menstrual period?

  • Abnormal bleeding?

  • In females, lower abdominal pain = GYN problem until proven otherwise

  • In females of child-bearing age, lower abdominal pain = ectopic pregnancy until proven otherwise


Physical exam

Physical Exam

  • Position and General Appearance

    • Still, refusing to move = Inflammation, peritonitis

    • Extremely restless = Obstruction

  • Gross appearance of abdomen

    • Distended

    • Discolored

    • Consider possible third spacing of fluids


Physical exam1

Physical Exam

  • Vital signs

    • Tachycardia = more important sign of volume loss than falling BP

    • Rapid, shallow breathing = possible peritonitis

    • Consider performing “tilt” test


Physical exam2

Physical Exam

  • Bowel sounds

    • Auscultate BEFORE palpating

    • One minute in each abdominal quadrant

    • Absent sounds = possible peritonitis, shock

    • High-pitched, tinkling sounds = possible bowel obstruction


Physical exam3

Physical Exam

  • Palpation

    • Palpate each quadrant

    • Palpate area of pain LAST

    • Do NOT check rebound tenderness in prehospital setting

    • ALL abdominal tenderness significant until proven otherwise


Management

Management

  • Oxygen by non-rebreather mask

  • IV LR or NS

  • PASG (demonstrated benefit in intrabdominal hemorrhage)

  • Keep patient from losing body heat

  • Monitor vital signs


Management1

Management

  • Monitor EKG

Consider possible MI with pain referred to abdomen in patients >30 years old

  • Keep patient npo

  • Analgesia controversial

  • Demerol is preferred narcotic analgesic


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