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Acute Abdomen

Acute Abdomen. Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Acute Abdomen. “The term “acute abdomen” should never be equated with the invariable need for operation.” - Cope It is important to make a diagnosis early Exclude medical diseases. HPI. Have a routine method of taking a HPI

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Acute Abdomen

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  1. Acute Abdomen Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D.

  2. Acute Abdomen • “The term “acute abdomen” should never be equated with the invariable need for operation.” - Cope • It is important to make a diagnosis early • Exclude medical diseases

  3. HPI • Have a routine method of taking a HPI • OPQRST • Ask about: vomiting, bowel function, bleeding, anorexia, menstruation

  4. Additional History • Make sure to ask about: • Prior episodes of similar complaints • Prior abdominal surgeries • PUD, diverticular disease, cholelithiasis, nephrolithiasis • Medications: steroids, NSAIDS

  5. Physical Exam • Palpation & percussion • Rigidity • Hyperesthesia • Check for hernias • Rectal exam • Vaginal exam when appropriate • Auscultation

  6. Signs • Obturator sign • Psoas sign • Rovsing’s sign • Dance’s sign • Cullen’s sign • Grey Turner’s sign • McBurney’s sign • Murphy’s sign • Valentino’s sign

  7. Referred Pain • Cholecystitis = R scapula • Appendicitis = periumbilical • Pancreatitis = back • Rectal disease = back • Nephrolithiasis = flank • Diaphragm irritation = shoulder

  8. Studies • Labs: WBC, BMP, amylase, lipase, LFT, ABG, beta-HCG, U/A • X-ray: CXR, KUB, CT scan, U/S, UGI • Additional studies: FAST, EGD, colonoscopy

  9. Forming a DDx • Start with broad categories: • Inflammation • Obstruction • Ischemia • Perforation • VINDICATE

  10. Clinical Diagnosis

  11. Diagnosis: Exam & DDx • Central/epigastric: pancreatitis, obstruction, early appendicitis, ruptured AAA, MI, gastric volvulus, gastritis • RUQ: cholecystitis, appendicitis (in pregnancy) • LUQ: perforated gastric ulcer, splenic rupture, gastritis, GER, Boerhaave’s syndrome, Mallory-Weiss tear, perinephric abscess, splenic artery aneurysm • RLQ: leaking duodenal ulcer, appendicitis, Meckel’s diverticulum, intussusception, ectopic pregnancy • LLQ: diverticulitis, sigmoid volvulus, UTI, SBO, IBD, ectopic pregnancy, endometriosis, CA • Generalized: perforated peptic ulcer • Flank: pyelonephritis

  12. Non-Surgical Dx • Respiratory: PE, PNA • Cardiac: pericarditis, MI • GI: gastroenteritis, pancreatitis, hepatitis • GU: obstructive nephrolithiasis, pyelonephritis, cystitis, testicular torsion • OB/GYN: torsion or rupture of ovarian cyst, ectopic pregnancy, endometritis, salpingitis • Heme: sickle cell crisis, leukemia, • Endocrine: Diabetic ketoacidosis • Vascular: ruptured AAA, dAA, mesenteric ischemia • MS: rectus sheath hematoma

  13. Making the Decision to Operate • Peritonitis • Severe / unrelenting pain • Hemodynamically unstable • Intestinal ischemia • Pneumoperitoneum • Complete obstruction

  14. Management Plan Think about: • Neuro: pain management • CV: appropriate monitoring, beta-blockade • Pulm: pre-operative bronchodilators • GI: NPO, NGT • GU: Foley • FEN: IVF • Heme: DVT prophylaxis • ID: pre-op antibiotics

  15. Take Home Points • Prompt diagnosis is critical • A complete H&P is important • All exams begin with the ABCs • Ideally, resuscitate prior to going to OR

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