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Acute Abdomen. David Gavriel MD Surgical department SZMC. Overview. Basic Definition and Principles Clinical Diagnosis / DDx Characterizing the pain Other history to elicit Ways to remember such a broad differential History & Physical / Labs / Imaging

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Acute Abdomen

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Acute Abdomen

David Gavriel MD

Surgical department

SZMC


Overview

  • Basic Definition and Principles

  • Clinical Diagnosis / DDx

    • Characterizing the pain

    • Other history to elicit

    • Ways to remember such a broad differential

    • History & Physical / Labs / Imaging

    • Non-surgical causes of acute abdomen

  • Clinical Management

  • Decision to Operate

  • Atypical presentations


Basic Definition and Principles

  • Signs and symptoms of intra-abdominal disease usually best treated by surgery

  • Proper eval and management requires one to recognize:

    • 1. Does this patient need surgery?

    • 2. Is it emergent, urgent, or can wait?

      • In other words, is the patient unstable or stable?

  • Learn to think in “worst-case” scenario

  • But remember medical causes of abd pain


Visceral vs. Parietal Pain innervation


Clinical Diagnosis

  • Characterizing the pain is the key

    • Onset, duration, location, character

  • Visceral pain → dull & poorly localized

    • i.e. distension, inflammation or ischemia

  • Parietal pain → sharper, better localized

    • Sharp “RUQ pain”(chol’y), “LLQ pain”(divertic)

  • Kidney / ureter → flank pain


Clinical Diagnosis – Pain cont’d

  • Location

    • Upper abdomen → PUD, chol’y, pancreatitis

    • Lower abdomen → Divertic, ovary cyst, TOA

    • Mid abdomen → early app’y, SBO

  • Migratory pattern

    • Epigastric → Peri-umbil → RLQ = Acute app’y

    • Localized pain → Diffuse = Diffuse peritonitis


Clinical Diagnosis

  • “Referred pain”

    • Biliary disease → R shoulder or back

    • Sub-left diaphragm abscess → L shoulder

    • Above diaphragm(lungs) → Neck/shoulder

  • Acute onset & unrelenting pain = bad

  • Pain which resolves usu. not surgical


GI symptoms

Nausea, emesis (? bilious or bloody)

Constipation, obstipation (last BM or flatus)

Diarrhea (? bloody)

Both Nausea/Diarrhea present usu. medical

Change in sx w eating?

NSAID use (perf DU)

Jaundice, acholic stools, dark urine

Drinking history (pancreas)

Prior surgeries (adhesions → SBO, ?still have gallbladder & appendix)

History of hernias

Urine output (dehydrated)

Constituational Sx

Fevers/chills

Sexual history

Other history


Physical Examination

  • Observation of the patient

    • Position of patient

    • Activity of patient

    • Appearance of abdomen

  • Auscultation

    • Bowel sounds, bruits

  • Percussion

  • Palpation

    • Masses, tenderness, rebound, hernias


Examination Patterns (Signs)


Evaluation Studies


Clinical Diagnosis

  • Location of pain by organ

  • RUQ

    • Gallbladder

  • Epigastrum

    • Stomach

    • Pancreas

  • Mid abdomen

    • Small intestine

  • Lower abdomen

    • Colon, GYN pathology


Clinical Diagnosis


Inflammation versus Obstruction


Localization of Pain


Localization of Pain – cont.


Localization of Pain – cont.


Non-Surgical Causes by Systems


Non Surgical Causes


Surgical Acute Abdominal Diseases


Think Broad categories for DDx

  • Inflammation

  • Obstruction

  • Ischemia

  • Perforation (any of above can end here)

    • Offended organ becomes distended

    • Lymphatic/venous obstrux due to ↑pressure

    • Arterial pressure exceeded → ischemia

    • Prolonged ischemia → perforation


Ischemia / Perforation

  • Acute mesenteric ischemia

    • Usually acute occlusion of the SMA from thrombus or embolism

  • Chronic mesenteric ischemia

    • Typically smoker, vasculopath with severe atherosclerotic vessel disease

  • Ischemic colitis

  • Any inflammation, obstructive, or ischemic process can progress to perforation

  • Ruptured abdominal aortic aneurysm


GYN Etiologies


Labs & Imaging


What do you see?


Abdominal X ray


Abdominal X ray


CT Scanning


CT scan

What is the diagnosis?

Acute appendicitis


CT Scanning


CT Scanning


Findings Suggesting Surgical Disease


Intra Abdominal Pressure Monitoring

  • Increased abdominal pressure can be a symptom of disease or the cause

  • Can decrease abd. visceral blood flow

  • Can decrease cardiac venous return

  • Can cause respiratory embarrassment

  • Can lead to GERD and aspiration


Abdominal Compartment Syndrome


“VAC-Pac” Closure


Differential Diagnosis

  • Correct diagnosis made 80% of time after history and physical exam

  • Sometimes diagnosis cannot be made preoperatively

  • Diagnostic laparoscopy can be helpful adjunct

  • Peritoneal lavage can be performed at bedside in ICU/ER in unstable patient


Pregnant Patients

  • Special emphasis placed on Gyn and surgical diagnoses

  • Hesitancy to operate and to perform X Ray imaging can delay diagnosis

  • Presentation patterns can be altered by pregnancy

  • Delayed diagnosis can threaten both mother and fetus


Pregnant Patient

  • Most common non-obstetrical surgical diseases in pregnancy are:

    • Appendicitis (1:1500)

    • Biliary tract disease (1-6:10,000)

    • Bowel obstructions (1:4,000)

    • Pancreatitis


Appendicitis in Pregnancy

  • Classic symptoms 60% of time

  • Nausea, vomiting, lower abd pain

  • Fever is uncommon

  • Leukocytosis present in normal pregnancy


Appendicitis in Pregnancy


Algorithms in Acute AbdomenAcute Severe Generalized Pain


Algorithms in Acute AbdomenGradual Onset Severe Generalized Pain


Algorithms in Acute AbdomenRight Upper Quadrant Pain


Algorithms in Acute AbdomenRight Lower Quadrant Pain


Algorithms in Acute AbdomenLeft Lower Quadrant Pain


Decision to operate

  • Peritonitis

    • Tenderness w/ rebound, involuntary guarding

  • Severe / unrelenting pain

  • “Unstable” (hemodynamically, or septic)

    • Tachycardic, hypotensive, white count

  • Intestinal ischemia, including strangulation

  • Pneumoperitoneum

  • Complete or “high grade” obstruction


Special Circumstances

  • Situations making diagnosis difficult

    • Stroke or spinal cord injury

    • Influence of drugs or alcohol

  • Severity of disease can be masked by:

    • Steroids

    • Immunosuppression (i.e. AIDS)

    • Threshold to operate must be even lower


Take Home Points

  • Careful history (pain, other GI symptoms)

  • Remember DDx in broad categories

  • Narrow DDx based on hx, exam, labs, imaging

  • Always perform ABC, Resuscitate before Dx

  • If patient’s sick or “toxic”, get to OR (surgical emergency)

    • Ideally, resuscitate patients before going to the OR

  • Don’t forget GYN/medical causes, special situations

  • For acute abdomen, think of these commonly (below)


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