1 / 30

THE ACUTE ABDOMEN

THE ACUTE ABDOMEN. Hugh M. Foy, MD Harborview Medical Center University of Washington School of Medicine. “BEGIN WITH THE END IN MIND”. Stephen Covey The 7 Habits of Highly Effective People. Acute Abdominal Pain. Considerations: VS: stable or unstable? PQRST

santo
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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. THE ACUTE ABDOMEN Hugh M. Foy, MD Harborview Medical Center University of Washington School of Medicine

  2. “BEGIN WITH THE END IN MIND” Stephen Covey The 7 Habits of Highly Effective People

  3. Acute Abdominal Pain • Considerations: • VS: stable or unstable? • PQRST • Precipitating or alleviating factors • Quality-bright, sharp, dull, achy • Radiation- scapula, inguinal, supraclav • Severity- 1 to 10 scale • Timing- sudden, insidious • Crampy or continuous

  4. HPI part 2 • Past Surgical History • Previous abdominal or pelvic operation • Prior work-up for abdominal pain • Past Medical History • IDDM • ASCVD

  5. Common Abdominal Conditions • Ileus from narcotics • Constipation/Obstipation • Appendicitis • Cholecystitis/Biliary Colic • Small Bowel Obstruction • Perforated Peptic Ulcer • Pancreatitis

  6. Past Medical History • Medications • Valproic acid • Allergies • Bugs, bites or stings

  7. LOOK • Description of abdominal habitus • scaphoid, • Flat • Rotund Scars, wounds, erythema Anatomic Confines

  8. Anatomic Landmarks • Divided in quadrants • RUQ, LUQ, RLQ, LLQ • Anatomic: • Epigastrium • Umbilical • Suprapubic (hypogastrium)

  9. Listen • Listen with stethoscope • Not necessary in all quadrants • Quantitative • Absent • Decreased • Hyperactive • Qualitative • Normal • Borbyrigmy • Obstructive • Bruits

  10. Bowel Tones • Pathologic • Obstructive • Hollow • Air-fluid interface • Like a pebble dropped in to a partially filled barrel • “Tinkles and Rushes”

  11. Percussion • Abdomen • Tympanitic gas • Dull fluid (ascites or blood) • Liver Span • mid clavicular line by convention • Bladder, Uterus • Rising out of the pelvis Percussion is also a very sensitive sign of peritonitis

  12. PALPATION Prepare the patient • warn them • make them comfortable • take tension off the abdominal wall • Pillow or bend the knees • Expose the entire abdomen • Xiphoid to pubis

  13. PALPATION • Note the patient’s attitude • (physically and emotionally) • Watch their eyes as you touch them • After percussion: • Softly at first • Deeper • LUQ-RUQ note liver edge • Then LLQ-RUQ

  14. The Painful Abdomen • Pain vs Tenderness • Distinction is critical to making the diagnosis • Be precise: • Conceptually, • Verbally • Written Documentation Pain- is a subjective symptom Tenderness is an objective sign

  15. Pain vs Tenderness • Based on abdominal innervation: • Visceral Pain • Sense stretching and ischemia only • mediated via Visceral Afferent fibers • Follow the blood supply • Difuse, not mapped 1:1 on sensory cortex

  16. Pain and Tenderness(continued) • Tenderness • Somatic Afferent Innervation • Parietal peritoneum • Abdominal Wall • Precisely mapped on sensory cortex

  17. Examination of the Acute Abdomen • Observe the pt. • Reassure • Auscultate • Percuss and Palpate • Begin in quadrant opposite the suspected pathology • Percussion is very sensitive peritoneal sign

  18. Examination of the Acute Abdomen II • Guarding • Voluntary • Involuntary • Peritoneal Signs: • Rebound • Percussion tenderness

  19. Peritoneal TendernessAssociated findings • Eyes dilate, • Exquisitely tender • “bright tenderness” • akin to fracture tenderness • “electric shock-like”

  20. Examination of the Painful Abdomen • Advanced palpation tricks • Sneak up on them • Distract with conversation • Watch their eyes • Palpate with the stethoscope • Bump the stretcher

  21. Advanced and Adjuvant Exams • Shifting Dullness • CVA Tenderness • Digital Rectal Exam • Bimanual Pelvic Exam • Listening to lower lung fields

  22. Exam for Ascites • Fluid Wave • Shifting Dullness • Associated findings: • Caput Medusa • Spider Angioma

  23. “6 Dermatomal” Pain Syndrome • Due to poorly localizing visceral innervation, diseases can present in vague, confusing manner • Pneumonia • Acute MI • GERD • Biliary Colic • PUD • Pancreatitis • Hepatitis

  24. Diagnostic Approach • Essential Questions: • Stable or Unstable? • Do I need the surgeon now? • Is it obvious that they need an operation?

  25. Diagnostic Approach • What is your clinical Diagnosis? • Options: • Upright CXray and Abdomen, KUB • CT + IV or PO contrast • Ultrasound • Nothing

  26. Diagnostic Modalities • CT: 15-20% false negative for acute perforation • Poor study for gallstones • Contrast obscures kidney stones

  27. When to call the surgeon? • Unstable VS- call immediately • Obvious peritonitis • Work up complete in stable, less obvious • CBC, coags • Blood gas • Lytes • Amylase • Bilirubin(s) • LFTs • Imaging

  28. Chores in the interim • ABCs • Does this pt need intubated, O2? • IVs- large bore, 2 if unstable • Resuscitation- NS vs LR • Bolus therapy- 20cc/kg, repeat if necessary • Foley Catheter • ?Central line • Type and Cross • Antibiotics- Gram Neg and Anaerobic • Cipro/Flagyl • Pip-Tazo • Cefotetan • Pain Medication?

  29. Common Pitfalls • Acute Mesenteric Ischemia • Intestinal Volvulus • Gallstone “Illeus” • AAA and backpain • “It’s just gastroenteritis”

  30. Evaluation of Abdominal PainSummary: • Patient Condition guides the urgency • Clinical Diagnosis is the first step • Imaging studies depend on Clinical Dx. • Patient Preparation is crucial to outcome

More Related