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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 abdomen1
Acute Abdomen
  • Anatomy review
  • Non-hemorrhagic abdominal pain
  • Gastrointestinal hemorrhage
  • Assessment
  • Management
abdominal cavity
Abdominal Cavity
  • Superior border = diaphragm
  • Inferior border = pelvis
  • Posterior border = lumbar spine
  • Anterior border = muscular abdominal wall
  • 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)
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
  • Inflammation of distal esophagus
  • Usually from gastric reflux, hiatal hernia
  • 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
  • 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
  • May lead to:
    • Peritonitis
    • Pseudocyst formation
    • Hemorrhage
    • Necrosis
    • Secondary diabetes
  • 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
  • Gall bladder inflammation, usually 2o to gallstones (90% of cases)
  • Risk factors
    • Five Fs: Fat, Fertile, Febrile, Fortyish, Females
    • Heredity, diet, BCP use
  • Acalculus cholecystitis
    • Burns
    • Sepsis
    • Diabetes
    • Multiple organ systems failure
  • Chronic cholecystitis (bacterial infection)
  • 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
  • Inflammation of vermiform appendix
  • Usually secondary to obstruction by fecalith
  • May occur in older persons secondary to atherosclerosis of appendiceal artery andischemic necrosis
  • 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
  • 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
  • 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
  • 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)
  • 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
  • Diverticula
    • Pouches in colon wall
    • Typically in older persons
    • Usually asymptomatic
    • Related to diets with inadequate fiber
  • Diverticula trap feces, become inflamed
  • Occasionally result in bright red rectal bleeding
  • Rupture may cause peritonitis, sepsis
  • Signs and Symptoms
    • Usually left-sided pain
    • May localize to LLQ (“left-sided appendicitis”)
    • Alternating constipation, diarrhea
    • Bright red blood in stool
  • 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
  • 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

  • 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
  • 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
  • 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
  • Urine
    • Change in urinary habits?
      • Frequency
      • Urgency
    • Color?
    • Odor?
  • 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)
  • 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
  • Oxygen by non-rebreather mask
  • IV LR or NS
  • PASG (demonstrated benefit in intrabdominal hemorrhage)
  • Keep patient from losing body heat
  • Monitor vital signs
  • 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